Integrated Exposure and Algal Ecotoxicological Assessments of Effluents from Secondary and Advanced-Tertiary Wastewater-Treatment Plants.

The great concern over the environmental impact of wastewaters has led to the designing of advanced treatment processes to upgrade conventional treatment plants and achieve a significant reduction of contaminants in receiving waters. In the present study we combined chemical and ecotoxicological analyses, aiming to evaluate the reduction of toxicity effects associated with the removal of micropollutants and to define the contribution of the detected compounds to the overall toxicity of the mixtures in a series of wastewater effluents collected from a secondary treatment (OUT 2) and from a tertiary activated carbon treatment (OUT 3) plant. The target compounds were selected after a screening procedure among pharmaceuticals, musk fragrances, and trace metals. The classical algal growth inhibition test was conducted on the original effluent samples and on different fractions obtained by solid-phase extraction (SPE) treatment. A good accordance was found between the removal of toxicity (30%-80%) and organic compounds (70%-80%) after the tertiary treatment, suggesting its high efficiency to improve the wastewater quality. The discrepancy between the contribution to the overall toxicity of the nonadsorbable compounds (i.e., inorganic or very polar organic compounds) as experimentally measured by the SPE bioassays (18%-76%) and calculated by the concentration addition approach (>97%) could be mitigated by including the bioavailability correction in metal-toxicity modeling of wastewater mixtures. For the organic compounds, the toxic equivalency method enabled us to quantify the portion of toxicity explained by the detected chemicals in both OUT 2 (82%-104%) and OUT 3 (5%-57%), validating the selection of the target molecules. The applied integrating approach could be implemented by the inclusion of both additional target chemicals and toxicity endpoints. Environ Toxicol Chem 2022;41:2404-2419. © 2022 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Sildenafil effects on exercise, neurohormonal activation, and erectile dysfunction in congestive heart failure: a double-blind, placebo-controlled, randomized study followed by a prospective treatment for erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED) is common in patients with congestive heart failure (CHF). ED reduces quality of life, and it may affect compliance, thereby impairing the success of CHF treatment. METHODS AND RESULTS: In the first phase (fixed-dose double-blind, randomized, placebo-controlled, two-way crossover study), we studied in 23 men with CHF the effects of 50 mg sildenafil on exercise and neurohormonal activation. Patients underwent a treadmill 6-minute cardiopulmonary walking (6'WT) test followed by a maximal cardiopulmonary exercise test (ET). In the second phase, patients received sildenafil, taken as required for ED. Sildenafil reduced the heart rate (HR) (bpm) before the 6'WT (from 75+/-15 to 71+/-14, P=0.02) and ET (from 75+/-15 to 71+/-15, P=0.02); the systolic blood pressure (mm Hg) before the 6'WT (from 116+/-18 to 108+/-18, P=0.004) and ET (from 116+/-15 to 108+/-17, P=0.001); the diastolic blood pressure before the 6'WT (from 69+/-9 to 63+/-11, P=0.01) and ET (from 70+/-8 to 65+/-10, P=0.004); and the Ve/VCO2 slope during the 6'WT (from 32+/-7 to 31+/-6, P=0.04) and ET (from 33+/-8 to 31+/-5, P=0.03). Sildenafil attenuated the HR increment during the 6'WT (P=0.003) and ET (P=0.000). Sildenafil increased the peak *O2 from 16.6+/-3.4 to 17.7+/-3.4 mL/kg per min (P=0.025) and the exercise time from 12.3+/-3.4 to 13.7+/-3.2 minutes (P=0.003). Sildenafil improved most scores of International Index of Erectile Function. CONCLUSIONS: Sildenafil was tolerated and effective for ED treatment in CHF, and improved the exercise capacity. The reduction of HR during exercise with sildenafil could theoretically decrease the myocardial oxygen consumption during sexual activity.

Biphasic hemodynamic effects of LDL-apheresis in common carotid artery.

OBJECTIVE: Heparin-induced Extracorporeal Low Density Lipoprotein Precipitation (HELP) Apheresis gives beneficial reductions in Low Density Lipoprotein (LDL) cholesterol levels; otherwise, extracorporeal circulation settings might elicit inflammation and platelet aggregation. The net effect of these variations on carotid hemodynamic has not been established. Aim of the present study was to investigate periprocedural variations of common carotid artery wall shear stress, circumferential wall tension, and Peterson's elastic modulus. METHODS: Measurements were sequentially performed on 22 procedures: immediately before apheresis (T1), within one hour after (T2), after 24 (T3) and 48 hours (T4). In order to confirm acute effects, in additional 30 procedures measurements were performed at T1 and T2. RESULTS: Mean shear stress was decreased at T2, with an improvement at T4. Mean circumferential wall tension showed an improvement at T4; arterial stiffness showed the same trend, but only close to statistical significance. The following 30 procedures, where measurements were performed at T1 and T2 only, confirmed previous results, showing a deep wall shear stress decrease at T2 (-21%). CONCLUSION: LDL apheresis seems to have a biphasic effect on common carotid hemodynamics: the acute worsening of shear stress, probably mediated by extracorporeal circulation, was followed by its improvement, possibly driven by LDL cholesterol reduction.

Dobutamine stress echocardiography predicts cardiac events or death in asymptomatic patients long-term after heart transplantation: 4-year prospective evaluation.

BACKGROUND: Cardiac allograft vasculopathy (CAV) remains the major cause of death after cardiac transplantation during long-term follow-up. Nevertheless, annual angiographic evaluation is difficult to perform routinely. We evaluated the value of clinical risk factors and non-invasive testing for cardiac allograft vasculopathy in predicting cardiac events or death in asymptomatic patients with normal ventricular function during long-term follow-up after heart transplantation. METHODS: We studied 39 patients, mean aged 48 +/- 13 years, at 86 +/- 31 months after heart transplantation. Patients underwent thallium scintigraphy, treadmill stress testing, dobutamine stress echocardiography, and angiography to detect CAV. We prospectively observed all patients an additional 4 years for acute myocardial infarction, congestive heart failure, or death. RESULTS: Angiography detected CAV in 15 patients (38%). Three patients had acute myocardial infarction and another 7 had congestive heart failure, representing 25% of cardiac events during the study period. Nine deaths (23%) occurred during the same observation time. Univariate analysis showed that increased body mass index, positive dobutamine stress echocardiography results, and positive angiography results were associated significantly with cardiac events or death during follow-up. In the absence of coronary angiography, stepwise logistic regression identified positive dobutamine echocardiography results as the unique independent predictor of cardiac events (p = 0.001) or death (p = 0.002). CONCLUSION: Cardiac events and death after heart transplantation increased during long-term follow-up of this population. However, dobutamine stress echocardiography is well tolerated and, in the absence of routine angiographic evaluation, may be a strong predictor of these events.

Methotrexate in acute persistent humoral rejection: an option for graft rescue.

Humoral response emerges as an important component in acute graft rejection and a new challenge to clinicians in posttransplant care. Management of recurrent episodes and persistent activation of the humoral component of the immune system, despite the usual therapeutic approach to rejection, remains unknown. This article describes the successful use of methotrexate as an option for rescuing a graft in this worrisome situation.

Can the cardiopulmonary 6-minute walk test reproduce the usual activities of patients with heart failure?

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45 +/- 12 years, ejection fraction 23 +/- 7%, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4 +/- 1.8, 9.8 +/- 1.9 (60 +/- 10%), and 13.3 +/- 2.2 (90 +/- 10%); heart rate (bpm) 142 +/- 12, 110 +/- 13 (77 +/- 9%), and 126 +/- 11 (89 +/- 7%); distance walked (m) 733 +/- 147, 332 +/- 66, and 470 +/- 48; and respiratory exchange ratio (R) 1.13 +/- 0.06, 0.9 +/- 0.06, and 1.06 +/- 0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p < 0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients.

Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with mitral regurgitation: initial results.

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7 +/- 3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1 +/- 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

Endocardite por Streptococcus bovis e neoplasias do cólon e reto / Streptococcus boviss endocarditis and colorectal neoplasmas

Objetivo - Avaliar a associação de endocardite por Streptococcus bovis com neoplasia de intestino grosso. Casuística e Métodos - Vinte episódios (19 pacientes) de endocardite por S.bovis dentre 396 (5,05%) acompanhados no período de 1978 a 1990. A média das idades foi de 57,68 anos, 16 (84,21%) doentes eram do sexo masculino. Em nove (45%) pacientes não havia história de cardiopatia. Em três, ocorreram manipulações prévias passíveis de induzir bacteremia. Evidências clínicas de neoplasia intestinal não foram identificadas em nenhum caso. O tempo médio de seguimento após alta hospitalar (17 casos) foi de 33,76 ± 27,37 meses. A avaliação intestinal foi realizada por enema opaco (11 casos), colonoscopia (cinco casos), sendo ambos os métodos realizados em cinco deles. Resultados - Foram diagnosticadas neoplasias intestinais em 12 (75%) dos 16 pacientes examinados. Necrópsia do único óbito (paciente não previamente investigado) não identificou sinais de neoplasia. Corresponderam a adenocarcinoma de cólon em um (8,33%) e a pólipos de aspecto histológico benigno em oito (66,6%). Em três casos não se definiu o caráter das tumorações...

Purpose - To evaluate the association of Streptococcus bovis endocarditis with large bowel neoplasms. Patients ant Method -Twenty episodes (19 patients ) of Streptococcus bovis endocarditis (5,05 % ) selected from 396 episodes of endocarditis followed up from 1978 to 1990. The mean age was 57,68 years, 16 (84,21%) were males. Previous heart disease was not known in nine (45%). Previous manipulation that might induce bacteremia was identified in three patients. Symptoms related to neoplasia of the digestive system were not informed. The mean time of follow up (17 casos) was 33,76 months, standard deviation 27,37 months. Sixteen patients were submitted to colonic evaluation (barium enema in 11, colonoscopy in 5 patients, and both were performed in 5 patients). Results - Bowel neoplasias were diagnosed in 12 (75%) of 16 patients submitted to colonic evaluation, one colonic adenocarcinoma in one (8,33%) patient, histologic benign polyps in eight (66,ó%). Two patients are waiting for colonoscopic ressection. ln one patient the polyp was lost after colonoscopic ressection...

Eficácia e tolerabilidade de um novo bloqueador dos canais de cálcio (Nitrendipina) no tratamento da hipertensäo arterial / Efficacy and tolerability of a new calcium antagonist (nitrendipine) in the treatment of hypertension

Objetivo: Avaliar a eficácia e a tolerabilidade da monoterapia por nitrendipina, 20 mg ao dia, em portadores de hipertensão arterial sistêmica leve ou moderada. Material e Métodos: Vinte pacientes submetidos durante seis semanas a estudo aberto comparado (droga x placebo), avaliados através de pressão arterial em posição ortostática, supina e após manobra de hand-grip a cada duas semanas e exames laboratoriais no início e final do estudo. Resultados: As pressões médias sistólica e diastólica apresentaram queda significativa no grupo tratado, nas posições supina (161 mmHg ± 11 para 138 mmHg ± 5 e 105 mmHg ± 5 para 81 mmHg ± 7 -p < 0,05), ortostática (153 mmHg ± 13 para 132 mmHg ± 13 e 104 mmHg ± 5 para 81 mmHg ± 7 -p < 0,05) e após hand-grip (170 mmHg ± 21 para 148 mmHg ± 22 e 108 mmHg ± 5 para 85 mmHg ± 7 -p < 0,05). O grupo placebo não apresentou variações significativas das pressões médias sitólica e diastólica em quaisquer das condições: supina (168 mmHg ± 8 para 168 mmHg 18 e 107 mmHg ± 5 para 107 mmHg ± 3 mmHg), ortostática (167 mmHg ± 9 para 163 mmHg ± 14 e 107 mmHg ± 5 para 107 mmHg ± 4) e após hand-grip (178 mmHg ± 17 para 173 mmHg ± 16 e 107 mmHg ± 4 para 108 mmHg ± 6. Não houve modificação significativa das médias da freqüência cardíaca em ambos os grupos após o tratamento. A elevação da freqüência cardíaca verificada após manobra de hand-grip também não se modificou. Dos eventuais efeitos adversos, observavam-se cefaléia, palpitação e tontura, que estiveram presentes em ambos os grupos (placebo e nitrendipina). Os exames eletrocardiográfico, radiológico e laboratorial não se alteraram ao longo do estudo...

Purpose: Assess the efficacy and tolerability of nitrendipine, 20 mg/day, in mild to moderate essential hypertension (diastolic blood pressure 95 to 114 mmHg). Material e Methods: Twenty patients in an open comparative trial (drug x placebo) during six weeks. Blood pressure and heart rate were measured in ortostatic and supine position and after hand-grip manewre every two weeks. Results: Systolic and diastolic blood pressure fell significatively in the treated group by the end of the study-supine (161 mmHg ± 11 to 138 mmHg ± 13 and 105 ± 5 to 81 mmHg ± 7 p < 0,05) and ortostatic position (153 mmHg ± 13 to 132 mmHg ± 13 and 104 mmHg ± 15 to 81 mmHg ± 7, p < 0,05) and after hand grip maneuver (170 mmHg ± 21 to 148 mmHg ± 22 and 108 mmHg ± 5 to 85 mmHg ± 7 p< 0,051. Significant modifications were not observed in systolic and diastolic blood pressure in placebo group under the following conditions: supine (168 mmHg ± 8 to 168 mmHg ± 17 and 107 mmHg ± 5 to 107 mmHg ± 3) and ortostatic positions (167 mmHg ± 9 to 163 mmHg ± 14 and 107 mmHg ± 5 to 107 mmHg ± 4) and after hand grip maneuore (178 mmHg ± 17 to 173 mmHg ± 16 and 107 mmHg ± 4 to 108 mmHg ± 6). Significant changes in heart rate did not occur in both groups after treatment. Heart rate elevation observed after hand grip maneuvre did not change. Adverse effects like headache, palpitation and dizziness occurred in both groups. Eletrocardiogram, x-ray and blood chemistries were not modified during the trial...

Valor preditivo da estimulaçäo ventricular programada após infarto do miocárdio / Predictive value of programmed ventricular stimulation after myocardial infarction

Objetivo - Encontrar relação entre arritmias ventriculares induzidas em laboratório de eletrofisiologia, através da estimulação ventricular programada e a ocorrência de eventos clínicos relevantes e, em particular, a morte súbita, em pacientes vitimados do primeiro episódio de infarto agudo do miocárdio. Casuísticas e Métodos - Foram estudados prospectiva e consecutivamente, 27 pacientes portadores do primeiro infarto do miocárdio não complicado, sendo todos eles do sexo masculino, variando as idades entre 47 e 70 anos com valor médio de 54 ± 6 anos. Após consentimento, os pacientes foram inicialmente submetidos a estudo cinecoronariográfico convencional e à estimulação ventricular programada utilizando-se protocolo com triplo extra-estímulo (S2 S3S4) 30 dias após o infarto. Além disto os pacientes foram submetidos a estudo eletrocardiográfico contínuo (sistema Holter), teste eletrocardiográfico de esforço e estudo radioisotópico para cálculo da fração de ejeção do ventrículo esquerdo (fase I). Os três últimos exames foram repetidos aos seis e 12 meses subseqüentes (fase II e III, respectivamente)...

Purpose - To find out whether is there a relation between electrophysiology laboratory ventricular arrhythmias through programmed ventricular stimulation, and the occurrence of relevant clinical events. particularly, sudden death, in patients victims of first episode of myocardial infarcation. Patients and Methods - Twenty-seven patients (all males) who suffered non-complicated first myocardial infarction, with age varying from 47 to 70 (mean 54 ± 6) years were prospectively and consecutively studied. Upon consent, patients were at first submitted to conventional cinecoronaryography and to programmed ventricular stimulation utilizing the S2, S3, S4 protocol, 30 days after infarction. Moreover, patients were submitted to continuous electrocardiographic (Holler system), exercise test, and radioisotopic studies for left ventricle ejection fraction (phase 1). The last three studies were subsequently repeated at 6 and 12 months (phases II and III), respectively.

Evolução clínica de portadoras de estenose mitral no ciclo gravídico-puerperal / Clinical evolution of women with mitral valve stenosis during pregnancy, delivery and puerperium

Objetivo - Estudar a evoluçäo clínica de portadoras de estenose mitral no ciclo gravídico-puerperal que iniciaram a gravidez em classe funcional (CF) I/II. Métodos - Noventa e três mulheres, divididas em três grupos: Grupo GE - 30 gestantes portadoras de estenose mitral com média de idade de 27,9 anos. 26(86,7%) apresentavam sobrecarga atrial esquerda e nove (30%) ventricular direita no eletrocardiograma. A área valvar mitral ao ecodopplercardiograma variou entre 0,7 a 1,9 (1,26) cm*. Grupo GN - 32 gestantes näo cardiopatas, com média de idade de 25,5 anos com eletrocardiograma e área valvar mitral ao ecodopplercardiograma normais. Grupo EM - 31 portadoras de estenose mitral, näo grávidas com média de idade de 25 anos. Dezenove (61,3%) apresentavam sobrecarga atrial esquerda e quatro (13%) sobrecarga ventricular direita no eletrocardiograma. A área valvar mitral variou entre 0,50 a 1,80 (média = 1,19) cm*. Em cada consulta foram anotados os dados sobre CF e complicaçöes. As complicaçöes investigadas foram congestäo pulmonar, endocardite infecciosa, arritmia cardíaca e tromboembolismo. Resultados - Vinte e seis (86,7%) pacientes do grupo GE modificaram a CF: 16 evoluíram para CF III e 10 para IV, no grupo GN, 18 (56,2%) pacientes evoluíram de CF I para II no decorrer da gestaçäo e no grupo EM, cinco (16%) evoluíram da CF I/II para III durante o estudo. Arritmia cardíaca, endocardite infecciosa näo foram registradas. Fenômeno tromboembólico foi identificado em um (3,2%) caso no grupo EM. Näo houve mortalidade. Conclusäo - A grande maioria das gestantes portadoras de estenose mitral, que iniciaram a gravidez em CF I/II evoluíram para CF III/IV, no decorrer da gestaçäo. Medidas como repouso, farmacoterapia e avalvoplastia por cateter-baläo contribuíram, na totalidade dos casos, para o termo da gestaçäo e ausência de mortalidade

Purpose The clinical evolution of women with mitral stenosis was studied during pregnancy, delivery and puerperium in inicial function (FCJ class I/II. Methods ­ Ninety-three women were divided in three groups. Group GE Pregnant women with mitral stenosis (n = 30, mean age 28 years); 26 (86.7%) patients had electrocardiographic signs of left atrial enlargement and nine (30%) had signs of right ventricular hypertrophy. The mitral valvar area was between 0.7 and 1.9 (mean = 1.26) cm2 at echod opplercardiogram, Group GM Normal pregnant women (n = 32; aged 25.4 years), the electrocardiogram and echodopplercardiogram were normal. Group EM - non pregnant patients, with mitral stenosis (n = 31.33 years); 19 (61,3%) had left atrial enlargement andfour (13%) had right ventricular hypertrophy. The mitral valvar area between 0.50 and 1.80 (mean = 1.19) cm2. The variables analyzed were FC and occurrence of the following complications. infective endocarditis, cardiac arrhythmias and thromboembolism. Results In GE group, 26 (86,7%) patients worsened the FC during gestation, 16 to FC III and 10 to FC IV. In GN group, 18 (56,2% ) patients changed from FC I to FC II during the gestation and in EM group 5 (16,2%) patients changed from FC I/II to III during the study. Cardiac arrhythmias and infective endocarditis were not observed; thromboembolic event was registered in one (3.2%) patients from EM group. There were no death in all groups. Conclusion ­ The large majority of pregnant with mitral stenosis that started pregnancy in FC I/II worsened to FC III/IV during gestation. Medical treatment and eventually balloon valvuloplasty were successfull measure to allow a full-term gestation without mortality

Compliance with pharmacological treatment in outpatients from a Brazilian cardiology referral center

To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.

Evoluçäo imediata e tardia de pacientes com prótese porcina / Immediate and late evolution of patients with porcine prostheses

Estudamos 316 pacientes com prótese porcina, 177 (50,8%) em posiçäo mitral, 155 (44,7%) em posiçäo aórtica e 15 (4,5%) em posiçäo triscúspide, por período de 3 a 60 meses (média de 46 meses). A disfunçao ocorreu em 27 (7,8%), sendo que apenas seis (2%) necessitaram retrocar a prótese: 2 (33,3%) por calcificaçäo, 2 (33,3%) por endocardite. A letalidade tardia foi de 2,8% (8 pacientes) sendo: 4 (39,5%) por endocardite, 1 (12.5%) por septicemia, 1 (12,5%) por broncopneumonia, 1 (12,5%) por edema agudo de pulmäo e 1 (12,5%) por causa idefinida. Na úlima consulta 96,2%) (289) dos sobreviventes estavam em CF I/II. A probalidade do portador de prótese porcina estar vivo e sem complicaçöes, ao final de cinco anos, foi estimada em 82,15%, semelhante a outros serviços. Portanto, concluimos que a prótese, apesar de näo ser a ideal, é aceitável para uso clínico

Tratamento cirúrgico da taquicardia por reentrada nodal: experiência inicial / Surgical treatment of nodal reentry tachycardia: initial experience

Quatro pacientes, (três do sexo feminino e idade variando entre 51 e 74 anos) portadores de taquicardias por reentrada nodal (TRN) recorrente e refratárias à terapêutica medicamentosa foram submetidos a tratamento cirúrgico. Os pacientes foram submetidos a estudo eletrofisiológico pré-operatório que permitiu o diagnóstico de TRN. Todos os pacientes tinham intervalo VA durante TRN, menor que 40 ms e a despolarizaçäo atrial retrógrada se iniciava na porçäo anterior ao nó AV. Além disso, havia captura atrial retrógrada de extra-estímulo ventriculares aplicada durante TRN sugerindo participaçäo de via anômala átrio nodal ou hisiana. O mapeamento intra-operatório feito durante estimulaçäo ventricular, mostrou despolarizaçäo atrial retrógrada posterior do nó AV. O procedimento cirúrgico consistiu na dissecçäo da porçäo posterior do nó AV com técnica derivada da utilizada para vias anômalas póstero-septais cuidando de preservar o tendäo de Todaro. Näo houve complicaçöes no ato cirúrgico e a estimulaçäo programada realizado ao redor do 15§ dia de pós-operatório foi incapaz de induzir TRN. Sete e doze meses após os pacientes estäo assintomáticos, em conduçäo AV normal e sem drogas anti-arrítmicas. Apesar do reduzido número de casos e do relativamente curto período de seguimento, o procedimento cirúrgico empregado se mostrou eficaz no controle da TRN preservando a conduçäo intacta

Estudo da história natural da doença arterial coronária: seguimento clínico a longo prazo de pacientes que recusaram o tratamento cirúrgico / Natural history of coronary artery disease: long-term clinical follow-up of patients that refused surgical treatment

Durante um período de oito anos foram avaliados prospectivamente 150 pacientes portadores de doença arterial coronária que recusaram o tratamento cirúrgico. Cento e nove eram do sexo masculino e 41 do feminino com idade média de 57 anos. De acordo com o número e local da estenose arterial (reduçäo maior ou igual a 75% da luz do vaso) os pacientes foram agrupados nos grupos I, II, III, IV e V respectivamente com envolvimento em uma, duas e três artérias, estenose tronco-equivalente e da artéria coronária esquerda. O seguimento ambulatorial constou de avaliaçäo clínica trimestral sendo pesquisado os seguintes dados: comprometimento dos sintomas de angina do peito, surgimento de insuficiência cardíaca, de arritmias ventriculares, de infarto do miocárdio e do óbito. Todos os pacientes foram medicados com associaçäo de drogas vasodilatadoras, bloqueadores dos receptores ß adrenérgicos, antogonistas dos ions cálcio e antiagregantes plaquetários. Cincoenta e dois pacientes foram submetidos a um segundo estudo angiográfico entre 3 a 6 anos (m = 4,2 anos) após o primeiro exame. Dos 150 pacientes, dois (1,3%) näo completaram o seguimento clínico, seis (4%) solicitaram o tratamento cirúrgico e seis (4%) evoluíram para óbito durante os oito anos de seguimento. Estes, pertenciam aos grupos III, IV e V. Observou-se remissäo dos síntomas anginosos de 88% de angina estável ou progressiva para 65% de assintomáticos. Ocorrência de novos infartos em 10% e de novos quadros de insuficiência cardíaca de 6%. Dos 52 pacientes que foram submetidos a reestudo angiografico observou-se 22% de oclusäo arterial, 26% de surgimento de novas estenoses arteriais e 52% sem progressäo da doença aterosclerótica. A funçäo ventricular permaneceu praticamente normal. A análise global dos resultados sugere implicaçöes de expressivo significado: a) pacientes portadores de doença arterial coronária com funçäo ventricular preservada, independente do número de arterias comprometidas e da severidade das estenoses luminares poderäo esperar excelente percentual de sobrevida...

Fibrilaçäo atrial na fase hospitalar do infarto do miocárdio / Atrial fibrillation in hospitalar phase of myocardial infarction

No período de junho de 1981 a maio de 1985 a ocorrência de fibrilaçäo atrial (FA) foi estudada em 1076 pacientes consecutivos internados na Unidade Coronária com diagnóstico de infarto agudo do miocárdio. Oitocentos e trinta e um (77%) eram do sexo masculino e 245 (23%) do feminino. A idade média (ñ 1 desvio-padräo) era de 54 ñ 10 anos. De acordo com a presença e o período de ocorrência da FA os pacientes foram agrupados em: 1) grupo A - ausência de FA; 2) grupo B - com episódio de FA nas primeiras 24 horas após o início dos sintomas e 3) grupo C - com FA após 24 horas e durante a internaçäo hospitalar. A presença de FA foi relacionada com o sexo, a idade, a existência de infarto prévio, a localizaçäo eletrocardiográfica do infarto, a observaçäo de distúrbio da conduçäo intraventricular do impulso elétrico, a fraçäo de ejeçäo do ventrículo esquerdo, a pericardite e a mortalidade. Episódios de FA foram notados em 10 (9,3%) dos 1076 pacientes, sendo 28 do grupo B e 72 do grupo C. No grupo B observou-se relaçäo entre a FA, a localizaçäo inferior do infarto e valores da fraçäo de ejeçäo maiores que 50%. A mortalidade do grupo B näo diferiu da observada no grupo sem FA. No grupo C notou-se relaçäo entre a FA, a idade acima dos 70 anos, localizaçäo anterior do infarto, distúrbio na conduçäo intraventricular, fracäo de ejeçäo menor que 50% e pericardite. Neste grupo, a mortalidade (37,5%) diferiu significantemente da do grupo B (7%). Os resultados indicam que a FA que surge nas primeiras horas näo está relacionada à extensäo do infarto. Por outra, a ocorrência de FA após a 24 horas está associada à magnitude da disfunçäo ventricular e, portanto, à extensäo do infarto. Nestas condiçöes, embora näo seja per se o fator determinante da mortalidade, constitui-se em achado clínico de importância prognóstica

Síndrome de pré-excitaçäo por fibras nodofasciculares (Mahaim): relato de dois casos / Pre-excitement syndrome by nodofascicular (Mahaim)fibers: report of 2 cases

A participaçäo de vias anômalas nodofasciculares ou de Mahaim no circulo de taquicardia clínica ou entäo no aspecto do eletrocardiograma (ECG) basal é descrita, respectivamente, em 2 pacientes. No caso 1, com crises recorrentes de taquicardia paroxística, o ECG basal näo mostrava qualquer forma de pré-excitaçäo e o QRS era normal. Durante a taquicardia, o QRS apresentava aspecto de bloqueio completo do ramo esquerdo (BCRE) e a freqüência cardíaca era de 180 bpm. Durante o estudo eletrofisiológico, demonstrou-se a presença de dupla via nodal, estando o início da taquicardia clínica na dependência de bloqueio da via rápida e conduçäo pela via lenta, induzido por extra-estímulos atriais. A transiçäo de conduçäo para a via lenta coincide com o encurtamento do intervalo HV e com o aparecimento de morfologia de BCRE. Quando se atinge intervalo crítico de alongamento da conduçäo pela via lenta nodal, a taquicardia clínica é disparada. Os componentes anterógrado (via lenta nodal - via nodofascicular) e retrógrado (porçäo proximal do ramo direto - tronco do feixe de His - via nodal rápida) podem ser estudados e a açäo benéfica do verapamil demonstrada. No caso 2, o paciente näo tinha taquicardia e o ECG basal mostrava sinusal intervalo PR = 0,18 e QRS com morfologia de BCRE. A presença de vias nodofasculares no determinismo da imagem de BCRE demonstrada pela presença de intervalo HV = 0 e pela normalizaçäo do QRS com estimulaçäo do feixe de His

Intervalo QT e taquicardia ventricular no infarto agudo do miocárdio / QT interval and ventricular tachycardia in acute myocardial infarction

Foram estudados 39 pacientes, com idade média 56 anos, na fase aguda do infarto do miocárdio, atendidos 7 + ou - 3 horas após o início dos sintomas. Na admissäo hospitalar, todos os casos foram submetidos à monitorizaçäo eletrocardiográfica contínua, durante 24 horas. Houve episódios de taquicardia ventricular (TV) em 24 pacientes. Procurou-se correlacionar a duraçäo do intervalo QT com o desenvolvimento de TV. Em todos os casos, foram feitas duas medidas do QY, corrigidos para a freqüência cardíaca, em períodos sem arritmias (QTC1 e QTC2). Nos casos com TV, calculou-se o QTC imediatamente antes da arritmia (QTC3). Em todos os casos, näo houve diferença significativa entre as médias de QTC1 e QTC2. O QTC3 näo diferiu significativamente do QTC1 nem de QTC2. Näo houve também diferença significativa entre QTC1 ou QTC2 dos pacientes com e sem TV. Por outra, 50% dos pacientes com TV e 67% dos sem TV mostraram valores de QTC1 ou QTC2 superiores ao limite normal (440ms). Desse modo, parece näo haver relaçäo entre a duraçäo do intervalo QT e o desenvolvimento de TV na fase aguda do infarto do miocárdio

Pode o teste ergoespirométrico de caminhada de seis minutos ser representativo das atividades habituais de pacientes com insuficiência cardíaca? / Can the cardiopulmonary 6-minute walk test reproduce the usual activities of patients with heart failure?

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45±12 years, ejection fraction 23±7 percent, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4±1.8, 9.8±1.9 (60±10 percent), and 13.3±2.2 (90±10 percent); heart rate (bpm) 142±12, 110±13 (77±9 percent), and 126±11 (89±7 percent); distance walked (m) 733±147, 332±66, and 470±48; and respiratory exchange ratio (R) 1.13±0.06, 0.9±0.06, and 1.06±0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p<0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients

Rotura do seio de valsalva esquerdo com formaçäo de pseudoaneurisma subepicárdico / Rupture of the left sinus of Valsalva forming a subepicardial pseudoaneurysm

Homem de 44 anos de idade, assintomático do ponto de vista cardiovascular, apresentou ao estudo radiológico do tórax massa calcificada em mediastino médio. Durante a investigaçäo diagnóstica foi identificada, em estudo cineangiográfico, rotura do seio de Valsalva esquerdo dirigida a regiäo subepicárdica do ventrículo esquerdo com formaçäo de pseudoaneurisma de grande extensäo, produzindo acentuada distorçäo da artéria coronária esquerda e de seus ramos principais. Foi realizado tratamento cirúrgico com fechamento do orifício ao nível do seio de Valsalva esquerdo com um retalho de pericárdio bovino e esvaziamento do saco aneurismático preenchido por trombos. A evoluçäo pós-operatória foi satisfatória. O exame anátomo-patológico de fragmento da aorta näo possibilitou o diagnóstico da etiologia da rotula

A healthy 44 year-old male patient presented a calcified mass in the middle mediastinum on a chest film. During diagnostic investigation cineangiograms showed a rupture of the lep sinus of Valsalva forming a large pseudoaneurysm that produced important distortion of the left coronary artery and it’s main branches. The patient was submitted to surgical repair through the closure of the orifice of the ruptured left sinus of Valsalva with a bovine pericardium patch. The subepicardium was filled with organized thrombi which were removed. He was discharged from the hospital after uncomplicated postoperative course. Pathological examination of the aortic fragment did not yield the etiology of the rupture.