Impact of left atrial compliance improvement on functional status after percutaneous mitral valvuloplasty.

BACKGROUND: Conventional hemodynamic parameters may not accurately predict symptomatic improvement after percutaneous mitral valvuloplasty (PMV). Changes in left heart chamber compliance following adequate relief o0066 mitral stenosis (MS) may be useful in determining functional capacity after PMV. This study aims to determine the acute effects of PMV on compliance of the left heart and whether its changes relate to the patient's functional capacity. METHODS: One-hundred thirty-seven patients with severe MS undergoing PMV were enrolled. Left atrial (Ca ) and left ventricular (Cv ) compliance were invasively estimated and net atrioventricular compliance (Cav ) was calculated before and immediately after the procedure. B-type natriuretic peptide (BNP) levels were obtained before and 24 hr after the procedure. The primary endpoint was functional status at 6-month follow-up, and the secondary endpoint was a composite of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, or stroke in patients in whom PMV was successful. RESULTS: The mean age was 43 ± 12 years, and 119 patients were female (87%). After PMV, Ca and Cav improved significantly from 5.3 [IQR 3.2-8.2] mL/mmHg to 8.7 [5.3-19.2] mL/mmHg (P < 0.001) and 2.2 [1.6-3.4] to 2.8 [2.1-4.1] mL/mmHg (P < 0.001), respectively, whereas Cv did not change (4.6 [3.2-6.8] to 4.4 [3.1-5.6]; P = 0.637). Plasma BNP levels significantly decreased after PMV, with no correlation between its variation and changes in left chamber compliance. At 6-month follow-up, NYHA functional class remained unchanged in 32 patients (23%). By multivariable analyses, changes in Ca immediately after PMV (adjusted OR 1.42; 95% CI 95% 1.02 to 1.97; P = 0.037) and younger age (adjusted OR 0.95; CI 95% 0.92-0.98; P = 0.004), predicted improvement in functional capacity at 6-month follow-up, independent of postprocedural data. The secondary endpoint were predicted by post-PMV mean gradient (adjusted HR 1.363; 95% CI 95% 1.027-1.809; P = 0.032), and lack of functional improvement at 6-month follow-up (adjusted HR 4.959; 95% 1.708-14.403; P = 0.003). CONCLUSIONS: Ca and Cav increase significantly after PMV with no change in Cv . The improvement of Ca is an important predictor of functional status at 6-month follow up, independently of other hemodynamic data. Postprocedural mean gradient and lack of short-term symptomatic improvement were predictors of adverse outcome.

Update on percutaneous mitral commissurotomy.

Percutaneous mitral commissurotomy (PMC) is the first-line therapy for managing rheumatic mitral stenosis. Over the past two decades, the indications of the procedure have expanded to include patients with unfavourable valve anatomy as a consequence of epidemiological changes in patient population. The procedure is increasingly being performed in patients with increased age, more deformed valves and associated comorbidities. Echocardiography plays a crucial role in patient selection and to guide a more efficient procedure. The main echocardiographic predictors of immediate results after PMC are mitral valve area, subvalvular thickening and valve calcification, especially at the commissural level. However, procedural success rate is not only dependent on valve anatomy, but a number of other factors including patient characteristics, interventional management strategies and operator expertise. Severe mitral regurgitation continues to be the most common immediate procedural complication with unchanged incidence rates over time. The long-term outcome after PMC is mainly determined by the immediate procedural results. Postprocedural parameters associated with late adverse events include mitral valve area, mitral regurgitation severity, mean gradient and pulmonary artery pressure. Mitral restenosis is an important predictor of event-free survival rates after successful PMC, and repeat procedure can be considered in cases with commissural refusion. PMC can be performed in special situations, which include high-risk patients, during pregnancy and in the presence of left atrial thrombus, especially in centres with specialised expertise. Therefore, procedural decision-making should take into account the several determinant factors of PMC outcomes. This paper provides an overview and update of PMC techniques, complications, immediate and long-term results over time, and assessment of suitability for the procedure.

Primary Angioplasty for Cardiac Allograft Vasculopathy Presenting as ST-Elevation Acute Myocardial Infarction during Endomyocardial Biopsy.

Cardiac allograft vasculopathy is still a major issue, with significative mortality in heart transplant patients, and the best therapeutic options are not yet established. The progressively higher survival rates after transplantation have made it a major concern. This is a case report about a patient who underwent cardiac transplantation due to chagasic cardiomiopathy. During an endomyocardial biopsy more than 2 years after the transplant, the patient arrested in ventricular fibrillation, with ST-elevation in anterior leads after defibrillation. The angiography showed total occlusion of proximal left anterior descending artery, promptly treated with primary angioplasty, with excellent angiographic and clinical results.

A percepção da clientela sobre as condições da sala pediátrica de pronto atendimento do Hospital das Clínicas, Belo Horizonte / The clientele's perception on the conditions of the pediatrics emercency room of the Hospital das Clínicas, Belo Horizonte

Objetivo: Procurou-se captar a percepção das crianças e de seus acompanhantes quanto a situações causadoras de estresse, provocadas pelo ambiente físico e social do Pronto Atendimento do Hospital das Clinicas da Universidade Federal de Minas Gerais. Métodos: Empregou-se metodologia de caráter qualitativo, utilizando as técnicas de entrevista e de observação. Os informantes foram crianças que se encontravam internadas no Pronto Atendimento e seus acompanhantes. Resultados: Os resultados mostraram que crianças e acompanhantes percebem a estadia no Pronto Atendimento como algo penoso, sem conforto, onde não há nada o que fazer para desviar a atenção da doença. A ausência de mecanismos de desvio da tensão estimula a angústia dos acompanhantes, no convívio com o ambiente estressante de doença e morte, próprio da sala de emergência. Os acompanhantes seguem a evolução de casos de doenças semelhantes às de seus filhos, criando a expectativa do mesmo desfecho para eles. Conclusões: Escutar a perspectiva da clientela constitui um elemento a mais na direção da humanização da assistência hospitalar. As sugestões feitas pela clientela apontam mudanças que podem ser atendidas com recursos criativos e pouco onerosos.

Objectives: To capture the perception of children and their companions regarding the stress-causing situations induced by the physical and social environment in the Emergency Room, Hospital das Clínicas, Universidade Federal de Minas Gerais. Methods: A methodology consisting of interviews and observation techniques was employed. The informers were children hospitalized in the Emergency Room and their companions. Results: Both children and companions perceive their stay at the Emergency Room as something painful, comfortless, where there is nothing to call one's attention away from the disease. The absence of tension deviation mechanisms sharpens the distress of the companions who follow the evolution of cases similar to their children's, thus creating an expectation of the same outcome for them. Conclusions: Listening to the patient's perspective constitutes itself an additional element towards the humanization of hospital assistance. The suggestions made consist of small changes that could be done with little expenses.