Uncovering the burden of Influenza in children in Portugal, 2008-2018.

BACKGROUND: Despite their higher risk of developing severe disease, little is known about the burden of influenza in Portugal in children aged < 5 years old. This study aims to cover this gap by estimating the clinical and economic burden of severe influenza in children, in Portugal, during ten consecutive influenza seasons (2008/09-2017/18). METHODS: We reviewed hospitalizations in children aged < 5 years old using anonymized administrative data covering all public hospitals discharges in mainland Portugal. The burden of hospitalization and in-hospital mortality directly coded as due to influenza was supplemented by the indirect burden calculated from excess hospitalization and mortality (influenza-associated), estimated for four groups of diagnoses (pneumonia or influenza, respiratory, respiratory or cardiovascular, and all-cause), through cyclic regression models integrating the incidence of influenza. Means were reported excluding the H1N1pdm09 pandemic (2009/10). RESULTS: The mean annual number of hospitalizations coded as due to influenza was 189 (41.3 cases per 100,000 children aged < 5 years old). Hospitalization rates decreased with increasing age. Nine-in-ten children were previously healthy, but the presence of comorbidities increased with age. Children stayed, on average, 6.1 days at the hospital. Invasive mechanical ventilation was used in 2.4% of hospitalizations and non-invasive in 3.1%. Influenza-associated excess hospitalizations between 2008 and 2018 were estimated at 1,850 in pneumonia or influenza, 1,760 in respiratory, 1,787 in respiratory or cardiovascular, and 1,879 in all-cause models. A total of 95 influenza-associated excess deaths were estimated in all-cause, 14 in respiratory or cardiovascular, and 9 in respiratory models. Over ten years, influenza hospitalizations were estimated to have cost the National Health Service at least €2.9 million, of which 66.5% from healthy children. CONCLUSIONS: Influenza viruses led to a high number of hospitalizations in children. Most were previously healthy. Results should lead to a reflection on the adequate preventive measures to protect this age group.

Excess hospitalizations and mortality associated with seasonal influenza in Portugal, 2008-2018.

BACKGROUND: Influenza can have a domino effect, triggering severe conditions and leading to hospitalization or even death. Since influenza testing is not routinely performed, statistical modeling techniques are increasingly being used to estimate annual hospitalizations and deaths associated with influenza, to overcome the known underestimation from registers coded with influenza-specific diagnosis. The aim of this study was to estimate the clinical and economic burden of severe influenza in Portugal. METHODS: The study comprised ten epidemic seasons (2008/09-2017/18) and used two approaches: (i) a direct method of estimating the seasonal influenza hospitalization incidence, based on the number of National Health Service hospitalizations with influenza-specific International Classification of Diseases (ICD) codes (ICD-9: 487-488; ICD-10: J09-J11), as primary or secondary diagnosis; (ii) an indirect method of estimating excess hospitalizations and deaths using broader groups of ICD codes in time-series models, computed for six age groups and four groups of diagnoses: pneumonia or influenza (ICD-9: 480-488, 517.1; ICD-10: J09-J18), respiratory (ICD-9: 460-519; ICD-10: J00-J99), respiratory or cardiovascular (R&C, ICD-9: 390-459, 460-519; ICD-10: I00-I99, J00-J99), and all-cause. Means are reported excluding the H1N1pdm09 pandemic (2009/10). RESULTS: The mean number of hospitalizations coded as due to influenza per season was 1,207, resulting in 11.6 cases per 100,000 people. The mean direct annual cost of these hospitalizations was €3.9 million, of which 78.6% was generated by patients with comorbidities. Mean annual influenza-associated R&C hospitalizations were estimated at 5356 (min: 456; max: 8776), corresponding to 51.5 cases per 100,000 (95% CI: 40.9-62.0) for all age groups and 199.6 (95% CI: 163.9-235.8) for the population aged ≥ 65 years. The mean direct annual cost of the estimated excess R&C hospitalizations was €15.2 million for all age groups and €12.8 million for the population aged ≥ 65 years. Mean annual influenza-associated all-cause deaths per 100,000 people were estimated at 22.7 for all age groups. CONCLUSIONS: The study findings suggest that there is an under-detection of influenza in the Portuguese population. A high burden of severe influenza remains to be addressed, not only in the elderly population but also in younger people.

Catheter ablation of the parahisian accessory pathways from the aortic cusps-Experience of 20 cases-Improving the mapping strategy for better results.

INTRODUCTION: Catheter ablation of the parahisian accessory pathways (PHAP) has been established as the definitive therapy for this type of arrhythmia. However, the PHAP proximity to the normal atrioventricular conduction system makes the procedure technically challenging. Here, we have reported a case series of 20 patients with PHAP who underwent aortic access ablation to evaluate the safety and efficacy of this approach in the PHAP ablation. METHODS AND RESULTS: The ablation through the aortic cusps was the successful approach in 13 of 20 (65%) of the cases. In 11 patients, the aortic approach was the initial strategy for ablation, and the accessory pathway was eliminated in seven (63.6%) of them. The aortic approach followed a failed right-sided attempt in nine patients. In six (66.7%) patients, the ablation was successful with the aortic approach. The only independent predictor for the successful ablation with each approach was the earliest ventricular activation before delta wave (predelta time) and a right-sided earliest ventricular activation of more than 23 ms had high sensitivity and specificity for right-sided success. Systematically using the two strategies (right and left approaches), the ablation of the PHAP was successful in 18 (90%) patients. CONCLUSION: The aortic approach seems to be a safe and effective strategy for the ablation of PHAP. It can be used when the right-sided approach fails or even considered as an initial strategy when the predelta time is less than 23 ms in the right septal region. When combining the right- and left-sided approaches, the success rate is high. We believe that the retrograde aortic approach remains a key tool for this challenging ablation.

Identifying the long-term care beneficiaries: differences between risk factors of nursing homes and community-based services admissions.

BACKGROUND: The Portuguese long-term care sector is classified into home and community-based services (HCBS) and three nursing home (NH) units: convalescence, medium term and rehabilitation, and long term and maintenance. AIMS: To identify the main factors of admission into each care setting and explore to what extent these populations are different. 14,140 patients from NH and 6844 from HCBS were included from all over the country. METHODS: A logistic regression was estimated to identify determinants of admission into NH care, using sociodemographic characteristics, medical conditions and dependence levels at admission as independent variables, and region of care, referral entity and placement process as control variables. Then, ordered logistic regression was used to identify the contribution of the above factors in each specific NH unit. RESULTS: Being female, not being married, not having family/neighbour support, being literate, having mental illness, being cognitively or physically impaired are the main predictors of being admitted into a NH. Within the NH units, placements of the large majority of patients were accurately predicted, based on the available variables. However, for around half of the patients referred to long-term care units, the model expected placements into medium-term units, while for those admitted into short-stay units, the model returned that 29% could have benefited from being admitted into a medium-term care unit. DISCUSSION AND CONCLUSIONS: Patients' accurate placement is a highly complex and challenging process, demanding more variables than the ones available for the model here presented. Our work confirms the need to collect other type of variables to improve the placement decision process.

Esthetic Considerations In Minimally Invasive Orthognathic Surgery.

Orthognathic surgery has long been successfully utilized to correct dentofacial deformities to help facilitate improved oral function and facial esthetics. The treatment, however, has been associated with a high degree of complexity and severe postoperative morbidity. More recently, minimally invasive orthognathic surgical procedures have emerged that offer potential long-term benefits such as less morbidity, a lower inflammation response, improved postoperative comfort, and better esthetic outcomes. This article examines the concept of minimally invasive orthognathic surgery (MIOS), discussing differences from traditional maxillary Le Fort I osteotomy, bilateral sagittal split osteotomy, and genioplasty procedures. MIOS protocols are described for various aspects of both the maxilla and mandible.

Burden and severity of children's hospitalizations by respiratory syncytial virus in Portugal, 2015-2018.

BACKGROUND: Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory infection (ALRI) in young children and is of considerable burden on healthcare systems. Our study aimed to evaluate ALRI hospitalizations related to RSV in children in Portugal. METHODS: We reviewed hospitalizations potentially related to RSV in children aged <5 years from 2015 to 2018, using anonymized administrative data covering all public hospital discharges in mainland Portugal. Three case definitions were considered: (a) RSV-specific, (b) (a) plus unspecified acute bronchiolitis (RSV-specific & Bronchiolitis), and (c) (b) plus unspecified ALRI (RSV-specific & ALRI). RESULTS: A total of 9697 RSV-specific hospitalizations were identified from 2015 to 2018-increasing to 26 062 for RSV-specific & ALRI hospitalizations-of which 74.7% were during seasons 2015/2016-2017/2018 (November-March). Mean hospitalization rates per season were, for RSV-specific, RSV-specific & Bronchiolitis, and RSV-specific & ALRI, respectively, 5.6, 9.4, and 11.8 per 1000 children aged <5 years and 13.4, 22.5, and 25.9 in children aged <2 years. Most RSV-specific hospitalizations occurred in healthy children (94.9%) and in children aged <2 years (96.3%). Annual direct costs of €2.4 million were estimated for RSV-specific hospitalizations-rising to €5.1 million for RSV-specific & ALRI-mostly driven by healthy children (87.6%). CONCLUSION: RSV is accountable for a substantial number of hospitalizations in children, especially during their first year of life. Hospitalizations are mainly driven by healthy children. The variability of the potential RSV burden across case definitions highlights the need for a universal RSV surveillance system to guide prevention strategies.

Defining clinical pharmacy and support activities indicators for hospital practice using a combined nominal and focus group technique.

Background Although clinical pharmacy is a crucial part of hospital pharmacist's day-to-day activity, its performance is not usually subject to a holistic assessment. Objective To define a set of relevant and measurable clinical pharmacy and support activities key performance indicators (cpKPI and saKPI, respectively). Setting Portuguese Hospital Pharmacies. Method After a comprehensive literature review focusing on the metrics already in use in other countries, several meetings with directors of hospital pharmacies were conducted to obtain their perspectives on hospital pharmacy practices and existing metrics. Finally, five rounds with a panel of 8 experts were performed to define the final set of KPIs, where experts were asked to score each indicator' relevance and measurability, and encouraged to suggest new metrics. Main outcome measure The first Portuguese list of KPIs to assess pharmacists' clinical and support activities performance and quality in hospital pharmacies. Results A total of 136 KPIs were assessed during this study, of which 57 were included in the original list and 79 were later added by the expert panel. By the end of the study, a total of 85 indicators were included in the final list, of which 40 are considered to be saKPI, 39 cpKPI and 6 neither. Conclusion A set of measurable KPIs was established to allow for benchmarking within and between Portuguese hospital Pharmacies and to elevate professional accountability and transparency. Future perspectives include the use of both cpKPIs and saKPIs on a national scale to identify the most efficient performances and areas of possible improvement.

Vitamin D-related polymorphisms and vitamin D levels as risk biomarkers of COVID-19 disease severity.

Vitamin D is a fundamental regulator of host defences by activating genes related to innate and adaptive immunity. Previous research shows a correlation between the levels of vitamin D in patients infected with SARS-CoV-2 and the degree of disease severity. This work investigates the impact of the genetic background related to vitamin D pathways on COVID-19 severity. For the first time, the Portuguese population was characterized regarding the prevalence of high impact variants in genes associated with the vitamin D pathways. This study enrolled 517 patients admitted to two tertiary Portuguese hospitals. The serum concentration of 25 (OH)D, was measured in the hospital at the time of patient admission. Genetic variants, 18 variants, in the genes AMDHD1, CYP2R1, CYP24A1, DHCR7, GC, SEC23A, and VDR were analysed. The results show that polymorphisms in the vitamin D binding protein encoded by the GC gene are related to the infection severity (p = 0.005). There is an association between vitamin D polygenic risk score and the serum concentration of 25 (OH)D (p = 0.04). There is an association between 25 (OH)D levels and the survival and fatal outcomes (p = 1.5e-4). The Portuguese population has a higher prevalence of the DHCR7 RS12785878 variant when compared with its prevalence in the European population (19% versus 10%). This study shows a genetic susceptibility for vitamin D deficiency that might explain higher severity degrees in COVID-19 patients. These results reinforce the relevance of personalized strategies in the context of viral diseases.Trial registration: NCT04370808.

A New Methodology for Use by a Single Caregiver to Bathe Bedridden Elderly Persons Using Advanced Mechatronic Systems.

In the framework of this paper, we aimed to propose a methodology for giving baths to elderly, bedridden persons, when this task is performed by a single caregiver. Usually, two caregivers are required for nursing a bedridden patient, especially when certain important tasks are needed (e.g., bathing the patient), but this is not always possible. The entire study considers the primary user's perspective-the caregiver-who is responsible for a wide range of tasks; thus, suffering physical and psychological exhaustion over time. A physical prototype has been developed for allowing caregivers to perform tests in a life-like environment, by means of the device and the methodology. This technology, therefore, will represent an important contribution to the quality of life of caregivers. Considering an increase in the share of the elderly population and the related problems that arise in daily care, this project intends to be beneficial contemporarily. The presented methodology has been successfully tested and validated.

Ten Years after the Creation of the Portuguese National Network for Long-Term Care in 2006: Achievements and Challenges.

The Portuguese National Network for Long-term Integrated Care (Rede Nacional de Cuidados Continuados, RNCCI) was created in 2006 as a partnership between the Ministry of Health and the Ministry of Labour and Social Solidarity. The formal provision of care within the RNCCI is made up of non-profit and non-public institutions called Private Institutions of Social Solidarity, public institutions belonging to the National Health Service and for-profit-institutions. These institutions are organized by type of care in two main settings: (i) Home and Community-Based Services and (ii) four types of Nursing Homes to account for different care needs. This is the first study that assess the RNCCI reform in Portugal since 2006 and takes into account several core dimensions: coordination, ownership, organizational structure, financing system and main features, as well as the challenges ahead. Evidence suggests that despite providing universal access, Portuguese policy-makers face the following challenges: multiple sources of financing, the existence of several care settings and the sustained increase of admissions at the RNCCI, the dominance of institutionalization, the existence of waiting lists, regional asymmetries, the absence of a financing model based on dependence levels, or the difficulty to use the instrument of needs assessment for international comparison.

Impact of long term care and mortality risk in community care and nursing homes populations.

OBJECTIVES: To identify the survival time, the mortality risk factors and the individuals' characteristics associated with cognitive and physical status at discharge, among the Portuguese long-term care (LTC) populations. SETTINGS: Home-and-Community-Based Services (HCBS) and three types of Nursing Homes (NH). PARTICIPANTS: 20,984 individuals admitted and discharged in 2015. MEASUREMENTS: The Kaplan-Meier survival analysis and the Cox Proportional Hazards Models were used to study the mortality risk; the Wilcoxon signed-rank test to identify the number of individuals with cognitive and physical changes between admission and discharge; two cumulative odds ordinal logistic regressions to predict the cognitive and physical dependence levels at discharge RESULTS: The mortality rate at HCBS was 30%, and 17% at the NH, with a median survival time of 173 and 200 days, respectively. The main factors associated with higher mortality were older age, male gender, family/neighbour support, neoplasms and cognitive/physical dependence at admission. In NH/HCBS, 26%/18% of individuals improve their cognitive status, while in physical status the proportion was 38%/27%, respectively. Finally, older age, being illiterate and being classified at the lowest cognitive and physical status at admission decrease the likelihood of achieving a higher level of cognitive and physical independence at discharge. CONCLUSIONS: The adoption of a robust and complete assessment tool, the definition of guidelines to enable a periodical assessment of individuals' autonomy and the adoption of benchmark metrics allowing the comparison of results between similar units are some of the main goals to be taken into account for future developments of this care in Portugal.

Ablação de via anômala em região de cúspide coronariana esquerda / Ablation of an anomalous pathway in the region of the left coronary leaflet

INTRODUÇÃO: Vias acessórias são comumente encontradas ao longo do ânulo tricuspídeo e mitral. A região de continuidade mitroaórtica é uma rara localização, com dados significativos limitados. DESCRIÇÃO: Homem de 52 anos com palpitações taquicárdicas frequentes e ECG com pré-excitação ventricular e onda delta positiva de V1 a V6, em DII, DIII e aVF, negativa em aVR e aVL, foi encaminhado para estudo eletrofisiológico e ablação. Medidas iniciais mostraram HV 0 ms e QRS 130 ms. Estudo confirmou presença de via acessória com condução bidirecional e maior fusão atrioventricular no pólo distal do cateter decapolar inserido no seio coronariano. Realizada punção transeptal e mapeamento com cateter terapêutico de 4 mm, sendo encontrada maior fusão atrioventricular (AV) em ritmo sinusal em região anterior do anel mitral. Entretanto, pulsos de radiofrequência (30W, 60°C) aplicados neste local foram ineficazes, atingindo baixa potência. Novas aplicações com cateter terapêutico de 8 mm introduzido em veia cardíaca magna apresentaram a mesma limitação. Optado por acesso retroaórtico e mapeamento de região subvalvar de cúspide coronariana esquerda, condizente com região de continuidade mitroaórtica, que evidenciou fusão AV e precocidade de 30 ms do eletrograma ventricular em relação ao início da onda delta. Pulsos de radiofrequência (50W, 60°C) eliminaram rapidamente a condução pela via acessória nesta localização. CONCLUSÃO: Na região da continuidade mitroaórtica é rara a presença de via acessória devido à sua composição por tecido fibroso. Em situações sugestivas de via acessória anterior esquerda em que não há sucesso com aplicações de radiofrequência em ânulo mitral, é válido o mapeamento de regiões pouco usuais para o correto diagnóstico e ablação eficaz.

Ablação septal combinada a ablação de FA: uma solução elegante na insuficiência mitral pelo SAM em obstrução grave da VSVE? / Septal ablation combined with AF ablation: an elegant solution in mitral insufficiency caused by SAM in severe LVOT obstruction?

Paciente 67 anos, portadora de fibrilação atrial e cardiomiopatia hipertrófica obstrutiva, com paroxismos de fibrilação atrial sintomáticos, com redução de classe funcional e internações frequentes. Apresenta dispneia a pequenos esforços, evoluindo para dispneia em repouso quando em fibrilação atrial. Apresenta gradiente máximo de 112mmHg provocado. Atrio esquerdo 59mm, volume indexado de 136ml/m2. Presença de insuficiência mitral grave associada a movimento anterior sistólico (SAM) da válvula mitral. Após discussão prolongada optamos por abordar as veias pulmonares associado a estratégia que pudesse mitigar o impacto negativo da insuficiência mitral causada pelo SAM. A ablação foi realizada via transseptal (veias pulmonares) e retoaortica (septo interventricular), como forma de permitir lesões mais prolongadas e evitar danos ao folheto anterior da Válvula mitral. Obtivemos reducao aguda de 84mmHg para 20mmHg (intubada sob anestesia geral). A paciente foi extubada ainda em sala, encaminhada a Uti. A despeito de hematoma inguinal na retirada do introdutor e uma fase inflamatória prolongada nas primeiras 48h, a paciente recebeu alta no 5 dia de pos operatório, assintomática. Este é o primeiro relato de ablação associada em portadora de obstrução grave da via de saída de ventrículo esquerdo. Procedimentos combinados podem ser realizados por equipes experientes, dependendo do reconhecimento de possíveis complicações.

Clinical findings, lesions, and viral antigen distribution in great gray owls (Strix nebulosa) and barred owls (Strix varia) with spontaneous West Nile virus infection.

West Nile Virus (WNV) infection manifests itself clinically a nd pathologically differently in various species of birds. The clinicopathologic findings and WNV antigen tissue distribution of six great gray owls (Strix nebulosa) and two barred owls (Strix varia) with WNV infection are described in this report. Great gray owls usually live in northern Canada, whereas the phylogenetically related barred owls are native to the midwestern and eastern United States and southern Canada. Naturally acquired WNV infection caused death essentially without previous signs of disease in the six great gray owls during a mortality event. Lesions of WNV infection we re dominated by hepatic and splenic necrosis, with evidence o f disseminatedintravascular coagulation in the great gray owls. WNV antigen was widely distributed in th e organs of the great gray owls and appeared totarget endothelial cells, macrophages, and hepatocytes. The barred owls represented two sporadic cases. They had neurologic disease with mental dullness that led to euthanasia. These birds had mild to moderate lymphoplasmacytic encephalitis with glial nodules and lymphoplasmacytic pectenitis. WNV antigen was sparse in barred owls and only present in a few brain neurons and renaltubular epithelial cells. The cause of the different manifestations of WNV disease in these fairly closely related owl species is uncertain.

Ablação de via anômala esquerda em posição semi-sentada utilizando acesso radial / Ablation of left anomalous pathway in semi-sitting position using radial approach

INTRODUÇÃO: A distrofia muscular tipo cintura do quadril cursa com lesão progressiva e irreversível. Devido a fraqueza dos músculos respiratórios e orofaríngeos que podem estar presentes nesses pacientes, além de sensibilidade aumentada e prolongada a sedativos e analgésicos, potencializando o risco de aspiração e apneia de início tardio, a extubação pós procedimento pode ser dramática, podendo evoluir para insuficiência respiratória pós extubação. DESCRIÇÃO: Relatamos o caso de uma mulher obesa de 46 anos que apresentava quadro avançado, com necessidade do uso de suporte ventilatório não invasivo e decúbito lateral durante o sono. A mesma não tolerava decúbito dorsal com inclinação inferior a 60 graus e era portadora de síndrome de Wolff-Parkinson-White por via anômala lateral esquerda, refratária ao tratamento combinado de amiodarona e atenolol. Discutido com equipe de anestesiologia e considerado que intubação endotraqueal incorreria em alta probabilidade de desmame difícil, bem como provável traqueostomia pré-extubação. Após longa deliberação sobre o caso optado por realização do procedimento em posição semi- -sentada (60 graus, guiado pela orientação dada pela paciente). Pela obesidade e angulação de membros inferiores, tornou-se inviável punção femoral. Optamos então por punção radial com introdutor slender 6F/7F, que permitiu o uso de um cateter terapêutico e acesso retroaórtico via artéria radial direita. Apesar da variação da angulação da fluoroscopia, foi possível a abordagem com cateter oito mm curva média 7F com sucesso e sem intercorrências. Importante observar que o procedimento foi relativamente bem tolerado, exceto por momentos de dor em membro superior direito sugestivos de espasmo em artéria radial, prontamente revertidos com infusão em bólus de solução de nitroglicerina no introdutor radial. A paciente recebeu alta na manhã seguinte ao procedimento por protocolo institucional. CONCLUSÃO: O acesso radial deve ser considerado em raras situações e pode ser uma solução factível em casos específicos como esse.

Ablação de taquicardia atrial cicatricial pós cirurgia de cavopulmonar total com tubo extracardíaco / Ablation of scarring atrial tachycardia after total cavopulmonary surgery with extracardiac tube

Paciente de 28 anos, com antecedentes de atresia tricúspide 1B, cirurgias de Glenn bidirecional bicaval em 1994 e cavopulmonar total com tubo extracardíaco fenestrado em 2006, atualmente apresentando internações recorrentes devido a taquicardia de QRS largo com padrão de bloqueio de ramo esquerdo e eixo superior, associado a instabilidade hemodinâmica, revertida com cardioversão elétrica e refratária ao uso de amiodarona 400mg/dia e metoprolol 50mg/dia. ECG basal apresentava bradicardia sinusal, com sinais de sobrecarga de ventrículo esquerdo e eixo superior. Ecocardiograma transtorácico demonstrou fenestração do tubo ­ átrio direito de 3,5mm, câmara atrial única e ventrículo único tipo esquerdo com ventrículo direito hipoplásico, FEVE:61%, refluxo mitral moderado. RNM do coração não identificou regiões de fibrose miocárdica.Posicionado cateter decapolar no interior do tubo extra-cardíaco e na câmara atrial, através da fenestração com bainha deflectível, e cateter circular para mapeamento. Após anestesia geral, o paciente manteve estabilidade hemodinâmica às custas de 0,7mcg/kg/min de noradrenalina e 10mcg/kg/min de dobutamina. A estimulação atrial induziu taquicardia atrial com padrão de BRE semelhante à taquicardia clínica. A angiotomografia de quatro câmaras foi utilizada para reconstrução geométrica e auxílio anatômico do procedimento. O mapa de ativação demonstrou circuito da taquicardia envolvendo a parede posterior da câmara atrial. Após aplicações de RF na parede posterior ocorreu alentecimento da taquicardia e as manobras de encarrilhamento demonstraram participação da parede lateral direita e do assoalho da câmara atrial no circuito da arritmia. Durante a realização da linha de ablação com extensão da vávula tricúspide atrésica até a parede posterior atrial houve interrupção da taquicardia. No interior do tubo foram observados potenciais fracionados que foram ablacionados e os testes com estimulação atrial não induziram arritmias. O paciente recebeu alta da UTI após 24h seguida de alta hospitalar com redução da amiodarona para 200mg/dia e não houve recorrência no seguimento ambulatorial.

Punção intercostal esquerda para mapeamento epicárdico em ablação de taquicardia ventricular em paciente obeso mórbido: relato de caso / Left intercostal puncture for epicardial mapping in ablation of ventricular tachycardia in a morbidly obese patient: case report

RESUMO: Ablação epicárdica pode ser dificultada pelo acesso difícil. Propomos descrever uma técnica alternativa utilizada em um paciente obeso mórbido. Relato de caso: homem 39 anos, portador de miocardiopatia dilatada idiopática e feve de 28%, foi internado em tempestade elétrica para ablação de TV. O mapeamento endocárdico evidenciou baixa voltagem em regiões ínfero-basal e apical endocárdicas do VE. Foram induzidas três morfologias de TV e após insucesso na ablação endocárdica, optado por mapeamento epicárdico. A primeira tentativa de acesso via subxifóide por punção com agulha Tuohy de 5 polegadas e, em sequência, por visão direta (janela cirúrgica) não resultaram em sucesso, devido à extensão do tecido adiposo. Realizado então punção entre 4° e 5° espaço intercostal esquerdo com acesso satisfatório ao epicárdio e mapeamento com cateter Livewire 2-2-2. Observada presença de áreas de baixa voltagem em região apical. Realizadas aplicações de radiofrequência (30w, 43°c) com cateter irrigado em áreas de interesse. Ao término da ablação, realizada nova estimulação sem indução de taquicardias sustentadas. Evoluiu satisfatoriamente do ponto de vista hemodinâmico, com desmame progressivo de drogas vasoativas e extubação no 2° po. porém intercorreu com infecção por covid-19 e pneumonia bacteriana associada no 5° po, retornando à ventilação mecânica, instabilidade hemodinâmica e posteriormente novos episódios de TV sustentada, evoluindo a óbito no 11° dia pós ablação. Discussão: o acesso epicárdico subxifóide anterior ou inferior é a via de escolha para ablação de arritmias ventriculares com circuito de reentrada epicárdico. Não foi encontrada na literatura descrição de acesso epicárdico através do espaço intercostal, como descrito neste caso, o que tornou viável a ablação da taquicardia ventricular. Esta abordagem surge como mais uma técnica para o manejo de cenários em que o acesso epicárdico por via subxifóide não é possível. REFERÊNCIAS: J Cardiovasc Electrophysiol,Vol 20, pp. 710-713, June 2009/Europace (2007) 9, 212­215/ UPtoDate ­ Overview of catheter ablation of cardiac arrhythmias/Europace (2012) 14, ii13­ii18/ Circulation. Volume 110, Issue 10, 7 September 2004; Pages 1197-1201.

Ablação de via acessória dentro de uma veia cava superior esquerda persistente: relato de caso / Accessory pathway ablation within a persistent left superior vena cava: case report

INTRODUÇÃO: O pleno conhecimento da anatomia vascular torácica é de suma importância para os profissionais envolvidos na realização de procedimentos invasivos. A persistência da veia cava superior esquerda (VCSE) é uma anomalia congênita incomum que pode coexistir com as vias atrioventriculares acessórias, sendo seu diagnóstico, na maioria das vezes, incidental. A VCSE é incorporada na formação do seio coronário durante o desenvolvimento normal, porém, se persistente, pode fornecer acesso direto ao seio coronário através da veia subclávia esquerda. De acordo com a literatura, a incidência da VCSE varia entre 0,3-0,5% na população geral, podendo atingir até 10% naqueles pacientes sabidamente portadores de alguma outra anomalia congênita cardíaca, e a sua correlação com a Síndrome de Wolf Parkinson White (WPW) pode chegar até a 4,5% nos pacientes submetidos ao estudo eletrofisiológico. DESCRIÇÃO: Paciente de 29 anos, masculino, esportista e sem comorbidades foi encaminhado para o laboratório de eletrofisiologia invasiva com diagnóstico de pré-excitação ventricular (Figura 1). Durante estudo eletrofisiológico foi observado veia cava superior esquerda persistente, através da venografia do seio coronário (Figura 2), associado a via acessória lateral esquerda de condução bidirecional. O mapeamento com cateter de ablação, de forma convencional, no interior da VCSE demonstrou maior fusão AV correspondente a parede lateral do átrio esquerdo (Figura 3). A ablação nesse local, durante estimulação ventricular, eliminou a condução retrógrada pela via acessória. Novo mapeamento, após punção transeptal, foi realizado na região lateral esquerda do anel mitral com evidencia de fusão AV (Figura 4). Nesse local, nova aplicação de radiofrequência eliminou a condução anterógrada pela via acessória. ECG pós ablação sem presença de pré-excitação (Figura 5). CONCLUSÃO: A VCSE pode ser usada como vantagem para mapeamento e ablação de uma via acessória do lado esquerdo, apesar do seio coronário dilatado. Descrevemos o caso de um paciente com diagnóstico de WPW e VCSE submetido a ablação bem-sucedida realizada dentro da veia cava superior esquerda e na região lateral esquerda do anel mitral.