Cardiorespiratory and muscle oxygenation responses to voluntary hypoventilation at low lung volume in upper body repeated sprints.

PURPOSE: To investigate the impact of voluntary hypoventilation at low lung volumes (VHL) during upper body repeated sprints (RS) on performance, metabolic markers and muscle oxygenation in Brazilian Jiu-Jitsu (BJJ) athletes. METHODS: Eighteen male well-trained athletes performed two randomized RS sessions, one with normal breathing (RSN) and another with VHL (RS-VHL), on an arm cycle ergometer, consisting of two sets of eight all-out 6-s sprints performed every 30 s. Peak (PPO), mean power output (MPO), and RS percentage decrement score were calculated. Arterial oxygen saturation (SpO2), heart rate (HR), gas exchange, and muscle oxygenation of the long head of the triceps brachii were continuously recorded. Blood lactate concentration ([La]) was measured at the end of each set. Bench press throw peak power (BPPP) was recorded before and after the RS protocol. RESULTS: Although SpO2 was not different between conditions, PPO and MPO were significantly lower in RS-VHL. V ˙ E, HR, [La], and RER were lower in RS-VHL, and VO2 was higher in RS-VLH than in RSN. Muscle oxygenation was not different between conditions nor was its pattern of change across the RS protocol influenced by condition. [La] was lower in RS-VHL than in RSN after both sets. CONCLUSION: Performance was significantly lower in RS-VHL, even though SPO2 was not consistent with hypoxemia. However, the fatigue index was not significantly affected by VHL, nor was the neuromuscular upper body power after the RS-VHL protocol. Additionally, [La] was lower, and oxygen consumption was higher in RS-VHL, suggesting a higher aerobic contribution in this condition.

Mediating Effect of Motivation on the Relationship of Fitness with Volitional High-Intensity Exercise in High-School Students.

We aimed to investigate the relationship between physical fitness and motivation in adolescents and analyze if the associations of physical fitness with volitional exercise intensity in adolescents are mediated by motivation. The participants were 108 adolescents (58 girls 16.0 ± 0.92 years). Cardiorespiratory fitness (CRF) was assessed using the Yo-YoITL1, and the push-up test was used to evaluate strength. Body composition was measured by bioelectrical impedance analysis. The intervention was applied in the first 10-15 min of each Physical Education class (PEC), twice a week, for 16 weeks and ranged from 14 to 20 all-out bouts intervals, adopting a 2:1 work to rest ratio. A cut-point of ≥90% of the maximal heart rate (HR) was used as a criterion for satisfactory compliance with high-intensity exercise. Volition intensity was assessed through a forearm wearable plethysmography heart rate sensor to ensure compliance with the exercise stimulus at the predetermined target HR zone. Motivation was estimated with a validated questionnaire (BREQ-3). Mediation effects were estimated using bootstrapped 95% confidence intervals and were deemed significant if zero was not included in the intervals, and values below 0.05 were considered to indicate statistical significance. The mediation analysis revealed a non-significant indirect effect of physical fitness through motivation on exercise intensity, specifically on CRF (B = -0.0355, 95% BootCI [-0.5838; 0.4559]), muscular fitness (B = -0.7284, 95% BootCI [-2.0272; 0.2219]) and body fat (B = 0.5092, 95% BootCI [-0.4756; 1.6934]). These results suggest that high or low values of motivation did not increase or decrease volitional high-intensity exercise, and lower levels of fitness (CRF, muscular and body fat) were associated with higher volitional exercise intensity. These findings highlight the need for regular moderate-to-vigorous physical exercise for maintaining or improving physical fitness, regardless of motivation regulations, and emphasize the importance of new strategies in PEC with acute vigorous-intensity activities that retain the health-enhancing effects.

Habitual physical activity minimizes healthcare costs resulting from comorbidities among adults with cardiovascular diseases.

BACKGROUND: Habitual physical activity (HPA) can be used as a non-pharmacological strategy to prevent and control chronic diseases, as well as playing a role in minimizing healthcare costs. OBJECTIVE: To verify the impact of HPA on healthcare costs at different levels of care, over 24 months, in an adult population with cardiovascular diseases (CVD), including individuals with or without comorbidities. METHODS: Two-hundred and seventy-eight adults with CVD, aged between 30 and 65 years, participated in the study. Information on healthcare costs was obtained from medical records and included primary, secondary, and tertiary levels. Comorbidities such as diabetes, dyslipidemia, arterial hypertension, and obesity were registered. HPA was measured using the Baecke questionnaire. Comparisons between groups were performed using Student's t (

Worldwide snapshot of trauma team structure and training: an international survey.

INTRODUCTION: Trauma teams (TTs) are a key tool in trauma care, as they bring a multidisciplinary approach to the trauma patient, improving outcomes. Excellent teamwork (TW) requires not only individual skills but also training at non-technical skills (NTS). Although there is evidence supporting TTs, there is little information regarding how they are organized and trained. With this study, we intend to assess the reality of TTs all over the world, focusing on how they are organized and trained. MATERIALS AND METHODS: We composed a 42-question sheet on Google Forms, in four different languages (English, Polish, Portuguese, and Spanish). The questions regarded the respondents' background, and their respective hospitals' trauma patient management, TT features and its training, NTS and TW. The survey was shared on social media, through the International Assessment Group of Online Surgical & Trauma Education community, and the European Society of Trauma and Emergency Surgery. Statistical analysis was performed on Statistical Package for the Social Sciences (SPSS®) version 27. RESULTS: We obtained 296 answers from 52 different countries, with 6 having at least 10 answers (Brazil, Portugal, Poland, Spain, Italy, and USA). While the majority of the respondents (97%) agreed that TTs can improve outcomes, only 61% have a TT in their hospital, with 69% of these being dedicated TTs. General surgery (76%), trauma surgery (68%), and anesthesia (66%) were the three most common specialties in the teams. Teams performed briefings and debriefings with a frequency of, at least, "often" in only 49% and 38%, respectively. Only 50% and 33% of the respondents stated that their hospital provided trauma management courses focusing on individual technical skills, and TT training courses, respectively. The Advanced Trauma Life Support (85%), the Definitive Surgical and Anesthetic Trauma Care (38%), and the European Trauma Course (31%) were the three trauma management courses of choice. Regarding TT training courses, the European Trauma Course (52%) and local/in-house (42%) courses were the most common ones. Most participants (93%) stated that NTS were highly important in trauma care. However, only 60% of the respondents had postgraduate training on NTS and TW, and only 24% had this type of training on an undergraduate level. CONCLUSION: The number of TTs worldwide does not match their relevance in trauma care. Institutions are not providing enough trauma courses, particularly TT training courses and NTS teaching. Implementing TT should include promotion of team courses, as well as team briefings and debriefings.

The Mediating Effect of Physical Fitness and Dietary Intake on the Relationship of Physical Activity with Body Composition in High School Students.

We aimed to investigate the relationship between physical activity (PA) and health-related physical fitness (PF) in adolescents and analyze if the associations of PA with body composition (BC) in adolescents are mediated by physical fitness or energy intake (EI). The participants were 236 adolescents (140 girls 16.1 ± 0.92 years). Cardiorespiratory fitness (CRF) was assessed using the Yo-YoITL1, and the push-up test was used to evaluate strength. BCs were measured on an electrical weight scale. Triaxial accelerometers were used to determine PA levels and moderate-to-vigorous PA (MVPA) levels. EI was estimated with a validated questionnaire. Mediation effects were estimated using bootstrapped 95% confidence intervals and were deemed significant if zero was not included in the intervals. The mediation analysis revealed an indirect effect of MVPA only through PF on BC, specifically through CRF on body fat (B = -0.0146, 95% BootCI (-0.0219; -0.0076)) and on lean body mass (B = 0.0096, 95% BootCI (0.0049; 0.0152)), as well as through upper body strength on body fat (B = -0.012, 95% BootCI (-0.0171; -0.0072)) and on lean body mass (B = 0.0059, 95% BootCI (0.003; 0.0095)). These results suggest that PA of at least a moderate intensity is relevant to BC and health-related PF in adolescents, regardless of the EI.

High-intensity interval training in high-school physical education classes: Study protocol for a randomized controlled trial.

BACKGROUND: School and Physical Education classes (PEC) are privileged spaces, promoters of positive changes for the rest of life. High-Intensity Interval Training (HIIT) is presented as a time-efficient alternative to aerobic training, as it leverages the number of exercise participants, resulting in improvements in health outcomes. Despite the widespread interest in the advantages that the HIIT methodology reveals, there is a lack of randomized controlled studies investigating the impact on adolescents, mainly adressing adolescents' environment, such as schools. This study aims to evaluate the utility of a HIIT program integrated into high-school PEC, as a strategy that allows students to improve their Physical Fitness, Physical Activity (PA) level, and Motivation for Exercise. METHODS: This study is a two-arm randomized controlled trial design with adolescents from the 10th to 12th grades (15-17 years). The trial will aim to recruit 300 students from 1 secondary school. The HIIT sessions will be applied in the first 10-15 min of each PEC, twice a week, for 16 weeks, ranged from 14 to 20 all-out bouts intervals, adopting a 2:1 work to rest ratio. A cut-point of ≥ 90% of maximal heart rate will be a criterion for satisfactory compliance to high-intensity exercise. A rated perceived exertion scale will be measured in each exercise session to estimate effort, fatigue, and training load. The control group will continue the usual programmed PEC. Study outcomes will be measured at baseline and after the HIIT program. Cardiorespiratory fitness is the primary outcome. Secondary outcomes include: muscular fitness, PA and motivation for exercise. DISCUSSION: HIIT protocols presents wide applicability in PEC and great adaptation to the facilities. The authors aim to provide novel HIIT protocols for schools.

Morphological Changes of the Hip Commonly Associated With Femoroacetabular Impingement Are Not Correlated With Rotational Range of Hip Motion in Elite Soccer Athletes.

BACKGROUND: Morphological changes characteristic of femoroacetabular impingement (FAI) are common in soccer players. However, the clinical relevance of such anatomical variations is still not well-defined. HYPOTHESIS: We hypothesized that high alpha angle values and/or acetabular retroversion index (ARI) are correlated with rotational range of motion (ROM) of the hip and that there are clinical-radiological diferences between the dominant lower limb (DLL) and nondominant lower limb (NDLL) in professional soccer players. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 59 male professional soccer players (average age 25.5 years, range 18-38 years) were evaluated in the preseason. As main outcome measures, we evaluated the alpha angle and the ARI and hip IR and ER ROM with radiographic analysis. RESULTS: The measurements taken on DLL and NDLL were compared and a significant difference was found between the sides in the ER (P = 0.027), where the DLL measures were 1.54° (95% CI, 0.18-2.89) greater than the NDLL. There were no significant differences between the sides in the measures of IR (P > 0.99), total ROM (P = 0.07), alpha angle (P = 0.250), and ARI (P = 0.079). The correlations between the rotation measurements and the alpha angle in each limb were evaluated and the coefficient values showed no correlation; so also between the ARI and rotation measures. CONCLUSION: Morphological changes of the femur or acetabulum are not correlated with hip IR and ER ROM in male professional soccer players. ER on the dominant side was greater than on the nondominant side. There was no significant difference in the other measurements between sides. CLINICAL RELEVANCE: In clinical practice, it is common to attribute loss of hip rotational movement to the presence of FAI. This study shows that anatomical FAI may not have a very strong influence on available hip rotational movement in professional soccer athletes.

Comparison between the Dominant and Non-dominant Sides of Athletes with Groin Pain.

Objective To compare the difference in range of motion (ROM) between the dominant and nondominant hips of the athletes and to correlate the results with groin pain, as well as to compare the differences in ROM among the main hip injuries. Methods The participants included 75 athletes, 56 males and 19 females, aged between 20 and 46 years old, who were diagnosed with hip injury. These individuals were subdivided according to the pathologies (femoroacetabular impact or labral lesion, adductor and pubic lesions and trochanteric syndrome) and characteristics of each hip were analyzed. Results A total of 150 hips (right and left) were measured for the present analysis. When comparing the ROM of the injured hip with the healthy hip, no statistically significant differences were found. There were also no significant differences between the amplitudes of hip movement when the main pathologies were compared. Conclusion The present study did not find differences in ROM rotation between the various pathologies of the hip.

Within-Session and Between-Session Reliability, Construct Validity, and Comparison Between Individuals With and Without Neck Pain of Four Neck Muscle Tests.

BACKGROUND: A variety of tests have been proposed to measure the performance of neck flexor muscles, but head-to-head comparisons hardly have been documented. OBJECTIVE: To compare reliability indexes, construct validity, and ability to discriminate between individuals with and without neck pain of 4 muscle tests (deep neck flexors endurance test [DNFET]; 2 variations of the craniocervical flexion test [CCFT1 and CCFT2]; and dynamometry). DESIGN: Reliability and validity study. SETTING: General community. PARTICIPANTS: A total of 66 participants, 33 with chronic idiopathic neck pain (mean ± standard deviation pain intensity: 3.2 ± 1.9) and 33 without neck pain, from the general population. METHODS/MAIN OUTCOME: Neck muscle functioning was assessed with the CCFT1, the CCFT2, the DNFET, and dynamometry on 2 separate sessions. Participants with neck pain also were assessed for pain intensity, disability, pain catastrophizing, and fear of movement. RESULTS: Relative reliability of all tests was at least moderate (intraclass correlation coefficient ≥ 0.62), whereas measurement error was high, particularly for the DNFET (95% minimum detectable change ≥ 23.00 seconds). All tests showed moderate correlation (r ≥ 0.3) with at least 2 pain-related measures and moderate-to-strong correlations with each other. Principal component analysis retained 2 factors explaining 68%-73% of the variance of the 4 muscle tests. Significant differences between groups were found for the DNFET and dynamometry (P < .05). CONCLUSION: The reliability indexes suggest that the DNFET and the CCFT may be more appropriate for group comparisons than for individual comparisons. The 4 tests seem to have construct validity, but they also seem to measure slightly different constructs. LEVEL OF EVIDENCE: III.

[Analysis of the intra-hospital attending of ventricular fibrilation/ventricular taquicardia simulated events]. / Análise do atendimento intra-hospitalar de eventos simulados de fibrilação ventricular/taquicardia ventricular.

OBJECTIVE: To analyze the time intervals between the beginning of the Ventricular Fibrilation/Ventricular Taquicardia (VF/VT) and the main procedures made. METHODS: Twenty VF/VT simulations were performed and filmed in a hospital environment, using a static mannequin, on random days at random times. All teams had the same level of skills. The times (in sec.) related to basic life support (BLS) - arrival of the team (AT), confirmation of the arrest (CAT), beginning of the CPR (IT) and the times related to the advanced life support (ALS) - 1st defibrillation (DT), 1st dose of adrenalin (AT) and orotracheal intubation (OTIT). The variables were analyzed and compared in two groups: intensive care unit (ICU) and wards with telemetry (TLW). RESULTS: The results in both groups was in that order (GW x ICU ) - AT (70.2+38.7 x 38.6+49.2); CCA (89.4+57.1 x 71+63.9); SC (166.8+81.1 x 142+66.2); FD (282.5+142.8 x 108.4+52.5); FE (401.4+161.7 x 263.3+122.8) e OI (470.3+150.6 x 278.8+98.8). Shows the comparison of the average times between the two groups. CONCLUSION: The differences noted in relation to DT, AT and OTIT favorable to ICU are associated to the facility of performance of the ALS maneuvers in such environment. The BLS-related times were similar in both groups, which reinforce the need for the use of semi-automatic defibrillators, even in a hospital environment.

Comparison between the Dominant and Non-dominant Sides of Athletes with Groin Pain / Comparação funcional entre membro dominante e não dominante em atletas com dor inguinal

Abstract Objective To compare the difference in range of motion (ROM) between the dominant and nondominant hips of the athletes and to correlate the results with groin pain, as well as to compare the differences in ROM among the main hip injuries. Methods The participants included 75 athletes, 56 males and 19 females, aged between 20 and 46 years old, who were diagnosed with hip injury. These individuals were subdivided according to the pathologies (femoroacetabular impact or labral lesion, adductor and pubic lesions and trochanteric syndrome) and characteristics of each hip were analyzed. Results A total of 150 hips (right and left) were measured for the present analysis. When comparing the ROM of the injured hip with the healthy hip, no statistically significant differences were found. There were also no significant differences between the amplitudes of hip movement when the main pathologies were compared. Conclusion The present study did not find differences in ROM rotation between the various pathologies of the hip.

Resumo Objetivo Comparar a diferença do arco de movimento (ADM) entre o quadril com lesão e o não lesionado de atletas com as principais patologias femoroacetabulares. Além disso, analisar a diferença da ADM do quadril em cada patologia considerada. Métodos Os participantes do presente estudo foram 75 atletas de diversas modalidades esportivas, sendo 56 mulheres e 19 homens, com idades entre 20 e 46 anos, os quais tinham diagnóstico de lesão do quadril. Esses indivíduos foram subdivididos em três grupos de acordo com as patologias (impacto femoroacetabular ou lesão labral, pubalgia ou lesão dos adutores e síndrome trocantérica) e as características de cada quadril foram analisadas. Resultados Um total de 150 quadris (direito e esquerdo) foram mensurados para a presente análise. Comparou-se o ADM do quadril lesado e do quadril saudável de cada atleta e não foram encontradas diferenças estatísticas. Da mesma forma, não houve diferença significativa entre a ADM do quadril entre as principais injúrias. Conclusão O presente estudo não encontrou diferenças no arco de movimento entre o quadril lesionado e o contralateral, bem como não houve diferença na amplitude dos movimentos entre as patologias femoroacetabulares analisadas.

Preliminary in-hospital experience with a fully automatic external cardioverter-defibrillator.

BACKGROUND: Ventricular fibrillation (VF) and ventricular tachycardia (VT) are frequently present as initial rhythms during in-hospital cardiac arrest. Although ample evidence exists to support the need for rapid defibrillation, the response to in-hospital cardiac arrest remains without major advances in recent years. The delay between the arrhythmic event and intervention is still a challenge for clinical practice. OBJECTIVE: To analyze the performance and safety of in-hospital use of a programmable, fully automatic external cardioverter-defibrillator (AECD). METHODS: We conducted a prospective study at the Emergency Department of a university hospital. A total of 55 patients considered to be at risk of sustained VT/VF were included. Patients underwent monitoring of their cardiac rhythm by the AECD. Upon detection of a ventricular tachyarrhythmia, the AECD was programmed to automatically deliver shock therapy. RESULTS: We recorded 19 episodes of VT/VF in 3 patients. The median time between the beginning of the arrhythmia and the first defibrillation was 33.4 s (21-65 s). One episode of spontaneous reversion of VT was documented 20 s after its origin and shock therapy was aborted. The defibrillation success was 94.4% (17/18) for the first shock and 100% (1/1) for the second shock. No case of inappropriate shock discharge was registered during the study period. CONCLUSION: The AECD has the feasibility to combine long-term monitoring with automatic defibrillation safely and effectively. It presents the possibility of providing rapid identification of, and response to, in-hospital ventricular tachyarrhythmias.

Brazilian Sepsis Epidemiological Study (BASES study).

INTRODUCTION: Consistent data about the incidence and outcome of sepsis in Latin American intensive care units (ICUs), including Brazil, are lacking. This study was designed to verify the actual incidence density and outcome of sepsis in Brazilian ICUs. We also assessed the association between the Consensus Conference criteria and outcome METHODS: This is a multicenter observational cohort study performed in five private and public, mixed ICUs from two different regions of Brazil. We prospectively followed 1383 adult patients consecutively admitted to those ICUs from May 2001 to January 2002, until their discharge, 28th day of stay, or death. For all patients we collected the following data at ICU admission: age, gender, hospital and ICU admission diagnosis, APACHE II score, and associated underlying diseases. During the following days, we looked for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock criteria, as well as recording the sequential organ failure assessment score. Infection was diagnosed according to CDC criteria for nosocomial infection, and for community-acquired infection, clinical, radiological and microbiological parameters were used. RESULTS: For the whole cohort, median age was 65.2 years (49-76), median length of stay was 2 days (1-6), and the overall 28-day mortality rate was 21.8%. Considering 1383 patients, the incidence density rates for sepsis, severe sepsis and septic shock were 61.4, 35.6 and 30.0 per 1000 patient-days, respectively. The mortality rate of patients with SIRS, sepsis, severe sepsis and septic shock increased progressively from 24.3% to 34.7%, 47.3% and 52.2%, respectively. For patients with SIRS without infection the mortality rate was 11.3%. The main source of infection was lung/respiratory tract. CONCLUSION: Our preliminary data suggest that sepsis is a major public health problem in Brazilian ICUs, with an incidence density about 57 per 1000 patient-days. Moreover, there was a close association between ACCP/SCCM categories and mortality rate.

Hemodynamic Effects of Noninvasive Ventilation in Patients with Venocapillary Pulmonary Hypertension.

Background: The hemodynamic effects of noninvasive ventilation with positive pressure in patients with pulmonary hypertension without left ventricular dysfunction are not clearly established. Objectives: Analyze the impact of increasing airway pressure with continuous positive airway pressure on hemodynamic parameters and, in particular, on cardiac output in patients with variable degrees of pulmonary hypertension. Methods: The study included 38 patients with pulmonary hypertension caused by mitral stenosis without left ventricular dysfunction or other significant valvulopathy. The hemodynamic state of these patients was analyzed in three conditions: baseline, after continuous positive pressure of 7 cmH2O and, finally, after pressure of 14 cmH2O. Results: The population was composed of predominantly young and female individuals with significant elevation in pulmonary arterial pressure (mean systolic pressure of 57 mmHg). Of all variables analyzed, only the right atrial pressure changed across the analyzed moments (from the baseline condition to the pressure of 14 cmH2O there was a change from 8 ± 4 mmHg to 11 ± 3 mmHg, respectively, p = 0.031). Even though there was no variation in mean cardiac output, increased values in pulmonary artery pressure were associated with increased cardiac output. There was no harmful effect or other clinical instability associated with use application of airway pressure. Conclusion: In patients with venocapillary pulmonary hypertension without left ventricular dysfunction, cardiac output response was directly associated with the degree of pulmonary hypertension. The application of noninvasive ventilation did not cause complications directly related to the ventilation systems.

Immediate and late results of percutaneous mitral valve repair in patients with mitral stenosis.

BACKGROUND: The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE: To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD: A total of 330 consecutive patients were followed-up by 47 +/- 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS: The procedure was successful in 305 cases (92.4%). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3%) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 +/- 26-month follow-up, 67 events occurred. The probability of survival without events was of 95% in one year, 75% in five years and 61% in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION: Mitral valve repair by balloon catheter is an effective procedure, as 60% patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patient's age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure.

Anticoagulação na insuficiência cardíaca e valvopatias / Anticoagulation in heart failure and valvulopathies

A insuficiência cardíaca e as valvopatias são entidades patológicas representativas de expressiva parte do universo das cardiopatia sem nosso meio. No curso de sua evolução, têm como denominador comum o risco de desenvolvimento de eventos tromboembólicos,responsáveis muitas vezes por graves sequelas neurológicas. Os mecanismos descritos por Virchov (hipercoagulabilidade, estase, e alteração da função do endotélio - parede vascular) estão presentes nestes pacientes e explicam a maior incidência desses eventos. Embora a compreensão do risco seja algo claro na literatura atual, menos claro é o real benefício da anticoagulação e ou antiagregação plaquetária para prevenção dos eventos tromboembólicos nessa população. Particularmente na presença de fibrilação atrial, ambas as entidades expõem os pacientes ao risco de fenômenos embólicos. Na eventual presença de próteses valvares, este risco pode ser ainda superior. A opção por uma terapia anticoagulante para a prevenção de um evento trombótico ou embólico deve ser baseada na avaliação particular do risco de um paciente e nos possíveis benefícios que a anticoagulação pode oferecer. Portanto, a prevenção do tromboembolismo deve fazer parte do manejo dos pacientes portadores de insuficiência cardíaca e doença valvar. Nesse artigo, procuramos revisar sumariamente aspectos epidemiológicos e os mecanismos envolvidos na gênese do risco trombótico desses pacientes e buscamos com base em estudos clínicos relevantes, meta-análises, revisões de literatura e diretrizes vigentes, identificar as situações de benefício da terapia antitrombóticanos pacientes com IC e valvopatias.

Heart failure (HF) and cardiac valvular disease are majorrepresentatives of the pathological cardiovascular diseases. In thenatural course of these diseases, they share a major denominator,the risk of thromboembolism, which in turn are responsible forsevere neurological damage. The mechanisms described by Virchov(hypercoagulability, stasis and alteration of the endotheliumfunction - the vascular wall) are present in these patients and explainthe higher incidence of these events. Although the understandingof the risk of thromboembolism is clear in the literature, it is notwell known the real benefit of anticoagulation and/or antiplatelettherapy for the prevention of thromboembolic events in patients atrisk. Particularly, in the presence of atrial fibrillation, both entitiesexpose these individuals to the risk of severe thromboembolism.When valvular prosthesis are present, this risk can be increasedseveral times. The choice of the best regimen of the anticoagulantand antiplatelet therapies to the prevention of thromboembolismshould be based in the individual risk of patients and in the possiblebenefits offered by the anticoagulation. As both heart failure andcardiac valvular diseases share the necessity of anticoagulation,this article reviews the epidemiology and mechanisms involved inthe genesis of thrombotic risk in these patients. Relevant clinicaltrials, meta-analysis, literature reviews and current guidelines arethe foundation to identify the benefits of antithrombotic therapy inthis population.

Hemodynamic Effects of Noninvasive Ventilation in Patients with Venocapillary Pulmonary Hypertension / Efeitos Hemodinâmicos da Ventilação não Invasiva em Pacientes com Hipertensão Pulmonar Venocapilar

Background: The hemodynamic effects of noninvasive ventilation with positive pressure in patients with pulmonary hypertension without left ventricular dysfunction are not clearly established. Objectives: Analyze the impact of increasing airway pressure with continuous positive airway pressure on hemodynamic parameters and, in particular, on cardiac output in patients with variable degrees of pulmonary hypertension. Methods: The study included 38 patients with pulmonary hypertension caused by mitral stenosis without left ventricular dysfunction or other significant valvulopathy. The hemodynamic state of these patients was analyzed in three conditions: baseline, after continuous positive pressure of 7 cmH2O and, finally, after pressure of 14 cmH2O. Results: The population was composed of predominantly young and female individuals with significant elevation in pulmonary arterial pressure (mean systolic pressure of 57 mmHg). Of all variables analyzed, only the right atrial pressure changed across the analyzed moments (from the baseline condition to the pressure of 14 cmH2O there was a change from 8 ± 4 mmHg to 11 ± 3 mmHg, respectively, p = 0.031). Even though there was no variation in mean cardiac output, increased values in pulmonary artery pressure were associated with increased cardiac output. There was no harmful effect or other clinical instability associated with use application of airway pressure. Conclusion: In patients with venocapillary pulmonary hypertension without left ventricular dysfunction, cardiac output response was directly associated with the degree of pulmonary hypertension. The application of noninvasive ventilation did not cause complications directly related to the ventilation systems. .

Fundamento: Os efeitos hemodinâmicos da ventilação não invasiva com pressão positiva em pacientes com hipertensão pulmonar sem disfunção ventricular esquerda não estão bem estabelecidos. Objetivos: Analisar o impacto da pressurização aérea crescente através da pressão positiva contínua das vias aéreas nos parâmetros hemodinâmicos e, principalmente, no débito cardíaco de pacientes com graus variáveis de hipertensão pulmonar. Métodos: Foram incluídos 38 pacientes com hipertensão pulmonar causada por estenose mitral sem disfunção ventricular esquerda ou outra valvopatia significativa. O estado hemodinâmico deses pacientes foi estudado em três condições: basal, após uso de pressão positiva contínua de 7 cmH2O e , finalmente, após pressão de 14 cmH2O. Resultados: A população foi composta por indivíduos predominantemente jovens, do sexo feminino e com elevação significativa da pressão arterial pulmonar (pressão sistólica média de 57 mmHg). De todas as variáveis analisadas, apenas a pressão de átrio direito apresentou variação ao longo dos momentos estudados (da condição basal para a de pressão de 14 cmH2O houve aumento de 8 ± 4 mmHg para 11 ± 3 mmHg, respectivamente, p = 0,031). Apesar de não ter havido variação do valor médio do débito cardíaco, valores mais elevados de pressões na artéria pulmonar estiveram associados ao aumento do débito cardíaco. Não houve efeito deletério ou qualquer instabilidade clínica associada ao uso da pressurização das vias aéreas. Conclusão: Em pacientes com hipertensão venocapilar pulmonar sem disfunção ventricular esquerda, a resposta ...

Resultados imediatos e tardios da valvoplastia mitral percutânea em pacientes com estenose mitral / Immediate and late results of percutaneous mitral valve repair in patients with mitral stenosis

FUNDAMENTO: A análise dos resultados imediatos e a longo prazo da valvoplastia mitral por catéter-balão (VMCB) ainda são escassos na literatura, principalmente no contexto nacional. OBJETIVO: Avaliar os resultados imediatos e tardios dos pacientes submetidos à VMCB. MÉTODO: 330 pacientes consecutivos foram seguidos por 47 ± 36 meses (até 126 meses). Análises univariadas e multivariadas avaliaram os fatores relacionados ao sucesso do procedimento, à reestenose e aos eventos tardios (morte ou necessidade de nova intervenção na valva mitral). O método de Kaplan-Meier estimou a sobrevida livre de eventos. RESULTADOS: Houve sucesso do procedimento em 305 (92,4 por cento). A anatomia valvar mitral foi o principal preditor de sucesso imediato do procedimento. Durante o seguimento, a reestenose ocorreu em 77 (23,3 por cento) pacientes e esteve associada a menor área valvar mitral e maior calcificação antes do procedimento. Ocorreram 67 eventos em um tempo médio de seguimento de 38 ± 26 meses. A probabilidade de sobrevida livre de eventos foi de 95 por cento em 1 ano, 75 por cento aos 5 anos e 61 por cento aos 10 anos. Os preditores de sobrevida livre de eventos foram: idade, escore ecocardiográfico e resultado imediato do procedimento. CONCLUSÃO: A VMCB é um procedimento efetivo, sendo que mais de 60 por cento dos pacientes estiveram livres de eventos ao final do seguimento. A condição anatômica da valva mitral e a idade do paciente foram os melhores preditores da sobrevida livre de eventos e devem ser levados em consideração na seleção dos pacientes para VMCB.

BACKGROUND: The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE: To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD: A total of 330 consecutive patients were followed-up by 47 ± 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS: The procedure was successful in 305 cases (92.4 percent). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3 percent) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 ± 26-month follow-up, 67 events occurred. The probability of survival without events was of 95 percent in one year, 75 percent in five years and 61 percent in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION: Mitral valve repair by balloon catheter is an effective procedure, as 60 percent patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patient's age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure. (Arq Bras Cardiol 2010; 94(3):383-390)

Análise do atendimento intra-hospitalar de eventos simulados de fibrilacão ventricular/taquicardia ventricular / Analysis of the intra-hospital attending of ventricular fibrilation/ventricular taquicardia simulated events

OBJETIVO: Analisar os intervalos de tempo entre o início da Fibrilacão Ventricular/Taquicardia Ventricular (FV/TV) e os principais procedimentos realizados. MÉTODOS: Foram realizadas e filmadas 20 simulacões de FV/TV em ambiente hospitalar, utilizando-se manequim estático, ocorridas em dia e hora aleatórios. Todas as equipes tinham o mesmo nível de habilidades. Foram analisados os tempos (em s) relativos ao suporte básico de vida (SBV) - chegada da equipe (TC) confirmacão da parada (TCP) início da RCP (TI) e os tempos relativos ao suporte avancado de vida (SAV) - 1º desfibrilacão (TD) 1º dose de adrenalina (TA) e intubacão orotraqueal (TIOT). As variáveis foram analisadas e comparadas em dois grupos: unidade de cuidados intensivos (UCI) e enfermarias com telemetria (ETL). RESULTADOS: ETL x UCI respectivamente - TC (70,2+38,7 x 38,6+49,2); TCP (89,4+57,1 x 71+63,9); TI (166,8+81,1 x 142+66,2); TD (282,5+142,8 x 108,4+52,5); TA (401,4+161,7 x 263,3+122,8) e TIOT (470,3+150,6 x 278,8+98,8). Apresenta a comparacão das médias de tempos entre os dois grupos. CONCLUSAO: As diferencas observadas em relacão a TD, TA e TIOT favoráveis à UCI estão associadas às facilidades de realizacão das manobras de SAV nesse ambiente. Os tempos relacionados ao SBV foram semelhantes nos dois grupos, reforcando a necessidade do uso de desfibriladores semi-automáticos mesmo em ambiente hospitalar.

Efeitos hemodinâmicos da ventilação não invasiva com pressão positiva em pacientes com estenose mitral sintomática / Hemodynamic effects of positive pressure noninvasive ventilation in patients with symptomatic mitral stenosis

Introdução: O uso de pressão positiva contínua em vias aéreas (CPAP) causa modificações hemodinâmicas favoráveis em pacientes com insuficiência cardíaca. Na presença de disfunção ventricular esquerda, mecanismos hemodinâmicos propostos associam seu uso ao aumento do débito cardíaco, através da redução do enchimento e da pressão transmural do ventrículo esquerdo. Estes efeitos talvez colaborem para o sucesso dessa terapia em pacientes com congestão pulmonar. Entretanto, até onde extensa revisão bibliográfica nos permite afirmar, não foram estudados os efeitos hemodinâmicos do CPAP em pacientes com estenose mitral, etiologia comum de congestão pulmonar em alguns países em desenvolvimento. Objetivos: Avaliar a resposta hemodinâmica dos pacientes portadores de estenose mitral sintomática durante o uso de CPAP. Métodos: Foram incluídos quarenta pacientes portadores de estenose mitral. Os critérios de exclusão foram: presença de disfunção ventricular esquerda, de outra valvopatia de grau moderado ou importante, de trombo intracavitário ao ecodopplercardiograma e de doença pulmonar obstrutiva crônica. Os pacientes foram avaliados em 3 condições diferentes: 1. condição basal, realizada ar ambiente; 2. uso de CPAP 7 cm H2O e 3. uso de CPAP 14 cm H2O. Foi realizada a medida de pressão arterial invasiva (aorta) e utilizado cateter de artéria pulmonar para a medida da pressão arterial pulmonar e débito cardíaco. Foram coletas amostras de gasometria arterial e venosa central. A variação percentual do volume sistólico (deltaVS) foi calculada tendo o valor na condição basal como 100% e foi correlacionada com as características clínicas, ecodopplercardiográficas, hemodinâmicas e gasométricas da condição basal. Os pacientes foram classificados em 3 grupos: grupo I - deltaVS <= -10%, grupo II - deltaVS entre -9,9% e +9,9% e grupo III - deltaVS >= +10%. Resultados: Durante a aplicação do CPAP, freqüência cardíaca, pressão arterial sistêmica e pressão arterial pulmonar...

Background: Continuous positive airway pressure (CPAP) impacts hemodynamic changes in heart failure patients by impending cardiac filling and reduces cardiac afterload by reducing left ventricular transmural pressure. These effects may collaborate for the success of this therapy in patients with pulmonary congestion. However, to your knowledge, no study has evaluated the hemodymanic effects of CPAP in patients with mitral stenosis, which is a common etiology of pulmonary congestion in some developing countries. Objectives: analyze the effects of CPAP on hemodynamic parameters in patients with symptomatic mitral stenosis. Methods: Forty patients with symptomatic mitral stenosis were included. They were monitored by aorta pressure and the insertion of a pulmonary artery catheter. Hemodynamic and gasometrical data were collected in each study period. Patients were evaluated in three study periods. Baseline condition was during spontaneous breathing. We applied CPAP 7 cm H2O in the second period and 14 cm H2O in the last period of the study. Were excluded patients with left ventricular systolic dysfunction, other valvopathy more than mild, and left atrial thrombi assessed by echocardiography and patients with history or symptom of chronic obstructive pulmonary disease. Percentage changes of stroke volume (deltaSV) were calculated with the values at baseline set as 100% and were correlated to clinical, ecocardiographic, hemodynamic and gasometrical data (at baseline). Patients were classified in group I if deltaSV was <= -10%, group II if deltaSV was between -9,9% and +9,9% or group III if deltaSV >= +10%. Results: During CPAP use, heart rate, systemic blood pressure and pulmonary artery pressure did not significantly change. At CPAP 7 cmH2O, deltaSV correlated positively with baseline values of diastolic pulmonary artery pressure, pulmonary artery occlusion pressure and mean transmitral gradient. There was no variable capable to distinguish the groups...