Immediate and long term evolution of valve replacement in children less than 12 years old

OBJECTIVE: The aim of this work was the follow-up and evaluation of valve replacement in children under 12 years of age. METHODS: Forty-four children less than 12 years old were underwent valve replacement at INCOR-HCFMUSP between January 1986 and December 1992. Forty (91%) were rheumatic, 39 (88.7%) were in functional classes II or IV, 19 (43.2%) were operated upon on an emergency basis, and 6 (13.6%) had atrial fibrillation. Biological prostheses (BP) were employed in 26 patients (59.1%), and mechanical prostheses (MP) in 18 (40.9%). Mitral valves were replaced in 30 (68.7%), aortic valves in 8 (18.2%), a tricuspid valve in 1 (2.3%), and double (aortic and mitral) valves in 5 (11.4) of the patients. RESULTS: Hospital mortality was of 4.5% (2 cases). The mean follow-up period was 5.8 years. Re-operations occurred in 63.3% of the patients with BP and in 12.5% of those with MP (p=0.002). Infectious endocarditis was present in 26.3% of the BP, but in none of the cases of MP (p=0.049). Thrombosis occurred in 2 (12.5%) and hemorrhage in one (6.5%) of the patients with a MP. Delayed mortality occurred in 5 (11.9%) of the patients over a mean period of 2.6 years; four had had BP and one had a MP (NS). Actuarial survival and re-operation-free curves after 10 years were respectively, 82.5±7.7 (SD)% and 20.6±15.9%. CONCLUSION: Patients with MP required fewer re-operation, had less infectious endocarditis and lower late mortality rates compared with patients with bioprostheses. The former, therefore, appear to be the best valve replacement for pediatric patients.

A new surgical approach for treating dilated cardiomyopathy with mitral regurgitation

OBJECTIVE: To evaluate the early outcome of mitral valve prostheses implantation and left ventricular remodeling in 23 patients with end-stage cardiomyopathy and secondary mitral regurgitation (NYHA class III and IV). METHODS: Mitral valvular prosthesis implantation with preservation of papillary muscles and chordae tendinae, and plasty of anteriun cuspid for remodeling of the left ventricle. RESULTS: The surgery was performed in 23 patients, preoperative ejection fraction (echocardiography) varied from 13% to 44% (median: 30%). In 13 patients associated procedures were performed: myocardial revascularization (9), left ventricle plicature repair (3) and aortic prosthese implantation (1). Early deaths (2) occurred on the 4th PO day (cardiogenic shock) and on the 20th PO day (upper gastrointestinal bleeding), and a late death in the second month PO (ventricular arrhythmia). Improvement occurred in NYHA class in 82.6% of the patients (P<0.0001), with a survival rate of 86.9% (mean of 8.9 months of follow-up). CONCLUSION: This technique offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy and secondary mitral regurgitation.

Short-term follow-up of patients after aneurysmectomy of the left ventricle

OBJECTIVE: Left ventricular aneurysm is a complication of myocardial infarction that can best be treated by reconstructive surgeries that can restore ventricular geometry. We analyzed immediate results in a group of consecutive patients who underwent surgical correction of left ventricular aneurysms. METHODS: From January '90 to August '99, 94 patients - mean age 58.4 (ranging from 36 to 73 years), 65 (69.1%) males and 9 ( 30.8%) females - were operated upon. Pre-operative ejection fraction ranged from 0.22 to 0.58 (mean = 0.52), and the aneurysm was located in the antero-lateral area in 90.4% of the cases. Functional class III and IV (NYHA) was present in 82 (87.2%) patients, and 12 (12.7%) were in functional class I and II. Congestive heart failure was the most frequent cause (77.6%), occurring in isolation in 24.4% or associated with coronary artery diseases in 53.2%. RESULTS: Short-term follow-up showed a 7.4% mortality, and low cardiac output was the main cause of death. Coming off pump was uneventful in 73 patients (77.6%), with a 3.2% mortality and with the use of inotropics in 20 (21.3%). One patient (1%) did not come off the pump. CONCLUSION: Surgical correction was adequate in the immediate follow-up of operated patients, and mortality was higher in patients with higher functional class.

Laser assisted extraction of pacemaker and implantable defibrillator leads

OBJECTIVE: To analyze the results of laser-assisted extraction of permanent pacemaker and defibrillator leads. METHODS: We operated upon 36 patients, whose mean age was 54.2 years, and extracted 56 leads. The reasons for extracting the leads were as follows: infection in 19 patients, elective replacement in 13, and other causes in 4 patients. The mean time of catheter placement was 7.5±5.5 years. Forty-seven leads were from pacemakers, and 9 were from defibrillators. Thirty-eight leads were in use, 14 had been abandoned in the pacemaker pocket, and 4 had been abandoned inside the venous system. RESULTS: We successfully extracted 54 catheters, obtaining a 96.4% rate of success and an 82.1% rate for complete extraction. The 2 unsuccessful cases were due to the presence of calcium in the trajectory of the lead. The mean duration of laser light application was 123.0±104.5 s, using 5,215.2±4,924.0 pulses, in a total of 24.4±24.2 cycles of application. Thirty-four leads were extracted from the myocardium with countertraction after complete progression of the laser sheath, 12 leads came loose during the progression of the laser sheath, and the remaining 10 were extracted with other maneuvers. One patient experienced cardiac tamponade after extraction of the defibrillator lead, requiring open emergency surgery. CONCLUSION: The use of the excimer laser allowed extraction of the leads with a 96% rate of success; it was not effective in 2 patients who had calcification on the lead. One patient (2.8%) had a complication that required cardiac surgery on an emergency basis.

Hypertension and clustering of cardiovascular risk factors in a community in Southeast Brazil: the Bambuí Health and Ageing Study

OBJECTIVE - A population-based prospective study was analysed to: a) determine the prevalence of hypertension; b) investigate the clustering of other cardiovascular risk factors and c) verify whether older differed from younger adults in the pattern of clustering. METHODS - The data comprised a representative sample of the population of Bambuí, Brazil. Multiple logistic regression was used to investigate the independent association between hypertension and selected factors. RESULTS - A total of 820 younger adults (82.5%) and 1494 older adults (85.9%) participated in this study. The overall prevalence of hypertension was 24.8% (SE=1.4 %), being higher in women (26.9±1.5%) than in men (22.0± 1.7%) (p=0.033). Hypertension was positively and significantly associated with physical inactivity, overweight, hypercholesterolemia hyperglycemia and hypertriglyceridemia. The coexistence of hypertension with 4 or more of these risk factors occurred 6 times more than expected by chance, after adjusting for age and sex (OR=6.3; 95%CI: 3.4-11.9). The pattern of risk factor clustering in hypertensive individuals differed with age. CONCLUSION - Our results reinforce the need to increase detection and treatment of hypertension and to approach patients' global risk profiles.

The Need for Pedagogical Qualifications for Teaching Cardiology to Undergraduate Students

OBJECTIVE: To report a training program in cardiology emphasizing changes in its pedagogical practice. These changes were put into practice by some teachers at the Medical School of Porto Alegre of the University of Rio Grande do Sul (FAMED/UFRGS) aiming to make faculty and student activities more dynamic and to promote more efficacious learning. The training program is directed at 5th semester medical students and aims at a behavioral change in teachers and students to promote more interaction, to favor exchanges, and to make the teaching-learning process easier, always maintaining the patient in the center of the medical activity. METHODS: The program emphasizes the definition of general and specific objectives for each activity to be developed by the students, with training in the area of admission to the cardiology service, with special emphasis on behavioral change in the cognitive, motor, affective, and attitudinal areas. Knowledge was developed by means of interactive seminars with initial and final assessment tests to identify students' and teachers' performance. The students were evaluated in an immediate, continuous, and progressive way in their daily activities and through comparison of the results of 2 tests, one applied at the beginning of the training and the other at its end. These 2 tests contained the same questions. RESULTS: We systematically assessed 560 students over 4 years. The mean grades of the tests performed prior to and after the 244 seminars were 7.38±1.66 and 9.17± 0.82, respectively (p<0.0001). For the tests applied at the beginning and at the end of the training, the mean grades were 5.61±1.61 and 9.37±0.90, respectively (p<0.0001). CONCLUSION: The program proved to be efficient both for the students' learning and for assessing their performance in a systematic and objective way.

Cross-sectional Study on Blood Pressure Control in the Department of Nephrology of the Escola Paulista de Medicina - UNIFESP

OBJECTIVE - To assess hypertension control rates in a specialized university-affiliated medical department, the influence of sex, diabetes, and obesity on that control, and the strategies for the treatment of hypertension. METHODS - We carried out a cross-sectional study with 1,210 patients followed up for at least 6 months. Information was gathered from medical and nursing records and comprised the following data: sex, age, weight, height, abdominal and hip circumferences, blood pressure, and class and number of the antihypertensive drugs prescribed. To assess obesity, we used body mass index and waist/hip ratio. Blood pressure was considered under control when its levels were below 140/90 mmHg. RESULTS - The study consisted of 73% females and 27% males. Most females (31.7%) were 50 to 59 years of age, and most males (28.3%) were 60 to 69 years. The blood pressure control rate found was 20.9% for the 1,210 patients and 23.4% for the hypertensive diabetic patients (n=290). Despite the low control rates found, 70% of the patients used 1 or 2 antihypertensive medications. A high prevalence of obesity (38%) was observed, and females had a greater abdominal obesity index than males did (90% vs 82%, p<0.05). Patients with a greater body mass index had less control of blood pressure. CONCLUSION - The percentage of hypertensive patients with controlled blood pressure levels was low and was associated with a high prevalence of obesity. These data indicate the need for reviewing the strategies of global treatment for hypertension.

Primary coronary angioplasty in 9,434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2%) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6% vs. 2000=13.1%; p<0.001). Coronary stent implantation increased (1996=20% vs. 2000=71.9%; p<0.001). Success was greater (1998=89.5% vs. 1999=92.5%; p<0.001). Reinfarction decreased (1998=3.9% vs. 99=2.4% vs. 2000=1.5%; p<0.001) as did emergency bypass surgery (1996=0.5% vs. 2000=0.2%; p=0.01). In-hospital deaths remained unchanged (1996=5.7% vs. 2000=5.1%, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95%] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95%] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure.

Impact of nutritional counseling in reducing serum cholesterol in public health service patients

OBJECTIVE: To assess the impact of nutritional attention on the lipid profile and nutritional status of hypercholesterolemic patients attended in health centers of Belo Horizonte. METHODS: Using nutritional attendance patient record cards from two health units, the evolution of the lipid profile and the nutritional state (BMI) was monitored of 96 hypercholesterolemic patients who received diet. The patients were appraised at the following moments: initial (1st consultation), after 3 months (2nd consultation) and last consultation (variable for each patient). RESULTS: On the first attendance, 44,4% of the patients presented not only high total cholesterol and LDL-c, but also hypertriglyceridemia and 70.3% were overweight or obese, but most patients (75.6%) presented adequate HDL-c levels. There was significant reduction in the BMI, total cholesterol, LDL-c values (p < 0.01) and also in the triglyceride levels (p < 0.05) in the first three months, without alteration in the HDL-c levels. A significant reduction (p < 0.01) was observed in the frequency of individuals with high cholesterol (from 89.6% down to 47.9%), high and very high LDL-c (from 82.6% down to 45.7%), as well as high and very high triglyceride (from 43.6% down to 16.7%). The observed reduction in frequency of the low HDL-c was statistically meaningless. CONCLUSION: This study evidences the effect of the nutritional attention on lipid profile in hypercholesterolemic patients, reinforcing the need for a multiprofessional team to attend them at the public health services.

Influence of balloon pressure inflation in patients undergoing primary coronary stent implantation during acute myocardial infarction: a quantitative coronary angiography analysis

OBJECTIVE:To verify the influence of moderate- or high-pressure balloon inflation during primary coronary stent implantation for acute myocardial infarction. METHODS: After successful coronary stent implantation, 82 patients were divided into 2 groups according to the last balloon inflation pressure: group 1 (³12 to <16 atm) and group 2 (³16 to 20 atm), each with 41 cases. All patients underwent late coronary angiography. RESULTS: In group 1, the mean stent deployment pressure was 13.58±0.92 atm, and in the group 2 it was 18.15±1.66 atm. Stents implanted with moderate pressures (³12 to <16 atm) had a significantly smaller postprocedural minimal lumen diameter, compared to with those with higher pressure, with lesser acute gain (2.7± 0.4 mm vs 2.9±04 mm; p=0.004), but the late lumen loss (0,9±0,8 mm vs 0,9±0,6 mm) and the restenosis (22% vs. 17.1%) and target-vessel revascularization rates (9.8% vs 7.3%) were similar between the groups. CONCLUSION: During AMI stenting, the use of high pressures (³16 atm) did not cause a measurable improvement in late outcome, either in the late loss, its index, and the net gain, or in clinical and angiographic restenosis rates.

Acute myocardial infarction: clinical and epidemiological profile and factors associated with in-hospital death in the municipality of Rio de Janeiro

OBJECTIVE: To study the factors associated with the risk of in-hospital death in acute myocardial infarction in the Brazilian public health system in Rio de Janeiro, Brazil. METHODS: Sectional study of a sample with 391 randomly drawn medical records of the hospitalizations due to acute myocardial infarction recorded in the hospital information system in 1997. RESULTS: The diagnosis was confirmed in 91.7% of the cases; 61.5% males; age = 60.2 ± 2.4 years; delta time until hospitalization of 11 hours; 25.3% were diabetic; 58.1% were hypertensive; 82.6% were in Killip I class. In-hospital mortality was 20.6%. Thrombolysis was used in 19.5%; acetylsalicylic acid (ASA) 86.5%; beta-blockers 49%; angiotensin-converting enzyme (ACE) inhibitors 63.3%; calcium channel blockers 30.5%. Factors associated with increased death: age (61-80 years: OR=2.5; > 80 years: OR=9.6); Killip class (II: OR=1.9; III: OR=6; IV: OR=26.5); diabetes (OR=2.4); ventricular tachycardia (OR=8.5); ventricular fibrillation (OR=34); recurrent ischemia (OR=2.7). The use of ASA (OR=0.3), beta-blockers (OR=0.3), and ACE inhibitors (OR=0.4) was associated with a reduction in the chance of death. CONCLUSION: General lethality was high and some interventions of confirmed efficacy were underutilizated. The logistic model showed the beneficial effect of beta-blockers, and ACE inhibitors on the risk of in-hospital death.