Echocardiographic assessment of the different left ventricular geometric patterns in hypertensive patients

OBJECTIVE: To identiy left ventricular geometric patterns in hypertensive patients on echocardiography, and to correlate those patterns with casual blood pressure measurements and with the parameters obtained on a 24-hour ambulatory blood pressure monitoring. METHODS: We studied sixty hypertensive patients, grouped according to the Joint National Committee stages of hypertension.. Using the single- and two-dimensional Doppler Echocardiography, we analyzed the left ventricular mass and the geometric patterns through the correlation of left ventricular mass index and relative wall thickness. On ambulatory blood pressure monitoring we assessed the means and pressure loads in the different geometric patterns detected on echocardiography RESULTS: We identified three left ventricular geometric patterns: 1) concentric hypertrophy, in 25% of the patients; 2) concentric remodeling, in 25%; and 3) normal geometry, in 50%. Casual systolic blood pressure was higher in the group with concentric hypertrophy than in the other groups (p=0.001). Mean systolic pressure in the 24h, daytime and nighttime periods was also higher in patients with concentric hypertrophy, as compared to the other groups (p=0.003, p=0.004 and p=0.007). Daytime systolic load and nighttime diastolic load were higher in patients with concentric hypertrophy ( p=0.004 and p=0.01, respectively). CONCLUSIONS: Left ventricular geometric patterns show significant correlation with casual systolic blood pressure, and with means and pressure loads on ambulatory blood pressure monitoring.

Clinical impact of transesophageal echocardiography in patients with stroke without clinical evidence of cardiovascular sources of emboli

OBJECTIVE: The purpose of this study is to evaluate the impact of transeophageal echocardiography on management of patients at low-risk for cardiogenic embolism to prevent new potential cardiovascular sources of emboli. METHODS: We studied 69 patients with ischemic stroke at low-risk for cardiogenic embolism. Transeophageal echocardiography was performed to access: left atrium enlargement; communication or aneurysm of the interatrial septum; patent foramen ovale; spontaneous echo contrast or intracavitary thrombi; the presence of intraaortic atherosclerotic plaques or thrombi; significant valvar morphologic alteration or dysfunction; left ventricle enlargement, hypertrophy, or contractile abnormality. Transesophageal echocardiography altered clinical management, and we adopted anticoagulant therapy or another procedure apart from the use of acetylsalicylic acid. RESULTS: Transeophageal echocardiography detected at least one abnormality in 40 cases (58%). Clinical conduct was adjusted after the performance of transesophageal echocardiography in 11 patients (15.9%); anticoagulation was added in 10 cases and surgical correction in one patient. CONCLUSION: Transeophageal echocardiography was a very useful tool in the secondary prevention for stroke in patients at low risk for cardiogenic embolism.

Use of transesophageal echocardiography during implantation of aortic endoprosthesis (stent). Initial experience

OBJECTIVE: To report the role played by transesophageal echocardiography during implantation of self-expanding aortic endoprostheses (stent) at a hemodynamics laboratory. METHODS: Thirteen patients underwent stent implantation in the descending thoracic aorta with the aid of transesophageal echocardiography during the entire procedure. Indications for stenting were as follows: 8 aortic dissections, 2 true aneurysms, 2 penetrating atherosclerotic ulcers, and 1 traumatic pseudoaneurysm. RESULTS: No complications resulting from the use of transesophageal echocardiography were observed. In 12 patients, the initial result was considered appropriate, with total or partial resolution of the major lesion confirmed by a posterior examination. In 1 patient, the procedure was suspended after transesophageal echocardiography and angiography showed that the proximal aortic diameter was inappropriate. Transesophageal echocardiography contributed to clarifying relevant points, such as aortic diameter, anatomic detail of the intimal lesion, and location and size of the communicating orifice. In addition, it facilitated placing the stent in the target lesion, reduced the time of exposure to radiation and the use of contrast medium, and provided rapid identification of intercurrent events, possibly reducing the total duration of the procedure. CONCLUSION: The use of transesophageal echocardiography during placement of aortic stents seems appropriate. The actual advantages of the procedure will be defined in a comparative prospective study.

The use of abciximab associated with primary angioplasty for treating acute myocardial infarction

OBJECTIVE: To assess the benefit resulting from the use of abciximab associated with primary angioplasty. The following parameters were analyzed in-hospital, at 30 days, and 6 months: (a) flow in the culprit artery; (b) ventricular function; (c) combined outcome of death, acute myocardial infarction, and aditional revascularization. METHODS: From November 1997 to June 1999, a longitudinal nonrandomized study with historical data of 137 patients with acute myocardial infarction within the first 12 hours. Patients undergoing primary angioplasty and were divided into 2 groups: those receiving (A) abciximab (26) or (B) conventional therapy (111). TIMI flow and regional ventricular function estimated by the standard deviation (SD)/chordis index were analyzed. RESULTS: At the end of angioplasty, TIMI 3 flow was observed in 76.9% and 83.8% of the patients in groups A and B, respectively (P=0.58). In the reevaluation, patients with TIMI flow <3 showed a 100% improvement in group A and a 33% in group B (P<0.0001). A significant improvement (P<0.0001) in regional ventricular function, by SD/chordis index, occurred in each group; no significant difference between groups however, was observed (29.9% x 20.2%; P=0.58). A nonsignificant reduction in the combined outcome in the in-hospital phase (3.85% A x 9.0% B; P=0.34) and on the 30th day (4.0% x 12.0%; P=0.22) was observed in group A. CONCLUSION: Abciximab improved blood flow. Primary angioplasty improved regional ventricular function independent of antithrombotic therapy. Abciximab showed a trend toward reducing the combined outcome in the in-hospital phase and on the 30th day.

Prevalence of Cardiac Arrhythmias During and After Pregnancy in Women with Chagas' Disease without Apparent Heart Disease

OBJECTIVE: To evaluate cardiac arrhythmias during and after pregnancy in women with Chagas' disease without apparent heart disease using dynamic electrocardiography. METHODS: Twenty pregnant women with Chagas' disease without apparent heart disease aged 19 to 42 years (26.96 ± 3.6) and a control group of 20 non-chagasic pregnant patients aged 16 to 34 years (22.5 ± 4.8). The patients were submitted to passive hemagglutination and indirect immunofluorescence for the detection of Trypanosoma cruzi evaluation, and electrocardiography, echocardiography and 24-h dynamic electrocardiography. RESULTS: Supraventricular premature depolarizations were observed in 18 (90%) patients and ventricular premature depolarization in 11 (55%) patients of both groups during pregnancy. After delivery, supraventricular premature depolarizations were present in 13 (60%) chagasic patients and in 16 (89.4%) control patients (P<=0.05). Ventricular premature depolarization were observed in 9 (45%) chagasic patients and 11 (57.8%) control patients. CONCLUSION: The prevalence of ventricular premature depolarization was similar for the chagasic and control groups during and after pregnancy. The incidence of supraventricular premature depolarizations was similar in the two groups during pregnancy, while after delivery a predominance was observed in the control group compared to the chagasic group.

Percutaneous Stent Implantation for Treating Multivessel Coronary Disease in Patients with and without Involvement of the Proximal Segment of the Anterior Descending Coronary Artery

OBJECTIVE: To assess coronary stent placement in patients with multivessel coronary disease and involvement of the proximal portion of the anterior descending coronary artery. METHODS: We retrospectively analyzed the in-hospital and late evolution of 189 patients with multivessel coronary disease, who underwent percutaneous coronary stent placement. These patients were divided into 2 groups as follows: group I (GI) - 59 patients with involvement of the proximal segment of the anterior descending coronary artery; and group II (GII) - 130 patients without involvement of the proximal segment of the anterior descending coronary artery. RESULTS: No significant difference was observed in the success rate of the procedure (91.5% versus 97.6%, p=0.86), nor in the occurrence of major adverse cardiac events (5.1% versus 1.5%, p=0.38), nor in the occurrence of major vascular complications (1.7% versus 0%, p=0.69) in the in-hospital phase. In the late follow-up, the incidence of major adverse cardiac events (15.4% versus 13.7%, p=0.73) and the need for new revascularization (13.5% versus 10.3%, p=0.71) were similar for both groups. CONCLUSION: The in-hospital and late evolution of patients with multivessel coronary disease with and without involvement of the proximal segment of the anterior descending coronary artery treated with coronary stent placement did not differ. This suggests that this revascularization method is an effective procedure and a valuable option for treating these types of patients.

Vector electrocardiographic alterations after percutaneous septal ablation in obstructive hypertrophic cardiomyopathy: possible anatomic causes

OBJECTIVE: Analyze the dromotropic disturbances (vector-electrocardiographic), and the possible anatomic causes, provoked by selective alcohol injection in the septal branch, for percutaneous treatment, of obstructive hypertrophic cardiomyopathy. METHODS: Ten patients with a mean age of 52.7 years underwent percutaneous septal ablation (PTSA) from october 1998; all in functional class III/IV). Twelve-lead electrocardiogram was performed prior to and during PTSA, and later electrocardiogram and vectorcardiogram according to Frank's method. The patients were followed up for 32 months. RESULTS: On electrocardiogram (ECG) prior to PTSA all patients had sinus rhythm and left atrial enlargement, 8 left ventricular hypertrophy of systolic pattern. On ECG immediately after PTSA, 8 had complete right bundle-branch block; 1 transient total atrioventricular block; 1 alternating transient bundle-branch block either right or hemiblock. On late ECG 8 had complete right bundle-branch block confirmed by vectorcardiogram, type 1 or Grishman. CONCLUSION: Septal fibrosis following alcohol injection caused a predominance of complete right bundle-branch block, different from surgery of myotomy/myectomy.

Comparison between young males and females with acute myocardial infarction

OBJECTIVE: To assess the differences between young males and females after acute myocardial infarction. METHODS: We retrospectively studied 236 patients (54 females and 182 males) after acute myocardial infarction and during hospital stay assessed the following parameters: risk factors; the treatment used; the pattern of coronary artery obstruction; left ventricular ejection fraction; complications; and, using a logistic regression model, the factors related to the occurrence of reinfarction and death. RESULTS: No significant difference was observed between the sexes in risk factors, pattern of coronary artery obstruction, and left ventricular function. The time interval between symptom onset and treatment was longer in females (p=0.03), who underwent thrombolysis (p=0.01) and angioplasty (p=0.03) less frequently than males did, but not myocardial revascularization. Female sex (OR = 5.98) and diabetes (OR = 14.52) were independent factors related to the occurrence of reinfarction and death. CONCLUSION: Young males and females after acute myocardial infarction did not differ in coronary risk factors, and clinical and hemodynamic characteristics. Females had their treatment started later, and they underwent chemical thrombolysis and angioplasty less frequently than males did. Female sex and diabetes were related to the occurrence of reinfarction and death.

Catheter ablation of atriofascicular Mahaim fibers guided by the activation potential

OBJECTIVE: To determine whether recording of the activation potential may be used as an isolated criterion to guide catheter ablation of atriofascicular Mahaim fibers. METHODS: We studied 6 patients (5 females, mean age of 26±7.3 years) with paroxysmal tachycardias with a wide QRS complex, whose electrophysiological study diagnosed atriofascicular Mahaim fibers. Mapping and catheter ablation were performed in sinus rhythm, guided only by the recording of the activation potential of the fiber. RESULTS: Efficacy in ablation was achieved in all patients. The fibers were located in the right lateral region of the tricuspid ring in 3 patients, right posterolateral region in 2, and right anterolateral region in 1. A mean of 5.3±3 radiofrequency applications was performed. The mean fluoroscopy time was 46.6±25 minutes, and the mean duration of the procedure was 178.6±108 minutes. No complication occurred. In a mean 20-month follow-up, all patients were asymptomatic and receiving no antiarrhythmic drugs. CONCLUSION: Catheter ablation of Mahaim fibers may be performed with good safety and efficacy by mapping the activation potential of the tricuspid ring in sinus rhythm.

Prevalence of systemic hypertension in students aged 7 to 14 years in the municipality of Barbacena, in the State of Minas Gerais, in 1999

OBJECTIVE: To detect the prevalence of systemic hypertension in children and to establish the relation between blood pressure levels and sex, age, ethnicity, weight, and height. METHODS: The prevalence of systemic hypertension and its relation to sex, age, ethnicity, weight, and height were studied in 611 students aged 7 to 14 years out of 19.928 students classified according to age, ethnicity, and sex, who underwent anthropometric evaluation and blood pressure measurement. Hypertensive individuals were considered those whose blood pressure level was > the 95th percentile for age and sex, confirmed on 3 examinations. RESULTS: The prevalence of hypertension was 16.6% in the first evaluation, and 4.6% and 2.5% in the subsequent evaluations. The mean blood pressure levels increased with age. Weight was important, not only to determine blood pressure in healthy children, but also to determine systemic hypertension in children, which was not observed with height despite the different studies. The prevalence of systemic hypertension in the different ethnic groups and the mean blood pressure levels according to sex were similar. CONCLUSION: In addition to routine physical examinations, age, weight, and appropriate cuff size should be considered when assessing blood pressure in children to prevent hypertension, morbidity and mortality, and to avoid placing a financial burden on health care providers.

Right ventricular structure and function as possible determinants of surgical outcome 30 years after repair of tetralogy of Fallot

OBJECTIVE: To identify the variables that may be involved in the persistence of symptoms (functional class II, III, or IV vs. I) in patients being followed up for 30 years after surgical repair of tetralogy of Fallot. METHODS: Fifty-three patients (27 women), who underwent corrective surgery for tetralogy of Fallot between 1960 and 1970, were studied. Their ages ranged from 7 months to 26 years. At the end of follow-up, 13 patients were asymptomatic and the remaining were in functional class II (N=24), III (N=15), and IV (N=1). To differentiate asymptomatic from symptomatic patients, the following variables were analyzed: age at surgery, need for widening the pulmonary ring and trunk, need for a second (2nd OP) or 3rd operation, residual defect of the interventricular septum, residual regurgitation of the pulmonary valve, systolic gradient through the right ventricular outflow tract, right ventricular dilation or hypertrophy (RVH), cardiothoracic index (CTI), right and left ventricular ejection fraction (RVEF/LVEF), and arrhythmias. RESULTS: The univariate analysis showed an association between the presence of symptoms and the 2nd OP (P=0.03), an increase in the CTI (P=0.0001), moderate to severe RVH (P=0.002), and dilation (P=0.0003). In the logistic regression model, the combination of the 2nd OP (P=0.008), the RVH (P=0.002), and the reduction in RVEF (P=0.01) determined the presence of symptoms. CONCLUSION: Despite the surgical treatment, right ventricular remodeling and performance were the major determinants in the late follow-up of tetralogy of Fallot.