The results of the Campaign for evaluating sphygmomanometers accuracy and their physical conditions

OBJECTIVE: To evaluate the sphygmomanometers calibration accuracy and the physical conditions of the cuff-bladder, bulb, pump, and valve. METHODS: Sixty hundred and forty five aneroid sphygmomanometers were evaluated, 521 used in private practice and 124 used in hospitals. Aneroid manometers were tested against a properly calibrated mercury manometer and were considered calibrated when the error was <=3mm Hg. The physical conditions of the cuffs-bladder, bulb, pump, and valve were also evaluated. RESULTS: Of the aneroid sphygmomanometers tested, 51% of those used in private practice and 56% of those used in hospitals were found to be not accurately calibrated. Of these, the magnitude of inaccuracy ranged from 4 to 8mm Hg in 70% and 51% of the devices, respectively. The problems found in the cuffs - bladders, bulbs, pumps, and valves of the private practice and hospital devices were bladder damage (34% vs. 21%, respectively), holes/leaks in the bulbs (22% vs. 4%, respectively), and rubber aging (15% vs. 12%, respectively). Of the devices tested, 72% revealed at least one problem interfering with blood pressure measurement accuracy. CONCLUSION: Most of the manometers evaluated, whether used in private practice or in hospitals, were found to be inaccurate and unreliable, and their use may jeopardize the diagnosis and treatment of arterial hypertension.

Heart transplantation in neonates and children. Intermediate-term results

OBJECTIVE: To assess intermediate-term outcome in children who have undergone orthotopic heart transplantation. METHODS: We carried out a longitudinal and prospective study between October '92 and June '99 comprising 20 patients with ages ranging from 12 days to 7 years (mean of 2.8 years). We employed a double immunosuppression protocol with cyclosporine and azathioprine and induction therapy with polyclonal antithymocyte serum. Survival and complications resulting from the immunosuppression protocol were analyzed. RESULTS:The double immunosuppression protocol and the induction therapy with polyclonal antithymocyte serum resulted in an actuarial survival curve of 90% and 78.2% at 1 and 6 years, respectively, with a mean follow-up period of 3.6 years. One patient died due to acute rejection 40 days after transplantation; another patient died 2 years after transplantation due to lymphoproliferative disorder; a third patient died because of primary failure of the graft; and a fourth patient died due to bronchopneumonia. The major complications were as follows: acute rejection, infection, nephrotoxicity, and systemic hypertension. The means of rejection and infection episodes per patient were 2.9 and 3.4, respectively. After one year of transplantation, a slight reduction in the creatinine clearance and systemic hypertension were observed in 7 (38.9%) patients. CONCLUSION: Heart transplantation made life possible for those patients with complex congenital heart diseases and cardiomyopathies in refractory congestive heart failure constituting a therapeutical option for this group of patients in the terminal phase.

Effects of carvedilol in heart failure due to dilated cardiomyopathy. Results of a double-blind randomized placebo-controlled study (CARIBE study)

OBJECTIVE: To assess the effects of carvedilol in patients with idiopathic dilated cardiomyopathy. METHODS: In a double-blind randomized placebo-controlled study, 30 patients (7 women) with functional class II and III heart failure were assessed. Their ages ranged from 28 to 66 years (mean of 43±9 years), and their left ventricular ejection fraction varied from 8% to 35%. Carvedilol was added to the usual therapy of 20 patients; placebo was added to the usual therapy of 10 patients. The initial dose of carvedilol was 12.5 mg, which was increased weekly until it reached 75 mg/day, according to the patient's tolerance. Clinical assessment, electrocardiogram, echocardiogram, and radionuclide ventriculography were performed in the pretreatment phase, being repeated after 2 and 6 months of medication use. RESULTS: A reduction in heart rate (p=0.016) as well as an increase in left ventricular shortening fraction (p=0.02) and in left ventricular ejection fraction (p=0.017) occurred in the group using carvedilol as compared with that using placebo. CONCLUSION: Carvedilol added to the usual therapy for heart failure resulted in better heart function.

The bussola study. Final results, conclusions and proposals

OBJECTIVE: To evaluate the use of thrombolytic and acetylsalicylic acid therapies in acute myocardial infarct patients as well as the availability of technical and human resources for the care of these patients in the emergency units of the city of Rio de Janeiro. Additional objectives were the evaluation of the use of primary angioplasty and the level of acceptance of SBC /RJ as an entity responsible for programs of continued medical education. METHODS: Interviews with physicians at 46 emergency units in the city of Rio de Janeiro. RESULTS: Of the 46 emergency units inspected, a policy of encouragement to use thrombolytic therapy was only prescribed in 6.5%. In 1/3 of the public wards no thrombolytic agents were available, and in none of them was access to primary angioplasty regularly available; 45.9% did not offer the minimal conditions required for the handling of cases of acute myocardial infarction; 60% of the physicians on-call (at both public and private emergency units), appeared not to know the importance of the use of acetylsalicylic acid in acute myocardial infarct patients; all physicians interviewed would participate in programs of continued medical education organized by the SBC/RJ. CONCLUSION: The study suggests there was: 1) the low probability of the use of thrombolytic therapy in the majority of the emergency units in of the city of Rio de Janeiro due to the inadequate policy of waiting for the transfer of the patient to coronary or intensive care unit; 2) a low awareness to the importance of early use of acetylsalic acid in acute myocardial infarct; 3) half of the emergency units of the public net do not have the minimal conditions required for the handling of cases of acute myocardial infarction; 4) a high level of credibility exists that would enable the SBC/RJ to set up programs for continued medical education to change the mentality regarding the use of thrombolytic therapy and of acetylsalicylic acid.

A comparative analysis of primary stenting and optimal balloon coronary angioplasty in acute myocardial infarction. Six month results from the STENT PAMI trial

OBJECTIVE: To compare the outcome of balloon PTCA with final coronary stenosis diameter (SD) <=30%, with elective coronary stenting. METHODS: We performed a comparative analysis of the 6 month outcomes in patients treated with primary stenting and those who obtained an optimal balloon PTCA result treated during the first 12 hours of AMI onset included in the STENT PAMI randomized trial. RESULTS: The results were analysed into 3 groups: primary stenting (441 patients, SD=22±6%), optimal PTCA (245 patients), and nonoptimal PTCA (182 patients, SD= 37±5%). At the end of the 6 months primary stent group presented with the lowest restenosis(23 vs. 31 vs. 45%, p=0.001, respectively). Ischemia-driven target vessel revascularization rate (TVR) (7 vs. 15.5 vs. 19%, p=0.001, respectively). CONCLUSION: At the 6 month follow-up, primary stenting offered the lowest restenosis and ischemia-driven TVR rates. Compared to optimal balloon PTCA. Nonoptimal primary balloon PTCA pts (SD=31-50%), had the worst late angiographic outcomes and should be treated more actively with coronary stent implantation.

Acute myocardial infarction in progressively elderly patients. A comparative analysis of immediate results in patients who underwent primary percutaneous coronary intervention

OBJECTIVE: Analysis of the in-hospital results, in progressively elderly patients who undergo primary percutaneous coronary intervention (PCI) in the first 24 hours of AMI. METHODS: The patients were divided into three different age groups (60/69, 70/79, and > or = 80 years) and were treated from 7/95 until 12/99. The primary success rate and the occurrence of major clinical events were analyzed at the end of the in-hospital phase. Coronary stent implantation and abciximab use were employed at the intervencionist discretion. RESULTS: We analyzed 201 patients with age ranging from 60 to 93 years, who underwent primary PCI. Patients with ages above 70 were more often female (p=.015). Those with ages above 80 were treated later with PCI (p=.054), and all of them presented with total occlusion of the infarct-related artery. Coronary stents were implanted in 30% of the patients. Procedural success was lower in > or = 80 year old patients (p=.022), and the death rate was higher in > or = 70 years olds (p=.019). Reinfarction and coronary bypass surgery were uncommon events. A trend occurred toward a higher combined incidence of major in-hospital events according to increased age (p=.064). CONCLUSION: Elderly patients ( > or = 70 years) presented with adverse clinical and angiographic profiles and patients > or = 80 years of age obtained reduced TIMI 3 flow success rates after primary PTCA, and those > or = 70 years had a higher death rate.

Unsupported valvuloplasty in children with congenital mitral valve anomalies. Late clinical results

OBJECTIVE: To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support. METHODS: We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67±3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10±9.50min, and ischemia time were 29.40±10.50min. The average clinical follow-up in mitral insufficiency was 41.52±53.61 months. In the stenosis group (4 patients) was 46.39±32.02 months, and in the double lesion group (3 patients), 39.41±37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17±39.51 months, stenosis 42.61±30.59 months, and in the double lesion 39.41±37.51 months. RESULTS: Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majorit y with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12mmHg, average of 10.7mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported. CONCLUSION: Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Percutaneous mechanical mitral commissurotomy performed with a Cribier's metallic valvulotome. Initial results

OBJECTIVE: To evaluate the immediate results of percutaneous mechanical mitral commissurotomy. METHODS: Thirty patients underwent percutaneous mechanical mitral commissurotomy performed with a Cribier's metallic valvulotome from 8/11/99 to 2/4/00. Mean age was 30.7 years, and 73.3% were women. With regards to functional class, 63.3% were class III, and 36.7% were class IV. The echocardiographic score had a mean value of 7.5± 1.8. RESULTS: The mitral valve area increased from 0.97±0.15cm² to 2.16±0.50cm² (p>0.0001). The mean diastolic gradient decreased from 17.9±5.0mmHg to 3.2±1.4mmHg. The mean left atrial pressure decreased from 23.6±5.4mmHg to 8.6±3.1mmHg, (p>0.0001). Systolic pressure in the pulmonary artery decreased from 52.7±18.3mmHg to 32.2±7.4mmHg. Twenty-nine cases were successful. One patient developed severe mitral regurgitation. Interatrial septal defect was observed and one patient. One patient had cardiac tamponade due to left ventricular perforation. No deaths occurred. CONCLUSION: This method has proven to be safe and efficient in the treatment of rheumatic mitral stenosis. The potential advantage is that it can be used multiple times after sterilization, which decreases procedural costs significantly.

Prognostic factors of the results of cardiopulmonary resuscitation in a cardiology hospital

OBJECTIVE: To analyze the early and late results of cardiopulmonary resuscitation in a cardiology hospital and to try to detect prognostic determinants of both short- and long-term survival. METHODS: A series of 557 patients who suffered cardiorespiratory arrest (CRA) at the Dante Pazzanese Cardiology Institute over a period of 5 years was analyzed to examine factors predicting successful resuscitation and long-term survival. RESULTS: Ressuscitation maneuvers were tried in 536 patients; 281 patients (52.4%) died immediately, and 164 patients (30.6%) survived for than 24 hours. The 87 patients who survived for more than 1 month after CRA were compared with nonsurvivors. Coronary disease, cardiomyopathy, and valvular disease had a better prognosis. Primary arrhythmia occurred in 73.5% of the >1-month survivor group and heart failure occurred in 12.6% of this group. In those patients in whom the initial mechanism of CRA was ventricular fibrillation, 33.3% survived for more than 1 month, but of those with ventricular asystole only 4.3% survived. None of the 10 patients with electromechanical dissociation survived. There was worse prognosis in patients included in the extreme age groups (zero to 10 years and 70 years or more). The best results occurred when the cardiac arrest took place in the catheterization laboratories. The worst results occurred in the intensive care unit and the hemodialysis room. CONCLUSION: The results in our series may serve as a helpful guide to physicians with the difficult task of deciding when not to resuscitate or when to stop resuscitation efforts.

Mechanical versus biological aortic valve implants in the elderly. A comparison of early and mid-term results

OBJECTIVE: Our aim was to compare, in a non randomized study, the surgical outcome in elderly patients with mechanical (Group 1; n=83) and bioprosthetic valve implants (Group 2; n=136). METHODS: During a three year period, 219 patients >75 years underwent Aortic Valve Replacement. The groups matched according to age, sex, comorbidity, valve pathology and concomitant Coronary Artery Bypass Surgery. Follow-up was a total of 469 patient-years (mean follow-up 2.1 years, maximum 4,4 years). RESULTS: Operative mortality was zero and the overall early mortality was 2.3 % (within 30 days). Actuarial survival was 87.5 ± 4.0% and 66.1 ± 7.7% (NS) at 4 years in Group 1 and Group 2, respectively. Freedom from valve-related death was 88.9 ± 3.8% in Group 1 and 69.9±7.9% (NS) in Group 2 at 4 years. CONCLUSION: Aortic Valve Replacement in the elderly (>75 years) is a safe procedure even in cases where concomitant coronary artery revascularization is performed. Only a few anticoagulant-related complications were reported and this may indicate that selected groups of elderly patients with significant life expectancy may benefit from mechanical implants .

Fontan Operation and the Cavopulmonary Technique: Immediate and Late Results According to the Presence of Atrial Fenestration

OBJECTIVE: To compare immediate and late results in patients with or without fenestration who underwent cavopulmonary anastomosis so that we could assess the efficiency of the technique. METHODS: Sixty-two patients underwent surgery between 1988 and 1999, 41 with fenestration (group I -G I) and 21 without fenestration (group II -G II). Tricuspid atresia was prevalent in group I (23-56%) and single ventricle was prevalent in group II (14-66%). Mean ages at the time of operation were 7.3 years in group I and 7.6 in group II. At late follow-up, mean ages were 10.6 years in group I and 12.8 years in group II. RESULTS: Immediate and late mortality were 7.3% in G-I and 4.7% in G-II. Significant pleural effusion occurred in 41.4% of G-I patients and in 23.8% of G-II patients. Significant pericardial effusion occurred in 29.2% and 14.2%, respectively, in groups I and II. Central venous pressure was greater in G-II, 17.7 cm in H2O, as opposed to 15 cm in G-I. Hospital stay was similar between the groups, 26.3 and 21.8 days, respectively. Cyanosis and arterial insaturation occurred in 5 patients, and 4 patients were in functional class II, all from G-I. At late follow-up, 58 (93.5%) were in functional class I. Sinus rhythm was present in 94%, and pulmonary perfusion was similar in both groups. Eleven patients who underwent spirometry had good tolerance to physical effort. CONCLUSION: Atrial fenestration did not improve the immediate or late follow-up of patients who underwent cavopulmonary anastomosis, and is, therefore, dispensable.

Mitral Valve Replacement and Remodeling of the Left Ventricle in Dilated Cardiomyopathy with Mitral Regurgitation: Initial Results

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7±3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1± 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

Late Results of Endoventricular Patch Plasty Repair in Akinetic and Dyskinetic Areas After Acute Myocardial Infarction

OBJECTIVE - To assess the surgical results of endoventricular patch plasty repair in akinetic and dyskinetic left ventricular areas. METHODS - We studied 52 patients who had undergone endoventricular patch plasty repair associated with myocardial revascularization. The preoperative functional class distribution was as follows: class I in 1 (1.9%) patient; class II in 2 (3.8%) patients; class III in 23 (44.2%) patients; and class IV in 26 (50%) patients. RESULTS - The immediate mortality rate was 7.6% (4 patients). The clinical outcome of 44 patients followed up within a mean postoperative time of 29±25 months was as follows: class I in 33 (75%) patients; class II in 7 (15.9%) patients; class III in 2 (4.5%) patients; and class IV in 2 (4.5%) patients. Comparison between pre- and postoperative catheterization in 21 patients showed that the ejection fraction increased from 46.3% to 51.3% (p=0. 17); the left ventricular systolic volume decreased from 76.4 mL to 57.5 mL, (p=0.078); and the left ventricular diastolic volume decreased from 141.2 mL to 105.8 mL (p=0.0 73). These findings showed the tendency toward improvement, but with nonsignificant results. CONCLUSION - The technique proved to be effective, to have a low mortality rate, to cause significant clinical improvement, an increase in ejection fraction, and a reduction in left ventricular volumes.