Muscarinic antibodies and heart rate responses to dynamic exercise and to the Valsalva maneuver in chronic chagasic patients

We have studied the cardiac chronotropic responses to the Valsalva maneuver and to dynamic exercise of twenty chronic chagasic patients with normal left ventricular function and no segmental wall abnormalities by two-dimensional echocardiogram. The absolute increase in heart rate of the patients (Δ = 21.5 ± 10 bpm, M±SD) during the maneuver was significantly diminished when compared to controls (Δ = 31.30 ± 70, M±SD, p = 0.03). The minimum heart rate (58.24 ± 8.90 vs. 62.80 ± 10, p = 0.68) and the absolute decrease in heart rate at the end of the maneuver (Δ = 38.30 ± 13 vs. Δ = 31.47 ± 17, p = 0.10) were not different from controls. The initial heart rate acceleration during dynamic exercise (Δ = 12 ± 7.55 vs. Δ = 19 ± 7.27, M±SD, p = 0.01) was also diminished, but the heart rate recovery during the first ten seconds was more prominent in the sero-positive patients (Median: 14, Interquartile range: (9.75-17.50 vs. 5(0-8.75, p = 0.001). The serum levels of muscarinic cardiac auto-antibodies were significantly higher in the chagasic patients (Median: 34.58, Interquartile Range: 17-46.5, Optical Density) than in controls (Median: 0, Interquartile Range: 0-22.25, p = 0.001) and correlated significantly and directly (r = 0.68, p = 0.002) with early heart rate recovery during dynamic exercise. The results of this investigation indirectly suggest that, the cardiac muscarinic auto-antibodies may have positive agonist effects on parasympathetic heart rate control of chagasic patients.

Proposal Intensity Adequacy of Expiratory Effort and Heart Rate Behavior During the Valsalva Maneuver in Preadolescents

Background: When performing the Valsalva maneuver (VM), adults and preadolescents produce the same expiratory resistance values. Objective: To analyze heart rate (HR) in preadolescents performing VM, and propose a new method for selecting expiratory resistance. Method: The maximal expiratory pressure (MEP) was measured in 45 sedentary children aged 9-12 years who subsequently performed VM for 20 s using an expiratory pressure of 60%, 70%, or 80% of MEP. HR was measured before, during, and after VM. These procedures were repeated 30 days later, and the data collected in the sessions (E1, E2) were analyzed and compared in periods before, during (0-10 and 10-20 s), and after VM using nonparametric tests. Results: All 45 participants adequately performed VM in E1 and E2 at 60% of MEP. However, only 38 (84.4%) and 25 (55.5%) of the participants performed the maneuver at 70% and 80% of MEP, respectively. The HR delta measured during 0-10 s and 10-20 s significantly increased as the expiratory effort increased, indicating an effective cardiac autonomic response during VM. However, our findings suggest the VM should not be performed at these intensities. Conclusion: HR increased with all effort intensities tested during VM. However, 60% of MEP was the only level of expiratory resistance that all participants could use to perform VM. Therefore, 60% of MEP may be the optimal expiratory resistance that should be used in clinical practice.

Heart rate changes during the Valsalva maneuver in patients with isolated aortic insufficiency

To determine the possible relationship between left ventricular dilatation and heart rate changes provoked by the Valsalva maneuver (Valsalva ratio), we studied 9 patients with isolated chronic aortic insufficiency. Left ventricular systolic function was assessed by two-dimensional echocardiography and cardiac catheterization. All patients were asymptomatic (functional class I of the New York Heart Association). The left ventricular internal diameters and volumes were significantly increased in all patients. The asymptomatic patients had either normal or slightly depressed ejection fraction (EF>0.40). The Valsalva ratio of these asymptomatic patients showed no significant correlation with the left ventricular volumes or with the left ventricular ejection fraction. In other words, parasympathetic heart rate control, as expressed by the Valsalva ratio, was normal in the asymptomatic patients with left ventricular dilatation and preserved left ventricular ejection fraction. Therefore, left ventricular dilatation may not be the major mechanism responsible for the abnormal parasympathetic heart rate control of patients with acquired heart disease

Is autonomic function associated with left ventricular systolic function in Chagas heart disease patients undergoing treatment for heart failure?

Introduction The association between cardiac autonomic and left ventricular (LV) dysfunction in Chagas disease (ChD) is controversial. Methods A standardized protocol that includes the Valsalva maneuver, a respiratory sinus arrhythmia (RSA) test, and an echocardiographic examination was used. Spearman correlation coefficients (rho) were used to investigate associations. Results The study population consisted of 118 ChD patients undergoing current medical treatment, with an average LV ejection fraction of 51.4±2.6%. The LV ejection fraction and diastolic dimension were correlated with the Valsalva index (rho=0.358, p<0.001 and rho=-0.266, p=0.004, respectively) and the RSA (rho=0.391, p<0.001 and rho=-0.311, p<0.001, respectively). Conclusions The impairment of LV function is directly associated with a reduction of cardiac autonomic modulation in ChD.

Anatomical and functional characteristics of the pelvic floor in nulliparous women submitted to three-dimensional endovaginal ultrasonography: case control study and evaluation of interobserver agreement

PURPOSE: To determine anatomical and functional pelvic floor measurements performed with three-dimensional (3-D) endovaginal ultrasonography in asymptomatic nulliparous women without dysfunctions detected in previous dynamic 3-D anorectal ultrasonography (echo defecography) and to demonstrate the interobserver reliability of these measurements. METHODS: Asymptomatic nulliparous volunteers were submitted to echo defecography to identify dynamic dysfunctions, including anatomical (rectocele, intussusceptions, entero/sigmoidocele and perineal descent) and functional changes (non-relaxation or paradoxical contraction of the puborectalis muscle) in the posterior compartment and assessed with regard to the biometric index of levator hiatus, pubovisceral muscle thickness, urethral length, anorectal angle, anorectal junction position and bladder neck position with the 3-D endovaginal ultrasonography. All measurements were compared at rest and during the Valsalva maneuver, and perineal and bladder neck descent was determined. The level of interobserver agreement was evaluated for all measurements. RESULTS: A total of 34 volunteers were assessed by echo defecography and by 3-D endovaginal ultrasonography. Out of these, 20 subjects met the inclusion criteria. The 14 excluded subjects were found to have posterior dynamic dysfunctions. During the Valsalva maneuver, the hiatal area was significantly larger, the urethra was significantly shorter and the anorectal angle was greater. Measurements at rest and during the Valsalva maneuver differed significantly with regard to anorectal junction and bladder neck position. The mean values for normal perineal descent and bladder neck descent were 0.6 cm and 0.5 cm above the symphysis pubis, respectively. The intraclass correlation coefficient ranged from 0.62-0.93. CONCLUSIONS: Functional biometric indexes, normal perineal descent and bladder neck descent values were determined for young asymptomatic nulliparous women with the 3-D endovaginal ultrasonography. The method was found to be reliable to measure pelvic floor structures at rest and during Valsalva, and might therefore be suitable for identifying dysfunctions in symptomatic patients.

Predictive factors for voiding dysfunction after transobturator slings

PURPOSE: To identify the predictive factors for voiding dysfunction after transobturator slings. METHODS: We retrospectively reviewed the records of all patients who underwent a transobturator sling between March 2003 and December 2008. A total of 514 women had available data with at least a six-week follow-up. Patients' demographics, preoperative symptoms, urodynamic testing including multichannel voiding studies and surgical variables were tabulated. Voiding dysfunction was defined by a catheterized or ultrasonographic postvoid residual greater than 100 cc (≥six weeks after the procedure) associated with any complaints of abnormal voiding. Univariate logistic regression analysis was performed with respect to postoperative voiding dysfunction. RESULTS: The patient population had a mean age of 58.5±12.9 years. Thirty-three out of 514 patients (6.4%) had postoperative voiding dysfunction according to our definition, and 4 (0.78%) required sling transection. No differences were observed between normal and dysfunctional voiders in age, associated prolapse surgery, preoperative postvoid residual, preoperative urinary flow rate, prior pelvic surgery, and menopausal status. Valsalva efforts during the preoperative pressure flow study was the only predictive factor for postoperative voiding dysfunction, 72.4% dysfunctional versus 27.6% normal (p<0.001). CONCLUSION: Preoperative Valsalva maneuver during the micturition could identify those at risk for voiding dysfunction after transobturator sling, and it should be noted during preoperative counseling.

Standardization of a computerized method for calculating autonomic function test responses in healthy subjects and patients with diabetes mellitus

The objectives of the present study were 1) to compare results obtained by the traditional manual method of measuring heart rate (HR) and heart rate response (HRR) to the Valsalva maneuver, standing and deep breathing, with those obtained using a computerized data analysis system attached to a standard electrocardiograph machine; 2) to standardize the responses of healthy subjects to cardiovascular tests, and 3) to evaluate the response to these tests in a group of patients with diabetes mellitus (DM). In all subjects (97 healthy and 143 with DM) we evaluated HRR to deep breathing, HRR to standing, HRR to the Valsalva maneuver, and blood pressure response (BPR) to standing up and to a sustained handgrip. Since there was a strong positive correlation between the results obtained with the computerized method and the traditional method, we conclude that the new method can replace the traditional manual method for evaluating cardiovascular responses with the advantages of speed and objectivity. HRR and BPR of men and women did not differ. A correlation between age and HRR was observed for standing (r = -0.48, P<0.001) and deep breathing (r = -0.41, P<0.002). Abnormal BPR to standing was usually observed only in diabetic patients with definite and severe degrees of autonomic neuropathy.

Aneurisma do Seio de Valsalva direito causando compressão coronariana extrínseca

O Aneurisma do Seio de Valsalva (ASV) é um distúrbio cardíaco raro. É mais frequentemente um defeito congênito, mas pode ser adquirido. A doença de Takayasu é uma causa extremamente rara desse distúrbio. A maioria dos casos de ASV não-roto é assintomática. A compressão da artéria coronária esquerda é uma manifestação não usual da doença, que pode causar angina, infarto do miocárdio ou morte. Esse relato de caso descreve um paciente negro de 19 anos, do sexo masculino, apresentando um ASV direito não-roto causado por doença de Takayasu, manifestado através de síndrome coronariana aguda, tratada cirurgicamente com sucesso.

Correlação entre a pressão de perda à manobra de Valsalva e a pressão máxima de fechamento uretral com a história clínica em mulheres com incontinência urinária de esforço

Objetivo: analisar a relação entre a pressão de perda com manobra de Valsalva e a pressão máxima de fechamento uretral com a queixa clínica em mulheres com incontinência urinária de esforço. Métodos: estudo retrospectivo no qual foram incluídas 164 pacientes com diagnóstico de incontinência urinária de esforço ou mista atendidas no setor de Uroginecologia e Cirurgia Vaginal do Departamento de Ginecologia da UNIFESP/EPM. As pacientes submeteram-se à anamnese padronizada, exame físico e estudo urodinâmico. A pressão de perda foi mensurada sob manobra de Valsalva (Valsalva leak point pressure - VLPP), com volume vesical de 200 mL. O perfil uretral foi realizado utilizando-se cateter de fluxo número 8, sendo medida a pressão máxima de fechamento uretral (PMFU). As pacientes foram agrupadas conforme a queixa clínica de perda urinária aos esforços e realizou-se análise estatística por meio do teste de chi² para verificar a proporção entre as variáveis. Utilizou-se, a seguir, a análise de variância (ANOVA) para verificar diferenças entre VLPP e PMFU com relação à gravidade subjetiva da incontinência. Resultados: a média de idade foi de 51,2 anos (19-82), sendo que 79 encontravam-se no menacme (48,2%) e 85 (51,8%) na pós-menopausa. A paridade média foi de 4,0 filhos (0-18). Houve correlação entre o número de pacientes com VLPP inferior a 60 cmH2O e a queixa clínica (p<0,0001), sendo que o grupo com perda urinária aos mínimos esforços teve média de 69,1 cmH2O na pressão de perda, o grupo com perda urinária aos moderados esforços teve média de 84,6 cmH2O e o grupo com perda urinária aos grandes esforços teve média de 90,6 cmH2O. Conclusões: VLPP correlacionou-se com a queixa clínica, sendo menor no grupo com perda aos mínimos esforços. Não houve correlação entre a PMFU e a queixa clínica.

Reproducibility of heart rate variability parameters measured in healthy subjects at rest and after a postural change maneuver

Heart rate variability (HRV) provides important information about cardiac autonomic modulation. Since it is a noninvasive and inexpensive method, HRV has been used to evaluate several parameters of cardiovascular health. However, the internal reproducibility of this method has been challenged in some studies. Our aim was to determine the intra-individual reproducibility of HRV parameters in short-term recordings obtained in supine and orthostatic positions. Electrocardiographic (ECG) recordings were obtained from 30 healthy subjects (20-49 years, 14 men) using a digital apparatus (sampling ratio = 250 Hz). ECG was recorded for 10 min in the supine position and for 10 min in the orthostatic position. The procedure was repeated 2-3 h later. Time and frequency domain analyses were performed. Frequency domain included low (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.4 Hz) bands. Power spectral analysis was performed by the autoregressive method and model order was set at 16. Intra-subject agreement was assessed by linear regression analysis, test of difference in variances and limits of agreement. Most HRV measures (pNN50, RMSSD, LF, HF, and LF/HF ratio) were reproducible independent of body position. Better correlation indexes (r > 0.6) were obtained in the orthostatic position. Bland-Altman plots revealed that most values were inside the agreement limits, indicating concordance between measures. Only SDNN and NNv in the supine position were not reproducible. Our results showed reproducibility of HRV parameters when recorded in the same individual with a short time between two exams. The increased sympathetic activity occurring in the orthostatic position probably facilitates reproducibility of the HRV indexes.

Exercise-induced ventricular arrhythmias and vagal dysfunction in Chagas disease patients with no apparent cardiac involvement

INTRODUCTION : Exercise-induced ventricular arrhythmia (EIVA) and autonomic imbalance are considered as early markers of heart disease in Chagas disease (ChD) patients. The objective of the present study was to verify the differences in the occurrence of EIVA and autonomic maneuver indexes between healthy individuals and ChD patients with no apparent cardiac involvement. METHODS : A total of 75 ChD patients with no apparent cardiac involvement, aged 44.7 (8.5) years, and 38 healthy individuals, aged 44.0 (9.2) years, were evaluated using echocardiography, symptom-limited treadmill exercise testing and autonomic function tests. RESULTS : The occurrence of EIVA was higher in the chagasic group (48%) than in the control group (23.7%) during both the effort and the recovery phases. Frequent ventricular contractions occurred only in the patient group. Additionally, the respiratory sinus arrhythmia index was significantly lower in the chagasic individuals compared with the control group. CONCLUSIONS : ChD patients with no apparent cardiac involvement had a higher frequency of EIVA as well as more vagal dysfunction by respiratory sinus arrhythmia. These results suggest that even when asymptomatic, ChD patients possess important arrhythmogenic substrates and subclinical disease.

Treatment of delayed rupture of the left ventricle after mitral valve replacement

Rupture of the left ventricle following mitral valve replacement is a catastrophic complication with deadly consequences. We report here the case of a 75-year-old man who underwent elective mitral valve replacement for severe mitral regurgitation. Delayed type 1 rupture of the left ventricle developed 3 hours postoperatively in the intensive care unit. A salvaging maneuver was used, which gained time, allowing reoperation and successful intraventricular repair.

Obstrucao Coronaria apos Implante por Cateter de Protese Valvar Aortica

Fundamentos: O implante por cateter de bioprótese valvar aórtica (TAVI) consolidou-se como alternativa para o tratamento de pacientes com estenose aórtica importante de alto risco cirúrgico. Contudo, há poucos dados na literatura com respeito à obstrução coronária que, apesar de rara, trata-se de grave complicação do TAVI. Objetivo: Avaliar, no contexto brasileiro, a presença dessa importante complicação. Métodos: Foram avaliados todos os casos de obstrução coronária incluídos no Registro Brasileiro de TAVI. Foram coletados dados clínicos, do procedimento, do manejo e de evolução intra-hospitalar. Resultados: Entre 418 pacientes consecutivos do registro, ocorreram três casos de obstrução coronária (incidência de 0,72%). Em sua totalidade, os pacientes eram do sexo feminino, sem cirurgia de revascularização miocárdica (CRM) prévia, com idade média de 85 ± 3 anos, EuroSCORE logístico de 15 ± 6% e STS de 9 ± 4%. Todos os casos foram realizados com a válvula balão-expansível Sapien XT. Em um dos pacientes, com dados de tomografia computadorizada pré-procedimento, verificaram-se origem das artérias coronárias baixa e seio de Valsalva estreito. Todos os pacientes apresentaram-se clinicamente com hipotensão importante e mantida, imediatamente após o implante da válvula, e, apesar de angioplastia com implante de stent, todos os pacientes foram a óbito, sendo dois periprocedimento e um durante hospitalização. Conclusão: A obstrução coronária como complicação do TAVI, apesar de rara, é potencialmente fatal, podendo ocorrer mais frequentemente em mulheres e com as próteses expansíveis por balão. Fatores anatômicos podem estar relacionados com sua ocorrência, ressaltando-se a importância de boa avaliação pré-procedimento no sentido de evitar essa grave complicação.

Heart Rate and Systolic Blood Pressure Variability on Recently Diagnosed Diabetics

Background:Diabetes affects approximately 250 million people in the world. Cardiovascular autonomic neuropathy is a common complication of diabetes that leads to severe postural hypotension, exercise intolerance, and increased incidence of silent myocardial infarction.Objective:To determine the variability of heart rate (HR) and systolic blood pressure (SBP) in recently diagnosed diabetic patients.Methods:The study included 30 patients with a diagnosis of type 2 diabetes of less than 2 years and 30 healthy controls. We used a Finapres® device to measure during five minutes beat-to-beat HR and blood pressure in three experimental conditions: supine position, standing position, and rhythmic breathing at 0.1 Hz. The results were analyzed in the time and frequency domains.Results:In the HR analysis, statistically significant differences were found in the time domain, specifically on short-term values such as standard deviation of NN intervals (SDNN), root mean square of successive differences (RMSSD), and number of pairs of successive NNs that differ by more than 50 ms (pNN50). In the BP analysis, there were no significant differences, but there was a sympathetic dominance in all three conditions. The baroreflex sensitivity (BRS) decreased in patients with early diabetes compared with healthy subjects during the standing maneuver.Conclusions:There is a decrease in HR variability in patients with early type 2 diabetes. No changes were observed in the BP analysis in the supine position, but there were changes in BRS with the standing maneuver, probably due to sympathetic hyperactivity.