Ascending aorta measurements as assessed by ECG-gated multi-detector computed tomography: a pilot study to establish normative values for transcatheter therapies

The aim of this study was to provide an insight into normative values of the ascending aorta in regards to novel endovascular procedures using ECG-gated multi-detector CT angiography. Seventy-seven adult patients without ascending aortic abnormalities were evaluated. Measurements at relevant levels of the aortic root and ascending aorta were obtained. Diameter variations of the ascending aorta during cardiac cycle were also considered. Mean diameters (mm) were as follows: LV outflow tract 20.3 +/- 3.4, coronary sinus 34.2 +/- 4.1, sino-tubular junction 29.7 +/- 3.4 and mid ascending aorta 32.7 +/- 3.8 with coefficients of variation (CV) ranging from 12 to 17%. Mean distances (mm) were: from the plane passing through the proximal insertions of the aortic valve cusps to the right brachio-cephalic artery (BCA) 92.6 +/- 11.8, from the plane passing through the proximal insertions of the aortic valve cusps to the proximal coronary ostium 12.1 +/- 3.7, and between both coronary ostia 7.2 +/- 3.1, minimal arc of the ascending aorta from left coronary ostium to right BCA 52.9 +/- 9.5, and the fibrous continuity between the aortic valve and the anterior leaflet of the mitral valve 14.6 +/- 3.3, CV 13-43%. Mean aortic valve area was 582.0 +/- 131.9 mm(2). The variation of the antero-posterior and transverse diameters of the ascending aorta during the cardiac cycle were 8.4% and 7.3%, respectively. Results showed large inter-individual variations in diameters and distances but with limited intra-individual variations during the cardiac cycle. A personalized approach for planning endovascular devices must be considered.

Une cause de cardiomyopathie dilatée chez l'enfant: le déficit primaire en carnitine [A cause of dilated cardiomyopathy in child: primary carnitine deficiency].

AIM: The aim of this case report was to show the importance to research metabolic etiology, especially a carnitine deficiency in dilated cardiomyopathy of children. CASE REPORT: A three years old Togolese child presented muscular hypotonia, dyspnea. Examination showed left galop murmur and systolic murmur 2/6. Chest X-ray showed cardiomegaly (CTI: 0.66), electrocardiogram, a sinusal rythm, left ventricle hypertrophy and T wave abnormalities. Echocardiogram showed a markedly dilated left ventricle with reduced systolic function (EF: 0.43; reference range 0.55-0.80) and moderate mitral regurgitation. The inflammatory signs where negatives. Magnetic resonance imaging don't show signs of ischemic or myocarditis. The levels of free and total plasmatic carnitine decreased: 3μmol/L (N: 18-48μmol/L) and 5μmol/l (N: 29-70μmol/L) respectively. Mutation analysis of the gene SLC22A5 confirms the diagnosis of primary systemic carnitine deficiency. Treatment with oral carnitine was started at 200mg/kg per day. Within three weeks of treatment, we observed the decrease of all symptoms and the left ventricular size and function normalized (EF: 0.62). He has now been on oral carnitine for live. CONCLUSION: Primary carnitine deficiency is a cause of dilated cardiomyopathy in child. It must systematically be suspected when a child presents a primitive cardiomyopathy. The treatment with oral carnitine for live is simple, with excellent prognosis.

Pulmonary hypertension complicating isolated atrial septal defect.

Atrial septal defect (ASD) typically is asymptomatic in infancy and early childhood and elective defect closure usually is performed at an age between 4 - 6 years. Severe pulmonary hypertension (PHT) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PHT complicating an isolated ASD and requiring early surgical correction in the fi rst year of life. 355 pediatric patients underwent treatment for an isolated ASD either surgically or by catheter intervention during a 10 year period (1996 - 2006) at two tertiary referral centers. 297 patients had secundum ASD and 58 primum ASD with mild to moderate mitral regurgitation. 8 infants were found with isolated ASD (six with secundum and two with primum ASD) associated with signifi cant PHT, accounting for 2.2% of all ASD patients in our centers. These 8 infants had invasively measured pulmonary artery pressures between 50 and 100% of systemic pressure. Median size of the ASD at the time of surgery was 14mm (7 - 20). They were operated in the fi rst year of life and had complicated postoperative courses requiring specifi c treatment for PHT for up to 16 weeks (median 12) postoperatively. Compared to ASD patients without PHT these infants had prolonged postoperative ICU stay of 5 - 9 days (median 8) and prolonged perioperative overall hospital stay of 8 - 32 days (median 15). Ultimate outcome in all 8 infants was good with persistent normalization of pulmonary pressures during mid-term follow-up of between 8 to 60 months (median 28). All other ASD patients had normal pulmonary pressures and mean age at defect closure was higher being 6.2 years for secundum ASD and 3.2 years for primum ASD. In conclusion, ASD is rarely associated with signifi cant PHT in infancy but then requires early surgery to normalize the prognosis of the patients.

No association between herpes simplex virus 1 and cardiac myxoma.

PRINCIPLES: Cardiac myxoma is the most commonly diagnosed cardiac tumour. Infection of herpes simplex virus 1 (HSV1) has been postulated to be a factor for this pathologic entity. The aim of the current study was to evaluate the association between HSV 1 and myxoma occurrence.METHODS: Between 1965 and 2005, 70 patients (36 female, mean age: 52.6 years) underwent a resection of myxoma. Selected variables such as hospital mortality and morbidity were studied. A follow-up (FU; mean FU time: 138 +/- 83 months) was obtained (76% complete). Immunohistological studies with monoclonal antibodies against HSV type 1 were performed on tumour biopsies of 40 patients.RESULTS: The mean age was 53 +/- 16 years (range 23 to 84 years, 51% female). Of the investigated population, 31 (44%) were in New York Heart Association (NYHA) class III-IV. Mitral valve stenosis was identified in 14 patients (20%), and in 25 (36%) patients mitral valve was insufficient. During hospitalisation 3 patients suffered from a transient neurological disorder, and in addition to myxoma resection 18 (25.7%) patients had to undergo an additional intervention. The overall survival rate was 91% at 40 years. There was no early postoperative mortality in follow-up, although 4 patients died and 2 patients had been re-operated on for recurrent myxomas after 2 and 9 years. Immunohistology revealed no positive signals for HSV-1 antigens among the 40 analysed cases.CONCLUSION: Complete surgical resection, septum included, was the treatment of choice and mandatory to prevent relapse. Peri-operative morbidity and mortality over 40 years remained low, and no association between HSV infection and occurrence of cardiac myxoma was found.

Frequency of severe pulmonary hypertension complicating "isolated" atrial septal defect in infancy.

Atrial septal defects (ASDs) are typically asymptomatic in infancy and early childhood, and elective defect closure is usually performed at ages of 4 to 6 years. Severe pulmonary hypertension (PH) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PH complicating an isolated ASD and requiring early surgical correction. During a 10-year period (1996 to 2006), 355 pediatric patients underwent treatment for isolated ASDs either surgically or by catheter intervention at 2 tertiary referral centers. Two hundred ninety-seven patients had secundum ASDs, and 58 had primum ASDs with mild to moderate mitral regurgitation. Eight infants were found with isolated ASDs (6 with secundum ASDs and 2 with primum ASDs) associated with significant PH, accounting for 2.2% of all patients with ASDs at the centers. These 8 infants had invasively measured pulmonary artery pressures of 50% to 100% of systemic pressure. They were operated in the first year of life and had complicated postoperative courses requiring specific treatment for PH for up to 16 weeks postoperatively. The ultimate outcomes in all 8 infants were good, with persistent normalization of pulmonary pressures during midterm follow-up of up to 60 months (median 28). All other patients with ASDs had normal pulmonary pressures, and the mean age at defect closure was significantly older, at 6.2 years for secundum ASDs and 3.2 years for primum ASDs. In conclusion, ASDs were rarely associated with significant PH in infancy but then required early surgery and were associated with excellent midterm outcomes in these patients.

Predictors of mortality from pump failure and sudden cardiac death in patients with systolic heart failure and left ventricular dyssynchrony: results of the CARE-HF trial.

BACKGROUND: Determining a specific death cause may facilitate individualized therapy in patients with heart failure (HF). Cardiac resynchronization therapy (CRT) decreased mortality in the Cardiac Resynchronization in Heart Failure trial by reducing pump failure and sudden cardiac death (SCD). This study analyzes predictors of specific causes of death. METHODS AND RESULTS: Univariate and multivariate analyses used 8 baseline and 3-month post-randomization variables to predict pump failure and SCD (categorized as "definite," "probable," and "possible"). Of 255 deaths, 197 were cardiovascular. There were 71 SCDs with a risk reduction by CRT of 0.47 (95% confidence interval 0.29-0.76; P = .002) with similar reductions in SCD classified as definite, probable, and possible. Univariate SCD predictors were 3-month HF status (mitral regurgitation [MR] severity, plasma brain natriuretic peptide [BNP], end-diastolic volume, and systolic blood pressure), whereas randomization to CRT decreased risk. Multivariate SCD predictors were randomization to CRT 0.56 (0.53-0.96, P = .035) and 3-month MR severity 1.82 (1.77-2.60, P = .0012). Univariate pump failure death predictors related to baseline HF state (quality of life score, interventricular mechanical delay, end-diastolic volume, plasma BNP, MR severity, and systolic pressure), whereas randomization to CRT and nonischemic cardiomyopathy decreased risk; multivariate predictors of pump failure death were baseline plasma BNP and systolic pressure and randomization to CRT. CONCLUSION: CRT decreased SCD in patients with systolic HF and ventricular dyssynchrony. SCD risk was increased with increased severity of MR (including the 3-month value for MR as a time-dependent covariate) and reduced by randomization to CRT. HF death was increased related to the level of systolic blood pressure, log BNP, and randomization to CRT. These results emphasize the importance and interdependence of HF severity to mortality from pump failure and SCD.

Connexin 43 expression in human hypertrophied heart due to pressure and volume overload.

Left ventricular hypertrophy (LVH) is due to pressure overload or mechanical stretch and is thought to be associated with remodeling of gap-junctions. We investigated whether the expression of connexin 43 (Cx43) is altered in humans in response to different degrees of LVH. The expression of Cx43 was analyzed by quantitative polymerase chain reaction, Western blot analysis and immunohistochemistry on left ventricular biopsies from patients undergoing aortic or mitral valve replacement. Three groups were analyzed: patients with aortic stenosis with severe LVH (n=9) versus only mild LVH (n=7), and patients with LVH caused by mitral regurgitation (n=5). Cx43 mRNA expression and protein expression were similar in the three groups studied. Furthermore, immunohistochemistry revealed no change in Cx43 distribution. We can conclude that when compared with mild LVH or with LVH due to volume overload, severe LVH due to chronic pressure overload is not accompanied by detectable changes of Cx43 expression or spatial distribution.

In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis.

IMPORTANCE: There are limited prospective, controlled data evaluating survival in patients receiving early surgery vs medical therapy for prosthetic valve endocarditis (PVE). OBJECTIVE: To determine the in-hospital and 1-year mortality in patients with PVE who undergo valve replacement during index hospitalization compared with patients who receive medical therapy alone, after controlling for survival and treatment selection bias. DESIGN, SETTING, AND PARTICIPANTS: Participants were enrolled between June 2000 and December 2006 in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. We evaluated the effect of treatment assignment on mortality, after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum. INTERVENTIONS: Valve replacement during index hospitalization (early surgery) vs medical therapy. MAIN OUTCOMES AND MEASURES: In-hospital and 1-year mortality. RESULTS: Of the 1025 patients with PVE, 490 patients (47.8%) underwent early surgery and 535 individuals (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44 [95% CI, 0.38-0.52] and lower 1-year mortality: HR, 0.57 [95% CI, 0.49-0.67]). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90 [95% CI, 0.76-1.07] and 1-year mortality: HR, 1.04 [95% CI, 0.89-1.23]). Subgroup analysis indicated a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21.2% vs 37.5%; P = .03). At 1-year follow-up, the reduced mortality with surgery was observed in the fourth (24.8% vs 42.9%; P = .007) and fifth (27.9% vs 50.0%; P = .007) quintiles of surgical propensity. CONCLUSIONS AND RELEVANCE: Prosthetic valve endocarditis remains associated with a high 1-year mortality rate. After adjustment for differences in clinical characteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. Further studies are needed to define the effect and timing of surgery in patients with PVE who have indications for surgery.

Propagação vegetativa do pessegueiro por alporquia

A produção de mudas de frutíferas perenes está baseada na multiplicação vegetativa por manter as características da planta de origem. No pessegueiro, as mudas são obtidas por enxertia de gema ativa. Como não existem relatos de utilização da alporquia na multiplicação do pessegueiro, este trabalho teve como objetivo avaliar sua eficiência na propagação desta frutífera. O experimento foi realizado na Embrapa Clima Temperado, Pelotas-RS, nos meses de junho a setembro de 2001 com as cultivares Chirua e Maciel. A alporquia foi realizada em quatro épocas. As plantas, na época I (06-06), apresentavam-se dormentes. Nas demais épocas, apresentavam flores no estádio de balão ou abertas (épocas II e III - 26-06 e 16-07), enquanto, na época IV (08-08), possuíam brotações e frutos em desenvolvimento. Foi retirado um anel entre 1,0 e 1,5 centímetro de largura da casca de cada ramo com um canivete de enxertia. Em cada ferimento, foram colocadas quatro gotas do ácido indolbutírico (3000 mg.L-1). Houve 100% de enraizamento. Em todos os ramos das duas cultivares, ocorreu a formação de raízes vigorosas e em grande número. Nas alporquias realizadas na época I, as raízes apresentaram maior ramificação. Os resultados foram satisfatórios, indicando que o método pode ser utilizado com sucesso no pessegueiro, principalmente em trabalhos de pesquisa que necessitem de um pequeno número de plantas idênticas geneticamente.

Germinação in vitro e armazenamento do pólen de Eugenia involucrata DC (Myrtaceae)

O objetivo do presente trabalho foi o de estabelecer condições adequadas para testes de germinação in vitro do pólen de cerejeira-do-rio-grande (Eugenia involucrata DC), bem como verificar a possibilidade de armazená-lo em freezer (-16,5°C). O pólen foi coletado de flores em estádio de balão e logo após a antese. Os meios de cultura testados foram o meio padrão (10% de açúcar e 1% de ágar em água destilada) e este acrescido de duas concentrações de H3BO3 (0,65mM e 1,3mM). Foram testadas as temperaturas de incubação de 25 e 30ºC. O período de incubação foi de três horas, para todos os tratamentos. A incubação a 25°C, em meio de cultura-padrão, proporcionou boas médias (61,4%) de germinação in vitro. Pólen coletado de flores após a antese apresentou maiores porcentagens de germinação. O boro não influenciou na germinação média do pólen. O pólen de cerejeira-do-rio-grande manteve sua viabilidade (60,0%) após 90 dias de armazenamento a -16,5°C. Entretanto, após 220 e 280 dias, esta foi reduzida para 40,6% e 24,2% e, após 530 dias, houve perda total de viabilidade.

Caracterização da curva de maturação de pêssegos 'Aurora-1', na região de Jaboticabal-SP

O objetivo deste trabalho foi caracterizar a curva de maturação de pêssegos 'Aurora-1' para a região de Jaboticabal-SP, através de avaliações físicas e químicas dos frutos. O experimento foi conduzido em pomar comercial, no município de Vista Alegre do Alto, onde foram marcados ramos de 15 plantas, com flores no estádio de "balão". Após 20 dias, iniciou-se a coleta dos frutos, com intervalos de 7 dias, até a sua maturação completa (111 dias). Através dos dados de altura e de diâmetro, verificou-se que os frutos da cultivar 'Aurora-1' seguiram o padrão de crescimento semelhante ao encontrado na literatura, que é de uma curva sigmoidal dupla, atingindo no final da maturação altura de 59,84±6,9 mm e diâmetro de 50,30±5,8 mm. Em relação ao peso dos frutos no período de 90 a 111 dias, houve incremento de 41,08 g para 58,82 g (43%). O teor de ácidos orgânicos e a firmeza diminuíram na mesma proporção em que ocorreu o aumento no conteúdo de sólidos solúveis e carboidratos solúveis durante o período de desenvolvimento. A coloração interna do fruto evoluiu, passando de amarelo-esverdeada para amarelo- intensa. A cor de fundo nas duas primeiras amostragens apresentaram valores semelhantes à cor interna, evoluindo a partir desse ponto de amarelo-esverdeada para alaranjada. Já a cor de recobrimento teve uma diferença mais pronunciada, passando de amarelo-esverdeada para vermelho-intensa, característica da cultivar. Esses resultados sinalizaram que, aos 90 e 97 dias, os frutos atingiram sua maturação fisiológica e que, aos 104 e 111 dias, encontravam-se sobremaduros.

Plan de cuidados para el paciente con Parkinson en tratamiento con L-Dopa intraduodenal

En 1817, James Parkinson describió por primera vez la enfermedad de Parkinson, quien la denominó"parálisis agitante" en alusión a los síntomas que provoca. Esta afección tiene una incidencia anual de 8-18 casos por cada 100.000 habitantes y afecta a personas mayores de 60 años, sin distinción sexual. Actualmente, no se dispone de ningún tratamiento médico ni quirúrgico que retrase su progresión. Por ello, el principal objetivo es intentar disminuir los síntomas y conseguir la independencia funcional del paciente. Los pacientes con Parkinson suelen recibir tratamiento a través de atención primaria y sólo recurren al hospital cuando presentan complicaciones de la enfermedad o para iniciar nuevas opciones de tratamiento. Uno de los tratamientos que se está utilizando actualmente es la administración de L-dopa intraduodenal a través de gastrostomía endoscópica percutánea. Esta opción de tratamiento se utiliza como alternativa al tratamiento con L-dopa en comprimidos cuando el paciente, tras una buena respuesta al tratamiento por vía oral (8-10 años), presenta un empeoramiento de la sintomatología que cursa con fluctuaciones motoras, en las que se alternan episodios de buena situación motora con incapacidad grave. En este artículo desarrollamos un plan de cuidados de un paciente con Parkinson en el que se ha decidido iniciar tratamiento con L-dopa intraduodenal. Entendemos que es importante conocer desde una óptica enfermera cuáles son los cuidados especiales que precisan este tipo de pacientes.

Estabelecimento de meio de cultura e quantificação da germinação de grãos de pólen de cultivares de marmeleiros

Visando a dar suporte aos trabalhos de melhoramento genético do marmeleiro (Cydoniaoblonga Mill.), voltados para a seleção de cultivares altamente produtivas, aptas a serem cultivadas em regiões subtropicais e produtoras de doces de qualidade superior, objetivou-se ajustar o meio de cultura básico para a germinação de grãos de pólen de diferentes cultivares dessa espécie e quantificar o número de estames, número de grãos de pólen por antera e por flor. O pólen utilizado foi da cultivar Portugal, obtido de anteras provenientes de flores em estádio de balão. Em seguida, com auxílio de um pincel, os grãos de pólen foram espalhados sobre a superfície de placas de Petri, contendo 20 mL de meio de cultura, de acordo com os seguintes experimentos: 1) concentrações de ágar (4; 6; 8 e 10 g L-1) e valores de pH (3,5; 4,5; 5,5 e 6,5); 2) concentrações de sacarose (0; 30; 60 e 90 g L-1); 3) concentrações de nitrato de cálcio (0; 200; 400 e 800 mg L-1); 4) concentrações de ácido bórico (0; 400; 800 e 1.200 mg L-1); e 5) tempo de emissão do tubo polínico (0; 1; 2; 3; 4; 5 e 6 horas após a inoculação), os quais foram montados de forma sequencial. Após, avaliou-se a taxa de germinação dos grãos de pólen das 27 cultivares (Alaranjado, Alongado, Apple, BA29, Bereckzy, Champion, Cheldow, Constantinopla, CTS 207, Dangers, De Patras, De Vranja, Dulot, Fuller, Mendoza INTA 37, Kiakami, Lajeado, Meeck Profilic, Meliforme, Pineapple, Portugal, Provence, Radaelli, Rea's Mamouth, Smyrna, Van Deman e Zuquerineta), além do número de estames, número de grãos de pólen por antera e por flor. Realizando-se as leituras da porcentagem de germinação após cinco horas de incubação, conclui-se que o meio de cultura para a germinação de grãos de pólen do marmeleiro deve ser acrescido de 68 g L-1 de sacarose e 366 mg L-1 de ácido bórico, sendo o pH aferido para 5,8 e o meio solidificado com 10 g L-1 de ágar. Foram constatadas diferenças entre as cultivares quanto à quantidade de grãos de pólen e à capacidade germinativa dos mesmos, que variou de 37,83% a 82,23% entre as cultivares. Os grãos de pólen da cultivar Alaranjado apresentaram maior porcentagem de germinação, além da maior quantidade de grãos de pólen por flor.

Tomografia computadorizada das patologias acometendo o compartimento iliopsoas

Este trabalho tem como objetivo revisar as patologias que acometem o compartimento iliopsoas. Foi realizada análise retrospectiva de casos com acometimento do compartimento iliopsoas avaliados por tomografia computadorizada (TC), no Departamento de Radiologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, nos últimos dez anos, confirmados por biópsia cirúrgica ou percutânea. Os principais diagnósticos encontrados foram neoplasias, abscessos e hematomas. Os achados tomográficos baseiam-se na extensão do acometimento iliopsoas, no grau de atenuação, margens da lesão, presença de gás e/ou calcificações, destruição óssea, infiltração da gordura e acometimento de estruturas abdominais adjacentes. A TC é o método de escolha na avaliação do compartimento iliopsoas, podendo ser utilizada para orientar biópsias percutâneas, cirúrgicas ou drenagem. Porém, os achados isolados do estudo por TC, sem o conhecimento da história clínica, não são específicos para permitir a diferenciação das diversas patologias que acometem o compartimento iliopsoas.

Utilização de álcool absoluto no tratamento das malformações venosas

O tratamento das malformações venosas pode ser realizado por ressecção cirúrgica ou esclerose farmacológica. Este estudo mostra os resultados de 12 pacientes com angiodisplasia submetidos a múltiplas aplicações diretas de etanol na lesão, após exame clínico e angiografia venosa percutânea. Dez pacientes referiram melhora dos sintomas e diminuição do tamanho da lesão. Todos os pacientes queixaram-se de ardência durante a aplicação, que cessou no máximo em 24 horas. As complicações encontradas foram três casos de úlceras pequenas na pele e um caso de hiperemia no membro tratado, associada a linfonodomegalia dolorosa. Concluiu-se que o tratamento escleroterapêutico das malformações venosas com infusão de pequenos volumes de etanol apresenta as vantagens de ser um tratamento seguro, eficaz, simples, fácil e rápido, de baixo custo, bem tolerado e com poucas complicações.