Noninvasive diagnosis of allograft vascular disease after heart transplantation

OBJECTIVE: To determine the predictive values of noninvasive tests for the detection of allograft vascular disease. METHODS: We studied 39 patients with mean ages of 48±13 years and a follow-up period of 86±13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or = 50% obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results. RESULTS: Allograft vascular disease was found in 15 (38%) patients. The Holter test showed 15.4% sensitivity, 95.5% specificity. For the treadmill stress test, sensitivity was 10%, specificity was 100%. When thallium scintigraphy was used, sensitivity was 40%, specificity 95.8%. On echocardiography with dobutamine, we found a 63.6% sensitivity, 91.3% specificity. When the dobutamine echocardiogram was associated with scintigraphy, sensitivity was 71.4%, specificity was 87%. CONCLUSION: In this group of patients, the combination of two noninvasive methods (dobutamine echocardiography and thallium scintigraphy) may be a good alternative for the detection of allograft vascular disease in asymptomatic patients with normal ventricular function.

Histoplasmosis as a late infectious complication following heart transplantation in a patient with Chagas' disease

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25% of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature.

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.

Can the Cardiopulmonary 6-Minute Walk Test Reproduce the Usual Activities of Patients with Heart Failure?

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45±12 years, ejection fraction 23±7%, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4±1.8, 9.8±1.9 (60±10%), and 13.3±2.2 (90±10%); heart rate (bpm) 142±12, 110±13 (77±9%), and 126±11 (89±7%); distance walked (m) 733±147, 332±66, and 470±48; and respiratory exchange ratio (R) 1.13±0.06, 0.9±0.06, and 1.06±0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p<0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients.

Doses intermitentes de estatina em pacientes em hemodiálise com LDL-colesterol espontaneamente baixo

FUNDAMENTO: A mortalidade na diálise continua elevada e ocorre principalmente por causas cardiovasculares. A inflamação participa da gênese da aterosclerose acelerada, calcificação vascular, desnutrição e anemia, e tem enorme impacto na sobrevida destes pacientes. As estatinas, através dos seus efeitos pleiotrópicos, podem representar uma opção terapêutica para atenuação do processo inflamatório crônico dos pacientes em hemodiálise. OBJETIVO: Avaliar os efeitos de uma baixa dose de sinvastatina sobre marcadores inflamatórios, parâmetros hematimétricos e nutricionais de pacientes em hemodiálise. MÉTODOS: Pacientes em hemodiálise clinicamente estáveis foram divididos, segundo os níveis basais de LDL-colesterol, em um grupo com níveis abaixo (Grupo 1) e outro com níveis iguais ou superiores a 100 mg/dl (Grupo 2) e tratados com sinvastatina por oito semanas. O Grupo 1 recebeu apenas 20 mg após cada sessão de diálise (dose intermitente), enquanto o Grupo 2 recebeu 20 mg/dia. Dados laboratoriais, índice de resistência a eritropoetina e parâmetros nutricionais foram obtidos antes e após o tratamento. RESULTADOS: Houve redução significativa e equivalente dos níveis de proteína C-reativa em ambos os grupos (35,97±49,23% vs 38,32±32,69%, p=0,86). No Grupo 1 também houve tendência a queda da resistência a eritropoetina (228,6±16,2 vs 208,9±16,2, p=0,058) e melhora dos parâmetros hematimétricos (hematócrito: 33,1±5,9% vs 36,1±4,5%, p=0,021). CONCLUSÃO: A dose intermitente mostrou-se tão eficaz quanto a dose usual em reduzir os níveis de proteína C-reativa e resistência a eritropoetina, além de melhorar os parâmetros hematimétricos, apontando para uma importante redução do risco cardiovascular avaliado por esses parâmetros.

Desarrollo de un test de detección temprana de trastornos de aprendizaje- test de velocidad de denominación.

La evaluación de la velocidad de denominación permite la identificación temprana de niños en riesgo de desarrollar dislexia. Por lo tanto es importante contar con un test de velocidad de denominación que sea adecuadamente diseñado para nuestro contexto cultural. Debido a que las pruebas de denominación creadas en otros contextos culturales no funcionan adecuadamente al aplicarse transculturalmente, es que se propone construir el Test de Velocidad de Denominación. Éste es un test neuropsicológico para evaluar la velocidad de denominación (implica cronometrar el tiempo necesario para la producción de los nombres correctos de figuras que se le presentan al individuo). Se diseñarán las láminas y se realizará un estudio piloto para determinar las figuras más adecuadas a incluir. Luego se realizará un estudio de validez del test. Para completar ambos estudios se propone administrar alrededor de cincuenta tests a niños en edad pre-escolar (cuatro y cinco años) para el estudio de diseño de las láminas; y a alrededor de cien niños de primer a tercer grado se les administrará el Test de Velocidad de Denominación y dos subtests de la batería de lectura LEE, para el estudio de validez.

Ecocardiografia transesofágica intraoperatória na cardiomiopatia hipertrófica septal

Relatamos caso de paciente portador de cardiomiopatia hipertrófica septal submetido a correção cirúrgica em que o emprego da ecocardiografia transesofágica intraoperatória proporcionou o planejamento da abordagem cirúrgica e o reconhecimento imediato do resultado operatório.

Demodicidae und Sarcoptidae, bearbeitet von prof. G. Canestrini und prof. P. Kramer. Mit 31 abbildungen im texte.

7

Trombólise na embolia pulmonar maciça com base na capnografia volumétrica

Trata-se do primeiro relato envolvendo uma paciente em pós-operatório recente de neurocirurgia submetida à trombólise química por embolia pulmonar (EP) maciça e, por não apresentar condições clínicas, sem exame de imagem. Dados clínicos, gasométricos e capnográficos permitiram decidir pela trombólise com segurança. O gradiente P(a-et)CO2 passou de 46,4 mmHg para 11,8 mmHg (normal < 5 mmHg) e a fração do espaço morto alveolar end-tidal passou de 0,85 para 0,37 (normal < 0,15) do período pré-trombólise para o sétimo dia pós-trombólise. Conclui-se que a capnografia volumétrica (CV) foi útil no diagnóstico, bem como no acompanhamento clínico da paciente.