ABSTRACT
O conhecimento sobre a estrutura e a função da circulação pulmonar evoluiu sensivelmente nas últimas décadas. A utilização de exames de imagem não invasivos para a avaliação da anatomia e da função dos vasos pulmonares e do coração ganhou ainda mais importância com o advento de tratamentos até então indisponíveis. Além do auxílio para o diagnóstico, as informações obtidas têm se mostrado fundamentais para o estabelecimento de prognósticos e como parâmetro de sucesso dos tratamentos. A presente revisão discute os diversos métodos que podem ser utilizados para a avaliação da circulação pulmonar por imagens existentes nos dias de hoje, desde técnicas amplamente disponíveis e de relativa baixa complexidade técnica, como a radiografia de tórax, até métodos complexos e promissores, como a tomografia de impedância elétrica.
Knowledge of the structure and function of pulmonary circulation has evolved considerably in the last few decades. The use of non-invasive imaging techniques to assess the anatomy and function of the pulmonary vessels and heart has taken on added importance with the recent advent of novel therapies. Imaging findings not only constitute a diagnostic tool but have also proven to be essential for prognosis and treatment follow-up. This article reviews the myriad of imaging methods currently available for the assessment of pulmonary circulation, from the simple chest X-ray to techniques that are more complex and promising, such as electrical impedance tomography.
Subject(s)
Humans , Diagnostic Imaging/methods , Pulmonary Circulation/physiologyABSTRACT
Objective: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Methods: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35 percent were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. Results: Mean left ventricular ejection fraction was 29±4 percent (ranged from 9 percent to 35 percent). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7 percent (9 patients). The 4-year survival rate was 89.7 percent. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5 percent. Left ventricular ejection fraction rise from 32±5 percent to 39±5 percent, p <0.001. Gated left ventricular ejection fraction at exercise/ rest increased markedly after surgery: from 27±8 percent/ 23±7 percent to 37±5 percent/ 31±6 percent, p <0.001. Conclusions: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/ functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/ rest.
Subject(s)
Female , Humans , Male , Middle Aged , Cardiomyopathies/surgery , Coronary Artery Bypass/mortality , Preoperative Care/standards , Stroke Volume/physiology , Ventricular Dysfunction, Left/surgery , Cardiomyopathies/physiopathology , Cardiomyopathies , Cardiomyopathies , Epidemiologic Methods , Hospital Mortality , Preoperative Care/methods , Treatment Outcome , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left , Ventricular Dysfunction, LeftABSTRACT
OBJETIVO: Elaborar e validar um protocolo para teste de caminhada de seis minutos em esteira (TC6est) para a avaliação de pacientes com hipertensão arterial pulmonar (HAP). MÉTODOS: A população do estudo foi composta por 73 pacientes com HAP diagnosticados através de cateterismo cardíaco direito, com ou sem inalação de NO. Todos os pacientes realizaram um TC6 em solo e três TC6est baseados em um protocolo de incremento de velocidade pré-determinado e intercalados por um período de repouso. Os pacientes que haviam realizado o teste hemodinâmico com inalação de NO realizaram o terceiro TC6est com a inalação da mesma dose de NO utilizada durante o cateterismo. RESULTADOS: Os resultados mostraram uma correlação da distância caminhada no TC6est com os dados hemodinâmicos, assim como com a classe funcional e com a distância caminhada no solo. Além disso, a distância percorrida no TC6est apresentou uma correlação significativa com a sobrevida, confirmando, portanto, sua correlação com a gravidade da doença. A inalação de NO durante o TC6est levou a variações compatíveis com as variações hemodinâmicas frente à mesma dose de NO, sugerindo que o protocolo em questão pode refletir o efeito de intervenções terapêuticas. CONCLUSÕES: Concluímos que a distância percorrida no TC6est é um marcador funcional e prognóstico na avaliação de rotina de pacientes com HAP.
OBJECTIVE: To develop and validate a protocol for the treadmill six-minute walk test (tread6MWT) to evaluate patients with pulmonary arterial hypertension (PAH). METHODS:The study population comprised 73 patients with PAH, diagnosed by means of right heart catheterization, with or without NO inhalation. All patients performed a hallway 6MWT and three tread6MWTs based on a pre-determined incremental speed protocol and interposed by a rest period. The patients who had been submitted to hemodynamic testing using NO performed the third tread6MWT while inhaling the same dose of NO that had been used during the catheterization. RESULTS: We found that the treadmill six-minute walk distance (tread6MWD) correlated with hemodynamic data, functional class and the hallway six-minute walk distance (6MWD). In addition, the tread6MWD correlated significantly with survival, thereby confirming the correlation with disease severity. Inhalation of NO during the tread6MWT led to variations that were consistent with the hemodynamic changes induced by the same dose of inhaled NO, suggesting that the protocol developed can reflect the effect of therapeutic interventions. CONCLUSIONS: We conclude that the tread6MWD is a useful prognostic and functional marker for the routine evaluation of PAH patients.
Subject(s)
Adult , Female , Humans , Male , Exercise Test/standards , Hypertension, Pulmonary/physiopathology , Walking/physiology , Analysis of Variance , Cardiac Catheterization , Exercise Test/instrumentation , Exercise Test/methods , Hemodynamics/physiology , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/mortality , Inhalation/physiology , Kaplan-Meier Estimate , Nitric Oxide/administration & dosageABSTRACT
A doença veno-oclusiva pulmonar (DVOP) é uma causa rara de hipertensão pulmonar. A biópsia cirúrgica era usualmente necessária para seu diagnóstico; entretanto, sua morbidade, mortalidade e seu impacto limitado levantou a discussão sobre o diagnóstico não-invasivo. Apresentamos um caso de uma paciente com dispnéia progressiva, hipoxemia e hipertensão pulmonar no cateterismo. A tomografia computadorizada revelou espessamento septal e micronódulos difusos. O lavado broncoalveolar revelou hemorragia alveolar oculta. Iniciou-se tratamento com antagonista da endotelina, que resultou em melhora clínica e funcional. A hemorragia alveolar oculta é uma característica da DVOP capaz de diferenciá-la da hipertensão pulmonar idiopática. Acreditamos que sua presença, associada à tomografia característica, seja suficiente para o diagnóstico de DVOP.
Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension. Surgical biopsy was usually required for diagnostic confirmation. However, the morbidity, mortality and limited benefit of this procedure have generated discussion regarding noninvasive diagnostic techniques. We present the case of a female patient with progressive dyspnea, hypoxemia and pulmonary hypertension, the last diagnosed via catheterization. Computed tomography revealed septal thickening and diffuse micronodules. Bronchoalveolar lavage revealed occult alveolar hemorrhage. Treatment with an endothelin antagonist was started, resulting in symptomatic and functional improvement. Occult alveolar hemorrhage differentiates PVOD from idiopathic pulmonary hypertension. We believe that this finding, in combination with characteristic tomographic findings, is sufficient to establish a diagnosis of PVOD.
Subject(s)
Female , Humans , Middle Aged , Hypertension, Pulmonary/etiology , Lung/pathology , Pulmonary Veno-Occlusive Disease/pathology , Biopsy , Bronchoalveolar Lavage , Bronchoscopy , Pulmonary Veno-Occlusive Disease/complications , Pulmonary Veno-Occlusive Disease/drug therapy , Receptors, Endothelin/antagonists & inhibitors , Receptors, Endothelin/therapeutic useABSTRACT
A hipertensão pulmonar associada ao tromboembolismo pulmonar crônico é a única forma potencialmente curável de hipertensão pulmonar, desde que o tratamento cirúrgico seja possível. Existem, entretanto, limitações para o diagnóstico não-invasivo definitivo. Apresentamos o caso de uma paciente de 40 anos, com diagnóstico confirmado de hipertensão arterial pulmonar idiopática desde 1994, a qual evoluiu com sobreposição de trombos em vasos pulmonares simulando hipertensão pulmonar associada ao tromboembolismo pulmonar crônico. O reconhecimento dessas condições, as quais apresentam alta mortalidade intra-operatória e baixa resolutividade cirúrgica, é muito difícil na prática clínica. Discutiremos a abordagem atual para a seleção de candidatos para o tratamento cirúrgico da hipertensão pulmonar associada ao tromboembolismo pulmonar crônico e as possíveis repercussões da seleção inadequada.
Chronic thromboembolic pulmonary hypertension is the only potentially curable form of pulmonary hypertension, assuming that surgical treatment is possible. However, there are hindrances to making a definitive, noninvasive diagnosis. We present the case of a 40-year-old female patient with idiopathic pulmonary arterial hypertension, confirmed in 1994. This patient developed thrombi in pulmonary vessels (as an overlap syndrome) mimicking chronic thromboembolic pulmonary hypertension. The identification of these conditions, which present high intraoperative mortality and unsatisfactory surgical resolution, is quite difficult in clinical practice. We discuss the current approach to candidate selection for surgical treatment of chronic thromboembolic pulmonary hypertension and the possible repercussions of inappropriate selection.
Subject(s)
Adult , Female , Humans , Endarterectomy , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/surgery , Pulmonary Embolism/diagnosis , Chronic Disease , Hemodynamics , Hypertension, Pulmonary/etiology , Patient Selection , Pulmonary Artery/physiopathology , Pulmonary Artery , Pulmonary Embolism/complications , Pulmonary Embolism/surgery , Vascular ResistanceABSTRACT
OBJECTIVES: Certain aspects of pulmonary pathology observed in autopsies of HIV/AIDS patients are still unknown. This study considers 250 autopsies of HIV/AIDS patients who died of acute respiratory failure and describes the demographic data, etiology, and histological pulmonary findings of the various pathologies. METHODS: The following data were obtained: age, sex, and major associated diseases (found at the autopsy). Pulmonary histopathology was categorized as: diffuse alveolar damage; pulmonary edema; alveolar hemorrhage; and acute interstitial pneumonia. Odds ratio of the HIV/AIDS-associated diseases developing a specific histopathological pattern was determined by logistic regression. RESULTS: A total of 197 men and 53 women were studied. The mean age was 36 years. Bacterial bronchopneumonia was present in 36 percent (91 cases) and Pneumocystis jiroveci pneumonia in 27 percent (68) of patients. Pulmonary histopathology showed acute interstitial pneumonia in 40 percent (99), diffuse alveolar damage in 36 percent (89), pulmonary edema in 13 percent (33), and alveolar hemorrhage in 12 percent (29) of patients. Multivariate analysis showed a significant and positive association between Pneumocystis jiroveci pneumonia and acute interstitial pneumonia (Odds ratio, 4.51; 95 percent CI, 2.46 - 8.24; p < 0.001), severe sepsis and/or septic shock and diffuse alveolar damage (Odds ratio, 3.60; 95 percent CI, 1.78 -7.27; p < 0.001), and cytomegalovirus and acute interstitial pneumonia (Odds ratio, 2.22; 95 percent CI, 1.01 - 4.93; p = 0.05). CONCLUSIONS: This report is the first autopsy study to include demographic data, etiologic diagnosis, and respective histopathological findings in patients with HIV/AIDS and acute respiratory failure. Further studies are necessary to elucidate the complete pulmonary physiopathological mechanism involved with each HIV/AIDS-associated disease.
Subject(s)
Adolescent , Adult , Child , Child, Preschool , Female , Humans , Infant , Male , Middle Aged , Young Adult , HIV Infections/pathology , Lung/pathology , Respiratory Insufficiency/pathology , Autopsy , Acquired Immunodeficiency Syndrome/pathology , Bacterial Infections/mortality , Bronchopneumonia/mortality , Cause of Death , Pneumonia, Pneumocystis/mortality , Retrospective Studies , Young AdultABSTRACT
O uso de inibidores de fosfodiesterase, mais especificamente o sildenafil, no tratamento da hipertensão arterial pulmonar mostrou bons resultados, indicados por melhora dos parâmetros hemodinâmicos e da capacidade funcional. Poucos estudos existem a respeito dos efeitos de seus análogos como o tadalafil. O presente caso refere-se a uma paciente com hipertensão arterial pulmonar idiopática em classe funcional IV (NYHA) com resposta significativa ao uso de tadalafil.
Phosphodiesterase inhibitors like sildenafil have already been shown to improve functional capacity and hemodynamics in the treatment of pulmonary arterial hypertension. Few studies address the effects of new phosphodiesterase inhibitors as tadalafil. We report a case of a patient with idiopathic pulmonary arterial hypertension in functional class IV (New York Heart Association) with significant response to treatment with tadalafil.
Subject(s)
Humans , Female , Adult , 3',5'-Cyclic-GMP Phosphodiesterases , Carbolines/therapeutic use , Hypertension, Pulmonary/drug therapy , Phosphodiesterase Inhibitors/therapeutic use , Severity of Illness IndexABSTRACT
OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of Säo Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69 percent) received antimicrobials on the day of study, 72 (57 percent) for treatment, and 15 (12 percent) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8 percent), non- intensive care unit nosocomial infection in 24 (33.3 percent), and intensive care unit-acquired infection in 22 patients (30.6 percent). Eleven patients (15.3 percent) had no defined type. The most frequently reported infections were respiratory (58.5 percent). The most frequently isolated bacteria were Enterobacteriaceae (33.8 percent), Pseudomonas aeruginosa (26.4 percent), and Staphylococcus aureus (16.9 percent; [100 percent resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8 percent. Patients with infection had a mortality rate of 34.7 percent. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms)...
Subject(s)
Humans , Male , Female , Middle Aged , Bacterial Infections/epidemiology , Cross Infection/epidemiology , Intensive Care Units , Brazil/epidemiology , Community-Acquired Infections/epidemiology , Drug Resistance, Microbial , Enterobacteriaceae , Hospitals, Teaching , Logistic Models , Prevalence , Risk FactorsABSTRACT
A isquemia miocárdica é o evento fisiopatológico final da doença arterial coronária (DAC). Quando desprovida de sintomatologia é denominada "isquemia miocárdica silenciosa", sendo a responsável pela maior parte dos eventos isquêmicos totais. Ainda permanecem incertos os porquês da näo percepçäo dolorosa ("angina") de certos episódios isquêmicos, bem como dos mecanismos fisiopatológicos que as desencadeiam. Claro está, no entanto, que os eventos silenciosos e sintomáticos näo se diferem quanto às alteraçöes miocárdicas estruturais e funcionais. O diagnóstico de isquemia silenciosa se estabelece quando da detecçäo de alteraçöes objetivas e características de dano miocárdico isquêmico. Dentre os métodos se configuram, principalmente, a eletrocardiografia de esforço, a monitorizaçäo eletrocardiográfica ambulatorial, o teste de perfusäo com tálio-201 e o ecocardiograma de esforço. Há outros, porém de menor utilizaçäo. Destaca-se a isquemia silenciosa pela sua importante relaçäo com o prognóstico dos portadores de DAC. Muitos estudos relatam participaçäo significativa daquela nos variados desfechos da DAC (angina, infarto agudo do miocárdio e morte súbita). O enfoque terapêutico varia para cada paciente, podendo iniciar-se com a mudança do estilo de vida (alteraçäo dos fatores de risco). A terapêutica medicamentosa se baseia na utilizaçäo de drogas antiisquêmicas (nitratos, beta-bloqueadores e antagonistas dos canais de cálcio) e antiplaquetários. o tratamento mais agressivo inclui a angioplastia coronária, a colocaçäo de stents e a cirurgia de revascularizaçäo do miocárdio.
Subject(s)
Humans , Coronary Disease , Myocardial Ischemia/surgery , Myocardial Ischemia/diagnosis , Myocardial Ischemia/physiopathology , Myocardial Ischemia/therapy , PrognosisABSTRACT
A ocorrência de rejeição hiperaguda no transplante de fígado (TF) é rara e controversa. Entretanto, na presença da mesma, frequentemente se faz necessário o retransplante. A importância dos testes de crossmatch e da compatibilidade HLA, já muito bem estabelecidas nos transplantes renais, ainda não está definida no TF. Embora vários estudos demonstrem piora da performance dos enxertos hepáticos e da evolução dos pacientes com teste de crossmatch positivo, as casuísticas ainda são pequenas e não suficientes para definir o papel destes testes imunológicos na seleção dos pacientes e nos cuidados pós-operatórios, principalmente no que se refere a imunossupressão. Neste estudo de revisão, discutimos aspectos da rejeição hiperaguda e sua participação nos episódios de rejeição no transplante de fígado, além de considerações sobre a importância clínica e imunológica de doadores crossmatch positivos e de alguns cuidados a serem tomados nesta situação
Subject(s)
Graft Rejection , Liver TransplantationABSTRACT
Encontra-se bem definido o papel dos aloanticorpos HLA no desencadeamento da rejeicao hiperaguda nos transplantes renais. Nos casos dos transplantes hepaticos, assim como nos transplantes cardiacos, permanece controverso o papel de anticorpos pre-formados na sobrevida do enxerto. Realizamos neste estudo extensa revisao da literatura medica recente publicada pelos grandes centros mundiais transplantadores de figado a respeito da importancia do crossmatch e da compatibilidade HLA nos resultados precoces e tardios do transplante de figado. Ainda longe da unanimidade, a compatibilidade imunologica HLA parece exercer influencias nos desempenhos precoce e tardio dos enxertos hepaticos, apesar do avanco dos imunossupressores. Entretanto a baixa incidencia de paciente transplantados com altos titulos de testes de crossmatch positivos, nao altera a sobrevida global das casuisticas analisadas, sendo controversa sua utilizacao como metodo de selecao frente aos custos de seu emprego, mas nao excluindo seu valor como auxiliar na orientacao da imunossupressao precoce e tardia destes pacientes