ABSTRACT
A fibrilação atrial é a arritmia mais relacionada à ocorrência de acidentes vasculares cerebrais isquêmicos. A prevenção desses eventos é o principal desafio no tratamento dos portadores de fibrilação atrial. A anticoagulação sistêmica com varfarina, apesar de efetiva, apresenta diversas limitações e o surgimento dos novos anticoagulantes orais expandiu as opções terapêuticas. No entanto, pacientes com elevado risco de sangramento quando expostos à anticoagulação podem se beneficiar da oclusão mecânica do apêndice atrial esquerdo. Ensaios clínicos demonstraram ser a oclusão percutânea do apêndice atrial esquerdo uma alternativa viável na prevenção de acidentes vasculares cerebrais nos pacientes com fibrilação atrial e restrição ao uso de anticoagulantes. Relatamos o primeiro implante da prótese WatchmanTM realizado em Minas Gerais em paciente com elevado risco de fenômenos tromboembólicos e contraindicação ao uso de anticoagulantes, em decorrência de condição vascular intracraniana passível de sangramento grave
Atrial fibrillation is the arrhythmia most closely related to the occurrence of ischemic strokes. The prevention of these events is the major challenge in the management of patients with atrial fibrillation. Systemic anticoagulation with warfarin while effective has several limitations and the emergence of new oral anticoagulants has expanded therapeutic options. However, patients with high risk of bleeding when exposed to anticoagulation may benefit from mechanical left atrial appendage closure. Clinical trials have demonstrated that percutaneous left atrial appendage closure is a viable alternative to prevent stroke in patients with atrial fibrillation and restrictions for the use of anticoagulants. We report the first WatchmanTM device implant performed in Minas Gerais in a patient with high risk of thromboembolic events and contraindication to anticoagulants due to an intracranial vascular condition that could lead to severe bleeding
Subject(s)
Humans , Male , Aged, 80 and over , Atrial Appendage , Atrial Fibrillation/complications , Atrial Fibrillation/therapy , Stroke , Anticoagulants/adverse effects , Arrhythmias, Cardiac/complications , Heart Atria , Prostheses and Implants , Risk Factors , Sex Factors , Thrombosis/therapyABSTRACT
Fundamentos O acesso percutâneo ao espaço pericárdico pela via transatrial poderia ser uma alternativa ao acesso subxifóide para o mapeamento e ablação de fibras miocárdicas subepicárdicas. O objetivo deste estudo foi avaliar a viabilidade de alcançar o espaço pericárdico normal através do apêndice auricular direito (AAD) por acesso transvenoso. Métodos e Resultados - Um sistema Mullins (8F), originalmente desenvolvido para alcançar o átrio esquerdo (AE) por punção transeptal foi utilizado neste estudo para transfixar o AAD (16) ou AE (1) em 17 suínos, com uma média de 26,9 ± 2,6 kg, e alcançar o espaço pericárdico normal. Um cateter 7F quadripolar com eletrodo distal com 4 ou 8 mm foi introduzido no espaço pericárdico para aplicações de radiofrequência. Em 15 (88%) animais o procedimento foi realizado sem instabilidade hemodinâmica (PA média inicial = 80,4 ± 11.7 mmHg; PA média final = 86,8 ± 9.7 mmHg, p = 0,11). Foi identificado e aspirado derrame pericárdico discreto (28,9 ± 27.6 ml/animal) durante o procedimento. O espaço pericárdico foi acidentalmente acessado por punção do ventrículo direito (VD) em um animal e por punção do anel da valva tricúspide em outro. Ambos apresentaram sangramento xii pericárdico importante e tamponamento cardíaco. Um dispositivo para oclusão do orifício de perfuração foi testado com sucesso em três porcos, dois no AD e um no VD, sem ocorrência de derrame pericárdico significativo. Conclusões O acesso transatrial ao espaço pericárdico pode ser potencialmente útil para mapeamento e ablação de arritmias cardíacas, bem como para drenagem imediata de um tamponamento cardíaco agudo.
Background A transvenous access to the pericardial space could provide a convenient route to map and ablate subepicardial myocardial fibers. The aim of this study was to evaluate the feasibility of reaching the normal pericardial space through the right atrial appendage (RAA) by transvenous access. Methods and Results An 8F Mullins system was used to transfix the right atrium (16) and left atrium (1) in 17 pigs with a mean of 26.9 ± 2.6 kg. A 7F quadripolar catheter with 4 or 8 mm distal tip electrode was introduced into the pericardial space to perform epicardial radiofrequency lesions. The pericardial space was successfully reached in 15 (88%) animals without hemodynamic instability (initial mean BP 80.4 ± 11.7 mmHg; final 86.8 ± 9.7 mmHg, p= 0,11). However, a mild pericardial serohemorrhagic effusion was identified and aspirated in all the animals (28.9 ± 27.6 ml/pig) during the procedure. The pericardial space was accidentally accessed through the right ventricle (RV) in one animal and through the tricuspid annulus in another, which presented important pericardial bleeding and cardiac tamponade. The hypothesis that an occlusion device could be useful to close the created atrial xiv orifice was tested successfully in thee pigs (two at RAA and one at RV) and without significant pericardial bleeding. Conclusions The right atrial appendage route might be potentially useful to access the normal pericardial space for mapping and ablating cardiac arrhythmias as well as to drain promptly an acute tamponade.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Cardiac Catheterization/methods , Pericardial Effusion/therapy , Electrophysiologic Techniques, Cardiac , Paracentesis/methods , SwineABSTRACT
OBJECTIVE - To assess the clinical, electrocardiographic, and electrophysiologic characteristics of patients (pt) with intra-His bundle block undergoing an electrophysiologic study (EPS). METHODS - We analyzed the characteristics of 16 pt with second-degree atrioventricular block and symptoms of syncope or dyspnea, or both, undergoing conventional EPS. RESULTS - Intra-His bundle block was documented in 16 pt during an EPS. In 15 (94 percent) pt, the atrioventricular block was recorded in sinus rhythm; 4 (25 percent) pt had intra-His Wenckebach phenomenon, which correlated with Mobitz I (MI) atrioventricular block on the electrocardiogram. Seven (44 percent) pt had 2:1 atrioventricular block, 2 of whom were asymptomatic (12.5 percent). One (6 percent) pt had intra- and infra-His bundle block. Clinically, 11 (68 percent) pt had syncope or presyncope, 3 (18 percent) had dyspnea on exertion, and 2 (12.5 percent) were asymptomatic. Eight (50 percent) pt had bundle-branch block as follows: 4 (25 percent) pt had left bundle-branch block, and 4 (25 percent) had right bundle-branch block. Left anterosuperior divisional block was observed in 3 pt (19 percent), 2 of whom with associated right bundle-branch block. CONCLUSION - Intra-His bundle block was observed in 11 percent of the pt with second-degree atrioventricular block, syncope or presyncope, or both, it being the most frequent clinical presentation. Intra-His bundle block was more common in the elderly (> 60 years) and among females. The most frequent electrocardiographic presentations were second-degree Mobitz I or type 2:1 atrioventricular block
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Bundle-Branch Block , Electrocardiography , Electrophysiologic Techniques, Cardiac , Aged, 80 and over , Bundle-Branch Block , Retrospective Studies , SyncopeABSTRACT
Os autores apresentam um caso de hemoglobinúria paroxística noturna cuja suspeita diagnóstica surgiu a partir da análise seqüencial da urina de coloração vermelho-acastanhada em paciente com história de hematúria recorrente. Sugerem que a urinálise pelo nefrologista aumenta as chances de acerto diagnóstico em situações semelhantes, assim como evita a realização desnecessária de exames complementares, como ilustrado no caso apresentado.
The authors present a case of paroxysmal nocturnal haemoglobinuria suspected when the urine was sequentially analyzed in a patient with history of recurrent hematuria. They suggest that the urinalysis done by nephrologists rises the chances of acorrect diagnosis in clinical situations like the one presented, as well as avoid that unnecessary tests to be done, as in the discussed case.