Uso de marcapasso provisório e definitivo em pacientes submetidos a transplante cardíaco ortotópico / Permanent and temporary pacemaker implantation after orthotopic heart transplantation

PURPOSE:To determine the indication for and incidence and evolution of temporary and permanent pacemaker implantation in cardiac transplant recipients. METHODS: A retrospective review of 114 patients who underwent orthotopic heart transplantation InCor (Heart Institute USP BR) between March 1985 and May 1993. We studied the incidence of and indication for temporary pacing, the relationship between pacing and rejection, the need for pemanent pacing and the clinical follow-up. RESULTS: Fourteen of 114 (12 per cent) heart transplant recipients required temporary pacing and 4 of 114 (3.5 per cent) patients required permanent pacing. The indication for temporary pacing was sinus node dysfunction in 11 patients (78.5 per cent) and atrioventricular (AV) block in 3 patients (21.4 per cent). The indication for permanent pacemaker implantation was sinus node dysfunction in 3 patients (75 per cent) and atrioventricular (AV) block in 1 patient (25 per cent). We observed rejection in 3 patients (21.4 per cent) who required temporary pacing and in 2 patients (50 per cent) who required permanent pacing. The previous use of amiodarone was observed in 10 patients (71.4 per cent) with temporary pacing. Seven of the 14 patients (50 per cent) died during follow-up. CONCLUSION: Sinus node dysfunction was the principal indication for temporary and permanent pacemaker implantation in cardiac transplant recipients. The need for pacing was related to worse prognosis after cardiac transplantation.

Pseudo-síndrome de marcapasso / Pseudo-pacemaker Syndrome / The pseudo-pacemaker syndrome

We describe three cases of the pseudo-pacemaker syndrome. One of them due to selective fast pathway fulguration of atrioventricular nodal reentrant tachycardia and two others have occurred in spontaneous form. All cases were related with the presence of first-degree atrioventricular block and sinus node tachycardia. The treatment was done with complete atrioventricular block induction catheter ablation and permanent pacemaker implantation in two patients. In conclusion, the procedure of radiofrequency ablation to control AV nodal reentry tachycardia must preserve the fast nodal pathway in order to avoid the pseudo-pacemaker syndrome and this syndrome can spontaneously occur and must be considered during investigation of etiology of syncope

Reprodutibilidade do teste de inclinação em pacientes com síncope neurocardiogênica / Reproducibility of Hecid-Up Tilt Test in Patients with Neurally Mediated Syncope

PURPOSE--In order to identify the reproducibility of head-up tilt test, a second test one week later in 22 patients with a positive first test, was performed. METHODS--The test was performed in a fasting state during the morning. The heart rate and blood pressure were monitored during 20 minutes in the supine position and then at 60 degrees for up to 40 minutes. The test were considered positive if the patient experienced syncope or pre-syncope with fall in systolic blood pressure > 30mmHg. The following aspects were evaluated: reproducibility of the positive response; the type of response (hypotension, asystole or hypotension plus bradycardia) and the time interval between tilt and the beginning of symptoms. RESULTS--Eighteen (82 per cent) patients had a second positive response; 14 (77.8 per cent) of then had the same type of response; and 17 (94 per cent) had syncope in similar time interval after tilt. CONCLUSION--The head-up tilt testing has good reproducibility, although its use in the therapeutic management needs a longer period of evaluation

Valor diagnóstico do teste de inclinçäo na avaliaçäo da síncope de origem indeterminada: resultados preliminares / Diagnostic value of the tilt test in the evaluation of syncope of unknown origin: preliminary results

PURPOSE--In order to identify neurally mediated syncope, head-up tilt testing was performed in patients with recurrent unexplained syncope. METHODS--The tests were performed in 125 patients in the fasting state, between 8:30 and 11:30 a.m. The blood pressure and heart rate were continuously monitored during 20 minutes in the resting state, and then, positioned at 60 degrees angle, for up to 40 minutes. A group of 20 patients with first negative test was submitted to intravenous isoproterenol in bolus of 2 micrograms every 2 minutes until symptoms occur or at a total dose of 8 micrograms. The test was considered positive when systolic blood pressure decreased at least 30 mmHg and the patient experimented syncope or pre-syncope. RESULTS--In 52 patients the test was positive (41.6 per cent ), 63.5 per cent of which had hypotension exclusively; 7.7 per cent asystole; and 28.8 per cent had hypotension and bradycardia. Nine of the 20 patients submitted to isoproterenol test were positive (45 per cent ). All patients recovered spontaneously after returning to supine position. CONCLUSION--Head-up tilt testing is a safe and effective method for the identification of neurally mediated syncope

Objetivo - Identificar a possível etiologia neuralmente mediada, em portadores de síncope de origem indeterminada (SOI) submetidos ao teste de inclinação. Métodos - Cento e vinte e cinco portadores de SOI foram submetidos, entre abril de 1991 a outubro de 1992, ao teste de inclinação, realizado pela manhã, em jejum, com período de repouso de 20min em decúbito horizontal e 40min a 60o, com monitorização contínua da pressão arterial (PA) e da freqüência cardíaca (FC). O teste sensibilizado consistiu na administração de isoproterenol em doses de 2µg a cada 2min a 60o , até a dose máxima de 8µg ou até o aparecimento de sintomas présincopais ou síncope e foi aplicado em um grupo de 20 pacientes nos quais o 1º teste havia sido negativo. O critério de positividade foi a queda sintomática da pressão arterial sistólica maior que 30mmHg. Resultados - Cinqüenta e dois (41,6%) indivíduos apresentaram testes positivos, dos quais 63,5% apresentaram resposta exclusivamente vasodepressora (queda da PA sem modificação da FC), 7,7% cardio-inibitória (assistolia) e 28,8% resposta mista. Dos 20 pacientes submetidos ao teste sensibilizado, 9 (45%) apresentaram resultados positivos. Todos recuperaram-se espontaneamente com o retorno para o decúbito horizontal. Conclusão - O teste de inclinação é um método eficiente e seguro na identificação da etiologia neurocardiogênica das síncopes até então de origem indeterminada

Resultados tardios da fulguraçäo da junçäo atrioventricular em pacientes com taquicardias supraventriculares utilizando choques de alta energia / Long Term Follow -up After Direct Current Catheter Ablation (High Energy) of the Atrioventricular Junction in Patients with Supraventricular Tachycardias

Purpose - To evaluate the long term efficacy and safety at long term after atrioventricular junction fulguration (complete AV block induction, using high energy shocks, to control drug-resistant supraventricular tachyarrythmias. Methods - Twenty-eigth patients, 17 (60,7%) men, with mean age 48,1 years, were submitted to one up to six ablation sessions with high energy shocks. The total delivered energy per patient was 1304 ± 868 J. Each shock ranged from 100 to 400J. Results - After 12 months, at least, 60,6% of patients were in complete atrioventricular block; three (10,8%) were assymptomatics without complete AV block, and infive (17,8%) the ablation was unsuccessful. Conclusion - AV junction ablation with high energy shocks is safe and efficient in long term follow-up

Objetivo - Avaliar a eficácia a longo prazo da fulguração da junção AV (indução de BAVT), utilizando choques de alta energia, para controle de arritmias supraventriculares refratárias a drogas. Métodos - Vinte e oito pacientes, 17 (60,7%) do sexo masculino, com média etária de 48,1 anos, foram submetidos a uma até seis sessões de fulquração da junção AV, com choques de alta energia. Cada paciente recebeu em média de um a dez choques. A energia total aplicada por paciente variou de 100 a 3200 J (1304 ± 868 J); cada choque foi de 100 a 400J. Resultados - No mínimo após 12 meses, 60,6% dos pacientes permaneceram em BAVT; 3 (10,8%) pacientes apresentam-se assintomáticos, com alterações na condução AV, sem apresentar BAVT. Em 5 (17,8%) pacientes o procedimento foi ineficaz. Conclusão - A fulguração da junção AV (indução de BA VT) com choques de alta energia é procedimento seguro e eficaz a longo prazo