Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial / Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

Abstract Background Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. Methods Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. Results Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p = 0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. Conclusions Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Resumo Justificativa A isquemia miocárdica perioperatória é comum em pacientes submetidos à cirurgia de fratura de quadril. Nosso objetivo foi avaliar a eficácia do bloqueio perioperatório contínuo do plexo lombar na redução do risco de eventos cardíacos isquêmicos em pacientes idosos submetidos à cirurgia para fraturas de quadril, expresso como uma redução de eventos isquêmicos por indivíduo. Métodos Pacientes com mais de 60 anos de idade, ASA II-III com fatores de risco para ou com doença coronariana conhecida foram incluídos neste estudo controlado e randomizado. Os pacientes foram aleatorizados para analgesia convencional usando analgésicos opioides para administração de analgesia intravenosa controlada pelo paciente (Intravenous Patient-Controlled Analgesia - IVPCA) ou analgesia contínua com o bloqueio do Plexo Lombar (PL), ambas iniciadas no pré-operatório e mantidas até o terceiro dia de pós-operatório. Monitoração contínua de ECG com análise do segmento ST foi registrada. Enzimas cardíacas seriadas e escores de dor foram registrados durante todo o período. Medimos a incidência de eventos isquêmicos por indivíduo registrados com monitoração contínua do segmento ST via Holter. Resultados Trinta e um pacientes (IVPCA 14, PL 17) foram incluídos. Não houve eventos cardíacos sérios durante o período de observação. O número de eventos isquêmicos registrados por sujeito durante o período de observação foi de seis no grupo PL e três no grupo IVPCA. Essa diferença não foi estatisticamente significativa (p = 0,618). Não houve diferenças estatisticamente significativas no número de casos com aumento dos valores de troponina no perioperatório (três casos no grupo LP e um caso no grupo IVPCA) ou em termos de escores de dor. Conclusões O uso da analgesia perineural contínua comparado ao da analgesia sistêmica convencional não modifica a incidência de eventos isquêmicos cardíacos no período perioperatório de pacientes idosos com fratura de quadril.

Cambios en el pronóstico a largo plazo de la hipertensión arterial pulmonar / Changes long term prognosis of 17 patients with pulmonary artery hypertension

Background: Pulmonary artery hypertension (PAH) is a progressive disease with high mortality. Major advances had been made in the treatment of this condition during the last decade. Aim: To characterize the clinical evolution and mortality of a cohort of Chilean patients. Material and Methods: Seventeen patients with PAH diagnosed in the last 10 years in two Chilean hospitals were enrolled. Measurements at diagnosis included hemodynamic variables and 6-minute walk test. The patients were followed clinically for 3 years and the observed mortality was compared with that predicted by the prognostic equation proposed by the historic registry of the National Institutes of Health (NIH). Results: The mean age of patients was 45 years and 80 percent had an idiopathic PAH. The mean median pulmonary artery pressure was 57 ± 15 mmHg, the cardiac index was 2.4 ± 0.7 l/min/m² and the right atrial pressure was 12 ± 8 mmHg. The 6-minute walk distance was 348 ± 98 m. All patients received anticoagulants. Eighty two percent received ambrisentan, 12 percent received bosentan, 29 percent received iloprost and 24 percent sildenafil. At the end of follow-up only 3 patients had died, with an observed survival rate of88, 82 and 82 percent at 1, 2 and 3 years, respectively. In contrast, the survival calculated according to the predictive formula of the NIH was 67, 56 and 45 percent, respectively. Among surviving patients, an improvement in exercise capacity was observed after one year (p < 0.05). Conclusions: The observed survival rate was significantly better than that estimated according to historical data. Furthermore, therapy was associated with an improvement in functional capacity after one year. This prognostic improvement is consistent with data of other contemporary registries published after the NIH Registry.

Monitoreo inalámbrico de presión arterial pulmonar en pacientes con insuficiencia cardíaca / Wireless pulmonary artery pressure monitoring in patients with congestive heart failure

Antecedentes: El monitoreo continuo y remoto de presiones intracardiacas ha sido reportado de utilidad en el manejo y prevención de hospitalización en pacientes con Insuficiencia Cardíaca (IC). Objetivos: Describir la técnica y las complicaciones en el seguimiento a mediano plazo de un sensor inalámbrico(Sensor CardioMEMS Heart Sure®) pulmonar; evaluar la exactitud de la determinación de la presión en arteriapulmonar (PAP) después de un año de implante y su correlación con la presión estimada por cateterismo cardíaco convencional (catéter de Swan-Ganz).Método: Fueron incluidos en el estudio pacientes con IC avanzada con al menos una hospitalización en el año previo al implante de este sensor. Se realizaron mediciones simultáneas con catéter de Swan-Ganz (SG) durante el implante y a los 60, 180 días y un año de seguimiento. Se empleó análisis de regresión lineal como una medida de la correlación entre los métodos. La variabilidad entre las técnicas se evaluó mediante análisis del Bland-Altman.Resultados: En este reporte fueron incluidos 27 pacientes, 24 hombres con edad promedio de 64+/-14.1 años y FE promedio de 25 por ciento, la gran mayoría en clase funcional III de la NYHA. Un paciente falleció 190 días post implante por causa extra cardíaca y otro falleció 45 días post implante por shock cardiogénico. La PAP sistólica, diastólica y media cuantificada a 60 días, 6 meses y un año post implante tuvo una correlación adecuada cuando se comparó con el cateterismo de SG preservando la calidad de la curva de presión obtenida desde el sensor. La calidad de la señal se ha mantenido hasta más de un año de seguimiento. Conclusión: Existió muy buena correlación entre las presiones obtenidas con el sensor y las mediciones del catéter de SG. Es necesario validar este sistema en un número mayor de enfermos y establecer su papel en el manejo de la IC crónica.

Background: Continuous and remote intracardiac pressure monitoring has been reported to be useful to manage patients with congestive heart failure (CHF) and to prevent rehospitalization. Aim: To describe the technical aspects and complications in the use of a wireless pulmonary artery pressure sensor (CardioMEMS Heart Sure© ) in a medium term follow up. Also, to evaluate de precision of pulmonary artery pressure (PAP) measurement one year after implantation of the device. Methods: Patients with advanced CHF with at least one hospitalization in the preceding year were included. PAP was measured through Swan Ganz catheterization at the time of device implantation and after 60 days, 6 months and one year of follow up. Linear regression was used to estimate inter method correlation and Bland-Altman analysis to estimate variability among methods Results: Twenty-seven patients (24 men) aged 64 +/-14.1 (SD) years, most of them in functional class III were included. The mean ejection fraction was 25 percent. One patient died 190 days after implant due to non cardiac causes and another 45 days post implant from cardiogenic shock. Systolic, diastolic and mean PAP was measured 60 days, 6 months and 1 year post implant. The correlation with Swan Ganz catheter measurement was adequate. The quality of the signal obtained from the PAP sensor was maintained at one year of follow up. Conclusion: A very good correlation between wireless and Swan Ganz measurements of PAP was observed. More extensive assessment of this method is needed to establish its usefulness in the management of patients with chronic CHF.

Evaluación hemodinámica ambulatoria mediante un nuevo sensor implantable inalámbrico en el seguimiento de pacientes con insuficiencia cardíaca: experiencia clínica inicial / Ambulatory hemodynamic evaluation of a new wireless implantable sensor in the follow up of patients with congestive heart failure: a preliminary experience

Antecedentes: El monitoreo hemodinámico puede contribuir al ajuste oportuno de terapia en insuficiencia cardíaca (IC). Existe un creciente interés en el desarrollo de sistemas que permitan el monitoreo en el ámbito extra hospitalario. Objetivo: Evaluar la exactitud de la determinación de presión de arteria pulmonar (PAP) del sensor CardioMEMS HeartSure (HS) comparado con catéter de Swan Ganz (SG) y Ecocardiografía (Eco) en el seguimiento de pacientes con IC. Método: 12 pacientes con IC NYHA clase II-IV fueron incluidos. El dispositivo HS fue implantado en la arteria pulmonar mediante técnica percutánea bajo visión angiográfica. La determinación de PAP se realizó mediante un sistema inalámbrico que otorga una curva de presión en tiempo real. Dos operadores independientes realizaron tres mediciones consecutivas por HS en cada visita. Se llevó a cabo una evaluación ecocardiográfica los días 2, 14, 30,60 y 90 post- implante. Mediciones simultáneas mediante SG se realizaron el día del implante y a los 60 días. Se empleó análisis de regresión lineal como una medida de la correlación entre métodos. La variabilidad entre métodos e interobservador se evaluó mediante análisis de Bland-Altman. Resultados: Todos los pacientes completaron el seguimiento a 30 días; cinco completaron el periodo de 90 días. La edad promedio fue de 63 +/- 14.6 años. La etiología de la IC era isquémica en 3 pacientes, valvular en 4 e idiopática en los 5 restantes. PAP sistólica (SPAP) fue de 64 +/- 22 y 58 +/- 22 mmHg medida por HS y SG, respectivamente. Ambos métodos mostraron una correlación significativa (r2 = 0.96, p<0.01), con una diferencia media de 6.2 +/- 4.5 mmHg. PAP diastólica (DPAP) fue de 23 +/- 14 y 28 +/- 16 mmHg para HS y SG, respectivamente, con una buena correlación entre las medidas (r 2 = 0.84) y una diferencia media de -1,6 +/- 6.8 mmHg. SPAP fue de 60 +/- 20 y 62 +/- 12 mmHg paraHS y Eco, respectivamente, con...

Background: hemodynamic monitoring may contribute to prompt adjustment of medical therapy in patients with congestive heart failure (CHF). There is a great interest in the development of system to perform this monitoring in ambulatory patients. Aim. To evaluate the accuracy of pulmonary artery pressure (PAP) determination using the CardioMEMS HeartSure (HS) sensor using Swan Ganz (SG) and echocardiography (Echo) measurements as gold standards in the followup of patients with CHF Methods: 12 patients with NYHA class II to IV CHF were included. The HS device was implanted in the pulmonary artery under angiographic vision. The determination of PAP was obtained from an online measurement using a wireless system allowing real time monitoring. In each visit two independent observers performed 3 consecutive measurements of PAP. An echocardiogram was performed at HS implantation and 14, 30, 60 and 90 days post implant. Simultaneous PAP by SG and HS were obtained at implantation time and 60 days later. Linear regression analysis was used to correlated measurements. Bland-Altman analysis was used to evaluate variability between methods and between observers. Results: All patients completed 30 days of follow up and 5 completed 90 days. Mean patient age was 63 years (SD 14.6). The cause of HF was ischemic in 3, valvular in 4 and idiopathic in the remaining 5 patients. Systolic PAP (SPAP) was 64 +/- 22 and 58 +/- 22 mmHg for HS and SG measurements respectively. r2 between methods was 0.96 (p<0.01) and mean difference was 6.2 +/- 4.5 mmHg. Diastolic PAP (DPAP) was 23 +/- 14 and 28 +/- 16 mmHg for HS andSG, respectively; r2 = 0.84, mean difference = -1,6 +/- 6.8 mmHg. SPAP was 60 +/- 20 and 62 +/-12 mmHg for HS and Echo, respectively; r2 =0.75 (p<0.01), mean difference -2.6 +/- 11 mmHg. No significant difference was observed between operator for HS measurement: mean difference -0.8 +/-6.5 and -2.5 +/- 5.7 mmHg for SPAP y DPAP, respectively.

Niveles de péptido natriurético cerebral y su relación con capacidad funcional y hemodinamia pulmonar en pacientes con hipertensión pulmonar primaria: Correlation with functional capacity and hemodynamic parameters / Brain natriuretic peptide in primary pulmonary ypertension

Background: Primary pulmonary hipertension (PPH) is a progressive disease leading to right heart failure and death. Right heart catherization and maximal or submaximal tests are employed to assess the course of the disease. A neurohormonal parameter such as pro-brain natriuretic peptide (BNP) would be helpful in the assessment of these patients. Aim: To study the correlation of BNP with functional status and non-invasive hemodynamic determinations in patients with PPH. Material and methods: Twelve patients (mean age: 48 years; 58% female) were evaluated with 6 minutes walk distance test (6-min WT), plasma BNP, systolic pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and cardiac output (CO) determined by echocardiogram. Plasma BNP levels were compared with normal subjects. Results: BNP levels were increased in PPH patients (1270±547 vs 48±8 pg/ml, p-value <0.01). Mean PAPs was 82±27 mmHg and the mean distance walked in 6 minutes was 407±113 meters. BNP levels were positively correlated with PVR (r=0.58, p-value=0.006) and negatively correlated with 6-min WT (r=-0.83, p-value <0.001). No correlation was found between BNP levels, PAPs and CO. Conclusions: In PPH patients, BNP levels are increased and correlate with functional class and PVR. Follow-up studies are needed to evaluate the role of BNP as a marker of progression and therapeutic response in PPH patients.