Prognostic Prediction of Cardiopulmonary Exercise Test Parameters in Heart Failure Patients with Atrial Fibrillation / Previsão Prognóstica dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca e Fibrilação Atrial

Abstract Background: Atrial fibrillation (AF) is associated with increased mortality in heart failure (HF) patients. Objective: To evaluate whether the risk of AF patients can be precisely stratified by relation with cardiopulmonary exercise test (CPET) cut-offs for heart transplantation (HT) selection. Methods: Prospective evaluation of 274 consecutive HF patients with left ventricular ejection fraction ≤ 40%. The primary endpoint was a composite of cardiac death or urgent HT in 1-year follow-up. The primary endpoint was analysed by several CPET parameters for the highest area under the curve and for positive (PPV) and negative predictive value (NPV) in AF and sinus rhythm (SR) patients to detect if the current cut-offs for HT selection can precisely stratify the AF group. Statistical differences with a p-value <0.05 were considered significant. Results: There were 51 patients in the AF group and 223 in the SR group. The primary outcome was higher in the AF group (17.6% vs 8.1%, p = 0.038). The cut-off value of pVO2 for HT selection showed a PPV of 100% and an NPV of 95.5% for the primary outcome in the AF group, with a PPV of 38.5% and an NPV of 94.3% in the SR group. The cut-off value of VE/VCO2 slope showed lower values of PPV (33.3%) and similar NPV (92.3%) to pVO2 results in the AF group. Conclusion: Despite the fact that AF carries a worse prognosis for HF patients, the current cut-off of pVO2 for HT selection can precisely stratify this high-risk group.

Resumo Fundamento: A fibrilação atrial (FA) está associada ao aumento da mortalidade em pacientes com insuficiência cardíaca (IC). Objetivo: Avaliar se o risco de pacientes com FA pode ser estratificado com precisão em relação aos pontos de corte do teste de esforço cardiopulmonar (TECP) para seleção do transplante cardíaco (TC). Métodos: Avaliação prospectiva de 274 pacientes consecutivos com IC com fração de ejeção do ventrículo esquerdo ≤ 40%. O endpoint primário foi um composto de morte cardíaca ou TC urgente no seguimento de 1 ano. O endpoint primário foi analisado através de vários parâmetros do TECP para a maior área sob a curva e para o valor preditivo positivo (VPP) e negativo (VPN) em pacientes com FA e ritmo sinusal (RS) para detectar se os atuais pontos de corte para a seleção de TC podem estratificar com precisão o grupo com FA. Diferenças estatísticas com valor de p < 0,05 foram consideradas significativas. Resultados: Havia 51 pacientes no grupo de FA e 223 no grupo RS. O endpoint primário foi maior no grupo FA (17,6% vs. 8,1%, p = 0,038). O valor de corte de pVO2 para a seleção do TC mostrou um VPP de 100% e um VPN de 95,5% para o endpoint primário no grupo FA, com um VPP de 38,5% e um VPN de 94,3% no grupo RS. O valor de corte da inclinação VE/VCO2 apresentou valores mais baixos de VPP (33,3%) e valor semelhante de VPN (92,3%) aos resultados de pVO2 no grupo FA. Conclusões: Apesar do fato de a FA apresentar um pior prognóstico para os pacientes com IC, o atual ponto de corte de pVO2 para a seleção de TC pode estratificar com precisão esse grupo de alto risco.

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality / Fibrilação Auricular de Novo no Infarto Agudo do Miocárdio com Supradesnível do Segmento ST: Preditores e Impacto na Terapêutica e Mortalidade

Abstract Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Resumo Fundamento: A fibrilação auricular de novo no contexto de infarto agudo do miocárdio representa um importante desafio com potencial impacto prognóstico. Objetivo: Determinar a incidência, impacto na terapêutica e mortalidade, e identificar possíveis preditores do aparecimento de fibrilação auricular de novo durante o internamento por infarto agudo do miocárdio com supradesnivelamento do segmento ST. Métodos: Estudamos todos os pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST inseridos consecutivamente de 2010 a 2017 num registro nacional português e comparamos dois grupos: 1 - sem fibrilação auricular; 2- com fibrilação auricular de novo. Efetuamos análise com modelo de regressão logística para avaliar o impacto de fibrilação auricular de novo na mortalidade intra-hospitalar e identificar preditores independentes para o seu aparecimento. Para teste de hipóteses, considerou-se significativo p < 0,05. Resultados: Estudamos 6325 pacientes, dos quais 365 (5.8%) apresentaram fibrilação auricular de novo. Não houve diferença no número de pacientes reperfundidos nem na estratégia de reperfusão. No grupo 2, terapêutica com betabloqueadores e IECA/ARA foi menos frequente, 20.6% tiveram alta sob anticoagulação oral e 16.1% sob terapêutica tripla. A fibrilação auricular de novo associou-se a maior incidência de complicações e mortalidade intra-hospitalar, mas não foi preditor independente de mortalidade intra-hospitalar. Identificamos idade, acidente vascular cerebral prévio, infarto inferior e bloqueio auriculoventricular completo como preditores independentes de fibrilação auricular de novo. Conclusões: A fibrilação auricular de novo continua sendo uma complicação frequente do infarto agudo do miocárdio, estando associada a aumento das complicações e mortalidade intra-hospitalar. Apenas 36.7% desses pacientes teve alta sob anticoagulação.

Morbimortalidad cardiovascular y variación del grado funcional en pacientes ancianos portadores de marcapasos / Medium-long term mortality and change in functional status in elderly patients with pacemaker

Resumen Antecedentes: Aproximadamente un 49% de los implantes se efectúan a individuos mayores de 80 años; sin embargo, la evidencia científica sobre mortalidad y cambio en la situación funcional de estos pacientes es muy pobre. Objetivo: Diseñamos un estudio prospectivo para analizar la morbimortalidad cardiovascular y la variación de su grado funcional a medio plazo en pacientes ancianos con electroestimulación permanente. Método: Estudio observacional prospectivo, que incluye 308 pacientes ancianos sometidos a implante de marcapasos en un hospital terciario entre 2012 y 2014. Como variables principales se evaluaron eventos cardiovasculares, mortalidad y grado funcional, con una media de seguimiento de 3.5 años. Resultados: El 60% de los pacientes incluidos en nuestro estudio tenían una edad superior a 80 años, y la indicación más frecuente fue el bloqueo auriculoventricular completo (44.3%), seguido de la fibrilación auricular lenta o bloqueada (16.7%). El modo de estimulación más frecuente en la muestra general fue el DDD (38.6%) (VVI en pacientes octogenarios, 38.7%). En el seguimiento, la mortalidad a largo plazo fue mayor en dispositivos ventriculares, especialmente en octogenarios (p = 0.001). El modo de estimulación ventricular (VVI) fue predictor independiente de mortalidad. A largo plazo, no se observó mejoría del índice de Barthel ni del grado funcional tras el implante del marcapasos. Conclusiones: La morbimortalidad cardiovascular en pacientes octogenarios portadores de marcapasos resulta superior a la de la población general, especialmente en dispositivos monocamerales. La electroestimulación permanente no se asocia con mejoría del grado funcional a medio-largo plazo en estos pacientes.

Abstract Background: Nowadays, 49% of patients with pacemakers are older than 80 years old. Nevertheless, mortality and change in functional status after pacemaker implantation are not well documented in elderly patients. Objective: We designed a prospective study to analyze cardiovascular mortality and change in functional status of elderly patients, medium-long term after pacemaker implantation. Methods: Observational study including pacemaker implants in individual older than 70 years old in a single center university hospital between 2012 and 2014. Analysis testing for an association between pacemaker system, medium-long term mortality and functional status after implantation were undertaken. Results: 60% of patients were older than 80 years old. Third-degree atrio-ventricular block (44.3%) and slow ventricular response atrial fibrillation (16.7%) were the most frequent electrocardiogram abnormalities, while bicameral DDD was the sort of pacing our department used the most (38.6%) (VVI in octogenarian patients, 38.7%). Long-term mortality was significantly higher in ventricular devices, especially in octogenarian patients (p = 0.001 respectively). Single-chamber VVI pacing acted as independent predictors of all-cause mortality in these individuals (p = 0.001). We found no significant improvement in Barthel index and functional status in this subgroup of patients, 3 years after pacing. Conclusion: Long-term mortality in individuals older than 80 years old with pacemaker implantation, was significantly higher comparing with general population, especially in ventricular devices. No significant improvement in functional status was detected in this subgroup of patients.

Hypothyroidism is a risk factor for atrial fibrillation after coronary artery bypass graft

Abstract Introduction: Few reports in the world have shown a differential effect of hypothyroidism in relation to morbidity and mortality following cardiac surgery. Objective: To determine the association between preoperative hypothyroidism, composite and disaggregated outcomes of mortality and complications in patients undergoing first-time isolated myocardial revascularization surgery. Methods: Historical cohort of patients undergoing myocardial revascularization between January 2008 and December 2014, with 626 patients included for evaluation of the composite and disaggregated outcomes of in-hospital mortality and complications (atrial fibrillation, surgical site infection and reoperation due to bleeding). A logistic regression model was used to determine the association between hypothyroidism and the onset of those outcomes. Results: Cohort of 1696 eligible patients for the study, with 1.8 mortality. Median age, female gender and prevalence of arterial hypertension were all significantly higher among hypothyroid patients. No differences were found in other preoperative or intraoperative characteristics. Hypothyroidism was associated with the presence of the composite outcome, RR 1.6 (1.04-2.4) and atrial fibrillation 1.9 (1.05-3.8). No association with mortality, infections or reoperation due to bleeding was found. Conclusion: Hypothyroidism is a disease that affects females predominantly and does not determine the presence of other comorbidities. Hypothyroidism is a risk factor for the onset of postoperative fibrillation in patients undergoing myocardial revascularization surgery. Postoperative care protocols focused on the prevention of these complications in this type of patients must be instituted.

Efectividad y seguridad del tratamiento anticoagulante con acenocumarol en fibrilación auricular no valvular / Effectiveness and safety of oral anticoagulation treatment with acenocoumarol in non-valvular atrial fibrillation

Background: Vitamin K antagonists significantly decrease the incidence of stroke but increase the risk of bleeding. Aim: To assess the effectiveness and risk of bleeding of vitamin K antagonists in non-valvular atrial fibrillation. Material and Methods: Retrospective cohort study of 524 patients, 236 women (45%) and 288 men (55%) with non-valvular atrial fibrillation (NVAF) admitted to the oral anticoagulation treatment (OAT) clinic at four public hospitals, between 2009 and 2012. They were followed until March 2013, measuring the quality of OAT, ischemic and bleeding events. Results: The mean follow-up was 26.1 months, with 1,154.7 person-years of follow-up accrued. The percentage of time in therapeutic range (TTR) was 35.2 ± 18%; this was deemed to represent the quality of OAT. The cumulative incidence of ischemic events, either stroke or systemic embolism, was 2.25/100 person-years, being greater in patients with previous embolism (Risk ratio 5.21, 95% confidence intervals 2.31- 11.73, p < 0.01). The cumulative incidence of major bleeding events-extracranial and intracraneal-was 4.08/100 person-years. The main site of extracranial major bleeding was the gastrointestinal tract (32%). Conclusions: In our clinical practice, the effectiveness of OAT with acenocoumarol in NVAF patients is similar to that published abroad. However, the incidence of bleeding complications is higher. The quality of the OAT measured by the TTR was lower than abroad.

Late Results of Cox Maze III Procedure in Patients with Atrial Fibrillation Associated with Structural Heart Disease / Resultados Tardios da Operação de Cox Maze III em Pacientes com Fibrilação Atrial Associada A Doença Cardíaca Estrutural

Abstract Background: Cox-Maze III procedure is one of the surgical techniques used in the surgical treatment of atrial fibrillation (AF). Objectives: To determine late results of Cox-Maze III in terms of maintenance of sinus rhythm, and mortality and stroke rates. Methods: Between January 2006 and January 2013, 93 patients were submitted to the cut-and-sew Cox-Maze III procedure in combination with structural heart disease repair. Heart rhythm was determined by 24-hour Holter monitoring. Procedural success rates were determined by longitudinal methods and recurrence predictors by multivariate Cox regression models. Results: Thirteen patients that obtained hospital discharge alive were excluded due to lost follow-up. The remaining 80 patients were aged 49.9 ± 12 years and 47 (58.7%) of them were female. Involvement of mitral valve and rheumatic heart disease were found in 67 (83.7%) and 63 (78.7%) patients, respectively. Seventy patients (87.5%) had persistent or long-standing persistent AF. Mean follow-up with Holter monitoring was 27.5 months. There were no hospital deaths. Sinus rhythm maintenance rates were 88%, 85.1% and 80.6% at 6 months, 24 months and 36 months, respectively. Predictors of late recurrence of AF were female gender (HR 3.52; 95% CI 1.21-10.25; p = 0.02), coronary artery disease (HR 4.73 95% CI 1.37-16.36; p = 0.01) and greater left atrium diameter (HR 1.05; 95% CI 1.01-1.09; p = 0.02). Actuarial survival was 98.5% at 12, 24 and 48 months and actuarial freedom from stroke was 100%, 100% and 97.5% in the same time frames. Conclusions: The Cox-Maze III procedure, in our experience, is efficacious for sinus rhythm maintenance, with very low late mortality and stroke rates.

Resumo Fundamento: A operação de Cox-Maze III é uma das variantes técnicas no tratamento cirúrgico da fibrilação atrial (FA). Objetivos: Estudar os resultados tardios da operação de Cox-Maze III, quanto à eficácia na manutenção de ritmo sinusal e taxas de mortalidade e acidente vascular cerebral (AVC). Métodos: Entre janeiro de 2006 a janeiro de 2013, 93 pacientes foram submetidos a operação de Cox-Maze III por corte e sutura associada a correção de cardiopatias estruturais. Avaliação do ritmo cardíaco ocorreu por Holter 24 horas. Taxas de sucesso da operação foram estudadas por métodos longitudinais e os preditores de recorrência por análise de regressão de Cox multivariada. Resultados: Foram excluídos 13 pacientes sobreviventes ao período intra-hospitalar cujo seguimento tardio não foi possível. Os 80 pacientes restantes tinham idade média de 49,9 ± 12 anos e 47 (58,75%) eram do sexo feminino. Acometimento da valva mitral ocorreu em 67 pacientes (83,7%). Valvopatia reumática ocorreu em 63 (78,7%). Setenta pacientes (87,5%) tinham fibrilação atrial persistente ou persistente de longa duração. O tempo médio de seguimento clínico com avaliação de Holter foi de 27,5 meses. Não houve óbitos intra-hospitalares. As taxas de manutenção de ritmo sinusal foram 88%, 85,1% e 80,6% aos 6 meses, 24 meses e 36 meses, respectivamente. Os preditores de recorrência tardia foram sexo feminino (RR 3,52; IC 95% 1,21-10,25; p = 0,02), doença arterial coronária (RR 4,73; IC 95% 1,37-16,36; p = 0,01) e maior diâmetro de átrio esquerdo (RR 1,05; IC 95% 1,01-1,09; p = 0,02). A sobrevida atuarial aos 12, 24 e 48 meses foi de 98,5% e as taxas atuariais livres de AVC nos mesmos períodos de 100%, 100% e 97,5%. Conclusões: A operação de Cox-Maze III, na nossa experiência, é eficaz na manutenção do ritmo sinusal, com baixíssimos índices de mortalidade e de AVC tardios.

Thromboembolism and bleeding risk scores and predictors of cardiac death in a population with atrial fibrillation / Escores de risco de tromboembolismo e de sangramento e preditores de morte cardíaca em uma população com fibrilação atrial

Abstract Background: Atrial fibrillation (AF) is a common arrhythmia, with risk of systemic embolism and death. It presents rheumatic etiology in up to 32% of developing countries, whose anticoagulation and evolution data are scarce. Objectives: to determine the predictors of cardiac death considering the clinical profile, thromboembolism and bleeding scores of patients with AF of a single center, with high prevalence of rheumatic heart disease. Methods: 302 patients with AF were studied, mean age 58.1 years; 161 women; 96 pts with rheumatic etiology. Patients underwent clinical and laboratory evaluation, measurement of risk scores and the mean follow-up of 12.8 months. Results: 174 were using warfarin. The averages of the HAS-BLED and ATRIA scores were 1.4 and 1.2, respectively. Percent time in therapeutic range of international normalized ratio was 45.8%. Thirty patients (9.9%) had cardiac death and 41 had some type of bleeding due to warfarin. By univariate analysis, there was statistical significance between cardiac death and permanent AF, blood pressure, systolic dysfunction, R2CHADS2, CCS, EHRA and HAS-BLED. There was no association with valvular AF. By multivariate analysis, systemic arterial and pulmonary artery pressures, classification CCS and systolic dysfunction showed statistical significance. Conclusions: There was no association between cardiac death and valvular AF. Independent predictors of cardiac death were low measures of blood pressure, higher score CCS classification and the presence of systolic ventricular dysfunction.

Resumo Fundamento: A fibrilação atrial (FA) é uma arritmia comum, com risco de embolia sistêmica e morte. Apresenta etiologia reumática em até 32% dos países em desenvolvimento, cujos dados de anticoagulação e evolução são escassos. Objetivos: Verificar as variáveis preditoras de morte cardíaca (MC) conforme o perfil clínico, os escores de tromboembolismo e de sangramento dos pacientes com FA de uma única instituição universitária, com alta prevalência de cardiopatia reumática. Métodos: Foram estudados 302 pts com FA, média de idade 58,1 anos; 161 mulheres; 96 pts com etiologia reumática. Os pts foram submetidos à avaliação clínica e laboratorial, ao cálculo dos escores de risco e ao seguimento clínico médio de 12,8 meses. Resultados: 174 pts estavam em uso de varfarina. As médias dos escores HAS-BLED e ATRIA foram de 1,4 e de 1,2, respectivamente. O cálculo da fração dos valores da razão normalizada internacional dentro do intervalo terapêutico foi de 45,8%. Houve MC em 30 pts (9,9%) e 41 apresentaram algum tipo de hemorragia em decorrência do uso de varfarina. Pela análise univariada, houve significância estatística entre MC e FA permanente, pressões arteriais, disfunção sistólica, R2CHADS2, CCS, EHRA e HAS-BLED. Não houve associação com FA valvar. Por meio da análise multivariada, a pressão arterial sistêmica e da artéria pulmonar, a classificação CCS e a disfunção sistólica apresentavam significância estatística. Conclusões: Não houve associação entre MC e FA valvar. Os preditores independentes de MC foram medidas baixas de pressão arterial, escores mais elevados da classificação CCS e a presença de disfunção ventricular sistólica.

Surgical treatment of atrial fibrillation in patients with rheumatic valve disease

Abstract Objective: To assess heart rhythm and predictive factors associated with sinus rhythm after one year in patients with rheumatic valve disease undergoing concomitant surgical treatment of atrial fibrillation. Operative mortality, survival and occurrence of stroke after one year were also evaluated. Methods: Retrospective longitudinal observational study of 103 patients undergoing rheumatic mitral valve surgery and ablation of atrial fibrillation using uni- or bipolar radiofrequency between January 2013 and December 2014. Age, gender, functional class (NYHA), type of atrial fibrillation, EuroSCORE, duration of atrial fibrillation, stroke, left atrial size, left ventricular ejection fraction, cardiopulmonary bypass time, myocardial ischemia time and type of radiofrequency were investigated. Results: After one year, 66.3% of patients were in sinus rhythm. Sinus rhythm at hospital discharge, lower left atrial size in the preoperative period and bipolar radiofrequency were associated with a greater chance of sinus rhythm after one year. Operative mortality was 7.7%. Survival rate after one year was 92.3% and occurrence of stroke was 1%. Conclusion: Atrial fibrillation ablation surgery with surgical approach of rheumatic mitral valve resulted in 63.1% patients in sinus rhythm after one year. Discharge from hospital in sinus rhythm was a predictor of maintenance of this rhythm. Increased left atrium and use of unipolar radiofrequency were associated with lower chance of sinus rhythm. Operative mortality rate of 7.7% and survival and stroke-free survival contribute to excellent care results for this approach.

Bajos niveles de colesterol HDL es un predictor de mortalidad y de fibrilación auricular postoperatoria posterior a la cirugía de revascularización miocárdica / Low HDL level is a predictor of post operative atrial fibrillation and mortality after coronary artery bypass surgery

Introducción: Se ha demostrado que bajos niveles de colesterol HDL (C-HDL) se asocian a una mayor incidencia de fibrilación auricular y de mortalidad global y cardiovascular. En un estudio observacional previo en nuestro centro, encontramos que un bajo nivel de C-HDL se asoció a mayor riesgo de fibrilación auricular postoperatoria (FAPO) en pacientes sometidos a cirugía de revascularización miocárdica (CRM). Objetivo: Evaluar si el bajo nivel de C-HDL se asocia a mayor incidencia de FAPO y mortalidad en un seguimiento a un año en un estudio controlado. Método: Se realizó un estudio observacional prospectivo que incluyó a 100 pacientes consecutivos sometidos a CRM por enfermedad coronaria estable sin antecedentes de FA y que ingresaron a la UCI Cardio-quirúrgica en ritmo sinusal. Se definió FAPO como FA con duración mayor a 5 minutos o 5 episodios de FA mayores a 30 segundos de duración en los primeros 5 días post operatorios. Se consideró bajo nivel de C-HDL a un valor < 30mg/dL. Los pacientes se siguieron por un año. Se utilizó un análisis univariado y multivaria-do para identificar factores predisponentes de FAPO y mortalidad. Resultados: 31 pacientes presentaron FAPO. El análisis multivariado mostró un incremento de FAPO con C-HDL <30mg/dL (OR 5.01, IC95% 1.3-18.8, p=0,017) y con albúmina <3,5 gr/dL (OR 6.42, IC95% 1.58-26.0, p=0,009). En un seguimiento de 14.1±1.7 meses. La mortalidad global fue 6% y un C-HDL <30mg/dL resultó ser un predictor independiente (HR 11.1, IC95% 1.1-38.4, p=0,039). Conclusión: En nuestra serie un C-HDL menor a 30mg/dL es un predictor independiente de FAPO y mortalidad posterior a la CRM.

Background: Low C-HDL level has been associated to an increased incidence of atrial fibrillation (AF) and cardiovascular mortality. Previously, we have observed that low C-HDL had the same type of association with post operative AF (POAF) and mortality following surgery for coronary artery disease. Aim: to evaluate whether a low C-HDL level is a predictor of POAF and mortality following revascularization surgery in a controlled study. Method: A prospective observational study included 100 consecutive patients undergoing revascularization surgery for stable coronary artery disease (CAD) in sinus rhythm and no prior AF. POAF was defined as AF sustained for more than 5 min or the occurrence of 5 or more episodes of AF extending for more than 5 seconds during the first 5 post operative days. A value <30 mg/dl was considered low C-HDL. Patients were followed for one year. Uni and multivariate analysis were used to identify predictors of POAF and mortality. Results: 31 patients developed POAF. A significant (p=0.017) OR of 5.01 (95% CI 1.3 - 18.8) between low C-HDL and POAF was shown. A similar association linked low serum albumin level to POAF (OR 6.4, C.I. 1.6 - 26). After 14.1 ± 1.7 months of follow-up global mortality was 6%. Low C-HDL turned out to be a significant predictor of mortality (H.R. 11.1, C.I. 1.1 - 38.4, p=0.04). Conclusion: Low C-HDL is an independent predictor of POAF and mortality after coronary artery revascularization surgery.

Idade avançada e incidência de fibrilação atrial em pós-operatório de troca valvar aórtica / Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

Objetivo: Descrever, em idosos, a correlação entre faixa etária e ocorrência de fibrilação atrial após cirurgia por estenose aórtica, além de avaliar a influência da ocorrência de fibrilação atrial na incidência de acidente vascular cerebral, tempo de internação e mortalidade hospitalar. Métodos: Estudo transversal retrospectivo incluindo pacientes com idade > 70 anos submetidos à cirurgia de troca valvar aórtica isolada. Resultados: Foram estudados 348 pacientes com idade média de 76,8±4,6 anos. A incidência de fibrilação atrial no pós-operatório foi 32,8% (n=114), sendo superior nos pacientes > 80 anos (42,9 vs. 28,8% 70-79 anos, P=0,017) e havendo significância estatística limítrofe (P=0,055) para tendência linear na correlação idade e incidência de fibrilação atrial. Verificou-se significativo maior tempo de internação na Unidade de Terapia Intensiva e hospitalar total, porém, não se observou maior taxa de acidente vascular cerebral ou de mortalidade hospitalar decorrente da fibrilação atrial. Conclusão: A incidência de fibrilação atrial no pós-operatório de cirurgia para estenose valvar aórtica em pacientes idosos com > 70 anos foi elevada e linearmente correlacionada ao avanço da idade, especialmente após 80 anos, causando aumento dos tempos de internação total e em Unidade de Terapia Intensiva, sem aumento significativo da morbimortalidade. O conhecimento desses dados é importante para evidenciar a necessidade de medidas profiláticas e de tratamento precoce dessa arritmia nesse subgrupo. .

Objective: This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. Methods: Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. Results: 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. Conclusion: Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup. .

Drogas anticoagulantes em pacientes com arritmia / Anticoagulants drugs in patients with arrhythmia

O uso de anticoagulantes para profilaxia de tromboembolismo restringe-se à Fibrilaçãom Atrial (FA) e Flutter Atrial (FLA). FA é a arritmia sustentada mais prevalente nos dias de hoje, com aumento da prevalência de acordo com o aumento da idade. Está associada com maior risco de Insuficiência Cardíaca, mortalidade e Acidente Vascular Encefalico (um em cada cinco), sendo este último associado à maior gravidade, incapacidade e mortalidade do que isquemias cerebrais de outra etiologia. Deste fato, vem a importância de um adequado tratamento antitrombótico a fim de se evitar a cardioembolia. Neste artigo, temos por objetivo indicar os principais fatores de risco para tromboembolismo na FA, as drogas indicadas para profilaxia antitrombótica, incluindo os novos anticoagulantes orais, sua principais indicações, benefícios e riscos, inclusive em situações especiais como cardioversão e ablação de FA.

The use of anticoagulants for thromboembolism prophylaxis is restricted to Atrial Fibrillation (AF) and Atrial Flutter (FLA). Atrial fibrillation is the most prevalent sustained arrhythmia nowadays, with an increasing prevalence during the aging process. It is associated with an increased risk of heart failure, mortality and stroke (one in five), which is associated with greater severity, disability and mortality than with any other etiology of cerebral ischemia. This fact justifies of an adequate antithrombotic treatment in order to avoid thromboembolism. In this article, we aim to outline the main risk factors of thromboembolism in AF, drugs indicated for antithrombotic prophylaxis, including new oral anticoagulant, the main indications, risks and benefits, including special situations such as electrical cardioversion and ablation of AF.

Uma nova curva no fio-guia para implantação prática e rápida da extremidade do eletrodo no septo interatrial alto ou no fascículo de Bachmann / A new curve on the guidewire for the quick and practical implant of the electrode tip in the high septum or in the Bachmann fascicle / Una nueva curva en el hilo guía para la implantación práctica y rápida de la extremidad del electrodo en el septo interatrial alto o el fascículo de Bachmann

A fibrilação atrial (FA) é a arritmia mais frequente na prática clínica diária, com altas porcentagens de morbidade e mortalidade. Alguns estudos que compararam a duração da onda P, os tempos de recuperação e a dispersão dos períodos refratários efetivos durante a estimulação em diferentes sítios das aurículas concluíram que, para prevenir a FA, os melhores locais para o implante de eletrodos são as aurículas e o septo interatrial alto (SIA). Entretanto, é necessário desenvolver ferramentas com boa relação custo-eficácia, seguras e de uso fácil, que requeiram o mínimo de treinamento e que permitam inplantar os eletrodos nos sítios considerados ótimos. As curvas clássicas pré-formadas, incluíndo o formato em J usado para implantes de eletrodos no apêndice atrial direito, não são adequadas para a implantação no SIA alto, tornando o procedimento árduo e demorado. Apresenta-se uma curva apropriada ao implante de eletrodos no SIA alto, assim como a técnica que deve ser utilizada para sua inserção correta. A curva é de fácil manuseio e a técnica permite abreviar o tempo e facilitar o procedimento de implante.

The atrial fibrillation (AF) is the most frequent in the every day clinical practice with high percentages of morbidity and mortality. Some studies compared the duration of the P wave, the recovery time and the dispersion of the effective refraction periods during the stimulation in different sites of the auricles and concluded that, in order to prevent the AF, the best sites to implant the electrodes are the auricles and high interatrial septum (HIS). However, it is necessary to develop tools with good cost - efficacy relationship, safe and easy to use, which also require minimum training and enable the implant of the electrodes in the sites that are considered excellent. The pre-formed classical curves, including the J-shape used in implants of electrodes in the right atrium appendix are not adequate for the implant in the HIS which make the procedure difficult and time consuming. An appropriate curve is presented for the implant of electrodes in the HIS as the technique that should be used for the correct insertion. The curve is easy to handle and the technique shortens time andprovides an easy implant procedure.

La fibrilación auricular (FA) es la arritmia más frecuente en la práctica clínica diaria, con porcentajes altos de morbilidad y mortalidad. Algunos estudios han comparado la duración de la onda P, los tiempos de recuperación y la dispersión de los períodos refractarios efectivos durante laestimulación en distintos sitios de las aurículas y han concluido que, para prevenir la FA, los mejores lugares para el implante de electrodos son las aurículas y el septo interauricular alto (SIA). Sin embargo, es necesario desarrollar herramientas con una buena relación costo-eficacia, seguras y de fácil manejo, que requieran poco tiempo de entrenamiento y que permitan implantar los electrodos en los sitios considerados óptimos. Las curvas clásicas preformadas, incluyéndose el formato en J utilizado para implantes de electrodos en el apéndice auricular derecho, no son adecuadas para la implantación en el SIA alto, lo que hace que el procedimiento sea arduo y demorado. Se presenta una curvaapropiada para el implante de electrodos en el SIA alto, así como la técnica que se debe utilizar para su inserción correcta. La curva es de fácil manejo y la técnica permite abreviar el tiempo y facilitar el procedimiento de implante.

Fatores intraoperatórios nas cirurgias de revascularização do miocárdio em hospitais do município do Rio de Janeiro / Intra-operative factors in coronary artery bypass graft (GABG) surgery in government hospitals, Rio de Janeiro, Brazil

Fundamentos: Performance cirúrgica depende de condições pré e pós-operatórias. Eventos que ocorrem no período intraoperatório também podem estas associados à evolução. Objetivo: Avaliar a associação de fatores intraoperatórios com época de óbito de pacientes submetidos à cirurgia de revascularização miocárdica (RVM), em quatro hospitais públicos da cidade do Rio de Janeiro, entre janeiro 1999 e dezembro 2001. Métodos: Selecionadas, em quatro hospitais públicos da cidde do Rio de Janeiro, amostras aleatórias e ponderadas de 150 prontuários de pacientes, entre sobreviventes e óbitos. Informações sobre características intraoperatórias e época do óbito foram coletadas retrospectivamente dos prontuários e das declarações de óbitos. Estimaram-se taxas de letalidade em diversas faixas de tempo até um ano após cirurgia. Resultados: Na sala de operações ocorreram 7,4 por cento dos ópbitos; até o terceiro dia, 40,3 por cento; e até o 15º dia, 69 por cento dos óbitos do primeiro ano. Ao final do primeiro ano, 14,9 por cento dos pacientes faleceram. Tempos mais elevados de circulação extracorporea ou de clampeamento aórtico ocorreram naqueles que morreram durante acirurgia. Baixo débito, parada cardiorrespiratória (PCR) e arritmia ventricular grave intraoperatórios se associaram significativamente com o óbito precoce. Fibrilação atrialintraoperatória se associou com óbito mais frequente nos segundo e terceiro dias de pós-operatório. Conclusão: Fatores intraoperatórios favoreceram aocorrência de óbitos precoces, representando 2/3 das mortes do primeiro ano.

Background: Although surgical performance depends largely on pre- and post-operative conditions, intraoperative events may also be associated with these outcomes.Objective: To evaluate the association between intraoperative factors and times of death among patientsundergoing CABG surgery in four government hospitals in the City of Rio de Janeiro, between January 1999 andDecember 2003. Methods: Random weighted samples of 150 patient records with survivors and deaths were selected at four government hospitals in the City of Rio de Janeiro. Information on intra-operative characteristics and timesof death was collected retrospectively from the medical records and declarations of death. The lethality rates were estimated for several timeframes extending up to a year after the operation. Results: 7.4% of the deaths occurred in the operating theater; 40.3% by Day 3 and by Day 15, 69% of the deaths occurring during the first year. By the end of the first year, 14.9% of the patients were deceased. Longerextracorporeal circulation or aortic clamping times were found among patients who died during surgery. Low debit, cardio-respiratory failure (CRF) and severe intra-operative ventricular arrhythmia were significantly associated with early death. Intra-operative atrialfibrillation was associated more frequently with death on the second and third days after surgery. Conclusion: Intra-operative factors contributed to theoccurrence of early deaths, representing two thirds of deaths during the first year after surgery.

Alternative Energy Sources for Surgical Treatment of Atrial Fibrillation in Patients Undergoing Mitral Valve Surgery: Microwave Ablation vs Cryoablation

The study aim was to compare maze outcomes using microwave ablation or cryoablation in patients with mitral disease and atrial fibrillation (AF). Between 1999 and 2005, 340 patients underwent mitral valve surgery and concomitant maze procedure involving either microwave ablation (n=96, MW group) or cryoablation (n=244, Cryo group). Mean age at operation was 50.0+/-12.5 yr. Follow-up period was 46.1+/-28.2 months. The Cryo group showed a longer aortic clamping time than the MW group (P=0.005). There were no differences in operative mortality and morbidity rates. The unadjusted 5-yr AF free rate was 61.3+/-1.2% in the MW group and 79.9+/-3.2% in the Cryo group (P=0.089). After adjustment, the MW group only showed a tendency toward more frequent AF recurrence than the Cryo group (Hazard ration 1.66, 95% confidence interval 0.89 to 3.07). Multivariate analysis revealed that older patient age (P<0.001) and greater left atrial size (P<0.001) were independent risk factors for AF recurrence. Although the use of microwave ablation results in shorter aortic clamping time, it has a tendency toward more frequent late AF recurrence than with cryoablation.

Effect of â-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction

INTRODUCTION: Oral â-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with â-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of â-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral â-blockers and mortality during the first 24 hours. RESULTS: a) The use of â-blockers was inversely correlated with the presence of atrial fibrillation (ñ = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5 percent in patients with atrial fibrillation, 9.2 percent in those without atrial fibrillation (ñ < 0.001; Odds Ratio = 4.52), and 17.5 percent in patients not treated with â-blockers and 6.7 percent in those who received the drug (ñ < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, ñ = 0.002). The use of â-blockers was inversely and independently correlated with mortality (OR = 0.53; ñ = 0.002). The patients who used â-blockers showed a lower risk of atrial fibrillation (OR = 0.59; ñ = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral â-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral â-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit.

Fibrilación auricular en el postoperatorio de cirugía cardiaca: factores de riesgo y morbimortalidad / Postoperative atrial fibrillation of cardiac surgery: risk factors and morbid-mortality

Introduction: postoperative atrial fibrillation (POAF) is the most frequent arrhythmia observed in patients undergoing a cardiac surgery. The worldwide incidence is 30 to 65 percent of cardiac surgery procedures, and is more frequent in patients undergoing a cardiac valve surgery. This arrhyhtmia implies an increment in the lenght and in the total costs of hospitalization, and is associated with serious adverse events like stroke, bleeding and death. The aim of this study was to know the incidence, risk factors, morbidity and mortality associated with POAF in our institution during one year. Main results: we analyze 321 patients that undergone a cardiac surgery during 2003. The incidence of POAF was 6,7 percent and the risk factors associated were the use of cold crystalloid cardioplegia (p < 0,05) and dyslipidemia (p < 0,05). Also, the left ventricle end diastolic diameter was larger but not significant (p = 0,053) in patients with POAF in comparison with patients without POAF. POAF results in an increment of the costs and the lenght of hospitalization. There was no mortality attributed to this arrhythmia in our patients. Conclusion: in this retrospective analysis of patients undergoing cardiac surgery there was a lower incidence of POAF in comparison with other series. The risk factors in this population of patients were the use of cold crystalloid cardioplegia and dyslipidemia. Although this arrhythmiawas associated with more days of hospitalization, there were no difference in mortality between patients with POAF and patients without POAF.

Fibrilação atrial no pós-operatório de cirurgia de revascularização do miocárdio: características do perfil clínico associadas a óbitos hospitalares / Postoperative atrial fibrillation following coronary artery bypass graft: clinical factors associated with in-hospital death

OBJETIVO: Identificar fatores associados à maior chance de óbitos hospitalares em pacientes submetidos a revascularização cirúrgica do miocárdio (RM), que tenham apresentado fibrilação atrial (FA) no pós-operatório. MÉTODOS: No período de 2000 a 2003, foi analisada uma série consecutiva de 397 pacientes submetidos a RM que desenvolveram FA no pós-operatório. Esses pacientes foram divididos em dois grupos (G), sendo o G1 formado pelos pacientes que sobreviveram (n=369) e o G2, por aqueles que faleceram na fase hospitalar (n=28). Foram realizados os testes t de Student e do qui-quadrado, sendo p significativo quando < 0,05. RESULTADOS: A análise comparativa entre o G1 e o G2 demonstrou não haver diferença entre os grupos quanto a idade (67,3 ± 8,4 anos vs 69,3 ± 9,6 anos; p = 0,4), sexo masculino (75,9 por cento vs 64,3 por cento; p = 0,1), hipertensão arterial sistêmica (75,3 por cento vs 85,7 por cento; p = 0,2) e insuficiência cardíaca congestiva (17 por cento vs 17 por cento; p = 1). O G2 apresentou maiores taxas de infarto agudo do miocárdio prévio (14,6 por cento vs 28,6 por cento; p = 0,05), fração de ejeção do ventrículo esquerdo < 40 por cento (12,2 por cento vs 32,1 por cento; p = 0,003), acidente vascular encefálico prévio (0,8 por cento vs 17,9 por cento; p = 0,03), intervenção coronariana percutânea prévia (19,5 por cento vs 39,3 por cento; p = 0,01), e revascularização cirúrgica do miocárdio prévia (19,3 por cento vs 35,7 por cento; p = 0,03). CONCLUSÃO: Antecedentes de infarto agudo do miocárdio, RM, intervenção coronariana percutânea, acidente vascular encefálico e déficit ventricular grave foram mais freqüentes no grupo que faleceu na fase hospitalar, sugerindo possível associação entre esses fatores e maior chance de óbito no pós-operatório de RM.

OBJECTIVE: To identify factors associated with a higher likelihood of in-hospital death in patients submitted to coronary artery bypass graft surgery (CABG) who developed atrial fibrillation (AF) postoperatively. METHODS: The authors analyzed data from 397 consecutive patients submitted to CABG that developed AF postoperatively between 2000 and 2003. The patients were divided into 2 groups: group 1 (G1) comprised patients who survived (n=369); and group 2 (G2) comprised patients who died during hospital stay (n=28). Statistical analysis was performed using Student's t test and chi-square test, and p values < 0.05 were considered significant. RESULTS: A comparative analysis between G1 and G2 showed that there was no difference between the groups as regards age (67.3 ± 8.4 versus 69.3 ± 9.6; p = 0.4), male gender (75.9 percent versus 64.3 percent; p = 0.1), systemic arterial hypertension (75.3 percent versus 85.7 percent; p = 0.2) and congestive heart failure (17 percent versus 17 percent; p = 1). Group 2 presented higher rates for previous acute myocardial infarction (14.6 percent versus 28.6 percent; p = 0.05), left ventricular ejection fraction < 40 percent (12.2 percent versus 32.1 percent; p = 0.003), previous cerebrovascular accident (0.8 percent versus 17.9 percent; p = 0.03), previous percutaneous coronary intervention (19.5 percent versus 39.3 percent; p = 0.01) and previous CABG (19.3 percent versus 35.7 percent; p = 0.03). CONCLUSION: Clinical history of acute myocardial infarction, CABG, percutaneous coronary intervention, cerebrovascular accident and severe ventricular dysfunction were significantly more frequent in the group that died during hospital stay, which suggests a possible association of these factors with a higher likelihood of death following CABG.

Criocoagulación de venas pulmonares como tratamiento complementario de la fibrilación auricular en cirugía valvular / Cryoablation of pulmonary veins as complementary treatment of atria I fibrillation in valvular surgery

Background: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. Aim: To evaluate CPV in patients with AF submitted to valvular surgery. Patients and Methods: Twenty one patients had simultaneous valvular surgery and CPV, 81 percent of them had permanent AFfor an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60°C for 2 minutes with two 15 mm cryoprobes applied simultaneously. Results: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8 percent (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50 percent of patients were in normal sinus rhythm and 25 percent persisted in AF. The remaining patients were in some type of regular rhythm. Conclusions: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50 percent of the cases, with low morbidity and mortality and little increment in surgical time.

Perfil clínico-epidemiológico da fibrilação atrial espontânea em cães / Clinical-epidemiological profile of spontaneous atrial fibrilation in dogs

Fundamentos: A fibrilação atrial (FA) é considerada a arritmia sustentada mais importante em medicina veterinária, estando usualmente associada à doença cardíaca estrutural, com manifestações clínicas de insuficiência cardíaca avançada. São poucos os trabalhos epidemiológicos na literatura internacional e raros os relatos no Brasil. Estudos comparativos sobre FA espontânea entre espécies têm sido raramente publicados. Objetivos: Conhecer o perfil-epidemiológico de uma coorte de cães portadores de FA espontânea, bem como comparar com o observado em seres humanos. Métodos: Estudo retrospectivo com os dados dos registros de 108 cães com fibrilação atrial diagnosticada através do eletrocardiograma, no período entre janeiro de 1999 e janeiro de 2006 e os resultados comparados com o disposto na literatura relacionados com FA em cães e em humanos. Os dados coletados incluíram raça, sexo, idade, peso e freqüência cardíaca. Resultados: A investigação identificou que os animais pertenciam a 21 raças pura e a mestiços de várias raças, de ambos os sexos, com peso variando entre 5,5kg e 68kg. Todos os animais apresentavam sinais de insuficiência cardíaca estágios C ou D (NYHA), sendo identifdicados através de ecocardiograma e radiografia de tórax três grupos de cardiopatias: cardiopatia dilatada (49 por cento), endocardiose valvar mitral (36 por cento) e o terceiro grupo (15 por cento) incluiu outras causas, congênitas e adquiridas...

Tratamento não-farmacológico da fibrilação atrial: sua evolução e estado da arte / Nonpharmacological atrial fibrilation treatment: evolution and sta-of-art

A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais comum na espécie humana, ocorrendo em 2 por cento da população adulta e aumentando a cada década até a prevalência de aproximadamente 10 por cento acima de 70 anos. Resulta em aumento da mortalidade e significante morbidade relacionada a acidente vascular encefálico isquêmico e taquicardiomiopatia. A ineficácia relativa do tratamento farmacológico, os riscos das drogas antiarrítmicas e o crescente reconhecimento das conseqüências da FA têm contribuído para a procura de métodos criativos destinados a restaurar o ritmo sinusal. Este artigo analisa as atuais técnicas de mapeamento, as vantagens e limitação da ablação por cateter, considerando os gatilhos e substrato da FA