Clinical predictors of prognosis in severe aortic stenosis in unoperated patients > or = 75 years of age.

In elderly patients with severe aortic stenosis, clinical evaluation can dictate decision making. Asymptomatic patients in normal sinus rhythm, without left atrial enlargement and without bundle branch block, can be safely followed clinically, regardless of echocardiographic findings.

Detection of cardiovascular abnormalities in the nursery of a general hospital in the Amazon region: correlation with potential risk factors.

Congenital heart diseases have been studied much more extensively in children than in neonates. In this study, we report on the findings from 57 neonates seen from June of 1995 through June 1996 in the nursery of a large public hospital in Belém, Pará, Brazil. All were routinely examined by a paediatrician just after birth, and, when indicated, these babies were referred to the cardiology unit of our Hospital for assessment by a paediatric cardiologist. Most of the diagnoses were made by means of Doppler and cross-sectional echocardiography with color flow mapping. Several abnormalities of the cardiovascular system were diagnosed. The most frequent was patency of the arterial duct. But, since many ducts closed spontaneously, ventricular septal defect was the most frequent lesion seen even in the nursery. Four defects (patent arterial duct, ventricular septal defect, atrial septal defect and pulmonary stenosis) together accounted for two thirds of all cardiac abnormalities. Associated non-cardiac anomalies were more frequent in those with simple lesions within the heart. All the babies with complex heart disease, and the majority of those designated as having significant lesions, died before they could be discharged. Several risk factors were investigated. Among maternal drugs, misoprostol emerged as having a possible teratogenic effect.

[Clinical profile of aged patients with severe aortic stenosis]. / Perfíl clínico de idosos portadores de estenose aórtica severa.

PURPOSE: To evaluate clinical symptoms and echocardiographic findings in elderly patients with severe aortic stenosis and possible gender differences. METHODS: We studied 54 patients, 24 (44.5%) males and 30 (55.5%) females aged 80.7 +/- 5.2 years with severe aortic stenosis. The following variables were analyzed: presence of clinical manifestations (dyspnea, angina, and syncope) and echocardiographic indices (left ventricular [LV] dimensions, ejection fraction [EF], and mass index). RESULTS: Dyspnea was the most frequent symptom with overall prevalence of 44%. EF was lower than 50% in only 2 patients. There were no gender differences in the prevalence of any of the clinical manifestations. Male patients had higher LV volumes (p < 0.05) and lower EF (p = 0.03). CONCLUSION: The data showing dyspnea as the most common clinical manifestation; EF > 50%; lower LV volumes and greater EF in female patients suggest that the adaptive mechanisms to this condition may be different between the two sexes.

Normas para segurança do portador de marcapasso / Safety rules for patients with artificial cardiac pacemaker

A estimulaçao elétrica artifical do coraçao, atualmente, deixou de ser apenas uma forma de salvar a vida de portadores de bloqueios atrio-ventriculares, passando a ser um modo de corrigir completa e fisiologicamente os distúrbios do ritmo cardíaco e do sincronismo atrioventricular. Este progresso, em contrapartida, vem exigindo do paciente que conheça melhor seu sistema de estimulaçao, hoje mais complexo, sendo, ainda, vulnerável a múltiplas interferências. Neste contexto, os cardiologistas e outros especialistas devem conhecer as normas gerais que regem o acompanhamento de pacientes portadores de marcapassos cardíacos, para que possam consultá-las e transmiti-las aos seus pacientes. No período pós-operatório imediato, cuidados como repouso e orientaçao terapêutica sao importantes. Durante a evoluçao, o paciente deve obedecer a rotina das avaliaçoes periódicas, ter cuidado com fontes de interferência e saber que o retorno progressivo às atividades normais dar-se-á de forma lenta e progressiva. Quando bem feitas, as avaliaçoes podem contribuir para a profilaxia de complicaçoes, para a detecçao de problemas incipientes e, conseqüentemente, para a melhora do estado hemodinâmico e da capacidade física dos pacientes. Exames complementares sao indispensáveis, como a radiografia do tórax, para o acompanhamento a longo prazo, e para a identificaçao de problemas cirúrgicos como uma fratura de eletrodo; o teste ergométrico para avaliar a resposta do paciente e do marcapasso ao exercício; e a prova de Holter de 24 horas, que permite tanto a identificaçao de problemas funcionais, como o controle do comportamento do marcapasso. Fontes domésticas que interferem com o marcapasso, como detectores de metal, aparelhos elétricos mal aterrados, forno de microondas, costumam causar interferências momentâneas, sem danos permanentes ao sistema implantado. As interferências médico-hospitalares que decorrem do uso de desfibrilador e de eletrocautério, do emprego de diatermia, de radiaçoes ionizantes e de ressonância magnética sao potencialmente deletérias aos marcapassos e devem ser bem conhecidas. Estes processos sao, às vezes, contra-indicados. As interferências por miopotenciais esqueléticos sao em geral tratadas com sucesso por reprogramaçao, porém devem sempre ser pesquisadas. Finalmente, as portas de entrada de infecçao merecem especial atençao, devido ao risco de endocardite bacteriana. O médico-assistente deve atuar no sentido de prevenir esta que tem sido a mais grave complicaçao dos portadores de marcapasso

[Safety rules for patients with artificial cardiac pacemaker]. / Normas para segurança do portador de marcapasso.

The recent progress in cardiac pacing increased the usefulness of artificial pacemakers. The initial purpose of avoiding Stokes-Adams attacks, was changed by a complex way to completely give back the physiologic response of cardiac rate and atrioventricular synchronism. However, this process forced the patients to take care of their pacemakers, and to spend more time in follow-up procedures. Additionally, the pacemakers became more vulnerable to environmental and hospital interferences. Basic rules, for all patients, are described in this paper, in order to improve their quality of life. Follow-up procedures are related in detail. It is described how programmed electronic evaluations can contribute to avoid complications, to detect subclinic problems and to improve the patient's haemodynamics and physical capacity. It shows also how to use complementary examinations, like thoracic X-rays, exercise testing and Holter monitoring to optimize the cardiac pacing system. Interferences in pacemakers are focused with special attention to myo-potentials, environmental electromagnetic fields, and damage to system owing to medical procedures, like therapeutic radiation, defibrillation and electrocauterization. The approach to infective processes in pacemakers gives special emphasis to prevention of direct surgical contamination, erosion of the skin, and haematogenic dissemination of distant infective focus.

[Cardiopulmonary exercise test in the evaluation of healthy elderly men]. / Avaliação cardiorrespiratória ao exercício no idoso sadio.

PURPOSE: To study methodological aspects and results of cardiopulmonary exercise tests in elderly. METHODS: Twenty-five men (mean age 65 +/- 5 years) performed a cardiopulmonary exercise test using a bicycle ergometer and a progressive continuous work load increase protocol was employed. A computadorized system (2001 CAD/Net System-MGC), which includes a gas analyser and a pneumotacograph, was used for on line monitoring of oxygen and carbon dioxide expired fraction and also of pulmonary flow. RESULTS: We observed the following values of oxygen uptake, pulmonary ventilation and respiratory gas exchange: rest=4 +/- 1 ml/kg-1/min-1, 11 +/- 2 l/min-1 and 0.80 +/- 0,1, respectively: anaerobic threshold=12 +/- 3 ml/kg-1/min-1, 29 +/- 6 l/min-1 and 0.90 +/- 0.1, respectively: respiratory compensation point=18 +/- 4ml/kg-1/min-1, 47 +/- 1 l/min-1 and 1.07 +/- 0.1, respectively, and peak of exercise = 13 +/- 5 ml/kg-1/min-1, 76 +/- 18 l/min-1 and 1.21 +/- 0.2, respectively. The anaerobic threshold and the respiratory compensation point were achieved at 53 +/- 11 and 77 +/- 9% of peak oxygen uptake respectively. The elderly shown slightly increased values of the relation volume dead/tidal volume at rest with a slightly smaller decrease of its values during exercise in comparison to data obtained from young healthy untrained subjects. The heart rate prescription for exercise based on the heart rate reserve was higher than that based on the cardiorespiratory and metabolic responses (113-126bpm vs 96-114bpm). CONCLUSION: The cardiorespiratory and metabolic responses pattern in the elderly is quite heterogeneous. The heart rate prescription for exercise based on conventional stress tests seems to overestimate cardiorespiratory and metabolic capacity in healthy elderly men. The determination of anaerobic threshold and respiratory compensation point from cardiopulmonary exercise test data optimize exercise prescription for healthy elderly men.

[Tetralogy of Fallot: considerations about morphologic features of a well described entity]. / Tetralogia de Fallot. considerações sobre aspectos morfológicos de uma entidade descrita com perfeição.

PURPOSE: To analyze some morphological aspects of the tetralogy of Fallot which have been raising controversies in the literature, due to the different approach to the nomenclature of congenital heart defects by different authors regarding the definition of double outlet right ventricle and its concomitance with tetralogy. METHODS: We reviewed the original description of the anomaly, and also analyzed the morphology of 22 anatomical specimens, describing the degree of aortic overriding, the type of ventricular septal defect, the degree of sub-pulmonary stenosis, etc. RESULTS: Regarding the degree of aortic overriding, there was only one case where that vessel connected predominantly to the left ventricle. In the remaining hearts, the degree of overriding was between 50% and 75% in 10 cases and greater than 75% in 11. The intensity of infundibular stenosis was evaluated as mild in half the available hearts, and the pulmonary valve was bicuspid in 11 cases. Right aortic arch was present in 40% of the available hearts and the ventricular septal defect had muscular borders in just one case (5%). CONCLUSION: We could conclude that if double outlet is only a type of ventricle-arterial connexion, and so, depending on the degree of overriding of the aorta over the trabecular septum, we may have the malformation coexisting with the tetralogy.

[Clinical course of women with mitral valve stenosis during pregnancy and puerperium]. / Evolução clínica de portadoras de estenose mitral no ciclo gravídico-puerperal.

PURPOSE: The clinical evolution of women with mitral stenosis was studied during pregnancy, delivery and puerperium in initial function (FC) class I/II. METHODS: Ninety-three women were divided in three groups: Group GE--Pregnant women with mitral stenosis (n = 30, mean age 28 years); 26 (86.7%) patients had electrocardiographic signs of left atrial enlargement and nine (30%) had signs of right ventricular hypertrophy. The mitral valvar area was between 0.7 and 1.9 (mean = 1.26) cm2 at echodopplercardiogram; Group GM--Normal pregnant women (n = 32; aged 25.4 years); the electrocardiogram and echodopplercardiogram were normal. Group EM--non pregnant patients, with mitral stenosis (n = 31.33 years); 19 (61.3%) had left atrial enlargement and four (13%) had right ventricular hypertrophy. The mitral valvar area between 0.50 and 1.80 (mean = 1.19) cm2. The variables analyzed were FC and occurrence of the following complications: infective endocarditis, cardiac arrhythmias and thromboembolism. RESULTS: In GE group, 26 (86.7%) patients worsened the FC during gestation, 16 to FC III and 10 to FC IV. In GN group, 18 (56.2%) patients changed from FC I to FC II during the gestation and in EM group 5 (16.2%) patients changed from FC I/II to III during the study. Cardiac arrhythmias and infective endocarditis were not observed; thromboembolic event was registered in one (3.2%) patients from EM group. There were no death in all groups. CONCLUSION: The large majority of pregnant with mitral stenosis that started pregnancy in FC I/II worsened to FC III/IV during gestation. Medical treatment and eventually balloon valvuloplasty were successful measure to allow a full-term gestation without mortality.

Myocardial bridges: morphological and functional aspects.

OBJECTIVE: To assess the arrangement of myocardial bridges. DESIGN: A necropsy study of 90 consecutive hearts (56 male, 34 female). RESULTS: Myocardial bridges, either single or multiple, were seen in 50 (55.6%) of the 90 hearts. The left anterior descending artery was the most commonly affected artery. Thirty five of the 50 hearts which contained in total 41 muscle bridges were dissected further with a magnifying glass. Two different types of muscle bridges could be identified. Thirty one of these 41 myocardial bridges were superficial, crossing the artery transversely towards the apex of the heart at an acute angle or perpendicularly. The remaining 10 myocardial bridges crossed the left anterior descending coronary artery and surrounded it by a muscle bundle that arose from the right ventricular apical trabeculae and crossed the artery transversely, obliquely, or helically before terminating in the interventricular septum. CONCLUSIONS: The superficial type of myocardial bridge does not seem to constrict the artery during systole but the deep muscle bridges, by virtue of their relation with the left anterior descending coronary artery, could twist the vessel and thus compromise its diastolic flow. This may result in ischaemia.