Preserved cardiorespiratory function and NT-proBNP levels before and during exercise in patients with recent onset of rheumatoid arthritis: the clinical challenge of stratifying the patient cardiovascular risks.

Rheumatoid arthritis (RA) is associated with an increased risk of myocardial infarction and congestive heart failure. In RA patients, elevated NT-proBNP levels have been reported to be a prognostic marker of left ventricular dysfunction. In this study, we evaluated cardiorespiratory functional capacity and NT-proBNP levels before and during cardiopulmonary exercise test in early RA (ERA) patients. Twenty ERA patients and 10 healthy controls were studied by color Doppler echocardiography to evaluate ventricular systolic and diastolic function. Arterial stiffness and wave reflections were quantified non-invasively using applanation tonometry of the radial artery. Cardiopulmonary treadmill test was performed to measure peak VO2 and VE/VCO2 parameters. NT-proBNP plasma levels were measured before and at the exercise peak during cardiopulmonary exercise. The peak oxygen uptake [VO2 (ml/min/kg)], the ventilatory equivalents for carbon dioxide (EqCO2), respiratory exchange ratio and arterial stiffness were similar between patients and controls during cardiopulmonary exercise test. Basal and peak cardiopulmonary exercise NT-proBNP plasma levels were comparable in ERA patients with respect to healthy controls. When we analyzed patients according to disease characteristics and cardiovascular risk factors, ERA patients with high disease activity, BMI > 25 kg/m2 and ACPA positivity presented significantly higher baseline and exercise peak NT-proBNP levels. Cardiorespiratory function is preserved in patients with recent onset of rheumatoid arthritis. The increased basal and exercise peak NT-proBNP plasma levels in patients with negative disease prognostic factors represent a possible marker to stratify the cardiovascular risk in patients with early rheumatoid arthritis.

[Occlusion of patent ductus using the Rashkind system. Initial experience]. / Oclusão de canal arterial persistente mediante utilização do sistema de Rashkind. Experiência inicial.

Three patients were submitted to the Rashkind device technique for closure of a patent ductus arteriosus. The percutaneous transvenous technique was employed in every cases. A 12 mm prosthesis was utilized in one case and 17 mm prostheses in the other two cases. In the first case, after temporary occlusion of the ductus arteriosus, the prostheses was removed due to the technical impossibility of evaluation of the proximal umbrella position. In the second and third cases, the prostheses were duly liberated in the proper position, thus occluding the defects. This technique does not require general anesthesia, is indicated in patients over 6 kgs of body weight, and is a therapeutic alternative to the habitual surgical procedure.

[Mammary-coronary anastomosis: a new technique of approach through the brachial route for angiographic study and angioplasty]. / Anastomose mamária-coronária: nova técnica de abordagem por via braquial para estudo angiográfico e angioplastia.

PURPOSE: A new technique of mammary artery catheterization, by a brachial artery approach, utilizing a pre-molded conventional Sones catheter is described. METHODS: In a series of 300 patients, 308 procedures were performed. Three hundred internal mammary-coronary anastomosis were studied. In eight cases angioplasty were performed, five in the anterior descending artery and three in the internal mammary artery itself, with recanalization of one of the three cases. The approach was through the brachial artery homolateral to the anastomosed mammary artery. After the conventional coronarographic and bypass studies were performed, the catheter was withdrawn and pre-molded, forming a closed loop of approximately 10 mm in its distal extremity. The loop was introduced through the arteriotomy reaching the origin of the vertebral artery. The internal mammary artery was then catheterized utilizing rotation and traction movements. In the percutaneous transluminal coronary angioplasty (PTCA) procedures, the Sones catheter was replaced by a Myler right coronary catheter with a 260 cm metallic wire. RESULTS: In the 308 procedures, the internal mammary artery was catheterized in 305 instances (99.03%). In the remaining three cases selective catheterization of the internal mammary artery was not possible. In these three cases there was extreme tortuosity of the subclavian artery. The only complication observed in this series was thrombosis of the brachial artery in two cases (90.65%). In the eight patients submitted to PTCA the existing lesions were successfully dilated. CONCLUSION: Catheterization of the internal mammary artery through a brachial approach utilizing a pre-molded Sones catheter was an efficient procedure, with low incidence of complications. This approach could be the elective technique in the services that habitually utilize the brachial artery approach. It could be also an alternative for those utilizing the Judkins technique, whenever the internal mammary artery catheterization is impossible due to the anatomic characteristics of the patient.

[Analysis of the mechanical properties of the left ventricle in patients with aortic valve disease]. / Análise das propriedades mecânicas do ventrículo esquerdo em portadores de valvopatia aórtica.

The morphological and functional aspects of the left ventricle (LV) were assessed by echocardiography and cardiac catheterization performed simultaneously in 41 patients. Eleven were normal (N), 14 had aortic stenosis (AS) and 16 had aortic regurgitation (AR). Of the 14 patients with AS, eight were in New York Heart Association (NYHA) functional class I and II (ASA group) and six were in NYHA functional class III and IV (ASB group). Of the 16 patients with AR, seven were in NYHA functional class I and II (ARA group) and nine in functional class III and IV (ARB group). In the ASA group normal values of the LV function were obtained because of the development of an adequate hypertrophy that in normalizing the systolic stroke was able to keep a suitable function. In the ASB group there was a reduction of the LV function due to an increase of the systolic stroke and to the reduction of the contractile muscle state. Thus, in the whole AS group we found an inversed relation between the ejection fraction and the systolic stroke. In the ARA group we found a normal cardiac function as consequence of an adequate development of the LV dilation and hypertrophy. Despite the find of reduction of the contractile state, the systolic stroke normalizing was capable to keep the cardiac function at normal values. The ARB group presented an important depression of the cardiac function due the increase of the systolic stroke and to the decrease of the contractile state of the cardiac muscle.

Hemodynamic determinants of coronary constriction in human myocardial bridges.

To study the physiopathology of myocardial bridges, we assessed the degree of systolic coronary artery constriction (%SC) in different hemodynamic situations in six patients submitted for coronary angiograms. There was an increase of %SC (p less than 0.05) with sodium nitroprusside (NP), no modification during fast atrial stimulation (AS), and a decrease (p less than 0.05) during noradrenaline infusion (Nor). Hemodynamic studies indicate an inverse relation (p less than 0.05) between %SC and systolic and diastolic aortic pressure and left ventricular dP/dt. There was no correlation between changes in %SC and changes in Vmax or heart rate. Thus we conclude that changes in systemic arterial pressure and coronary perfusion pressure may significantly affect the degree of severity of myocardial bridges, possibly through an influence upon intraluminal coronary pressure and an intramyocardial tension relationship.