Ventricular Synchrony in Para-Hisian Cardiac Pacing as an Alternative for Physiological Cardiac Activation (Indirect Recruitment of the His Bundle?). / Sincronia Ventricular na Estimulação Cardíaca Parahissiana: Alternativa por Ativação Cardíaca Fisiológica (Estimulação Indireta do Feixe de His)?

BACKGROUND: Artificial cardiac pacing by direct or indirect His bundle capture results in synchronous ventricular contraction (physiological pacing). OBJECTIVES: To compare cardiac synchronization, technical characteristics, and electronic parameters between two techniques of indirect His-bundle pacing: non-selective (NS-HBP) vs para-Hisian pacing (PHP). METHODS: The experimental intervention (between November 2019 and April 2020) consisted of implanting a DDD pacemaker in patients who had left ventricular ejection fraction (LVEF) > 35%. The resulting cardiac synchronization was compared using an electrocardiographic algorithm that analyzed QRS variation and the technical characteristics of non-selective Hisian pacing (DDD-His) and para-Hisian pacing (DDD-Var). RESULTS: Of 51 total patients (men: 28), 66.7% (34) were allocated to the DDD-Var group and 33.3% (17) to the DDD-His group. The mean ages in each group were 74 and 79 years, respectively. In the DDD-Var group, QRS variation (ventricular synchrony) improved after implantation (p < 0.001). In post-implantation ECG, 91.2% of the DDD-Var group presented a physiological pacing pattern, which was similar to the DDD-His group (88.2%; p = 0.999). The paced QRS axis was also similar (physiological) for both groups. Intraoperative fluoroscopy time (XRay) during implantation was lower for the para-Hisian technique (median 7 min in the DDD-Var group vs 21 min in the DDD-His group, p < 0.001). The mean QRS duration increased in the DDD-Var group (114.7 ms pre-implantation vs 128.2 ms post-implantation, p = 0.044). The mean post-implantation R-wave amplitude was 11.2 mV in the DDD-Var group vs 6.0 mV in the DDD-His group, p = 0.001. CONCLUSION: Para-Hisian pacing appears to indirectly recruit the His bundle, which would make this an effective and comparable strategy for physiological pacing, resulting in synchronous ventricular contraction similar to that of non-selective Hisian pacing.

FUNDAMENTO: A estimulação cardíaca artificial (ECA) por captura direta ou indireta do feixe de His resulta em contração ventricular sincrônica (ECA fisiológica). OBJETIVOS: Comparar sincronia cardíaca, características técnicas e resultados de parâmetros eletrônicos entre duas técnicas de ECA indireta do feixe de His: a não seletiva e a parahissiana. MÉTODOS: Intervenção experimental (novembro de 2019 a abril de 2020) com implante de marca-passo definitivo (MPd) DDD em pacientes com fração de ejeção ventricular esquerda > 35%. Foram comparadas a sincronia cardíaca resultante mediante algoritmo de análise eletrocardiográfica da variância espacial do QRS e as características técnicas associadas a cada método entre ECA hissiana não seletiva (DDD-His) e parahissiana (DDD-Var). RESULTADOS: De 51 pacientes (28 homens), 34 (66,7%) foram alocados no grupo DDD-Var e 17 (33,3%), no grupo DDD-His, com idade média de 74 e 79 anos, respectivamente. No grupo DDD-Var, a análise da variância espacial do QRS (índice de sincronia ventricular) mostrou melhora após o implante de MPd (p < 0,001). Ao ECG pós-implante, 91,2% dos pacientes do grupo DDD-Var mostraram padrão fisiológico de ECA, comprovando ativação similar à do DDD-His (88,2%; p = 0,999). O eixo do QRS estimulado também foi similar (fisiológico) para ambos os grupos. A mediana do tempo de fluoroscopia do implante foi de 7 minutos no grupo DDD-Var e de 21 minutos no DDD-His (p < 0,001), favorecendo a técnica parahissiana. A duração média do QRS aumentou nos pacientes do DDD-Var (114,7 ms pré-MPd e 128,2 ms pós-implante, p = 0,044). A detecção da onda R foi de 11,2 mV no grupo DDD-Var e de 6,0 mV no DDD-His (p = 0,001). CONCLUSÃO: A ECA parahissiana comprova recrutamento indireto do feixe de His, mostrando-se uma estratégia eficaz e comparável à ECA fisiológica ao resultar em contração ventricular sincrônica similar à obtida por captura hissiana não seletiva.

Sincronia Ventricular na Estimulação Cardíaca Parahissiana: Alternativa por Ativação Cardíaca Fisiológica (Estimulação Indireta do Feixe de His)? / Ventricular Synchrony in Para-Hisian Cardiac Pacing as an Alternative for Physiological Cardiac Activation (Indirect Recruitment of the His Bundle?)

Resumo Fundamento A estimulação cardíaca artificial (ECA) por captura direta ou indireta do feixe de His resulta em contração ventricular sincrônica (ECA fisiológica). Objetivos Comparar sincronia cardíaca, características técnicas e resultados de parâmetros eletrônicos entre duas técnicas de ECA indireta do feixe de His: a não seletiva e a parahissiana. Métodos Intervenção experimental (novembro de 2019 a abril de 2020) com implante de marca-passo definitivo (MPd) DDD em pacientes com fração de ejeção ventricular esquerda > 35%. Foram comparadas a sincronia cardíaca resultante mediante algoritmo de análise eletrocardiográfica da variância espacial do QRS e as características técnicas associadas a cada método entre ECA hissiana não seletiva (DDD-His) e parahissiana (DDD-Var). Resultados De 51 pacientes (28 homens), 34 (66,7%) foram alocados no grupo DDD-Var e 17 (33,3%), no grupo DDD-His, com idade média de 74 e 79 anos, respectivamente. No grupo DDD-Var, a análise da variância espacial do QRS (índice de sincronia ventricular) mostrou melhora após o implante de MPd (p < 0,001). Ao ECG pós-implante, 91,2% dos pacientes do grupo DDD-Var mostraram padrão fisiológico de ECA, comprovando ativação similar à do DDD-His (88,2%; p = 0,999). O eixo do QRS estimulado também foi similar (fisiológico) para ambos os grupos. A mediana do tempo de fluoroscopia do implante foi de 7 minutos no grupo DDD-Var e de 21 minutos no DDD-His (p < 0,001), favorecendo a técnica parahissiana. A duração média do QRS aumentou nos pacientes do DDD-Var (114,7 ms pré-MPd e 128,2 ms pós-implante, p = 0,044). A detecção da onda R foi de 11,2 mV no grupo DDD-Var e de 6,0 mV no DDD-His (p = 0,001). Conclusão A ECA parahissiana comprova recrutamento indireto do feixe de His, mostrando-se uma estratégia eficaz e comparável à ECA fisiológica ao resultar em contração ventricular sincrônica similar à obtida por captura hissiana não seletiva.

Abstract Background Artificial cardiac pacing by direct or indirect His bundle capture results in synchronous ventricular contraction (physiological pacing). Objectives To compare cardiac synchronization, technical characteristics, and electronic parameters between two techniques of indirect His-bundle pacing: non-selective (NS-HBP) vs para-Hisian pacing (PHP). Methods The experimental intervention (between November 2019 and April 2020) consisted of implanting a DDD pacemaker in patients who had left ventricular ejection fraction (LVEF) > 35%. The resulting cardiac synchronization was compared using an electrocardiographic algorithm that analyzed QRS variation and the technical characteristics of non-selective Hisian pacing (DDD-His) and para-Hisian pacing (DDD-Var). Results Of 51 total patients (men: 28), 66.7% (34) were allocated to the DDD-Var group and 33.3% (17) to the DDD-His group. The mean ages in each group were 74 and 79 years, respectively. In the DDD-Var group, QRS variation (ventricular synchrony) improved after implantation (p < 0.001). In post-implantation ECG, 91.2% of the DDD-Var group presented a physiological pacing pattern, which was similar to the DDD-His group (88.2%; p = 0.999). The paced QRS axis was also similar (physiological) for both groups. Intraoperative fluoroscopy time (XRay) during implantation was lower for the para-Hisian technique (median 7 min in the DDD-Var group vs 21 min in the DDD-His group, p < 0.001). The mean QRS duration increased in the DDD-Var group (114.7 ms pre-implantation vs 128.2 ms post-implantation, p = 0.044). The mean post-implantation R-wave amplitude was 11.2 mV in the DDD-Var group vs 6.0 mV in the DDD-His group, p = 0.001. Conclusion Para-Hisian pacing appears to indirectly recruit the His bundle, which would make this an effective and comparable strategy for physiological pacing, resulting in synchronous ventricular contraction similar to that of non-selective Hisian pacing.

Abdome agudo inflamatório em pediatria / Inflammatory acute abdome in pediatrics

A etiologia mais comumente relacionada ao quadro de abdome agudo inflamatório na criança é a apendicite aguda. O diagnóstico é essencialmente clínico, mas quando houver dúvida diagnóstica, podem ser empregados métodos de imagem. A conduta varia de acordo com o estágio da doença.

The etiology most commonly related to inflammatory acute abdomen in children is acute appendicitis. The diagnosis is primarily clinical, but imaging methods can be used when there is diagnostic uncertainty. Management varies according to the stage of the disease.

Parada cardiorrespiratória / Cardiorespiratory arrest

Os suportes básicos e avançados de vida continuam a ser a chave para melhorar os resultados de sobrevivência da parada cardiorrespiratória (PCR). O objetivo deste artigo é atualizar a abordagem da PCR, enfatizando os diferentes cenários clínicos e individualizando as terapias conforme o ritmo e a etiologia.

Basic life support and advanced cardiovascular life support continue to be the key to improve survival rates of sudden cardiac arrest (SCA). The purpose of this article is to update the approach to SCA, emphasizing the different clinical scenarios and individualizing therapies according to rhythm and etiology.

Pneumonia da comunidade: diagnóstico e manejo inicial / Community pneumonia: diagnosis and initial management

A Pneumonia é a principal causa de morte por doença infecciosa em países subdesenvolvidos.¹ No Brasil, a pneumonia adquirida na comunidade é uma das principais causas de internação por doença. Afeta principalmente homens, com taxas de hospitalização mais elevadas em menores de 5 e maiores de 80 anos.²

Pneumonia is the first cause of death in underdeveloped countries.¹ In Brazil, Community-Acquired Pneumonia is one of the main causes of hospitalization due to disease. It affects mostly males, with higher hospital admission rates in those with less than 5 and more than 80 years old.²

Abordagem e manejo do acidente botrópico / Approach and management of botropic accident

Acidentes ofídicos são comuns no Brasil, sendo as serpentes do gênero Bothrops as responsáveis pela maioria dos acidentes. Se não tratados de forma adequada, estes acidentes podem determinar alta morbimortalidade. O presente artigo tem como objetivo auxiliar a identificação, abordagem diagnóstica e manejo terapêutico dos acidentes botrópicos.

Snakebites are common in Brazil and Bothrops snakes are responsible for most accidents. If not properly treated, these accidents can result in serious morbidity and mortality to the patient. This article aims to assist the identification, diagnosis and therapeutic management of Bothrops snakebites.

Primary cutaneous adenoid cystic carcinoma of the upper lid: a case report and literature review.

To report on the diagnostic challenge of an adenoid cystic carcinoma arising from the eyelid. A 77-year-old male was referred to our center with a clinical diagnosis of upper eyelid chalazion for a lesion that had appeared 2 years before. A loss of cilia was observed over the cutaneous area of induration, but there was no reddening or ulceration. Incisional biopsy was performed and the specimen was submitted in formalin for histopathological examination. On light microscopy, the lesion was composed of basaloid epithelial and myoepithelial cells that were arranged in strands or nests and associated with cystic spaces that contained a deeply eosinophilic secretory substance and an Alcian blue-positive material, characteristic of adenoid cystic carcinoma. After histological diagnosis, tumor re-excision was performed to ensure adequacy of resection margins, as well as a sentinel lymph node procedure, resulting in complete excision of the malignant tumor. No recurrence was observed during the first 18 months after surgery. Adenoid cystic carcinoma is a rare and aggressive epithelial malignancy, which tends to grow slowly and should be considered in the differential diagnosis of eyelid tumors simulating chalazion.

Anterior segment examination in paediatric patients: the closed probe system.

The anterior segment examination with the use of immersion shells has always required general anesthesia or deep sedation in very young children. The purpose of this paper is to describe a new examination technique that uses a closable standoff screwed to high frequency transducer to examine the anterior segment of pediatric patients with no sedation or anesthesia. A 35-MHz probe (nominal frequency) was screwed into an open plastic cylinder closed by a biocompatible changeable Mylar film and filled with distilled water (Hiscan, Optikon, Rome, Italy). A total of 33 pediatric patients (min 1 month; max 192 months; mean 71.30; median 63; SD +/- 56.53) were examined with this system for the following pathologies: vitreoretinal problems (n=8), congenital cataract (n=7), cysts at different sites (n=4), uveitis (n=3), congenital glaucoma (n=3), traumatized eyes (n=3), retinoblastoma (n=2), retinopathy of prematurity (n=2) and bilateral corneal congenital opacity (n=1). The probe was used both in contact with the lid skin in the very young or over the conjunctiva after topical anesthesia. Although many artifacts exist due to the free eye movements and Mylar membrane duplication artifacts, all images clearly depicted normal anatomy and pathologic findings, especially the iris, ciliary body and ciliary processes. The use of movie recording (8 images per second) helps reduce the examination time and is of great help if after-movements are to be shown. With the present technique, the examinations may be repeated more frequently with no problems.

Encephalofacial angiomatosis (Sturge-Weber syndrome): report of three cases.

The purpose is to show and discuss the findings in three cases of Sturge-Weber syndrome. One adult and two children were examined in the last three years. The girl was scanned after diode laser treatment for her right eye glaucoma. Ultrasonographic examinations were performed with 20- and 25-MHz probes (nominal frequencies) for posterior pole and 35-MHz probe (closed system, HiScan Optikon 2000, Rome, Italy) for anterior segment. All cases were characterized by choroid thickening due to capillary hemangioma. The thickening was not regular and the use of 25-MHz probe proved superior in visualizing the two layers (choroid vs. sclera), showing a striking reflectivity difference between them. All cases also showed enlarged vortex veins and some anomalous vessels adjacent to the external surface of the sclera, i.e. posterior episcleral dilated vessels. In one case only, very anomalous tortuous vessels were found in the orbit. Disk cupping and/ or pseudo cupping was always present in all cases; in the oldest patient only, who had a thinner choroid, it was possible to display a concave bottom of the cup instead of the straight, small, highly reflective segment representing the cribrosa. Serous retinal and choroid detachments were present as temporary complications after glaucoma treatment. In conclusion, choroid, facial and encephalon involvement in Sturge-Weber syndrome is widely described in ocular oncology books, whereas by far less attention is paid to orbital involvement. Anterior dilated episcleral vessels are visible and till now the posterior vessel involvement has only been demonstrated in some pathology specimens.

Orbital dermoid cyst of childhood: clinical pathologic findings, classification and management.

To analyze the characteristics and treatment outcomes of pediatric orbital dermoid cysts. Chart review of consecutive pediatric biopsy-proven dermoid cysts surgically removed at the Department of Ophthalmology, Maggiore Hospital, between 2000 and 2007. We excised dermoid cysts from 30 children (30 eyes) whose mean age at the time of surgery was 24 months (range 6-84). The most common presentation of the cyst was a palpable or partially palpable mass (100%), followed by a superior lid ptosis (10%). Twenty patients (67%) had superficial cysts with margins well-definable by palpation, and 10 patients (33%) had deep cysts that extended beyond the orbital rim with an incomplete palpation of margins requiring imaging studies. The most frequent localization of the cysts was the superior temporal zygomatico-frontal suture (86.6%), followed by the superior nasal frontal suture (10%). Complete removal of the cysts was achieved and confirmed histopathologically, and there were no recurrences among the patients at a mean follow-up of 28 months (range 6-73). One child, however, developed a temporary orbital hematoma. The superficial cysts had an anatomic mean diameter of 10 mm (range 2.5-15), and the mean age of the patients at surgery was 19 months (range 6-31). The deep cysts had a larger diameter with a mean of 14 mm (range 10-30) (P = 0.008), and the children were older at presentation with a mean age of 34 months (range 15-84) (P = 0.03). There was a statistically significant difference (P < 0.05) between the two groups (superficial and deep) when comparing age and diameter. Cysts with palpably distinct margins (superficial) can be easily and completely excised with no recurrence. Cysts with indistinct margins need detailed computed tomography or magnetic resonance imaging investigation because they may require deep orbital dissection. Complete excision of the cyst's capsule may be difficult as a result. In our review we have not found cysts with intracranial extension.