Assessing cardiac resynchronization therapy response in heart failure patients: a comparative analysis of efficacy and outcomes between transvenous and epicardial leads.

Cardiac resynchronization therapy (CRT) is an effective treatment for selected heart failure (HF) patients. Although transvenous implantation is the standard method, it is not feasible in some patients, so the epicardial lead emerges as an alternative. We aim to compare CRT response, procedure-related complications, and the occurrence of clinical outcomes between patients with transvenous and epicardial leads. In a single-center retrospective study, we enrolled consecutive HF patients submitted to CRT implantation with a defibrillator between 2013 and 2022. Clinical response was defined as an improvement of at least one of the New York Heart Association classes with no occurrence of cardiovascular death or HF hospitalization in the first year of follow-up. Echocardiographic response was attained with an increase in left ventricular ejection fraction 10% or a reduction of left ventricular end-diastolic volume >15% at 6-12 months after CRT implantation. Major adverse cardiovascular events (MACE) (cardiovascular mortality and HF hospitalization) and all-cause mortality were evaluated. From a total of 149 patients, 38% (n=57) received an epicardial lead. Clinical (63% versus 60%, p=0.679) and echocardiographic (63% versus 60%, p=0.679) responses were similar between the transvenous and epicardial groups. Patients in the transvenous group had a shorter hospital stay (2 versus 7 days, p<0.001). Procedure-related complications were comparable between groups (24% versus 28%, p=0.572), but left ventricular lead-related complications were more frequent in the transvenous group (14% versus 2%). During a median follow-up of 4.7 years, the rate of MACE was 30% (n=44), with no differences in both groups (p=0.591), neither regarding HF hospitalization (p=0.917) nor cardiovascular mortality (p=0.060). Nevertheless, the epicardial group had a higher rate of all-cause mortality (35% versus 20%, p=0.005), the majority occurring during long-term follow-up (>12 months), with no deaths in the postoperative period. Considering the comparable rates of CRT response, procedure-related complications, and MACE between groups, we conclude that epicardial lead is a feasible alternative for CRT when transvenous lead implantation is not possible. The occurrence of a higher number of all-cause deaths in epicardial patients in the long-term follow-up was mainly due to infectious complications (unrelated to the lead) and the progression of oncological/chronic diseases.

Power losses reduction in a variable linear power supply using the LM317 voltage regulator.

In this work, the design and development of a new variable linear power supply, using the LM317 regulator, is proposed. The originality of this power supply is related with the control of the rectifier circuit, which is based on a reference of voltage, superimposed on the output voltage. This reference is used in the control strategy to maintain a constant voltage between the input and the output voltages of the LM317 regulator. Due to this strategy, the heating losses are greatly reduced, allowing to increase the efficiency of the regulator to about 90%, and to reduce the requirements of the cooling system. Moreover, drawbacks of conventional power supplies are mitigated, where the developed variable linear power supply delivers a current of 3 A and a variable output voltage, from 1.2 V to 30 V. The LM317 regulator was modeled by its thermal equivalent structure associated with a heatsink to study the heat transfer problem. The modeling was performed on the Matlab Simulink software, and the theoretical results were validated by a set of experimental tests using the LM317 regulator.

Lactobacillus pentosus B231 Isolated from a Portuguese PDO Cheese: Production and Partial Characterization of Its Bacteriocin.

Bacteriocin B231 produced by Lactobacillus pentosus, isolated from an artisanal raw cow's milk protected designation of origin Portuguese cheese, is a small protein with an apparent relative mass of about 5 kDa and active against a large number of Listeria monocytogenes wild-type strains, Listeria ivanovii and Listeria innocua. Bacteriocin B231 production is highly dependent on the type of the culture media used for growth of Lact. pentosus B231. Replacement of glucose with maltose yielded the highest bacteriocin production from eight different carbon sources. Similar results were recorded in the presence of combination of glucose and maltose or galactose. Production of bacteriocin B231 reached maximal levels of 800 AU/ml during the stationary phase of growth of Lact. pentosus B231 in MRS broth at 30 °C. Bacteriocin B231 (in cell-free supernatant) was sensitive to treatment with trypsin and proteinase K, but not affected by the thermal treatment in range of 55-121 °C, or freezing (-20 °C). Bacteriocin production and inhibitory spectrum were evaluated. Gene encoding plantaricin S has been detected in the genomic DNA. Virulence potential and safety of Lact. pentosus B231 were assessed by PCR targeted the genes gelE, hyl, asa1, esp, cylA, efaA, ace, vanA, vanB, hdc1, hdc2, tdc and odc. The Lact. pentosus B231 strains harbored plantaricin S gene, while the occurrence of virulence, antibiotic resistance and biogenic amine genes was limited to cytolysin, hyaluronidase, aggregation substance, adhesion of collagen protein, gelatinase, tyrosine decarboxylase and vancomycin B genes.

Radiofrequency ablation of atrial fibrillation during concomitant cardiac surgery.

OBJECTIVES: We present the experience of our centre with radiofrequency ablation of atrial fibrillation concomitantly with cardiac surgery Methods: 170 patients underwent atrial fibrillation ablation with uni/bipolar-radiofrequency. They were followed for 3-months and then as appropriate for the cardiac disease. In 2013, patients still alive underwent rhythm monitoring with ECG and 24-hour tape if in sinus rhythm RESULTS: Mean age was 65 years old and 42% of the patients were male. Paroxysmal AF was rare (7%). Most patients had preserved ejection fraction and dilated left atria (diameter 53.2±7.5 mm). The most common indication for cardiac surgery was valve disease. More than 75% of the patients underwent prophylactic closure of the left atrial appendage. Pulmonary vein isolation was performed in all patients, followed by other left atrial ablation lines. Overall, surgical complications were rare, being the most frequent pacemaker implantation (15%). Median length of stay was 9 days (p25-p75:7-14). At discharge, 69% of the patients were in sinus rhythm, being 90% on anticoagulation and 69% on amiodarone. In-hospital mortality was less than 3% (5 patients), none of them related to the ablation procedure. At 3 months, 50% of the patients were in sinus rhythm, being 92% on anticoagulation and 75% on antiarrhythmic drugs. Direct current cardioversion was successful in 8 of 12 patients. In the multivariate analysis, being in sinus rhythm at discharge was the single independent predictor of maintaining sinus rhythm at 3 months. In 2013 (469 patients-year), 40% of the patients were in sinus rhythm, being 80% on anticoagulation and 45% on antiarrhythmic drugs. CONCLUSIONS: Concurrent atrial fibrillation ablation with radiofrequency achieves satisfactory and stable recovery of sinu rhythm without adding significant operative risk and post-operative complications.

Late right ventricular perforation: a rare complication of a pacemaker implantation.

Right ventricular perforation by a pacemaker lead is a rare complication of pacemaker implantation, with an incidence inferior to 1%. It usually occurs at the time of lead insertion or during the first 24 hours after the procedure (acute perforation).Late right ventricular perforation, defined as occurring at least 1 month after lead implantation, is even rarer. The clinical presentation varies widely and is mainly related to the stimulation of extracardiac structures and/or lead dysfunction.Its diagnosis may be difficult and must be complemented by appropriate imaging methods. The optimal management strategy remains controversial, varying from surgery to more conservative treatments. The authors present a case of late right ventricular myocardium lead perforation occurring in a 56-year-old-male patient, approached with open surgery.

[Mycotic aneurysm of the left ventricular free wall complicating aortic valve endocarditis]. / Aneurisma micótico da parede livre do ventrículo esquerdo como complicação de endocardite da válvula aórtica.

We report the case of a 34-year-old man with aortic valve infective endocarditis caused by methicillin-resistant Staphylococcus aureus, complicated by an aortic annular abscess. A 23-mm St. Jude HP aortic mechanical prosthesis was implanted. The pre-discharge echocardiogram revealed a mycotic aneurysm of the basal posteroinferior wall, confirmed by cardiac magnetic resonance imaging, and it was decided to reintervene. The aneurysm was closed with a patch and the mitral valve had to be replaced. Although a small leak from the aneurysm patch persisted on the pre-discharge transthoracic echocardiogram, there was no trace of the aneurysm at nine-month re-evaluation. This case illustrates a rare complication of aortic valve endocarditis and shows the evolution of the mycotic aneurysm after closure via a transmitral approach.

Do exército de sombras ao soldado-cidadão': saúde, recrutamento militar e identidade nacional na revista nação armada (1939-1947) / From the army of shadows to the citizen soldier: health, military conscription and national identity in the revista nação armada (1939-1947)

A presente pesquisa aborda a importância do tema da saúde no discurso dos militares brasileiros (mais especificamente do Exército) a respeito da construção de uma identidade nacional no período do Estado Novo (1937-1945), com particular ênfase aos anos relativos à Segunda Guerra Mundial. Para isso, serão analisados os textos publicadosna revista Nação Armada, revista civil-militar consagrada à segurança nacional, editada, com periodicidade mensal, entre novembro de 1939 e março de 1947. Buscou-se avaliar de que maneira a concepção destes militares sobre os problemas sanitários do país (particularmente no âmbito das Forças Armadas), e sobre as intervenções necessárias à sua solução, foi central para a afirmação e a legitimação do papel do Exército como força política e ideológica decisiva para o projeto de “regeneração” do “povo brasileiro” e de elaboração de uma “nova nação” naquele período do primeiro governo do Presidente Getúlio Vargas. Dentre os temas abordados pela revista, as questões relacionadas à saúde estavam, em particular, associadas à questão do recrutamento militar, que ganhou especial visibilidade e importância no contexto do conflito mundial. Preconizando os valores e práticas da higiene, da educação física e da eugenia como elementos fundamentais para a conformação de um “soldado-cidadão”, “apto” a atuar não apenas na guerra, mas fundamentalmente como exemplo/modelo para o “novo homem brasileiro”, a análise dos discursos veiculados em Nação Armada proporciona a compreensão histórica dos significados e práticas que nortearam a afirmação pública dos militares como grupo encarregado e aparelhado para promover a “cura”, o “fortalecimento” e o“engrandecimento” da nação de acordo com os preceitos ideológicos firmados pelo regime estadonovista.

This research addresses the importance of health as a theme in the publicdiscourse of military leaders in Brazil (especially those of the Army) with respect to the construction of a national identity during the Estado Novo period (1937-1945), with particular emphasis on the years during the Second World War. In pursuit of this theme, texts published in Nação Armada, revista civil-militar consagrada à segurança nacional (November 1939 to March 1947), are analyzed. An analysis is undertaken ofthe ways that military officers’ notions of national health issues (particularly as found in their soldiers), and also their belief in a need for interventions was crucial for the affirmation and legitimization of the Army as a political and ideological force decisive in the project towards “regeneration” of the Brazilian people and towards theelaboration of a “new nation” during Getúlio Vargas’s first term as president. Among the themes tackled by the magazine, those concerning public health were particularly focused on military recruitment, it being so visible and important during World War II.Extolling the value of good hygiene, physical fitness and even eugenics as fundamental to the making of any “citizen-soldier” as “qualified” to serve not only in war, but as an exemplary “New Brazilian Man,” the discourse promulgated in the Nação Armada is seen, in this analysis, as a means to historical comprehension of theideals and practices which shaped public approval of the Armed Forces as a group suitable and equipped to promote the “healing” and “strengthening” and “uplifting” ofthe republic in accord with the ideological assumptions of the “estadonovista” regime. Thus the present research aims to contribute to present-day historical inquiry into publichealth in Brazil during the first half of the 20th century in its several intersections with the debates in the political and social life in Brazil.

Do 'Exército de Sombras' ao 'Soldado-Cidadão': saúde, recrutamento militar e identidade nacional na Revista Nação Armada (1939-1947) / From the 'Army of Shadows' to the 'Citizen Soldier': health, military conscription and national identity in the 'Revista Nação Armada' (1939-1947)

A presente pesquisa aborda a importância do tema da saúde no discurso dos militares brasileiros (mais especificamente do Exército) a respeito da construção de uma identidade nacional no período do Estado Novo (1937-1945), com particular ênfase aos anos relativos à Segunda Guerra Mundial. Para isso, serão analisados os textos publicadosna revista Nação Armada, revista civil-militar consagrada à segurança nacional, editada, com periodicidade mensal, entre novembro de 1939 e março de 1947. Buscou-se avaliar de que maneira a concepção destes militares sobre os problemas sanitários do país (particularmente no âmbito das Forças Armadas), e sobre as intervenções necessárias à sua solução, foi central para a afirmação e a legitimação do papel do Exército como força política e ideológica decisiva para o projeto de “regeneração” do “povo brasileiro” e de elaboração de uma “nova nação” naquele período do primeiro governo do Presidente Getúlio Vargas. Dentre os temas abordados pela revista, as questões relacionadas à saúde estavam, em particular, associadas à questão do recrutamento militar, que ganhou especial visibilidade e importância no contexto do conflito mundial. Preconizando os valores e práticas da higiene, da educação física e da eugenia como elementos fundamentais para a conformação de um “soldado-cidadão”, “apto” a atuar não apenas na guerra, mas fundamentalmente como exemplo/modelo para o “novo homem brasileiro”, a análise dos discursos veiculados em Nação Armada proporciona a compreensão histórica dos significados e práticas que nortearam a afirmação pública dos militares como grupo encarregado e aparelhado para promover a “cura”, o “fortalecimento” e o“engrandecimento” da nação de acordo com os preceitos ideológicos firmados pelo regime estadonovista. (AU)

Pseudo-pericardial tamponade after cardiac surgery.

Cardiac tamponade is a common cause of hypotension and low output after cardiac surgery. The authors present a case of false tamponade diagnosis on transesophageal echocardiography in a patient who underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was not confirmed at surgery, and the cause of the abnormal right atrial filling was a prominent Eustachian valve trapped in the suture for correction of an iatrogenic inferior vena cava laceration. Such a complication must be kept in mind when repairing inferior vena cava lacerations and should be more widely known.

[Ventricular cardiac resynchronization--initial surgical experience]. / Ressincronização cardíaca ventricular--experiência cirúrgica inicial.

Cardiac resynchronization therapy (CRT) is a recent method for patients with myocardial failure resulting from systolic malfunction. CTR is achieved by simultaneous stimulation of both ventricles which resynchronizes the time of depolarization of the left ventricle and improves myocardial contractility, diminishing mitral regurgitation. Usually the TCR is applied percutaneously/transvenously but in some cases it is impossible to use such techniques due to several reasons. The authors of this article suggest the minithoracotomy as an alternative approach of the left ventricle for implantation of the epicardic electrode. This technique has proven to be simple and safe, allowing short implantation times in comparison with the traditional technique, as well as a better choice of the site of electrode implantation.

Heart transplantation. A Portuguese hospital center's experience.

Cardiac transplantation is the gold standard therapy for patients below 60 years presenting with severe heart failure (HF) despite maximal medical therapy, who have no other surgical option and no contraindications to this procedure. We evaluated our experience with this important form of heart failure therapy. Between February 1987 and December 2002, 32 patients, aged 37 +/- 16 years, 19 males, with ejection fraction of 18 +/- 7%, underwent heart transplantation in our center. Seven (22%) patients were in NYHA class IV with hemodynamic support. Seventeen (53%) patients had idiopathic dilated cardiomyopathy (DCM), 7 (22%) had ischemic DCM, 3 (9%) had valvular DCM and the remainder had other causes of left ventricular dysfunction. Overall survival rate was 68% at first year post-transplantation, 59% at 5 years and 59% at 10 years. One year after cardiac transplantation, 95% of patients were in NYHA class I and the rest were in NYHA class II. Among the 13 patients who died, in five (18%) death occurred during the first month: the most frequent cause was hemodynamic failure. Causes of late death were: allograft vasculopathy (n = 3), allograft rejection (n = 1), infection (n = 1), sudden death (n = 1), hemodynamic failure (n = 1) and bradyarrhythmia (n = 1). Among the patients followed for more than one year, only three died. Early complications were: infection (8 episodes, 7 of respiratory location), right heart failure (3 patients), pericardial effusion (5 patients) and others (7 patients). Late complications were: a) allograft rejection: 17 (53%) patients, 72 episodes (10 ISHLT grade 3, 6 of whom were treated with intravenous corticotherapy, 8 grade 2 and 54 grade 1); b) infections: 19 (59%) patients; 35 episodes, 25 requiring hospitalization: 10 (28%) involving the respiratory tract, 6 (17%) the oropharynx, 5 (14%) the urinary tract, 4 (11%) the skin and 10 (28%) of undetermined location; c) chronic allograft rejection: 6 (19%) patients; d) arterial hypertension: 14 (45%) patients; d) renal failure: 5 (16%) patients; e) diabetes: 2 (6%) patients; f) cancer: 2 (6%) patients. Patients with severe heart failure and a very poor prognosis who underwent cardiac transplantation in our hospital showed marked improvement in functional capacity and quality of life and had an overall survival similar to the results of international heart transplantation registries. Complications during follow-up were similar to those usually described in the literature.