The addition of renal sympathetic denervation to pulmonary vein isolation reduces recurrence of paroxysmal atrial fibrillation in chronic kidney disease patients.

BACKGROUND: Atrial fibrillation (AF) frequently complicates chronic kidney disease (CKD). AF treatment is challenging and requires complete pulmonary vein isolation (PVI). Recently, renal sympathetic denervation (RSD) has been reported to reduce AF recurrence when performed alongside PVI. METHODS: A prospective therapeutic study of patients with controlled hypertension and paroxysmal AF was undertaken. Renal function was evaluated using estimated glomerular filtration rate. Outcomes for patients with normal renal function who underwent PVI (n = 101) were compared with those for CKD patients who underwent either PVI alone (n = 96) or PVI + RSD (n = 39). The primary endpoint was recurrence of AF recorded by 24-h Holter monitoring. RESULTS: During the 22.4 ± 12.1 months following intervention, the incidence of AF recurrence was higher in CKD patients treated with PVI alone (61.5 %) than in CKD patients treated with PVI + RSD (38.5 %; HR 1.86, 95 % CI 1.14-3.03, P = 0.0251) or patients without CKD subjected to PVI (35.6 %; hazard ratio (HR) 2.27, 95 % confidence interval (CI) 1.51-3.42, P < 0.0001). In particular, the addition of RSD to PVI significantly reduced AF recurrence in CKD stage 4, but not stage 2 or 3, patients. Ambulatory blood pressure and mean heart rate were not different between groups or time points. No complications of either procedure were observed. CONCLUSIONS: PVI + RSD is a safe treatment that is superior to PVI alone for treatment of paroxysmal AF in CKD patients.

Pulmonary vein isolation alone and combined with renal sympathetic denervation in chronic kidney disease patients with refractory atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) commonly occurs in association with chronic kidney disease (CKD), resulting in adverse outcomes. Combining pulmonary vein isolation (PVI) and renal sympathetic denervation (RSD) may reduce the recurrence of AF in patients with CKD and hypertension. We considered that RSD could reduce the recurrence of AF in patients with CKD by modulating sympathetic hyperactivity. Our goal was to compare the impact of PVI + RSD with that of PVI alone in patients with concurrent AF and CKD. METHODS: This was a single-center, prospective, longitudinal, randomized, double-blind study. Forty-five patients with controlled hypertension, symptomatic paroxysmal AF and/or persistent AF, stage 2 or 3 CKD, and a dual-chamber pacemaker were enrolled from January 2014 to January 2015. We assessed the 30-second recurrence of AF recorded by the pacemaker, 24-hour ambulatory blood pressure measurements, estimated glomerular filtration rate, albuminuria, echocardiographic parameters, and safety of RSD. RESULTS: No patient developed procedural or other complications. The ambulatory blood pressure measurements did not differ within the PVI + RSD group or between the PVI + RSD and PVI groups throughout the study. Significantly more patients in the PVI + RSD group than in the PVI group were free of AF at the 12-month follow-up evaluation. The PVI group had an unacceptable response to ablation with respect to changes in echocardiographic parameters, whereas these parameters improved in the PVI + RSD group. CONCLUSION: PVI + RSD were associated with a lower AF recurrence rate than PVI alone; it also improved renal function and some echocardiographic parameters. These encouraging data will serve as baseline information for further long-term studies on larger patient populations.

Proof of concept study: renal sympathetic denervation for treatment of polymorphic premature ventricular complexes.

BACKGROUND OR PURPOSE: Polymorphic premature ventricular complexes (PVCs) are very common, appearing most frequently in patients with hypertension, obesity, sleep apnea, and structural heart disease. Sympathetic hyperactivity plays a critical role in the development, maintenance, and aggravation of ventricular arrhythmias. Recently, the relevance of sympathetic activation in patients with ventricular arrhythmias was reported, and this finding suggested a potential role for catheter-based renal sympathetic denervation in reducing the arrhythmic burden. METHODS: We evaluated the effectiveness of the renal sympathetic denervation (RSD) in comparison to antiarrhythmic pharmacologic therapy in reducing polymorphic PVCs refractory to medication therapy and cardiac parameters assessed by 24-h Holter monitoring and cardiac magnetic resonance (CRM), respectively, in patients with structurally normal heart. RESULTS: Thirty-four patients were included in this study, 14 served as control, and 20 were treated with an ablation cardiac catheter with open irrigated tip. RSD was performed by a single operator following the standard technique. All the patients included had polymorphic PVCs and structurally normal heart. Data were obtained at baseline at the 12th month of follow-up (sixth month after RSD or adjustment of antiarrhythmic dosage). In RSD group, we observed a significant decrease in the number of polymorphic PVCs from baseline 36,091 ± 3327 to 3, 6, 7 (first month after RSD, without drugs), and 12 months (sixth month after RSD, without drugs) of follow-up, 31,009 ± 3251, 20,411 ± 3820, 7701 ± 1549, and 1274 ± 749, respectively, in all patients, P < 0.0001 to all the comparisons between the mean of each time point with the mean of every other time point. No changes in mean 24-h ABPM and renal function in both groups were observed at 12th month of follow-up. However, 24-h Holter mean heart rate decreased in control group at 12th month of follow-up, which did not happen with the RSD group. At the sixth month post-RSD in comparison to baseline, a significant reduction in the number of polymorphic PVCs (∆ = -34,817 ± 3590, P < 0.0001) was observed, as well as, in CRM parameters such as left ventricular mass/body surface area (∆ = -5.4 ± 2.1 g/m2, P < 0.0001) and left ventricular ejection fraction (∆ = +3.0 ± 1.8 %, P < 0.0001). In comparison to control group at the same time point, these findings were statistically superior in RSD group (P > 0.05). A significant correlation was found between the Δ number of polymorphic PVCs at the sixth month (r = -0.6723, P = 0.0012) after the RSD and the total number of RSD ablated spots. CONCLUSIONS: Polymorphic PVCs refractory to medication therapy may be modifiable by RSD in patients without structural heart disease. Although encouraging, our data are preliminary and need to be validated in a large population and in long term.

Registro de arritmias em pacientes com marcapassos e doença renal crônica de leve a moderada (RYCKE): resultados de um estudo de coorte observacional / Register of arrhythmias in patients with pacemakers and mild to moderate chronic kidney disease (RYCKE): results from an observational cohort study

O presente estudo examinou pacientes submetidos a implante de marcapasso dupla-câmara em decorrência de doença do nó sinusal ou bloqueio atrioventricular de 3o ou 2o graus do tipo 2 na doençarenal crônica em estágios 2, 3 e 4. O estudo teve como objetivo registrar os eventos arrítmicos durante 12 mesesde acompanhamento e comparar a incidência e a gravidade deles nas diferentes fases da doença renal crônica.Método: No total, 305 pacientes foram avaliados a cada 4 meses até 12 meses de acompanhamento. Os eventosarrítmicos foram avaliados em cada visita de acompanhamento. Resultados: Dentro do mesmo grupo de estágio da doença renal crônica não houve diferença entre as causas doença do nó sinusal e bloqueio atrioventricular, a respeito da ocorrência de qualquer arritmia. No entanto, menor incidência de taquicardia atrial/fibrilação atrial foi observada para todas as comparações entre todos os pacientes e os mesmos subgrupos em pacientes no estágio 2 (total: 58%; doença do nó sinusal: 63%; bloqueio atrioventricular: 51%), comparativamente aos estágios 3 (total:87%, P < 0,0001; doença do nó sinusal: 89%, P = 0,0020; bloqueio atrioventricular: 84%, P = 0,0019) e 4 (total: 85%, P < 0,0001; doença do nó sinusal: 81%, P = 0,0409; bloqueio atrioventricular: 90%, P < 0,0001). Em relação à taquicardia ventricular não sustentada/taquicardia ventricular sustentada, foi observada incidência mais elevada para todas as comparações entre todos os pacientes e os mesmos subgrupos em pacientes no estágio 4 (total: 32%; doença do nó sinusal: 16%; bloqueio atrioventricular: 16%), comparativamente aos estágios 3 (total: 11%, P = 0,0007; doença do nó sinusal: 9%, P = 0,0110; bloqueio atrioventricular: 14%, P = 0,0441) e 2 (total: 3%, P < 0,0001; doença do nó sinusal: 3%, P < 0,0001; bloqueio atrioventricular: 4%, P < 0,0001). Conclusão: Nossos resultados sugerem que quanto mais avançado o estágio da doença renal crônica maior a incidência de arritmias malignas...

The present study evaluated patients who had received a dual chamber pacemaker implant due to sinus node disease or 3rd/2nd degree type 2 atrioventricular block in chronic kidney disease stages 2, 3 and 4. The study was aimed at registering arrhythmic events for 12 months of follow-up and comparing their incidence and severity in different stages of chronic kidney disease. Method: Three hundred and five patients were evaluated every 4 months up to 12 months of follow-up. Arrhythmic events were assessed at each follow-up visit. Results: Within the same chronic kidney disease stage group there was no difference between the causes ofsinus node disease and atrioventricular block for the occurrence of any arrhythmia. However, a lower incidence of atrial fibrillation/tachycardia was observed for all comparisons among all patients and the same subgroups in stage 2 patients (total: 58%; sinus node disease: 63%; atrioventricular block: 51%) compared to stages 3 (total: 87%,P < 0.0001; sinus node disease: 89%, P = 0.0020; atrioventricular block: 84%, P = 0.0019) and 4 (total: 85%,P < 0.0001; sinus node disease: 81%, P = 0.0409; atrioventricular block: 90%, P < 0.0001). Regarding nonsustained/ sustained ventricular tachycardia, a higher incidence was observed for all comparisons among all patients and the same subgroups in stage 4 patients (total: 32%; sinus node disease: 16%; atrioventricular block: 16%) compared to stages 3 (total: 11%, P = 0.0007; sinus node disease: 9%, P = 0.0110; atrioventricular block: 14%, P = 0.0441) and 2 (total: 3%, P < 0.0001; sinus node disease: 3%, P < 0.0001; atrioventricular block: 4%,P < 0.0001). Conclusion: Our findings suggest that the more advanced the stage of chronic kidney disease, thegreater the incidence of malignant arrhythmias...

A Case Report of Renal Sympathetic Denervation for the Treatment of Polymorphic Ventricular Premature Complexes: Expanding Horizons.

Premature ventricular complexes are very common, appearing most frequently in patients with hypertension, obesity, sleep apnea, and structural heart disease. Sympathetic hyperactivity plays a critical role in the development, maintenance, and aggravation of ventricular arrhythmias. Recently, Armaganijan et al reported the relevance of sympathetic activation in patients with ventricular arrhythmias and suggested a potential role for catheter-based renal sympathetic denervation in reducing the arrhythmic burden. In this report, we describe a 32-year-old hypertensive male patient presenting with a high incidence of polymorphic premature ventricular complexes on a 24  hour Holter monitor. Beginning 1 year prior, the patient experienced episodes of presyncope, syncope, and tachycardia palpitations. The patient was taking losartan 100  mg/day, which kept his blood pressure (BP) under control, and sotalol 160  mg twice daily. Bisoprolol 10  mg/day was used previously but was not successful for controlling the episodes. The 24  hour Holter performed after the onset of sotalol 160  mg twice daily showed a heart rate ranging between 48 (minimum)-78 (average)-119 (maximum) bpm; 14,286 polymorphic premature ventricular complexes; 3 episodes of nonsustained ventricular tachycardia, the largest composed of 4 beats at a rate of 197 bpm; and 14 isolated atrial ectopic beats. Cardiac magnetic resonance imaging with gadolinium perfusion performed at rest and under pharmacological stress with dipyridamole showed increased left atrial internal volume, preserved systolic global biventricular function, and an absence of infarcted or ischemic areas. The patient underwent bilateral renal sympathetic denervation. The only drug used postprocedure was losartan 25  mg/day. Three months after the patient underwent renal sympathetic denervation, the mean BP value dropped to 132/86  mmHg, the mean systolic/diastolic 24  hour ambulatory BP measurement was reduced to 128/83  mmHg, and the 24  hour Holter monitor showed a heart rate ranging between 51 (minimum)-67 (average)-108 (maximum) bpm, 854 polymorphic premature ventricular complexes, and no episodes of nonsustained ventricular tachycardia.

Pulmonary artery ablation to treat pulmonary arterial hypertension: a case report.

INTRODUCTION: Idiopathic pulmonary arterial hypertension is defined as a group of diseases characterized by a progressive increase in pulmonary vascular resistance that results in right heart failure and premature death. Although therapies exist to improve hemodynamic instability and symptoms, there is no cure for pulmonary arterial hypertension and it remains a life-threatening condition. A recent study performed in China reported, for the first time, the effect of pulmonary arterial denervation on functional capacity and hemodynamics in patients with refractory idiopathic pulmonary arterial hypertension. CASE PRESENTATION: We report a case of a 60-year-old white Brazilian man, with controlled hypertension and stage 2 obesity who complained of progressive fatigue with moderate to light exertion of approximately 1 year's duration. During this period, he underwent myocardial perfusion scintigraphy without evidence of obstructive ischemic disease. He had no clinical evidence of systolic heart failure. He had undergone biological mitral valve replacement 3 years previously for mitral valve stenosis and ablation of atrioventricular nodal reentry tachycardia 18 months previously. At the time of valve replacement, he had no reported evidence of pulmonary arterial hypertension. His echocardiogram showed normal function of a mitral prosthesis, normal global left ventricular systolic function (left ventricular ejection fraction 62 % measured using the Teichholz method), stage I diastolic dysfunction, and a mean systolic pulmonary arterial blood pressure of 50 mmHg. In the 6-minute walk test, the patient walked 104 meters. Catheterization of his right heart chambers and pulmonary arteries confirmed the diagnosis of pulmonary hypertension. Electroanatomic reconstruction of the right ventricular outflow tract and pulmonary artery was performed under direct fluoroscopic visualization, and a merger was made with a formatted image of cardiac computed tomography angiography. Then we performed irrigated cardiac catheter ablation of the pulmonary trunk. CONCLUSIONS: At the patient's 3-month follow-up, he showed improvement in functional class for fatigue on major exertion, increased distance walked in the 6-minute walk test, and reductions in pressure of both the right cavities and the pulmonary artery. Currently, with 6 months of clinical follow-up, the patient has maintained his functional classification and is pedaling his bicycle.

Infarto do miocárdio e mixoma em átrio esquerdo / Myocardial infarction and myxoma in the left atrium / Infarto del Miocardio y Mixoma en Aurícula Izquierda

Os mixomas são os tumores cardíacos primários benignos mais comuns, sendo que a grande maioria localiza-se no átrio esquerdo; 80 por cento têm sua origem no septo interatrial e 5 por cento deles são biatrial. Clinicamente, apresentam-se, quase sempre, com sinais e sintomas de doença valvular mitral ou de eventos tromboembólicos. Este relato ilustra um caso de mixoma em átrio esquerdo, projetando-se através da valva mitral para o ventrículo esquerdo e simulando uma estenose mitral, que evoluiu com acidente vascular cerebral isquêmico (AVCi) e infarto agudo do miocárdio (IAM), como complicações tromboembólicas. O ecocardiograma continua a ser uma ferramenta valiosa no diagnóstico e o tratamento cirúrgico imediato é necessário para evitar desfechos fatais.

Myxomas are the most common benign primary cardiac tumors, the vast majority located in the left atrium and 80 percent originates in the atrial septum and 5 percent of them are biatrial.Usually present, often with signs and symptoms of mitral valve disease or thromboembolic events. This report illustrates a case of myxoma in left atrium protrudind through the mitral valve into the left ventricle, simulating stenotic mitral valve disease, which evolved with ischemic stroke (AIS) and acute myocardial infarction (MI) as thromboembolic events. Echocardiography continues to be a valuable tool in the diagnosis and surgical treatment is immediately necessary to prevent fatal outcomes.

Los mixomas son los tumores cardíacos primarios benignos más comunes, siendo que la gran mayoría se localiza en la aurícula izquierda; el 80% tiene su origen en el septo interauricular y el 5% de ellos son biauriculares. Clínicamente, se presentan, casi siempre, con señales y síntomas de enfermedad valvular mitral o de eventos tromboembólicos. Este relato ilustra un caso de mixoma en aurícula izquierda, proyectándose a través de la válvula mitral hacia el ventrículo izquierdo y simulando una estenosis mitral, que evolucionó con accidente vascular cerebral isquémico (AVCi) e infarto agudo del miocardio (IAM), con complicaciones tromboembólicas. El ecocardiograma continua siendo una herramienta valiosa en el diagnóstico y el tratamiento quirúrgico inmediato es necesario para evitar desenlaces fatales.

Myocardial revascularization surgery with regional anesthesia without an endotracheal tube in conscious patients.

OBJECTIVE: To report initial experience with myocardial revascularization surgery (MRS) performed on patients who were totally awake and without an endotracheal tube. METHODS: Between January 1994 and May 2001, 272 patients underwent MRS without extracorporeal circulation. In 24, the operations were performed without the use of an endotracheal tube and with the patients totally awake and breathing normally. The age ranged from 51-75 years with the predominant male sex. Epidural thoracic administrations of the anesthesia was performed. Surgery was performed through a habitual anterolateral thoracotomy. During the entire procedure, the left lung remained partially collapsed. RESULTS: The 24 patients progressed well through the surgery. Pneumothorax time ranged from 70-190 minutes. No electrocardiographic, echocardiographic, or enzymatic alterations occurred that characterized pre- and postoperative infarcts. Twenty-three patients were stable enough to be released after 24 hours. CONCLUSION: This technique could be performed on an large number of selected patients. However, more experience is necessary.

Cirurgia de revascularização do miocárdio com anestesia regional, sem tubo orotraqueal em pacientes acordados / Myocardial revascularization surgery with regional anesthesia without an endotracheal tube in conscious patients

OBJECTIVE: To report initial experience with myocardial revascularization surgery (MRS) performed on patients who were totally awake and without an endotracheal tube.METHODS: Between January 1994 and May 2001, 272 patients underwent MRS without extracorporeal circulation. In 24, the operations were performed without the use of an endotracheal tube and with the patients totally awake and breathing normally. The age ranged from 51-75 years with the predominant male sex. Epidural thoracic administratios of the anesthesia was performed. Surgery was performed through a habitual anterolateral thoracotomy. During the entire procedure, the left lung remained partially collapsed.RESULTS: The 24 patients progressed well through the surgery. Pneumothorax time ranged from 70-190 minutes. No electrocardiographic, echocardiographic, or enzymatic alterations occurred that characterized pre- and postoperative infarcts. Twenty-three patients were stable enough to be released after 24 hours.CONCLUSION: This technique could be performed on an large number of selected patients. However, more experience is necessary

Implante intra-miocárdico de artéria torácica interna: cirurgia de Vineberg / Internal mammary artery myocardial implantation: Vineberg's procedure

OJBETIVOS: Demonstrar nossa experiência com o implante da artéria torácica interna, para revascularização do miocárdio, procedimento proposto por Vineberg, em 1946. CASUISTICA E MÉTODO: De agosto de 1994 a setembro de 1998, foram operados 10 pacientes nos quais foi implantada a artéria torácica interna esquerda na parede ântero-lateral do ventrículo esquerdo. Em todos esses pacientes também foi feito enxerto de safena aorto-coronária. A idade dos pacientes variou de 42 a 73 anos, tendo sexo masculino prevalecido (60 por cento). Todos os pacientes apresentavam doença coronária arterosclerótica difusa, mas com miocárdio viável. A indicação para o implante de artéria torácica interna foi feita durante a operação, devido a impossibilidade de fazer enxerto ou endarterectomia. RESULTADOS: Todos os pacientes estavam muito bem no pós-operatório imediato. O reestudo angiográfico foi feito em 9 pacientes entre 45 dias e 23 meses de pós-operatório, mostrando patência da artéria implantada e uma vasta rede que se comunicava com a coronária nativa. CONCLUSAO: O implante de artéria torácica interna em miocárdio viável pode ter lugar no arsenal terapêutico da revascularização miocárdica, em casos especiais. Agora, baseados nos erros do passado, podemos selecionar os pacientes e obter melhores resultados. É uma técnica pouco estudada, que deveria ser mais usada, assim possibilitando uma avaliação mais precisa de sua eficácia

Ligadura videotoracoscópica da persistência do canal arterial / Videothoracoscopic closure of patent ductus arteriosus

OBJETIVO: Demonstrar a técnica de fechamento da Persistência do Canal Arterial (PCA), destacando a simplicidade e singularidade do método. CASUÍSTICA E MÉTODO: No período de março de 1994 a novembro de 1999, 40 pacientes (pac), com idade entre 8 meses e 17 anos e predominando o sexo masculino, foram submetidos a operação de fechamento da PCA através de videotoracoscopia. O paciente é colocado em decúbito lateral direito, sob anestesia geral com intubação seletiva do pulmão direito. São usados quatro trocateres: um de 3 mm no 3º espaço intercostal (EIC) esquerdo na linha axilar anterior e outro trocater de 5 mm no 3º (EICE) na linha axilar média. A ótica 30 graus infantil é introduzida em um trocater de 3 mm no 5º EICE na linha axilar posterior e outro trocater de 5 mm no 5º EICE na linha axila anterior. A identificação do canal é feita tendo como parâmetro anatômico os nervos frênico e vago. Após o isolamento, o canal é duplamente clipado ou ligado com fio de algodão grosso com nó interno. Terminado o procedimento, o pulmão é expandido sob visão direta, não havendo necessidade de drenar o tórax. RESULTADOS: Obtivemos sucesso inicial em 37 pac (92,5 por cento), sendo necessária reversão para operação convencional em 3 pac (7,5 por cento). Não houve óbito nem complicações e o tempo médio de hospitalização foi de 48 horas. CONCLUSÃO: Acreditamos ser o procedimento eficaz, seguro, com pequeno índice de complicações, custo baixo e uma curva de aprendizado também pequena.

Aortoscopia no tratamento das dissecções agudas da aorta / Aortoscopy in the treatment of acute dissecting aneurysms of the aorta

No período de janeiro a dezembro de 1998 , foram operados 10 pacientes portadores de dissecção aguda da aorta (DA Ao) 4 do tipo A e 6 do tipo B. O sexo masculino predominou e a idade dos pacientes variou de 34 a 78 anos. Em todos foram realizadas aortoscopias usando hipotermia profunda com parada circulatória total. Usou-se um gastroscópio, obtendo visão do lume da Ao, sendo que todos os pacientes tinham menos que 15 dias da doença. No tipo A, havia re-entrada abaixo da subclávia esquerda em 2 pacientes e, nos outros 2, na bifurcação das ilíacas. No tipo B, havia re-entrada ao nível das renais em 2 pacientes e, ao nível da bifurcação da Ao e das ilíacas, em 4. Em 2 pacientes do tipo A, a aortoscopia orientou na colocação de uma "Tromba de Elefante" como complemento. Nos outros 2, orientou na inversão do sentido da linha arterial. No tipo B, orientou na perfeita colocação da "Tromba de Elefante" e, em 4 pacientes, utilizamos a aortoscopia como complemento diagnóstico. O tempo utilizado na aortoscopia não alterou a morbimortalidade. Podemos concluir que a aortoscopia é um método de diagnóstico rápido, com boa definição das alterações anatômicas da Ao, permitindo um tratamento efetivo. Nos casos agudos instáveis podemos dispensar alguns exames pré-operatórios para não retardarmos a operação. O diagnóstico da re-entrada nos seguimentos inferiores da Ao ajuda a evitar a dissecção retrógrada. Acreditamos que a aortoscopia poderá, no futuro, ser de grande ajuda no diagnóstico e tratamento das DA Ao, bem como de outras lesões da Ao (AO)_

Cirurgia conservadora da valva mitral / Conservative surgery of the mitral valve

Foram tratados 105 pacientes com doença da valva mitral: 48 deles apresentavam estenose mitral pura, 15 estenose mitral mais insuficiência tricúspide, 4 estenose mitral mais estenose aórtica, 8 estenose mitral mais insuficiência aórtica e 30 apresentavam insuficiência mitral pura...O estudo hemodinâmico, realizado no pós-operatório dos pacientes com correção da insuficiência, revelou bom desempenho hemodinâmico com a cirurgia. Houve 4 reoperações no pós-operatório imediato e uma tardia; a mortalidade global foi de 3,9%; comparou-se os resultados destas cirurgias com resultados das trocas valvares por diversos tipos de próteses disponíveis. Comparou-se também os resultados deste tipo de correção valvar com os outros tipos de cirurgias conservadoras, chegando-se à conclusão de que devemos sempre preferir a conservação da valva do paciente em vez de substitui-la por uma prótese; das técnicas de conservação valvar, esta se faz corrigindo o defeito de cada componente do aparelho valvar, separadamente, é a mais fisiológica e de resultado mais duradouro.

Tratamento cirúrgico da endocardite infecciosa näo-protética / Surgical treatment of non-prosthetic infective endocarditis

Quinze pacientes com endocardite infecciosa foram revistos a partir da experiência dos autores nos dois últimos anos. A idade variou de 16 a 44 anos, näo havendo nítida prevalência quanto ao sexo ou à raça. A maior parte das hemoculturas era negativa. Os pacientes tinham prognóstico reservado, apresentando pelo menos duas ou três das indicaçöes cirúrgicas maiores estabelecidas na literatura. Apesar de o risco operatório ser alto, a mortalidade pré-operatória foi de 0% e a pós-operatória de 20%. Em vista destes resultados e da alta morbidade com o tratamento clínico isolado, recomendam uma conduta agressiva com a intervençäo cirúrgica precoce, o que seguramente melhora em muito a sobrevida desses enfermos. Enfatizam que o ecocardiograma é muito importante na decisäo a ser tomada e que no ato operatório deve ser feito inventário de todas as válvulas cardiácas, fontes possíveis de sépsis pós-operatória. Os autores apresentam, também baseados na experiência acumulada através dos anos, critérios maiores e menores para indicaçäo cirúrgica em endocardite infecciosa

Hipertensäo arterial sistêmica: tratamento cirúrgico / Systemic arterial hypertension: surgical treatment

Os autores apresentam o caso de um paciente de 35 anos portador de hipertensäo arterial maligna, decorrente de estenose severa da artéria renal esquerda. Houve cura completa com a cirurgia de revascularizaçäo (ponte de safena). Tecem consieraçöes a respeito de conduta, controvérsias e diagnóstico diferencial desta enfermidade