[Non-invasive evaluation of ventricular ejection force by Doppler echocardiography]. / Determinação não invasiva da força de ejecção ventricular esquerda por ecocardiografia Doppler.

UNLABELLED: Left ventricular ejection force as been purpose as a new Doppler ejection phase index, to assess left ventricular performance. In order to evaluate its usefulness, 33 patients undergoing cardiac catheterization were prospectively study. We considered three groups based on angiographic ejection fraction: group A-- > or = 55% (11 patients), group B--35 to 55% (10 patients), and group C-- < or = 35% (10 patients). All patients were in sinus rhythm and mitral regurgitation > I/IV or aortic valve disease were exclusion criterion. The following parameters, derived from Pulsed Doppler aortic velocities curves, were analyzed: peak velocity (cm/s), acceleration time (s), velocity time integral over the acceleration time (VTI Ac-cm), mean acceleration (cm/s2) and ejection force (g.cm/s2). Ejection force as calculated using the mass-acceleration concept, ad: ejection force = mean acceleration x VTI Ac x CsA x 1.06 (CsA - 2D cross sectional area of the aortic annulus; 1.06 - mass density of blood, g/cm3). [table: see text] CONCLUSIONS: The present study confirms that Doppler echocardiography can be used for the assessment of left ventricular performance based on noninvasive measurements and that Doppler derived ejection force is an accurate index for this purpose. However, ejection force evaluation, taking in account the results obtained for mean acceleration, a much less time consuming Doppler derived parameter, appears not to show any clinical advantage.

[Atrial fibrillation and coronary disease]. / Fibrilhação auricular e doença das coronárias.

OBJECTIVE: To study the incidence of atrial fibrillation in patients (pts) with angiographic coronary artery disease and its relation with clinical and angiographic parameters. DESIGN: Retrospective study. SETTING: Six hundreds consecutive pts, submitted to diagnostic coronary angiography, performed in Hemodynamic Laboratory of Santa Marta Hospital (from 88/04/03 to 90/05/04). MATERIAL AND METHODS: From six hundreds pts were excluded 43 because they had also valvular heart disease and/or minimal coronary artery lesions. Two groups were considered: Group I-pts with atrial fibrillation (n = 7) and Group II-pts in sinus rhythm (n = 549). We evaluated the following parameters: age, sex, clinical history, basal ECG, cardiac enlargement in chest X-ray, angiographic score of LVF, left ventricular diastolic pressure (LVDP), ventricular aneurysm, mitral regurgitation and number of vessels disease. RESULTS: We only found significant statistically differences between the two groups concerning the following parameters: a) age-mean age was superior in group I (Group I-64.2 +/- 8.2 versus 56.3 +/- 9.6), the number of pts older than 60 years in group I was 75% vs 33.8% in group II (p < 0.02); b) heart failure-the incidence was superior in group I, 37.5% vs 9% in group II (p < 0.03); c) cardiac enlargement in chest X-ray-75% pts of group I vs 22% of group II (p < 0.002); d) moderate to severe mitral regurgitation-25% of pts in group I vs 5% of pts of group II (p < 0.05). CONCLUSIONS: Atrial fibrillation is an unusual rhythm in pts with angiographic coronary artery disease. Its presence is related with age, clinical evidence of heart failure, cardiac enlargement and moderate to severe mitral regurgitation.

[The complications associated with the performance of heart catheterizations (diagnostic and therapeutic). The results in the Hemodynamics Laboratory of Hospital de Santa Marta]. / Complicações associadas com a realização de cateterismos cardíacos (diagnósticos e terapêuticos). Resultados do Laboratório de Hemodinâmica do Hospital de Santa Marta.

OBJECTIVES: To evaluate the morbidity and mortality with cardiac catheterization (diagnostic and intervention). DESIGN: Retrospective analysis of complications occurring within 24 h of a cardiac catheterization, in three consecutive years (1989-1991). SETTING: Patients admitted to the Haemodynamic Laboratory of Santa Marta Hospital-Lisbon. PATIENTS: 4014 patients submitted to diagnostic and interventional procedures. MATERIALS AND METHODS: Registry analyze in order to obtain the following data: pathology, age, vascular approach and complications of cardiac catheterization. RESULTS: In three years there were 4014 cardiac procedures. 53.6% were performed in patients with coronary artery disease, 20% with valvular heart disease, 8.1% with congenital heart disease, 16.1% with others pathologies and 2.2% revealed normal vessels in coronary angiography. The incidence of ischemic heart disease was progressively higher in the studied years: 51.9% in 1989, 52.4% in 1990 and 55.2% in 1991. Data from population age showed the same tendency: mean age was 51, 53 and 55 years, respectively. Femoral approach was attempted in 95% of the studies, and the axillary in 2.15%. Complications of diagnostic and interventional cardiac procedures occurred in 3% of the patients. Dead occurred in 0.14%; arrhythmia, 0.37%; vascular, 0.14%; vasovagal/pyrogen reactions, 0.73%; myocardial infarction, 0.05%; and others, 1.58%. CONCLUSION: The diagnostic and interventional cardiac catheterization in experienced laboratories are a safe procedure with a reduced incidence of major complications.

Clinical and electrophysiologic characteristics in patients with Wolff-Parkinson-White pattern.

OBJECTIVES: (1) To obtain a relation between clinical and electrophysiologic characteristics in patients with Wolff-Parkinson-White pattern. To evaluate the atrial vulnerability for inducing atrial fibrillation and its relation to the electrophysiologic protocol phase. (3) To study the effects of flecainide on the treatment of induced sustained supraventricular arrhythmias. SETTING: Department of Cardiology at Santa Marta Hospital. METHODS: An electrophysiologic testing was performed in twenty-three consecutive patients aged from 14 to 55 years, with Wolff-Parkinson-White (WPW) pattern on ECG. Two groups of patients were considered: group I with 12 asymptomatic or nearly asymptomatic patients; group II with 11 symptomatic patients. The parameters studied were the anterograde effective refractory period of the accessory pathway, the number of patients with different types of supraventricular tachycardias (SVT), the relation between the stimulation protocol phase (scanning/DDT/burst) and the occurrence of atrial fibrillation, and the effects of the flecainide on the treatment of induced sustained supraventricular arrhythmias. RESULTS: Statistically significant differences were obtained between group I and II concerning the number of patients in whom induced atrial fibrillation with conduction by the accessory pathway and RR < or = 250 msec was found (0 vs 6, p = 0.0045). No differences were obtained among the anterograde refractory period, the induction of atrial fibrillation independently of the type of atrioventricular conduction, and the induction of atrioventricular reentrant tachycardia and or atrial flutter. The induction of atrial fibrillation was attained during the Scanning/DDT protocol phase in 7 patients in whom this arrhythmia was found with conduction by the accessory pathway and in 2 without preexcitation. All the induced sustained supraventricular arrhythmias were converted by intravenous flecainide. CONCLUSIONS: (1) Only the symptomatic patients have a high risk profile which suggest that electrophysiologic testing do not need to be performed in those with no symptoms. (2) As atrial vulnerability is higher in patients with induced atrial fibrillation and conduction by the accessory pathway, a more intensive ambulatory control seems to be necessary. (3) The results of intravenous flecainide administration on the treatment of sustained induced supraventricular arrhythmias, advocate its use during the electrophysiologic procedures in patients with ventricular preexcitation and WPW pattern.

[Cardiovascular syphilis. Report of 2 cases]. / Sífilis cardiovascular. A propósito de dois casos.

We present two cases of cardiovascular syphilis being one of them a curious case of chronic pericardial effusion associated with cardiovascular complications of lues. In this article we will make as well a review of cardiovascular syphilis.

Effects of diltiazem on myocardial ischemia in patients with coronary artery disease.

OBJECTIVES: To evaluate the effect of diltiazem on the characteristics of ischemic episodes detected by Holter monitoring in a group of patients with proven coronary artery disease. SETTING: Department of Cardiology, Santa Marta Hospital, Lisbon. METHODS: Eleven selected out-patients, aged 48 to 79 years, with transient ST-segmental depression on Holter monitoring and proven coronary artery disease, were submitted to a double-blind crossover placebo controlled study, during hospitalization. The total ischemic burden of each patient and an analysis of ischemic episodes were evaluated before and during the drug/placebo phase trial. Three groups of ischemic episodes were considered: group I constituted by 66 episodes found on basal Holter recording; group II by 28 episodes detected during placebo trial and group III by 12 episodes detected during diltiazem trial. RESULTS: A reduction of the number of ischemic episodes was predominantly observed with the diltiazem administration. Statistically significant differences were observed between basal and placebo groups and especially between basal and diltiazem groups concerning the mean maximum ST-segment depression (2.17 vs 1.80; p = 0.030 and 2.17 vs 1.54; p = 0.0091). Significant differences were also obtained between the above mentioned groups concerning the heart rate variation from the onset of ST-segment depression to its maximum depression (13.5 vs 9.69; p = 0.023 and 13.5 vs 2.91; p = 0.01) and from two minutes before the onset of ST-segment depression to its maximum depression (21.2 vs 12.67; p = 0.012 and 21.2 vs 8.75 p = 0.016). CONCLUSIONS: Diltiazem seems to reduce the number of ischemic episodes in patients with coronary artery disease, during hospitalization. The study of its effects on the characteristics of ischemia requires further investigation with a greater number of patients. The limitations of the present study, described in the discussion, must be taken into account in future pharmacological investigations with Holter monitoring.

[Successful operation of aortic abscess ruptured into left atrium. Diagnostic importance of color coded Doppler echocardiography]. / Abcesso aórtico com rotura para a aurícula esquerda, operado com sucesso. Importância diagnóstica do eco-Doppler codificado a cor.

Myocardial abscesses are a serious complication of infectious endocarditis. A 60 years old male patient with subaortic ring abscess is reported. A fistula developed between the left ventricular outflow tract and the left atrium. Doppler echocardiography was of outmost importance for diagnosis. Surgery was successfully performed.

Functional significance of premature ventricular complex morphology evaluated during treadmill exercise stress test in patients with coronary artery disease.

OBJECTIVES: To evaluate the relation between premature ventricular complexes morphology and left ventricular myocardial systolic function in patients with proved coronary artery disease. SETTING: Department of Cardiology at General Hospital. METHODS: From 112 patients (pts) with proved coronary artery disease, thirty-three pts with premature ventricular complexes (PVC) detected during treadmill exercise stress test were selected. Two groups of pts were considered: group I-20 pts with regular contour or with a narrow notching (< 40 ms; type I PVC) and group II-13 patients with wide notching (> 40 ms; type II PVC). In each group the following parameters were studied: ejection fraction, QRS duration, duration of exercise, number of metabolic units and the prevalence of ventricular aneurysm and mitral regurgitation. RESULTS: Statistical significant differences were found between group I and II concerning the mean ejection fraction (59.2% vs 48.6%; p < 0.05). The prevalence of ventricular aneurysm and mitral regurgitation was higher in patients with type II ventricular premature complexes (10% vs 30%). CONCLUSION: Particular characteristics of premature ventricular complexes detected during treadmill exercise stress test, in patients with proved coronary artery disease, suggest the presence of left ventricular myocardial systolic dysfunction.

Coronariographic significance of heart rate variation related to ischemic episodes in patients undergoing peripheral vascular surgery.

OBJECTIVES: To evaluate the characteristics of myocardial ischemia during daily life and their coronariographic significance in a group of patients with proven coronary artery disease undergoing peripheral vascular surgery. SETTING: Department of Cardiology--Central Hospital--Lisbon. METHODS: In 14 patients undergoing peripheral vascular surgery and in whom coronariography revealed coronary significative lesions, Holter monitoring was performed during a 24-hour period. Two groups of ischemic episodes were considered: Group A constituted by 44 episodes detected in patients with left main or three vessel disease and group B by 12 episodes detected in patients with one ot two vessel disease. In each group the ischemic parameters were studied. RESULT: The incidence of myocardial ischemia was 64%. Statistically significant differences were observed between group A and B concerning the mean heart rate variation from two minutes before the onset of ST-segment depression to its onset (2.39 bpm vs 8.75 bpm; p < 0.05), from the onset of ST-segment depression to its maximal depression (4.43 bpm vs 16.67 bpm; p < 0.001) and from two minutes before St-segment depression to its maximal depression (6.82 bpm vs 25.4 bpm; p < 0.00001). No differences were found in duration and maximal ST-segment depression. CONCLUSION: Particular characteristics of heart rate variation related to the ischemic episodes seem to have a relation with the severity of coronary artery disease in patients undergoing peripheral vascular surgery.

[Annuloaortic ectasia: report of a case]. / Ectasia anulo aórtica: a propósito de um caso.

The authors describe a case of a patient with annuloaortic ectasia (AAE) and severe aortic regurgitation. The diagnostic was made by angiography. He was submitted to a Bentall's procedure; replacement of the ascending aorta by a conduit and of aortic valve by a mechanical prosthesis with reimplantation of coronary arteries into the conduit. The only complication was atrial fibrillation with fast ventricular response. Nowadays he is clinically well, in NYHA class I. The authors make some considerations about AAE, its surgical treatment and its results.

[Arrhythmic profiles evaluated by Holter's technique in sick sinus syndrome]. / Perfis arrítmicos avaliados por método de Holter na doença do nódulo sinusal.

OBJECTIVES: The aim of this study was to evaluate in a group of patients with sick sinus syndrome: 1) Characteristics of arrhythmia on Holter monitoring. 2) Value of Holter monitoring to select patients for pacemaker implantation. SETTING: Department of Cardiology in a Central Hospital. METHODS: In 40 patients (27 men and 13 women, aged 37 to 83 years) Holter monitoring during a 24-hour period was performed. According to the arrhythmia profiles four groups of patients were considered: group A--with severe sinus bradycardia; group B--with sinus bradycardia associated to sinoatrial exit block or to sinus pauses; group C--characterized by the bradycardia-tachycardia syndrome and group D--defined by the finding of atrial fibrillation with a slow ventricular response. Symptoms and the presence of structural heart disease were evaluated. RESULTS: In this patients population, 24 patients had coronary artery disease and/or hypertensive heart disease. A severe sinus bradycardia was found in 14 patients (group A) and in other 11 patients it was accompanied by sinoatrial exist block of sinus pauses (group B); 12 patients had the bradycardia-tachycardia syndrome (group C) and periods of atrial fibrillation with a slow ventricular response were found in 3 other patients (Group D). Nonspecific clinical pattern was observed in this population. CONCLUSIONS: Holter monitoring was important to the diagnosis of sick sinus syndrome and for posterior definitive pacemaker implantation. Coronary artery disease and/or hypertensive heart disease were the main pathologies found in this study, being the severe sinus bradycardia and the bradycardia-tachycardia syndrome the principal manifestations of the sick sinus syndrome.

[Hemodynamic assessment after heart transplantation]. / Avaliação hemodinâmica após transplantação cardíaca.

OBJECTIVE: Comparative analysis of the results of the hemodynamic evaluations performed at the preoperative period, during the first week and at the end of the first and second years, after orthotopic heart transplantation. DESIGN: Retrospective study of hemodynamic evaluation of patients submitted to orthotopic cardiac transplantation from April 1987 to April 1990. SETTING: Transplanted patients admitted at the cardiology and cardio-toracic surgery departments of the Hospital Santa Marta. PATIENTS: 15 patients (eleven males and four females) aged 21 to 55 years (mean = 33.3 +/- 10.5), with the preoperative diagnosis: dilated cardiomyopathy in 11, ischemic heart disease in three and hypertrophic cardiomyopathy in one patient. All the patients were on triple immunosuppressive therapy (cyclosporine A, azatioprine and prednisolone) at the time of the first week evaluation. Three of the eight patients evaluated at the end of the first year were with double immunosuppressive regimen (without steroids), seven at NYHA functional class I and one patient at class II. The three patients evaluated at the end of the second year were on triple immunosuppressive regimen and in class I. INTERVENTIONS: We considered, preoperatively (PrOp), at the first week (1W), and at the end of the first (1Y) and second (2Y) years: mean right atrial pressure (RA), systolic pulmonary arterial pressure (PAs), mean pulmonary arterial pressure (PAm), pulmonary capillary wedge pressure (PCW), mean systemic arterial pressure (SAm), cardiac index (CI), pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR). At 1Y and 2y there were also considered the left ventricular end-diastolic pressure (LVEDP) and the ejection fraction (Ej). RESULTS: (table; see text) The results found at 2Y were similar to those showed at 1Y. At 1Y and 2Y LVEDP and Ej were normal. CONCLUSIONS: A high prevalence of mild to moderate hemodynamic disturbances characterizes the early post-operative period in cardiac transplantation. Abnormal pressures on right atrium, pulmonary artery, pulmonary capillary wedge pressure, are found on a significant number of patients, and pulmonary and systemic vascular resistances are also elevated. However at the end of the first year there is a significant improvement compared with the first week. Normality is the hallmark of hemodynamic evaluation performed in transplant recipients at the end of the first and second years.

[Dysrhythmic profile and clinical aspects in a population of 23 patients with hypertrophic cardiomyopathy]. / Perfil disrítmico e aspectos clínicos numa população de 23 doentes com cardiomiopatia hipertrófica.

OBJECTIVES: To evaluate: 1. The incidence and characteristics of ventricular arrhythmias on Holter monitoring and their relation to the clinical, functional and morphological aspects. 2. The survival and therapeutical efficiency of amiodarone in a subgroup of patients with ventricular tachycardia. SETTING: Department of Cardiology in a General Hospital. METHODS: 23 patients (pts) aged 19 to 74 years with an echocardiographic diagnosis of cardiomyopathy were studied during a four year period by 24 hours Holter monitoring. Ventricular arrhythmias were defined according the Lown classification. Patients were classified according to: obstructive or nonobstructive hypertrophy (funtional groups, 11 and 12 pts respectively), asymmetric hypertrophy of the septum or ventricular concentric hypertrophy or apical hypertrophy (morphological groups, 18, 3 and 2 pts respectively). They were also classified according medical therapy (pharmacological with B-blockers or calcium antagonists and nonpharmacological groups, 7 and 16 pts respectively). RESULTS: the incidence of severe ventricular arrhythmias was 57.1% and 62.5% in the pharmacological and nonpharmacological groups respectively. In both obstructive and nonobstructive forms, severe ventricular arrhythmias were also found (7/8 pts in each group). 12 pts with asymmetric hypertrophy of the septum and 2 pts with the concentric hypertrophic form also had severe ventricular arrhythmias. Five pts with nonsustained ventricular tachycardia have been submitted to oral amiodarone therapy in a dosage of 200 mg daily. All these pts are alive (follow-up ranged from 15 to 54 months) and in five no significant ventricular arrhythmias have been detected on serial Holter records. CONCLUSIONS: the incidence of ventricular arrhythmias was high in this patients population and no definitive relation could be found between the severity of ventricular arrhythmias and the previous described groups. Meanwhile, classic medical therapy seems not to alter the incidence and the characteristics of ventricular arrhythmias. On other hand, amiodarone therapy seems to abolish ventricular tachycardia in a large percentage of cases and no death occurred during a significant period of time (maximal 54 months).

[Biopsy of the right ventricle endomyocardium. Experience at the Santa Marta Hospital]. / Biópsia do endomiocárdio do ventrículo direito. Experiência do Hospital de Santa Marta.

OBJECTIVE: To review the experience of Santa Marta Hospital in the right ventricle endomyocardial biopsy technique. DESIGN: Retrospective analysis of the results, diagnostic value and complications of the myocardial biopsies performed between April/87 and March/90. PATIENTS AND INTERVENTIONS: 255 biopsies were performed; 221 on 13 patients submitted to orthotopic heart transplantation (nine male and four female, aged between 21 and 55 years old), and the remaining on 34 patients (22 male and 12 female aged between 15 and 64 years old), mainly on cardiomyopathies. RESULTS: In 221 biopsies performed in heart transplant recipients, we found: 109 with no rejection, 21 with moderate rejection, 57 with mild rejection and only one case showed severe rejection. In this group six biopsies were considered inconclusive. In the group of patients not submitted to heart transplantation the histological findings were inespecific in the great majority of the cases. In the 255 procedures four complications were detected (1.56%), with no mortality; two hemopericardium with tamponade (0.78%), one pneumothorax and one atrial fibrillation. CONCLUSIONS: Endomyocardial biopsy essential for histological diagnosis of acute rejection following heart transplantation has revealed to be a save procedure with a small number of complications.

[Hypertrophic non-obstructive cardiomyopathy associated with interauricular communication. Report of a case]. / Cardiomiopatia hipertrófica não obstrutiva associada a comunicação interauricular. Apresentação de um caso.

It is unusual the association between hypertrophic cardiomyopathy and atrial septal defect. We present in this paper the results of the tests done to one patient with these two diseases and profit to make an update of the bibliography on this subject.