Spectroscopy of kaonic atoms at DAFNE and J-PARC

The interaction of antikaons (K−) with nucleons and nuclei in the low-energy regime represents a very active research field in hadron physics. A unique and rather direct experimental access to the antikaon-nucleon scattering lengths is provided by precision X-ray spectroscopy of transitions in low-lying states in the lightest kaonic atoms (i.e. kaonic hydrogen and deuterium). In the SIDDHARTA experiment at the electron-positron collider DAFNE of LNFINFN we measured the most precise values of the strong interaction observables in conic hydrogen. The strong interaction on the 1s ground state of the electromagnetically bound K-p atom causes an energy shift and broadening of the 1s state. SIDDHARTA will extend the spectroscopy to kaonic deuterium to get access to the antikaon-neutron interaction and thus the isospin dependent scattering lengths. At J-PARC a kaon beam is used in a complementary experiment with a different setup for spectroscopy of kaonic deuterium atoms. The talk will give an overview of the of the upcoming experiments SIDDHARTA and the complementary experiment at J-PARC.Furthermore, the implications of the experiments for the theory of low-energy strong interaction with strangeness will be discussed.

The kaonic atoms research program at DAΦNE: from SIDDHARTA to SIDDHARTA-2

The interaction of antikaons with nucleons and nuclei in the low-energy regime represents an active research field in hadron physics with still many important open questions. The investigation of light kaonic atoms, in which one electron is replaced by a negatively charged kaon, is a unique tool to provide precise information on this interaction; the energy shift and the broadening of the low-lying states of such atoms, induced by the kaon-nucleus hadronic interaction, can be determined with high precision from the atomic X-ray spectroscopy, and this experimental method provides unique information to understand the low energy kaon-nucleus interaction at the production threshold. The lightest atomic systems, like the kaonic hydrogen and the kaonic deuterium deliver, in a model-independent way, the isospin-dependent kaon-nucleon scattering lengths. The most precise kaonic hydrogen measurement to-date, together with an exploratory measurement of kaonic deuterium, were carried out in 2009 by the SIDDHARTA collaboration at the DAΦNE electron-positron collider of LNF-INFN, combining the excellent quality kaon beam delivered by the collider with new experimental techniques, as fast and very precise X-ray detectors, like the Silicon Drift Detectors. The SIDDHARTA results triggered new theoretical work, which achieved major progress in the understanding of the low-energy strong interaction with strangeness reflected by the antikaon-nucleon scattering lengths calculated with the antikaon-proton amplitudes constrained by the SIDDHARTA data. The most important open question is the experimental determination of the hadronic energy shift and width of kaonic deuterium; presently, a major upgrade of the setup, SIDDHARTA-2, is being realized to reach this goal. In this paper, the results obtained in 2009 and the proposed SIDDHARTA-2 upgrades are presented.

[Multiple peritrochanteric and pubic calcifications in a young woman on hemodialysis with severe renal osteodystrophy successfully treated with sevelamer+cinacalcet+paracalcitol combination therapy]

Secondary hyperparathyroidism is a frequent complication of chronic renal failure that can induce severe bone disease and negatively influence the cardiovascular outcome. Therefore, nephrologists should attempt to reach the targets recommended by national and international guidelines using all the available therapeutic strategies. We describe the case of a 37-year-old woman affected by spina bifida and myelomeningocele who had been on hemodialysis since 1993. In July 2006 she developed secondary hyperparathyroidism complicated by peritrochanteric calcifications which did not respond to standard therapy. Because it was impossible to perform a parathyroidectomy, we started medical therapy with a combination of sevelamer hydrochloride, paracalcitol and cinacalcet, which resulted in progressive improvement of laboratory data and osteodystrophy. A diagnosis of mixed secondarytertiary hyperparathyroidism was made, but a progressive increase in iPTH to very high levels suggested a rapid evolution toward a pure tertiary form.

L-arginine reduces heart rate and improves hemodynamics in severe congestive heart failure

BACKGROUND

Stimulated endothelium-derived relaxing factor-mediated vasodilation and conduit artery distensibility are impaired in congestive heart failure (CHF). L-arginine could have a potentially beneficial role in CHF, acting through the nitric oxide (NO)-L-arginine pathway or by growth hormone increment.

HYPOTHESIS

This study was undertaken to investigate the effects of L-arginine on heart rate, hemodynamics, and left ventricular (LV) function in CHF.

METHODS

In seven patients (aged 39 +/- 8 years) with CHF, we obtained the following parameters using echocardiography and an LV Millar Mikro-Tip catheter simultaneously under four conditions: basal, during NO inhalation (40 ppm), in basal condition before L-arginine infusion, and after L-arginine intravenous infusion (mean dose 30.4 +/- 1.9 g).

RESULTS

Nitric oxide inhalation increased pulmonary capillary wedge pressure from 25 +/- 9 to 31 +/- 7 mmHg (p < 0.05), but did not change echocardiographic variables or LV contractility by elastance determination. L-arginine decreased heart rate (from 88 +/- 15 to 80 +/- 16 beats/min, p<0.005), mean systemic arterial pressure (from 84 +/- 17 to 70 +/- 18 mmHg, p < 0.007), and systemic vascular resistance (from 24 +/- 8 to 15 +/- 6 Wood units, p<0.003). L-arginine increased right atrial pressure (from 7 +/- 2 to 10 +/- 3 mmHg, p<0.04), cardiac output (from 3.4 +/- 0.7 to 4.1 +/- 0.8 l/min, p < 0.009), and stroke volume (from 40 +/- 9 to 54 +/- 14 ml, p < 0.008). The ratios of pulmonary vascular resistance to systemic vascular resistance at baseline and during NO inhalation were 0.09 and 0.075, respectively, and with L-arginine this increased from 0.09 to 0.12.

CONCLUSION

L-arginine exerted no effect on contractility; however, by acting on systemic vascular resistance it improved cardiac performance. L-arginine showed a negative chronotropic effect. The possible beneficial effect of L-arginine on reversing endothelial dysfunction in CHF without changing LV contractility should be the subject of further investigations.

Cardiopulmonary exercise testing in children with heart failure secondary to idiopathic dilated cardiomyopathy

STUDY OBJECTIVE

To determine and compare the cardiopulmonary responses of healthy children and children with heart failure due to idiopathic dilated cardiomyopathy (IC) to progressive treadmill exercise testing.

SETTING

University teaching hospital specializing in cardiology.

PATIENTS OR PARTICIPANTS

Twenty-six children with stable, chronic heart failure (left ventricular ejection fraction < 45%) caused by IC (IC group) and 12 healthy children (control group).

INTERVENTIONS

After 12-lead resting ECG, all children underwent progressive treadmill exercise testing using a modified Naughton protocol. Tests were performed in a controlled-temperature exercise facility, at least 2 h after a light meal.

MEASUREMENTS AND RESULTS

Cardiopulmonary parameters were assessed at rest, at anaerobic threshold (AT), and at peak exercise. At rest, the tidal volume (VT) and O(2) consumption (VO(2)) for heart rate (O(2) pulse) were lower, while the heart rate, respiratory rate, and ventilatory equivalent for O(2) (minute ventilation [VE]/VO(2)) were higher in the IC group compared with the control group. At AT, the systolic BP, O(2) pulse, VT, exercise duration, VO(2), CO(2) production (VCO(2)), and VE were lower, while the VE/VO(2) and ventilatory equivalent for CO(2) (E/CO(2)) were higher in the IC group (p < 0.05). At peak exercise, the IC group had a significantly lower systolic BP, O(2) pulse, VE, VT, exercise duration, VO(2), and VCO(2), but higher VE/VO(2) and VE/VCO(2) than the control group (p < 0.05). The VE/VCO(2) slope was significantly higher for the IC group. No correlation existed between variables evaluated at rest vs during exercise.

CONCLUSIONS

Gas exchange analysis performed during exercise successfully differentiated children with heart failure from healthy children.

Histoplasmosis as a late infectious complication following heart transplantation in a patient with Chagas' disease

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25% of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature.

Noninvasive diagnosis of allograft vascular disease after heart transplantation

OBJECTIVE

To determine the predictive values of noninvasive tests for the detection of allograft vascular disease.

METHODS

We studied 39 patients with mean ages of 48+/-13 years and a follow-up period of 86+/-13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or =50% obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results.

RESULTS

Allograft vascular disease was found in 15 (38%) patients. The Holter test showed 15.4% sensitivity, 95.5% specificity. For the treadmill stress test, sensitivity was 10%, specificity was 100%. When thallium scintigraphy was used, sensitivity was 40%, specificity 95.8%. On echocardiography with dobutamine, we found a 63.6% sensitivity, 91.3% specificity. When the dobutamine echocardiogram was associated with scintigraphy, sensitivity was 71.4%, specificity was 87%.

CONCLUSION

In this group of patients, the combination of two noninvasive methods (dobutamine echocardiography and thallium scintigraphy) may be a good alternative for the detection of allograft vascular disease in asymptomatic patients with normal ventricular function.

Analysis of the risk factors for allograft vasculopathy in asymptomatic patients after cardiac transplantation

OBJECTIVE

To study the influence of immune and nonimmune risk factors on the development of allograft vasculopathy after cardiac transplantation.

METHODS

We studied 39 patients with a mean age of 46+/-12 years. The following variables were analyzed: weight (kg), body mass index (kg/m2), donor's age and sex, rejection episodes in the first and second years after transplantation, systolic and diastolic blood pressures (mmHg), total cholesterol and fractions (mg/dL), triglycerides (mg/dL), diabetes, and cytomegalovirus infection. The presence of allograft vasculopathy was established through coronary angiography.

RESULTS

Allograft vasculopathy was observed in 15 (38%) patients. No statistically significant difference was observed between the two groups in regard to hypertension, cytomegalovirus infection, diabetes, donor's sex and age, rejection episodes in the first and second years after transplantation, and cholesterol levels. We observed a tendency toward higher levels of triglycerides in the group with disease. Univariate and multivariate analyses showed statistically significant differences between the two groups when we analyzed the body mass index (24.53+/-4.3 versus 28.11+/-4.6; p=0.019).

CONCLUSION

Body mass index was an important marker of allograft vasculopathy in the population studied.

Left ventricular regional wall motion, ejection fraction, and geometry after partial left ventriculectomy. Influence of associated mitral valve repair

OBJECTIVE

Left partial ventriculectomy has been proposed for treatment of heart failure. We investigated the effects of isolated left partial ventriculectomy and left partial ventriculectomy associated with mitral annuloplasty on refractory heart failure due to idiopathic dilated cardiomyopathy.

METHODS

Nineteen patients underwent partial left partial ventriculectomy associated with mitral annuloplasty and six patients isolated left partial ventriculectomy. In two patients the left partial ventriculectomy associated with mitral annuloplasty was combined with tricuspid annuloplasty. We evaluated before and after the surgery (24+/-14 days): the functional class, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (EF), regional wall motion, hemodynamics, mitral regurgitation, left ventricular geometry and coronary angiography.

RESULTS

For the overall group LVEF improved from 14.5+/-8.0 to 30.3+/-12.2% (P<0.0002) and right ventricular EF from 21.2+/-7.1 to 28.4+/-8.3% (P<0.002). In patients who underwent left partial ventriculectomy associated with mitral annuloplasty LVEF increased from 14.5+/-8.6 to 29.5+/-12.2% (P<0. 002). Isolated left partial ventriculectomy increased LVEF from 13. 5+/-7.5 to 31.5+/-11.1% (P<0.04). Distal segments of marginal branches of the circumflex artery were not visualized by coronary angiography. Left partial ventriculectomy associated with mitral annuloplasty reduced the wedge pressure from 25.0+/-12.1 to 18.0+/-7. 0 mmHg (P<0.03) and increased cardiac output from 3.8+/-0.8 to 4. 6+/-1.1 l/min (P<0.004), while isolated left partial ventriculectomy increased cardiac output from 3.7+/-1.0 to 4.8+/-1.3 l/min (P<0.03). Regional wall motion increment was more evident in anterolateral region from 4.2+/-6.8 to 14+/-8.3% (P<0.002) except in two patients. Left ventricular geometry changed in most patients, but a homogeneous pattern was not identified. Seven patients died during a mean follow-up of 546+/-276 days. Survivors had improvement in functional class. Augmentation of LVEF >5% was associated with a favorable clinical outcome with improvement in clinical status without death.

CONCLUSIONS

Effects of left partial ventriculectomy are not necessarily dependent upon reduction of mitral regurgitation or changes in left ventricular geometry. However, risk of death after the surgery must be reduced for a clinical application.

Treatment of persistent rejection with methotrexate in stable patients submitted to heart transplantation

OBJECTIVE

To evaluate the use of methotrexate for the treatment of recurrent rejection in heart transplant recipients.

METHODS

We studied 6 patients submitted to heart transplantation that showed rejection grade >/= 3A (ISHLT) in two consecutive endomyocardial biopsy specimens. The dose was 11.26+/-3.75 mg/week. The evaluated data were: ventricular function, endomyocardial biopsy, white cell count and number of rejection episodes before and after methotrexate administration.

RESULTS

There was a reduction in the number of rejection episodes (5.17+/-1.47 before methotrexate; 2.33+/-1.75 after 6 months and 3.17+/-2.99 after 12 months of treatment, p=0. 0193). The ventricular function was normal with ejection fraction of 76.5+/-4.80 before and 75.6+/-4.59 after methotrexate (p=0.4859). One patient did not finish the treatment because he showed signs of rejection associated with severe pericardial effusion. Five patients had a reduction in the white cell count (8,108+/-23.72 before and 5650+/-1350 after methotrexate, p=0.0961). One pulmonary infection with complete resolution after antibiotic treatment was observed.

CONCLUSION

Methotrexate in low doses is an effective adjunct therapy in the treatment of recurrent rejection after heart transplantation.

Permanent and temporary pacemaker implantation after orthotopic heart transplantation

PURPOSE

To determine the indication for and incidence and evolution of temporary and permanent pacemaker implantation in cardiac transplant recipients.

METHODS

A retrospective review of 114 patients who underwent orthotopic heart transplantation InCor (Heart Institute USP BR) between March 1985 and May 1993. We studied the incidence of and indication for temporary pacing, the relationship between pacing and rejection, the need for permanent pacing and the clinical follow-up.

RESULTS

Fourteen of 114 (12%) heart transplant recipients required temporary pacing and 4 of 114 (3.5%) patients required permanent pacing. The indication for temporary pacing was sinus node dysfunction in 11 patients (78.5%) and atrioventricular (AV) block in 3 patients (21.4%). The indication for permanent pacemaker implantation was sinus node dysfunction in 3 patients (75%) and atrioventricular (AV) block in 1 patient (25%). We observed rejection in 3 patients (21.4%) who required temporary pacing and in 2 patients (50%) who required permanent pacing. The previous use of amiodarone was observed in 10 patients (71.4%) with temporary pacing. Seven of the 14 patients (50%) died during follow-up.

CONCLUSION

Sinus node dysfunction was the principal indication for temporary and permanent pacemaker implantation in cardiac transplant recipients. The need for pacing was related to worse prognosis after cardiac transplantation.

Myocardial fiber diameter as a good indicator of outcome in Batista's operation

BACKGROUND

Despite the initial promissory results of partial left ventriculectomy, or Batista's operation, the postoperative mortality associated with the procedure has been too high. We described a histopathologic study performed to identify histological parameters that could help to determine outcomes of patients undergoing this procedure.

METHODS AND RESULTS

Myocardial fiber diameter, myocardial fibrosis, thickness of the compact wall, and number of cells presenting from the endocardium to epicardium were analyzed in 32 patients with idiopathic dilated cardiomyopathy who underwent Batista's operation. Data were grouped by patients who died < or = 6 months and patients who survived for > 6 months after the surgical procedure. Additional analyses were performed to compare results according the causes of death and to test the application of these results to biopsy.

RESULTS

Myocardial fiber diameter was the only index that could distinguish the two groups. Myocardial fiber diameter < 22 microm distinguished the group of patients who survived the 6-month postoperative period from patients who died during that time with sensitivity of 85.7 and specificity of 72.2. The subendocardial region of the compact wall and the trabecular portion of the wall exhibited comparable results.

CONCLUSION

Our results indicate that the myocardial fiber diameter of samples from the trabecular or subendocardial compact wall regions may help predict the outcome of left ventriculectomy. Samples from the trabecular or subendocardial compact wall regions were used for analysis. Further prospective studies involving left ventricular endomyocardial biopsies are necessary to confirm if the use of myocardial fiber diameter in the selection of patients for surgery improves the index of success of Batista's operation. Other factors that are involved remain unclear.

Growth hormone for optimization of refractory heart failure treatment

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 microg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 % to 18 % and to 28 % later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2 to 13.4 and to 16.2ml/kg/min later). The patient was "de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure.

Exercise and heart failure. Relation of the severity of the disease to the anaerobic threshold and the respiratory compensation point

OBJECTIVE - To identify, the anaerobic threshold and respiratory compensation point in patients with heart failure. METHODS - The study comprised 42 Men,divided according to the functional class (FC) as follows: group I (GI) - 15 patients in FC I; group II (GII) - 15 patients in FC II; and group III (GIII) - 12 patients in FC III. Patients underwent a treadmill cardiopulmonary exercise test, where the expired gases were analyzed. RESULTS - The values for the heart rate (in bpm) at the anaerobic threshold were the following: GI, 122+/-27; GII, 117+/-17; GIII, 114+/-22. At the respiratory compensation point, the heart rates (in bpm) were as follows: GI, 145+/-33; GII, 133+/-14; GIII 123+/-22. The values for the heart rates at the respiratory compensation point in GI and GIII showed statistical difference. The values of oxygen consumption (VO2) at the anaerobic threshold were the following (in ml/kg/min): GI, 13. 6+/-3.25; GII, 10.77+/-1.89; GIII, 8.7+/-1.44 and, at the respiratory compensation point, they were as follows: GI, 19.1+/-2. 2; GII, 14.22+/-2.63; GIII, 10.27+/-1.85. CONCLUSION - Patients with stable functional class I, II, and III heart failure reached the anaerobic threshold and the respiratory compensation point at different levels of oxygen consumption and heart rate. The role played by these thresholds in physical activity for this group of patients needs to be better clarified.

Different microcirculatory and interstitial matrix patterns in idiopathic dilated cardiomyopathy and Chagas' disease: a three dimensional confocal microscopy study

OBJECTIVE

To analyse the morphological aspects of the extracellular matrix and microcirculation to clarify whether chronic Chagas' cardiopathy (CCC) is an accurate model to study the pathogenesis of idiopathic dilated cardiomyopathy (IDCM).

DESIGN

Thick histological myocardial sections were prepared to analyse collagen, and microcirculation was examined during confocal laser and light microscopy.

SETTING

The specimens were prepared at the pathology service of the Heart Institute of São Paulo, Brazil.

PATIENTS

Nine control hearts, eight IDCM hearts, and 10 CCC hearts were studied after necropsy.

MAIN OUTCOME MEASURES

The number of collagen struts per 100x field, the area of fibrosis (%), and the diameters of arterioles and capillaries were measured in each heart to establish outcome.

RESULTS

A smaller number (mean (SD)) of collagen struts was seen in the hearts in the IDCM group (9.1 (4.1)) than in the control (22.4 (3.2)) (p < 0.05) or CCC (15.7 (7.4)) (p > 0.05) groups. Fibrosis was greater in the CCC hearts (13.8 (10.5)%) than in the IDCM hearts (5.9 (6.6)%) (p > 0.05). Major increases in arteriole (65.4 (9.9) microm) and capillary (9.9 (1.7) microm) diameters were seen in the CCC hearts but not in the IDCM hearts (arteriole diameter 40.3 (7.9) microm; capillary diameter 7.9 (1.3) microm).

CONCLUSIONS

Hearts demonstrating CCC and IDCM present different extracellular and microvessel alterations. This suggests that distinct pathogenic mechanisms are responsible for each condition and that CCC is not an effective model to study IDCM.

Radiofrequency catheter ablation of ventricular tachycardia guided by nonsurgical epicardial mapping in chronic Chagasic heart disease

We report a case of a 63-year-old women with Chagas' disease and recurrent, syncopal VT treated by RF catheter ablation in whom endocardial application of RF energy was guided by nonsurgical epicardial mapping. The procedure was undertaken in the electrophysiology laboratory under deep anesthesia. VT was interrupted after 2.4 seconds of application and rendered noninducible afterwards. Two weeks after the procedure, a distinct morphology VT was induced by programmed ventricular stimulation, and the patient was started on amiodarone, remaining asymptomatic 12 months after the procedure.

Determinants of midterm outcome of partial left ventriculectomy in dilated cardiomyopathy

BACKGROUND

Partial left ventriculectomy has been proposed for treatment of severe cardiomyopathies. This study reports midterm results of this procedure in 37 patients with dilated cardiomyopathy.

METHODS

All patients were in New York Heart Association class III (16) or IV (21). Partial ventriculectomy was associated with mitral annuloplasty in 27 patients and with mitral replacement in 2.

RESULTS

There were seven operative deaths (18.9%). During a mean follow-up of 18.2+/-9.3 months, 9 more patients died. Actuarial survival was 56.7%+/-8.1% at 6 and 24 months. Analysis of factors influencing outcome showed that midterm survival was significantly affected only by myocardial cell diameter. Otherwise, functional class improved from 3.5+/-0.5 to 1.8+/-0.9 in the survivors (p < 0.001). Furthermore, left ventricular diastolic volume decreased from 523+/-207 to 380+/-148 mL (p < 0.001), and left ventricular ejection fraction increased from 17.1%+/-4.6% to 23%+/-8% (p < 0.001), whereas significant changes in cardiac index, stroke index, and pulmonary pressures were found at 1 month of follow-up. Although left ventricular diastolic volume tended to increase in the late postoperative period, left ventricular ejection fraction and hemodynamic variables did not change significantly.

CONCLUSIONS

Partial ventriculectomy improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy for up to 24 months of follow-up. Nevertheless, this procedure's clinical application is limited by the high mortality observed in the first postoperative months. Otherwise, new perspectives may be advised by the identification that partial ventriculectomy results seem to be influenced by compromised myocardial cells.

Fibrinolytic potential is significantly increased by oestrogen treatment in postmenopausal women with mild dyslipidaemia

OBJECTIVE

To study the effects of oestrogen replacement treatment on fibrinolytic potential in postmenopausal women.

DESIGN

Randomised, double blind, placebo controlled trial of oral 17 beta-oestradiol.

SETTING

Subjects were evaluated in the outpatient setting.

PATIENTS

Nineteen postmenopausal women with mild dyslipidaemia, aged 44 to 69 years (mean (SD) 55.7 (6.7)).

MAIN OUTCOME MEASURES

Fibrinolytic activity (fibrin plate assay) and tissue plasminogen activator (t-PA) antigen were measured at baseline and after three, six, and nine weeks of each treatment.

RESULTS

After nine weeks of 2 mg oestradiol treatment, there was a significant increase in fibrinolytic potential compared with placebo, as indicated by an increase in fibrinolytic activity (mean (SEM), 80 (9) v 54 (5) mm2 of lysis in the fibrin plate, 2 mg v placebo, p = 0.002) and a decrease in t-PA antigen (5.8 (0.9) v 8.4 (1.2) ng/ml, 2 mg v placebo, p < 0.001). There was a similar trend with the 1 mg dose but the changes were less noticeable.

CONCLUSIONS

Hormone replacement treatment with 17 beta-oestradiol for nine weeks significantly increased fibrinolytic potential in postmenopausal women with mild dyslipidaemia. This suggests that the cardioprotective effect of oestrogen may be mediated, in part, by an increase in fibrinolytic potential.

[Effects of carvedilol (beta 1, beta 2, alpha 1 bloker) on refractory congestive heart failure]

PURPOSE

The effects of beta-blockers on severe heart failure are not well known. We investigated the effects of carvedilol (beta 1, beta 2, alpha 1-blocker) on symptoms, functional class (FC), and left ventricular function in patients with refractory heart failure.

METHODS

We studied 21 patients, mean age 56 +/- 10 years, 9 in FC IV, e 12 in FC III (intermittently with class IV). The initial dosage was 6.25 mg, and it was increased progressively as tolerated. The mean dose was 42 +/- 11 mg. The patients were submitted to routine clinical evaluation, and electrocardiogram. We determined after 196 +/- 60 days of follow-up the left ventricular end diastolic dimension (by echocardiogram), and left ventricular ejection fraction (using MUGA).

RESULTS

Carvedilol was well tolerated by 16 (76%) patients. One patient is in FC II during increment of the dosage. Eight patients were in FC I, and 7 in FC II at 196 +/- 60 days of follow-up. Heart rate decreased from 96 +/- 15 to 67 +/- 10 bpm (p < 0.0001), left ventricular end diastolic diameter from 73 +/- 13 to 66 +/- 12 mm (p < 0.009), and the left ventricular ejection fraction increased from 0.21 +/- 0.06 to 0.34 +/- 0.12 (p < 0.0003).

CONCLUSION

Carvedilol may have beneficial effects on cardiac function, remodeling process, and FC. If tolerated, it seems to be a potential alternative option in the medical treatment of refractory heart failure. However, investigations are still necessary to clarify the long-term effects of carvedilol on this specific subgroup of patients.

Higher incidence of malignant neoplasms after heart transplantation for treatment of chronic Chagas' heart disease

BACKGROUND

Heart transplantation is a new therapeutic procedure to treat heart failure resulting from Chagas' disease. Experimental studies have demonstrated neoplastic effects of benznidazole, which is used for treatment of Trypanosoma cruzi infection. We compared the incidence and characteristics of neoplasia after heart transplantation for treatment of chronic Chagas' disease with those of other diseases.

METHODS

Sixteen patients with Chagas' disease and 75 patients with other diseases underwent heart transplantation. Benznidazole was administered to 14 patients with Chagas's disease either for prophylaxis (4 patients) or for treatment of Chagas' disease reactivation (10 patients).

RESULTS

The survival rate of patients in the nonchagasic group was 90% at 1 year and 82.4% at 2 years, and the survival rate in the chagasic group was 63% at 1 year and 57% at 2 years. Six of 16 patients (37.5%) with Chagas' disease had malignant tumors after a mean follow-up time of 25.3+/-2.1 months in contrast to 2 of 75 patients (2.7%) in the nonchagasic group after 34.6+/-3.6 months of follow-up. In the chagasic group, lymphoproliferative disorder was diagnosed in three patients, Kaposi's sarcoma in two, and squamous cell carcinoma in one patient. Reactivation of T. cruzi infection was diagnosed in all patients who had lymphoproliferative disorder. One patient without Chagas' disease had lymphoproliferative disorder in the lung, and another had malignant schwannoma affecting the skin.

CONCLUSIONS

We found a higher incidence of malignant neoplasia after heart transplantation for treatment of chronic Chagas' disease. It is likely that the neoplasia is the result of chronic infection with an immunomodulator protozoan, immunosuppression, reactivation of the T. cruzi infection, or the toxicity of therapeutic intervention with benznidazole.

[Stenting in a recently implanted stent in a saphenous vein graft for optimizing angiographic results]

A 60 year-old woman with progressive angina who had been submitted to saphenous bypass-graft to right coronary artery and a left mammary artery graft to anterior descending artery eight years previously, underwent implantation of a Gianturco Roubin II stent in the proximal third of the saphenous vein graft. The result was suboptimal by persistence of a residual stenosis probably due to prolapse of atherosclerotic material through the coil spaces. Another stent (Palmaz-Schatz biliar stent) was implanted at the previously stented site with no residual stenosis. Another Palmaz-Schatz biliar stent was successfully implanted in the distal body of the graft to treat another lesion (passing through the previously stents without difficulty). Stenting a stent, in selected situations, is a useful tool to optimize the angiographic result of stent implantation.

Clinical outcome after left ventricular surgical remodeling in patients with idiopathic dilated cardiomyopathy referred for heart transplantation: short-term results

BACKGROUND

Left ventricular partial ventriculectomy (LVPV), an unconventional operation to reverse some aspects of the cardiac remodeling, has been proposed for treatment of congestive heart failure.

METHODS AND RESULTS

Twenty-four patients (age 46+/-9 years) referred to heart transplantation underwent isolated LVPV or LVPV associated to valve annuloplasty. Patients were in New York Heart Association functional class IV (15) or III (9) due to idiopathic dilated cardiomyopathy. Functional class, left and right ventricular ejection fraction (radionuclide), left ventricular end-diastolic and end-systolic diameter, and fractional shortening (by echocardiography), and hemodynamic variables were determined. The mean follow-up was 474+/-174 days. Survival at 30, 180, and 365 days was 92+/-6%, 67+/-10%, and 63+/-10%, respectively. Nine patients died, and the cause was associated with arrhythmias in 4 patients. The left ventricular end-diastolic diameters before and at 23+/-14 days, 188+/-27, and 365+/-14.8 days of follow-up were 82.6+/-9.8, 68.9+/-7.8, 69.9+/-6.9, and 70+/-5.3 mm, respectively (P=0.0001). The left ventricular end-systolic diameters were 73.5+/-7.4, 55.9+/-7.5, 57.4+/-7.8, and 55+/-5.5 mm (P=.0001). Fractional shortenings were 13+/-3, 19+/-4, 18+/-5, and 22+/-2%, respectively (P=.0001). The left ventricular ejection fractions before and 18+/-14, 188+/-26, and 369+/-3.6 days after the surgery were 17.2+/-4.7, 24.5+/-8.3, 24.5+/-7.4, and 23.7+/-6.1%, respectively (P=.004). The right ventricular ejection fractions were 20.5+/-6.2, 27.9+/-8.4, 28.2+/-10.1, and 27.4+/-7.3% (P=0.02). Pressures were unchanged. There was improvement in cardiac index from 2.11+/-0.52 to 2.53+/-0.64 L/min (P=.0037). Norepinephrine blood levels reduced from 702+/-258 to 439+/-307 pg/mL (P=.001). Most surviving patients presented improvement in functional class. Sustained ventricular tachycardias were observed in 9 patients (38%).

CONCLUSIONS

The left ventricular partial ventriculectomy may improve the left and right ventricular function, functional class, and cardiac output. These initial results were associated to high prevalence of sustained ventricular tachycardia. The ventriculectomy introduces the concept that reduction of left ventricular chamber diameter may improve cardiac function in heart failure. Further progress is necessary to improve the results and evaluate its proper role in the management of heart failure.

Normal high energy phosphate ratios in "stunned" human myocardium

OBJECTIVES

We sought to investigate whether alterations in cardiac high energy phosphates occur in postischemic "stunned" human myocardium.

BACKGROUND

Transient postischemic myocardial dysfunction is a common phenomenon that occurs in a variety of clinical settings in the absence of necrosis, and its pathogenesis is still unclear. Cardiac high energy phosphates are reduced during ischemia, and persistently altered myocardial high energy phosphate metabolism has been suggested as a mechanism contributing to stunning.

METHODS

We studied 29 patients with a first anterior myocardial infarction (MI) who underwent successful reperfusion within 6 h of the onset of chest pain. These patients underwent 31P magnetic resonance spectroscopy (MRS) a mean of 4 days after MI for measurement of left ventricular contractility and relative high energy phosphate metabolites. Twenty-one patients underwent a second 31P MRS study a mean of 39 days after MI. Eight volunteers served as control subjects.

RESULTS

Global and infarct area wall motion scores improved significantly between the early and late studies. No difference was found between early cardiac phosphocreatine (PCr)/beta-adenosine triphosphate (beta-ATP) ratios in patients and control subjects ([mean +/- SD] 1.51 +/- 0.17 vs. 1.61 +/- 0.18, respectively, p = 0.17) or between early and late study results in patients (1.51 +/- 0.17 vs. 1.53 +/- 0.17, respectively, p = 0.6). For alpha of 0.05, the study had a 90% power to detect a 9% difference.

CONCLUSIONS

The results of this study demonstrate normal myocardial PCr/ATP ratios in patients with myocardial stunning after reperfusion and suggest that relative cardiac high energy phosphates are not depleted in stunned human myocardium.

[Long-term course and complications of arterial hypertension after heart transplantation]

PURPOSE

To evaluate the progression of arterial hypertension (AH) and its consequences, in patients submitted to cardiac transplantation (CT) in use of cyclosporine (CY).

METHODS

In 65 patients submitted to orthotopic CT, we evaluated blood pressure, serum creatinine and blood levels of CY before, 15 and 30 days, and 6, 12, 24, 48 and 60 months after CT; in 20 patients we analyzed cardiac index and systemic vascular resistance pre-CT, 15 and 30 days, 6 and 12 months after CT; in 33 patients, we studied anatomic and functional modifications by echocardiography, 24 +/- 13 months after CT.

RESULTS

Thirty days after CT, AH was present in 58.5% (50% mild), and after one year, 93% of patients were hypertensives (85% moderate-to-severe), remaining unchanged during the rest of follow-up. The serum creatinine progressively increased, reaching values significantly higher than those pre-CT after one year, persisting with a mild increment until 60 months. Echocardiography showed left ventricle hypertrophy in 54% of patients, all of which had normal function. Two patients died as a direct consequence of hypertensive complications.

CONCLUSION

AH in patients submitted to CT on CY use occurs early, increases in prevalence and severity during the follow-up and is mediated by an increase in vascular resistance. Also, the AH does not correlate to CY blood levels or nefrotoxicity, but it can impair renal function and compromise longevity of transplantation by inducing ventricular hypertrophy.

Nitric oxide inhalation reduces pulmonary tidal volume during exercise in severe chronic heart failure

Multiple mechanisms have been proposed to explain the hyperventilation and the limited exercise capacity in congestive heart failure (CHF) including increased intrapulmonary pressures, total pulmonary resistance, and airway abnormalities. We investigated the hypothesis that inhalation of nitric oxide could influence the maximum exercise capacity and excessive ventilatory response to exercise in CHF. Fifteen patients in CHF (mean age 48 +/- 12 years) underwent a control and a nitric oxide inhalation progressive treadmill exercise test with 30 ppm. We determined the maximum oxygen consumptiom (peak VO2), CO2 production (VCO2), minute pulmonary ventilation (VE), respiratory rate, tidal volume (VT), ventilatory equivalent for oxygen (VE/VO2), ventilatory equivalent for carbon dioxide (VE/VCO2), estimated physiologic dead space/tidal volume ratio (VD/VT), VE/VCO2 slope, heart rate, systemic arterial pressure, VE/exercise time slope, and VT/exercise time slope during every incremental exercise. Mean maximum exercise values of heart rate, systolic systemic arterial pressure, diastolic systemic arterial pressure, VD/VT, respiratory rate, peak VO2, VO2/heart rate, VE/CO2, and maximum exercise time were unchanged by inhalation of nitric oxide. There was a strong trend toward reduction of VE/VO2 from 53 +/- 15 to 47 +/- 12 (p = 0.051) and in maximum VE from 58 +/- 21 to 48 +/- 17 L x min(-1) (p = 0.059). Maximum VT decreased from 1639 +/- 556 to 1406 +/- 479 ml (p = 0.04). The VE/VCO2 slope was reduced from 43 +/- 12 to 35 +/- 8 (p = 0.018). Two patients had signs of pulmonary congestion during peak exercise or the recovery period with inhalation of nitric oxide. The VE/exercise time slope and VT/exercise time slope during incremental exercise were reduced by inhalation of nitric oxide, demonstrating a statistically significant minor increase in VE and VT. Inhalation of nitric oxide attenuated the excessive increase in VT response to exercise in CHF. The L-arginine-nitric oxide pathway may be involved in mechanisms contributing to hyperventilation during exercise in CHF.

Effect of acute administration of estradiol 17 beta on aortic blood flow in menopausal women

Acute administration of estradiol 17beta increases aortic blood flow velocity in menopausal women. This suggests that the effect of the ovarian hormone on cardiac dynamics is mainly dependent on a reduction in peripheral vascular resistances.

[Cardiac amyloidosis. A disease with many faces and different prognosis]

PURPOSE

To identify the principal forms of cardiac amiloydosis presentation in a terciary hospital.

METHODS

Eight cases with cardiac amyloidosis were identified. Five were women, their ages ranged from 23 to 83 years (mean 62). After a medical history and clinical examination the patients were submitted to complementary tests: electrocardiogram (EKG), echocardiogram (ECHO), scintigraphy with technecium pirophosphate and cardiac biopsy these results allowed the identification of their clinical situation.

RESULTS

Seven patients referred dyspnea, 6 were in heart failure, 1 patient had syncope. The EKG identified complete atrioventricular (AV) block in 4 patients, and antero septal inactive area in the other 4. The ECHO showed normal cardiac diameter in all (mean left ventricular diastolic diameter of 46.8) and slight reduction of left ventricular ejection fraction; hypertrophy of the left ventricular septal and posterior walls in all cases, in 7 cases there was a hyper refractile granular sparkling ECHO. Two different groups were identified: one with complete AV block and the second with restrictive cardiomyopathy. The prognosis was different in these two groups. Those with complete AV block evolved better after pacemaker implantation and those with restrictive cardiomyopathy had refractory heart failure and 3 of them died.

CONCLUSION

The increased free wall and septal thickness, the slight systolic dysfunction and the infiltration aspect at ECHO allow us to identify the great majority of the cases. Those patients with restrictive cardiomyopathy evolve with refractory heart failure and most of them die in a few months.

Usefulness of ST-segment depression in non-infarct-related electrocardiographic leads in predicting prognosis after thrombolytic therapy for acute myocardial infarction

This study investigated both the in-hospital and long-term prognostic significance of ST-segment depression in non-infarct-related leads in patients who received thrombolytic therapy after acute myocardial infarction (AMI). We evaluated 221 consecutive patients who were admitted with their first AMI and underwent thrombolysis. Patients were followed for an average of 31 months and were classified into 3 groups: group 1 included 51 patients with persistent ST-segment depression, group 2 had 97 patients with transient ST-segment depression, and group 3 consisted of 73 patients without ST-segment depression (absent). Group 1 had significantly worse long-term survival during follow up by Kaplan-Meier analysis (55%) versus group 2 (81%) and group 3 (94%) (p = 0.0004) and higher event rates. This prognostic significance seemed to be maintained in both the anterior and inferior wall AMI groups. Multivariate analysis, using the Cox model, showed that Killip class, in-hospital left ventricular ejection fraction, and the persistence of ST-segment depression on the predischarge electrocardiogram (group 1) were independent predictors of survival. ST-segment depression in non-infarct-related leads on the predischarge electrocardiogram is an independent risk factor for worse long-term survival after anterior as well as inferior AMI treated with thrombolytic therapy.

An in situ quantitative immunohistochemical study of cytokines and IL-2R+ in chronic human chagasic myocarditis: correlation with the presence of myocardial Trypanosoma cruzi antigens

Inflammatory cells positive for the cytokines IL-2, IL-4, IL-6, TNF-alpha, and IFN-gamma and for IL-2R, as well as CD8+ and CD4+ T cells and B cells were quantified using an immunoperoxidase technique in 25 fresh myocardial fragments from patients presenting with chronic chagasic cardiomyopathy. The presence of Trypanosoma cruzi antigens (Ags) in the myocardium was also investigated. The cases were grouped into group A (no Ag), group B (scarce extramyocardial fiber Ags), and group C (intramyocardial pseudocysts and extramyocardial fiber Ags). IL-2 was detected in very few cells (0.30 +/- 0.40 positive cells/hpf), suggesting immunological imbalance in chronic chagasic patients. IFN-gamma+ was the cytokine most frequently demonstrated (7.52 +/- 5.87 positive cells/hpf) and there was a good correlation between the number of IFN-gamma+ cells and CD8+ T cells in group A. IL-4+ cells were present in higher numbers in group C (2.78 +/- 1.49 positive cells/hpf). TNF-alpha+ (1.59 +/- 1.68 positive cells/hpf) and IL-6+ (2.76 +/- 2.32 positive cells/hpf) cells were present in moderate numbers. Fewer B cells were present, not related with the intensity of T. cruzi Ags. These results suggest that cytokines, as they occur in other infectious diseases, play a fundamental role in the control of T. cruzi in chronic human chagasic disease. A fatal outcome seems to be associated with the increased production of cytokines derived from the Th2 subpopulation of the CD4+ T cells.

Association of an increase in CD8+ T cells with the presence of Trypanosoma cruzi antigens in chronic, human, chagasic myocarditis

The role of Trypanosoma cruzi in the pathogenesis of myocarditis in the chronic phase of Chagas' disease is still controversial, with autoimmune mechanisms frequently being proposed. In the present work, we demonstrate that higher numbers of CD8+ T cells are correlated with the presence of parasite antigens, suggesting an important role for the parasite in the development of myocardial inflammation. Quantification of the mean numbers of CD8+ and CD4+ T cells per 400x microscopic field was performed in myocardial specimens from 33 chronic chagasic patients with heart failures (nine biopsies and 24 necropsies), using an immunoperoxidase technique. The cases were grouped according to a semiquantitative score of the relative amounts of T. cruzi antigens: group 1 = absent (14 cases); group 2 = scarce extracellular or intramacrophagic antigens (12 cases); group 3 = many extracellular or intramacrophagic antigens plus T. cruzi intramyocytic pseudocysts (seven cases). The mean numbers of CD8+ and CD4+ T cells in groups 1,2, and 3 were 6.94 and 3.79, 13.89 and 6.24, and 17.91 and 5.97, respectively. The numbers of CD8+ T cells in groups 2 and 3 were significantly higher compared with group 1 (no T. cruzi antigens), but were not different from each other. Scarce, extramyocytic T. cruzi antigens were associated with an intense inflammatory infiltrate, suggesting that delayed-type hypersensitivity immune mechanism is induced by the parasite; intact myocardiocytes containing parasites did not show an inflammatory reaction around them. A poor inflammatory response was frequently associated with many extramyocytic antigens and myocardial parasite pseudocysts, suggesting that active proliferation and dissemination of the parasites occur when the immunologic response is diminished. The number of CD4+ T cells did not vary significantly among the three groups. We conclude that the CD8+ T cell is the main cell type responsible for immune activation in chronic, human, chagasic myocarditis and is probably activated by the presence of T. cruzi antigens associated with internal myocytic host antigens. The absence of a significant member of CD4+ T cells in the presence of T. cruzi antigens suggests inhibition of CD4+ T cell activation or the lack of a class II major histocompatibility complex molecule presentation mechanism.

[Intermittent antero-medial divisional block in patients with coronary disease]

We report the case of a 69 year-old male who developed congestive heart failure functional class IV (NYHA). The admission electrocardiogram (EKG) revealed sinus rhythm, PR interval of 240 ms, QRS interval of 110 ms, the QRS vector of 0 degree, Q waves from V1 to V6, tall R waves from V1 to V4 that decreased to V5 and V6. The vectocardiogram had anteriorization of the electrical forces of QRS, with vector half area in the horizontal plane at +60 degrees. After two years the patient had a myocardial infarction, the EKG at the admission had the same pattern and after two days developed important changes: enlargement of QRS interval with length of 160 ms, QRS vector of +100 degrees, R waves at D2, D3 e AVF that increase from D2 to D3, QS at D1, AVL, AVR and V1, rS at V2 and V3, R wave is notched and thickened+ at V5 and V6, that return to the initial pattern after one day. The patient progressed to death in the eighth day after infarction. This case reported a intermitent pattern of EKG that is an uncontestable proof to the existence of the left middle fascicular block.

[Radiological findings in endomyocardial fibrosis]

PURPOSE

To determine through conventional radiology the type of ventricular involvement in endomyocardial fibrosis (EMF).

METHODS

We analyzed 56 cases with EMF confirmed by angiocardiography and 9 by postmortem study, aged between 16 and 56 years (mean 32); there were 42 females. Only one radiologist analyzed X-rays without any knowledge of the cineangiography findings.

RESULTS

The right side of the heart was primarily involved in 9 patients and the cardiac silhouette was characteristically globular and had oligemic pulmonary fields (66.66%). The cardiothoracic ratio was 0.62 +/- 0.11. Out of 9 patients, 8 were female. The left side of the heart was established as being primarily involved in 11 cases and simulated rheumatic mitral disease. The cardiothoracic ratio was 0.51 +/- 0.09 and there were increased pulmonary fields in 63.6%. The biventricular disease occurred in 36 cases. There were radiologic findings of right and left side. The cardiothoracic ratio was 0.63 +/- 0.06 and there was oligemic pulmonary fields in 38.8%, increased pulmonary fields in 33.3% and was normal in 27.7%. There were 4:1 females.

CONCLUSION

The radiological study is fundamental in the initial diagnosis of EMF. The type of involvement could be done in 66.07% of all cases by chest X-ray.

[Persistence of palpitations after successful radiofrequency catheter ablation]

PURPOSE

The aim of this study was to determine prevalence and the underlying mechanism of persistent palpitations after successful radiofrequency ablation of reentrant nodal tachycardia and atrioventricular tachycardia.

METHODS

One hundred twenty consecutive patients (mean age of 36 +/- 16 years) who underwent radiofrequency catheter ablation of atrioventricular or reentrant nodal tachycardia constituted the analyzed group. Prevalence of palpitations was investigated during out-clinic visits and telephone interviews. Patients complaining of palpitations were divided in 2 groups: 1) those in whom palpitations lasted more than 30 seconds, and 2) those in whom the paroxysms lasted < 30 seconds (group II). All patients underwent clinical evaluation, ECG and Holter monitoring. Transesophageal atrial pacing and electrophysiologic stimulation were carried out when judged necessary.

RESULTS

During a follow up period of 9 +/- 4 months, 52 patients complained of palpitations. In 31 group I patients, palpitations were related to ventricular and atrial premature beats as shown during Holter monitoring. In group II patients, eight had recurrence, five presented a new arrhythmia not recognized previously to the ablative procedure and two patients had their symptoms related to arrhythmias recognized before ablation but taken as asymptomatic. The mechanism of palpitations was not identified in six patients.

CONCLUSION

Palpitations may persist in 43% of patients who undergo radiofrequency ablation to treat reentrant nodal tachycardia and atrioventricular tachycardia. Recurrence and treatment are more likely when palpitations last longer than 30 seconds.

[Results of aortic stenosis surgery in patients with severe ventricular dysfunction]

PURPOSE

To study the short and long term clinical course of patients with severe aortic stenosis after surgical treatment of the valvular lesion.

METHODS

Thirty survivors among 31 consecutive patients with severe left ventricular dysfunction (LVD) due to aortic stenosis (AS) were submitted to clinical and echocardiographic follow-up during a mean of 30 months after surgical treatment of the valvular lesion. Twenty five (83.3%) patients were male with a mean age of 50 years (25 to 74). Before operation the following parameters were obtained: diastolic left ventricular diameter (DLVD), shortening fraction (SF), left ventricular ejection fraction (LVEF), aortic valve area (AVA), left ventricular-aortic pressure gradient (PG) and NYHA functional class (FC). During the follow up, after the surgical procedure, FC, DLVD, LVEF and SF could be analysed and compared with previous data.

RESULTS

A significant rise in SF (p = 0.001) and LVEF (p = 0.0001), as well as a decrease in DLVD (p = 0.001) were observed in the follow up. Symptoms lessened in severity in the majority of patients. Three of our patients died with progressive LVD and heart failure, after at least 36 months of follow-up. These results indicate that when operation is carried out in patients with AS and left ventricular failure, a significant improvement in left ventricular function and in symptoms takes place. Although the risk of surgical treatment is increased in this group of patients, LVD should not be considered a contraindication to the procedure.

CONCLUSION

The left ventricular dysfunction is not a contraindiction for the surgical treatment of the aortic stenosis.

[Effects of partial ventriculectomy on left ventricular mechanical properties, shape, and geometry in patients with dilated cardiomyopathy]

PURPOSE

To investigate the short-term effects of the partial ventriculectomy (resection of lateral wall associated to mitral annuloplasty) on cardiac mechanics, contractility, shape and geometry of the left ventricle (LV).

METHODS

Eleven male patients with severe congestive heart failure due to dilated cardiomyopathy were studied. The mean age was 51 +/- 7 years and the functional class was III (five patients) or IV (six patients) before the surgery. Patients were evaluated before and at 17 +/- 4 days after the surgery by simultaneous LV pressure and echocardiographic data. End-diastolic pressure (EDP-mmHg), wall stress (EDS-g/cm2) and diameter (EDD-cm); endsystolic wall stress (ESS) and diameter (ESD), fractional shortening (FS-%) and maximal elastance (Emax-mmHg/ cm/s); the diastolic slope of the pressure-diameter (Kp-mmHg/cm) and stress-strain (Km-g/cm2) loops; shape (L/ EDD, adimensional, where L is the LV long axis) and geometry (Th/EDD, adimensional, where TH is the LV diastolic thickness) were obtained.

RESULTS

1) The ressected muscle fragments (diamond shape) were 10.8 +/- 1.3 cm in length and 5 +/- 0.6 cm in width; 2) all patients were discharged from hospital (15-29 days) in class I (eight cases), II (two), and III (one); 3) it was observed a decrease in EDP (24.3 +/- 7.7 x 17.5 +/- 3.2, p = 0.016); in EDD (8.0 +/- 0.7 x 7.2 +/- 0.8, p = 0.002); in EDS (57.9 +/- 26.8 x 37.4 +/- 19.2, p = 0.005); in ESS (199 +/- 46.9 x 102.8 +/- 33.1, p = 0.004); in ESD (7.1 +/- 0.7 x 5.7 +/- 0.8, p < 0.001); in Kp (22.3 +/- 15.9 x 11.5 +/- 6.9, p = 0.014); and in K(m) (467.4 +/- 212 x 214.6 +/- 87.4, p = 0.01); and, 4) it was noted an increase in FS (11.5 +/- 1.8 x 19.8 +/- 3.9, p < 0.001); in Emax (13.8 +/- 2.2 x 18.6 +/- 3.2, p < 0.001); and in L/EDD (1.32 +/- 0.1 x 1.47 +/- 0.13, p < 0.007) and Th/Dd (0.11 +/- 0.04 x 0.17 +/- 0.08, p < 0.038).

CONCLUSION

The partial ventriculectomy showed multiple significant beneficial effects in these dilated myopathic hearts.

[When should we stop cardiopulmonary resuscitation in patients brought to the emergency room in cardiac arrest without pre-hospital care?]

PURPOSE

The decision of stopping cardiopulmonary resuscitation (CPR) in patients brought to emergency room in arrest remains a challenge. Such decision is even more difficult when someone is brought by bystanders, after an acute loss of consciousness without any out-of-hospital care. To evaluate the probability of survival of these patients we reviewed retrospectively charts in our institution, during a period of five years.

METHODS

One hundred and one patients that fulfilled these characteristics came to our emergency in arrest. The time to arrival since symptoms started, cardiac rhythm at first electrocardiogram (EKG), age, gender, initial CPR success, late outcomes and previous diseases were obtained. Patients were divided in two groups regarding which cardiac rhythms they had at first EKG: A-patients arriving in asystole; and VF-patients arriving in ventricular fibrillation. To evaluate time to arrival, we arbitrarily choose 15 min as a reference point.

RESULTS

In these 101 subjects the mean age was 62 +/- 13.7 years and 63 (62.3%) were men. Previous heart disease was documented in 74 [dilated cardiomyopathy in 22 (21.7%), coronary heart disease in 41 (40.6%), arterial hypertension in 25 (24.7%) and others in 6 (5.6%)]. In 66 episodes we were sure of the time patients spent before arrival (mean 2.5 +/- 11 min). Only in 63 subjects we had no doubts about the rhythm at entrance: VF in 37 (58.7%), A in 22 (34.9%) and an accelerated idioventricular rhythm (AIR) in four (6.3%). Time to arrival was 18.6 +/- 10.6 in VF vs 32.5 +/- 11.7 min in A (p = 0.012). Fourteen (13.8%) subjects resumed a supraventricular rhythm with systolic pressure > or = 90 mmHg after CPR and all of them were in VF (13) or AIR (one). Nine patients (8.9%) evolved in coma. Only five (4.9%) were discharged from the hospital without any neurological disturbance and their time to arrival ranged from one to 15 (9 +/- 5.8) min.

CONCLUSION

Delayed arrival to the emergency room (> 15 min) associated with asystole were predictors of unsuccessful CPR, and both data are helpful in deciding when to stop CPR in subjects arriving at the emergency department with no out-of-hospital care.

Compliance with pharmacological treatment in outpatients from a Brazilian cardiology referral center

To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.

[Risk factors in elderly patients selected by primary care physicians for hypolipemic treatment]

PURPOSE

To evaluate the influence of age on response to pravastatin treatment in patients treated by community physicians.

METHODS

According to age, 873 patients were divided in three groups: group A with ages ranging from 45 to 59 years (n = 55), group B with ages from 60 to 64 years (n = 182) and group C with ages from 65 to 70 years (n = 143). After four weeks only with diet orientation, patients received 10 mg/day of pravastatin for 12 weeks.

RESULTS

There was a greater prevalence of risk factors in elderly patients: hypertension (45.7%, 54.4% and 57.1% in groups A, B and C respectively p = 0.0165), diabetes mellitus (9.3%, 17.6% and 25.8% respectively in groups A, B and C p < 0.0001), and previous heart disease (23.1%, 34.3% and 34.7% in groups A, B and C respectively p < 0.001). During the period of diet orientation there was a similar total cholesterol reduction in the three groups (about 10.5%), the reduction reached 30.0% with the introduction of pravastatin for 12 weeks. Low density cholesterol level decreased during the diet period in the three groups (about 10.5%), pravastatin prescription induced further reduction (about 31.7%). The high density cholesterol level (HDL) increased significantly with pravastatin treatment (12.7%). After pravastatin treatment the increase in HDL levels was more significantly among those patients with initial low levels of HDL (< 35 mg/dL) in the three groups.

CONCLUSION

In patients selected by community physicians to receive lipid lowering therapy, increased age was associated with greater prevalence of risk factors and heart disease. Regardless of age, there was a good response to pravastatin treatment, however less than half of patients had received treatment prior to the protocol.

[Acute effects of ibopamine on left ventricular mechanics and contractility in patients with idiopathic dilated cardiomyopathy]

PURPOSE

The effects of ibopamine (IBO) on left ventricular (LV) mechanics and contractility have not been described. The aim of this study was to test the hypothesis that IBO has a contractile effect at a dose of 200 mg.

METHODS

Ten male patients (43 +/- 7 years) with refractory heart failure due to idiopathic dilated cardiomyopathy were studied. The patients were submitted to simultaneous echo-Doppler and hemodynamic (microtip catheter) studies, before (B) and after (20, 40 and 60 minutes) a dose of 200 mg of IBO. LV pressure/diameter and stress/strain relations were obtained. Subsequently, heart rate (HR-bpm), cardiac output (CO-L/m), end-diastolic pressure (EDP-mmHg); fractional shortening (FS-%); maximal elastance (Emax-mmHg/cm/s); end systolic (ESS-g/cm2) and end-diastolic (EDS-g/cm2) stress; chamber (Kp-mmHg/cm) and muscle (K(m)-g/cm2) stiffness, and the time of constant relaxation (Tau-ms) were analyzed.

RESULTS

Results were presented as mean +/- standard deviation for conditions before and after IBO (20, 40 and 60 minutes) respectively. There was no change in HR (99 +/- 7; 100 +/- 7; 99 +/- 8; 99 +/- 10). Significant increases were observed in CO (4.13 +/- 1.28; 4.95 +/- 1.38; 5.13 +/- 1.86; 5.18 +/- 1.57), FS (13.7 +/- 2.4; 15.4 +/- 2.8; 15.9 +/- 1.8; 16.1 +/- 2.0), and Emax (14.8 +/- 3.2; 16 +/- 3.6; 17.7 +/- 4.2; 17.6 +/- 4.2). A transient (20 minutes) increase followed by a decrease (40 and 60 minutes) occurred in EDP (26.3 +/- 4.2; 30.6 +/- 6.4; 24.6 +/- 5.6; 22.3 +/- 4.6), EDS (79.7 +/- 22.8; 91.7 +/- 29.6; 79 +/- 31; 63 +/- 17.3), and Kp (27.2 +/- 12.6; 60 +/- 26.7; 27.9 +/- 11.7; 28.1 +/- 11).

CONCLUSION

IBO has a beneficial effect on LV systolic and diastolic function as well as on contractility in patients with heart failure due to idiopathic dilated cardiomyopathy.

Mid-term results of heart transplantation, cardiomyoplasty, and medical treatment of refractory heart failure caused by idiopathic dilated cardiomyopathy

BACKGROUND

Heart transplantation is the surgical procedure of choice for treatment of refractory heart failure. However, it benefits a small number of patients because of the limited number of donors and selection criteria of recipients. Cardiomyoplasty is an alternative surgical procedure for heart failure. The aim of this investigation was to report our experience with heart transplantation, cardiomyoplasty, and clinical treatment of heart failure caused by idiopathic dilated cardiomyopathy.

METHODS

Ninety patients with refractory heart failure caused by idiopathic dilated cardiomyopathy were observed from May 1988 to March 1993. The patients had New York Heart Association functional class III or IV symptoms. The patients were divided in three groups according to the treatment received: heart transplantation (33 patients), cardiomyoplasty (25 patients), or medical treatment (32 patients). We studied the event-free curve, the New York Heart Association functional class, the left ventricular ejection fraction, and the morbidity of the groups in the follow-up of 19 +/- 16 months. We considered as an event death or crossover to another group because of severe symptoms.

RESULTS

The event-free rate in the cardiomyoplasty group was 92%, 88%, 79%, 74%, and 62% at 3, 9, 12, 18, and 24 months of follow-up, respectively. The event-free rate after heart transplantation was 82%, 78%, 82%, 75%, and 69% at 3, 9, 12, 18, and 24 months, respectively. The event-free rate in the medical treatment group was 78%, 65%, 61%, 48%, and 48% at 3, 9, 12, 18, and 24 months, respectively. All surviving patients in the heart transplantation group had functional class I symptoms. After cardiomyoplasty 90% of surviving patients had class I or II symptoms and 10% had class III symptoms. However, in the medical treatment group 27% of surviving patients had class I or II symptoms and 67% had class III or IV symptoms. In the cardiomyoplasty group left ventricular ejection fraction increased from 20% +/- 3% to 24.4% +/- 6.3% at 6 months (p < 0.05). In the heart transplantation group the left ventricular ejection fraction normalized, and the mean value of the left ventricular ejection fraction did not change in the medical treatment group. The need for endomyocardial biopsy and the incidence of rejection and infection were characteristics of the heart transplantation group.

CONCLUSIONS

In properly selected patients, cardiomyoplasty and heart transplantation seem to be associated with improvement in survival and functional class at mid-term follow-up. Heart transplantation was more effective than cardiomyoplasty for functional class improvement.

[Normal maximal functional capacity in patients with congestive heart failure due to Chagas' cardiomyopathy]

PURPOSE

To compare patients with heart failure due to Chagas' cardiomyopathy and maximal oxygen consumption greater than 20mL/kg-1/min-1 to normal individuals.

METHODS

We studied 104 male patients with heart failure due to Chagas' cardiomyopathy, functional classe II-IV, age 18 to 65 years (40.3 +/- 9.0), and 23 normal sedentary male individuals (GI) age 17 to 51 years (35 +/- 8.7). Maximal oxygen consumption (VO2max) was obtained using a Beckman metabolic measurement cart, and left ventricular ejection fraction (EF) by conventional transthoracic echocardiography. Comparisons between means were made with t-test.

RESULTS

Thirty seven patients (35.6%) presented VO2max above 20mL/kg-1/min-1 (G2), with values ranging from 20.5 to 30 (24.5 +/- 2.9) and EF between 19 and 63% (42 +/- 11.7). GI had VO2max between 21 and 42mL/kg-1/min-1 (33.3 +/- 5.6) and EF between 70 and 82% (75.1 +/- 3.2). Ages were not significantly different for the two groups (p = 0.1136). VO2max and EF were lower in G2, and this was statistically significant (p < 0.0001).

CONCLUSION

These results indicate that patients with congestive heart failure due to Chagas disease may show values of VO2max, greater than 20mL/kg-1/min-1 which does not mean that they have normal maximal functional capacity.

[Effects of rejection on the contractile reserve of the graft after heart transplantation]

PURPOSE

To test the hypothesis that rejection could affect the contractility and contractile reserve of left ventricle after heart transplantation.

METHODS

Echocardiographic parameters and noninvasive blood pressure end-systolic pressure (ESP), heart rate (HR), end diastolic (EDV) and end-systolic (ESV) volumes, ejection fraction (EF), end-systolic stress (ESS) and the end-systolic relation (ESS/ESV) were recorded in 68 studies in 11 patients, seven days-12 months after heart transplantation. Accordingly with the endomyocardial biopsies results were divided into two groups: group A-with no rejection (53 studies), and group B-with rejection (15 studies).

RESULTS

The nitroprusside infusion changed significantly and in the same way, all the parameters except the ESS/ESV ratio (A = 5.5 +/- 1.7 x B = 4.8 +/- 1.5 g/cm2/mL, p = NS); there was a decrease in ESP (A = 107 +/- 15 and B = 109 +/- 12 mmHg, p = NS), EDV (A = 68 +/- 19 and B = 81 +/- 12 mL, p = NS), ESV (A = 12 +/- 5 and B = 18 +/- 12 mL, p = NS) and ESS (A = 59 +/- 13 and B = 82 +/- 20g/cm2, p = NS); there was an increase in HR (A = 94 +/- 9 and B = 93 +/- 16bpm, p = NS) and EF (A = 83 +/- 5 and B = 79 +/- 8%, p = NS). In the dobutamine study it was observed differences for both groups, except for ESP (A = 156 +/- 26 and B = 149 +/- 26mmHg, p = NS). The increase in HR, EF and ESS/ESV ratio was greater in group A (HR-A = 117 +/- 19 and B = 102 +/- 25bpm, p < 0.05; EF-A = 91 +/- 4 and B = 78 +/- 11%, p < 0.05; ESS/ESV-A = 13.1 +/- 6 and B = 6.1 +/- 3.1 g/cm2/mL, p < 0.05). For group A it was smaller the EDV (57 +/- 18 x 94 +/- 35 mL, p < 0.05), ESV (5 +/- 3 x 24 +/- 20 mL, p < 0.05) and ESS (57 +/- 21 x 102 +/- 40 g/cm2, p < 0.05).

CONCLUSION

Rejection may not induce changes in resting left ventricular contractility, however, the contractile reserve is depressed during an episode of moderate to severe rejection.