Pedro Silva Cunha

Hospital de Santa Maria, Lisboa, Lisbon, Portugal

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Publications (27)13.87 Total impact

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    ABSTRACT: We report the case of a 52-year-old man who presented to our emergency department (ED) after three episodes of syncope in the seven hours before admission. During his stay in the ED he had recurrent ventricular tachycardia (VT) requiring external electrical cardioversion. A 12-lead electrocardiogram (ECG) showed a short QT (SQT) interval (270 ms, QTc 327 ms), with frequent R-on-T extrasystoles triggering sustained polymorphic VT. After exclusion of other precipitating causes, the patient was diagnosed as having SQT syndrome (SQTS) according to the Gollob criteria. To our knowledge, this is the first known documentation of an SQT-caused arrhythmic episode on a 12-lead ECG, as well as the first reported case of SQTS in Portugal. The patient received an implantable cardioverter-defibrillator and was discharged. At a follow-up assessment 14 months later he was symptom-free, interrogation of the device showed no arrhythmic events, and the ECG showed a QT interval of 320 ms (QTc 347 ms).
    Revista Portuguesa de Cardiologia. 10/2014; 33.
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    ABSTRACT: The demonstrated benefits of cardiac resynchronization therapy (CRT) in reducing mortality and hospitalizations for heart failure, improving NYHA functional class and inducing reverse remodeling have led to its increasing use in clinical practice. However, its potential contribution to complex ventricular arrhythmias is controversial.We present the case of a female patient with valvular heart failure and severe systolic dysfunction, in NYHA class III and under optimal medical therapy, without previous documented ventricular arrhythmias. After implantation of a CRT defibrillator, she suffered an arrhythmic storm with multiple episodes of monomorphic ventricular tachycardia (VT), requiring 12 shocks. Subsequently, a pattern of ventricular bigeminy was observed, as well as reproducible VT runs induced by biventricular pacing. Since no other vein of the coronary sinus system was accessible, it was decided to implant an epicardial lead to stimulate the left ventricle, positioned in the left ventricular mid-lateral wall. No arrhythmias were detected in the following six months. This case highlights the possible proarrhythmic effect of biventricular pacing with a left ventricular lead positioned in the coronary sinus venous system.
    06/2014;
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    ABSTRACT: The classic transvenous implantation of a permanent pacemaker in a pectoral location may be precluded by obstruction of venous access through the superior vena cava or recent infection at the implant site. When these barriers to the procedure are bilateral and there are also contraindications or technical difficulties to performing a thoracotomy for an epicardial approach, the femoral vein, although rarely used, can be a viable alternative. We describe the case of a patient with occlusion of both subclavian veins and a high risk for mini-thoracotomy or videothoracoscopy, who underwent implantation of a permanent single-chamber pacemaker via the right femoral vein.
    Revista Portuguesa de Cardiologia (English Edition). 06/2014;
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    ABSTRACT: Os benefícios demonstrados com a terapêutica de ressincronização cardíaca (TRC) na redução da mortalidade e hospitalização por ICC, melhoria da classe funcional e obtenção de remodelagem inversa em doentes selecionados com insuficiência cardíaca (ICC), têm contribuído para a crescente utilização destes dispositivos na prática clínica. No entanto, permanece controverso o impacto da TRC como fator causador de arritmias ventriculares complexas. Apresentamos o caso duma doente com cardiopatia valvular operada, disfunção sistólica grave e ICC classe III da NYHA, com terapêutica médica otimizada, sem documentação prévia de arritmias ventriculares significativas. Após implantação do sistema de TRC com cardioversor-desfibrilhador, desenvolveu quadro de tempestade arrítmica com múltiplos episódios de taquicardia ventricular monomórfica (TV) e necessidade de 12 choques, mantendo padrão de bigeminismo ventricular reprodutível e indução de salvas de TV pelo pacing biventricular. Dada a inacessibilidade a outra veia tributária do seio coronário foi decidido implantar elétrodo epicárdico em localização diferente (de veia póstero-lateral para posição lateral-mediana), sem registo de recorrência de arritmias num follow-up de seis meses. Este caso sugere que a TRC pode contribuir para um efeito pró-arrítmico com consequências clínicas potencialmente graves.
    Revista Portuguesa de Cardiologia (English Edition). 05/2014;
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    ABSTRACT: The classic transvenous implantation of a permanent pacemaker in a pectoral location may be precluded by obstruction of venous access through the superior vena cava or recent infection at the implant site. When these barriers to the procedure are bilateral and there are also contraindications or technical difficulties to performing a thoracotomy for an epicardial approach, the femoral vein, although rarely used, can be a viable alternative. We describe the case of a patient with occlusion of both subclavian veins and a high risk for mini‐thoracotomy or videothoracoscopy, who underwent implantation of a permanent single‐chamber pacemaker via the right femoral vein.
    Revista Portuguesa de Cardiologia. 01/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: The demonstrated benefits of cardiac resynchronization therapy (CRT) in reducing mortality and hospitalizations for heart failure, improving NYHA functional class and inducing reverse remodeling have led to its increasing use in clinical practice. However, its potential contribution to complex ventricular arrhythmias is controversial.We present the case of a female patient with valvular heart failure and severe systolic dysfunction, in NYHA class III and under optimal medical therapy, without previous documented ventricular arrhythmias. After implantation of a CRT defibrillator, she suffered an arrhythmic storm with multiple episodes of monomorphic ventricular tachycardia (VT), requiring 12 shocks. Subsequently, a pattern of ventricular bigeminy was observed, as well as reproducible VT runs induced by biventricular pacing. Since no other vein of the coronary sinus system was accessible, it was decided to implant an epicardial lead to stimulate the left ventricle, positioned in the left ventricular mid‐lateral wall. No arrhythmias were detected in the following six months. This case highlights the possible proarrhythmic effect of biventricular pacing with a left ventricular lead positioned in the coronary sinus venous system.
    Revista Portuguesa de Cardiologia. 01/2014;
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    ABSTRACT: Brugada syndrome is a rare syndrome, with an estimated prevalence in Europe of 1-5/10 000 population, whose initial clinical presentation can be sudden death. Although it has a characteristic electrocardiographic pattern, this can be intermittent. The authors present the case of a 32-year-old man, with no family history of syncope or sudden death, who went to the emergency department for syncope without prodromes. The initial electrocardiogram (ECG) in sinus rhythm documented an isolated and non-specific ST-segment elevation in V2. During further diagnostic studies, a repeat ECG revealed type 1 Brugada pattern. This pattern was later seen in a more marked form during a respiratory infection. The patient subsequently underwent electrophysiological study, followed by implantation of an implantable cardioverter-defibrillator (ICD), with an episode of ventricular fibrillation converted via ICD shock two months after implantation.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/2013; · 0.59 Impact Factor
  • Mário Oliveira, Pedro Silva Cunha, Nogueira da Silva
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    ABSTRACT: With a widening of indications for cardiac devices, especially in view of the clinical benefits of implantable cardioverter-defibrillators and cardiac resynchronization therapy, the number of patients with such devices is growing steadily. However, the resources required, and the need for long-term regular interrogation in dedicated clinics, represent a significant burden for already overstretched electrophysiology teams and hospital services. Remote telemonitoring is increasingly used for such follow-up, as it is a safe and effective alternative to conventional follow-up programs in outpatient clinics. This technology has been shown to be technically reliable, enabling early identification of device malfunction, arrhythmic events and heart failure decompensation, while reducing the risk of under-reporting, the number of outpatient clinic visits and hospitalizations due to cardiac events, and healthcare costs. Further studies are needed to determine how best to implement this new technology in a cost-effective manner, and what new legislation governing the use of remote monitoring in clinical practice may be required. In this article, we describe current systems, review the technical and clinical evidence in the literature regarding remote monitoring of implantable cardiac devices, and expand on outstanding questions.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 03/2013; 32(3):185–190. · 0.59 Impact Factor
  • Mário Oliveira, Pedro Silva Cunha, Nogueira da Silva
    [Show abstract] [Hide abstract]
    ABSTRACT: With a widening of indications for cardiac devices, especially in view of the clinical benefits of implantable cardioverter-defibrillators and cardiac resynchronization therapy, the number of patients with such devices is growing steadily. However, the resources required, and the need for long-term regular interrogation in dedicated clinics, represent a significant burden for already overstretched electrophysiology teams and hospital services. Remote telemonitoring is increasingly used for such follow-up, as it is a safe and effective alternative to conventional follow-up programs in outpatient clinics. This technology has been shown to be technically reliable, enabling early identification of device malfunction, arrhythmic events and heart failure decompensation, while reducing the risk of under-reporting, the number of outpatient clinic visits and hospitalizations due to cardiac events, and healthcare costs. Further studies are needed to determine how best to implement this new technology in a cost-effective manner, and what new legislation governing the use of remote monitoring in clinical practice may be required. In this article, we describe current systems, review the technical and clinical evidence in the literature regarding remote monitoring of implantable cardiac devices, and expand on outstanding questions.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 02/2013; · 0.59 Impact Factor
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    ABSTRACT: Cardiovascular disease is among the main causes of mortality and morbidity worldwide. Despite significant advances in medical and interventional therapy, the prognosis of conditions such as ischemic heart disease is still dismal. There is thus a need to investigate new therapeutic tools, one of which is stem cell therapy. Hematopoietic stem cells are the most studied type, and the fact that their biology is relatively well understood has led to their being used in preclinical research and clinical trials. However, the results of some of these studies have been controversial, which has opened the way for studies on other cell types, such as mesenchymal stem cells. These cells have immunomodulatory properties which suggest that they have therapeutic potential in cardiology. In the present article, the authors review the state of the art regarding mesenchymal stem cells, from basic and translational research to their use in clinical trials on ischemic heart disease, heart failure and arrhythmias, and discuss possible future uses.
    Revista Portuguesa de Cardiologia. 01/2013; 32(1):43–47.
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    ABSTRACT: Cardiovascular disease is among the main causes of mortality and morbidity worldwide. Despite significant advances in medical and interventional therapy, the prognosis of conditions such as ischemic heart disease is still dismal. There is thus a need to investigate new therapeutic tools, one of which is stem cell therapy. Hematopoietic stem cells are the most studied type, and the fact that their biology is relatively well understood has led to their being used in preclinical research and clinical trials. However, the results of some of these studies have been controversial, which has opened the way for studies on other cell types, such as mesenchymal stem cells. These cells have immunomodulatory properties which suggest that they have therapeutic potential in cardiology. In the present article, the authors review the state of the art regarding mesenchymal stem cells, from basic and translational research to their use in clinical trials on ischemic heart disease, heart failure and arrhythmias, and discuss possible future uses.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2012; · 0.59 Impact Factor
  • Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/2012; 31(4):321–322. · 0.59 Impact Factor
  • Revista Portuguesa de Cardiologia (English Edition). 04/2012; 31(4):321–322.
  • Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 03/2012; 31(4):321-2. · 0.59 Impact Factor
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    ABSTRACT: We report the case of a 59-year-old patient, with a history of severe chest trauma with rib fractures at the age of 20 and recent onset of fatigue and palpitations, who was diagnosed with atrial tachycardia, which was converted pharmacologically. Cor triatriatum or Ebstein's anomaly were suspected on initial imaging studies (transthoracic echocardiography and MRI).Due to recurrence of arrhythmia, he subsequently underwent repeat echocardiographic evaluation, which established a diagnosis of right atrial aneurysm. The arrhythmia was converted electrically. The patient has remained asymptomatic during 18 months of follow-up, without arrhythmia recurrence, medicated with carvedilol (after an initial period with amiodarone) and warfarin.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 03/2012; 31(3):237–239. · 0.59 Impact Factor
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    ABSTRACT: We report the case of a 59-year-old patient, with a history of severe chest trauma with rib fractures at the age of 20 and recent onset of fatigue and palpitations, who was diagnosed with atrial tachycardia, which was converted pharmacologically. Cor triatriatum or Ebstein's anomaly were suspected on initial imaging studies (transthoracic echocardiography and MRI). Due to recurrence of arrhythmia, he subsequently underwent repeat echocardiographic evaluation, which established a diagnosis of right atrial aneurysm. The arrhythmia was converted electrically. The patient has remained asymptomatic during 18 months of follow-up, without arrhythmia recurrence, medicated with carvedilol (after an initial period with amiodarone) and warfarin.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 01/2012; 31(3):237-9. · 0.59 Impact Factor
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    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2011; 30(12):937-8. · 0.59 Impact Factor
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    ABSTRACT: Background Cardiac resynchronization therapy (CRT) has significant benefits in selected patients (P). The impact of this modality in the incidence of ventricular tachyarrhythmias remains controversial. We analysed the occurrence of appropriate therapies in P submitted to CRT combined with a cardioverter-defibrillator (ICD).Methods Study of 123 P with left ventricular ejection fraction (LVEF) <35%, submitted to successful implantation of CRT-ICD or ICD alone (primary prevention).ResultsMean age was 63±12 years, LVEF of 25±6%, median follow-up of 372 days. CRT-ICD implanted in 63P (group A) and ICD alone in 60P (group B). Group A has 86% of clinical responders, lower prevalence of ischemic cardiomyopathy (30% vs. 72%), and more P in class III of the NYHA before device implantation (90% vs. 7%) compared with ICD alone patients. There were no differences in the incidence of appropriate therapies (19% vs. 12%) or in the time for first therapy (305 days vs. 293 days). Total mortality was 11% in group A and 12% in group B. Kaplan-Meier curves for arrhythmic events in patients with CRT showed no significant differences (HR 3.02, 95% CI 0.82 – 11.09, p=NS) when compared to patients without CRT.Conclusions In P submitted to CRT-ICD for primary prevention, despite a higher rate of responders, the incidence of appropriate therapies is not different from those with an ICD alone.
    Revista Portuguesa de Cardiologia. 11/2011; 30(11):823–828.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cardiac resynchronization therapy (CRT) has significant benefits in selected patients (P). The impact of this modality in the incidence of ventricular tachyarrhythmias remains controversial. We analysed the occurrence of appropriate therapies in P submitted to CRT combined with a cardioverter-defibrillator (ICD). Study of 123 P with left ventricular ejection fraction (LVEF) < 35%, submitted to successful implantation of CRT-ICD or ICD alone (primary prevention). Mean age was 63 +/- 12 years, LVEF of 25 +/- 6%, median follow-up of 372 days. CRT-ICD implanted in 63P (group A) and ICD alone in 60P (group B). Group A has 86% of clinical responders, lower prevalence of ischemic cardiomyopathy (30% vs. 72%), and more P in class III of the NYHA before device implantation (90% vs. 7%) compared with ICD alone patients. There were no differences in the incidence of appropriate therapies (19% vs. 12%) or in the time for first therapy (305 days vs. 293 days). Total mortality was 11% in group A and 12% in group B. Kaplan-Meier curves for arrhythmic events in patients with CRT showed no significant differences (HR 3.02, 95% CI 0.82 - 11.09, p = NS) when compared to patients without CRT. In P submitted to CRT-ICD for primary prevention, despite a higher rate of responders, the incidence of appropriate therapies is not different from those with an ICD alone.
    Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 10/2011; 30(11):823-8. · 0.59 Impact Factor
  • Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 05/2011; 30(5):559-63. · 0.59 Impact Factor