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ABSTRACT: Treadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations.
To determine: 1. the prevalence of IVG in a selected population of false positives on treadmill stress testing; 2. whether this prevalence is different from that described for non-selected populations; 3. whether patient characteristics are related to the presence of IVG; 4. the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure.
We evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05).
1. The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients. 2. This prevalence is significantly higher than that described for non-selected populations. 3. Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disesase/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG. 4. The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 06/2012; 31(7-8):485-92.
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Maria Salomé Carvalho,
Pedro de Araújo Gonçalves,
Hugo Marques,
Pedro Jerónimo De Sousa,
Rita Calé,
Helder Dores,
Daniel Ferreira,
Francisco Pereira Machado,
Ana Aleixo,
Miguel Mota Carmo, José Roquette
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ABSTRACT: Anomalous origin of coronary arteries represents a clinical challenge not only because of the anatomical variability, but also the possible functional consequences, pathophysiological mechanisms involved and the absence of large series in the literature that would provide evidence for clinical and therapeutic orientation. The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 05/2012;
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ABSTRACT: Cardiac CT provides noninvasive information on cardiac anatomy, particularly in coronary artery disease. However, exposure to radiation has been identified as a limitation of this exam. The aim of this study was to evaluate variations in radiation dose over time and to identify variables associated with use of higher radiation doses.
A prospective registry of 643 patients who underwent 64-slice dual source cardiac CT scan (Dual source CT--Somaton Definition, Siemens-Medical) during 2007 and 2008 was analyzed.
The sample was divided into quartiles according to the chronological order of the exams. There was a progressive reduction in median radiation dose in the quartiles analyzed (Q1: 8.9 [5.9-14.1], Q2: 6.6 [5.5-10.7], Q3: 6.4 [5.3-8.7], Q4: 6.1 [5.2-7.9] mSv), significant when the first quartile was compared with the others (p < 0.05). Along with this reduction, was a progressive increase in the use of a tube voltage of 100 kV (p < 0.001). Predictors of a higher radiation dose were higher body mass index, previous cardiac surgery, atrial fibrillation during acquisition, longer acquisition time and use of a tube voltage of 120 kV. When one or more of these variables were present (one third of the population), the radiation dose was significant higher (12.1 [9.5-14.8] vs. 5.7 [5.0-6.7] mSv, p < 0.001).
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2010; 29(11):1655-65.
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Nuno Cardim,
Júlia Toste,
Vanessa Carvalho,
Igor Nunes,
Daniel Ferreira,
Vanda Carmelo,
Ana S N Oliveira,
José Ferro,
Sylvie Mariana,
Adelaide Almeida,
Francisco P Machado, José Roquette
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ABSTRACT: Thromboembolism is a major cause of death in cancer patients. The association between paraneoplastic hypercoagulability of oncological patients and long-term central venous catheters (CVC) may result in CVC associated thrombosis. Patent Foramen Ovale (PFO), especially when associated with atrial septal aneurysm (ASA) is a risk factor for paradoxical embolism. We report a case of paradoxical embolism with stroke in an oncological patient with a huge CVC thrombus playing "ping-pong" with an hypermobile ASA with a PFO. We review the management of hypercoagulability in oncologic patients and discuss the potential role of routine transthoracic echocardiography before the implantation of long term central venous catheters to identify predisposing conditions to paradoxical embolism and select patients for anticoagulant therapy.
Cardiovascular Ultrasound 03/2010; 8:6. · 1.26 Impact Factor
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Nuno Cardim,
Júlia Toste,
Vanessa Carvalho,
Igor Nunes,
Daniel Ferreira,
Vanda Carmelo,
Ana Oliveira,
José Ferro,
Sylvie Mariana,
Adelaide Almeida,
Francisco Machado, José Roquette
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ABSTRACT: Abstract
Thromboembolism is a major cause of death in cancer patients. The association between paraneoplastic hypercoagulability of oncological patients and long-term central venous catheters (CVC) may result in CVC associated thrombosis. Patent Foramen Ovale (PFO), especially when associated with atrial septal aneurysm (ASA) is a risk factor for paradoxical embolism. We report a case of paradoxical embolism with stroke in an oncological patient with a huge CVC thrombus playing "ping-pong" with an hypermobile ASA with a PFO. We review the management of hypercoagulability in oncologic patients and discuss the potential role of routine transthoracic echocardiography before the implantation of long term central venous catheters to identify predisposing conditions to paradoxical embolism and select patients for anticoagulant therapy.
Cardiovascular Ultrasound. 01/2010;
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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 04/2009; 28(3):341-4.
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ABSTRACT: A 66-year-old female with Streptococcus viridans aortic and tricuspid infective endocarditis develops, during the course of antibiotic therapy, rupture of a right coronary sinus of Valsalva aneurysm to the right ventricle. An urgent cardiac surgery is preformed with implantation of a mechanical aortic prosthesis and a right coronary sinus plasty. Six months later a huge aortic pseudoaneurysm is diagnosed and she is submitted to a second uneventful surgery. A review is done for the significant features with discussion of diagnosis and therapy.
European Heart Journal – Cardiovascular Imaging 11/2006; 7(5):394-7. · 2.32 Impact Factor
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ABSTRACT: To identify the psychological factors that influence post-surgery pain perception in patients undergoing coronary artery bypass graft surgery (CABG).
This was an exploratory correlational study of 91 patients (71 men and 20 women) who underwent CABG (aortocoronary anastomosis) by sternotomy. Mean age was 63.8 + 9.6 years (between 39 and 84). The following instruments were used: visual analogical scales at 24, 48 and 96 hours of post-surgery; demographic characteristics survey; pain expectations scale; perceived support scale; self-efficacy scale, Mental Inventory (5 items); health perception scale; and satisfaction with treatment, doctors and nurses (American Pain Society questionnaire) at 96 hours after surgery.
Patients who had presented high expectations of pain, perceived more support, presented high levels of self-efficacy to deal with pain or were male, felt less pain. Furthermore, patients who presented better mental health, perceived their general health as being good, or expressed greater satisfaction with treatment, felt less pain. Pain was not influenced by age, level of education or satisfaction with doctors and nurses.
After the first 48 hours following surgery, the pain experience is influenced by psychosocial factors, in particular by expectation of pain and of self-efficacy, perceived support, perception of general and mental health, and satisfaction with pain treatment. The results confirm the need to bring together different kinds of knowledge for a broad, multidisciplinary approach to postoperative CABG pain treatment, focusing, along with other aspects, on management of patients' expectations.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2005; 24(10):1221-31.
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ABSTRACT: The case of a 43-year-old man with diabetes and alcoholism admitted to the emergency room with shock, fever, pleuritic chest pain and systemic symptoms is presented. Laboratory tests revealed anemia, leukocytosis, thrombocytopenia, high sedimentation rate and D-dimers, hypoxemia and hypocapnea. He also had sinus tachycardia, rSR' in V1 and an opacity on the periphery of the right pulmonary field. Blood and urine cultures were negative, as were serological markers. The echocardiogram showed a large mass adhering to the tricuspid valve, suggestive of myxoma. The patient underwent surgery, and anatomopathological examination of the mass showed it to be a bacterial vegetation, with no agent isolated. It is pointed out that differential diagnosis is difficult between a myxoma with systemic symptomatology associated with a possible pulmonary embolism, and tricuspid endocarditis with negative blood culture associated with a septic pulmonary embolism, which turned out to be the diagnosis in this patient.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 07/2005; 24(6):875-82.
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ABSTRACT: Left ventricular ejection fraction (LVEF) is accepted as an important prognostic marker in patients (pts) with implantable cardioverter-defibrillators (ICD). The impact of this therapeutic approach in the survival of pts with life-threatening arrhythmias and severe left ventricular dysfunction remains a matter of discussion.
To evaluate the long-term clinical implications of severe left ventricular dysfunction in pts with an ICD implanted for secondary prevention of sudden cardiac death (SD).
Out of 70 pts undergoing ICD implantation in our institution over four consecutive years, we studied 24 pts with LVEF <35% and a post-ICD follow-up of >12 months (87.5% male; age 62.79 years). The index arrhythmia was ventricular tachycardia in 19 cases and SD with ventricular fibrillation in 5 cases. The underlying disease was ischemic cardiomyopathy (n=19), dilated cardiomyopathy (n=4) and hypertensive heart disease (n=1). Mean LVEF at the time of implant was 25 +/- 7% (between 11% and 34%; NYHA class II/III in 83.3%). A du chamber system was implanted in 5 cases, and an ICD plus cardiac resynchronization pacing in 2 cases. There was no perioperative mortality. At the time of discharge, 71.2% of the pts were taking amiodarone and 66.7 % beta-blockers. During a 38 +/- 16-month follow-up (4 appointments/year), we analyzed the following parameters: rehospitalization for cardiovascular cause, appropriate ICD shocks, inappropriate detections/therapy, nonfatal major arrhythmic events (arrhythmic storm, therapeutic exhaustion, recurrent ventricular tachycardia), cardiac mortality, SD and total mortality. Results: Forty-five readmissions (1.9 +/- 2.3/pt) occurred in 14 pts (58%), 24.4% due to congestive heart failure. Appropriate ICD shocks (without hospitalization) occurred in 62.5% of the pts, 16.6% had inappropriate therapy (50% because of increased heart rate due to atrial fibrillation) and 37.5% suffered nonfatal major arrhythmic events. Death due to SD was 4.2%, cardiac mortality 12.5% and total mortality 25%.
Severe left ventricular dysfunction is common in ICD pts. During long-term follow-up, the majority of these pts receive appropriate ICD shocks, which emphasizes the importance of SD prevention in this population. The frequent documentation of supraventricular arrhythmias (causing inappropriate ICD therapy) and nonfatal major arrhythmic events also reflects the presence of a worse arrhythmic substrate in this subgroup. Despite the poor initial prognosis associated with ventricular tachyarrhythmias in pts with severe left ventricular dysfunction, ICD therapy may contribute to a better long-term clinical outcome.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/2005; 24(4):487-98.
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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 04/2004; 23(3):465-7.
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ABSTRACT: To assess the feasibility of performing pulmonary angiography using MRI with contrast enhancement in patients with pulmonary vascular disease.
We present our experience in ten individuals, two controls and eight patients who underwent the exam after injection of a gadolinium-based contrast agent on a 1 Tesla MR scanner using a time-of-flight sequence and breath-holding during injection of contrast.
Pathology in the main pulmonary artery and its major branches was detected easily while resolution at the segmental and subsegmental levels was inadequate.
Contrast-enhanced magnetic resonance pulmonary angiography is feasible on a 1 Tesla MR scanner for the study of pathology of the main pulmonary artery and its major branches, like massive pulmonary embolism. However its ability to detect and define distal vessel pathology as found in chronic thromboembolic pulmonary hypertension and small pulmonary emboli is limited.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 01/2004; 22(12):1471-6.
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ABSTRACT: Purpose: To assess the results obtained in very high-risk patients, which are those patients with an EUROSCORE greater than 13 points. Material and methods: From September 2001 to September 2003, thirty-three very high-risk patients were operated on in our department, which represents 1.6% of all the surgical activity during that period of time, being 17 male and 16 female, with an average of 69 years old (maximum 86 and minimum 32). Diagnosis includes: post infarction CIV 5, coronary insufficiency 11, aortic dissection 3, mitral prosthesis 3, valvular disease 9, aortic prosthesis disfunction 2. Fifteen patients underwent an emergency procedure, 12 were urgent and the remaining 6 were electively operated on. Results: Overall post-operative mortality was 12 patients (36%), being 6 emergent, 5 urgent and 1 elective patient. Patients who survived the operation had longer intensive care and hospital admission periods, which will be analyzed in detail. Conclusion: Surgery can be justified in very high risk patients. Despite the high perioperative mortality and longer periods of hospital stay, they will be otherwise condamned to death, if surgery would not be performed.
Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 02/2003; 10(4):169-170.
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ABSTRACT: To assess the safety and feasibility of transfer of patients requiring urgent cardiac surgery, from a hospital without onsite cardiac surgical facilities, after insertion of an intra-aortic balloon pump (IABP) to maintain clinical and hemodynamic stability, a retrospective review of all cardiac charactheterizations was performed. Sixty-two patients required IABPs, among whom 24 were transported to a surgical center from the outskirts of Lisbon to the city center in an ambulance accompanied by a physician, a nurse and paramedical personnel.
Patients who required hemodynamic support with IABPs usually had unstable angina with critical coronary lesions requiring immediate surgical intervention, hypotensive patients with mechanical complications after an AMI, and patients with AMI who did not receive thrombolytic therapy, and with coronary lesions not amenable to percutaneous coronary intervention. All patients reached the surgical center alive, and no patient had either hemodynamic or electrical instability during transport.
Surface transport of patients requiring emergency cardiac surgery after insertion of IABPs is safe, feasible and may provide circulatory and clinical stability in a subset of critically-ill patients.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2002; 21(10):1115-23.
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ABSTRACT: To assess the feasibility of performing high resolution reconstructed three-dimensional aortic angiography on a 1 Tesla magnetic resonance imaging scanner in patients with aortic diseases.
Seventeen patients underwent thirty-one MR exams that included fast spin echo, gradient echo and time-of-flight angiography acquisitions after administration of a commercially available gadolinium contrast agent injected as a bolus.
All scans were well tolerated and aortic lumen opacification was achieved at the appropriate time in all patients. The angiography scans were obtained with breath-held sequences that required approximately 25 seconds to scan and six to eight minutes to form a three-dimensional reconstruction.
Three-dimensional aortic angiography is feasible on a 1 Tesla scanner, with images of extremely high quality and resolution, achieved in a few minutes. It is possible to acquire all the information that conventional or fast spin echo provides from the reconstructed three-dimensional scans, avoiding the need for the cumbersome acquisition of the spin echo images, improving speed and decreasing imaging times, which may be of importance in patients with acute aortic syndromes.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 21(7-8):839-47.
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ABSTRACT: The authors report the clinical case of a 32 years old woman who suffered a spontaneous dissection of the common trunk, anterior descending, intermediary and circumflex coronary arteries, on the 6th post partum day. The diagnosis of acute myocardial infarction was made, through ECG and enzymatic studies and the patient was transferred to a Coronary Unit. Coronary angiography disclosed those lesions and the patient underwent a triple coronary bypass graft, under extracorporeal circulation. The post operative course was uneventful. Eight months after the operation she was found in good condition, free of symptoms and with a normal pattern of life.
Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 12(3):153-6.
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ABSTRACT: In this paper the authors proceed to a revision of the three main methods employed for cerebral protection in aortic arch surgery, namely the deep hypothermia and total circulatory arrest, the retrograde cerebral perfusion and the selective anterograde cerebral perfusion. After a deep analysis on their advantages and disadvantages, they proposed the utilization of an association of methods (integrated approach) that has proved to be extremely well succeed in their clinical practice, specially in high-risks patients.
Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 10(3):109-14.
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Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 10(2):91-2.
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José Roquette
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ABSTRACT: In this article the author evokes the figures of the past-presidents of the Portuguese Society for Cardio-Thoracic and Vascular Surgery, since its foundation, and enhances their qualities, regarded as examples for the new generations of cardio-thoracic and vascular surgeons in training. He approaches and describes the skills and personal requirements considered as essentials to be developed nowadays, by all those who dedicate their lives to those exciting and passionate surgical specialities.
Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 11(4):185-8.
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Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular 11(3):167.
