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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;
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ABSTRACT: We report the case of a man presenting with acute myocardial infarction and a history of percutaneous coronary intervention with implantation of a drug-eluting stent, which was now fractured. This case highlights the growing recognition of stent fracture as a potential mechanism for late stent thrombosis in the drug-eluting stent era. Following the case report, we review the literature on the incidence, contributing factors and clinical impact of stent fracture.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 02/2011; 30(2):213-21.
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Alexandra Toste,
Luísa Moura Branco,
Ana Galrinho,
Ana Lousinha, António Fiarresga,
Mário M Oliveira,
João Abreu,
João João Mendes,
Lurdes Ferreira,
Ana Leal,
Rui Cruz Ferreira
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ABSTRACT: Left ventricular noncompaction is a genetic disorder that is thought to be related to an arrest in endomyocardial development. It is characterized by the presence of a prominent trabecular meshwork and deep recesses. In order to better characterize this recently described disorder, whose prognosis remains unclear, we review eight cases diagnosed at our hospital, describing their clinical, electrocardiographic and echocardiographic features as well as therapy and follow-up. We also discuss the most relevant data from the literature concerning pathogenesis, clinical presentation, diagnostic criteria, therapy and prognosis.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 12/2010; 29(12):1847-64.
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ABSTRACT: The authors present the case of a 35-year-old woman admitted to her local hospital with right upper limb paresis, which led to a diagnosis of ischemic stroke, confirmed by brain magnetic resonance imaging (MRI). Investigation of the embolic source by transesophageal echocardiography (TEE) revealed a patent foramen ovale (PFO), with spontaneous right-to-left shunt. In May 2009 percutaneous closure of the PFO was performed with a BioSTAR bioabsorbable implant, under TEE and fluoroscopic control. Transthoracic echocardiography was performed one, three and six months after the procedure, and TEE was repeated after nine months, in each case showing correct implant positioning, with no residual leak. The patient has been asymptomatic since the stroke episode. The authors discuss the importance of bioabsorbable implants for PFO closure, and their advantages over the previously used permanent synthetic implants.
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):1737-42.
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Ruben Ramos,
Lino Patrício,
Luís Bernardes,
Duarte Cacela,
Lídia Sousa, António Fiarresga,
José Maria Gonçalves,
Alexandra Toste,
Ana Lousinha,
José Alberto Oliveira,
Lurdes Ferreira,
Valeska Andreozzi,
Rui Cruz Ferreira
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ABSTRACT: Primary angioplasty is accepted as the preferred treatment for acute myocardial infarction in the first 12 hours. However, outcomes depend to a large extent on the volume of activity and experience of the center. Continuous monitoring of methods and results obtained is therefore crucial to quality control.
To describe the demographic, clinical and angiographic characteristics as well as in-hospital outcomes of patients undergoing primary PCI in a high-volume Portuguese center. We also aimed to identify variables associated with in-hospital mortality in this population.
This was a retrospective registry of consecutive primary PCIs performed at Santa Marta Hospital between January 2001 and August 2007. Demographic, clinical, and angiographic characteristics and in-hospital outcomes were analyzed. Independent predictors of in-hospital mortality were identified by multivariate logistic regression analysis.
A total of 1157 patients were identified, mean age 61+/-12 years, 76% male. Mean pain-to-balloon time was 7.6 hours and primary angiographic success was 88%. Overall in-hospital mortality was 6.9%, or 5.5% if patients presenting in cardiogenic shock were excluded from the analysis. Previous history of heart failure, cardiogenic shock on admission, invasive ventilatory support, major hemorrhage, and age over 75 years were found to be associated with increased risk of in-hospital death. Conclusions: In this center primary PCI is effective and safe. Angiographic success rates and in-hospital mortality and morbidity are similar to other international registries. Patients at increased risk for adverse outcome can be identified by simple clinical characteristics such as advanced age, cardiogenic shock on admission, mechanical ventilation and major hemorrhage during hospitalization.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 10/2009; 28(10):1063-84.
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ABSTRACT: Treatment of acute coronary syndromes (ACS) has changed considerably in the last few years, as reflected in various proposals for guidelines by the ACC/AHA/ESC based on clinical evidence. We analyzed the clinical implementation of these recommendations in our patient population between 2002 and 2005.
This was a retrospective study of 368 patients admitted in 2002 and 420 patients admitted in 2005 for ACS (with and without ST-segment elevation). We analyzed clinical characteristics and treatment strategies.
There were no differences in terms of age, gender ratio, risk factors for coronary artery disease, or previous myocardial revascularization. There was a decrease in the number of patients with previous myocardial infarction and renal insufficiency on admission, and an increase in patients with ST-segment elevation on admission. Treatment with clopidogrel (6% vs. 87%), beta-blockers (54% vs. 79%), angiotensin-converting enzyme inhibitors (72% vs. 84%) and statins (78% vs. 91%) increased (all with p < 0.001). On the other hand, there was a slight decrease in the use of aspirin (98% vs. 95%, p = 0.039) (with greater use of clopidogrel) and ticlopidine was no longer used (46% vs. 0%, p < 0.001). Use of glycoprotein IIb/IIIa receptor antagonists did not change significantly (66% vs. 67%, p = NS). Percutaneous coronary interventions increased (53% vs. 67% p < 0.001). There was no difference in in-hospital mortality (8.2% vs. 6.4%) or 30-day mortality (9.0% vs. 8.6%), but mortality was lower at one-year follow-up (17.1% vs. 11.7%, p = 0.039). Statins and beta-blockers are independent predictors of mortality during follow-up, with a protective effect.
Between 2002 and 2005, treatment of ACS improved significantly according to existing guidelines, leading to improvement in medium-term mortality.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 07/2008; 27(6):803-12.
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ABSTRACT: To evaluate whether NT-proBNP levels are associated with resting hemodynamic parameters assessed by thoracic electrical bioimpedance (TEB) in patients with chronic heart failure (CHF).
We studied 55 consecutive patients with dilated cardiomyopathy and CHF--42 male, aged 50.3 +/- 13.5 years, 39% ischemic, 36% in NYHA functional class III and 9% in class IV, left ventricular ejection fraction 24.7 +/- 8.2%, 85% in sinus rhythm. After 15 minutes of rest, NT-proBNP was obtained and TEB studies were performed (BioZ ICG Monitor, CardioDynamics; mean of 20 minutes acquisition). Thoracic fluid content (TFC) is a TEB parameter that shows a good correlation with pulmonary capillary wedge pressure.
NT-proBNP levels ranged from 42 to 12983 pg/ml (mean = 2505.8, SD = 2608.0, median = 1545). The correlations obtained presented in the table.
In patients with CHF resting NT-proBNP levels correlate with SVI, LCWI and TFC assessed by TEB, the strongest correlation being with TFC.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2007; 26(10):1021-8.
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Rita Marín Fernandes,
Luísa Moura Branco,
Ana Galrinho,
Ana Teresa Timóteo,
Anabela Tavares,
Joana Feliciano,
Ricardo Oliveira, António Fiarresga,
Andreia Mamede,
Nuno Banazol,
Jose Roquette,
Rui Cruz Ferreira
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ABSTRACT: Caseous calcification of the mitral annulus is a rare form of mitral annular calcification, whose etiology is not completely understood and which can lead to an erroneous diagnosis of intracardiac tumor. The authors describe the cases of six patients, five of them female, mean age 74.8 +/- 6.4 years (65-81). Four patients presented with heart failure, two with atrial fibrillation and five with hypertension. Round, echogenic images, 18-26 mm in their largest diameter with a central echolucent area, were identified by transthoracic echocardiography on the lateral and posterior segments of the mitral annulus. Severe mitral regurgitation was also found in four patients. Only three patients with severe mitral regurgitation and heart failure were operated on, and one patient refused surgical treatment. A caseous mass, similar to toothpaste, was obtained from the mitral annulus zone during surgery.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2007; 26(10):1059-70.
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ABSTRACT: Microvolt T-wave alternans (TWA) have been accepted as a tool for assessing vulnerability to ventricular tachyarrhythmias. There is lack of data concerning prospective temporal variations in TWA measurements after acute myocardial infarction (AMI). We analysed the temporal patterns of TWA in post-AMI patients.
TWA tests were performed <1 month (TWA_early) and 6 months (TWA_late) after AMI in 51 consecutive patients treated with successful percutaneous coronary intervention (PCI). Twenty seven patients (53%) had anterior wall infarctions and 24 (47%) had inferior/lateral wall infarctions. TWA was measured during a treadmill manual exercise protocol and defined as positive, negative and indeterminate. Group A included patients with TWA negative in both tests and Group B included those with TWA abnormal (positive or indeterminate) at first or second determinations. TWA_early was negative, positive and indeterminate in 38 (74.6%), 8 (15.6%) and 5 (9.8%) patients, respectively, whereas TWA_late was negative, positive and indeterminate in 30 (58.9%), 14 (27.4%) and 7 (13.7%) patients, respectively. TWA_early was classified as normal in 74.6% and abnormal in 25.4% of the cases, and TWA_late was normal in 58.9% and abnormal in 41.1%. TWA tests were concordant in 36 patients (70.6%) and discordant 15 patients (29.4%). At TWA_late, 10 patients (19.6%) changed from TWA negative to TWA abnormal and 4 patients (7.8%) from TWA abnormal to TWA negative. After TWA_early+TWA_late, 45% of the patients had 1 test classified as abnormal. Left ventricular ejection fraction was <50% in 22% of Group A and 52% of Group B (P = 0.037).
In the era of primary PCI, temporal changes in TWA measurements may occur frequently during the first 6 months post-AMI. These findings should be considered in risk stratification strategies following AMI.
Annals of Noninvasive Electrocardiology 04/2007; 12(2):98-103. · 1.10 Impact Factor
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ABSTRACT: Isolated anterior mitral leaflet cleft (not associated with atrio-ventricular septal defect) is a rare cause of congenital mitral regurgitation, and the treatment consists of direct suturing of the cleft. We present a clinical case with this entity.
European Heart Journal – Cardiovascular Imaging 02/2007; 8(1):59-62. · 2.32 Impact Factor
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ABSTRACT: Conventional risk stratification after acute myocardial infarction is usually based on the extent of myocardial damage and its clinical consequences. However, nowadays, more aggressive therapeutic strategies are used, both pharmacological and invasive, with the aim of changing the course of the disease.
To evaluate whether the number of drugs administered can influence survival of these patients, based on recent clinical trials that demonstrated the benefit of each drug for survival after acute coronary events.
This was a retrospective analysis of 368 consecutive patients admitted to our ICU during 2002 for acute coronary syndrome. A score from 1 to 4 was attributed to each patient according to the number of secondary prevention drugs administered--antiplatelets, beta blockers, angiotensin-converting enzyme inhibitors and statins--independently of the type of association. We evaluated mortality at 30-day follow-up.
Mean age was 65 +/- 13 years, 68% were male, and 43% had ST-segment elevation acute myocardial infarction. Thirty-day mortality for score 1 to 4 was 36.8%, 15.6%, 7.8% and 2.5% respectively (p < 0.001). The use of only one or two drugs resulted in a significant increase in the risk of death at 30 days (OR 4.10, 95% CI 1.69-9.93, p = 0.002), when corrected for other variables. There was a 77% risk reduction associated with the use of three or four vs. one or two drugs. The other independent predictors of death were diabetes, Killip class on admission and renal insufficiency.
The use of a greater number of secondary prevention drugs in patients with acute coronary syndromes was associated with improved survival. A score of 4 was a powerful predictor of mortality at 30-day follow-up.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 12/2006; 25(12):1109-18.
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ABSTRACT: It is accepted that the timing of myocardial revascularization in patients undergoing PTCA for the treatment of acute myocardial infarction (AMI) may improve the clinical outcome. However, its impact on microvolt T-wave alternans (TWA), a recognized tool for assessing vulnerability to ventricular tachyarrhythmias that can cause sudden cardiac death in infarction survivors, remains unknown.
To analyze TWA in patients with AMI treated by PTCA and assess whether the timing of myocardial revascularization can influence TWA measurements.
We studied 79 patients (67 male; 57 +/- 11 years) who underwent successful PTCA for the treatment of AMI. The presence of TWA was assessed using a HearTwave system (Cambridge Heart, Inc.) within 30 days of AMI. Orthogonal Frank XYZ leads and associated vector magnitude (microvolt alternans sensors) and 7 standard ECG leads were recorded during a treadmill manual exercise protocol to increase heart rate slowly to approximately 110 bpm. TWA was considered positive if the sustained alternans microvoltage was > or = 1.9 microV at heart rates of > 100 bpm, negative if the criteria for positivity were not met while maintaining heart rate at > or =105 bpm (maximum negative heart rate), and inconclusive if it could not be definitively classified as either positive or negative. Patients were excluded if they had atrial fibrillation, > 10 extrasystoles/min, bradycardia 40 beats/min, wide QRS complex, congestive heart failure or implanted pacemaker, or were under antiarrhythmic therapy. The presence of positive or inconclusive TWA (non-negative TWA) was considered a risk marker for the occurrence of life-threatening ventricular arrhythmias. TWA results were compared between the group of patients who underwent PTCA within 24h of AMI (early PTCA; n=45) and those treated >24h after hospital admission (late PTCA; n=34).
TWA was positive in 16 patients (20.2%), negative in 56 (70.9%) and inconclusive in 7 (8.9%). Overall, TWA was non-negative in 29.1% of the patients. In the early PTCA group, TWA was non-negative in 9 patients (20%) (6 positive and 3 inconclusive) and negative in 36 (80%). In the late PTCA group, TWA was non-negative in 14 patients (41%) (10 positive and 4 inconclusive) and negative in 20 (59%) (p < 0.05). There were no differences in left ventricular ejection fraction between the two groups. No spontaneous ventricular arrhythmias, syncope or deaths were recorded in the first 60 days after hospital discharge. Five patients (7%) were re-admitted with angina.
In a population of AMI survivors: a) the prevalence of non-negative TWA was 25%, despite myocardial revascularization by PTCA; b) PTCA performed within 24h of onset of AMI significantly reduced the number of patients with non-negative TWA, suggesting a lower arrhythmic risk. These findings should be investigated in larger studies.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/2006; 25(4):379-87.
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ABSTRACT: We present the case of a patient evaluated for a continuous murmur, in which a ruptured congenital sinus of Valsalva aneurysm with fistulization to the right atrium was demonstrated by echocardiography. The authors review the relevant clinical features of this entity.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 02/2006; 25(1):79-85.
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ABSTRACT: Renal insufficiency (RI) is associated with higher morbidity and mortality in patients (P) with coronary artery disease and in P submitted to angioplasty. In ST-segment elevation acute myocardial infarction (STEAMI), this impact has not been well demonstrated.
To evaluate the impact of RI in P with STEAMI.
We evaluated 160 P admitted with STEAMI, mean age of 62+/-14 years, 76% male. We determined creatinine levels on admission. RI was defined as a level >1.5 mg/dl. Analysis of clinical, electrocardiographic and laboratory variables was performed, in relation to the endpoint defined as the occurrence of death at 30-day follow-up.
There were 16 deaths (10%) at 30-day follow-up. P with RI (n=21) were older (68+/-11 vs 61+/-14 years, p<0.001), more often had diabetes (57 vs 24 %, p=0.004) and presented more often with Killip class > or =2 (57 vs 12%, p<0.001). The use of statins (62 vs 83%, p=0.05) and beta-blockers (24 vs 65%, p<0.001) was lower in P with RI. Mortality was higher in RI P (62 vs 2%, p<0.001). The univariate predictors of death were age > or =75 years, diabetes, Killip class > or =2 on admission, RI, non-use of statins and beta-blockers and use of diuretics. In multivariate analysis, independent predictors of death at 30 days were RI (HR 29.6, 95% CI 6.3-139.9, p<0.001) and non-use of beta-blockers (HR 0.13, 95% CI 0.02-1.01, p=0.01).
In P admitted for STEAMI, the presence of RI was an independent predictor of death at 30 days whereas the usage of beta-blockers was protective.
Kardiologia polska 10/2005; 63(4):373-8; discussion 379-80. · 0.51 Impact Factor
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ABSTRACT: The therapeutic approach to severe pulmonary arterial hypertension (PAH), whether primary or secondary to connective tissue disorders, thromboembolic phenomena or congenital heart disease with Eisenmenger syndrome, has evolved in recent years following the introduction of selective pulmonary vasodilators, including prostacyclin analogs and endothelin receptor antagonists.
To correlate three different endpoints (6-minute walk test, Tei index and peak tricuspid regurgitation velocity by Doppler echocardiographic study) during follow-up of PAH patients under selective vasodilator therapy.
Eleven patients (9 female, age 42 +/- 18 years) with severe PAH (> or = 65 mmHg), 64% with Eisenmenger syndrome, in NYHA class > or = II, were assessed during a follow-up of 11 +/- 8 months. Eight patients were already under therapy with iloprost or bosentan.
There was no correlation between the three endpoints before and after therapy as assessed by Pearson's correlation coefficient. There was, however, an improvement in all of them after selective vasodilatory therapy.
Therapeutic response can be accurately measured by the traditional endpoint (6-minute walk test) or by echocardiographic endpoints. However, the lack of correlation between them excludes their use as alternatives in patient follow-up.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 03/2005; 24(3):399-404.
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ABSTRACT: There is some controversy about the ideal type of revascularization in the context of primary angioplasty (percutaneous coronary intervention--PCI) for acute myocardial infarction (AMI). The presence of additional stenosis, especially if complex, can have an impact on prognosis.
To evaluate medium-term (1-year) prognosis according to the presence of complex additional stenosis after primary PCI.
A retrospective study of 138 consecutive patients admitted to our unit for ST-segment elevation AMI who underwent primary PCI. Patients were followed up for 1 year and divided in 2 groups: without complex additional stenosis (n = 69, 61 +/- 14 years, 62% males) and with complex additional stenosis (n = 69, 65 +/- 13 years, 73% males, p = NS). We evaluated demographic characteristics, risk factors for coronary artery disease, previous cardiac history and signs of heart failure on admission. Angiographic characteristics, medication and PCI outcome were also evaluated. The impact of these variables on the combined end-point of death, reinfarction, and myocardial revascularization at 1 year was assessed.
The angiographic success rate was 96.4%. Twenty-four percent of patients were aged 75 years or over and 4.3% of the total population were in Killip class IV on admission. Anterior AMI was slightly more common in the non-complex additional stenosis group (60% vs. 44%, p = 0.06), and inferior AMI in the complex additional stenosis group (26% vs. 42%, p = 0.07). One-vessel disease was more prevalent in the group without complex additional stenosis, as expected (86% vs. 11%, p < 0.001) and stent implantation was also more frequent in this group (96% vs. 86%, p = 0.08). There were no differences in other variables. Death/reinfarction/revascularization was more frequent in the group with complex additional stenosis (13% vs. 32%, p = 0.014). Sixty-seven per cent of the events occurred in the first 30 days of follow-up. At 1 year, univariate predictors of outcome were Killip class > or = 2, TIMI flow < 3 in the infarct-related vessel after PCI, non-use of glycoprotein IIb/IIIa receptor antagonists, beta-blockers or statins, multivessel disease, and the presence of complex additional stenosis (log rank, p = 0.003). Using multivariate regression analysis, the independent predictors of outcome at 1 year were Killip class > or = 2 (OR 0.28; 95% CI 0.08-0.93, p = 0.037) and the presence of complex additional stenosis (OR 0.32; 95% CI 0.12-0.84, p = 0.020).
The presence of complex additional stenosis after primary PCI had a worse prognosis at 1 year, suggesting the need for further interventions to stabilize the plaque, particularly in the first 30 days after AMI.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 06/2004; 23(6):853-64.
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ABSTRACT: We present the case of a sixty-two-year-old man evaluated for a dyspnea episode. Echocardiographic study revealed a tumor in the right atrium that was related to a right kidney neoplasm. Complete resection was possible with a combined thoracic and abdominal approach. Pathological study indicated a renal cell carcinoma.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 24(7-8):997-1003.
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ABSTRACT: A better understanding of the characteristics of patients that come to the anticoagulation (AC) clinic of a tertiary hospital could lead to better healthcare provision and reduce the number of thromboembolic and bleeding complications.
To evaluate the characteristics of patients followed at our AC clinic and to determine which factors could predict an increased risk of complications.
Data obtained by doctors through a questionnaire from patients attending the AC clinic of our hospital were analyzed. Demographic characteristics (gender, age, literacy, educational level), classical coronary artery disease (CAD) risk factors, the diagnosis that led to oral anticoagulation therapy (OAT) and its duration, the number of INR determinations, the minimum, maximum and current INR value and complications of OAT were studied. Complications were defined as bleeding and/or thromboembolic events occurring during the course of OAT.
Of the 101 patients enrolled, 74 were female (73.3%), with a mean age of 6410 years (21-85). This population had had 4.53.5 years of schooling and there was a 15% incidence of illiteracy. The main reason for OAT was mechanical valve prosthesis implantation (56.4%). Each patient had an average of one CAD risk factor. The mean number of months of OAT was 99.489 (1-360). Sixty-six patients (65.3%) knew the reason for the therapy. Each patient had 1.20.6 INR determinations per month. Forty-five patients had bleeding and/or thromboembolic complications during OAT. There were 50 bleeding complications in 41 patients, seven leading to hospital admission. There were 7 thromboembolic events (central or peripheral), in 7 patients. The patients were divided into two groups: group I--with complications (GI) and group II--without complications (GII). There were 45 patients in GI, mean age 63.59.1 years (39-80), and 56 patients in GII, mean age 64.711.3 years (21-85). A greater number of complications were found in patients with mitral valve mechanical prostheses (GI--60.6%; GII--9.4%; p = 0.024). More complications were also found in patients with recommended maximum INR >3 (GI--55.2; GII--44.8; p = 0.013) and in those who had undergone dental procedures (GI--68.3%; GII--31.7; p < 0.001). The duration of OAT had the greatest predictive value for the development of complications (GI--138.196.5 months; GII--67.868.2 months; p < 0.00005). Multivariate analysis identified OAT duration as the only independent predictive factor.
The high percentage of illiteracy found in this observational study could have hindered understanding of this sometim&e complex therapy. However, in our study this was not a significant predictor of complications. The predictive factors for bleeding and/or thromboembolic complications during OAT were the duration of therapy, the recommended maximum INR value and dental procedures. After multivariate analysis only the first variable was shown to be significant in this context.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 24(7-8):957-68.
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Ruben Ramos,
Luísa Branco,
Ana Agapito,
José Alberto Oliveira,
Lídia Sousa,
Ana Galrinho, António Fiarresga,
Alexandra Toste,
Ana Lousinha,
Mário Oliveira,
J Nogueira Da Silva,
Rui Cruz Ferreira
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ABSTRACT: Adults with repaired tetralogy of Fallot (TOF) may be at risk for progressive right ventricular (RV) dilatation and dysfunction, which is commonly associated with arrhythmic events. In frequently volume-overloaded patients with congenital heart disease, tissue Doppler imaging (TDI) is particularly useful for assessing RV function. However, it is not known whether RV TDI can predict outcome in this population.
To evaluate whether RV TDI parameters are associated with supraventricular arrhythmic events in adults with repaired TOF.
We studied 40 consecutive patients with repaired TOF (mean age 35 +/- 11 years, 62% male) referred for routine echocardiographic exam between 2007 and 2008. The following echocardiographic measurements were obtained: left ventricular (LV) ejection fraction, LV end-systolic volume, LV end-diastolic volume, RV fractional area change, RV end-systolic area, RV end-diastolic area, left and right atrial volumes, mitral E and A velocities, RV myocardial performance index (Tei index), tricuspid annular plane systolic excursion (TAPSE), myocardial isovolumic acceleration (IVA), pulmonary regurgitation color flow area, TDI basal lateral, septal and RV lateral peak diastolic and systolic annular velocities (E' 1, A' 1, S' 1, E' s, A' s, S' s, E' rv, A' rv, S' rv), strain, strain rate and tissue tracking of the same segments. QRS duration on resting ECG, total duration of Bruce treadmill exercise stress test and presence of exercise-induced arrhythmias were also analyzed. The patients were subsequently divided into two groups: Group 1--12 patients with previous documented supraventricular arrhythmias (atrial tachycardia, fibrillation or flutter) and Group 2 (control group)--28 patients with no previous arrhythmic events. Univariate and multivariate analysis was used to assess the statistical association between the studied parameters and arrhythmic events.
Patients with previous events were older (41 +/- 14 vs. 31 +/- 6 years, p = 0.005), had wider QRS (173 +/- 20 vs. 140 +/- 32 ms, p = 0.01) and lower maximum heart rate on treadmill stress testing (69 +/- 35 vs. 92 +/- 9%, p = 0.03). All patients were in NYHA class I or II. Clinical characteristics including age at corrective surgery, previous palliative surgery and residual defects did not differ significantly between the two groups. Left and right cardiac chamber dimensions and ventricular and valvular function as evaluated by conventional Doppler parameters were also not significantly different. Right ventricular strain and strain rate were similar between the groups. However, right ventricular myocardial TDI systolic (Sa: 5.4+2 vs. 8.5 +/- 3, p = 0.004) and diastolic indices and velocities (Ea, Aa, septal E/Ea, and RV free wall tissue tracking) were significantly reduced in patients with arrhythmias compared to the control group. Multivariate linear regression analysis identified RV early diastolic velocity as the sole variable independently associated with arrhythmic history (RV Ea: 4.5 +/- 1 vs. 6.7 +/- 2 cm/s, p = 0.01). A cut-off for RV Ea of < 6.1 cm/s identified patients in the arrhythmic group with 86% sensitivity and 59% specificity (AUC = 0.8).
Our results suggest that TDI may detect RV dysfunction in patients with apparently normal function as assessed by conventional echocardiographic parameters. Reduction in RV early diastolic velocity appears to be an early abnormality and is associated with occurrence of arrhythmic events. TDI may be useful in risk stratification of patients with repaired tetralogy of Fallot.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 29(7-8):1145-61.
