[Initial experience in percutaneous closure of interatrial communication with the amplatzer device]

PURPOSE

To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder.

METHODS

Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8.7 to 20 mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure.

RESULTS

Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects.

CONCLUSION

The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.

[Coronary arteriography with a very low profile catheter: efficacy and safety of the procedure and of the 60 minute hospital discharge]

PURPOSE

To evaluate the feasibility, efficacy and safety of the use of 4F Judkins catheters for coronary angiography.

METHODS

From August/95 to January/96, 70 patients with suspected coronary artery disease underwent coronary cineangiography by the Judkins technique, with 4F catheters. Following puncture of the right femoral artery, 4F sheaths were introduced. At the end of the procedure, the sheath was removed and manual compression was applied for 15 min. Patients were oriented to walk under specialized supervision, 60 min after the procedure, and discharged after 4h.

RESULTS

Thirty nine (56%) patients were male, the age ranged from 31 to 83 (mean 57) years and weight from 43 to 101 (mean 69) kg. Optimal quality images were obtained in 62 patients (88%). It was necessary to use larger caliber catheters (6 and 8F) in 8 patients, due to femoral tortuosity or inadequate opacification of coronary arteries. There were no vascular complications nor major bleedings. In only 2 cases (3%) there was a minor bleeding, treated by new local compression. Sixty (85%) patients walked after 60 +/- 5 min and were discharged after 4h.

CONCLUSION

The use of 4F catheters for coronary angiography by femoral approach allowed early deambulation with no major bleeding. Image quality was good, with little contrast used and short hospital stay. This technique may lead to a simpler less traumatic and less invasive coronary angiography.

Flow visualization studies to improve the spiral pump design

The spiral pump (SP) uses centrifugal and axial pumping principles simultaneously, through a conical shaped impeller with threads in its surface. Flow visualization studies were performed in critical areas of the SP. A closed circuit loop was filled with glycerin-water solution (40%). Amberlite particles (80 mesh) were illuminated by a planar helium-neon laser light (7 mW). The particle velocities were recorded with Kodak (TMAX-400) black and white film, and the flow behavior was studied with a micro video camera and color video printer. The flow visualization studies showed no turbulence or stagnant areas in the inlet and outlet ports of the SP. When using the impeller with one lead, at the top of the threads some recirculation appeared when the total pressure head increased. Two new impellers were made. One of them had the same conical shape with a thread having 2 leads. The second had a thread with 2 leads, but it also had a bigger cone angle. These modifications improved the pump hydrodynamic performance, decreasing the recirculation in pumping conditions that require pressures over 200 mm Hg.

[Influence of the clinical presentation on immediate and long-term results after rotational atherectomy]

PURPOSE

To analyse the influence of unstable coronary syndromes (UCS) in the early and late prognosis after rotational atherectomy (RA).

METHODS

We treated 236 patients with RA between Aug/1992 and May/1996. Patients were divided into two groups: A) stable coronary syndromes 120 (51%) patients; B) UCS: 116 (49%) patients.

DEFINITIONS

1) procedure success (PS)--lesion success in all locations were RA use was attempted, without a major complication; 2) late coronary events (LCE)--angina, MI, additional revascularization or death.

RESULTS

There was a significant predominance of age > 70 (A = 14% x B = 24%, p = 0.03) in B and previous MI (A = 32% x B = 11%, p = 0.0001) in A. Other characteristics were similar in both groups, including complex lesions (type B2/C), which were observed in 77% A stenosis and 80% B lesions. PS was 95% in A and 92% in B (p = NS). In-hospital major complications were observed in 2.5% A and 4.3% B patients, (p = NS). One patient died in each group. A and B patients had similar time of follow-up. LCE occurred in 25% A and 39% B patients (p = 0.002). Recurrence of angina (36% x 23%; p = 0.01) and target lesion revascularization (29% x 18%; p = 0.03) were also more frequently required in B cases.

CONCLUSION

This study suggests that UCS (group A) does not implicate in worse acute results after RA. However, UCS patients present greater incidence of late coronary events, particularly recurrence of angina and target-lesion revascularization.

Characteristics of a blood pump combining the centrifugal and axial pumping principles: the spiral pump

Two well-known centrifugal and axial pumping principles are used simultaneously in a new blood pump design. Inside the pump housing is a spiral impeller, a conically shaped structure with threads on the surface. The worm gears provide an axial motion of the blood column through the threads of the central cone. The rotational motion of the conical shape generates the centrifugal pumping effect and improves the efficiency of the pump without increasing hemolysis. The hydrodynamic performance of the pump was examined with a 40% glycerin-water solution at several rotation speeds. The gap between the housing and the top of the thread is a very important factor: when the gap increases, the hydrodynamic performance decreases. To determine the optimum gap, several in vitro hemolysis tests were performed with different gaps using bovine blood in a closed circuit loop under two conditions. The first simulated condition was a left ventricular assist device (LVAD) with a flow rate of 5 L/min against a pressure head of 100 mm Hg, and the second was a cardiopulmonary bypass (CPB) simulation with a flow rate of 5 L/min against 350 mm Hg of pressure. The best hemolysis results were seen at a gap of 1.5 mm with the normalized index of hemolysis (NIH) of 0.0063 +/- 0.0020 g/100 L and 0.0251 +/- 0.0124 g/100 L (mean +/- SD; n = 4) for LVAD and CPB conditions, respectively.

[The percutaneous closure of patent ductus arteriosus with the Rashkind technic. The initial experience of the Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil]

The authors report their experience with the percutaneous closure of the patent ductus arteriosus with the Rashkind technique. They performed 42 procedures with a success of 97.6% and one embolization episode. The mean age was 8.7 +/- 6.7 years, the mean weight was 25.0 +/- 15.8 Kg and the minimum diameter of the ductus was 4.0 +/- 1.3 mm. The immediate overall prevalence of residual shunt was 48.8% falling to 21% in a mean follow-up of 17 +/- 13 months in 29 cases. Two patients underwent late reocclusion: one with a new umbrella and the other with a coil. Another patient had an immediate severe residual shunt and it was reoccluded in the same procedure with a coil. The anatomical type and minimum internal diameter of the ductus, age and weight, size of the umbrella and the rotation of the umbrella were not predictors of residual shunt. There were no deaths, hemolysis, endarteritis or fracture of the umbrella's arms. One patient remained with a slight gradient in the left pulmonary artery. The authors conclude that the Rashkind technique is safe and efficient and has good long term results. It should be considered as the first line therapeutic modality in the treatment of selected patients with persistent ductus arteriosus.

[Diagnosis using nuclear medicine of anterior descending artery stenosis in patients with left bundle branch block]

PURPOSE

To evaluate septal perfusion and contractility in patients with left bundle branch block (LBBB).

METHODS

Twenty patients were submitted to myocardial scintigraphy with Tecnecium-99m isontrile after exercise and dipyridamole infusion. The septal contractility was observed during the radionuclide ventriculography. All patients were submitted to coronariography.

RESULTS

Twenty patients were studied and 17 (85%) had a normal left anterior descending (LAD) artery. Nine (53%) patients had abnormalities in septal perfusion after the exercise and 2 (12%) after dipyridamole infusion. All patients had abnormalities in septal contractility during the radionuclide ventriculography.

CONCLUSION

The myocardial scintigraphy after dipyridamole infusion showed better specificity in the diagnosis of a LAD lesion. The radionuclide ventriculography was an efficient method to evaluate the septal contraction abnormalities in patients with LBBB.

[Efficacy of repeat coronary dilatation in patients with restenosis of the anterior descending artery]

PURPOSE

To analyze the clinical characteristics, acute and long term results of repeat percutaneous transluminal coronary angioplasty (PTCA) for restenosis of the proximal left anterior descending coronary artery (LDA) METHODS: We studied 113 patients, 79% male, mean age 59 years, 49.5% had stable angina, with single vessel proximal LDA disease undergoing repeat PTCA for a first restenosis from January/88 to December/92. We examined the in hospital outcome (success rate and complications) and long term follow up (angina status, occurrence of myocardial infarction (MI), death and need for repeat PTCA or coronary artery bypass graft (CABG) of this subgroup.

RESULTS

Primary success was 96%. Complications included: 1% MI, 1% emergency CABG and 1% procedural death. Follow up data (mean 42 months) was available in 102 (94%) out of 109 patients with successful repeat PTCA: 64 (63%) patients were asymptomatic, 5 (5%) had a MI and 28 (27%) required repeat PTCA or CABG. Actuarial 5 year freedom from death was 94%, freedom from death and MI was 91% and freedom from death, MI and repeat PTCA or CABG was 52%.

CONCLUSION

Repeat PTCA is an effective treatment for proximal LAD restenosis with a high success rate, low incidence of procedural complications and provides excellent long term cardiac survival, however repeat revascularization is frequently required.

[Surgical treatment of infective endocarditis]

PURPOSE

To analyse, retrospectively, 83 patients with infective endocarditis (IE) that were operated during the acute phase of the disease and to identify possible subgroups with distinct mortality.

METHODS

Between 1985 to 1990, 83 patients comprised the subject of this analysis. Fifty-one (61%) were male, aged between 3 months to 71 years, mean of 31.4 +/- 16.7 years.

RESULTS

We could identify two subgroups that were most frequently operated on: the left side IE and the Staphylococcus aureus; and 77 (43%) had left sided IE (p < 0.001). When discriminated accordingly to the specifically etiologic agent (Staphylococcus aureus) this difference continues to be statistically significant: of 29 left sided IE by this agent 13 (45%) were operated on, whereas from 22 right sided IE by the same agents, just 3 (14%) were operated on (p < 0.05). The two major etiologic agents did not show any statistically significant difference in the number of patients that needed to be operated on: on those 51 patients with Staphylococcus aureus IE, 16 (31%) were treated surgically, while from the 60 patients with Streptococcus viridans, 22 (37%) underwent to surgical procedure (p- NS). The mortality in the patients treated by surgery was 32%, and those with Staphylococcus aureus IE were responsible for 46% of the total surgical deaths.

CONCLUSION

Surgical treatment were most frequently used in the patient with left sided IE independently of the etiologic agent.

[Infective endocarditis associated with pregnancy]

PURPOSE

To report the intra-hospitalar and late follow-up of patients with infective endocarditis (IE) acquired in the pregnancy or puerperium.

METHODS

Eleven patients, between 1984-1992 according to the beginning of the IE episode (fever and other signals) were studied. Patients were divided in two groups: IE of pregnancy (7 cases), and puerperal IE (4 cases).

RESULTS

In the pregnancy IE group, mitral valve was affected in 6 (85%), and aortic valve in 1 (15%). During the course of the treatment, two patients had to be operated on, respectively, in the 24th and 28th week of the pregnancy. The 1st one had a successfully mitral valve replacement by a biological prosthesis but 48 h later she aborted, and the 2nd presented neurological complication (intracerebral hemorrhage) in the immediate post-operative period of a successfully mitral valve replacement by biological prosthesis. She was undergone to a cesarean but the fetus remained alive for 24 h only. If we look at the newborns (fetus), only 4 of them survived. Out of 3 fetal deaths, 2 had close association with mother cardiac surgeries. In the pregnant period acquired IE, 3 (47%) mothers died. In the puerperium group, 2 mitral valves and 2 aortic valves had IE. Two of them had to be operated on due to an important aortic regurgitation and cardiac failure. There were no deaths in this group.

CONCLUSION

During pregnancy, IE showed a high morbi-mortality for mother and concept. The mother's neurological complications played a major role in the poor outcome during the pregnancy period.

[Pulmonary atresia with intact ventricular septum. Valvar perforation by radiofrequency]

Six days old neonate with pulmonary atresia and intact ventricular septum is reported in which a communication was established between the right ventricle and the pulmonary artery. The membraneous atresia was perforated with a special radiofrequency catheter 2F connected to a Hat 200S radiofrequency generator (Osypka). The energy necessary to perforation was 15W. After perforation of the atresia, balloon dilation was performed (balloon diameter: 2, 3, 4mm of coronary angioplasty and 5, 8mm Penta Medi-tech). The valve was completely opened giving the continuity between right ventricle and pulmonary artery.

[Chronic phase of Chagas disease. Clinical aspects and course of the disease]

PURPOSE

To evaluate the clinical and evolutive aspects of chronic chagasic patients.

METHODS

Three hundred chronic chagasic patients, 180 females, with age ranging from 19 to 81 years (55.6 +/- 13.1) were retrospectively studied. Patients were divided according to the following clinical types: indeterminated, cardiac (with the subtypes: arrhythmogenic, dilated and mixed), digestive isolated and digestive plus cardiac involvement. The following variables were analysed: prevalence of each clinical forms, symptoms, electrocardiographic pattern and clinical outcome.

RESULTS

At the start of the study, 73 (24.3%) patients were in indetermined type, 106 (35.3%) in cardiac arrhythmogenic, 95 (31.6%) in mixed, 7 (2.3%) in dilated, 16 (5.3%) in digestive plus cardiac type and 3 (1%) in the pure digestive type. The most prevalent symptoms were dyspnea on efforts (57%), palpitations (41.33%) and chest pain (33%). The most frequent electrocardiographic pattern was right bundle branch block plus antero-superior fascicular block, in 30% of the patients. The average follow-up time was 7.8 +/- 6.1 years and the outcome was considered good in 20 patients (6.6%), stable in 214 (71.3%) and bad in 66 (23%). At the end of the follow-up, 9 patients have evaluated from the indeterminated to the cardiac and digestive types, and 19 (17.92%), from the arrhythmogenic to mixed cardiac subtype. The follow-up was lost in 79 patients (26.3%), most of them, probably dead.

CONCLUSION

With a mean time of 7.8 years, 12.3% of the patients in the indeterminated type evolved to the cardiac and/or digestive type; right brundle branch block with antero-superior fascicular block was the most prevalent electrocardiographic pattern; the outcome was stable or good in the majority of these patients.

[Infective endocarditis in children and adolescents]

PURPOSE

To assess infective endocarditis (IE) predisposing factors, etiologic agents and hospital course in infants and adolescents.

METHODS

We Studied 222 patients admitted under compatible IE diagnosis, from 1985 to 1990. The population of this study is fifty patients (23%) under 16 years of age.

RESULTS

Rheumatic valvular disease, as predisposing cardiopathy was proeminent within 9 to 16 years of age, markedly Statistical difference when compared to age range of 0 to 8 years (p < 0.05). Among congenital cardiopathies, the most frequent were: interventricular septal defect (26.0%) and tetralogy of Fallot (21.7%). Blood cultures, surgical material or emboli cultures were positive in 35 (70.0%) assessed patients. Streptococcus viridans (45.7%) and Staphylococcus aureus (42.8%) were the etiologic agents most often isolated. It was found that endocarditis by Staphylococcus aureus had mortality rate of 53.3% [(clinical (66.6%) and surgical (44.4%)], (p < 0.05) when compared to those by Streptococcus viridans; with total mortality of 6.2% (no clinical death and 16.6% in the surgical group). Total in-hospital mortality (clinical and surgical) was 26.0% (13 deaths).

CONCLUSION

IE in infants and adolescents in this studied population presented Streptococcus viridans responsible for 46.7% of patients with endocarditis and the Staphylococcus aureus for 42.8% were the etiologic agents most often found. Total, clinical and surgical mortality was greater in patients with endocarditis by Staphylococcus aureus when compared with those by Streptococcus viridans. Among the congenital cardiopathies, whether operated on or not, ventricular septal defect and of Fallot's tetralogy were the most involved ones; rheumatic cardiopathy Still remains a significant predisposing factor to infective IE in our country.

[Endocarditis due to Mycobacterium chelonei in a valvular prosthesis]

Male aged 40 year, with infective endocarditis in valvular prosthesis caused by Mycobacterium chelonei. This agent is unusual in this situation and rarely identified by the blood cultures.

[Radiologic signal of dehiscence of Starr-Edwards aortic prosthesis]

A male 54 years-old patient with infective endocarditis through Staphylococcus aureus with prosthesis of Starr-Edwards aortic with clinical and echocardiographic signs compatible with dysfunction classified as severe. The x-ray images presented double silhouette of the prosthesis, thus suggesting its partial dehiscence. This case report points out that the detailed analysis of the X-ray may supply relevant data for the diagnosis of one of this complication thus influencing on management and prognosis.

[Antihypertensive effect of urapidil in mild to moderate arterial hypertension. Randomized, double-blind versus placebo study]

PURPOSE

To evaluate the efficacy and tolerability of urapidil (a new central and peripheral antihypertensive agent) in patients with mild to moderate essential hypertension.

METHODS

Thirty-one patients were randomized, double-blindly, to receive either placebo (15 patients) or urapidil (16 patients) for 3 months. The initial dose of urapidil was 30mg twice daily, per oral. The dose was increased progressively till achievement of good blood pressure control or the dose of 60mg three times a day.

RESULTS

Seventy percent of the patients on urapidil group responded to therapy against 30% on the placebo group. There were 3 cases of hypertensive crises (2 on urapidil and 1 on placebo) on the early therapy. The adverse events with urapidil were unfrequent and the most common were headache and dizziness. There were no modification on blood sugar and lipids level.

CONCLUSION

Urapidil appears to be a safe antihypertensive agent in the treatment of mild to moderate essential hypertension. It also did not demonstrate any clinical effect on the carbohydrates and lipids profile.

[Coronary angioplasty using double balloon in artery of large calibre (hugging balloons)]

In this case report the transluminal coronary angioplasty was performed in a oversized right coronary artery with a severe lesion with thrombus inside, using the Hugging balloon technique (two dilatation balloon catheters used simultaneously). This technique achieved minimal residual lesion and had a favorable clinical outcome of the patient.

[Acute occlusion after coronary angioplasty. Early management and late course]

PURPOSE

Assess the efficacy of the different strategies employed in the management of acute closure and verify the late prognosis of patients who develop this complication.

METHODS

From january 1987, through December 1990, 2315 consecutive patients underwent percutaneous transluminal coronary angioplasty (PTCA) in our Institution. We analyzed 100 patients who had had acute closure of the dilated vessel determining the total incidence of myocardial infarction and death, the effectiveness of the different treatment strategies and clinical and angiographic predictors of poor in-hospital outcome. Late follow-up was obtained in the hospital survivors.

RESULTS

The incidence of acute myocardial infarction in the group of 100 patients was 57%; death occurred in 12% of the patients. Forty-one individuals were referred to emergency bypass surgery, 35 received clinical treatment and 24 underwent redilatation of the vessel. Those managed clinically had a higher incidence of myocardial infarction compared to the ones who underwent either redilatation or surgery (74.3% versus 50% and 48.8%). The in-hospital mortality rate was significantly higher in patients with left ventricular ejection fraction < 45% (44.4%, p < 0.001) and in procedures involving the left anterior descending artery (20%, p < 0.05); patients undergoing repeat dilatation had the lower death rate (4.2% versus 8.6% in the clinical group and 17.1% in the surgical group). Late follow-up was obtained in 65 of 88 hospital survivors (mean follow-up = 17 months). Patients who underwent repeat dilatation were significantly less symptomatic in the follow-up than those who received medical therapy during the acute phase (89% versus 60.9% of patients without symptoms respectively, p < 0.05). Patients who were referred to surgery had also a tendency towards having less symptoms (87.5% of asymptomatic patients in the late follow-up) although the difference was not statistically significant (0.01 > p > 0.05).

CONCLUSION

Acute coronary occlusion is a serious complication of angioplasty and is associated with high rates of major complications (myocardial infarction, death). Low left ventricular ejection fraction and PTCA involving the left anterior descending are predictors of higher in-hospital mortality in patients with acute closure. Late outcome is less favourable in patients submitted to clinical treatment in the acute phase.

[Mitral double catheter-balloon valvuloplasty, hemodynamics evaluation of 52 cases one year after the procedure]

PURPOSE

To evaluate the late hemodynamic and angiographic results of 52 patients who underwent mitral valvoplasty by the double balloon technique in the treatment of the rheumatic mitral stenosis.

METHODS

The mean follow-up was of 18 months and the patients had a Doppler-echocardiogram and cardiac catheterization one year after dilatation. Of the 52 patients 84.6% were female and the mean age was 21.9% years. Eighty one percent were in NYHA class I whereas 5.7% had atrial fibrillation at the end of 18 months.

RESULTS

Immediately after valvoplasty 46 patients (88.5%) had a valvar area larger, and 6 (11.5%) smaller than 1.5 cm2. The first group had a good clinical outcome with maintenance of the clinical, echocardiographic and angiographic results in the late follow-up, including the diastolic gradient and the valvar area. Of the 6 cases with mitral area smaller than 1.5 cm2, 2 had a good clinical evolution, 2 were re-dilated, 1 was scheduled for surgery and the last one is under clinical management but with poor hemodynamic results. Three (5.7%) cases developed an atrial septal defect after the procedure, with hemodynamic repercussion in 1. Mitral regurgitation developed in 16 cases (+ in 8, +/++ in 8) without changes during the follow-up period.

CONCLUSION

Double balloon mitral valvoplasty is a safe effective method in the treatment of the rheumatic mitral stenosis, and offers a better evolution in patients with a valvar area larger than 1.5 cm2 after the dilatation.

[Blood pressure variability and left ventricular hypertrophy in arterial hypertension]

PURPOSE

To evaluate the left ventricular hypertrophy correlation with blood pressure variability during day and night time as well as throughout the 24h period.

METHODS

Fifteen patients with mild to moderate essential hypertension underwent to bi-dimensional echocardiographic study and to 24h ambulatory blood pressure monitorization. Left ventricular mass was calculated according to previous validated formulas. The standard deviation of the mean blood pressures during day-time, night-time and 24h period was taken as blood pressure variability indices. The mean age of the group was 42 years old; 9 patients were male and all were white.

RESULTS

This study showed that only the systolic and diastolic blood pressure variability during the 24h period correlated significantly with left ventricular mass, (r = 0.53 and p < 0.05; r = 0.58 and p < 0.05 respectively). There was no significant correlation of the day-time and night-time pressures variability with left ventricular mass.

CONCLUSION

The systolic and diastolic blood pressure variability during the 24h period may be one of the many determinants of left ventricular hypertrophy in patients with mild to moderate hypertension.

[Nonsurgical treatment of coronary pulmonary arteriovenous fistula]

Fifty eight year old man, with dyspnea, fatigue and progressive angina underwent cinecoronarography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to occlude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronarography 6 months later showed the maintainance of the initial results.