[Laser coronary angioplasty for an intrastent stenosis].
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Adult↗
Biomedical subjects
R Seabra-Gomes
Publications and source records attributed to R Seabra-Gomes.
[The role of abciximab in the prevention of the acute thrombotic complications of coronary angioplasty].
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Abciximab↗
What are the limits for the Ross operation?
The Ross operation is physiologically the best approach for aortic valve replacement. At the Hospital de Santa Cruz 22 consecutive pulmonary autograft operations have been performed in patients with a mean age of 49 (range 17-65) years. Six patients had mitral valve disease, two had aortic aneurysms and one had a ventricular septal defect. Subcoronary implantation of the autograft was performed in 20 patients. A partial inclusion aortic root replacement technique was used in one and the aortic root was replaced in another. There were no hospital or late deaths. Two patients required autograft replacement at 3 and 9 months postoperatively because of regurgitation. One of these cases was caused by an abnormality of the pulmonary valve and since then echocardiographic assessments of this valve have been performed routinely and have detected significant pulmonary incompetence in four patients who otherwise would have been operated on using the Ross procedure.
Adolescent↗
[Implantable cardioverter-defibrillators in patients resuscitated from sudden death and in patients with sustained refractory ventricular tachycardia].
OBJECTIVE: The aim of this study was to evaluate the results of our experience with implantable cardioverter-defibrillator therapy. PATIENT SELECTION: We treated with implantable cardioverter-defibrillator (ICD) 18 patients, 15 male and 3 female, mean age 51 years, ranging from 12 to 76 years, with life threatening ventricular arrhythmias. Eleven patients were resuscitated from cardiac arrest and seven had refractory ventricular tachycardia. The underlying condition was coronary artery disease in 12 patients, dilated cardiomyopathy in two, congenital long QT syndrome in one, mitral regurgitation in one and idiopathic in two patients. METHODS: All patients underwent cardiac catheterization and electrophysiological study before ICD implantation. In the first patient epicardial leads were used, but a transvenous approach was used in the remaining 17 patients. The device was implanted in an abdominal position in all patients. Defibrillation and pacing threshold tests were performed during the implantation procedure and whenever necessary. After implantation, patients were followed up in an outpatient basis, with evaluation of therapy efficacy and reprogramming of the device if required. The mean follow-up time was 16 months, ranging from 1 to 40 months. RESULTS: The implantation was successful and without complications in all patients. Defibrillation threshold was considered within normal range, with an electrode impedance ranging from 40 to 65 Ohms. During the follow-up period no deaths occurred, 8 patients (44%) had episodes of VT or VF that were successfully treated, with shock in six patients, with antitachycardia pacing in one and with both modalities in another patient. Inappropriate shocks were observed in three patients (16%). The device was reprogrammed in five patients. CONCLUSIONS: Our experience with implantable ICD in patients who survived cardiac arrest or with refractory VT has shown a low surgical risk with no mortality. The incidence of ICD discharges was high, with a satisfactory efficacy rate and the number of inappropriate shocks was acceptable. The careful patient selection made possible a good cost/benefit relation.
Adolescent↗
[The 3-year prognosis of patients with suspected coronary disease and a normal myocardial scintigraphy with thallium-dipyridamole].
OBJECTIVES: To assess the 3-year prognosis of patients with suspected coronary artery disease and a normal dipyridamole-thallium scintigram. POPULATION: 43 patients, 16 male and 27 female, mean age 55.8 +/- 9.2 years with suspected coronary artery disease. Forty-two patients had anginal complaints. There was a previous positive treadmill exercise test in 14 patients. All the patients had a normal dipyridamole-thallium SPECT. METHODS: Dipyridamole was infused at a rate of 0.56 mg/kg in 4 minutes followed by 3 minutes of low-level cycloergometer exercise. Two mCi of thallium-201 were injected 3 minutes after the end of dipyridamole infusion. Stress and redistribution SPECT acquisitions were performed respectively 5-10 minutes and 4 hours after thallium-201 injection. The cardiac events during a 3-year follow-up were analysed. RESULTS: No patient had unstable angina, PTCA, CABG or death. One patient suffered an inferior myocardial infarction 28 months after the scintigraphy. The event rate was 0.78% per patient per year. CONCLUSION: Three-year prognosis in patients with suspected coronary artery disease after a normal dipyridamole thallium SPECT is excellent approaching that of the general population.
Adult↗
[The radiofrequency catheter ablation of occult accessory atrioventricular pathways].
OBJECTIVE: The aim of this study was to evaluate our results of radiofrequency catheter ablation (RFCA) of concealed accessory atrioventricular pathways (CP). PATIENT SELECTION: We treated with RFCA 19 patients, with 21 CP, 10 men and 9 women, mean age 37 +/- 16 years, with supraventricular tachycardia (SVT) and absence of ventricular pre-excitation in the electrocardiogram (ECG). These patients comprised 50% of the patients who underwent RFCA for SVT and had no ventricular pre-excitation in the ECG. The diagnosis of CP was made by electrophysiologic study, based on the demonstration of a pathway capable of retrograde conduction only. METHODS: The RFCA was performed without antiarrhythmic drugs in the same session of the electrophysiologic diagnosis. The location of the CP site was obtained by catheter mapping, looking for the earliest atrial retrograde activation during tachycardia or ventricular pacing. RESULTS: The CP had a right-sided location in only 2 patients who had an incessant form of SVT, the CP in these patients exhibit decremental conduction--permanent junctional reciprocating tachycardia. In the other patients the CP was left-sided, lateral in 11 patients, posterior in 3, postero-septal in 3 and medial septal in one patient. In 9 patients there was a simultaneous ventricular activation in the his bundle electrogram and in the electrogram of the ablation site, suggesting partial anterograde penetration of the stimuli on the accessory pathway. Success criteria were achieved in 18 patients (95%) corresponding to 20 CP. CONCLUSIONS: The prevalence of CP in the presence of SVT without ventricular pre-excitation is high, almost all left-sided. The CP displays eccentric atrial activation during SVT. It is possible that CP are capable of partial anterograde conduction as well. The success rate of RFCA is high.
Adolescent↗
[The radiofrequency catheter ablation of ventricular tachycardia].
OBJECTIVE: The aim of this study was to evaluate our results of radiofrequency catheter ablation (RFCA) of ventricular tachycardia. PATIENT SELECTION: We treated with RFCA nine patients, six male and three female, mean age 36 +/- 12 years with ventricular tachycardia (VT), who fulfilled the following criteria; 1) recurrent VT; 2) resistant fo medical therapy despite the use of more than one antiarrhythmic drug; 3) inducible by programmed ventricular stimulation; 4) hemodynamically well tolerated. The VT etiology was coronary artery disease (CAD) in three patients, dilated cardiomyopathy in one, right ventricular dysplasia in one and it was idiopathic in four (being fascicular in three and catecholaminergic right ventricular outflow tract VT in one). METHODS: The RFCA was performed under antiarrhythmic medication. The adequate ablation site was obtained by mapping of the VT, looking for the earliest ventricular activation, identification of isolated mid-diastolic potentials during sinus rhythm or presystolic during VT, good pace mapping (at least 10 of the 12 standard ECG leads), and high frequency short duration spikes, the so called P potentials in fascicular VT. Primary success achieved when occurred termination of VT during application of RF energy and/or VT was no longer inducible by programmed stimulation with the same stimulation protocol. RESULTS: Global primary success rate was 89%, being 100% in idiopathic VT, and 80% in VT associated with structural heart disease. In a follow-up period of 12 +/- 14 months all patients were alive, 75% free of VT in the idiopathic VT group; and 50% in patients with structural heart disease. One of these patients underwent cardioverter defibrillator implantation to treat a fast VT with a new morphology not treated by ablation, and the other two had VT modification with a significant reduction in the number of episodes. CONCLUSIONS: Radiofrequency catheter ablation of VT has shown a good success rate, and it is a valuable alternative in patients with hemodynamically tolerable VT, refractory to drug treatment, highly symptomatic and without surgical indication. In cases of idiopathic VT we had a high rate success and we think that RFCA will probably become the primary indication in symptomatic patients.
Adult↗
[The maximum heart rate in the exercise test: the 220-age formula or Sheffield's table?].
OBJECTIVE: To determine in the maximum cardiac rate in exercise test of apparently healthy individuals may be more properly estimated through 220-age formula (Astrand) or the Sheffield table. DESIGN: Retrospective analysis of clinical history and exercises test of apparently healthy individuals submitted to cardiac check-up. PARTICIPANTS: Sequential sampling of 170 healthy individuals submitted to cardiac check-up between April 1988 and September 1992. MATERIAL AND METHODS: Comparison of maximum cardiac rate of individuals studied by the protocols of Bruce and modified Bruce, in interrupted exercise test by fatigue, and with the estimated values by the formulae: 220-age versus Sheffield table. RESULTS: The maximum cardiac heart rate is similar with both protocols. This parameter in normal individuals is better predicted by the 220-age formula. CONCLUSIONS: The theoretic maximum cardiac heart rate determined by 220-age formula should be recommended for a healthy, and for this reason the Sheffield table has been excluded from our clinical practice.
Adult↗
[Predictive value of coronarography in the localization of arterial lesions responsible for future infarcts of the myocardium].
OBJECTIVES: To evaluate the capability of coronary angiography, when performed in stable conditions, to predict which arterial segment will be responsible for future acute myocardial infarction. POPULATION: 17 patients (15 men and 2 woman), mean age 52 +/- 12 years, who suffered a myocardial infarction (AMI), and had been previously submitted to coronary angiography. After the myocardial infarction all the patients had a new angiography. METHODS: The coronary angiographies performed before and after the AMI were compared, by simultaneous visualization of the films, and the segment related to the AMI was determined with the help of ECG and ventriculography. Among the arterial segments with in the coronary angiography performed before the AMI and who were found to be related with it, three Groups were considered: A-with no angiographic lesion; B-with less then 70% lesion; C-with a lesion equal or superior to 70% (angiographically significant). RESULTS: In nine patients the arterial segment related to AMI belonged to group A. In four patients it belonged to group B and in four to C. Segments with angiographically significant lesions were responsible for AMI in less then one fourth of the patients. CONCLUSIONS: Coronary angiography, when performed in stable conditions, has a low predictive value to determine the localization of the arterial segment related to future AMI.
Adult↗
[Exertion syncopal crisis in the young, associated with idiopathic long QT syndrome].
The cases of two young patients with repetitive syncopal attacks due to idiopathic long QT syndrome (ILQTS) are reported. Both had been primarily misdiagnosed for seizures. In one of the cases the QT interval in the ECG at rest was normal. The same patient had a previous episode of cardiac arrest with ventricular fibrillation. The treadmill stress test was of great value, revealing polymorphic ventricular tachycardia induced by exercise, and evaluating the efficacy of beta-blocking therapy in the follow-up. The ILQTS should be considered a possible etiology in any patient presenting with new onset seizures, especially in the young. The treatments were different in both cases. In the first one, the treatment with nadolol (100 mg od) revealed to be very effective with total remission of symptoms. The treadmill stress test performed 15 days after the beginning of treatment did not show any ventricular arrhythmias, and it was assumed that the patient was effectively protected against ventricular arrhythmias. After 4.5 months of follow up, no syncopal episodes occurred. In the second case due to young age, the frequency, and the severity of the attacks (cardiac arrest with ventricular fibrillation), and the inefficacy of beta-adrenergic-blocking agents, the implantable cardioversor-defibrillator was the treatment chosen, although the beta blocking therapy was maintained to reduce the number of arrhythmic events. The ILQTS is a rare anomaly related to sudden cardiac death. The ILQTS is characterised by the association of several distinctive electrocardiographic features, among which prolongation of the QT interval is the best known. Life-threatening arrhythmia occurs usually under conditions of physical or psychological stress. Relatively effective therapies do exist and are represented by antiadrenergic interventions: beta-adrenergic-blocking agents are the treatment of choice. When they fail, left sympathetic denervation or the automatic implantable cardioversor-defibrillator have also proved to be effective.
Adult↗
[Clinical and echocardiographic assessment of surgical replacement of the aortic valve with lung autograft: results after 2 years].
OBJECTIVE: The goal of this study was to evaluate the clinical and echocardiographic results of a cohort of patients subjected to aortic valve replacement with pulmonary autograft (Ross procedure). DESIGN: We studied prospectively with clinical and echocardiographic evaluation all patients subjected to this type of aortic valve surgery, before operation, intraoperatively, before hospital discharge and at the end of this study in September 1994 and we analysed the evolution of the results during the follow-up period. PATIENTS: 22 consecutive patients 12 men and 10 women mean age 48 +/- 14 years subjected to Ross operation between April 1992 and June 1994. METHODS: Patients were studied with transesophageal echocardiography intraoperatively and transthoracic echocardiography. Two-dimensional and M-mode evaluation, continuous and pulsed wave Doppler and color coded Doppler were performed, with assessment of the morphology and Doppler profile of both the autograft and the homograft in pulmonary position. RESULTS: No early or late mortality was registered, and apart two patients who were reoperated, all patients were asymptomatic in the last medical visit. There was no incidence of thromboembolic events even though no anticoagulation has been used. Aortic regurgitation was present in 14 patients, grade 1 in 11 patients and grade 2 in three. In the last echocardiogram performed the analysis of aortic flow, demonstrated absence of significant transvalvular gradient (maximal aortic gradient of 5.6 +/- 0.4 mmHg and mean aortic gradient of 1.8 +/- 0.08 mmHg). Pulmonary regurgitation was absent in nine patients, and present in 13, considered trivial in all cases. CONCLUSIONS: These data suggest that this type of surgery has a low operative risk, with absence of thromboembolic complications and excellent clinical and echocardiographic results.
Adolescent↗
[Anomalous insertion of mitral papillary muscles in obstructive hypertrophic myocardiopathy. Report of 2 cases].
Hypertrophic obstructive cardiomyopathy is a pathologic entity whose features are complex and diverse. Its surgical treatment generally requires myectomy. When the left ventricle outflow gradient is also due to mitral valve abnormalities, mitral valve replacement has been considered as the treatment of choice for the relief of the obstruction. We report two cases in which transesophageal echocardiography has allowed a good definition of this complex area of the heart and a better diagnosis and treatment of its components. Its use led to the diagnosis of abnormal papillary muscles inserted directly in the anterior leaflet of the mitral valve, with severe left ventricle outflow obstruction. Surgical treatment consisted of septal myectomy and excision of the muscles, thus preventing the need for mitral replacement. Systolic anterior motion of the mitral valve subsided and the outflow gradients became negligible. This new approach for the treatment of hypertrophic obstructive cardiomyopathy will be of benefit for patients in whom the anomalous insertion of the papillary muscles are recognized before surgery, thus preventing mitral valve replacement.
Adult↗
Left ventricular function after late thrombolysis with alteplase in myocardial infarction.
OBJECTIVE: Late thrombolytic treatment (after 6 hours from pain onset) for acute myocardial infarction has been shown to improve survival in a cohort of patients. The mechanisms underlying such benefit have been debated and a controversy exists about the influence of late thrombolysis over left ventricular function as one potential mechanism. The present study intended to clarify the effects of late thrombolysis with alteplase on left ventricular function parameters. DESIGN: Prospective, multicenter, randomised, double-blind study. Ancillary study to LATE trial. PATIENTS: We studied 103 patients, 81.6% men, randomly allocated to alteplase (100 mg over 3 hours) or placebo 6 to 24 hours after onset of myocardial infarction. METHODS: Left ventricular function parameters by radionuclide ventriculography were evaluated at 1 and 6 months after myocardial infarction. RESULTS: At 1 month, left ventricular ejection fraction was 48.86% on alteplase and 43.19% in placebo group (p = 0.028), with greater benefits for septal and apical regions. At 6 months no significant differences were found. CONCLUSIONS: Those data suggest that late thrombolysis with alteplase improves left ventricular function 1 month after myocardial infarction although the difference did not persist at 6 months. Improvement of left ventricular function shall, therefore, be considered as one of the possible mechanisms underlying the benefit of late thrombolysis.
Double-Blind Method↗
[Coronary disease in women --risk factors, diagnostic and therapeutic approaches].
OBJECTIVE: To characterize and evaluate the prognosis of coronary artery disease in women. SETTING: Hospital with referral for cardiac catheterization, since 1982. PATIENTS: We studied post-menopause patients, not under hormonal replacement therapy, to whom coronary artery disease (CAD) was diagnosed by coronary angiography in the first 5 years of activity of our centre. Patients should have at least five years of follow-up (Group W-84 patients). METHODS: Risk factors for CAD were studied in Group W, and compared with a group of male patients with CAD and a group of women without CAD, that underwent coronary arteriography in the same period of time. RESULTS: Most risk factors for CAD were more prevalent in women with CAD, with special focus on hyperlipidaemia and hypertension. Cigarette smoking was more frequent in men. At the time of coronary arteriography, most patients were in NYHA class I-II and CCS class 3-4. On follow-up 68 patients were revascularized (bypass graft on most). At five years, five patients died and most survivors were a NYHA class I-II and CCS class 1-2. Patients with multivessel disease (MVD), were older, more symptomatic and with more risk factors than patients with single vessel disease (SVD). Follow-up was on medical treatment 17% of the patients and included revascularization procedures in 83% of MVD patient's disease and 77% of patients with SVD patients. Cardiac events (unstable angina, myocardial infarction, admission for cardiac failure) occurred in 49% of MVD and 32% of SVD patients, and distribution of CCS and NYHA classes at 5 years were similar in both subgroups. CONCLUSIONS: The present study characterize the group of women with CAD as having a high prevalence of risk factors, with a large proportion of multivessel disease and high rates of revascularization. Prognosis at five years was favourable in this group. Multivessel disease was associated with presence of more risk factors and increased clinical severity before catheterization, but at five years the prognostic was similar to single disease, therapeutic options, notably the high rate of revascularization, could account for these results.
Coronary Disease↗
[Myocardial infarction in patients with single-vessel disease: are there clinical or angiographic markers of viability?].
OBJECTIVE: To assess whether some of the clinical and angiographic variables usually associated with the severity of coronary artery disease could be considered as markers of viability after myocardial infarction. PATIENTS: We studied 41 patients with previous Q wave infarction and single-vessel coronary artery disease. METHODS: Patients were studied with thallium-201 SPECT, two imaging acquisitions were performed: stress and reinjection three to four hours later under nitroglycerin effect. Perfusion and viability were compared to clinical and angiographic variables, including the degree of patency and colateralization. RESULTS: In the infarct related area, 66 % of the 177 perfusion defects were considered reversible (definite in 40 %). In patient analysis, 28 patients were considered as having reversibility (18 with definite and 10 with possible reversibility). None of the clinical or stress test variables were significantly associated with reversibility; all these variables had extremely poor negative predictive values and only stress-induced ST depression had a reasonable positive predictive value (85 %). There was no association between TIMI grade and reversibility. In segments supplied by a TIMI 0 artery, a higher rate of fixed perfusion defects was associated with the absence of collateral circulation (75 % vs 22%; p < 0.013). Furthermore, severe impairment of contractility did not predict absence of viability, we identified as viable 55 % of akinetic segments and 29 % of segments classified angiographically as aneurysm. CONCLUSIONS: These data suggest that common clinical and angiographic markers of severity of coronary artery disease are not useful in the detection of viable myocardium after myocardial infarction. Collateral circulation to occluded arteries was associated with viability, but its absence did not exclude it. Viability detection with appropriated tests, namely stress reinjection thalium scintigraphy should perhaps be considered as a routine procedure after myocardial infarction, especially when interventional therapy is to be considered.
Adult↗
[Infectious endocarditis caused by Q fever. Apropos of a clinical case].
Endocarditis is a rare, but some times fatal, complication of Q fever. Its diagnosis is difficult and it is based on non-specific cardiac findings and a high title of phase I antibodies. The treatment is based on tetracyclines alone or in combination with cotrimoxazole, for long periods of time. The therapeutic efficacy is evaluated by the measurement of phase I antibodies, every three months. The relapses are frequent despite the long period of antibiotic therapy. We report what is probably the first case of Q fever prosthesis endocarditis in Portugal, as a complication following an acute episode of Q fever.
Adult↗
[Modification of the lipid profile in coronary patients undergoing cardiac rehabilitation].
To assess the effect of continuous and controlled exercise training on the lipid profile of coronary pts. in a cardiac rehabilitation program, we evaluated forty-nine males aged 56.8 +/- 9.6 years, thirty-two with previous surgical myocardial revascularization, two submitted to percutaneous transluminal coronary angioplasty and fifteen on exclusive pharmacological therapy. Patients with changes in drugs that could potentially induce modifications in serum lipid values, were excluded. The values of total cholesterol, triglycerides, HDL-cholesterol, the HDL-cholesterol/total cholesterol ratio, weight and the body mass index at admission of training phase, end of training phase (III)-21 patients (Group I) and maintenance (IV)-28 patients (Group II), were assessed. The training phase (III) had a duration of 3-4 months and maintenance (IV) nine months. In Group I, evaluated at the end of the training period (phase III), there was no significant modification in lipid profile reduction; only 1% and 20% reduction (p = NS) in values of total cholesterol and triglycerides, was detected. The HDL-cholesterol rose 12.5% (p = NS), and the HDL cholesterol/total cholesterol ratio 10.5% (p = NS). In Group II (at the end of the maintenance phase-IV-) there was no important change in total cholesterol levels. The HDL-cholesterol rose 19.5% (p = 0.003) and the HDL-cholesterol/total cholesterol ratio, also increased 33.3% (p < 0.0001). The benefit in relation to triglycerides was restricted to patients with higher values (> 200 mg/dl), where a reduction of 36% (p = 0.004) was found. There was no change in the weight or in body mass index, induced by the program. We concluded that the participation in a cardiac rehabilitation program induces a favourable modification of lipid profile in our population, with potential interest for secondary prevention of coronary heart disease. This change was particularly in serum values of triglycerides, HDL-cholesterol and the ratio HDL-cholesterol/total cholesterol. In what concerns triglycerides, the benefits were seen only in the group of patients with the highest serum values.
Adult↗
[Experience with dl-sotalol in the treatment of supraventricular arrhythmia].
OBJECTIVES: To review the results of our experience with oral dl-sotalol for preventive treatment of supraventricular tachyarrhythmias (atrial fibrillation and paroxysmal supraventricular tachycardia). POPULATION: 51 patients, 28 female and 23 male, mean age 46.2 +/- 14.4 years, from outpatient arrhythmology clinics of our institution, with recurrent supraventricular tachyarrhythmias (atrial fibrillation in 24 patients and paroxysmal supraventricular tachycardia in 27). All the patients, but one, had normal left ventricular function. Dl-sotalol was first choice medication in only three patients. Previously 2 +/- 1.3 antiarrhythmic drugs had been used. METHODS: Retrospective evaluation of therapeutic response (number of clinical recurrences according to a semi-quantitative scale) and secondary effects of dl-sotalol during a minimum follow-up of 18 months. The mean daily dose was 205 +/- 90 mg (80 to 400 mg). RESULTS: In 37% of the patients there were no clinical recurrences of arrhythmia during follow-up. In 37% of the patients there was a significant reduction in recurrences. In 26% there was no change in the number of recurrences. There were no significant differences in response between patients with atrial fibrillation and those with paroxysmal supraventricular tachycardia. Secondary effects occurred in 16% of the patients: symptomatic bradycardia, asthma or sexual dysfunction. No patient had heart failure, torsades de pointes, syncope or death. CONCLUSIONS: From our experience, DL-sotalol seems to be a good therapeutic alternative for the preventive treatment of supraventricular tachyarrhythmias, with a low risk in patients with good ventricular function.
Adult↗