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Background: Erectile dysfunction (ED) is common in patients with congestive heart failure (CHF). ED reduces quality of life, and it may affect compliance, thereby impairing the success of CHF treatment., Methods and Results: In the first phase (fixed-dose double-blind, randomized, placebo-controlled, two-way crossover study), we studied in 23 men with CHF the effects of 50 mg sildenafil on exercise and neurohormonal activation. Patients underwent a treadmill 6-minute cardiopulmonary walking (6'WT) test followed by a maximal cardiopulmonary exercise test (ET). In the second phase, patients received sildenafil, taken as required for ED. Sildenafil reduced the heart rate (HR) (bpm) before the 6'WT (from 75+/-15 to 71+/-14, P=0.02) and ET (from 75+/-15 to 71+/-15, P=0.02); the systolic blood pressure (mm Hg) before the 6'WT (from 116+/-18 to 108+/-18, P=0.004) and ET (from 116+/-15 to 108+/-17, P=0.001); the diastolic blood pressure before the 6'WT (from 69+/-9 to 63+/-11, P=0.01) and ET (from 70+/-8 to 65+/-10, P=0.004); and the Ve/VCO2 slope during the 6'WT (from 32+/-7 to 31+/-6, P=0.04) and ET (from 33+/-8 to 31+/-5, P=0.03). Sildenafil attenuated the HR increment during the 6'WT (P=0.003) and ET (P=0.000). Sildenafil increased the peak *O2 from 16.6+/-3.4 to 17.7+/-3.4 mL/kg per min (P=0.025) and the exercise time from 12.3+/-3.4 to 13.7+/-3.2 minutes (P=0.003). Sildenafil improved most scores of International Index of Erectile Function., Conclusions: Sildenafil was tolerated and effective for ED treatment in CHF, and improved the exercise capacity. The reduction of HR during exercise with sildenafil could theoretically decrease the myocardial oxygen consumption during sexual activity.

Background: Stimulated endothelium-derived relaxing factor-mediated vasodilation and conduit artery distensibility are impaired in congestive heart failure (CHF). L-arginine could have a potentially beneficial role in CHF, acting through the nitric oxide (NO)-L-arginine pathway or by growth hormone increment., Hypothesis: This study was undertaken to investigate the effects of L-arginine on heart rate, hemodynamics, and left ventricular (LV) function in CHF., Methods: In seven patients (aged 39 +/- 8 years) with CHF, we obtained the following parameters using echocardiography and an LV Millar Mikro-Tip catheter simultaneously under four conditions: basal, during NO inhalation (40 ppm), in basal condition before L-arginine infusion, and after L-arginine intravenous infusion (mean dose 30.4 +/- 1.9 g)., Results: Nitric oxide inhalation increased pulmonary capillary wedge pressure from 25 +/- 9 to 31 +/- 7 mmHg (p < 0.05), but did not change echocardiographic variables or LV contractility by elastance determination. L-arginine decreased heart rate (from 88 +/- 15 to 80 +/- 16 beats/min, p<0.005), mean systemic arterial pressure (from 84 +/- 17 to 70 +/- 18 mmHg, p < 0.007), and systemic vascular resistance (from 24 +/- 8 to 15 +/- 6 Wood units, p<0.003). L-arginine increased right atrial pressure (from 7 +/- 2 to 10 +/- 3 mmHg, p<0.04), cardiac output (from 3.4 +/- 0.7 to 4.1 +/- 0.8 l/min, p < 0.009), and stroke volume (from 40 +/- 9 to 54 +/- 14 ml, p < 0.008). The ratios of pulmonary vascular resistance to systemic vascular resistance at baseline and during NO inhalation were 0.09 and 0.075, respectively, and with L-arginine this increased from 0.09 to 0.12., Conclusion: L-arginine exerted no effect on contractility; however, by acting on systemic vascular resistance it improved cardiac performance. L-arginine showed a negative chronotropic effect. The possible beneficial effect of L-arginine on reversing endothelial dysfunction in CHF without changing LV contractility should be the subject of further investigations.

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 microg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 % to 18 % and to 28 % later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2 to 13.4 and to 16.2ml/kg/min later). The patient was "de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure.

Purpose: The effects of beta-blockers on severe heart failure are not well known. We investigated the effects of carvedilol (beta 1, beta 2, alpha 1-blocker) on symptoms, functional class (FC), and left ventricular function in patients with refractory heart failure., Methods: We studied 21 patients, mean age 56 +/- 10 years, 9 in FC IV, e 12 in FC III (intermittently with class IV). The initial dosage was 6.25 mg, and it was increased progressively as tolerated. The mean dose was 42 +/- 11 mg. The patients were submitted to routine clinical evaluation, and electrocardiogram. We determined after 196 +/- 60 days of follow-up the left ventricular end diastolic dimension (by echocardiogram), and left ventricular ejection fraction (using MUGA)., Results: Carvedilol was well tolerated by 16 (76%) patients. One patient is in FC II during increment of the dosage. Eight patients were in FC I, and 7 in FC II at 196 +/- 60 days of follow-up. Heart rate decreased from 96 +/- 15 to 67 +/- 10 bpm (p < 0.0001), left ventricular end diastolic diameter from 73 +/- 13 to 66 +/- 12 mm (p < 0.009), and the left ventricular ejection fraction increased from 0.21 +/- 0.06 to 0.34 +/- 0.12 (p < 0.0003)., Conclusion: Carvedilol may have beneficial effects on cardiac function, remodeling process, and FC. If tolerated, it seems to be a potential alternative option in the medical treatment of refractory heart failure. However, investigations are still necessary to clarify the long-term effects of carvedilol on this specific subgroup of patients.

Multiple mechanisms have been proposed to explain the hyperventilation and the limited exercise capacity in congestive heart failure (CHF) including increased intrapulmonary pressures, total pulmonary resistance, and airway abnormalities. We investigated the hypothesis that inhalation of nitric oxide could influence the maximum exercise capacity and excessive ventilatory response to exercise in CHF. Fifteen patients in CHF (mean age 48 +/- 12 years) underwent a control and a nitric oxide inhalation progressive treadmill exercise test with 30 ppm. We determined the maximum oxygen consumptiom (peak VO2), CO2 production (VCO2), minute pulmonary ventilation (VE), respiratory rate, tidal volume (VT), ventilatory equivalent for oxygen (VE/VO2), ventilatory equivalent for carbon dioxide (VE/VCO2), estimated physiologic dead space/tidal volume ratio (VD/VT), VE/VCO2 slope, heart rate, systemic arterial pressure, VE/exercise time slope, and VT/exercise time slope during every incremental exercise. Mean maximum exercise values of heart rate, systolic systemic arterial pressure, diastolic systemic arterial pressure, VD/VT, respiratory rate, peak VO2, VO2/heart rate, VE/CO2, and maximum exercise time were unchanged by inhalation of nitric oxide. There was a strong trend toward reduction of VE/VO2 from 53 +/- 15 to 47 +/- 12 (p = 0.051) and in maximum VE from 58 +/- 21 to 48 +/- 17 L x min(-1) (p = 0.059). Maximum VT decreased from 1639 +/- 556 to 1406 +/- 479 ml (p = 0.04). The VE/VCO2 slope was reduced from 43 +/- 12 to 35 +/- 8 (p = 0.018). Two patients had signs of pulmonary congestion during peak exercise or the recovery period with inhalation of nitric oxide. The VE/exercise time slope and VT/exercise time slope during incremental exercise were reduced by inhalation of nitric oxide, demonstrating a statistically significant minor increase in VE and VT. Inhalation of nitric oxide attenuated the excessive increase in VT response to exercise in CHF. The L-arginine-nitric oxide pathway may be involved in mechanisms contributing to hyperventilation during exercise in CHF.

We report the case of a 69 year-old male who developed congestive heart failure functional class IV (NYHA). The admission electrocardiogram (EKG) revealed sinus rhythm, PR interval of 240 ms, QRS interval of 110 ms, the QRS vector of 0 degree, Q waves from V1 to V6, tall R waves from V1 to V4 that decreased to V5 and V6. The vectocardiogram had anteriorization of the electrical forces of QRS, with vector half area in the horizontal plane at +60 degrees. After two years the patient had a myocardial infarction, the EKG at the admission had the same pattern and after two days developed important changes: enlargement of QRS interval with length of 160 ms, QRS vector of +100 degrees, R waves at D2, D3 e AVF that increase from D2 to D3, QS at D1, AVL, AVR and V1, rS at V2 and V3, R wave is notched and thickened+ at V5 and V6, that return to the initial pattern after one day. The patient progressed to death in the eighth day after infarction. This case reported a intermitent pattern of EKG that is an uncontestable proof to the existence of the left middle fascicular block.

Purpose: To compare patients with heart failure due to Chagas' cardiomyopathy and maximal oxygen consumption greater than 20mL/kg-1/min-1 to normal individuals., Methods: We studied 104 male patients with heart failure due to Chagas' cardiomyopathy, functional classe II-IV, age 18 to 65 years (40.3 +/- 9.0), and 23 normal sedentary male individuals (GI) age 17 to 51 years (35 +/- 8.7). Maximal oxygen consumption (VO2max) was obtained using a Beckman metabolic measurement cart, and left ventricular ejection fraction (EF) by conventional transthoracic echocardiography. Comparisons between means were made with t-test., Results: Thirty seven patients (35.6%) presented VO2max above 20mL/kg-1/min-1 (G2), with values ranging from 20.5 to 30 (24.5 +/- 2.9) and EF between 19 and 63% (42 +/- 11.7). GI had VO2max between 21 and 42mL/kg-1/min-1 (33.3 +/- 5.6) and EF between 70 and 82% (75.1 +/- 3.2). Ages were not significantly different for the two groups (p = 0.1136). VO2max and EF were lower in G2, and this was statistically significant (p < 0.0001)., Conclusion: These results indicate that patients with congestive heart failure due to Chagas disease may show values of VO2max, greater than 20mL/kg-1/min-1 which does not mean that they have normal maximal functional capacity.

Background: Heart transplantation is the surgical procedure of choice for treatment of refractory heart failure. However, it benefits a small number of patients because of the limited number of donors and selection criteria of recipients. Cardiomyoplasty is an alternative surgical procedure for heart failure. The aim of this investigation was to report our experience with heart transplantation, cardiomyoplasty, and clinical treatment of heart failure caused by idiopathic dilated cardiomyopathy., Methods: Ninety patients with refractory heart failure caused by idiopathic dilated cardiomyopathy were observed from May 1988 to March 1993. The patients had New York Heart Association functional class III or IV symptoms. The patients were divided in three groups according to the treatment received: heart transplantation (33 patients), cardiomyoplasty (25 patients), or medical treatment (32 patients). We studied the event-free curve, the New York Heart Association functional class, the left ventricular ejection fraction, and the morbidity of the groups in the follow-up of 19 +/- 16 months. We considered as an event death or crossover to another group because of severe symptoms., Results: The event-free rate in the cardiomyoplasty group was 92%, 88%, 79%, 74%, and 62% at 3, 9, 12, 18, and 24 months of follow-up, respectively. The event-free rate after heart transplantation was 82%, 78%, 82%, 75%, and 69% at 3, 9, 12, 18, and 24 months, respectively. The event-free rate in the medical treatment group was 78%, 65%, 61%, 48%, and 48% at 3, 9, 12, 18, and 24 months, respectively. All surviving patients in the heart transplantation group had functional class I symptoms. After cardiomyoplasty 90% of surviving patients had class I or II symptoms and 10% had class III symptoms. However, in the medical treatment group 27% of surviving patients had class I or II symptoms and 67% had class III or IV symptoms. In the cardiomyoplasty group left ventricular ejection fraction increased from 20% +/- 3% to 24.4% +/- 6.3% at 6 months (p < 0.05). In the heart transplantation group the left ventricular ejection fraction normalized, and the mean value of the left ventricular ejection fraction did not change in the medical treatment group. The need for endomyocardial biopsy and the incidence of rejection and infection were characteristics of the heart transplantation group., Conclusions: In properly selected patients, cardiomyoplasty and heart transplantation seem to be associated with improvement in survival and functional class at mid-term follow-up. Heart transplantation was more effective than cardiomyoplasty for functional class improvement.

Background: The effects of cardiomyoplasty on cardiopulmonary exercise test characteristics are not fully known., Methods and Results: We determined in 19 patients who underwent cardiomyoplasty for treatment of refractory heart failure (New York Heart Association [NYHA] functional class III) before (pre) and at 6-month follow-up (post) maximum oxygen consumption (peak VO2), NYHA functional class, and resting left ventricular ejection fraction (LVEF) (MUGA). We analyzed the results according to pre peak VO2 < or > 14 mL/kg per minute and the correlation between the changes in absolute values of LVEF and peak VO2. Pre- and post-peak VO2 values were 15.9 +/- 4.4 and 18.6 +/- 6.4 mL/kg per minute, respectively (P = .059). In the subgroup with pre-peak VO2 < 14 mL/kg per minute, the peak VO2 increased from 11.1 +/- 1.9 to 16.4 +/- 6.2 mL/kg per minute (P = .02). The subgroup with peak VO2 > 14 mL/kg per minute showed pre- and post-peak VO2 of 19.2 +/- 2.6 and of 20.1 +/- 7 mL/kg per minute, respectively (P = .06). The pre-total exercise time of the entire group increased from 688.4 +/- 222.1 to 833.7 +/- 241.6 seconds (P < .04). For the subgroup with preoperative peak VO2 < 14 mL/kg per minute, exercise time improved from 585 +/- 76.9 to 825 +/- 186.3 seconds (P < .01). In the subgroup with preoperative VO2 > 14 mL/kg per minute, the preexercise and postexercise time was 763.6 +/- 264.4 and 840 +/- 282 seconds, respectively (P = .4). Pre-LVEF increased from 20.6 +/- 3.3% to 24.2 +/- 7.8% at 6 months of follow-up (P = .02). At 6 months of follow-up, 9 patients were in NYHA functional class I and 10 were in class II. There was no correlation between LVEF values and absolute values of peak VO2 before (r = .123, P = .6) and after (r = .27, P = .2) cardiomyoplasty. A weak correlation was observed between the changes in absolute values of peak VO2 and LVEF from the preoperative to the postoperative period (r = .48, P = .048)., Conclusions: Cardiomyoplasty is a useful method for improving NYHA functional class and LVEF in patients with heart failure. Peak VO2 < 14 mL/kg per minute before cardiomyoplasty may be a selection criterion with which to determine improved exercise capacity after surgery. The effects of cardiomyoplasty on LVEF appear to be partially associated with maximum exercise capacity changes.

Background: The fundamental determinant of the natural history of Chagas' disease is cardiac involvement., Methods and Results: We studied 104 male patients with congestive heart failure due to Chagas' disease to estimate the survival distribution function and to evaluate age, functional class (FC), maximal oxygen consumption (VO2max), and ejection fraction (EF) as predictors of survival. Statistical evaluation was performed through univariate (Student's t test and chi 2 test) and multivariate analyses (Cox's regression model). Overall survival was 66% at 1 year, 56% at 3 years, and 48% at 5 years. Ages were not statistically different (P = .9811) between survivor (40.3 +/- 8.7) and nonsurvivor (40.3 +/- 9.4) groups. The ejection fraction(s) were statistically different (P = .0001) between survival (43.6 +/- 9.9) and nonsurvival (30.6 +/- 8.1) groups, as was VO2max (P = .0001) (21.0 +/- 4.7 and 15.0 +/- 4.9, respectively). Most of the surviving patients were in FC II and most of the nonsurvivors were in FC IV (P = .0001). VO2max (P = .0001) and EF (P = .0008) are highly associated with survival time in the multivariate analysis, but FC (P = .0578) is less important. Age (P = .9811) did not influence survival., Conclusions: We conclude that 50% of the patients with heart failure due to Chagas' disease die in 47 months and that VO2max and EF are important indices of survival in this group.

Purpose: To evaluate the effect on symptoms, exercise capacity (stress test) and myocardial response (Echo, and Holter) of ibopamine or captopril in patients with congestive heart failure., Methods: Double-blind, parallel randomized study of 18 patients, 9 in each group, studied during three months at the outpatient clinic. Twelve were male, 6 female, all in heart failure functional class II or III. The age ranged from 27 to 67 year-old (mean 48.7 years). The patients received captopril 50 mg tid or ibopamine 100 mg tid., Results: The patients presented clinical improvement in both groups. At the stress test there was an increase of exercise time from 9 to 17 minutes and from 12 to 16 minutes with captopril and ibopamine respectively. The Echo study showed respectively to captopril and ibopamine groups a left ventricular and diastolic diameter increase from 72 to 74 and from 74 to 75mm and a increase from 0.35 to 0.38 and from 0.35 to 0.39 of the left ventricular ejection fraction. The incidence of ventricular arrhythmias was similar in both groups., Conclusion: These data show that ibopamine improved cardiac function, increasing the cardiac output, ejection fraction and exercise time and did not increase the incidence of arrhythmias. This effect is similar to that observed with captopril.

Purpose: To evaluate patient selection for heart transplantation or dynamic cardiomyoplasty., Methods: We evaluated 380 patients from April 1991 to July 1993. The ages ranged between 16 and 68 (mean 43.5 +/- 11.46) years, 303 (79.7%) were male. The diagnoses were dilated cardiomyopathy in 163 (42.9%), Chagas' cardiomyopathy in 70 (18.4%), ischemic heart disease in 61 (16.1%), hypertensive heart disease in 40 (10.5%), valvular heart disease in 23 (6.1%), alcoholic cardiomyopathy in 12(3.2%), peripartum cardiomyopathy in 5 (1.3%) and myocarditis of unknown etiology in 5 (1.3%)., Results: The indication of heart transplantation was eventually done in 55 (14.4%), and 19 (5%) were submitted to transplantation. Dynamic cardiomyoplasty was indicated in 9 (2.3%) patients and was performed in 8 (2.1%). In 30 (7.8%) patients there were clinical contraindications for transplantation. Conventional surgical treatment was indicated for 12 (3.1%) patients: myocardial revascularization and/or ventricular aneurismectomy in 5, surgical treatment of valvular heart disease in 6 and of atrial fibrillation in 1. Socioeconomic limitations precluded transplantation in 43 (11.3%) and psychic limitations hindered transplantation in 23 (6.0%) patients. Refusal of procedure by the patient occurred in 10 (2.6%) cases. Improvement of the symptoms occurred in 69 (18.1%) patients., Conclusion: A small percentage of patients are eligible and are eventually submitted to heart transplantation or dynamic cardiomyoplasty. New strategies may be delineated during follow up, as deferring transplantation or conventional surgical treatment of ischemic or valvular heart disease. Sociopsychic evaluation is an important step in the care of the patients.

Cardiomyoplasty has recently been used as a surgical treatment for refractory heart failure, but its results have not been well described in quality-of-life patterns. We studied the quality of life of 14 patients (13 men, with a mean age of 43.3 +/- 7.4 years) submitted to this procedure for treatment of dilated or ischemic cardiomyopathies. They were approached by personal, structured interviews before and 13 +/- 9 months after the procedure, focusing on the following areas: physical activity, food and sleep patterns, working status, social activity, sexual activity, psychologic state, and perceptions and expectations about the treatment. The presence of limitation descriptors (discomfort, disability, and dissatisfaction) was recorded for all patients. The results showed an important decrease in limitation of physical activity, sleep pattern, social activity, and perceptions and expectations about the treatment. These findings suggest that cardiomyoplasty may improve the quality of life of a selected group of patients.

Purpose: To evaluate the toxicity of thiocyanate induced by the infusion of sodium nitroprusside in patients with severe congestive failure., Methods: We studied 23 patients with congestive heart failure, in class IV (NYHA) under continuous infusion of sodium nitroprusside with doses varying between 0.5 and 5.5 micrograms/kg/min. Clinical evaluation, thiocyanate serum dosage and laboratorial evaluation of renal, hepatic and pulmonary functions were done., Results: Seventeen patients (74%) presented toxic levels of thiocyanate (over 10 micrograms/ml), with the average of 29.9 +/- 4.4 micrograms/ml. Only renal function was related to the presence of intoxication. Clinical evaluation was not accurate to diagnose the thiocyanate toxicity in the patients., Conclusion: Sodium nitroprusside is potentially toxic, especially when the renal function is abnormal. Thiocyanate dosage is useful in diagnosing nitroprusside induced toxicity and then it contributes to an adequate treatment and prevention of clinical toxicity.

We report the case of 22 year-old male who developed coronary artery disease two years after orthotopic cardiac transplantation, manifested as congestive heart failure NYHA functional class III. The left ventricular radioisotopic evaluation at rest revealed worsening of left ventricular ejection fraction from 50% to 39% (normal value > or = 55%) and septal hypokinesia. The hemodynamic and coronariographic study showed two subocclusive lesions at the mid portion and distal portion of the left descending coronary artery and the patient underwent PTCA of both lesions, successfully reducing them to 30%. A new radionuclide and echocardiographic evaluation of left ventricular function at rest, showed marked improvement of global function no regional abnormalities, increasing the ejection fraction from 39% to 45%. The patient showed improvement of NYHA functional class, passing to functional class II and was discharged home. We conclude that PTCA could be performed in a successful manner in this patient.

We describe the hemodynamic and neurohormonal data during ventricular assistance device system support as a bridge to heart transplantation of one patient, 30 years old, with heart failure due to Chagas' heart disease in functional class IV. We determined the pressures in mmHg of right atrium (RA), pulmonary artery pressure (PAP), pulmonary wedge pressure (WEDGE), arterial blood pressure (AP), and the cardiac output (CO) in l/min. In addition, the blood levels of norepinephrine (Ne), renin (Re), epinephrine (Ep), lactate and the mixed venous oxygen pressure (pVO2) were determined. The CO increased from 2.14 to 3.9-4.2 l/min, the AD decreased from 26mmHg to 8mmHg, the MPAP reduced from 38mmHg to 14-24mmHg, the WEDGE reduced from 25 to 4mmHg and the AP become normal. The Ne reduced from 1927pg/ml to 983pg/ml, the lactate reduced from 99mg/dl to 22mg/dl and the pVO2 increased from 28mmHg to 43mmHg. The EP remained between 81pg/ml and 129pg/ml, the renin activity remained between 113ng/ml/hr and 136ng/ml/hr. Thus, during the ventricular assistance device system support there was a improvement in hemodynamic and neurohormonal conditions. The patient underwent successful heart transplantation.

Purpose: To study the consequences of a diet with usual salt quantity (non salt-restricted) on hospital treatment of congestive heart failure (CHF), in behalf of a better food intake., Methods: Thirty-two patients admitted to compensation of class III or IV CHF, randomly allowed to group I (2 g salt per day diet) or II (10 g salt). Hypertensive, renal failure or restrictive syndrome cases were excluded. Oral medication and water intake were standardized; furosemide dosage was adjusted on a daly basis, allowing the study of this drug's requirements in each group. Compensation of CHF was defined as a return to classes I or II without edema., Results: Group I included 14 and group II 18 patients. There was no significant difference between groups respective to the time needed for compensation of CHF (7.5 x 6.6 days, mean) percentual weight loss (12.2 x 10.0%), cumulative furosemide dosage (568 x 599 mg), mean daily furosemide dosage per kilogram of lean weight (1.43 x 1.58 mg/kg/day), and to 24-hour urinary excretion of sodium (241 x 254 mEq) and potassium (38.8 x 53.9 mEq). Small elevations of blood urea and potassium were an uniform trend. There was no significant alteration of plasmatic sodium. Food intake was adequate. There was one death for each group, from causes not directly related to CHF., Conclusion: Dietary salt intake did not adversely influence in-hospital compensation of severe CHF in studied group. In selected cases, adoption of a more liberal diet in this aspect may allow the patient a better ingestion of food.

A twenty-three years old woman, without previous heart disease developed endocarditis with negative bloods cultures on the fourth month of her third pregnancy. Fever was controlled through antibiotics, however she developed cardiac insufficiency and was submitted to surgery for replacement of aortic valve with a bioprosthesis. The post operative period showed no problems and the patient was discharged on the forty second day after admission. On the thirty ninth week of pregnancy she gave cesarean birth, without complications. The newly born, apgar 5 (1 min.) and 7 (5 min) presented signs of neurological problems, characterized on the second month as a cerebral atrophy. Among various possible factors, the most likely would be cardiopulmonary bypass circulation as the cause of the neurological malformation.

Purpose: To evaluate the behavior of single chamber stimulation system, rate responsive with vibration sensing, taking into consideration the results of long term clinical follow-up., Patients and Methods: From september 1986 to april 1989, 70 patients received pacemakers with vibration sensing. Sixty four patients (91.9%) implanted Activitrax I model and six (8.1%) Activitrax II. Thirty-one (44.3%) were men and the mean age was 51.2 years. Fifty-one patients (72.9%) had complete atrioventricular block, 11 (15.7%) sinus node dysfunction, one (1.4%) sinus node and atrioventricular disease, and one (1.4%) for therapeutic support of arrhythmia. The etiology of these dysfunctions were Chagas' disease in 31.4%, myocardiosclerosis in 35.7%, post-operative in 15.6%, post-av node fulguration in 5.8% and idiopathic in 11.5%. The group was submitted to clinic and electronic evaluation and laboratory examinations: echocardiogram, dynamic ECG, stress test and ergoespirometric test. The mean follow-up as 19.6 months., Results: Clinic evaluations: decrease in congestive heart failure functional class in 86% of the patients. No recurrence of syncopes and no cardiac deaths. Echocardiogram: increase in ejection fraction in 42% of patients. Dynamic ECG: appropriate rate response in 94.3% of patients (good cronotropic response). Ergoespirometry: increase in oxygen consumption in 75% of studied cases, Electronic evaluation: absence of generator dysfunction; complications in 18% of cases, all corrected by reprogramation., Conclusion: The single chamber cardiac stimulation system with vibration sensing showed safety, efficacy and low rate of complications.

Fourteen patients with congestive heart failure due to chronic Chagas' disease had hemodynamic studies before and 20, 40 and 60 minutes and 24 hours after intravenous amiodarone. Amiodarone was given initially as a bolus (5 mg/kg); after 1 hour a continuous infusion was maintained for 24 hours (total dose 900 to 1,050 mg). During the first hour of observation, heart rate and cardiac index decreased and mean right atrial, left ventricular end-diastolic pressures and pulmonary and systemic vascular resistances increased. Except for heart rate and mean right atrial pressure, all hemodynamic variables returned to control values at 24 hours. Thus, myocardial depression occurred with a dose of 5 mg/kg within the first hour of intravenous administration. Amiodarone must be cautiously administered by bolus, especially in patients with cardiac failure.

A multicenter double-blind placebo-controlled investigation was carried out in 42 patients with severe congestive heart failure who were given ibopamine (SB-7505), the 3,4-diisobutyryl ester of N-methyldopamine, for a period of 10 days in addition to previous treatment with digitalis and diuretics. Symptoms were evaluated by using a suitable score; some patients were submitted to an exercise test along with other clinical tests. Compared with placebo, ibopamine induced no significant changes in heart rate and arterial blood pressure. Clinical scores were lower after ibopamine than after placebo (p less than 0.01). Functional capacity, defined as the duration (in s) of a maximum symptom-limited exercise test using the ergometric bicycle with a constant 25-W workload, was significantly higher after ibopamine than after placebo (p less than 0.05). So a clear symptomatic improvement was observed after ibopamine in cardiac patients with prolongation of exercise time and reduced clinical scores. In conclusion, the results obtained, along with the slight improvement in the systolic time intervals, indicate that ibopamine is capable of improving cardiac performance in patients with advanced heart failure who display symptoms despite treatment with digitalis and diuretics.

The authors analyze the presence of active myocarditis in endomyocardial biopsies from 38 patients with chronic Chagas' disease diagnosed serologically. The patients were divided into three clinical groups of increasing severity. Group I: 13 patients with normal electrocardiograms, normal chest x-rays, and no symptoms; Group II: 13 patients with abnormal electrocardiograms and no cardiomegaly; and Group III: 12 patients with abnormal electrocardiograms, cardiomegaly and heart failure. In order to diagnose myocarditis activity, two sets of criteria were used: one mainly observing histopathologic aspects of inflammatory cells aggressing cardiac fibers; and the other counting the mean number of lymphocytes per high power microscopic field. The results of both methods showed a higher incidence of active myocarditis in the clinical group with heart failure. The present report clearly shows the important role played by activity of myocarditis in the development of heart failure in chronic Chagas' disease. Therefore, the possibility of using drugs to control early stages of the activity of the inflammatory process is suggested. On the other hand, endomyocardial biopsy (EMB) seems to be an adequate method to evaluate the intensity of the cardiac inflammatory process in Chagas' heart disease.

Thirty nine patients with cardiomyopathy were evaluated by a hemodynamic study at rest and during isotonic exercise. These patients were divided into two groups on the basis of their left ventricular ejection fraction (LVEF): A, control group (LVEF greater than 40%, N = 19); B, severe congestive heart failure group (LVEF less than or equal to 40%, N = 20). Patients in group A showed adequate cardiovascular responses to exercise, i.e. increased cardiac index (80%) and stroke volume index (17%), decreased systemic vascular resistance (36.8%) but no significant change in pulmonary arteriolar resistance values. In contrast, patients in group B showed a slight and heart rate-dependent increase in cardiac index (38.5%), no improvement of stroke volume index (-3.4%), decreased systemic vascular resistance (21.6%) and increased pulmonary arteriolar resistance (41.2%) with exercise. This group also showed a significant increase in right atrial pressure that might reflect a decrease in right ventricular performance secondary to an abnormal pulmonary vascular response during exercise.