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Summary Background COVID-19 can lead to multiorgan failure. Dapagliflozin, a SGLT2 inhibitor, has significant protective benefits for the heart and kidney. We aimed to see whether this agent might provide organ protection in patients with COVID-19 by affecting processes dysregulated during acute illness. Methods DARE-19 was a randomised, double-blind, placebo-controlled trial of patients hospitalised with COVID-19 and with at least one cardiometabolic risk factor (ie, hypertension, type 2 diabetes, atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease). Patients critically ill at screening were excluded. Patients were randomly assigned 1:1 to dapagliflozin (10 mg daily orally) or matched placebo for 30 days. Dual primary outcomes were assessed in the intention-to-treat population: the outcome of prevention (time to new or worsened organ dysfunction or death), and the hierarchial composite outcome of recovery (change in clinical status by day 30). Safety outcomes, in patients who received at least one study medication dose, included serious adverse events, adverse events leading to discontinuation, and adverse events of interest. This study is registered with ClinicalTrials.gov , NCT04350593 . Findings Between April 22, 2020 and Jan 1, 2021, 1250 patients were randomly assigned with 625 in each group. The primary composite outcome of prevention showed organ dysfunction or death occurred in 70 patients (11·2%) in the dapagliflozin group, and 86 (13·8%) in the placebo group (hazard ratio [HR] 0·80, 95% CI 0·58–1·10; p=0·17). For the primary outcome of recovery, 547 patients (87·5%) in the dapagliflozin group and 532 (85·1%) in the placebo group showed clinical status improvement, although this was not statistically significant (win ratio 1·09, 95% CI 0·97–1·22; p=0·14). There were 41 deaths (6·6%) in the dapagliflozin group, and 54 (8·6%) in the placebo group (HR 0·77, 95% CI 0·52–1·16). Serious adverse events were reported in 65 (10·6%) of 613 patients treated with dapagliflozin and in 82 (13·3%) of 616 patients given the placebo. Interpretation In patients with cardiometabolic risk factors who were hospitalised with COVID-19, treatment with dapagliflozin did not result in a statistically significant risk reduction in organ dysfunction or death, or improvement in clinical recovery, but was well tolerated. Funding AstraZeneca.

Diretrizes da Sociedade Brasileira de Cardiologia sobre Angina Instavel e Infarto Agudo do Miocardio sem Supradesnivel do Segmento ST – 2021

1. Introducao Atualmente, ha grande variedade de estrategias intervencionistas – tanto transcateter, quanto cirurgicas – que podem ser indicadas para pacientes portadores de valvopatia cardiaca, com objetivo de reducao da morbimortalidade associada a esta doenca. O correto momento de indicacao e o tipo de tratamento intervencionista estao atrelados ao preciso diagnostico anatomico e funcional da valvopatia cardiaca e a uma minuciosa avaliacao global do paciente. Estas Diretrizes Brasileira de Valvopatias de 2020, alem da compilacao de evidencias cientificas e opiniao [...]

LDL-C como fator de risco A causalidade entre LDL-C plasmatico e a reduzida captacao mediada pelo receptor de LDL-C na fisiopatologia da DCV tem sido estabelecida com muita consistencia. Para pacientes com muito alto risco de eventos prematuros, incluindo aqueles com hipercolesterolemia familiar (HF), LDL-C elevado e um fator de risco extremamente prevalente. […] Indicacoes do Uso de Inibidores da PCSK9 em Pacientes com Alto Risco e Muito Alto Risco Cardiovascular

Necrotizing fasciitis is a rare soft tissue infection and a life-threatening emergency, often fatal. Its incidence and management are described plentifully in the medical literature regarding the most common anatomical sites involved like the abdomen, lower and upper limbs, and perineum. However, available data and case reports of chest wall necrotizing fasciitis after thoracic procedures are scarce, mainly after major cardiac operations. We report and discuss a case of necrotizing fasciitis of the chest wall occurring in the immediate postoperative period of a cardiac procedure, and include a brief review of the concepts, pathophysiology, and treatment reported in the medical literature. We emphasize the need for early diagnosis and urgent and effective surgical debridement. Of importance is the fact that we have not found any references in the literature to cases similar or equal to the one we describe here, which occurred in the postoperative period of a cardiac procedure.

O tratamento clínico das dissecções agudas da aorta do tipo B tem mortalidade em torno de 25% menor que a mortalidade cirúrgica. O tratamento cirúrgico das dissecções crônicas também produz uma morbidade e mortalidade elevadas. A utilização de "stents"auto-expansíveis endovasculares pode ser uma nova alternativa no tratamento destas lesões. De abril a dezembro de 1998 foram implantados 15 "stents" endovasculares, 10 em dissecções agudas e 5 em crônicas. A idade dos pacientes variou entre 48 e 75 anos (média=60,53±9,73 anos) com 66,6% do sexo masculino. Os pacientes foram submetidos à esternotomia mediana, circulação extracorpórea (CEC) com hipotermia profunda (18° - 20°C), parada circulatória total (PCT) e perfusão cerebral retrógrada (PCR). A aorta transversa foi incisada e implantado o "stent" na aorta descendente sob auxílio de aortoscopia. Foram analisados os tempos de CEC, pinçamento aórtico, PCT, PCR, reaquecimento, ventilação mecânica, internação, sangramento trans e pós-operatório, reposição sangüínea, gasometria, curva de eventos e sobrevida. A mortalidade hospitalar (30 dias) foi de 6,6%; 2 pacientes foram reoperados com 3 e 6 meses após a operação com dissecção da aorta ascendente e aneurisma roto distal ao "stent". Quatorze vêm sendo acompanhados com 1 a 8m de evolução, sendo que 85,7% estão livres de eventos e curva de sobrevida de 93,1%(240 dias). Concluímos que o implante de "stent"intraluminais auto-expansíveis apresentou mortalidade menor na fase aguda da doença (6,6%) comparada à nossa experiência anterior com o tratamento clínico (30%). Apesar da amostra ser pequena, o procedimento parece ser promissor e necessita mais acompanhamento. The clinical treatment of acute type B aortic dissection has a mortality of about 25%, therefore, less than surgical mortality. The surgical treatment of chronic dissections also produces a high morbidity and mortality. The use of self-expanding endovascular stents offers a new alternative for the treatment of this disease. From April to December 1998, 15 endovascular stent grafts were implanted, 10 in acute dissections and 5 in chronic aneurysms. Ages ranged from 48 to 75 years (mean = 60.53±9.73 years), with 66.6% males. The patients were submitted to medium sternotomy, extracorporeal circulation (ECC), with deep hipothermia (18°-20°C), total circulatory arrest (TCA), and retrograde cerebral perfusion (RCP). The transverse aorta was incised and the stent was implanted in the descending proximal aorta with the aid of aortoscopy. The times of ECC, aortic clamping, TCA, RCP, rewarming, mechanic ventilation, hospitalization, trans and post-operative bleeding, blood replacement, arterial samples, event curve and survival curve were analysed. The hospital mortality (30 days) was 6.6%; two patients were reoperated 3 and 6 months after surgery with aortic ascending dissection and new distal aneurysm to the stent, 14 have been followed up from 1 to 8 months post-operative, 85.7% are free of events with a survival curve of 93.1% (240 days). We conclude that the self-expanding intraluminal stents implant presented a lower mortality during the acute stage of the disease (6.6%) compared to our previous experience with clinical treatment (30%). In spite of the small sample the procedure seems to be promising and needs more follow up.

Objective: To compare in-hospital outcomes in aortic surgery in our cardiac surgery unit, before and after foundation of our Center for Aortic Surgery (CTA). Methods: Prospective cohort with non-concurrent control. Foundation of CTA required specialized training of surgical, anesthetic and intensive care unit teams, routine neurological monitoring, endovascular and hybrid facilities, training of the support personnel, improvement of the registry and adoption of specific protocols. We included 332 patients operated on between: January/2003 to December/2007 (before-CTA, n=157, 47.3%); and January/2008 to December/2010 (CTA, n=175, 52.7%). Baseline clinical and demographic data, operative variables, complications and in-hospital mortality were compared between both groups. Results: Mean age was 58±14 years, with 65% male. Group CTA was older, had higher rate of diabetes, lower rates of COPD and HF, more non-urgent surgeries, endovascular procedures, and aneurysms. In the univariate analysis, CTA had lower mortality (9.7 vs. 23.0%, P=0.008), which occurred consistently across different diseases and procedures. Other outcomes which were reduced in CTA included lower rates of reinterventions (5.7 vs 11%, P=0.046), major complications (20.6 vs. 33.1%, P=0.007), stroke (4.6 vs. 10.9%, P=0.045) and sepsis (1.7 vs. 9.6%, P=0.001), as compared to before-CTA. Multivariable analysis adjusted for potential counfounders revealed that CTA was independently associated with mortality reduction (OR=0.23, IC 95% 0.08 – 0.67, P=0.007). CTA independent mortality reduction was consistent in the multivariable analysis stratified by disease (aneurysm, OR=0.18, CI 95% 0.03 – 0.98, P=0.048; dissection, OR=0.31, CI 95% 0.09 – 0.99, P=0.049) and by procedure (hybrid, OR=0.07, CI 95% 0.007 – 0.72, P=0.026; Bentall, OR=0.18, CI 95% 0.038 – 0.904, P=0.037). Additional multivariable predictors of in-hospital mortality included creatinine (OR=1.7 [1.1-2.6], P=0.008), urgent surgery (OR=5.0 [1.5-16.7], P=0.008) and thoracoabdominal aneurysm (OR=24.6 [3.1-194.1], P=0.002). Conclusion: Thoracic aorta surgery in specialized center was associated with lower incidence of complications and all-cause mortality as compared to usual care. Objetivo: Comparar desfechos intrahospitalares em pacientes submetidos a cirurgia da aorta torácica e toracoabdominal, antes e após a constituição do Centro Especializado de Tratamento da Aorta (CTA). Métodos: Coorte prospectiva com controle não contemporâneo. A criação do CTA envolveu treinamento cirúrgico especializado, sala híbrida, monitorização neurológica, capacitação de pessoal de apoio, aperfeiçoamento dos registros e uso de protocolos específicos. Foram incluídos 332 pacientes operados em 2 períodos: janeiro/2003 a dezembro/2007 (pré-CTA, n=157, 47,3%); e janeiro/2008 a dezembro/2010 (CTA, n=175, 52,7%). As características demográficas, clínicas, dados cirúrgicos, complicações e mortalidade hospitalar foram comparados nos 2 grupos. Resultados: A idade média foi 58±14 anos, com 65% sexo masculino. O grupo CTA teve idade, prevalência de diabete (DM) e glicemia maiores; menor prevalência de doença pulmonar obstrutiva crônica e insuficiência cardíaca; maior proporção de aneurismas e cirurgias eletivas; e mais procedimentos endovasculares que o pré-CTA. Na análise univariada, o grupo CTA mostrou redução de mortalidade (9,7% x 23,0%, P=0,008), que foi consistente nos diferentes subgrupos estratificados por patologia e por procedimento. O grupo CTA teve também redução de reoperações (5,7% x 11%, P=0,046), complicações maiores (20,6% x 33,1%, P=0,007), acidente vascular cerebral (4,6% x 10,9%, P=0,045) e sepse (1,7% x 9,6%, P=0,001), comparado ao pré-CTA. Na análise multivariada, o CTA se associou de forma independente a redução de mortalidade hospitalar (OR=0,23, IC 95% 0,08 - 0,67, P=0,007). A redução de mortalidade do CTA também ocorreu na análise estratificada por patologia (cirurgias de aneurisma, OR=0,18, IC 95% 0,03 - 0,98, P=0,048; cirurgias de dissecção, OR=0,31, IC 95% 0,09 - 0,99, P=0,049) e por procedimento (híbridos, OR=0,07, IC 95% 0,007 - 0,72, P=0,026; Bentall, OR=0,18, IC 95% 0,038 – 0,904, P=0,037). Também foram preditores independentes de mortalidade a creatinina pré-operatória (OR=1,7, IC 95% 1,1-2,6, P=0,008), a cirurgia de urgência (OR=5,0, IC 95% 1,5-16,7, P=0,008) e o aneurisma toracoabdominal (OR=24,6, IC 95% 3,1-194,1, P=0,002). Conclusão: O tratamento cirúrgico de patologias da aorta torácica e toracoabdominal em centro especializado, em comparação ao tratamento usual, se associou a menor incidência de complicações e mortalidade global.

Results We included 192 octogenarians (83±3y, 53% male, EF 61 ±13%. ES I=10,1 [7,9-17,2] , ES II=3,6 [2,6-5,5]. Surgeries included CABG (35,9%), Valve (41,1%), CABG + valve (44, 22,9%). The observed in-hospital outcomes were: early reoperation (5,2%), MACCE (12,5%), in-hospital mortality (12,0%). ES II was higher in CABG + valve group compared to isolated CABG and valve groups (6,1±4,8% vs 4,2±3,6% e 4,5±3,4%, p=0,028). Corresponding observed mortality rates were 20,5%, 11,6%, and 7,6% (p=0,108). Clinical performance of ES II was poor. O/E ratio was: entire cohort (2,55), CABG (2,76), Valve (1,69), CABG + valve (3,36), p 15). Calibration of ES II in these strata were 0; 2,88; 2,50; e 2,6, respectively (Hosmer-Lemeshow p

Holt-Oram syndrome was first described in 1960 as an association of familial heart disease and musculoskeletal abnormalities. The most important findings include atrial septal defects, atrioventricular conduction abnormalities, vascular hypoplasia, and upper limb musculoskeletal deformities. We report two patients with this syndrome in the same family and discuss the variability of the musculoskeletal abnormalities and their association with the cardiac morphologic defects. Both patients in this study had associated eosinophilia, which has not been reported in the literature.

Newer oxygenators with the latest technologies are designed to attenuate the immune response, including lymphopenia, prompted by cardiopulmonary bypass (CPB) in cardiac surgery. We evaluated the effect of CPB, comparing an oxygenator with a venous-arterial shunt and a conventional oxygenator with regard to lymphocyte's early activation and apoptosis induction and its implications in post-CPB lymphopenia. Patients undergoing coronary artery bypass graft surgery with CPB, using either a conventional oxygenator or one with a venous-arterial shunt, had blood samples drawn at anesthetic induction (baseline); the beginning and end of the CPB; and at 6, 12, and 24 hours after surgery. Analysis by flow cytometry was undertaken to assess the expression of lymphocyte surface markers (CD3+, CD25+, CD26+, CD69+) and apoptosis (annexin V). Twenty patients were studied; 10 used a conventional oxygenator, and 10 used an oxygenator with venous-arterial shunt. Postoperative lymphopenia (50% decrease), 35% increased expression of CD69+, and 56% decrease in annexin V were significant comparing baseline to 24 hour value, similarly in both groups. Early activation (expression of CD69+) and degree of apoptosis (expression of annexin V) of lymphocytes after CBP in cardiac surgery was similarly observed in both types of oxygenators. The observed lymphopenia after CPB does not appear to be secondary to apoptosis.

Objective - To assess the effectiveness of metoprolol in preventing clinically detectable atrial fibrillation (AF) and flutter after coronary artery bypass graft (CABG) surgery . Methods - An open, randomized study was carried out to treat 200 patients who had undergone isolated CABG surgery with extracorporeal circulation. The patients were randomized to either receive metoprolol orally or not to receive the medication in the postoperative period. The outcomes were the detection of sustained atrial AF and flutter, which were symptomatic or required treatment. The patients with the following characteristics were excluded from the study: baseline left ventricular ejection fraction < 35%; previous AF; history of bronchospasm; second- and third-degree atrioventricular blocks, low cardiac output, and heart failure. Results - Arrhythmias occurred in 11 out of 100 patients in the metoprolol group and in 24 out of 100 patients in the control group (P=0.02). The relative risk (RR) was 0.46 (95% CI = 0.24-0.88), and the number necessary to treat (NNT) and avoid the outcome was 8 patients. AF was the arrhythmia most frequently observed (30/35). In 38 patients aged 70 years or more, the arrhythmias occurred in 2 out of 19 patients in the metoprolol group and in 10 out of 19 patients in the control group (χ2 Yates: P=0.01). The relative risk was 0.20 (95% CI = 0.05-0.79) and the number necessary to treat was 2 patients. Conclusion - Metoprolol is effective in preventing AF and flutter in the postoperative period of CABG surgery, and this effect was more evident in the group of elderly patients.

Cardiac angiosarcomas are malignant tumors that almost invariably have a short and fatal evolution. The therapeutic approach includes surgery, chemotherapy, and radiation therapy, alone or in combination. Heart transplantation is an attractive option in nonresectable tumors, even though the current experience is still limited. However, in most patients, the diagnosis is still established late, and survival is only slightly altered by the proposed treatments, mainly due to previously existing and undetected metastases. We report a case that illustrates the therapeutic dilemma faced with this neoplasia, and we discuss the case based on a literature review.

OBJETIVO: Analisar os resultados e a viabilidade da ventriculectomia parcial esquerda (VPE) como ponte para transplante cardíaco (TX). DELINEAMENTO: Estudo de coorte histórica e prospectivo. CASUÍSTICA E MÉTODOS: Cinquenta e três pacientes (pts) foram submetidos a VPE em um período de 5 anos. Destes, 7 pts com contra-indicação inicial ao TX, idades variando de 37 a 64 anos, 5 homens e 2 mulheres, com miocardiopatia dilatada, foram subseqüentemente relistados e transplantados. Foram analisados a fração de ejeção (FE), o diâmetro diastólico final do ventrículo esquerdo (DDFVE), a CF da NYHA, o consumo máximo de oxigênio (VO2 máx) e os escores de qualidade de vida (QV) antes da VPE, aos 3 e 6 meses, e pré-transplante. RESULTADOS: Os valores expressos a seguir referem-se, respectivamente, àqueles obtidos antes da VPE, aos 3 e 6 meses e antes do TX. Variação da CF da NYHA: 3,71±0,49, 2,57±1,13 (p=0,011), 3,0±1,29 e 3,86±0,38. Evolução da FE: 25,17±6,15, 35,5±8,41 (p=0,013), 32,33±7,12 e 26,17±3,76. Variação do DDFVE: 79,16±10,85, 67,66±9,2, 65,83±9,57 e 64,25±8,99. O VO2 máx era de 8,12±3,47 antes da VPE e de 13,2±7,75 aos 6 meses (p=0,068). Variação dos escores de QV: 4,29±1,25, 3,0±1,41 (p=0,050), 3,29±1,8 e 4,57±1,13. Foram transplantados 7/53 pts (13,20%). A sobrevida, até a data do transplante, variou de 7 a 37 meses (18,71±11,78 meses). O seguimento foi de 100%. CONCLUSÃO: A curto prazo melhoraram a CF da NYHA, a QV, o VO2 máx, o DDFVE e a FE dos pts. Estes resultados sugerem a possibilidade da indicação da VPE como ponte para TX. Entretanto, a mortalidade elevada no primeiro semestre pós-operatório limita a sua indicação rotineira como ponte para TX. Estudos futuros poderão validar ou não esta possibilidade. OBJECTIVE: To assess the suitability of Partial Left Ventriculectomy (PLV) as a bridge to transplantation. BACKGROUND: Cohort study, prospective. MATERIAL AND METHODS: Fifty-three patients were submitted to PLV in a time frame of 5 years. Seven out of 53 patients, ages ranging from 37 to 64 years old, 5 males and 2 females, all with idiopathic dilated cardiomyopathy, were transplanted afterwards. Ejection fraction, NYHA functional classes, maximum oxygen consumption, left ventricular end-diastolic diameter and Quality of Life Scores were analysed preoperatively and then at three and six months and immediately before transplantation. RESULTS: The numerical values mentioned below are referred to the data obtained pre-ventriculectomy, at 3 and 6 postoperative months and immediately before transplantation. NYHA functional classes: 3.71 ± 0.49, 2.57 ± 1.13 (p=0.011), 3.0 ± 1.29 and 3.86 ± 0.38. Ejection fraction: 25.17 ± 6.15, 35.5 ± 8.41 (p=0.013), 32.33 ± 7.12 and 26.17 ± 3.76. Left ventricular end-diastolic diameter: 79.16 ± 10.85, 67.66 ± 9.2, 65.83 ± 9.57 e 64.25±8.99. Maximum VO2 was 8.12 ± 3.47 pre-VPE and increased to 13.2 ± 7.75 at six months (p=0.068). Quality of life scores: 4.29 ± 1.25, 3.0 ± 1.41 (p=0.050), 3.29 ± 1.8 e 4.57 ± 1.13. 7/53 patients (13.20%) were subsequently transplanted. Survival time, from PLV up to TX ranged from 7 to 33 months (18.71±11.78). Follow-up was 100%. CONCLUSION: Improvement in quality of life, NYHA functional classes and maximum VO2 consumption, as well as increase in ejection fraction and sustained decrease in left ventricular end-diastolic diameter, in short-term, can benefit patients previously excluded from TX and bring them back to the awaiting list. However, high immediate mortality rates in overall casuistry can limit its routine indication as a biological bridge to transplantation.

Objetivos: Avaliar a indicação, sobrevida, qualidade de vida e arritmias após Ventriculectomia Parcial Esquerda (VPE) e relatar seu uso como ponte para transplante. Casuística e Métodos: Quarenta e um pacientes (pt) operados no período de dezembro de 1994 a dezembro de 1997,com idades de 32 a 70 anos, com miocardiopatia dilatada, classe funcional IV-92,6% e III-7,3% com contra-indicação para transplante e má qualidade de vida. Ecocardiogramas e estudos eletrofisiológicos (EEF) pré e pós-operatórios foram realizados. Clinicamente, agrupados pela NYHA e pelo Protocolo de Qualidade de Vida (QV). Resultados: Em 15 pacientes examinados aos 30 e 90 dias de pós-operatório por ecocardiograma obtivemos os dados da tabela abaixo: Sobrevida de 66%, 53%, 40% e 36,6% aos 3, 6, 12 e 24 meses, respectivamente. Aos 3 anos a mortalidade imediata e tardia é de 21,5 % e 42,1%,com total de 63,6 %. Menor mortalidade relacionada a arritmia quando não se conseguiu induzí-la no pós-operatório. A qualidade de vida melhorou (72,7 % em NYHA I e II e 81,8% em QV I e II) e dois foram transplantados posteriormente. Conclusões: Melhoraram a dinâmica cardíaca, a QV e a classe funcional (NYHA).O EEF identificou pacientes com maior risco de arritmias pós-operatórias. A sobrevida de 36% em 3 anos é encorajadora, levando-se em conta a gravidade dos casos. A seleção de pacientes não tem ainda critérios inequívocos. Background: Batista Partial Left Ventriculectomy has been used as a surgical alternative in the treatment of end-stage heart failure. However as a novel procedure it ensues many questions and answers. Objectives: To evaluate surgical indication, survival, quality of life and the incidence of lifethreatening or fatal arrhythmias after partial left ventriculectomy and report its availability as a biological bridge to transplantation. Material and Methods: Forty-one patients were operated on from December 1994 to December 1997, ages ranging from 32 to 70 years, in whom a diagnosis of dilated cardiomyopathy was established. NYHA functional class IV (92.6%) and III (7.3%), contraindication to heart transplantation and poor quality of life were part of the inclusion criteria. Echocardiograms and electrophysiologic studies (EPS) were performed. They were clinically grouped according to their NYHA functional class and categorized concerning our own quality of life protocol. Results: A group of 15 patients showed sustained decrease in heart dimensions and functional parameters at 30 and 90 postoperative days, as follows: where FE = fractional shortening, EF = ejection fraction, LVED = left ventricular end-dimensions both diastolic and systolic. Survival was 66%, 53%, 40% and 36.6% at 3, 6, 12 and 24 months of follow-up, respectively. At the conclusion of this 3 year period the immediate and late mortalities are 21.5 % and 42.1 %, with an overall mortality of 63.6%. EPSs probably can predict less mortality rate due to ventricular arrhythmias when those are not induced postoperatively. Quality of life was better postoperatively (72.7 % in NYHA classes I and II and 81.8% in QOL I and II) and two patients were transplanted after primary PLVs. Conclusions: Cardiac dynamics, Quality of Life and NYHA functional classes improved in all survivors. EPSs can provide useful information concerning the probability of fatal ventricular arrhythmias and the need for implantable cardioverter-defibrillators. Survival is encouraging if we keep in mind the seriousness of this cohort of patients. Patient selection is still controversial.

A insuficiência cardíaca congestiva refratária a tratamento clínico tem no transplante cardíaco ortotópico a sua melhor opção cirúrgica. Escassez de doadores, morbidade significativa associada com a terapêutica anti-rejeição, aterosclerose coronária e custos consideráveis associados com o transplante são fatores responsáveis pela sua limitada aplicação. Para os que se encontram na lista para transplante, o período de espera de 6 meses a 1 ano pode levar à deterioração hemodinâmica e expressivo número de mortes. A sobrevida, na lista de espera, pode ser de 46% em 1 ano (1). Afora isso, um significativo número de pacientes tem contra-indicação para transplante, por apresentar hipertensão e resitência pulmonar elevadas. A ventriculectomia parcial esquerda (VPE) (2, 3), restaurando o raio do ventrículo esquerdo e melhorando, assim, a relação massa-volume e o desempenho sistólico, pode propiciar diminuição da pressão e da resistência arterial pulmonar, em alguns pacientes.Medically refractory heart failure is traditionally managed with cardiac transplantation although some limited success has also been obtained in selected patients with alternative surgical options. Scarce donors, significant morbidity secondary to the antirejection therapy, post-transplantation coronary disease and the high costs of transplantation programs, all together are limiting factors. For those on the waiting list of transplantation the one year mortality may be as high as 46%. Furthermore, a significant number of patients have contraindication to transplantation due to severe pulmonary arterial hypertension and elevated pulmonary vascular resistance. Partial Left Ventriculectomy (PLV) attempts to relieve symptoms of congestive heart failure by reducing left ventricular dimensions and mass and restoring the normal mass-to-volume ratio of the left ventricle. As a consequence, cardiac index and forward ejection fraction increase thus unloading the pulmonary vascular bed. The ultimate result is a decrease in both pulmonary arterial pressure and resistance, in some patients.

A estimulação de dupla câmara (DDD) com eletrodo único usando eletrodo atrial flutuante está limitada em função dos altos limiares encontrados para captura atrial. Avaliamos um sistema novo de cabo eletrodo para estimulação atrial que utiliza dois anéis atriais com pulsos de onda quadrada simultâneos unipolares lançados com polaridade oposta. O primeiro pulso é aplicado ao pólo distal do eletrodo e é positivo, o segundo pulso é aplicado ao pólo proximal do eletrodo e é negativo, ambos em relação à carcaça do gerador. O atraso entre os dois pulsos é programável entre 0,0 ms e 1,0 ms. A distância entre os anéis a nível atrial é de 10 mm e a distância entre o pólo distal atrial e o eletrodo ventricular unipolar pode ser selecionado entre 11, 13 e 15 cm. O posicionamento dos anéis a nível atrial é selecionado de acordo com a medida do limiar de estimulação do pulso bifásico simultâneo, incluindo manobras respiratórias para confirmar a captura/sense contínuos. O gerador de pulso tem uma única conexão para o eletrodo e a capacidade de aplicar os pulsos programáveis de onda quadrada com polaridades opostas, com atrasos programáveis de 0,0 a 1,0 ms. O gerador pode ser programado para estimulação VDD com eletrodo único. Este sistema foi implantado em 4 pacientes com bloqueio AV total e função sinusal normal. Os limiares de estimulação atrial e diafragmático foram medidos com várias configurações do pulso, larguras e atrasos, intra e pós-operatórios. A porção média do átrio direito foi selecionada como a melhor posição para os anéis atriais com captura contínua durante inspiração profunda. As medidas intra-operatórias e pós-operatórias (48 horas) foram: Limiar Intra-operatório Pós-operatório atrial unipolar 3,2 + 0,47 V não realizada atrial (bifásico simultâneo) 1,6 + 0,37 V 3,37 + 0,84 V diafragmático acima de 7 V 5,21 + 0,3 V sense de onda P 2,35 + 1,3 mV 1,27 + 0,8 mV Os pacientes tiveram alta com o gerador programado no modo VDD. A evolução de 30 dias após o implante mostrou perda de captura atrial transitória durante inspiração em 1 paciente, apesar da ausência de outras variações no limiar, comparado com a evolução de 48 horas pós implante. Em conclusão, a estimulação bifásica simultânea reduz o limiar de estimulação atrial, ao mesmo tempo em que mantém o sense atrial adequado com uma margem de segurança em relação à estimulação diafragmática. Single lead, dual chamber (DDD) pacing with an atrial floating electrode is limited by high atrial capture thresholds. We evaluated a new atrial stimulation lead with two atrial ring electrodes on a single lead and overlapping unipolar square wave pulses of an opposite polarity. The first pulse is applied to the distal electrode and is positive, the second pulse is to the proximal electrode and is negative, both with respect to the pacemaker housing. The delay between the two pulses is programmable between 0.0 ms to 1.0 ms. The distance between the atrial electrode rings is 10 mm and the distance from the distal atrial ring to the unipolar ventricular electrode can be selected to be 11, 13 or 15 cm. The positioning of the atrial ring is selected according to the measured overlapping biphasic pulse thresholds, including respiratory maneuvers to confirm continuous capture/sensing. The pulse generator has a single lead connection and the capability of delivering the two atrial square wave opposite programmable pulses, with delays from 0.0 to 1.0 ms. The generator may be programmed to the single lead unipolar VDD mode. This system was implanted in 4 patients with complete AV block with normal sinus mode fuction. Atrial and diaphragmatic thresholds for various pulse configurations, widths and delays were measured intra and postoperatively. The midportion of RA was selected as the best location for the atrial rings with continuous capture during deep inspiration. The intra and postoperative (48hrs) measurements were: Threshold Intra-op POstop. (48hrs) Atrial unipolar 3.2 + 0.47 V not measurable Atrial (overlapping biphasic) 1.6 + 0.37 V 3.37 + 0.84 V Diaphragmatic above 7 V 5.21 + 0.3 V wave sensing 2.35 + 1.3 mV 1.27 + 0.8 mV The patients were discharged in the VDD mode. Evaluation thirty days after showed transient loss of atrial capture during inspiration in one patient in spite of absence of other threshold changes compared to the 48 hours evaluation. In conclusion, overlapping biphasic stimulation reduces the atrial pacing thresholds while maintaining adequate atrial sensing with a safe margin regarding diaphragmatic stimulation.

Results We included 235 pts (61±13y, 66%male). Group 1 (aneurysms 61%) and Group 2 (dissections, ulcer, hematoma 36%). Others: 3%. Procedures: aortic root replacement (26,5%), Bentall procedure (23,5%), endovascular (28%), hybrid surgery (19%), aortoplasty and Tirone (3%); concomitant procedures in 20% of cases. Group 2 had higher BP, more urgent and hybrid procedures, greater pump/ ischemia time, smaller aortic size and less Bentall procedure. Mortality was 8,5% (Group 1, 4,6%; Group 2, 15,5%, p=0,004). Rate of MACCE was 19,2% (Group 1, 11,3%; Group 2, 33,7%, p < 0,001). Reoperation occurred in 7,3%, complications 34,2%, stroke 4,3%, AKIN 7,3%, respiratory complications 15,9%. Medullary ischemia developed in 2 patients (0,8%). By multivariate logistic regression, independent predictors of death were hybrid procedure [OR = 7,51 (1,05–53,4) p = 0,044], aortic size [OR = 1,05 (1,02-1,10) p = 0,005] and pump time [OR=1,10 (1,01–1,20) p = 0,034]; predictors of MACCE were urgent surgery [OR = 7,17 (1,10-49,5) p = 0,045], combined aneurysms [22,4 (1,42-353) p = 0,027], and concomitant mitral valve surgery [OR = 46,5 (1,3-166) p = 0,035]. Endovascular procedure was independently associated with reduction of MACCE incidence [OR = 0,05 (0,004-0,730) p = 0,045].

Introducao A indicacao da intervencao cirurgica ou percutânea no paciente com doenca valvar esta atrelada ao preciso diagnostico anatomico e funcional, alem do conhecimento da historia natural da doenca. Nesta atualizacao da Diretriz Brasileira de Valvopatias de 2011, sao contemplados apenas pacientes com valvopatia anatomicamente importante (estagios C e D da Diretriz da American College of Cardiology (ACC)/ American Heart Association (AHA), de 2014). As tabelas e fluxogramas que aqui constam demonstram passos sequenciais que norteiam o diagnostico anatomico, etiologico [...]