1998;71(6) – ABC CARDIOL

Relato de Caso

Absence of the right atrioventricular connection. Morphological and clinical presentation when the dominant ventricle is morphologically right

José Fernando Cavalini et al. Vera Demarchi Aiello Munir Ebaid

Absent right atrioventricular connection, with the left atrium connected to a dominant left-sided morphologically right ventricle is a rare situation. We report five cases with these anatomical features, with emphasis on the morphological and clinical aspects. Although this combination of lesions is very uncommon, the sequential segmental analysis can easily provide an accurate description of the anomaly.

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Quantification of mitral prosthesis regurgitation by transesophageal echocardiography. Evaluation of different methods

Cláudio Henrique Fischer et al. Orlando Campos Fº Valdir Ambrósio Moisés José Marconi Almeida Sousa … Cristiano Vieira Machado Edgar Bezerra de Lira Fº José Lázaro de Andrade Antonio Carlos de Camargo Carvalho Dirceu Vieira Santos Fº

PURPOSE: To evaluate the different methods for grading mitral regurgitation (MR) by transesophageal echocardiography (TEE) in patients with clinical suspicion of mitral prosthesis dysfunction. METHODS: Cardiac catheterization (Cath) was performed in 15 patients for grading the severity of prosthetic MR, divided in two groups based on the presence or absence of severe MR. Prosthetic MR was quantified by TEE using methods commonly used for MR of native valves: subjective assessment by color Doppler, objective assessment based on absolute jet area and on its relative area (jet area/left atrial area) and assessment based on the presence of systolic flow reversal in pulmonary vein. RESULTS: Prosthetic MR was mostly transprosthetic (14 patients) and eccentric (11 patients). There was significant correlation (p7cm²) and relative (jet area >35% of left atrial area) jet areas did not reveal significant correlation with the angiographic grade and showed clear underestimation by TEE when the last method was used. However, there was good correlation (p30% were considered as cut point. CONCLUSION: TEE correctly identified angiographic severe mitral prosthesis regurgitation, mainly by the presence of systolic flow reversal in pulmonary vein and subjective assessment. The estimation of severity of the prosthetic MR by absolute or relative jet area seems to be limited and should be used with caution due to eccentricity of the regurgitant jet, frequently seen in mitral prosthesis dysfunction.

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The significance of alcohol abstinence in alcoholic cardiomyopathy with moderate left ventricular dysfunction

Francisco Manes Albanesi Fº et al. Márcia Bueno Castier Silvia Helena Cardoso Boghossian Tatiana Tavares da Silva

PURPOSE: To evaluate the role of a 12 month alcohol abstinence period in patients with moderate left ventricular dysfunction treated with anticongestive therapy. METHODS: Prospective observational study with 20 patients with alcoholic cardiomyopathy (ACM), 9 (45%) in functional class (FC) II and 11 (55%) in FC III, 16 (80%) men, mostly black (55%), from 35 to 56 (x=45) years old, heavy alcohol users (>80g ethanol for 51 to 112 (x=88) months. At the beginning, all agreed to participate with psychotherapy and clinical evaluation. After 12 months, they were divided in G-I, formed by those who remained abstemious and G-II of non-abstemious. RESULTS: After 12 months, among the 11(55%) who remained in psychotherapy, 8 were in G-I, among those who did not 9 (45%), only 2 (22,22%) remained abstemious (G-I). At the end of the evaluation period, both groups had the same number of patients. Comparing them, we observed: a) lower mean systolic and diastolic left ventricular diameters in G-I; b) more hospitalizations in G-II (3); c) more patients with stable or better clinical evolution in G-I. CONCLUSION: Despite the initial will, only 50% reached abstinence. When it was reached, patients had a better evolution in left ventricular systolic diameter and abstinence should always be tried even in the presence of moderate left ventricular dysfunction.

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Myocardial revascularization surgery through a left minithoracotomy

Wilson Luiz da Silveira et al. Adélio Ferreira Leite Ersival Pereira Artiaga Fernando César Queiroz … Keyla Alves Ferreira Maria Cristina de Carvalho Márcio Alves da Silva Marcus Abdulmassih del Papa Lincoln Henrique Costa Olympia M. B. Rodrigues da Cunha Hernando Nazzeta Vilmondes Gonçalves de Oliveira

PURPOSE: There is, today, a global tendency towards a surgical approach privileging very small incisions, the so-called minimally invasive intervention, which results in a less aggressive action. The introduction of this new technique makes it possible to dissect the left internal thoracic artery (LITA) and to perform in the anastomosis with the anterior interventricular artery (AIA) through a left minithoracotomy. METHODS: From May of 1996 to october of 1997, 11 patients with ischemic heart disease and a single proximal lesion of the AIA were submitted to a myocardial revascularization (MR). The surgical approach consisted of a left anterolateral thoracotomy through the 4th left intercostal space, of approximatly 10cm, and in the last 6 cases, resection of part of the cartilage of the 4th and 5th ribs, dissection of the LITA, as well as opening and repair of the pericardium adjacent to the AIA was done. All patients received a single bypass to the AIA with a graft of the LITA, without extracorporeal circulation. RESULTS: The patients’ age varied between 46 and 76 years (mean = 58,55). Ten patients (90,90%) were males and 1 (9,09%) was a female. Hospital stay ranged from 4 to 8 days, with the average of 5,2 days. None of the patients presented any electrocardiographic change in the immediate post-operatory period. During the control period one patient developed a clot in the distal LITA, with important compromise of the flow. In another patient the stenosis was at the level of the anastomosis. Both were successfully submitted to angioplasty. There were no deaths in the groups studied. CONCLUSION: The absence of deaths suggests to us that MR surgery carried out with this minimally invasive technique, in selected groups and is an excellent alternative to the revascularization of the AIA.

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Flail mitral valve leaflet diagnosed by transesophageal echocardiography. Report and evolution of 35 cases

Mônica M. C. Caldas et al. Lúcia M. A. Fenelon William A. M. Esteves Tamara Katina … Nilson Maia Márcia M. Barbosa

PURPOSE: To describe transesophageal echocardiographic findings in patients presenting with flail mitral valve and to obtain their clinical follow-up. METHODS: From January/93 to March/97, 1675 patients were submitted to transesophageal echocardiogram at our institution; 35 of them were diagnosed as having flail mitral valve and their clinical follow-up was obtained. RESULTS: Thirty-five patients with the diagnosis of flail mitral valve were studied. Mean age was 65±15 years (12-87) and 27 (77%) were male. The posterior leaflet was involved in 25 (71%) patients. Ruptured chordae tendineae was present in all but one patient in whom flail mitral valve was due to a very elongated and redundant chordae. The etiology was prolapse and/or mixomatous degeneration in 16 patients, degenerative in 10, ischemic in 5, rheumatic in 4 and endocarditis in 3. Mitral regurgitation was severe in 25 (71%) patients and moderate in 10 (29%). The mean follow-up was 375±395 days (1 to 1380). Nineteen patients were followed clinically and 16 were submitted to surgery (transesophageal echocardiogram findings were confirmed in all 16). Overall mortality was high (34%). Among the survivors, 17 are in NYHA class I and 6 in class II. CONCLUSION: The diagnosis of flail mitral valve by transesophageal echocardiography is accurate, allowing for the definition of its mechanism and etiology, as well as the evaluation of hemodynamic compromise. The observed high mortality at the time of diagnosis may be related to the severity of the disease causing the flail mitral valve. Although non-operated survivors are doing well, the observed low functional class in these patients may be related to the short period of follow-up.

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Chagas heart disease and contractility rate responsive pacing controlled by autonomic nervous system variations

Oswaldo Tadeu Greco et al. Roberto Vito Ardito Dorotéia Rossi Silva Souza Max Schaldach

PURPOSE: To analyse the performance of the artificial cardiac stimulation with the VVIR pacemaker whose sensor is adjusted by the variations of the autonomic nervous system in Chagas disease patients with deficiency of the conduction system. METHODS: Forty-seven Chagas disease patients have been studied, 28 male between 24 and 68 years old, 36 patients had complete AV block, 8 had 2nd degree AV block and the other 3 had sinus node disease. The patients were in class I (4), II (15), III (16) and IV (12) according to the NYHA. A 12-month-follow-up with constant clinical evaluations was carried out after pacemaker implantation. Patients were divided in 2 different groups according to the HR at rest – group 1: >65 beats per minute (bpm) and group 2: <=65bpm, for a comparative study considering: 1) HR at stress test after the implantation; 2) arterial blood pressure at rest after the implantation and, 3) evaluation of the identified electrodes such as TIR-60-UP and others. RESULTS: The group 1 had greater HR at rest, and a smaller variation of values at stress than group 2. This shows that with this type of stimulation system it is possible to control each patient separately. The values of blood pressure at rest and during stress were not different between groups. According to the factors analysed the TIR-60-UP electrode had the same performance as the others. CONCLUSION: The VVIR pacemaker with the sensor adjusted by the ANS variations has provided the Chagas patients with a restoration of their physiological mechanisms. 74% of them had the improvement of either one or 2 functional classes.

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Overall experience with percutaneous occlusion of the patent ductus arteriosus

Carlos Augusto Cardoso Pedra et al. Simone Rolim Fenandes Fontes Pedra César Augusto Esteves Sérgio Luís Navarro Braga … Maria Aparecida Paula Silva Tarcísio Luís Valle de Almeida Maria Virgínia Tavares Santana José Eduardo Moraes Rego Sousa Valmir Fernandes Fontes

PURPOSE: To evaluate the overall experience of our institution with percutaneous occlusion of the patent ductus arteriosus. METHODS: Since December/92, 150 patients underwent 178 procedures (85 – Rashkind technique; 87 – Gianturco coils; 6 – Duct Occlud). Median age was 6.5 years (1 to 57). Mean minimum ductal diameter was 3.05±1.24mm (1 to 8). Clinical and echocardiographic evaluations were performed periodically. RESULTS: Adequate implantation was achieved in 143 (95.3%) patients. Prevalence of immediate residual shunting was 52.1%, falling to 15.9% during follow-up. This figure decreased to 5.2% after new additional procedures. Umbrella and coil embolization occurred in 1 and 12 procedures, respectively. Hemolysis and mild stenosis of left pulmonary artery were observed in one patient each. There was no mortality. CONCLUSION: This therapeutic modality is safe and efficacious with good follow-up results.

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Heart rate response and its variability during different phases of maximal graded exercise

Denise de Oliveira Alonso et al. Claudia Lucia de Moraes Forjaz Liliane Onda Rezende Ana Maria F. W. Braga … Antonio Carlos Pereira Barretto Carlos Eduardo Negrão Maria Urbana Pinto Brandão Rondon

PURPOSE: Heart rate variability (HRV) has been studied at rest as a non-invasive tool for the assessment of cardiac autonomic control and, its attenuation is related to cardiovascular risk. However, during exercise, when important neural changes take place, HRV behaviour is not well established. The aim of this investigation was to study the heart rate (HR) and HRV responses during the different metabolic phases of maximal graded exercise in young men. METHODS: Seventeen men (age 28±6 years) were submitted to a graded cardiopulmonary exercise test in a cycloergometer (30W/3min). To study HR and HRV (standard-deviation), the eletrocardiographic signal was amplified and acquired beat-to-beat in a computer at a frequency of 125 Hz (AT/Codas). RESULTS: The HR increases concomitantly to the increase in exercise intensity. The HRV was significantly lower than rest values after exercise intensities of 60% of peak exercise oxygen uptake, 45-60% of maximal power and, after anaerobic threshold intensity. CONCLUSION: This results suggest that HRV measured by standard deviation of HR decreases during exercise phases when HR increment is determined mainly due to vagal withdrawal.

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Absence of the right atrioventricular connection. Morphological and clinical presentation when the dominant ventricle is morphologically right

Quantification of mitral prosthesis regurgitation by transesophageal echocardiography. Evaluation of different methods

The significance of alcohol abstinence in alcoholic cardiomyopathy with moderate left ventricular dysfunction

Myocardial revascularization surgery through a left minithoracotomy

Flail mitral valve leaflet diagnosed by transesophageal echocardiography. Report and evolution of 35 cases

Chagas heart disease and contractility rate responsive pacing controlled by autonomic nervous system variations

Overall experience with percutaneous occlusion of the patent ductus arteriosus

Heart rate response and its variability during different phases of maximal graded exercise

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