Case 6/2001 - The patient is an 11-year-old girl with Takayasu's arteritis and heart failure (Instituto do Coração do Hospital das Clínicas - FMUSP - São Paulo).
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Child↗
Biomedical subjects
M C Giorgi
Publications and source records attributed to M C Giorgi.
Relation between interstitial myocardial collagen and the degree of clinical impairment in Chagas' disease.
Cardiac performance is negatively associated with interstitial collagen in Chagas' cardiomyopathy. The magnitude of dysfunction is related to the degree of collagen, and this association seems to exhibit a threshold above it if definite cardiac deterioration occurs.
Adult↗
Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy.
OBJECTIVE: This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy. METHODS: Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months. RESULTS: Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up. CONCLUSIONS: Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.
Cardiomyopathy, Dilated↗
[Myocardial perfusion study in patients with right bundle branch block].
PURPOSE: To evaluate the sensitivity and specificity of myocardial perfusion scintigraphy in the detection of coronary artery disease in patients with right bundle branch block (RBBB). METHODS: Thirty one patients (24 male, 62.3 +/- 10.5 years) with RBBB, submitted to myocardial perfusion scintigraphy associated with exercise (n = 7) or dipyridamole (n = 24) and previous cinecoronariography were studied retrospectively. Left ventricle scintigraphic image was divided in three segments corresponding to the three main epicardic coronary territories in a total of 93 segments. Cineangiographic and scintigraphic data were then compared according to the different artery territories. RESULTS: Twenty three patients had significant lesions (> or = 60%) in one or more coronary arteries and eight had no obstruction. Forty nine segments were irrigated by normal coronary arteries and 44 were related to arteries that had significant lesions. Twenty out of twenty three patients showed alterations in perfusion (sensitivity = 87%). All patients without coronary obstructions showed normal perfusion scintigraphy (specificity = 100%). One of the segments perfused by normal coronaries showed abnormal scintigraphy. Scintigraphy showed perfusion defects in 29 out of 44 segments with coronary obstructions. Sensitivity and specificity of the method for each arterial territory were 72% and 100% (left descending coronary artery), 67% and 94% (right coronary artery), 55% and 100% (circunflex coronary artery), respectively. CONCLUSION: The presence of RBBB does not modify the sensitivity and specificity of the method in the detection of coronary artery disease.
Bundle-Branch Block↗
Plasma lipid profile and coronary artery disease in Brazilian hemodialysis patients.
We studied the prevalence of lipid disorders and of coronary artery disease and the main factors affecting plasma lipids in a cohort of Brazilian hemodialysis patients. The investigation comprised 75 adult hemodialysis patients and 200 normal controls matched for age, sex, race and body mass index. Mean values for plasma lipids were within normal limits in the dialysis group. Total cholesterol (184 +/- 44 vs. 201 +/- 46 mg/dl), LDL (110 +/- 36 vs. 131 +/- 44 mg/dl) and HDL (40 +/- 13 vs. 47 +/- 12 mg/dl) were significantly lower in the dialysis patients (P < 0.01), whereas VLDL (32 +/- 14 vs. 21 +/- 12 mg/dl) and triglyceride (161 +/- 71 vs. 111 +/- 70 mg/dl) were increased (P < 0.01). Increased triglyceride was observed in 24% of the dialysis patients, a prevalence two to three times lower than that reported in the literature. In the dialysis group, the variables positively related to total cholesterol were hypertension (P < 0.05) and gender (female) (P < 0.05); to LDL and HDL, hypertension (P < 0.05 and P < 0.01, respectively); and to triglyceride, use of propranolol (P < 0.01). Age, race, duration of hemodialysis, body mass index and plasma creatinine did not affect plasma lipids. The prevalence of coronary artery disease, established by invasive and noninvasive methods, was 10.7% while in the literature 20-35% of the unselected hemodialysis patients present obstructive coronariopathy. We conclude that the plasma lipid profile of Brazilian hemodialysis patients is similar to those reported in American and European literature, whereas the prevalence of hypertriglyceridemia and of coronary artery disease appears to be reduced.
Adult↗
Blood pressure influences the occurrence of complex ventricular arrhythmia in hemodialysis patients.
We investigated the relationship between blood pressure and the occurrence of complex ventricular arrhythmias (multiform, couplets, or runs) as assessed by 48-hour Holter monitoring in 74 stable long-term hemodialysis patients (44.5 +/- 12 years old; 54% men; 74% whites; dialysis duration, 51.3 +/- 36.1 months; systolic pressure, 146.6 +/- 19.3 mm Hg; diastolic pressure, 89.2 +/- 12.1 mm Hg; prevalence of arterial hypertension, 33.8%). Systolic and diastolic pressures represented the average of all predialysis determinations during the 3 months preceding the tests. Hemodialysis was performed midway through the Holter monitoring period. M-mode and bidimensional echocardiograms and myocardial perfusion tests were also obtained from all patients. Complex arrhythmias were observed in 37 individuals (50%). Univariate analysis showed that systolic pressure (P < .001), diastolic pressure (P < .05), age (P < .001), left ventricular posterior wall thickness (P < .01), left ventricular mass index (P < .05), and ischemic alterations on myocardial perfusion tests (P < .005) were significantly associated with complex arrhythmias. With the use of a multivariate model (stepwise logistic regression analysis) only systolic pressure (P < .01) and age (P < .05) were independently associated with complex arrhythmias. Sex; angina; dialysis duration; New York Heart Association functional class; use of digitalis; plasma levels of creatinine, sodium, potassium, calcium, and phosphate; hematocrit; left ventricular fractional shortening; left ventricular diastolic diameter; and ST segment deviation were not correlated with complex arrhythmias. The severity and frequency of complex arrhythmias were not influenced by hemodialysis. At follow-up (5 to 80 months) 5 patients had died of sudden death, 4 of whom were hypertensive and older than 45 years.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Predictors of mortality in long-term haemodialysis patients with a low prevalence of comorbid conditions.
BACKGROUND: Total and cardiovascular mortality rates for haemodialysis patients are still high despite the continuous improvement of dialysis technology. This trend may be a consequence of the increased number of elderly patients and patients with concurrent systemic diseases admitted to dialysis programmes. The objective of the present investigation was to determine the predictors of mortality more closely related to uraemic status and to dialysis treatment by studying relatively young haemodialysis patients with a low prevalence of comorbid conditions using the Cox proportional hazards model. METHODS: Seventy-four haemodialysis patients with a low prevalence of extrarenal diseases (mean age 44.5 +/- 12.1 years, mean dialysis duration 51.3 +/- 36.1 months) were submitted to extensive cardiological and clinical evaluation and followed prospectively for a median period of 60.8 months (range: 5.1-79.8). There were only three diabetics and all patients denied previous myocardial infarction. RESULTS: At follow-up 23 patients had died, 10 of cardiac causes. Five-year survival rates were 70% for overall mortality and 83% for cardiac mortality. Age over 44 years (relative risk 3.73; 95% confidence interval 1.35-10.26) and serum creatinine (inverse correlation) (relative risk 0.73; 95% confidence interval 0.57-0.94) were shown to be independently associated with global mortality by the Cox proportional hazards analysis. Gender, race, dialysis duration, interdialytic weight gain, angina, NYHA classification, hypertension, LV hypertrophy, LV systolic and diastolic dysfunction, complex ventricular arrhythmias and altered myocardial perfusion tests were not significant predictors of overall mortality. There were crude associations between cardiac mortality and cardiothoracic and Sokolow indices (P < 0.01) and age, NYHA classification, systolic hypertension, LV wall and septum hypertrophy, LV dilatation and complex ventricular arrhythmias (P < 0.05). CONCLUSION: In the absence of serious comorbid conditions, the survival of patients on long-term haemodialysis is influenced by nutritional status (as indicated by lower serum creatinine) and age.
Adult↗
[Study of myocardial viability by thallium-201 SPECT. Conventional redistribution versus reinjection].
PURPOSE: To verify if a third series of images acquired by reinjection thallium-201, 24h after conventional myocardial perfusion with the radioisotope, improves the identification of myocardial viability segments. METHODS: We studied 30 patients, mean age 57.7 +/- 9.4 years, with old myocardial infarction using thallium (Tl)-201 SPECT (single-photon-emission computed tomography), and we obtained 3 series of images (stress, redistribution after 4h and reinjection after 24h. Cardiac images were divided in 5 segments (apical, lateral, anterior, septal and inferior) and each one received a value by a score system according to the Tl-201 myocardial uptake (0 = normal uptake; 1 = mild hypoperfusion; 2 = moderate hypoperfusion; 3 = severe hypoperfusion or no myocardial uptake). We considered viable myocardium when the uptake of Tl-201 in the segment related to the myocardial infarction increased at least 1 point in two different axis of Tl-201 SPECT. RESULTS: Seven (23.3%) patients demonstrated increase of Tl-201 uptake only at reinjection images, showing a higher efficacy of the method. Nine (30%) patients showed persistent hypoperfusion at all series of images suggesting only fibrosis in the area related to the infarction. Fourteen (46.7%) patients showed increase of Tl-201 concentration at redistribution images; among these patients, six showed improvement of myocardial uptake at reinjection. This condition were interpreted as regional chronic ischemic process: hibernating myocardium. CONCLUSION: Tl-201 hypoperfusion at redistribution images without significant changes in relation to the stress images do not represent fibrosis at all. The reinjection technic was better than conventional redistribution in the detection of viable myocardium. This data allows a better therapeutic orientation.
Adult↗
Left ventricular function during dynamic exercise in untrained and moderately trained subjects.
The influence of exercise training on left ventricular function at rest (R), at anaerobic threshold (AT), and during peak exercise (PE) was evaluated in 12 healthy untrained and 13 trained (T) subjects who underwent Doppler echocardiography at R and radionuclide ventriculography at R and during exercise. The end-diastolic volume and stroke volume were significantly higher in the T group than in the untrained group at R. The ejection fraction rose significantly from R to AT and from AT to PE (80.0 +/- 0.84 vs. 83.6 +/- 0.91%), but no significant difference was observed between groups. The peak diastolic filling rate rose significantly during exercise, with a further significant increase observed in the T group (AT, 6.38 +/- 0.40 vs. 5.01 +/- 0.16 end-diastolic counts/s; PE, 8.24 +/- 0.42 vs. 7.15 +/- 0.35 end-diastolic counts/s). The percent variation of minimal systolic counts fell significantly at AT and PE in relation to R. Our data demonstrate that exercise training produces a significant increase in peak diastolic filling rate but no change in systolic function during exercise and that metabolic acidosis caused by exercise does not limit systolic function.
Acidosis↗
[Scintigraphy of myocardial perfusion combined with pharmacologic stress with dipyridamole].
PURPOSE: To analyze adverse reactions (AR), hemodynamic and electrocardiographic changes and thallium scintigraphy (TS) results, during pharmacological stress with dipyridamole (SD), correlating these data to the presence and extension of coronary artery disease (CAD). METHODS: We studied 126 patients, 66 had no evidence of cardiovascular disease (G1) and 60 had critical occlusive CAD > or = 70% stenosis (G2). Most of them were male, mean age 56.5 +/- 10.9 years old. All patients were submitted to TS after receiving 0.56 mg/kg of dipyridamole intravenously (0.14 mg/min during 4 min) followed by 111MBq of thallium-chloride-201. Conventional ECG was recorded before and after SD; heart rate (HR) and arterial pressure (AP) were monitored during dipyridamole infusion. All signals and/or symptoms were observed. RESULTS: Cine-coronarography showed 22 patients (37%) with one vessel disease (VD) (G2a), 26 (46%) with two VD (G2b) and 12 (20%) with three VD (G2c). Of the 126 patients 63% did not present symptoms. Flushing (25%) and sick-headache (12%) were most frequent AR. Typical angina was reported by one G1 patient (1.5%) and six G2 patients (10%) (p < 0.05). HR increased 18.09 +/- 12.27% and 12.40 +/- 4.90%, systolic blood pressure varied -5.2 +/- 7.5% and -4.3 +/- 6.5% in G1 and G2, respectively. These parameters are not correlated to CAD presence and extension. ST depression and ectopic beats occurred in 5% and 11% of G1 patients, in 15% and 30% of G2 patients, respectively (p < 0.05). Typical angina was more common in G2a and G2b; ST changes in G2b and G2c; and arrhythmia in G2c (not significant). Sensitivity of TS associated to SD was 84%, comparable to stress exercise thallium test. CONCLUSION: TS associated to SD, a noninvasive, safe with low morbidity and few collateral effects method is an option to patients with limitations to physical exercise tests.
Adult↗
Amplitude analysis of stress technetium-99m methoxy isobutylisonitrile images in coronary artery disease.
To determine the role of rest and stress gated technetium-99m methoxyisobutylisonitrile (sestamibi), in the detection of coronary artery disease, routine Fourier analysis of these images was performed with the best septal left anterior oblique (LAO) position of 20 patients (17 men, 3 women; aged 40-75 years) who also underwent rest or redistribution/stress single photon emission tomography (SPET) (99mTc-sestamibi and Thallium-201), gated blood pool imaging and coronary angiogram. There were 6 patients with single-vessel disease, 6 with two-vessel disease, 4 with three-vessel disease, 2 with coronary spasms, 1 with a patent graft and 1 with anginal episodes but a normal angiogram result. Three normal volunteers (2 women, 1 man; aged 24-26 years) also had rest and stress gated blood pool as well as rest and stress gated 99mTc-sestamibi imaging. Rest and stress 99mTc-sestamibi amplitude and phase images depicted regional myocardial wall shortening from the outer layer of the myocardium to the center of the left ventricle as follows: a high amplitude halo of maximal negative count rate variation; a circular thinner halo of negligible amplitude; a central region of maximal positive count rate variation, as the images evolved from end-diastole to end-systole. Similar patterns with regional differences represented abnormal myocardial wall shortening. 99mTc-sestamibi and 201Tl SPET images were in agreement in 90% of the patients and 92% of myocardial regions. 201Tl SPET detected 83% of angiographically proven lesions, as compared with 80% for 99mTc-setamibi SPET and 80% for the amplitude images. The amplitude images demonstrated a larger number of other abnormalities not predicted on the angiogram, probably because they were able to detect regions with a potential for flow improvement and transient regional wall shortening abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Ventricular function by radionuclide ventriculography in malignant hypertension.
Malignant hypertension is a unique and natural model for the study of abnormalities of left ventricular function due to arterial hypertension, because the development and regression of these abnormalities can be observed in a short period. Studies of ventricular function by radionuclide ventriculography, either before or after therapy, have not been previously reported in malignant hypertensive patients. We used this methodology to study left ventricular function in 17 malignant/accelerated hypertensive patients at the time of admission to the hospital and 3, 6, and 9 months after discharge. Seventy percent of patients (12 of 17) had symptoms of congestive heart failure at admission. We compared these data with those obtained in 12 normotensive subjects and 13 mild-to-moderate untreated hypertensive patients. Blood pressure of malignant hypertensive patients was 213 +/- 26/140 +/- 17 mm Hg at admission and 165 +/- 23/101 +/- 15 after 9 months of therapy. Radionuclide ventriculography at admission showed that peak filling rates of malignant hypertensive patients (2.13 +/- 0.21 end-diastolic volume [counts] [EDV]/sec) were significantly lower than those in normotensive subjects (2.40 +/- 0.41) and in mild-to-moderate hypertensive patients (2.46 +/- 0.21). In contrast, peak ejection rates were significantly higher in malignant hypertensive patients (3.44 +/- 0.38 EDV/sec) than in the two control groups (3.01 +/- 0.32 and 3.10 +/- 0.43, respectively). Ejection fractions were similar in the three groups of patients. After 9 months of therapy, peak filling rates of malignant hypertensive patients increased to 2.38 +/- 0.35 EDV/sec, whereas peak ejection rates decreased to 2.89 +/- 0.43 EDV/sec, both not significantly different from data in controls.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Latissimus dorsi cardiomyoplasty in the treatment of patients with dilated cardiomyopathy.
Stimulated skeletal muscle grafts have been proposed as a means to reinforce ventricular wall in the treatment of severe myocardial failure. Latissimus dorsi cardiomyoplasty was performed in 11 patients with advanced heart failure due to cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximal medical therapy. There were no operative deaths. Eight patients were followed for a mean of 10.8 months. Two patients remain in muscle conditioning protocol. One patient died with latissimus dorsi ischemia and congestive heart failure. Four of the eight patients in long-term follow-up are in NYHA class I, three in class II, and one in class III. At 3 months of follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.5 +/- 3.6% to 26.8 +/- 8.1% (p less than 0.01). Doppler-echocardiography demonstrated that left ventricular segmental wall shortening improved from 11.3 +/- 2.5% to 16.5 +/- 3.9% (p less than 0.01) and left ventricular stroke volume from 22.9 +/- 4.6 to 33.1 +/- 10 ml (p less than 0.01). Cardiopulmonary exercise test showed that maximal oxygen consumption during treadmill test increased from 14.8 +/- 3.7 to 18.2 +/- 3.3 ml/kg.min (p less than 0.05). At 6 months of follow-up, all the above values remained essentially unchanged. Furthermore, nonsustained ventricular tachycardia was abolished without specific medical therapy in four patients. Thus, cardiomyoplasty improves left ventricular function, reverses congestive heart failure, and may improve long-term survival in severe cardiomyopathies.
Adult↗
Gallium-67 imaging in the diagnosis of blastomycosis.
67Ga imaging was used in a group of 13 untreated patients with documented South American blastomycosis in an attempt to obtain additional information on the site and extent of the lesions. All diagnoses were confirmed by demonstration of the fungi in the lesions or body fluids. Serologic tests were performed on all patients. 67Ga imaging was correlated with X-ray in all patients, and with bone imaging when bony lesions were suspected. 67Ga imaging was positive for all lesions detected on chest X-ray and by clinical evaluation. More importantly, lesions clinically unsuspected and missed by other diagnostic techniques were shown on 67Ga imaging: bony and hepatic lesions in three patients; a brain lesion in one patient and parotid gland involvement in five patients. There was good agreement between 67Ga imaging and clinical and laboratory data, scintigraphy being more sensitive. Follow-up studies after specific therapy demonstrated decreased uptake in the lungs and other sites. 67Ga imaging is a useful tool for detection of suspected and unsuspected lesions of blastomycosis and to evaluate the response of the disease to specific therapy.
Adult↗