RESUMO

BACKGROUND: Cardiac allograft vasculopathy (CAV) remains the major cause of death after cardiac transplantation during long-term follow-up. Nevertheless, annual angiographic evaluation is difficult to perform routinely. We evaluated the value of clinical risk factors and non-invasive testing for cardiac allograft vasculopathy in predicting cardiac events or death in asymptomatic patients with normal ventricular function during long-term follow-up after heart transplantation. METHODS: We studied 39 patients, mean aged 48 +/- 13 years, at 86 +/- 31 months after heart transplantation. Patients underwent thallium scintigraphy, treadmill stress testing, dobutamine stress echocardiography, and angiography to detect CAV. We prospectively observed all patients an additional 4 years for acute myocardial infarction, congestive heart failure, or death. RESULTS: Angiography detected CAV in 15 patients (38%). Three patients had acute myocardial infarction and another 7 had congestive heart failure, representing 25% of cardiac events during the study period. Nine deaths (23%) occurred during the same observation time. Univariate analysis showed that increased body mass index, positive dobutamine stress echocardiography results, and positive angiography results were associated significantly with cardiac events or death during follow-up. In the absence of coronary angiography, stepwise logistic regression identified positive dobutamine echocardiography results as the unique independent predictor of cardiac events (p = 0.001) or death (p = 0.002). CONCLUSION: Cardiac events and death after heart transplantation increased during long-term follow-up of this population. However, dobutamine stress echocardiography is well tolerated and, in the absence of routine angiographic evaluation, may be a strong predictor of these events.

Assuntos

Doença das Coronárias/mortalidade , Dobutamina , Ecocardiografia sob Estresse , Transplante de Coração/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Doença das Coronárias/epidemiologia , Doença das Coronárias/etiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Tempo

RESUMO

Humoral response emerges as an important component in acute graft rejection and a new challenge to clinicians in posttransplant care. Management of recurrent episodes and persistent activation of the humoral component of the immune system, despite the usual therapeutic approach to rejection, remains unknown. This article describes the successful use of methotrexate as an option for rescuing a graft in this worrisome situation.

Assuntos

Cardiomiopatia Dilatada/cirurgia , Rejeição de Enxerto/prevenção & controle , Transplante de Coração/imunologia , Metotrexato/administração & dosagem , Doença Aguda , Adulto , Formação de Anticorpos/fisiologia , Cardiomiopatia Dilatada/diagnóstico , Relação Dose-Resposta a Droga , Esquema de Medicação , Sobrevivência de Enxerto , Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Humanos , Masculino , Prognóstico , Imunologia de Transplantes , Resultado do Tratamento

RESUMO

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.

Assuntos

Disfunção Erétil/tratamento farmacológico , Tolerância ao Exercício/efeitos dos fármacos , Insuficiência Cardíaca/tratamento farmacológico , Norepinefrina/sangue , Piperazinas/administração & dosagem , Vasodilatadores/administração & dosagem , Administração Oral , Pressão Sanguínea/efeitos dos fármacos , Estudos Cross-Over , Relação Dose-Resposta a Droga , Método Duplo-Cego , Disfunção Erétil/sangue , Disfunção Erétil/complicações , Teste de Esforço/efeitos dos fármacos , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/complicações , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/efeitos dos fármacos , Satisfação do Paciente/estatística & dados numéricos , Piperazinas/efeitos adversos , Estudos Prospectivos , Purinas , Citrato de Sildenafila , Sulfonas , Resultado do Tratamento , Vasodilatadores/efeitos adversos

RESUMO

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45 +/- 12 years, ejection fraction 23 +/- 7%, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4 +/- 1.8, 9.8 +/- 1.9 (60 +/- 10%), and 13.3 +/- 2.2 (90 +/- 10%); heart rate (bpm) 142 +/- 12, 110 +/- 13 (77 +/- 9%), and 126 +/- 11 (89 +/- 7%); distance walked (m) 733 +/- 147, 332 +/- 66, and 470 +/- 48; and respiratory exchange ratio (R) 1.13 +/- 0.06, 0.9 +/- 0.06, and 1.06 +/- 0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p < 0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients.

Assuntos

Baixo Débito Cardíaco , Teste de Esforço/métodos , Atividades Cotidianas , Adulto , Análise de Variância , Tolerância ao Exercício , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Caminhada

RESUMO

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45±12 years, ejection fraction 23±7 percent, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4±1.8, 9.8±1.9 (60±10 percent), and 13.3±2.2 (90±10 percent); heart rate (bpm) 142±12, 110±13 (77±9 percent), and 126±11 (89±7 percent); distance walked (m) 733±147, 332±66, and 470±48; and respiratory exchange ratio (R) 1.13±0.06, 0.9±0.06, and 1.06±0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p<0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients

Assuntos

Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Baixo Débito Cardíaco , Teste de Esforço , Atividades Cotidianas , Análise de Variância , Tolerância ao Exercício , Fatores de Tempo , Caminhada

RESUMO

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7 +/- 3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1 +/- 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

Assuntos

Cardiomiopatia Dilatada/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Remodelação Ventricular , Adulto , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/diagnóstico por imagem , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Estudos Prospectivos , Ultrassonografia

RESUMO

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19 percent to 30 percent (mean: 25.7±3.4 percent), and the postoperative ejection fraction ranged from 21 percent to 40 percent (mean: 31.1± 5.8 percent). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period

Assuntos

Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Cardiomiopatia Dilatada , Implante de Prótese de Valva Cardíaca , Valva Mitral , Insuficiência da Valva Mitral , Remodelação Ventricular , Cardiomiopatia Dilatada , Ventrículos do Coração , Valva Mitral , Insuficiência da Valva Mitral , Estudos Prospectivos

RESUMO

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25 percent of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature

Assuntos

Humanos , Masculino , Adulto , Cardiomiopatia Chagásica/cirurgia , Transplante de Coração/efeitos adversos , Histoplasmose/diagnóstico , Histoplasmose/etiologia

RESUMO

OBJECTIVE: To determine the predictive values of noninvasive tests for the detection of allograft vascular disease. METHODS: We studied 39 patients with mean ages of 48Ý13 years and a follow-up period of 86Ý13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or = 50 percent obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results. RESULTS: Allograft vascular disease was found in 15 (38 percent) patients. The Holter test showed 15.4 percent sensitivity, 95.5 percent specificity...

Assuntos

Humanos , Adulto , Pessoa de Meia-Idade , Doença das Coronárias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Transplante de Coração

RESUMO

OBJECTIVE: To study the influence of immune and nonimmune risk factors on the development of allograft vasculopathy after cardiac transplantation. METHODS: We studied 39 patients with a mean age of 46 + or - 12 years. The following variables were analyzed: weight (kg), body mass index (kg/m²), donor's age and sex, rejection episodes in the first and second years after transplantation, systolic and diastolic blood pressures (mmHg), total cholesterol and fractions (mg/dL), triglycerides (mg/dL), diabetes, and cytomegalovirus infection. The presence of allograft vasculopathy was established through coronary angiography. RESULTS: Allograft vasculopathy was observed in 15 (38 percent) patients. No statistically significant difference was observed between the two groups in regard to hypertension, cytomegalovirus infection, diabetes, donor's sex and age, rejection episodes in the first and second years after transplantation, and cholesterol levels. We observed a tendency toward higher levels of triglycerides in the group with disease. Univariate and multivariate analyses showed statistically significant differences between the two groups when we analyzed the body mass index (24.53 + or - 4.3 versus 28.11 + or - 4.6; p=0.019). CONCLUSION: Body mass index was an important marker of allograft vasculopathy in the population studied

Assuntos

Humanos , Feminino , Pessoa de Meia-Idade , Criança , Adolescente , Adulto , Doença das Coronárias/etiologia , Rejeição de Enxerto/imunologia , Transplante de Coração/efeitos adversos , Transplante de Coração/imunologia , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Brasil/epidemiologia , Cineangiografia , Seguimentos , Rejeição de Enxerto/epidemiologia , Modelos Logísticos , Fatores de Risco