Subocclusive transvenous approach of dural arteriovenous fistula

Introdução: As fístulas arteriovenosas durais (FAVd) são usualmente adquiridas e quando apresentam drenagem venosa cortical estão associadas a um risco elevado de hemorragia. Podem ser tratadas por embolização (transarterial ou transvenosa), cirurgicamente ou pela combinação das duas técnicas. A embolização por via transvenosa induz uma trombose iatrogénica do seio venoso, acarretando risco de enfarte venoso e/ou hemorragia. Objectivo: Rever os casos de FAVd do seio lateral submetidas a embolização transvenosa. O nosso principal objectivo é avaliar a eficácia e a morbilidade deste tipo de tratamento e o segundo é discutir as possíveis vantagens de uma abordagem suboclusiva na primeira sessão de tratamento. Resultados: Os autores apresentam seis casos clínicos de FAVd, cujas formas de apresentação foram: diminuição da acuidade visual (3); sopro pulsátil no ouvido (3); cefaleias (2); hemorragia subaracnoideia (1); hipoacusia subjectiva (1); edema da papila (1); défice motor (1). Angiograficamente: Cognard IIa (3), IIab (2) e IV (1), todas com envolvimento dos seios laterais. As principais aferências eram: ACE ipsilateral (6); ACI ipsilateral (6); AV ipsilateral (6); ACE contralateral (5); AV contralateral (5); ACI contralateral (3); ACP ipsilateral (1). O tratamento inicial foi sempre a abordagem transarterial, com resultados angiográficos aceitáveis, embora transitórios. Posteriormente optou-se pela via transvenosa com preenchimento do seio lateral com GDC coils. Em cinco dos doentes decidiu-se pela suboclusão, com persistência de algumas aferências. Em quatro, a angiografia subsequente demonstrou trombose “espontânea” do seio lateral com resolução clínica e angiográfica da doença. Num deles a trombose ocorreu ainda durante a sessão inicial. Todos os procedimentos decorreram sem complicações e nenhum dos doentes desenvolveu novos défices neurológicos focais. Conclusões: A abordagem transvenosa das FAVd obteve um sucesso técnico e clínico assinalável, sem presença de complicações. Pensamos que a suboclusão do seio venoso com coils poderá induzir menor alteração hemodinâmica aguda, possibilitando uma trombose mais lenta, diminuindo o risco de complicações, mas com resolução angiográfica ulterior da FAVd

Results of a school-based asthma assessment from the upKids questionnaire validation study

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Resting Heart Rate, Functional Capacity and Prognosis in Heart Failure Patients: Atrial Fibrillation Versus Sinus Rhythm

Background: Higher resting heart rate (HR) is associated with lower exercise capacity and worse prognosis in patients with heart failure (HF). However, recent studies question this relationship in HF patients in atrial fibrillation (AF). We aimed to examine and compare the relationships between resting HR, exercise capacity and outcomes in HF patients in AF and sinus rhythm (SR). Methods: 282 ambulatory patients with symptomatic HF and left ventricular ejection fraction≤40% were divided according to rhythm status into SR and AF group. All patients were followed for 60 months and the combined endpoint was defined as cardiac death, urgent heart transplantation or need for mechanical circulatory support. Results: In the patients enrolled (mean LVEF 27±7%), 19.1% had AF. The composite endpoint occurred in 24.4% during follow-up. There were no differences regarding maximal effort, but AF group had lower exercise capacity. In the SR group, there was an inverse relationship between resting HR and exercise capacity (r-0.189, p 0.004). In the AF group, this relationship was reversed as higher resting HR was associated with better exercise tolerance (r 0.314, p 0.021). Regarding outcomes, patients in SR with a resting HR higher than 72 bpm had higher risk of composite outcome than those with lower resting HR (p 0.033), but this was not evident in AF patients. Conclusion: The impact of resting HR on exercise capacity and prognosis differed entirely between AF and SR, suggesting that HR control may need to be managed differently for AF and SR in HF patients.info:eu-repo/semantics/publishedVersio

Dapagliflozin Impact on the Exercise Capacity of Non-Diabetic Heart Failure with Reduced Ejection Fraction Patients

Background: Dapagliflozin has been shown to reduce morbidity and mortality in Heart Failure with reduced Ejection Fraction (HFrEF), but its impact on exercise capacity of non-diabetic HF outpatients is unknown. Methods: Adult non-diabetic HF patients with a left ventricular ejection fraction (LVEF) <50% were randomized 1:1 to receive dapagliflozin 10 mg or to continue with HF medication. Patients underwent an initial evaluation which was repeated after 6 months. The variation of several clinical parameters was compared, with the primary endpoint being the 6 month peak oxygen uptake (pVO2) variation. Results: A total of 40 patients were included (mean age 61 ± 13 years, 82.5% male, mean LVEF 34 ± 5%), half being randomized to dapagliflozin, with no significant baseline differences between groups. The reported drug compliance was 100%, with no major safety events. No statistically significant difference in HF events was found (p = 0.609). There was a 24% reduction in the number of patients in New York Heart Association (NYHA) class III in the treatment group as opposed to a 15.8% increase in the control group (p = 0.004). Patients under dapagliflozin had a greater improvement in pVO2 (3.1 vs. 0.1 mL/kg/min, p = 0.030) and a greater reduction in NT-proBNP levels (-217.6 vs. 650.3 pg/mL, p = 0.007). Conclusion: Dapagliflozin was associated with a significant improvement in cardiopulmonary fitness at 6 months follow-up in non-diabetic HFrEF patients.info:eu-repo/semantics/publishedVersio

O Valor Prognóstico do Ponto Ótimo Cardiorrespiratório após Prova de Esforço Cardiorrespiratória Submáxima na Insuficiência Cardíaca

Introduction: Peak oxygen consumption (pVO2) is a key parameter for assessing the prognosis of heart failure with reduced ejection fraction (HFrEF). However, it is less reliable when the cardiopulmonary exercise test (CPET) is not maximal. Objective: To compare the prognostic power of various exercise parameters in submaximal CPET. Methods: Adult patients with HFrEF undergoing CPET in a tertiary center were prospectively assessed. Submaximal CPET was defined as a respiratory exchange ratio ≤1.10. Patients were followed for one year for the primary endpoint of cardiac death and urgent heart transplantation (HT). Various CPET parameters were analyzed as potential predictors of the combined endpoint and their prognostic power (area under the curve [AUC]) was compared using the Hanley-McNeil test. Results: CPET was performed in 442 HFrEF patients (mean age 56±12 years, 80% male), of whom 290 (66%) had a submaximal CPET. Seventeen patients (6%) reached the primary endpoint. The cardiorespiratory optimal point (COP) had the highest AUC value (0.989, p<0.001), and significantly higher prognostic power than other tested parameters, with pVO2 presenting an AUC of 0.753 (p=0.001). COP ≥36 had significantly lower survival free of HT during follow-up (p<0.001) and presented a sensitivity of 100% and a specificity of 89% for the primary endpoint. Conclusion: COP had the highest prognostic power of all parameters analyzed in a submaximal CPET. This parameter can help stratify HFrEF patients who are physiologically unable to reach a maximal level of exercise.info:eu-repo/semantics/publishedVersio

Prognostic Prediction of Cardiopulmonary Exercise Test Parameters in Heart Failure Patients with Atrial Fibrillation

Background: Atrial fibrillation (AF) is associated with increased mortality in heart failure (HF) patients. Objective: To evaluate whether the risk of AF patients can be precisely stratified by relation with cardiopulmonary exercise test (CPET) cut-offs for heart transplantation (HT) selection. Methods: Prospective evaluation of 274 consecutive HF patients with left ventricular ejection fraction ≤ 40%. The primary endpoint was a composite of cardiac death or urgent HT in 1-year follow-up. The primary endpoint was analysed by several CPET parameters for the highest area under the curve and for positive (PPV) and negative predictive value (NPV) in AF and sinus rhythm (SR) patients to detect if the current cut-offs for HT selection can precisely stratify the AF group. Statistical differences with a p-value <0.05 were considered significant. Results: There were 51 patients in the AF group and 223 in the SR group. The primary outcome was higher in the AF group (17.6% vs 8.1%, p = 0.038). The cut-off value of pVO2 for HT selection showed a PPV of 100% and an NPV of 95.5% for the primary outcome in the AF group, with a PPV of 38.5% and an NPV of 94.3% in the SR group. The cut-off value of VE/VCO2 slope showed lower values of PPV (33.3%) and similar NPV (92.3%) to pVO2 results in the AF group. Conclusion: Despite the fact that AF carries a worse prognosis for HF patients, the current cut-off of pVO2 for HT selection can precisely stratify this high-risk group.info:eu-repo/semantics/publishedVersio

Three-Dimensional Speckle-Tracking Echocardiography for the Global and Regional Assessments of Left Ventricle Myocardial Deformation in Breast Cancer Patients Treated with Anthracyclines

Background: Assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for diagnosing cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle-tracking echocardiography (STE) has several advantages, it is not used in this setting. Methods: 105 breast cancer patients who underwent serial echocardiographic assessment during anthracycline therapy were included. STE was used to estimate 2D GLS, 3D GLS, 3D global circumferential strain (GCS), 3D global radial strain (GRS), and 3D global area strain (GAS). CTRCD was defined as an absolute decrease in 2D/3D LVEF > 10% to a value 15%. Results: 24 patients developed CTRCD. There was a significant worsening of all 3D strain parameters during chemotherapy. 3D strain regional analysis showed impaired contractility in the anterior, inferior, and septal walls. Variations of 3D GRS and 3D GCS were associated with a higher incidence of CTRCD and the variation of 3D GRS was an independent predictor of CTRCD. Variations of 3D GCS and 3D GRS had a good discrimination for predicting CTRCD, with optimal cutoff values of - 34.2% for 3D GCS and - 34.4% for 3D GRS. These variations were observed 45 and 23 days before the diagnosis of CTRCD, respectively. Conclusion: Variations of 3D strain parameters were predictive of and preceded CTRCD, and thus have added value over currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered to offer targeted monitoring and timely initiation of cardioprotective treatment.info:eu-repo/semantics/publishedVersio