The Brazilian Society for Cardiovascular Surgery (SBCCV) and Brazilian Society for Extracorporeal Circulation (SBCEC) standards and guidelines for perfusion practice

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Evaluation of the activity mode rate variable pulse generator

To evaluate the physiologic benefits of the rate response estimulation, 48 patients were submited to a 24 hours Holter recording and paired tolerance treadmill test (AAI VVI and AAI-R/VVI-R modes, selected in random order) one month after implantation of an activity sensing pacemaker Activitrax 8400. Mean age of the patients was 46 years and indications for pacing included atrial arrhythmias (16 patients) or A-V conduction disturbances (32 patients, including 25 with complete A-V block). The underlying disease was Chagas cardiomiopathy, in 32 patients. Initial pacemaker setting was: basic rate: 60 or 70 ppm; maximum activity rate: 125 ppm; activity threshold: medium, rate response: 5. The 24 hours Holter recording documented appropriate changes in heart during daily activities. Oversensing, which resulted in pacing interval fluctuations, was diagnosed in two patients and required pacemaker reprograming. Treadmill test showed a significant increase in heart rate during exercise: mean control value: 66.9 ppm; 4 min.: 84.6 ppm; 6 min.: 90.5 ppm (P < 0.05). In the paired test, the AAI/VVI-Activity mode enabled the patients to increase heart rate (12.5%) and exercise time (20.2%; P < 0.05). None of the patients presented exercise induced ventricular arrhythmias in mode AAI/VVI-Activity; on the other hand, 12 patients showed ventricular arrhythmia during exercise in mode AAI/VVI. Clinical improvement and more active life was referred by all patients in this short follow-up period. The Activitrax 8400 was effective in improving patients exercise capacity.Quarenta e oito pacientes com marcapasso unicameral de ajuste automático de freqüência de pulso mediado por movimentação corporal (AAI-R/VVI-R) foram avaliados através da eletrocardiografia dinâmica, para correlacionar a atividade física com a variação da freqüência de estímulos e teste ergométrico em esteira (pareados e randomizados em modo AAI/VVI e modo AAI-R/VVI-R), para quantificar a capacidade de realizar esforço físico, um mês após o implante do gerador de pulso Activitrax 8400. A idade média dos pacientes era de 46 anos e a etiologia predominante da arritmia que motivou o implante era a miocardiopatia chagásica. O eletrocardiograma ambulatorial mostrou modificações apropriadas na freqüência cardíaca (exceto em 1 paciente, que permaneceu em ritmo sinusal). Teste ergométrico no modo AAI-R/VVI-R mostrou elevação significativa na freqüência cardíaca com relação ao valor médio controle: de 66,9+0,8 ppm para 84,6+2,1 ppm aos 14 minutos 90,5*2,8 ppm aos 6 minutos e 95,7+2,9 ppm aos 8 minutos (P < 0,05). O modo AAI-R/VVI-R possibilitou um aumento no tempo de exercício de 20,2% quando comparado ao modo AAI/VVI (P < 0,05). Em 12 pacientes, arritmias ventriculares foram detectadas durante o exercício em modo AAI/VVI, mas não no modo AAI-R/VVI-R. No curto período avaliado (1 mês), os pacientes referiram melhora clínica e puderam reassumir vida mais ativa. O gerador de pulsos Activitrax 8400 mostrou-se efetivo e seguro. A estimulação unicameral com variação da freqüência de pulso melhorou a capacidade de realizar exercícios físicos, quando comparada com a estimulação em freqüência pré-determinada.Hospital Evangélico de CuritibaInstituto de Moléstias Cardiovasculares de São José do Rio PretoInstituto de Cardiologia do Rio Grande do SulHospital Santa Isabel de SalvadorSanta Casa de Misericórdia de MaríliaEscola Paulista de MedicinaSanta Casa de Misericórdia de CuritibaHospital da Beneficência Portuguesa de São PauloUNIFESP, EPMSciEL

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction

Health status after invasive or conservative care in coronary and advanced kidney disease

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of &lt;30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, 120.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, 122.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, 121.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, 122.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy