Valvoplastia com cateter-balao na estenose pulmonar valvar isolada

Orientador: Danton Richlin Da Rocha LouresDissertaçao (mestrado) -Universidade Federal do Paraná. . Curso de Pós-Graduaçao em CardiologiaResumo: A valvoplastia pulmonar com cateter-balão (VPCB) tem sido utilizada recentemente para desobstruir valvas pulmonares estenosadas. A indicação é feita para pacientes com estenose pulmonar valvar isolada. O objetivo deste trabalho foi: a) avaliar os achados clínicos, eletrocardiográficos e radiológicos pré e pós VPCB; b)correlacionar os dados hemodinâmicos e angiográficos pré e pós VPCB ; c) comprovar a eficácia e efetividade da VPCB. Dezenove pacientes com EPV isolada foram submetidos à VPCB. Previamente a valvoplastia sete pacientes (36,9%) encontravam-se na classe funcional, dez pacientes (52,6%) encontravam-se na classe funcional II e dois pacientes (10,5%) encontravam-se na classe funcional III. A fadiga foi o sintoma encontrado em todos os pacientes. O frêmito sistólico em área pulmonar era palpável em dezesseis pacientes (84,2%). Após a valvoplastia treze pacientes (68,4%) tornaram-se assintomáticos, três pacientes (15,8%) encontravam-se na classe funcional I e três pacientes não retornaram para reavaliação clínica. Quatorze pacientes (73,7%) não apresentavam fadiga e dois pacientes (10,5%) apresentavam poucos sintomas de fadiga. O sopro sistólico em foco pulmonar diminuiu de intensidade na maioria dos pacientes, porém permaneceu em todos os pacientes. O sopro diastólico não foi detectado antes ou após a valvoplastia pulmonar. O frêmito sistólico-em área pulmonar persistiu palpável em dois pacientes (10,5%) e nos demais foi abolido .Previamente a valvoplastia a PSVS média de 96,5 ± 39,7 mmHg, decresceu significativamente pós valvoplastia para média de 40,1 ± 17,0 mmHg, p < 0,01. O GPVD-TP prévio a valvoplastia médio de 79,2 ± 39,4mmHg, decresceu significativamente pós-valvoplastia para GPVD-TP médio de 19,6 ± 14,7 mmHg, p < 0,01. A relação PSVD /P SA oX100 previa à valvoplastia média de 99,7 ± 41,1%, decresceu significativamente pós-valvoplastia para média 39,3 ± 16,9%,p < 0,01. O percentual de obstrução valvar pré-valvoplastia médio de 62,2 ± 9,9% decresceu significativamente pós-valvoplastia para média de 28,6 ± 11,5%, p < 0,01. No controle evolutivo após um tempo de seguimento médio de 10,6m, a média da PSVD foi 42,7 ± 13,2 mmHg. A média do GPVD - TP foi 20,5 ± 12,6 mmHg. A média, da PSVD/PSAoX100 foi 40,9 ± 13,1%. A média do PO-3 foi 31,1 ± 8,8% . Não houve evidencias estatísticas de que as médias no controle evolutivo tivessem se modificado. Não se observou correlação entre o percentual de obstrução e o gradiente pressórico VD-TP. Dois pacientes apresentaram gradiente pressórico infundibular pós VPCB. Um paciente apresentou reestenose e foi submetido a nova dilatação a valva ser displasia. Outro paciente foi submetido a uma segunda valvoplastia e com balão maior na segunda vez e obteve-se melhor resultado. A regressão da área cardíaca foi observada. A média do índice cardiotorácico prévio de 0,52 ± 0,06, decresceu significativamente após valvoplastia para 0,47 ± 0,04, p < 0,01. Um paciente apresentou BAVT transitório pelo período de sete dias. A amplitude de R em media de 20,2 ± 17,0 mm, de cresceu para 9,7 ± 8,7 mm, p < 0,01. O SÂQRS prévio a valvoplastia médio de + 125,9° ± 33,2° , decresceu significativamente para +.104,7° ± 37,8° , p < 0,01. Não houve óbito. Nossas observações nos levaram a concluir que: a valvoplastia com cateter-balão foi um procedimento seguro e eficaz na liberação da EPV isolada. Provocou queda significativa da PSVD, do GPVD-TP e da PSVD/PSAoX100. Os resultados obtidos apos a valvoplastia mantiveram-se no controle evolutivo. Os valores tabelados por Rowllat e col. para anel valvar pulmonar foram semelhantes aos medidos nas cineangiografias. Não se observou relação entre o gradiente pressórico e o percentual de obstrução valvar. Os resultados desfavoráveis foram observados na EPV displásica e onde havia escolha inadequada do cateter-balão.Abstract: Pulmonary valvoplasty with a balloon catheter has been 1 recently done to dilate stenotic pulmonic valves. It is indicated for patients with isolated pulmonary valve stenosis. The aim of this study is to describe the technique, to evaluate and correlate clinical, electrocardiographic, radiologic, hemodynamic and angiographic data derived from the mentional, and to assess the efficacy and effectivity of the procedure. Nineteen patients were submitted to pulmonary valvoplasty. Previously to the valvoplasty seven patients (36,9%) were in functional class I, ten patients (52,6%) were in functional class II, and two patients (10,5%) were in functional class III. All patients complained of tiredeness; a systolic thrill was palpable in the pulmonary area in sixteen patients (84,2%). Thirteen patients (68,4%) became assymptomatic after the valvoplasty, three patients (15,8%) were in functional class I, and three patients were lost to follow-up. Fourteen patients (73,7%) no longer complained of tiredeness, and two patients (10,5%) had tiredeness of a lesser degree. The systolic murmur heard in the pulmonary area decreased in intensity in the majority of patients however it did not disapear in none of them. A diastolic murmur was never heard.The systolic thrill was palpable in only two patients (10,5%) after the procedure. After the valvoplasty the right ventricle systolic pressure significantly decreased from a mean of 96,5 ± 39,7 mmH g , to a mean of 40,1 ± 17,0 mmHg, p < 0,01. The pressure gradient between right ventricle and pulmonary artery significantly fell from a mean of 79,2 ± 39,4 mmHg, to a mean of 19,6 ± 14,7 mmHg, p < 0,01. The ratio of right ventricle systolic pressure to aortic systolic pressure times one hundred (RVSP/AoSPX 100) significaj2 tly fell from a mean of 99,7 ± 41,1% to a mean of 39,3 ± 16,9%,p < 0,01.The percentage of valve stenosis significantly decreased from a mean of 62,2 ± 9,9% to a mean of 28,6 ± 11,5%, p< 0,01. After a mean time of 10,6 months of follow-up the following registrations were made: the mean RVSP was 42,7 ± 1.3,2mmHg, the mean pressure gradient between RV and PAP was 20,5 ± 12,6 mmHg, and the mean ratio R V S P /A oS PX100 was 40,9 - 13,1%. The mean percentage of valve obstrution was 31,1 ± 8,8%. These results were not statistically different :from those found immediately after valvoplasty. No correlation between valve obstruction and pressure gradient (RV-PA) was found. Two patients showed an infundibular pressure gradient after valvoplasty. One patient had re-stenosis and was unsuccessfully redilated; this was attributed to valve dysplasia. One patient was redilated with larger sized balloon withan improved result. A decrease in heart was observed: the mean cardiothora -cic index significantly fell from 0,52 ± 0,06 to a mean of 0,47 ± 0,04, p < 0,01. One patient showed complete heart block that resumed sinus rhythm within one week. The mean R wave amplitude in decreased from a mean of 20,2 ± 17,0 mmHg to a mean of 9,7 ± 8,7 mm, p < 0,01. The QRS angle significantly decreased from a mean of + 125,9 ± 33,2 to a mean of + 104,7 ± 37,8, p < 0,01. No death was registered during this study. The conclusions are that the balloon catheter valvoplasty is a safe and effective procedure in the treatment of the isolated pulmonic valve stenosis. A significant fall in RVSP, in RV-PA pressure gradient, and in the ratio between RVSP/AoSPX100 is showed. The results obtained after the precedure and in the follow-up were no different. The pulmonic valve ring values obtained by Rowllat et al were similar to our re -suits measured by angiography. No correlation between pressure gradient and valve obstruction was found. Unsuccessull results were found in pulmonic valve dysplasia and when an inadequate choice of the balloon catheter was made

Intervenção Indevida de Terceiros em Contratos: teoria e responsabilidade por danos causados

Este artigo é um breve estudo sobre a intervenção de terceiro em contrato em que este não é parte. Deste modo, primeiro foi feita uma análise de quem é o terceiro estudado, trazendo conceitos que o definam. Seguindo há demonstração das teorias existentes da intervenção de terceiro no direito comparado, o uso de um caso concreto para melhor exemplificar a teoria e, por fim, as possibilidades de adoção desta teoria no Brasil

Recent Strategies and Outcomes of Transcatheter Closure for Patent Ductus Arteriosus

ope

Transcatheter closure of small ductus arteriosus with amplatzer vascular plug

PurposeThe purpose of this study was to share our experience of transcatheter closure of small patent ductus arteriosus (PDA) by using an Amplatzer vascular plug (AVP).MethodsWe reviewed the medical records of 20 patients who underwent transcatheter closure at Samsung Medical Center and Sejong General Hospital from January 2008 to August 2012. The size and shape of the PDAs were evaluated by performing angiograms, and the PDA size and the AVP devices size were compared.ResultsThe mean age of the patients was 54.9±45.7 months old. The PDAs were of type C (n=5), type D (n=12), and type E (n=3). The mean pulmonary end diameter of the PDA was 1.7±0.6 mm, and the aortic end diameter was 3.6±1.4 mm. The mean length was 7.3±1.8 mm. We used 3 types of AVP devices: AVP I (n=5), AVP II (n=7), and AVP IV (n=8). The ratio of AVP size to the pulmonary end diameter was 3.37±1.64, and AVP size/aortic end ratio was 1.72±0.97. The aortic end diameter was significantly larger in those cases repaired with AVP II than in the others (P=0.002). The AVP size did not significantly correlate with the PDA size, but did correlate with smaller ratio of AVP size to aortic end diameter (1.10±0.31, P=0.032).ConclusionTranscatheter closure of small PDA with AVP devices yielded satisfactory outcome. AVP II was equally effective with smaller size of device, compared to others

Complications after Transcatheter Closure of Patent Ductus Arteriosus

To evaluate the short- and mid-term results and complications ensuing the transcatheter closure of patent ductus arteriosus (PDA). Between October 1999 and December 2005, 117 patients (34 males and 83 females) underwent attempted percutaneous closure of PDA with a minimum diameter of more than 3 mm. Follow-up evaluations were conducted at 1 day and 1, 3, 6, 12 months after the performance of the transcatheter closure. The median age of patients at catheterization was 11 yr (range, 0.6 to 68 yr), median weight was 30 kg (range, 6 to 74 kg), and the median diameter of PDA was 4 mm (range, 3 to 8 mm). This procedure was conducted successfully in 114 patients (97.4%), using different devices. Major complications were detected in 4 patients (3.4%); significant hemolysis (2), infective endocarditis (1), failed procedure due to embolization (1). Minor complications occurred in 6 patients (5.1%); mild narrowing of the descending aorta (2) and mild encroachment on the origin of the left pulmonary artery (4). Although the transcatheter closure of PDA may be considered to be effective, several complications, including hemolysis, embolization, infective endocarditis, and the narrowing of adjacent vessels may occur in certain cases

Multiple thromboembolism with multiple causes in a 69-year-old woman: a case report

<p>Abstract</p> <p>Introduction</p> <p>Aggressive, recurrent embolisms require accurate etiologic diagnosis. We describe the case of a 69-year-old Italian Caucasian woman with recurrent arterial embolisms in whom several sources and triggers of thrombosis were detected.</p> <p>Case presentation</p> <p>The patient, a 69-year-old Italian Caucasian woman, presented with a systemic embolism that was initially attributed to atrial fibrillation. The recurrence of embolisms despite anti-thrombotic therapy prompted a re-evaluation of the clinical presentation. New potential causes of thrombosis emerged in this patient, including thrombocytosis associated with the <it>JAK2 V617F </it>mutation and the very rare mural thrombosis of the descending aorta. A mural thrombus in the pulmonary artery was detected contiguous with the aortic mural thrombosis, raising the possibility of a clinically silent ductus Botalli as the initiating event. The patient was treated with warfarin, aspirin, hydroxyurea, and surgery.</p> <p>Conclusions</p> <p>The diagnosis was achieved via systematic use of imaging procedures and reconsideration of blood tests performed to explore the diagnosis of thrombosis. This allowed a deeper and more detailed analysis of the case beyond the conventional approach, which would have aimed to identify one cause for the condition at hand, in this case, atrial fibrillation. The broader approach that we used resulted in the diagnosis of multiple embolisms from multiple sites and multiple causes.</p

A New High-Sensitivity Subsurface Sensing System

We developed a prototype geophysical system that currently has a dynamic range of 126dB. We also calculate the full potential of our design to achieve a dynamic range of greater than 160dB, which is orders of magnitude higher than what is currently offered by state of the art technology in geophysical instrumentation. We have been successful in reducing measurement errors that are common limiting factors in achieving high measurement sensitivity in practice. We reduced the measurement error caused by mechanical deformations of the measurement apparatus from 70PPM to less than 1PPM. As a result of developing a novel measurement method for using a rotating antenna array and digital nulling, we achieved a level of temporal drift of less than 1PPM over a 50 minute time period, which is a significant improvement compared to the drift of greater than 100PPM for the state of the art geophysical instrumentation. We also used a method of simultaneous calibration of the secondary fields in order to correct the measured data for the long-term gain variations in the system response. As a result, we reduced the percentage error in the RE and IM components of the target response measured over a 105-minute period of time from 5% and 80% to 0.5% and 2%, respectively. We have gained a substantial reduction of the measurement errors caused by the background response of the earth by using the antenna array in a vertical orientation relative to the earth's surface. We demonstrated that our measurement method increases survey efficiency because of a more informative set of data. We tested our prototype system with a section of steel pipe, which is a standard target used to determine the sensitivity of commercial metal detectors. The measurement results showed that our current system will detect this particular target at a 2.0m depth below the earth's surface, which is 0.5m better than the 1.5m detection depth achieved by the EM61-MK2. When the full potential of our design is realized, we estimate the projected depth of detection to increase to 9m, which is six times greater than the detection depth achieved by the EM61-MK2

Valvoplastia com cateter-balao na estenose pulmonar valvar isolada

Orientador: Danton Richlin Da Rocha LouresDissertaçao (mestrado) -Universidade Federal do Paraná. . Curso de Pós-Graduaçao em CardiologiaResumo: A valvoplastia pulmonar com cateter-balão (VPCB) tem sido utilizada recentemente para desobstruir valvas pulmonares estenosadas. A indicação é feita para pacientes com estenose pulmonar valvar isolada. O objetivo deste trabalho foi: a) avaliar os achados clínicos, eletrocardiográficos e radiológicos pré e pós VPCB; b)correlacionar os dados hemodinâmicos e angiográficos pré e pós VPCB ; c) comprovar a eficácia e efetividade da VPCB. Dezenove pacientes com EPV isolada foram submetidos à VPCB. Previamente a valvoplastia sete pacientes (36,9%) encontravam-se na classe funcional, dez pacientes (52,6%) encontravam-se na classe funcional II e dois pacientes (10,5%) encontravam-se na classe funcional III. A fadiga foi o sintoma encontrado em todos os pacientes. O frêmito sistólico em área pulmonar era palpável em dezesseis pacientes (84,2%). Após a valvoplastia treze pacientes (68,4%) tornaram-se assintomáticos, três pacientes (15,8%) encontravam-se na classe funcional I e três pacientes não retornaram para reavaliação clínica. Quatorze pacientes (73,7%) não apresentavam fadiga e dois pacientes (10,5%) apresentavam poucos sintomas de fadiga. O sopro sistólico em foco pulmonar diminuiu de intensidade na maioria dos pacientes, porém permaneceu em todos os pacientes. O sopro diastólico não foi detectado antes ou após a valvoplastia pulmonar. O frêmito sistólico-em área pulmonar persistiu palpável em dois pacientes (10,5%) e nos demais foi abolido .Previamente a valvoplastia a PSVS média de 96,5 ± 39,7 mmHg, decresceu significativamente pós valvoplastia para média de 40,1 ± 17,0 mmHg, p < 0,01. O GPVD-TP prévio a valvoplastia médio de 79,2 ± 39,4mmHg, decresceu significativamente pós-valvoplastia para GPVD-TP médio de 19,6 ± 14,7 mmHg, p < 0,01. A relação PSVD /P SA oX100 previa à valvoplastia média de 99,7 ± 41,1%, decresceu significativamente pós-valvoplastia para média 39,3 ± 16,9%,p < 0,01. O percentual de obstrução valvar pré-valvoplastia médio de 62,2 ± 9,9% decresceu significativamente pós-valvoplastia para média de 28,6 ± 11,5%, p < 0,01. No controle evolutivo após um tempo de seguimento médio de 10,6m, a média da PSVD foi 42,7 ± 13,2 mmHg. A média do GPVD - TP foi 20,5 ± 12,6 mmHg. A média, da PSVD/PSAoX100 foi 40,9 ± 13,1%. A média do PO-3 foi 31,1 ± 8,8% . Não houve evidencias estatísticas de que as médias no controle evolutivo tivessem se modificado. Não se observou correlação entre o percentual de obstrução e o gradiente pressórico VD-TP. Dois pacientes apresentaram gradiente pressórico infundibular pós VPCB. Um paciente apresentou reestenose e foi submetido a nova dilatação a valva ser displasia. Outro paciente foi submetido a uma segunda valvoplastia e com balão maior na segunda vez e obteve-se melhor resultado. A regressão da área cardíaca foi observada. A média do índice cardiotorácico prévio de 0,52 ± 0,06, decresceu significativamente após valvoplastia para 0,47 ± 0,04, p < 0,01. Um paciente apresentou BAVT transitório pelo período de sete dias. A amplitude de R em media de 20,2 ± 17,0 mm, de cresceu para 9,7 ± 8,7 mm, p < 0,01. O SÂQRS prévio a valvoplastia médio de + 125,9° ± 33,2° , decresceu significativamente para +.104,7° ± 37,8° , p < 0,01. Não houve óbito. Nossas observações nos levaram a concluir que: a valvoplastia com cateter-balão foi um procedimento seguro e eficaz na liberação da EPV isolada. Provocou queda significativa da PSVD, do GPVD-TP e da PSVD/PSAoX100. Os resultados obtidos apos a valvoplastia mantiveram-se no controle evolutivo. Os valores tabelados por Rowllat e col. para anel valvar pulmonar foram semelhantes aos medidos nas cineangiografias. Não se observou relação entre o gradiente pressórico e o percentual de obstrução valvar. Os resultados desfavoráveis foram observados na EPV displásica e onde havia escolha inadequada do cateter-balão.Abstract: Pulmonary valvoplasty with a balloon catheter has been 1 recently done to dilate stenotic pulmonic valves. It is indicated for patients with isolated pulmonary valve stenosis. The aim of this study is to describe the technique, to evaluate and correlate clinical, electrocardiographic, radiologic, hemodynamic and angiographic data derived from the mentional, and to assess the efficacy and effectivity of the procedure. Nineteen patients were submitted to pulmonary valvoplasty. Previously to the valvoplasty seven patients (36,9%) were in functional class I, ten patients (52,6%) were in functional class II, and two patients (10,5%) were in functional class III. All patients complained of tiredeness; a systolic thrill was palpable in the pulmonary area in sixteen patients (84,2%). Thirteen patients (68,4%) became assymptomatic after the valvoplasty, three patients (15,8%) were in functional class I, and three patients were lost to follow-up. Fourteen patients (73,7%) no longer complained of tiredeness, and two patients (10,5%) had tiredeness of a lesser degree. The systolic murmur heard in the pulmonary area decreased in intensity in the majority of patients however it did not disapear in none of them. A diastolic murmur was never heard.The systolic thrill was palpable in only two patients (10,5%) after the procedure. After the valvoplasty the right ventricle systolic pressure significantly decreased from a mean of 96,5 ± 39,7 mmH g , to a mean of 40,1 ± 17,0 mmHg, p < 0,01. The pressure gradient between right ventricle and pulmonary artery significantly fell from a mean of 79,2 ± 39,4 mmHg, to a mean of 19,6 ± 14,7 mmHg, p < 0,01. The ratio of right ventricle systolic pressure to aortic systolic pressure times one hundred (RVSP/AoSPX 100) significaj2 tly fell from a mean of 99,7 ± 41,1% to a mean of 39,3 ± 16,9%,p < 0,01.The percentage of valve stenosis significantly decreased from a mean of 62,2 ± 9,9% to a mean of 28,6 ± 11,5%, p< 0,01. After a mean time of 10,6 months of follow-up the following registrations were made: the mean RVSP was 42,7 ± 1.3,2mmHg, the mean pressure gradient between RV and PAP was 20,5 ± 12,6 mmHg, and the mean ratio R V S P /A oS PX100 was 40,9 - 13,1%. The mean percentage of valve obstrution was 31,1 ± 8,8%. These results were not statistically different :from those found immediately after valvoplasty. No correlation between valve obstruction and pressure gradient (RV-PA) was found. Two patients showed an infundibular pressure gradient after valvoplasty. One patient had re-stenosis and was unsuccessfully redilated; this was attributed to valve dysplasia. One patient was redilated with larger sized balloon withan improved result. A decrease in heart was observed: the mean cardiothora -cic index significantly fell from 0,52 ± 0,06 to a mean of 0,47 ± 0,04, p < 0,01. One patient showed complete heart block that resumed sinus rhythm within one week. The mean R wave amplitude in decreased from a mean of 20,2 ± 17,0 mmHg to a mean of 9,7 ± 8,7 mm, p < 0,01. The QRS angle significantly decreased from a mean of + 125,9 ± 33,2 to a mean of + 104,7 ± 37,8, p < 0,01. No death was registered during this study. The conclusions are that the balloon catheter valvoplasty is a safe and effective procedure in the treatment of the isolated pulmonic valve stenosis. A significant fall in RVSP, in RV-PA pressure gradient, and in the ratio between RVSP/AoSPX100 is showed. The results obtained after the precedure and in the follow-up were no different. The pulmonic valve ring values obtained by Rowllat et al were similar to our re -suits measured by angiography. No correlation between pressure gradient and valve obstruction was found. Unsuccessull results were found in pulmonic valve dysplasia and when an inadequate choice of the balloon catheter was made