Orientador: Orlando Petrucci Junior / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-11T10:51:42Z (GMT). No. of bitstreams: 1 Souza_FernandoSergioOlivade_D.pdf: 1025341 bytes, checksum: 15ba5e4c6177129ac03b697eb1f59cb9 (MD5) Previous issue date: 2008 / Resumo: A estimulação elétrica biventricular apresenta bons resultados no tratamento da insuficiência cardíaca congestiva refratária em portadores de cardiomiopatia dilatada com distúrbios de condução interventricular. OBJETIVO: Apresentar proposição utilizando técnica original simplificada para o implante de eletrodo de estimulação ventricular esquerda epicárdica, baseado na anatomia radiológica e no eletrograma intracavitário,enfatizando o componente atrial, demonstrando o resultado, complicações, ressaltando tempo total de utilização de fluoroscópio. CASUÍSTICA E MÉTODO: De Outubro de 2001 a Março de 2007 foram realizados 234 implantes de marca-passo biventricular em pacientes previamente selecionados, utilizando-se anatomia radiológica e observação de eletrograma intracavitário, dando-se prioridade ao componente atrial, demonstrando a taxa de sucesso, complicações e tempo total de utilização de radioscopia. RESULTADOS: O implante do sistema, utilizando-se a estimulação do ventrículo esquerdo via seio coronariano não foi possível em 19(8,1%) pacientes. Em 30(12,8%) pacientes foram observadas dificuldades na canulação do óstio coronário e em 52(22%) pacientes observaram-se dificuldades de progressão do eletrodo através do seio coronário. O tempo médio de utilização de radioscopia foi 18,69(±15,2) min. CONCLUSÃO: A utilização da técnica simplificada para cateterização do seio coronário sem utilização de bainha, baseada na anatomia radiológica e no eletrograma intracavitário, enfatizando o componente atrial, no tratamento de portadores de cardiomiopatia dilatada avançada, pela terapia de ressincronização cardíaca, demonstrou resultado satisfatório, índice de complicações pequeno, e baixa exposição do operador a radiação ionizante / Abstract: Biventricular pacing has present good results in treatment of congestive cardiac heart failure in patients with dilated miocardyopathy and interventricular conduction disturbance. PURPOSE: to present a proposal of using a original simplified technique for left epicardial ventricular lead stimulation, based on the radiological imaging of the anatomy and intracavitary electrogram, emphasizing the atrial component, showing the results, complications, highlighting the total fluoro time. METHODS: From October, 2001 up to March, 2007, 234 biventricular pacemaker implantations were performed in previously selected patients, using radiological anatomy and observation of the intracavitary electrogram, focusing on the atrial component, and showing the success rate, complications and total time of radioscopy utilization. RESULTS: The implantation of the system using left ventricular pacing via coronary sinus was not possible in 19(8,1%) patients. Difficulties on the cannulation of the coronary ostium were felt in 30(12,8%) patients and difficulties of lead advancement through the coronary sinus were felt in 52(22%) patients. The mean time of radioscopy utilization was 18.69(±15,2) min. CONCLUSION: the use of a simplified technique for coronary sinus cannulation without the aid of a sheath, based on the radiological imaging of the anatomy and intracavitary electrogram, emphasizing the atrial component, for the treatment of advanced dilated cardiomyopathy patients with cardiac resynchronization therapy, has shown satisfactory results, low incidence of complications, and low exposure of the operator to ionizing radiation / Doutorado / Cirurgia / Doutor em Cirurgia

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Approximately 20% of congestive heart failure (CHF) patients are readmitted within 30 days of hospital discharge, a rate which may be affected by in-hospital and post-discharge care. Reducing this rate is important to hospitals, both to improve outcomes and to avoid reductions in Medicare reimbursement. Assessing outcomes within a short post-discharge window best measures the impact of the care, planning, and followup of that admission; but most research on the effects of changes in CHF care has measured outcomes over periods longer than 30 days, adding the unpredictable long-term course of CHF to the factors affecting the outcome. As well, almost no studies to date have included the appreciable effects of CHF comorbidities in their analyses. This study addresses these needs by measuring rates of 30-day all-cause readmission, and by adjusting for comorbidities and demographic factors in our analysis. We hypothesize that an improved CHF care protocol including both in-hospital and post-discharge components will reduce the risk of readmission, and may alter the rate of change of that risk. We have analyzed as an interrupted time series data on 2764 discharges of CHF patients from a hospital that implemented such a change to assess the effect of the new protocol on the readmission risk and on the trend in that risk, comparing outcomes in the 22 months preceding introduction of the new protocol to those in the first 31 months of full implementation. Using multiple logistic regression, we have tested for an association between the new protocol and both the unadjusted risk of readmission, and that risk in a model including comorbidities and demographic factors as covariates. Neither model found a statistically significant association between introduction of the protocol and log-odds of readmission (unadjusted p = 0.847, adjusted p = 0.755) or between introduction of the protocol and change in risk of readmission over time (unadjusted p = 0.437, adjusted p = 0.313). These results, in comparison with other published results, can clarify what changes to care protocols have been shown to be effective. Further, post hoc power analysis of this study can inform study design for further research.

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A minority of patients with end-stage disease are referred to palliative medicine for consultation in advanced heart failure. Educating stakeholders, including primary care, cardiology, and critical care of the benefits of hospice and palliative medicine for patients with poor prognosis, may increase appropriately timed referrals and improve quality of life for these patients. This article reviews multiple tools useful in prognostication in the setting of advanced heart failure.

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Orientador: Marlos Gonçalves Sousa / Resumo: A doença valvar mitral tem alta prevalência em todo o mundo e é a enfermidade cardiovascular mais diagnosticada em cães. A referida enfermidade cardíaca possui caráter progressivo, que frequentemente leva à insuficiência cardíaca congestiva. Por sua vez, a insuficiência cardíaca congestiva é uma síndrome clínica complexa que leva a um baixo débito cardíaco, hipotensão e hipoperfusão tecidual, fazendo com que as demandas de diversos órgãos não sejam devidamente supridas. Com o intuito de ajustar a falha do coração como bomba, o organismo ativa uma série de mecanismos compensatórios que, em curto prazo, normalizam a pressão arterial. Dentre esses mecanismos, se destaca como um dos mais importantes, ativação do sistema nervoso autônomo simpático. Todavia, a ativação desses mecanismos, em logo prazo, resulta em progressão da disfunção ventricular, morte dos cardiomiócitos, desenvolvimento de sinais clínicos e óbito. Quando o débito cardíaco é prejudicado pela falha da função ventricular, a hipotensão relativa estimula os barorreceptores a ativar o sistema nervoso autônomo simpático, conduzindo ao aumento da concentração sérica de noradrenalina na insuficiência cardíaca congestiva. A noradrenalina é uma catecolamina endógena sintetizada pelas células cromafins na medula adrenal, que age em receptoresα1-adrenérgicos, promovendo o aumento da resistência vascular sistêmica, e em receptores β1-adrenérgicos, exercendo atividade inotrópica e cronotrópica positivas. No tratamento da insu... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Mitral valve disease has a high prevalence worldwide and is the most diagnosed cardiovascular disease in dogs. The referred cardiac disease presents a progressive character, which often leads to congestive heart failure. In turn, congestive heart failure is a complex clinical syndrome that leads to low cardiac output, hypotension and tissue hypoperfusion, causing the demands of various organs not to be adequately met. In order to adjust heart failure as a pump, the body activates a series of compensatory mechanisms that, in the short term, normalize blood pressure. Among these mechanisms, it stands out as one of the most important, sympathetic autonomic nervous system activation. However, the activation of these mechanisms, in the long term, results in progression of ventricular dysfunction, death of cardiomyocytes, development of clinical signs and death. The main mechanism is the activation of sympathetic autonomic nervous system. When cardiac output is impaired by failure of ventricular function, relative hypotension stimulates baroreceptors to activate the sympathetic autonomic nervous system, leading to increased serum noradrenaline concentration in congestive heart failure. Noradrenaline is an endogenous catecholamine synthesized by chromaffin cells in the adrenal medulla, which acts at α1 -adrenergic receptors, promoting the increase of systemic vascular resistance, and at β1 -adrenergic receptors, exerting positive inotropic and chronotropic activity. In the treatment... (Complete abstract click electronic access below) / Mestre