La grossesse induit de profonds changements hémodynamiques et métaboliques de l’organisme maternel qui ont des conséquences sur le cœur. L’adaptation du cœur à cette condition physiologique nécessite un remodelage de sa structure et par conséquent des ajustements de sa fonction. Les mécanismes responsables de ces adaptations sont en grande partie inconnus. Cependant, ces connaissances sont essentielles pour la compréhension des complications cardiovasculaires, telle que l’hypertension gestationnelle (HG), qui constituent un risque pour la santé de la mère et du fœtus. Afin de caractériser les adaptations du cœur lors de la grossesse, l’originalité de notre approche expérimentale consistait à étudier le remodelage à l’échelle des cardiomyocytes du ventricule gauche. Ainsi, notre premier objectif était de déterminer les modifications structurales et fonctionnelles des cardiomyocytes chez la rate en vue d’identifier les altérations lors de l’HG. Chez les rates gestantes, le remodelage structural des cardiomyocytes se caractérise par une hypertrophie cellulaire avec une augmentation proportionnelle des dimensions. L’HG a été induite par un supplément sodique (0.9% NaCl) dans la diète. L’inadaptation structurale lors de l’HG se traduit par une diminution du volume cellulaire. L’étude des modifications fonctionnelles a révélé que lors de la gestation le fonctionnement contractile des cellules est dépendant de l’adaptation du métabolisme maternel. En effet, les substrats énergétiques, lactate et pyruvate, induisent une augmentation de la contractilité des cardiomyocytes. Cet effet est plus faible dans les cellules des rates hypertendues, ce qui suggère des anomalies du couplage excitation-contraction, dans lequel les courants calciques de type L (ICa-L) jouent un rôle important. Paradoxalement, le lactate et le pyruvate ont induit une augmentation de la densité des courants ICa-L seulement chez les rates hypertendues. Le récepteur aux minéralocorticoïdes (RM) est connu pour son implication dans le remodelage structuro-fonctionnel du cœur dans les conditions pathologiques mais pas dans celui induit par la grossesse. Notre deuxième objectif était donc de déterminer le rôle du RM dans l’adaptation de la morphologie et de la contractilité des cardiomyocytes. Des rates gestantes ont été traitées avec le canrénoate de potassium (20 mg/kg/jr), un antagoniste des RM. L’inhibition des RM pendant la gestation empêche l’hypertrophie cellulaire. De plus, l’inhibition des RM bloque l’effet du lactate et du pyruvate sur la contractilité. Chez la femme, la grossesse est associée à des changements des propriétés électriques du cœur. Sur l’électrocardiogramme, l’intervalle QTc est plus long, témoignant de la prolongation de la repolarisation. Les mécanismes régulant cette adaptation restent encore inconnus. Ainsi, notre troisième objectif était de déterminer le rôle du RM dans l’adaptation de la repolarisation. Chez la rate gestante, l’intervalle QTc est prolongé ce qui est corroboré par la diminution des courants potassiques Ito et IK1. L’inhibition des RM pendant la gestation empêche la prolongation de l’intervalle QTc et la diminution des courants Ito. Les travaux exposés dans cette thèse apportent une vision plus précise du remodelage cardiaque induit par la grossesse, qui est permise par l’étude à l’échelle cellulaire. Nos résultats montrent que lors de la gestation et de l’HG les cardiomyocytes subissent des remodelages morphologiques contrastés. Notre étude a aussi révélé que lors de la gestation, la fonction contractile est tributaire des adaptations métaboliques et que cette relation est altérée lors de l’HG. Nos travaux montrent que la régulation de ces adaptations gestationnelles fait intervenir le RM au niveau de la morphologie, de la relation métabolisme/fonctionnement contractile et de la repolarisation. En faisant avancer les connaissances sur l’hypertrophie de la grossesse, ces travaux vont permettre d’améliorer la compréhension des complications cardiovasculaires gestationnelles. / Pregnancy is characterized by marked hemodynamic and metabolic changes, which have consequences on the heart. The adaptation of the heart to this physiological situation requires a remodeling of its structure, and consequently functioning adjustments. Mechanisms responsible for these adaptations are largely unknown. However, this knowledge is essential for the understanding of cardiovascular complications, such as gestational hypertension (GH), which represents a risk for the mother and the fœtus. To characterize cardiac adaptations to pregnancy, our experimental approach consisted in studying this remodelling at the level of left ventricle cardiomyocytes. Therefore, our first objective was to determine structural and functional modifications of cardiomyocytes in pregnant rats to be able to identify their variations in GH. In pregnant rats, structural remodelling of cardiomyocytes was characterized by a proportional volume expansion. GH was induced by a high sodium supplement (0.9% NaCl). In hypertensive rats, we observe significant cell volume shrinkage. The study of functional modifications elicited a strong relationship between metabolic adaptations and cell contractility. According to our results, in pregnant rats cardiomyocyte contractility was increased in presence of energy substrates lactate and pyruvate. This effect was weaker in the cells from hypertensive rats. This suggested modifications of the excitation-contraction coupling, in which L-type calcium currents (ICa-L) play an important role. Unexpectedly, lactate and pyruvate induced a significant increase in ICa-L only in hypertensive rats. In pathological conditions, mineralocorticoid receptors (MR) have been shown to mediate structural as well as functional remodelling of the heart. Our study is the first to investigate MR involvement in cardiac remodelling during pregnancy. Thus, our second objective was to determine MR involvement in cardiomyocyte remodelling. For this study, pregnant rats were treated with potassium canrenoate of (20 mg / kg / day), a MR antagonist. Our results revealed that MR inhibition during the pregnancy elicited a significant decrease of cell volume. MR inhibition has also affected metabolism and cellular functioning relationship. Indeed, plasma concentration of lactate was lower, which was in correlation with its blunted effect on cell contractility. In women, pregnancy-induced hypertrophy is associated with changes in electrical properties of the heart. Indeed, repolarisation is prolonged, which is characterised by a longer duration of QTc interval on the electrocardiogram. Regulation mechanisms involved in this adaptation are still largely unknown. Our third objective was therefore to determine the role of MR in the adaptation of repolarisation to pregnancy. Pregnancy induced a prolongation in QTc interval, which correlates with a decrease in potassium currents Ito and IK1. MR inhibition prevented QTc interval prolongation and the lowering of Ito. Our study gives a new insight of pregnancy-induced cardiac hypertrophy, which is provided by investigations at the cellular level. Our results demonstrate that pregnancy and GH are characterised by opposite remodellings. Moreover, in pregnancy the contractile function is dependent on metabolic adaptations. This is all the more glaring in GH as metabolic alterations induced modifications of electric properties to maintain contractile functioning. Furthermore, our work reveals MR involvement in the regulation of morphology, metabolism/contractility relationship, and repolarisation. By improving the knowledge of hypertrophy during pregnancy, this work contributes to improve the understanding of pregnancy-induced cardiac complications.

A Miocardiopatia hipertrófica foi descrita há mais de 50 anos e é a cardiopatia de causa genética mais comum no mundo. Pacientes portadores de miocardiopatia hipertrófica podem apresentar maior risco de eventos arrítmicos graves e morte súbita. Assim torna-se importante o desenvolvimento de técnicas de rastreio desse subgrupo de pacientes para, quando necessário, indicar tratamento específico como o implante de CDI. O realce tardio é a manifestação de fibrose nos exames de imagem como tomografia computadorizada do coração e/ou ressonância cardíaca em pacientes com cardiopatias e quando presente em grandes quantidades, pode estar relacionado a maior incidência de eventos fatais. O eletrocardiograma é ferramenta de baixo custo, não invasiva e difundida nos serviços de saúde brasileiros. O objetivo desse estudo é avaliar a correlação entre a presença e localização de realce tardio na tomografia computadorizada do coração e o achado de fibrose pelo escore de Selvester no eletrocardiograma de repouso de portadores de MCPH, determinar a prevalência de fibrose miocárdica entre os pacientes, comparando a sensibilidade, especificidade, valor preditivo positivo e negativo do escore de Selvester. Foram analisados 112 pacientes do ambulatório de miocardiopatia do Instituto Dante Pazzanese de Cardiologia portadores de miocardiopatia hipertrófica sendo incluídos 75 desses. Foram divididos em dois grupos: Portadores de CDI com 60 pacientes e sem CDI com 15 pacientes. Foram coletados dados clínicos, ecocardiográficos, eletrocardiografia digital e tomografia computadorizada do coração. Foram realizados os cálculos do escore de Selvester e a mensuração e localização de realce tardio nos cortes tomográficos dos pacientes. A correlação dos resultados foi analisada pelo método de regressão linear. As características e frequências mais marcantes do grupo foram sexo masculino 49,4%, idade 41,63 ± 15,16, classe funcional I/II - NYHA 90,6%, fibrilação atrial 21,3%, baixa prevalência de comorbidades como hipertensão arterial 37,3%, diabetes 4%, dislipidemia 17,3%, clearence de creatinina > 60mL/min em 100% e ausência de doença coronariana estabelecida, fração de ejeção do ventrículo esquerdo preservada de 69,9 ± 5,46, medida do septo interventricular de 21,04 ± 6,23 e prevalência de gradiente > 30mmHg na via de saída do ventrículo esquerdo de 37,3%. Dos fatores de risco clássicos, morte súbita familiar e história de síncope eram as mais prevalentes com 57,3% cada, o uso do beta-bloqueador ocorreu em 89,3%. A massa de fibrose pela tomografia computadorizada foi de 9,87 ± 10,79 equivalendo a porcentagem de 5,66 ± 6,16, tendo prevalência em 88% da amostra. Já pelo escore de Selvester, encontramos 8,44 ± 7,39 de porcentagem de fibrose com prevalência de 76%. Na análise de kappa para a variável categórica fibrose entre o escore de Selvester e a tomografia computadorizada do coração, foi encontrada fraca correlação com r = 0,38 (p < 0,01). Enquanto variável contínua aplicando o método de regressão linear, foi encontrada correlação forte com r = 0,7 (p < 0,01). A sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo do escore de Selvester para o diagnóstico de fibrose foram de, respectivamente, 84,8%, 88,8%, 98,2% e 44,4%. A localização da fibrose apresentou correlação fraca entre os métodos com r = 0,16 (p < 0,01). Os dados desse estudo indicam que há moderada correlação entre o escore de Selvester e o realce tardio pela tomografia computadorizada na quantificação de fibrose em pacientes portadores de miocardiopatia hipertrófica. / Hypertrophic cardiomyopathy is considered the most common genetic cardiovascular disease and has been recognized for 50 years. Patients with hypertrophic cardiomyopathy may present risk of arrhythmic events and sudden cardiac death. Thus, it is important to develop screening techniques for this subgroup of patients to indicate, when necessary, specific treatment as implantable cardioverter defibrillator. Late enhancement is fibrosis manifestation in images exam as multidetector computed tomography and/or magnetic cardiac resonance and if present in large quantities may be related to a higher incidence of fatal events. The electrocardiogram is a low-cost, non-invasive tool that is present in most Brazilian health services. The purpose of this study was to test the presence and location correlation between the Selvester and the late enhancement in the multidetector computed tomography, to determine the prevalence of myocardial fibrosis among patients, comparing the sensitivity, specificity, positive and negative predictive value of the Selvester QRS score. A total of 112 patients from the Institute of Cardiology Dante Pazzanese outpatient clinic with hypertrophic cardiomyopathy were analyzed, and 75 of them were included. They were divided into two groups: ICD patients with 60 patients and no ICD with 15 patients. Clinical, echocardiographic, digital electrocardiography and computed tomography of the heart were collected. The Selvester score was calculated and the measurement and location of late enhancement in the tomographic sections of the patients were performed. The correlation of the results was analyzed by the linear regression. The most remarkable features and frequencies of the group were male gender 49.4%, age 41.63 ± 15.16 years, functional class I / II - NYHA 90.6%, atrial fibrillation 21.3%, low prevalence of comorbidities as hypertension 37.3%, diabetes 4%, dyslipidemia 17.3%, creatinine clearance > 60mL/min in 100% and absence of known coronary artery disease, left ventricular ejection fraction preserved 69.9 ± 5.46, measured of the interventricular septum 21.04 ± 6.23 and prevalence of gradient > 30mmHg in the left ventricular outflow tract 37.3%. Classic risk factors as sudden family death and history of syncope were the most prevalent 57.3% each, the use of beta-blocker occurred in 89.3%. The mass of fibrosis by multidetector computed tomography was 9.87 ± 10.79g, representing a percentage of 5.66 ± 6.16, with a prevalence of 88% of the sample. Selvester QRS score, was found 8.44 ± 7.39 percent of fibrosis with a prevalence of 76%. In the kappa analysis for the categorical variable between the Selvester score and the computed tomography of the heart, we found a weak correlation r = 0.38 (p <0.01), as a continuous variable applying the linear regression, a strong correlation was found r = 0.7 (p <0.01). The sensitivity, specificity, positive predictive value and negative predictive value of the Selvester QRS score for the diagnosis of fibrosis were 84.8%, 88.8%, 98.2% and 44.4%, respectively. The location of the fibrosis showed weak correlation between the methods r = 0.16 (p <0.01). The results of this study indicate there is a moderate correlation between the Selvester QRS score and the late enhancement by multidetector computed tomography in the quantification of fibrosis in patients with hypertrophic cardiomyopathy.

Introdução: as sequelas de queimaduras na morfologia, mobilidade das estruturas motoras orais e nas funções orofaciais, como mastigação, deglutição e fala, são frequentes em pacientes com queimaduras graves na região de cabeça e pescoço. Objetivo: verificar a efetividade de um programa de reabilitação fonoaudiológica da motricidade orofacial em pacientes com queimaduras em cabeça e pescoço. Método: participaram da pesquisa 29 indivíduos encaminhados para avaliação e reabilitação ao Ambulatório de Funções da Face da Divisão de Fonoaudiologia do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de abril de 2016 a abril de 2018. Os critérios inclusão adotados na pesquisa foram: idade > = 6 anos; queimadura de terceiro grau caracterizada por perda epidérmica e dérmica em áreas de cabeça e pescoço; realização de tratamento cirúrgico prévio da ferida; ausência de falhas dentárias; presença de queixas relacionadas às alterações motoras orais; quadro clínico estável (conforme registros em prontuários médicos); alimentação por via oral exclusiva. Os pacientes foram divididos em dois grupos considerando o tempo da queimadura: Grupo 1 (G1) - pacientes com até um ano após a queimadura; Grupo 2 (G2) - pacientes com mais de um ano após a queimadura. A gravidade da queimadura foi determinada pela escala ABSI (The Abbreviated Burn Severity Index), aplicada no primeiro atendimento hospitalar do paciente. Todos os participantes foram submetidos à avaliação fonoaudiológica em dois momentos distintos, pré e pós-programa terapêutico. A avaliação foi composta pelos seguintes protocolos clínicos: Avaliação Miofuncional Orofacial com Escores Expandido (AMIOFE-E), verificação da amplitude mandibular (abertura oral máxima, lateralização para a direita e esquerda e protrusão mandibular) e medida antropométrica do canto de olho à comissura labial. O programa terapêutico adotado foi composto por 8 sessões semanais individuais, com duração de trinta minutos cada. O programa terapêutico foi composto por: manobras de compressão e alongamento em tecido cicatricial, manobras de alongamento intra e extra orais dos músculos da face, exercícios para mobilidade da musculatura da face e região cervical e exercícios para a adequação das funções de mastigação e deglutição. Resultados: a análise estatística evidenciou que o G2 apresentou idade significativamente maior que o G1. Nas análises intragrupos, tanto G1 quanto G2 apresentaram diferenças estatísticas para todos os itens do AMIOFE-E: aparência e condição postural; mobilidade e funções orofaciais (mastigação e deglutição). Quanto às medidas de amplitude mandibular, ambos os grupos apresentaram aumento significativo da medida de abertura oral máxima. Nas análises intergrupos, não foram observadas diferenças significativas entre G1 e G2, indicando que a melhora foi semelhante para ambos os grupos. Conclusão: a pesquisa comprova a eficácia do programa fonoaudiológico, baseado em evidências e com controle de resultados, em pacientes com queimaduras de terceiro grau em cabeça e pescoço. Os resultados demonstraram que ambos os grupos apresentaram melhora significativa na atividade miofuncional oral e na amplitude mandibular. Quando comparados os resultados obtidos entre G1 e G2, não foi observada diferença relevante, indicando que o tratamento proposto foi eficiente, independentemente do tempo entre a queimadura e o início do tratamento / Introduction: alterations in the morphology and mobility of the oral motor structures, and orofacial functions (i.e. mastication, swallowing and speech) are often observed in patients who suffered severe head and neck burns. Purpose: the purpose of the present study was to verify the effectiveness of a myofunctional orofacial rehabilitation program for patients with head and neck burns. Method: participants of this study were 29 individuals referred to the Division of Orofacial Myology of Instituto Central do Hospital das Clínicas of the School of Medicine, University of São Paulo, between April 2016 and April 2018, for oral motor assessment and rehabilitation. Inclusion criteria were as follows: age >= 6 years; third degree burns to the head and neck (i.e. epidermal and dermal loss); previous surgical treatment to the wound; complete dentition; oral motor alterations deficits; medical stability (according to medical records); receiving all nutrition by mouth. Patients were divided in two groups according to the onset of the injury: Group 1 (G1) - patients with injuries less than a year old; Group 2 (G2) - patients with injuries more than a year old. Burn severity was determined by the ABSI (The Abbreviated Burn Severity Index) according to the patient\'s first hospital record. All participants underwent clinical assessment that involved an oral motor evaluation (Expanded Protocol of Orofacial Myofunctional Evaluation with Scores - OMES-E), the assessment of the mandibular range of movements (maximal incisor distance, right and left lateral excursions and protrusion) and an anthropometric assessment (measurement of the distance between the commissures of mouth and the corners of the eyes). For comparison purposes, assessments were performed pre and post-treatment. The rehabilitation program involved 8 individual 30 minute weekly sessions. The rehabilitation program involved: compression and stretching maneuvers on the scar tissue; intra and extra oral stretching maneuvers of the facial muscles; facial and cervical muscles mobility exercises; mastication and swallowing exercises. Results: the statistical analysis indicated that G2 was significantly older than G1. When comparing pre and post-treatment results, both group of patients presented significant differences considering the items on the OMES-E (i.e. appearance and posture, mobility and orofacial functions), and the maximal incisor opening. The analysis comparing the performance of G1 and G2 did not indicate differences between the groups. Conclusion: The results of the study indicated that the rehabilitation program was effective for third degree burns on the head and neck, demonstrating significant improvement of the oral myofunctional parameters and of the maximal incisor opening. The results also suggest that the maturation of the scar tissue did not have an influence on the results of the treatment program

FUNDAMENTOS: O polimorfismo e a atividade da enzima conversora da angiotensina (ECA) contribuem, de forma significante, na expressão fenotípica e no prognóstico de pacientes com cardiomiopatia. OBJETIVOS: Determinar o polimorfismo da ECA, realizar a sua dosagem sérica e correlacioná-los com o grau de hipertrofia miocárdica e o índice de massa do ventrículo esquerdo em pacientes com cardiomiopatia hipertrófica (CMH) nas formas familiar e não familiar. CASUÍSTICA E MÉTODO: Foram estudados 136 pacientes consecutivos com CMH (69 da forma familiar e 67 da forma não familiar) com média de idade de 40,53±17,45 anos, sendo 76 do sexo masculino. Os indivíduos foram submetidos ao ecocardiograma para obtenção das medidas do septo interventricular, parede posterior e massa do ventrículo esquerdo e coleta de sangue para determinação do polimorfismo e dosagem sérica da atividade da ECA. RESULTADOS: Quanto ao genótipo do polimorfismo do gene da ECA, encontramos DD 47(35%), ID 71(52%) e II 18 (13%), sendo que do genótipo DD 34% na forma familiar e 36% na forma não familiar. A média da atividade da ECA foi de 56.414±19.236 para os pacientes com CMH na forma familiar e de 55.085±22.634 para a forma não familiar (p = 0,714). A média do índice de massa do ventrículo esquerdo na forma familiar foi 154±63 g/m2 e na forma não familiar foi 174±57 g/m2 (p = 0,008). A média do septo interventricular nas formas familiar e não familiar foi, respectivamente, 19±5 mm e 21±5 mm (p = 0,020). A média da parede posterior do ventrículo esquerdo nas formas familiar e não familiar foi, respectivamente, 10±2 mm e 12±3 mm (p = 0,0001). Não observamos correlação entre o polimorfismo e o grau de hipertrofia miocárdica (p = 0,651). Houve correlação positiva entre a atividade da ECA e o índice de massa do ventrículo esquerdo (p = 0,038). Os pacientes com a forma familiar, pela curva de regressão logística, possuíam o risco de apresentar índice de massa maior ou igual 190 g/m2, somente com o dobro do valor da atividade da ECA, quando comparados aos pacientes com a forma não familiar (p = 0,022). CONCLUSÕES: Não houve diferença estatisticamente significante entre o genótipo do polimorfismo e da atividade da ECA nos pacientes com CMH nas formas familiar e não familiar. Não houve correlação entre o polimorfismo da ECA e o grau de hipertrofia miocárdica. Houve correlação positiva entre a atividade da ECA e o índice de massa do ventrículo esquerdo. / BACKGROUND: The polymorphism and the activity of the angiotensin converting enzyme (ACE) contributes of significant form in the phenotypic expression and the prognostic of patients with cardiomyopathy. OBJECTIVES: To determine the ACE polymorphism and ACE plasma levels in patients with hypertrophic cardiomyopathy (HCM) in the familial and nonfamilial forms and to correlate it with the degree of myocardium hypertrophy and with the left ventricular mass index. PATIENTS AND METHODS: 136 consecutive patients with HCM (69 of familial and 67 of nonfamilial forms) were studied. The mean age was 40.53±17.45 years, 76 were male. The individuals were submitted to the Echo-Doppler for the measurement of interventricular septum, wall thickness and the left ventricular mass index. The blood samples were taken for extraction of the DNA for the polymerase reaction and measurement of ACE plasma levels. RESULTS: Regarding the genotype of the ACE gene polymorphism, we found DD 47 (35%), ID 71 (52%) and II 18 (13%), being that of genotype DD 34% in the familial and 36% in the nonfamilial forms. The mean of the activity of the ACE was 56.414±19.236 for the patients with HCM in the familial form and 55.085±22.634 in the non familial form (p = 0.714). The mean of the left ventricular mass index in the familial form was 154±63 g/m2 and in the nonfamilial form was 174±57 g/m2 (p = 0.0080). The mean of interventricular septum in the familial and nonfamilial forms was 19±5 mm and 21±5 mm (p = 0.0200), respectively. The mean of the wall thickness in the familial and nonfamilial forms was 10±2 mm and 12±3 mm (p = 0.0001), respectively. We did not observe correlation between the polymorphism and the degree of myocardium hypertrophy (p = 0.651). A positive correlation between the activity of the ACE and the left ventricular mass index (p = 0.038) was observed. In patients with the familial form, using a logistic regression curve, they had the risk to present the left ventricular mass index >= 190 g/m2, only with the double of the value of the activity of the ACE, when compared with the patients in the nonfamilial form (p = 0.022). CONCLUSIONS: There was no difference between the patients with HCM in the familial and nonfamilial forms regarding genotype of the polymorphism and activity of the ACE. There was no correlation between the polymorphism of the ACE with the degree of myocardium hypertrophy. Positive correlation with the activity of the ACE and the left ventricular mass index was observed.

Introdução: O tratamento alternativo de Redução septal percutânea (RSP) em pacientes com cardiomiopatia hipertrófica obstrutiva é relativamente novo e há poucos trabalhos publicados sobre a evolução tardia. Objetivos: Avaliar nos pacientes com cardiomiopatia hipertrófica obstrutiva sintomáticos e refratários ao tratamento clínico, tratados com RSP, a sobrevida cardíaca e global, qualidade de vida, eventos maiores e as alterações encontradas no eletrocardiograma (ECG), ecocardiograma(ECO) e Holter 24h antes e na evolução tardia de até 15 anos. Método: Foram incluídos pacientes consecutivos que realizaram RSP no Instituto Dante Pazzanese de Cardiologia e no Hospital do Coração de Outubro de 1998 até junho de 2013. Todos os pacientes realizaram exame clínico, ECG e ECO, e a maioria Holter 24h e responderam o questionário DASI antes e pós-RSP. Os dados qualitativos foram descritos em frequências absolutas e relativas e os quantitativos resumidos em médias ± desvios padrão. Para as variáveis quantitativas foram utilizados modelos ANOVA com medidas repetidas, seguidos pelo método de comparações múltiplas de Bonferroni. O nível de significância de 0,05 foi aceito. Resultados: Dos 56 pacientes incluidos, 28 (50%) eram homens, a idade média foi 53,2 ±15,5 anos sendo 2 crianças e 11 (19,6%) tinham coronariopatia. A maioria estava em classe funcional III-IV, o gradiente médio basal por ECO foi 92,8 ± 3,3 mmHg, a espessura do septo 23,9 ± 0,6 e 62,5% tinha insuficiência mitral (IM) moderada. Durante a internação 1 (1,7%)paciente implantou marcapasso. Durante o seguimento de 7,4 ± 4 anos ocorreram 3 implantes de CDI, 2 por prevenção secundaria e 1 marcapasso, 1 nova RSP, 3 cirurgias de miectomias e houve 7 (12,5%) óbitos, apenas 2 de causa cardíaca. O tempo médio de sobrevida, estimado pelo método de Kaplan Meier foi de 13,3 anos (IC95% 12,2 a 14,5 anos), com expectativa de sobrevida de 96,4% em 1 ano, 87,7% em 5 anos e 81,0% a os 12 anos pós-RSP. Houve melhora significativa na qualidade de vida pelo questionário DASI e na classe funcional da NYHA que passou de 3,6 ± 0,5 para 1,2 ± 0,5 no pós-RSP. Na última avaliação do ECO o gradiente 9,37 ± 6,7 mmHg, o septo 12,87 ± 0,98 mm e a IM foi discreta em 90% todos com p < 0,001. Das variáveis analisadas somente o gradiente no estresse, p=0,039 e a massa p=0,024 foram associados a pior prognóstico. Conclusões: A redução septal percutânea mostrou, na evolução tardia com 100% de seguimento, ser uma técnica segura, eficaz em manter os benefícios tardiamente com baixa mortalidade, oferecendo melhora significativa da classe funcional e da qualidade de vida para os pacientes. / Introduction: Percutaneous septal Reduction (PSR) is a relatively new alternative treatment in patients with obstructive hypertrophic cardiomyopathy and there are few published studies on late evolution. Objectives: Evaluate in symptomatic patients with hypertrophic obstructive cardiomyopathy refractory to medical treatment and who underwent PSR, cardiac and overall survival, quality of life, major events and changes found on the electrocardiogram (ECG), echocardiography (ECHO) and Holter 24h before and after PSR during an evolution up to 15 years. Method: Consecutive patients who were submitted to RSP in Dante Pazzanese Institute of Cardiology and Heart Hospital from October 1998 were included. All patients went through clinical, ECG and ECHO examination, and nearly all answered DASI questionnaire, 24-hour Holter monitoring before and after PSR. Qualitative data were described as absolute and relative frequencies and quantitative summarized as means ± standard deviations. ANOVA models were used for quantitative variables with repeated measures, followed by Bonferroni method for multiple comparison. Significance level of 0.05 was accepted. Results: From 56 patients included, 28 (50%) were men , the mean age was 53.2 ± 15.5 years with 2 children and 11 (19.6%) had coronary artery disease . Most were in functional class III - IV from NYHA, the mean baseline ECO gradient was 92.8 ± 3.3 mmHg, the septal thickness 23.9 ± 0.6mm and 62.5 % had moderate mitral regurgitation (MR). During hospitalization 1 (1.7%) patient required permanent pacemaker. During follow-up of 7.4 ± 4 years, 3 patient required ICD implantation, 2 (for secondary prevention), 1 permanent pacemaker, 1 new RSP, 3 myectomy surgery. There were 7 (12.5%) deaths but only 2 of cardiac causes. The median survival time estimated by the Kaplan Meier was 13.3 years (95% CI 12.2 to 14.5 years), with expected survival of 96.4% at 1 year, 87.7% at 5 years and 81.0% at 12 years post-PSR. Significant improvement was seen in quality of life inferred by DASI questionnaire answers and NYHA functional class from 3.6 ± 0.5 to 1.2 ± 0.5. In last evaluation we found statistical significant reduction in ECO gradient 9.37 ± 6.7 mmHg, septum thikness 12.87 ± 0.98 mm and MR was mild in 90 % of patients. Of the variables analyzed only stress gradient (p = 0.039) and mass (p = 0.024) were associated with worse prognosis. Conclusions: The results of this study suggest that percutaneous septal reduction in late evolution with no loses in follow-up, is a safe technique, effective in reducing ventricular gradient and preserving the benefits in long-term evolution with low mortality, offering significant improvement in functional class and quality of life for patients.

INTRODUÇÃO: A ecocardiografia tridimensional em tempo real (E3DTR) vem provando sua acurácia para quantificar os volumes do ventrículo esquerdo (VE), fração de ejeção (FEVE) e massa em pacientes com cardiomiopatia. Na cardiomiopatia hipertrófica (CMH), onde a morfologia ventricular pode estar muito alterada, a análise das estruturas cardíacas é fundamental para indicação da terapêutica ideal. A ressonância magnética cardiovascular (RMC) é um método superior na análise segmentar do VE em comparação a ecocardiografia bidimensional (E2D), mas com alta complexidade e existente em poucos centros diagnósticos, com contraindicações e limitações para a sua realização. MÉTODOS: Estudo transversal, comparativo, duplo cego, em 20 portadores de CMH, com E2D, E3DTR e RMC realizados com intervalo máximo de 06 meses e armazenados em formato digital. A espessura das paredes, volumes, função sistólica e massa ventricular esquerda foram analisados pelos métodos ecocardiográficos e pela RMC, assim como o movimento anterior sistólico da valva mitral, o índice geométrico do VE e o índice sistólico de dissincronia do VE. ANÁLISE ESTATÍSTICA: Análise estatística pelo coeficiente de concordância de Lin, correlação linear de Pearson e modelo de Bland-Altman. RESULTADOS: Foi obtida exeqüibilidade elevada acima de 94%, dependente do parâmetro avaliado. Concordância satisfatória e forte correlação linear evidenciada para a análise segmentar (Rc>0.84 e r>0.85; p<0.0001) observada para os métodos ecocardiográficos comparados à RMC, com concordância excelente entre os métodos ecocardiográficos (Rc=0,92 e r=0,92, p<0,0001). Concordância satisfatória e forte correlação linear para a fração de ejeção do VE (Rc=0.83 e r=0.93; p<0.0001) pela E3DTR comparada à RMC. Concordância excelente e forte correlação linear para o VDFVE e VSFVE pela E3DTR comparada à RMC e pela E2D comparada à E3DTR (Rc>0.90 and r>0.95; p<0.0001), assim como para a massa do VE, para os métodos E3DTR e RMC (Rc=0.96 e r=0.97; p<0.0001). Evidenciada maior exeqüibilidade da análise do MAS pela E3DTR. O índice geométrico do VE foi >0,15mmxm²xml-1 para todos os métodos. Observada correlação negativa entre o índice de dissincronia do VE e o percentual de fibrose miocárdica, sem significância estatística. CONCLUSÕES: A E3DTR é precisa e superior à E2D na avaliação da distribuição da hipertrofia miocárdica, quantificação dos volumes, função e massa ventricular esquerda em pacientes com CMH quando comparada à RMC, e parece ser superior na análise do MAS, pela melhor visão espacial da valva mitral.Todas as medidas do índice geométrico do ventrículo esquerdo estavam acima de 0,15mmxm²xml-1, compatível com CMH. Não foi identificada correlação entre o índice sistólico de dissincronia ventricular esquerda e a fibrose miocárdica. / INTRODUCTION: Real-time three-dimensional echocardiography (RT3D) has been demonstrated an accurate technique for the quantification of left ventricular (LV) volumes, ejection fraction (LVEF), and mass. In patients with hypertrophic cardiomyopathy (HCM), in which alterations of ventricular morphology are common, cardiac structural analysis is of utmost importance for guiding adequate therapy. Although magnetic resonance imaging (MRI) seems to have better definition for segmental analysis than two-dimensional echocardiography, (2D-E), it is considered a complex test with low availability and some limitations for use. METHODS: Comparative and double-blinded study in 20 patients with HCM. All patients underwent 2DE, RT3D and MRI within maximal interval of 6 months. Parameters analyzed by echocardiography and MRI included: wall thickness, LV volumes, systolic function, LV mass, systolic anterior motion of mitral valve, LV geometric index and LV dyssynchrony index. Statistical analysis was performed by Lin agreement coefficient, Pearson linear correlation and Bland-Altman model. RESULTS: Feasibility for measurements by MRI and echocardiography was 94%. There was good agreement and linear correlation between segmental analysis by echocardiography and MRI (Rc>0.84 and r>0.85; p<0.0001) and excellent correlation between 2DE and RT3DE (Rc=0.92 and r=0.92; p<0.0001). We also observed good agreement and linear correlation between RT3DE and MRI for ejection fraction (Rc=0.83 and r=0.93; p<0.0001) and excellent agreement and linear correlation between RT3DE and MRI for LV end diastolic volume and LV end systolic volume determinations (Rc>0.90 and r>0.95; p<0.0001) and mass (Rc=0.96 and r=0.97; p<0.0001). The feasibility for systolic anterior motion of mitral valve was higher by RT3DE (91%) than 2DE (64%). LV geometric index was >0.15 mmxm²xml-1 for all techniques. There was no correlation between LV dyssynchrony index and the percentage of myocardial fibrosis. CONCLUSIONS: RT3D is an accurate technique with superior performance than 2DE for the evaluation of myocardial hypertrophy localization, LV volume and functional determination as well as for LV mass assessment in patients with HCM in comparison with MRI. In addition, it seems to be superior for the analysis of systolic anterior motion due to its better spatial view of mitral valve. All measurements of LV geometric index were above the value of 0.15 mmxm²xml-1, and such findings are compatible with HCM. No correlation between LV dyssynchrony index by RT3D and the percentage of myocardial fibrosis determined by MRI was identified.

L'objectif de ce travail de recherche est le développement, la mise au point et la validation d'une méthode de spectroscopie multi-modalités en diffusion élastique et autofluorescence pour caractériser des tissus cutanés cicatriciels hypertrophiques in vivo. Ces travaux sont reposés sur trois axes. La première partie des travaux présente l'instrumentation : développement d'un système spectroscopique qui permet de réaliser des mesures de multimodalités in vivo de manière automatique et efficace. Des procédures métrologiques sont mise en place pour caractériser le système développé et assurer la repétabilité les résultats de mesure. La deuxième partie présente une étude préclinique. Un modèle animal et un protocole expérimental ont été mises en place pour créer des cicatrices hypertrophiques sur lesquelles nous pouvons recueillir des spectres à analyser. La troisième partie porte sur la classification des spectres obtenus. Elle propose des méthodes algorithmiques pour débruiter et corriger les spectres mesurés, pour extraire automatiquement des caractéristiques spectrales interprétables et pour sélectionner un sous-ensemble de caractéristiques "optimales" en vue d'une classification efficace. Les résultats de classification réalisée respectivement par trois méthodes (k-ppv, ADL et RNA) montrent que la faisabilité d'utiliser la spectroscopie bimodale pour la caractérisation de ce type de lésion cutané. Par ailleurs, les caractéristiques sélectionnées par notre méthode montrent que la cicatrisation hypertrophique implique un changement de structure tissulaire et une variation de concentration de porphyrine / This research activity aims at developing and validating a multimodal system combining diffuse reflectance spectroscopy and autofluorescence spectroscopy in characterizing hypertrophic scar tissues in vivo. The work relies on three axes. The first part concerns the development of an automatic system which is suitable for multimodal spectroscopic measurement. A series of calibration procedures are carried out for ensuring the reliability of the measurement result. The second part presents a preclinical study on an animal model (rabbit ear). An experimental protocol was implemented in order to create hypertrophic scars on which we can collect spectra to analyze. The third part deals with the classification problem on the spectra obtained. It provides a series of algorithmic methods for denoising and correcting the measured spectra, for automatically extracting some interpretable spectral features and for selecting an optimal subset for classification. The classification results arched using respectively 3 different classifiers (knn, LDA and ANN) show the ability of bimodal spectroscopy in characterization of the topic skin lesion. Furthermore, the features selected my selection method indicate that the hypertrophic scarring may involve a change in tissue structure and in the concentration of porphyrins embedded in the epidermis

Die hypertrophe Kardiomyopathie ist eine autosomal dominant vererbte Herzmuskelerkrankung. Es kommt zu einer asymmetrischen Hypertrophie insbesondere des Herzmuskels. Symptome sind unspezifisch und reichen von Dyspnoe bis hin zu Synkopen. Gelegentlich ist der plötzliche Herztod die erste Manifestation der Erkrankung. Molekulargenetische Untersuchung des Genomes dieser Patienten zeigten, dass diese Patienten Mutationen im Proteinen des Sarkomers aufwiesen. Hierunter fällt das beta-MHC-Gen und alpha-Tropomysin-Gen. Wir untersuchten 45 nicht miteinanderverwandte Patienten auf Mutationen im beta-MHC-Gen und im alpha-Tropomysin-Gen. Folgende molekulargenetische Untersuchungen wurden angewendet: Polymerase-Ketten-Reaktion, Single-Strand-Polymorphismus-Anlyse und Sequenzierung. Bei 6 Patienten (13%) fanden wir eine Mutation im beta-Myosin-Gen. Kein Patient hatte eine Mutation im alpha-Tropomyosin-Gen. In der Literatur wird eine Mutation im beta-MHC-Gen in bis zu 35% und im alpha-Tropomyosin-Gen in bis zu 3% der Fälle angenommen. Unsere Patienten hatten die Mutationen: Exon 13 Arg403Trp und Val411Ile, Exon 19 Arg719Trp, Exon 20 Ile736Thr, Exon 21 Leu796Phe und Exon 23 Cys905Phe. Die Mutationen Arg403Trp und Arg719Trp waren vorher bereits bekannt. Die Mutationen, Ile736Thr, Val411Ile, Leu796Phe und Cys905Phe wurden in der Form von uns erstmals ermittelt. Offensichtlich besitzen unsere Patienten überdurchschnittlich häufiger Mutationen in anderen Genen, die in dieser Studie nicht untersucht wurden. Der Phänotyp der Krankheit der HCM war bei unserem Patientenkollektiv sehr heterogen, und es ließen sich keine signifikanten Unterscheidungen eststellen. So haben wir uns darauf beschränkt, bei den 6 Patienten mit Mutationen nur nach den von Burn et al. (1997) aufgestellten Risikofaktoren zu suchen, die einen plötzlichen Herztod herbeiführen können, und haben sie danach in Patienten mit einem höheren oder niedrigeren Risiko eingestuft. Kriterien für ein erhöhtes Risiko, einen plötzlichen Herztod zu erleiden, wurden von Patienten mit den Mutationen: Exon 13 Arg403Trp, Exon 13 Val411Ile, Exon 19 Arg719Trp, Exon 20 Ile736Thr und Exon 21 Leu796Phe erfüllt. Mutationen an diesen Positionen sind auch in der Literatur mit einem erhöhten Risiko für einen plötzlichen Herztod assoziiert worden. Der Patient mit der Mutation im Exon 23 Cys905Phe wies wenige Risikofaktoren auf und unterscheidet sich somit nicht von den in der Literatur beschriebenen Patienten. Wir konnten dies mit unseren Ergebnissen bestätigen. / Hypertrophic Cardiomyopathy is disease of the cardiac muscle which results in an asymmetric hypertrophy especially of the interventricularseptum of the heart. It is transmitted in an autosomal dominant way. The symptoms are unspecific reaching from dyspnoe to syncopes. Sometimes the sudden death is the first manifestation of the disease. Molekular genetic researches showed that in the patients genes Mutations in proteins of the sarkomer were detectable. Two of them are alpha-Tropomyosin and beta-Myosin Heavy Chain. We examined 45 unrelated Patient of the existence of Mutations in alpha-Tropomyosin and beta-Myosin Heavy Chain. We used following Examinations: PCR, SSCP, Sequencing. A mutation in the beta-Myosin Heavy Chain were found in 6 Patients (13%), non in alpha-Tropomyosin. Generally mutations are expected in 35% in beta-Myosin Heavy Chain and 3% in alpha-Tropomyosin. Our patients seem to have mutations in genes we did not examine in this study. We detected Mutations in: Exon 13 Arg403Trp and Val411Ile, Exon 19 Arg719Trp, Exon 20 Ile736Thr, Exon 21 Leu796Phe und Exon 23 Cys905Phe. Mutation Arg 403Trp and Arg719Trp have been known in this form before, the others were new. As the phenotypes of our patients were heterogenous and not significantly to be distinguished we looked for risk factors for sudden death as described by Burn et al. 1997 within our group of patients with mutations. Five Persons showed risk factors as discribed: Exon 13 Arg403Trp and Val411Ile, Exon 19 Arg719Trp, Exon 20 Ile736Thr, Exon 21 Leu796Phe. The person with the mutation Exon 23 Cys905Phe showed no risk factors for sudden death. Our results correlate with those of earlier studies. The patient with the mutation Exon 23 Cys905Phe was classified as a low risk patient while the other mutations correlate with a further high risk.

O estudo de mutações genéticas como causa das cardiomiopatias teve início com a descoberta de mutações em proteínas sarcoméricas que levavam à Cardiomiopatia Hipertrófica, desde então, alterações em diversos genes, de proteínas contráteis ou não, foram descobertas e listadas como a responsável pelo desenvolvimento de diferentes cardiomiopatias. Estudar o efeito destas mutações nos cardiomiócitos destes pacientes permanecia um desafio devido ao difícil acesso às células cardíacas. Em 2007, a técnica de reprogramação de células somáticas em células-tronco pluripotentes foi descoberta. Pelo fato das células-tronco pluripotentes serem capazes de ser diferenciadas em cardiomiócitos, surgiu-se a possibilidade de se estudar essas células de indivíduos portadores das mutações genéticas. Esta tese teve como objetivo a criação de um modelo celular para estudar a Cardiomiopatia Hipertrófica causada por mutações genéticas. Inicialmente foi estabelecido um protocolo de reprogramação celular para se estabelecer linhagens celulares das células-tronco induzidas de um paciente com mutação no gene MYH7. Tendo as células caracterizadas, elas foram diferenciadas em cardiomiócitos através de um protocolo adaptado de protocolos de diferenciação direta em cardiomiócitos. Os cardiomiócitos gerados apresentaram características moleculares e funcionais semelhantes à cardiomiócitos primários humanos e foi visualizado, através de microscopia eletrônica de transmissão, que os cardiomiócitos do paciente com alteração genética possuíam grande proporção de sarcômeros desorganizados em comparação a cardiomiócitos de indivíduos saudáveis. Em conclusão, o modelo celular desenvolvido sugere ser possível o estudo do efeito de mutações genéticas em Cardiomiopatia Hipertrófica. / The study of genetic mutations as the cause of cardiomyopathies initiates with the discovery of mutations in sarcomeric proteins genes that lead to Hypertrophic Cardiomyopathy. Since then, mutations in several genes, coding to sarcomeric proteins or not, were discovered and listed as the reason to the cardiomyopathies. To study the effect of these mutations was a challenge due the difficulty to accesses cardiac cells. In 2007, the technique of reprogramming somatic cells into pluripotent stem cells was discovered. The fact that the pluripotent stem cells are capable of differentiating into cardiomyocytes opened the opportunity to study these cells from individuals with genetic mutations. This thesis aimed to create a cellular model to study Hypertrophic Cardiomyopathy caused by genetic mutations. Initially we established a cell reprogramming protocol to establish induced stem cells lines from a patient with mutation in MYH7 gene. Having characterized the cells, they were differentiated into cardiomyocytes using an adapted protocol from direct differentiation protocols. Cardiomyocytes generated showed molecular and functional characteristics similar to human primary cardiomyocytes and were visualized by means of transmission electron microscopy. The patient\'s cardiomyocytes had a large proportion of disorganized sarcomeres compared to cardiomyocytes from healthy individuals. In conclusion, the cell model developed suggests that it is possible to study the effect of genetic mutation in Hypertrophic Cardiomyopathy using induced pluripotent stem cells derived cardiomyocytes.

Estudos epidemiológicos e experimentais tem mostrado consistentemente que tanto as exposições agudas e crônicas à poluição do ar estão associadas com uma variedade de doenças cardiovasculares. A poluição atmosférica é composta por uma mistura de substâncias nocivas incluindo partículas e gases. Os efeitos adversos cardiovasculares são mais comumente atribuídos às partículas e experimentos toxicológicos tem demonstrado diferentes mecanismos pelos quais a exposição às partículas pode provocar estes efeitos. Neste estudo nos investigamos os efeitos do tempo (7, 15 e 21 dias) de exposição as partículas ambientais (dose = 600 g/m³) nos parâmetros funcionais e morfológicos do coração de ratos normais e ratos com hipertrofia ventricular esquerda (HVE) induzida pelo isoproterenol (agonista não seletivo -adrenérgico de ação direta) (1,2 mg/kg). A utilização de ratos com HVE foi motivado pelo fato de que a existência de uma doença cardiovascular prévia representa um fator de risco elevado para estes indivíduos. Nossos dados mostraram que o tempo de exposição ao material particulado concentrado é um fator importante para a magnitude dos efeitos sobre a função e morfologia do coração, como mostrado pelo aumento da variabilidade da frequência cardíaca, diminuição da frequência cardíaca e aumento no volume de tecido conjuntivo no miocárdio do ventrículo esquerdo. Os ratos com HVE mostraram efeitos similares, porém mais graves sobre o coração, que incluíram diminuição da pressão arterial e aumento da hipertrofia dos cardiomiócitos em comparação com ratos com HVE não expostos. Concluindo, nossos resultados corroboram com achados anteriores que mostram que a poluição atmosférica particulada induz alterações no controle autonômico do coração e que indivíduos com doenças cardiovasculares preexistentes são mais afetados que indivíduos normais. Mostramos ainda que o material particulado concentrado é capaz de induzir alterações na microestrutura do miocárdio, dependendo da dose acumulada de exposição / Epidemiological and experimental studies have consistently shown that both short- and long-term exposures to air pollution are associated with a variety of cardiovascular diseases. Air pollution is composed by a mixture of noxious substance including particles and gases. The cardiovascular adverse effects are more commonly attributed to particles and toxicological experiments have demonstrated several mechanisms by which particle exposure may trigger these effects. In this study we investigated the effects of time (7, 15 and 21 days) of exposure to concentrated ambient particles (dose = 600 g/m³) on morphofunctional parameters of the heart in normal and rats with left ventricular hypertrophy (LVH) induced by isoproterenol (nonselective -adrenergic agonist with direct action) (1.2 mg/kg). The use of LVH rats was motivated by the fact that individuals with cardiovascular diseases are considered at higher risk for effect of ambient PM. Our data have shown that time is an important factor on the magnitude of the effects of concentrated ambient particles on heart function and morphology, as shown by increased HRV (heart rate variability), decreased heart rate and increased volume of connective tissue in left ventricle myocardium. LVH rats presented similar outcomes but more severe effects on the heart which included decreased blood pressure and increased cardiomyocyte hypertrophy compared to non-exposed LVH rats. In conclusion, our results corroborate with previous findings that particulate air pollution induces changes in the autonomic control of the heart and that individual with previous cardiovascular disease are more affected than normal ones. We have further shown that concentrated ambient particles are capable of inducing changes in the microstructure of the myocardium depending on accumulated dose of exposure