RCAAP Repository

Abstract Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

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Abstract Background: Obesity affects a large part of elderly individuals worldwide and is considered a risk predictor for the development of chronic diseases such as cardiac diseases, the leading causes of death in the elderly population. Objective: To investigate the prevalence of obesity and associated factors, with emphasis on the occurrence of other diseases and on food consumption in elderly individuals treated at the Brazilian Unified Health System (Sistema Único de Saúde, SUS). Methods: Cross-sectional sampling study performed in the city of Goiânia (Brazil) including elderly individuals (≥ 60 years) receiving primary care. During home visits, we performed anthropometric measurements and applied a structured, standardized, and pre-tested questionnaire assessing socioeconomic, demographic and lifestyle conditions, occurrence of diseases, and food consumption. We performed multiple Poisson regression analysis using a hierarchical model and adopting a significance level of 5%. Results: We evaluated 418 elderly patients with a mean age of 70.7 ± 7 years. Their body mass indices had a mean value of 27.0 kg/m2 and were higher in women than in men (27.4 kg/m2 versus 26.1 kg/m2, respectively, p = 0.017). Obesity had a prevalence of 49.0%, a risk 1.87 times higher between the ages of 60-69 years and 70-79 years, and a rate 1.4 times higher among individuals with more than four morbidities. On multivariate analysis, the factors associated with obesity were age 60-69 and 70-79 years, inadequate consumption of whole-wheat grains and adequate consumption of fruit, musculoskeletal diseases, diabetes mellitus, and acute myocardial infarction. Conclusions: Obesity had a high prevalence in the evaluated elderly population and was associated with food consumption, musculoskeletal disease, diabetes mellitus, and acute myocardial infarction.

Abstract Background: Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients. Objectives: To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization. Methods: Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014. Results: Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups. Conclusion: Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Abstract Background: There is still debate about the relationship between changes in ventricular repolarization on the surface electrocardiogram and cirrhosis severity. Objective: To study the relationship between variables related to ventricular repolarization and the clinical severity of the cirrhotic disease. Methods: We selected 79 individuals with hepatic cirrhosis, classified according to the Child-Pugh-Turcotte criteria (Child A, B, and C). We measured the QT and corrected QT (QTc) intervals, and the interval between the peak and the end of the T wave (TpTe), and we identified their minimum, maximum, and mean values in the 12-lead electrocardiogram. We also calculated the dispersion of the QT (DQT) and QTc (DQTc) intervals. Results: In 12 months of clinical follow-up, nine subjects underwent hepatic transplantation (Child A: 0 [0%]; Child B: 6 [23.1%]; Child C: 3 [18.8%]; p = 0.04) and 12 died (Child A: 3 [12.0%]; Child B: 4 [15.4%]; Child C: 5 [31.3%]; p = 0.002). No significant differences were observed between the cirrhotic groups related to the minimum, maximum, and mean values for the QT, QTc, TpTe, DQT, and DQTc intervals. A minimum TpTe interval ≤ 50 ms was a predictor for the composite endpoints of death or liver transplantation with a sensitivity of 90% and a specificity of 57% (p = 0.005). In the Cox multivariate analysis, the Child groups and a minimum TpTe of ≤ 50 ms were independent predictors of the composite endpoints. Conclusion: The intervals QT, QTc, DQT, DQTc, and TpTe have similar distributions between different severity stages in cirrhotic disease. The TpTe interval proved to be a prognostic marker in subjects with cirrhosis, regardless of disease severity (NCT01433848).

Abstract Background: Hyperthyroidism is currently recognized to affect the cardiovascular system, leading to a series of molecular and functional changes. However, little is known about the functional influence of hyperthyroidism in the regulation of cytoplasmic calcium and on the sodium/calcium exchanger (NCX) in the cardiac muscle. Objectives: To evaluate the functional changes in papillary muscles isolated from animals with induced hyperthyroidism. Methods: We divided 36 Wistar rats into a group of controls and another of animals with hyperthyroidism induced by intraperitoneal T3 injection. We measured in the animals' papillary muscles the maximum contraction force, speed of contraction (+df/dt) and relaxation (-df/dt), contraction and relaxation time, contraction force at different concentrations of extracellular sodium, post-rest potentiation (PRP), and contraction force induced by caffeine. Results: In hyperthyroid animals, we observed decreased PRP at all rest times (p < 0.05), increased +df/dt and -df/dt (p < 0.001), low positive inotropic response to decreased concentration of extracellular sodium (p < 0.001), reduction of the maximum force in caffeine-induced contraction (p < 0.003), and decreased total contraction time (p < 0.001). The maximal contraction force did not differ significantly between groups (p = 0.973). Conclusion: We hypothesize that the changes observed are likely due to a decrease in calcium content in the sarcoplasmic reticulum, caused by calcium leakage, decreased expression of NCX, and increased expression of a-MHC and SERCA2.

Abstract Introduction: A recently published study raised doubts about the need for percutaneous treatment of nonculprit lesions in patients with acute coronary syndromes (ACS). Methods: Retrospective, unicentric, observational study. Objective: To analyze the long-term outcomes in patients undergoing treatment of the culprit artery, comparing those who remained with significant residual lesions in nonculprit arteries (group I) versus those without residual lesions in other coronary artery beds (group II). The study included 580 patients (284 in group I and 296 in group II) between May 2010 and May 2013. We obtained demographic and clinical data, as well as information regarding the coronary treatment administered to the patients. In the statistical analysis, the primary outcome included combined events (reinfarction/angina, death, heart failure, and need for reintervention). The comparison between groups was performed using the chi-square test and ANOVA. The long-term analysis was conducted with the Kaplan-Meier method, with a mean follow-up of 9.86 months. Results: The mean ages were 63 years in group I and 62 years in group II. On long-term follow-up, there was no significant difference in combined events in groups I and II (31.9% versus 35.6%, respectively, p = 0.76). Conclusion: The strategy of treating the culprit artery alone seems safe. In this study, no long-term differences in combined endpoints were observed between patients who remained with significant lesions compared with those without other obstructions.

Abstract Background: Heart failure (HF) is a highly prevalent syndrome. Although the long-term prognostic factors have been identified in chronic HF, this information is scarcer with respect to patients with acute HF. despite available data in the literature on long-term prognostic factors in chronic HF, data on acute HF patients are more scarce. Objectives: To develop a predictor of unfavorable prognostic events in patients hospitalized for acute HF syndromes, and to characterize a group at higher risk regarding their clinical characteristics, treatment and outcomes. Methods: cohort study of 600 patients admitted for acute HF, defined according to the European Society of Cardiology criteria. Primary endpoint for score derivation was defined as all-cause mortality and / or rehospitalization for HF at 12 months. For score validation, the following endpoints were used: all-cause mortality and / or readmission for HF at 6, 12 and 24 months. The exclusion criteria were: high output HF; patients with acute myocardial infraction, acute myocarditis, infectious endocarditis, pulmonary infection, pulmonary artery hypertension and severe mitral stenosis. Results: 505 patients were included, and prognostic predicting factors at 12 months were identified. One or two points were assigned according to the odds ratio (OR) obtained (p < 0.05). After the total score value was determined, a 4-point cut-off was determined for each ROC curve at 12 months. Two groups were formed according to the number of points, group A < 4 points, and group B = 4 points. Group B was composed of older patients, with higher number of comorbidities and predictors of the combined endpoint at 6, 12 and 24 months, as linearly represented in the survival curves (Log rank). Conclusions: This risk score enabled the identification of a group with worse prognosis at 12 months.

Abstract Background: Cardioinhibitory vasovagal response is uncommon during the tilt test (TT). Heart rate variability (HRV) by use of spectral analysis can distinguish patients with that response. Objective: To compare the HRV in patients with cardioinhibitory vasovagal syncope (case group - G1) with that in patients without syncope and with negative response to TT (control group - G2). Methods: 64 patients were evaluated (mean age, 36.2 years; 35 men) and submitted to TT at 70 degrees, under digital Holter monitoring. The groups were paired for age and sex (G1, 40 patients; G2, 24). Results: In G1, 21 patients had a type 2A response and 19 had type 2B, with mean TT duration of 20.4 minutes. There was a greater low frequency (LF) component (11,6 versus 4,5 ms2, p=0.001) and a lower low/high frequency ratio in the supine position (3,9 versus 4,5 ms2, p=0.008) in G1, with no difference during TT between the groups. Applying the receiver operating characteristic curve for cardioinhibitory response, the area under the curve was 0.74 for the LF component in the supine position (p = 0.001). The following were observed for the cutoff point of 0.35 ms(2) for the LF component: sensitivity, 97.4%; specificity, 83.3%; positive predictive value, 85.3%; negative predictive value, 96.9%; and positive likelihood ratio, 5.8. Conclusion: HRV in the supine position allowed identifying patients with syncope and cardioinhibitory response with a high negative predictive value and likelihood ratio of 5.8.

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Abstract Extracorporeal membrane oxygenation (ECMO) is a well-established tool of cardiopulmonary circulatory support for cardiopulmonary failure in children and adults. It has been used as a supportive strategy during interventional procedures in neonates with congenital heart disease. Herein, we describe a neonate with hypoplastic left heart syndrome who underwent stenting of the Sano shunt and left pulmonary artery after Norwood Sano operation using intra-procedural ECMO support. The use of ECMO as a bridge to recovery might be a feasible and reasonably safe adjunctive approach in the treatment of complications in selective case of neonates having undergone the Norwood Sano procedure.

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OBJETIVO: Realizar um levantamento de dados epidemiológicos em prontuários, avaliando a evolução neurológica dos pacientes vítimas de lesões por arma de fogo na coluna vertebral durante a internação hospitalar, que foram operados entre 1991 e 2010. MÉTODOS: Os dados foram tabulados por meio de estatística descritiva, buscando significância estatística entre a melhora neurológica e o procedimento cirúrgico individualizado para cada caso. Dos 290 pacientes operados, 115 deram entrada no HGE com quadro clínico de paralisia sensitiva e motora, correspondendo a 39,66% do total, sendo os pacientes Frankel A os mais prevalentes da nossa casuística. RESULTADOS: Esses pacientes evoluíram com menor possibilidade de reversão dos déficits neurológicos, com 94,78% não apresentando melhora na alta hospitalar. Os portadores de lesão medular incompleta apresentaram evolução neurológica em 94,59 % dos operados. CONCLUSÃO: Não foi encontrada significância estatística para a melhora neurológica com relação aos procedimentos cirúrgicos realizados nos pacientes vítimas de lesões por arma de fogo na coluna vertebral.

OBJECTIVE: To examine the relationship between sagittal balance parameters and different symptoms of spinal disease in patients with lumbar canal stenosis (LCS) and controls. METHODS: In this prospective, diagnostic, case-control study, we included all patients consecutively admitted to a public teaching hospital for surgical treatment of LCS between July 2010 and October 2011, aged more than 40 years, with back pain plus radiculopathy or neurogenic claudication, and controls without LCS. Magnetic resonance and x-rays allowed the measurement of sagittal axis parameters. Clinical data, the Oswestry Disability Index and the visual analogue scale of pain were assessed. RESULTS: 23 patients were in the Stenosis group, and 17 were controls. The Stenosis group presented lower values of total lumbopelvic lordosis and regional lordosis L1, L2 and L3. In LCS patients and back pain, total lumbopelvic and regional lordosis at L1, L2 and L3 were smaller. Those with stenosis and radiculopathy had higher values of pelvic tilt and lower total lumbopelvic lordosis and regional lordosis in L1 and L2. In patients with claudication, regional lumbopelvic lordosis in L1 and L2 and the T9 sagittal offset were smaller. All patients with pain had higher values of thoracic kyphosis, regional lumbopelvic lordosis in L1, lower values for pelvic tilt, sagittal T1 offset, sacro-femoral distance and overhang compared to patients without pain. CONCLUSIONS: This study shows significant correlations between symptoms and sagittal axis parameters between patients with and without spinal canal stenosis and also in subgroups of the patients with stenosis with different complaints.

OBJETIVO: Avaliar o uso da monitorização neurofisiológica intraoperatória (MNIO) por cirurgiões de coluna brasileiros. MÉTODO: A coleta de dados foi realizada através de um questionário aplicado em 307 cirurgiões de coluna brasileiros, durante o 11º Congresso de Cirurgia Espinhal e XIII Congresso da Sociedade Brasileira de Coluna. RESULTADOS: Dos cirurgiões entrevistados, 42% são neurocirurgiões e 58% ortopedistas. A maioria (72,3%) relatou que já fez uso do MNIO, entretanto apenas 29,6% utilizam este procedimento rotineiramente. Destes 39% são ortopedistas. Entre os neurocirurgiões, a maior parte (84%) relatou não utilizar MNIO como rotina. Nos casos de deformidade, 85,7% dos profissionais disseram usar rotineiramente a MNIO. Do total, 68,1% responderam que não tinham fácil acesso à MNIO, sendo que 10% deles atuam na região Centro-oeste do país e 11%, na região Nordeste. Dos que relataram facilidade de acesso ao procedimento, 77% atuam na região Sudeste. A média de idade dos participantes foi 41,9 anos, com mediana de 39,0, desvio padrão de 11,3 e intervalo de confiança de 1,3. Para o tempo de formação médica, a média foi 17,8 anos, com mediana de 14,0 e intervalo de confiança 1,2. Em relação ao tempo de prática em cirurgia de coluna encontrou-se que 56,3% têm até 10 anos de prática. CONCLUSÃO: A maioria dos cirurgiões de coluna já fez uso da MNIO, contudo poucos utilizam-na como rotina. A região Sudeste é onde se encontra maior facilidade de acesso à MNIO, ao contrário das regiões Centro-oeste e Nordeste.

OBJETIVO: Determinar através de cortes tomográficos e reconstrução tridimensional a incidência de mal posicionamento de parafusos em pacientes submetidos ao tratamento cirúrgico da Escoliose idiopática do adolescente. MÉTODOS: Foram analisados exames tomográficos de 8 pacientes, tratados cirurgicamente no Hospital de Base de São José do Rio Preto-SP, realizada instrumentação posterior partindo de T2 /T4 a L4/L5 totalizando 164 parafusos. RESULTADOS: 32,9% (n=54) apresentavam posicionamento com risco potencial,ou seja desvio acima de 2 milímetros, sendo 20,1% (n=33) com invasão lateral, 9,1% (n=15) com invasão medial, 3,6 %(n=6) com invasão anterior. Dos parafusos que ofereciam risco potencial a relação com aspecto da curva foi de 46% (n=25) na concavidade, 35% (n=19) na convexidade e 19% (n=10) em vértebras adjacentes a curva. CONCLUSÃO: Os limites de penetração aceitáveis, assim como os métodos de mensuração ainda não foram padronizados, a técnica "free hand' mostrou-se segura, apesar da violação dos pedículos. A tomografia computadorizada pré-operatória, auxilia no planejamento cirúrgico e na redução das complicações.

OBJETIVO: Comparar a colocação de geléia Gelfoan® versus a colocação apenas de dreno de sucção na área doadora, avaliando a dor pós-operatória, presença de complicações e seguimento dos pacientes. MÉTODOS: Foram randomizados por programa de computador 30 pacientes, sendo que em 14 pacientes foi utilizado Gelfoan® com anestésico e em 16 pacientes utilizamos dreno de sucção. Todos os pacientes foram avaliados em cinco períodos consecutivos, sendo avaliada a dor baseada na Escala Visual Analógica (VAS) e observado a incidência de complicações. Foram incluídos pacientes com abordagem anterior ou posterior, sendo considerado como fonte doadora única a crista ilíaca. Foram incluídos pacientes com 18 a 70 anos de idade de ambos os sexos. RESULTADOS: Foi observado que a dor pós-operatória foi menor com Gelfoan® nas primeiras avaliações, mas na média o resultado foi semelhante, não apresentando diferença estatística entre ambas as técnicas. Na média das avaliações, a escala visual analógica de dor foi de dois; não se observando complicações na área da retirada do enxerto. CONCLUSÃO: A abordagem com Gelfoan® com bupivacaina melhora a dor nas primeiras 48h pós-cirurgia, quando comparada com dreno de sucção a vácuo, mas na média ambas a técnicas são seguras, com presença de dor residual nas duas intervenções, mas com baixo índice de complicações. Não observamos complicações em nosso estudo.

Spinal cord injuries remain an important factor of morbimortality in current society, involving mainly males from adolescence to adulthood. Among the sequelae caused by spinal cord injuries, the impairment of the sexual system is highly relevant since it affects the quality of sexual life and paternity. Infertility is secondary to multiple events such as erectile dysfunction, anejaculation, seminal biochemical modification and morphology of spermatozoa. Current therapies for the infertile spinal cord injured patient focus on the ejaculation stimulus followed by intrauterine insemination, leaving seminal low quality as the major factor of infertility in these patients. In this scenario, therapy with hyperbaric oxygenation, which is still being studied, represents an alternative treatment since it focuses on the central nervous system injured by the trauma and the testicular tissue in order to decrease spinal damage and to preserve the physiological regulation of the urogenital system as a form of avoiding infertility.

A terapêutica cirúrgica da escoliose degenerativa consiste habitualmente em instrumentações e fusões mais ou menos extensas e associa-se a morbilidade significativa. A evolução tecnológica tem aberto caminho a técnicas menos invasivas que permitem obter resultados sobreponíveis aos das técnicas tradicionais minimizando a agressão cirúrgica. Descreve-se o caso de uma paciente do sexo feminino, de 63 anos, submetida a descompressão lombar posterior, em Janeiro de 2009, por alterações degenerativas marcadas. Poucos meses após a cirurgia a paciente referiu aumento das lombalgias e ciatalgia direita. O estudo imagiológico demonstrou agravamento de escoliose degenerativa L2-L5 associada a extrusão discal L2-L3 direita calcificada, fractura bilateral dos pedículos de L3 e espondilolistese degenerativa grau 1 L5-S1. Foi submetida a reintervenção cirúrgica por técnica minimamente invasiva consistindo em TLIF's L2-L3, L3-L4, L4-L5 e L5-S1 e fixação transpedicular L2-S1 bilateral, com correcção da deformidade no plano sagital e coronal. O caso clínico apresentado ilustra o potencial das abordagens minimamente invasivas no tratamento cirúrgico de escolioses degenerativas, devendo ser uma opção sempre presente considerando os benefícios potenciais para o paciente.