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- ItemAcesso aberto (Open Access)Análise da recorrência de fibrilação atrial durante terapia com sotalol ou quinidina(Sociedade Brasileira de Cardiologia - SBC, 1998-01-01) Veloso, Henrique Horta [UNIFESP]; De Paola, Angelo Amato Vincenzo [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)PURPOSE: To analyze the recurrences of atrial fibrillation in patients treated with sotalol or quinidine. METHODS: After conversion to sinus rhythm, 121 patients with paroxysmal atrial fibrillation were randomized to sotalol (58 patients) or quinidine (63 patients) and followed-up during 6 months. Symptoms and ventricular rates on the 12 lead electrocardiogram of the arrhythmic events were compared between the two groups. Clinical and echocardiographic characteristics were analyzed as predictors of atrial fibrillation recurrence. RESULTS: Seventeen (14%) patients relapsed into atrial fibrillation; 7 (12%) were treated with sotalol and 10 (16%) with quinidine. Recurrence occurred later in the sotalol group (median 69 days) in comparison with the quinidine group (median 10 days) (p=0.04). Symptoms were present in 14 (82%) patients during the initial crisis and in 10 (47%) during recurrence. Recurrence was less symptomatic during antiarrhythmic therapy (p<0.04), with no statistical differences between the two groups. Only patients treated with sotalol had ventricular rates during the recurrences lower than during initial crisis (p<0.02). All variables failed to predict recurrence of atrial fibrillation. CONCLUSIONS: evention of atrial fibrillation. Recurrence was less symptomatic during antiarrhythmic therapy. Patients treated with sotalol relapsed to atrial fibrillation later and had ventricular rates during recurrences significantly lower than during the initial crisis.
- ItemSomente MetadadadosAnticoagulation for atrial fibrillation: Underutilization in a Brazilian tertiary outpatient clinic(Clinical Cardiology Publ Co, 2004-11-01) Mesas, Cezar Eumann [UNIFESP]; Veloso, Henrique Horta [UNIFESP]; De Paola, Angelo Amato Vincenzo [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Despite a clear benefit of anticoagulation in patients with atrial fibrillation for the prevention of stroke, treatment rates are disappointingly low in clinical practice in the industrialized countries. This survey demonstrates similar rates in a Brazilian tertiary outpatient clinic, with only 55% of patients at high risk receiving dose-adjusted warfarin. Poor patient education and healthcare system limitations are considered important barriers. Strategies to improve treatment rates should target specific problems at each location.
- ItemSomente MetadadadosCardiac Index Assessment by the Pressure Recording Analytic Method in Critically Ill Unstable Patients After Cardiac Surgery(Elsevier B.V., 2013-12-01) Barille, Luigi; Landoni, Giovanni; Pieri, Marina; Ruggeri, Laura; Maj, Giulia; Nigro Neto, Caetano [UNIFESP]; Pasin, Laura [UNIFESP]; Cabrini, Luca [UNIFESP]; Zangrillo, Alberto; Ist Sci San Raffaele; Dante Pazzanese Inst Cardiol; Universidade Federal de São Paulo (UNIFESP)Objective: the authors measured cardiac index in unstable patients after cardiac surgery with the Pressure Recording Analytic Method (PRAM) and compared it with the reference method of thermodilution (ThD) with the pulmonary artery catheter; using the hypothesis that there were no significant differences between the 2 methods.Design: A prospective study.Setting: Cardiac surgery intensive care unit in a teaching hospital.Participants: Ninety-four measurements from 59 patients with ongoing high doses of inotropic drugs and/or an intra-aortic balloon pump for low-cardiac-output syndrome after cardiac surgery were studied.Interventions: the pulmonary artery catheter and the radial or femoral arterial catheter for measuring blood pressure were already in place for standard hemodynamic monitoring.Measurements and Main Results: the mean of the total Cl measurements was 2.94 +/- 0.67 L/min/m(2) with PRAM and 2.95 +/- 0.63 L/min/m(2) with ThD, with no significant difference according to the linear mixed models analysis. the PRAM and ThD techniques were similar in unstable patients without atrial fibrillation (mean bias 0.047 +/- 0.395 L/min/m(2) and a percentage error of 29%), while no agreement between PRAM and ThD was found in unstable patients with atrial fibrillation (mean bias 0.195 +/- 0.885 L/min/m(2) and a percentage error of 69%).Conclusion: Cardiac index measurements after cardiac surgery performed with PRAM and with ThD showed a good agreement in hemodynamically unstable patients given high doses of inotropes and/or an IABP in patients in sinus rhythm, but not in those with atrial fibrillation. (C) 2013 Elsevier Inc. All rights reserved.
- ItemSomente MetadadadosEffectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation(Elsevier B.V., 2003-04-01) Paola, Angelo Amato Vincenzo de [UNIFESP]; Figueiredo, Edilberto [UNIFESP]; Sesso, Ricardo [UNIFESP]; Veloso, Henrique Horta [UNIFESP]; Nascimento, Luiz Olympio T [UNIFESP]; SOCESP Inv; Universidade Federal de São Paulo (UNIFESP)Background: Atrial fibrillation is the most common sustained cardiac arrhythmia and has an important impact on costs of medical assistance. Traditional interventions to convert atrial fibrillation to sinus rhythm are antiarrhythmic drugs and external electrical cardioversion. However, the best option for starting the cardioversion is not well established. Methods: in a multicentre randomised trial of 139 patients with persistent atrial fibrillation lasting less than 6 months, we compared the effectiveness and the cost-effectiveness ratio of initial treatment with chemical or electrical cardioversion. Subjects who did not achieve sinus rhythm with chemical cardioversion were considered to undergo electrical cardioversion and vice-versa. Results: the efficacy of the initial attempt for cardioversion was similar with chemical or electrical cardioversion (74 vs. 73%, P = 0.95). However, the strategy of starting with antiarrhythmic drugs was more effective than with electrical procedure (96 vs. 84%, P = 0.0016). Initiating with chemical cardioversion was also less expensive than with electrical cardioversion (US$1240 vs. US$1917; P = 0.002). Life-threatening complications occurred only during chemical cardioversion (5%), all of them in patients with structural heart disease. Conclusions: in patients with persistent atrial fibrillation of less than 6 months, initial chemical or electrical cardioversion appear to be similar but the strategy of starting the cardioversion with antiarrhythmic drugs is more effective and less expensive than starting with the electrical procedure. Patients with structural heart disease undergoing chemical cardioversion seem to be more susceptible to severe complications. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.
- ItemSomente MetadadadosEmbolic Stroke of Undetermined Source in Latin America A Review(Lippincott Williams & Wilkins, 2017) Cantu-Brito, Carlos; Silva, Gisele Sampaio [UNIFESP]; Ameriso, Sebastian F.Background: Stroke is a major health concern throughout Latin America. As elsewhere, no precise cause can be determined for a substantial portion of strokes. In 6 studies since 2010 in the region, 16% to 43% of ischemic strokes were identified as cryptogenic. The term embolic stroke of undetermined source (ESUS) has been proposed as more clinically useful and positively defined than the vague term cryptogenic. The epidemiology of ESUS in Latin America is largely unknown. Review Summary: This article aims to provide a description of the epidemiology of ESUS in Latin America and practical information regarding available diagnostic procedures and current guidelines. Atrial fibrillation (AF) is a significant risk factor for stroke, observed in approximately 10% of Mexican and Brazilian stroke patients. Previously unknown AF has been detected through extended monitoring in numerous studies of stroke patients, including 8% of patients in an Argentinian study, and is a possible contributing cause of ESUS. External or implantable outpatient cardiac monitoring has shown increased diagnostic yield for the detection of intermittent AF versus standard cardiac monitoring, but is infrequently used in Latin America. Conclusions: Undiagnosed AF is likely to contribute significantly to cryptogenic stroke and ESUS. Research is needed to continue evaluation of the optimum means of identifying clinically relevant occult AF. In view of the thromboembolic mechanism of ESUS, anticoagulant therapy may prove useful in prevention of recurrence. Ongoing trials are evaluating use of dabigatran, rivaroxaban, or apixaban versus aspirin for reducing the risk of recurrent stroke in patients with previous ESUS.
- ItemAcesso aberto (Open Access)Estudo transversal das estratégias de tratamento clínico na fibrilação atrial(Sociedade Brasileira de Cardiologia - SBC, 2012-03-01) Oliveira, Lucas Hollanda [UNIFESP]; Mallmann, Fabrício Bonnoto [UNIFESP]; Botelho, Fábio Nardo [UNIFESP]; Paul, Luiz Carlos [UNIFESP]; Gianotto, Marcio [UNIFESP]; Abt, Rafael de Biase [UNIFESP]; Silva, Nilton José Carneiro [UNIFESP]; Luize, Christian Moreno [UNIFESP]; Nogueira, Fernando Lopes [UNIFESP]; Carvalho, Ricardo Sobral [UNIFESP]; De Paola, Angelo Amato Vincenzo [UNIFESP]; Cirenza, Claudio [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)BACKGROUND: Despite the high prevalence and clinical importance of atrial fibrillation (AF), there is no Brazilian study about the clinical profile of patients with AF and the most used treatment strategy (heart rhythm control vs. heart rate control) for them. OBJECTIVE: To assess the most used treatment strategy for AF in an outpatient clinic specialized in the management of that disease. In addition, the clinical profile of the population studied was provided. METHODS: Cross-sectional study assessing sequentially, in 167 patients with AF, the most used treatment strategy, as well as their clinical profile. A standardized form was used for data collection. The statistical analysis was performed by using the SPSS® software, version 13.0. RESULTS: In that population at high risk for thromboembolic events (61% had CHADS2 > 2), 54% of the patients had paroxysmal or persistent AF, 96.6% used vitamin K antagonists or acetylsalicylic acid, and 76.6% used beta-blocker (heart rate, 81.2% x heart rhythm, 58.8%; p < 0.05). Heart rate control was the most used treatment strategy (79.5% x 20.5%; p < 0.001). A statistical tendency towards more patients with ventricular dysfunction (15.2% x 2.9%; p = 0.06), CHADS2 > 2 (60.5% x 39.5%; p = 0.07) and heart valve diseases (25.8% x 11.8%; p = 0.08) was observed in the heart rate control group. CONCLUSION: In that population at high risk for thromboembolic events, the heart rate control strategy was the most used.
- ItemSomente MetadadadosPercutaneous Epicardial Left Atrial Appendage Closure: Preliminary Results of an Electrogram Guided Approach(Wiley-Blackwell, 2009-08-01) Friedman, Paul A.; Asirvatham, Samuel J.; Dalegrave, Charles [UNIFESP]; Kinoshita, Masayoshi; Danielsen, Andrew J.; Johnson, Susan B.; Hodge, David O.; Munger, Thomas M.; Packer, Douglas L.; Bruce, Charles J.; Mayo Clin; Universidade Federal de São Paulo (UNIFESP); Mayo Clin Hlth SolutBackground: Pharmacologic therapies to prevent stroke in atrial fibrillation (AF) have numerous limitations, prompting the development of device-based therapies. We investigated whether an electrogram-based approach using a novel hollow suture can safely capture and ligate the left atrial appendage (LAA).Methods and Results: A novel system for closure of the LAA within the confines of the closed pericardium with a single sheath puncture was tested in 4 dogs. the tool used to grasp the appendage was fitted with electrodes and utilized electrical navigation to identify and confirm LAA capture. A hollow suture preloaded with a mechanical support wire to permit its manipulation and fluoroscopic visualization was advanced over the grasper, and the wire removed after the suture was positioned. the LAA was successfully closed in all dogs. in 2 dogs, after closure, a thoracotomy was performed and the LAA amputated without bleeding, confirming closure integrity. Necropsy confirmed closure in all animals.Conclusions: Using electrical navigation, percutaneous epicardial LAA ligation with a remotely tightened suture was performed successfully within the confines of the intact pericardial space. This technique may allow decreasing the risk of stroke in AF patients without the need for thoracotomy or an endocardially placed prosthetic device.(J Cardiovasc Electrophysiol, Vol. 20, pp. 908-915, August 2009).
- ItemSomente MetadadadosQuantitative modeling of the accuracy in registering preoperative patient-specific anatomic models into left atrial cardiac ablation procedures(Amer Assoc Physicists Medicine Amer Inst Physics, 2014-02-01) Rettmann, Maryam E.; Holmes, David R.; Kwartowitz, David M.; Gunawan, Mia; Johnson, Susan B.; Camp, Jon J.; Cameron, Bruce M.; Dalegrave, Charles [UNIFESP]; Kolasa, Mark W.; Packer, Douglas L.; Robb, Richard A.; Mayo Clin; Clemson Univ; Georgetown Univ; Universidade Federal de São Paulo (UNIFESP); David Grant Med CtrPurpose: in cardiac ablation therapy, accurate anatomic guidance is necessary to create effective tissue lesions for elimination of left atrial fibrillation. While fluoroscopy, ultrasound, and electroanatomic maps are important guidance tools, they lack information regarding detailed patient anatomy which can be obtained from high resolution imaging techniques. for this reason, there has been significant effort in incorporating detailed, patient-specific models generated from preoperative imaging datasets into the procedure. Both clinical and animal studies have investigated registration and targeting accuracy when using preoperative models; however, the effect of various error sources on registration accuracy has not been quantitatively evaluated.Methods: Data from phantom, canine, and patient studies are used to model and evaluate registration accuracy. in the phantom studies, data are collected using a magnetically tracked catheter on a static phantom model. Monte Carlo simulation studies were run to evaluate both baseline errors as well as the effect of different sources of error that would be present in a dynamic in vivo setting. Error is simulated by varying the variance parameters on the landmark fiducial, physical target, and surface point locations in the phantom simulation studies. in vivo validation studies were undertaken in six canines in which metal clips were placed in the left atrium to serve as ground truth points. A small clinical evaluation was completed in three patients. Landmark-based and combined landmark and surface-based registration algorithms were evaluated in all studies. in the phantom and canine studies, both target registration error and point-to-surface error are used to assess accuracy. in the patient studies, no ground truth is available and registration accuracy is quantified using point-to-surface error only.Results: the phantom simulation studies demonstrated that combined landmark and surface-based registration improved landmark-only registration provided the noise in the surface points is not excessively high. Increased variability on the landmark fiducials resulted in increased registration errors; however, refinement of the initial landmark registration by the surface-based algorithm can compensate for small initial misalignments. the surface-based registration algorithm is quite robust to noise on the surface points and continues to improve landmark registration even at high levels of noise on the surface points. Both the canine and patient studies also demonstrate that combined landmark and surface registration has lower errors than landmark registration alone.Conclusions: in this work, we describe a model for evaluating the impact of noise variability on the input parameters of a registration algorithm in the context of cardiac ablation therapy. the model can be used to predict both registration error as well as assess which inputs have the largest effect on registration accuracy. (C) 2014 American Association of Physicists in Medicine.
- ItemAcesso aberto (Open Access)Treatment of atrial fibrillation with radiofrequency ablation and simultaneous multipolar mapping of the pulmonary veins(Sociedade Brasileira de Cardiologia - SBC, 2001-11-01) Rocha Neto, Almino C. [UNIFESP]; Farias, Roberto Lima [UNIFESP]; De Paola, Angelo Amato Vincenzo [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: To demonstrate the feasibility and safety of simultaneous catheterization and mapping of the 4 pulmonary veins for ablation of atrial fibrillation. METHODS: Ten patients, 8 with paroxysmal atrial fibrillation and 2 with persistent atrial fibrillation, refractory to at least 2 antiarrhythmic drugs and without structural cardiopathy, were consecutively studied. Through the transseptal insertion of 2 long sheaths, 4 pulmonary veins were simultaneously catheterized with octapolar microcatheters. After identification of arrhythmogenic foci radiofrequency was applied under angiographic or ultrasonographic control. RESULTS: During 17 procedures, 40 pulmonary veins were mapped, 16 of which had local ectopic activity, related or not with the triggering of atrial fibrillation paroxysms. At the end of each procedure, suppression of arrhythmias was obtained in 8 patients, and elimination of pulmonary vein potentials was accomplished in 4. During the clinical follow-up of 9.6±3 months, 7 patients remained in sinus rhythm, 5 of whom were using antiarrhythmic drugs that had previously been ineffective. None of the patients had pulmonary hypertension or evidence of stenosis in the pulmonary veins. CONCLUSION: Selective and simultaneous catheterization of the 4 pulmonary veins with microcatheters for simultaneous recording of their electrical activity is a feasible and safe procedure that may help ablation of atrial fibrillation.