Browsing by Author "Elvas, L"
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- Cardiac resynchronization therapy in the elderly: A realistic option for an increasing population?Publication . António, N; Elvas, L; Gonçalves, L; Providência, LACardiac resynchronization therapy (CRT) has become a mainstay of heart failure treatment. Since heart failure is a disease primarily affecting older patients it is important to evaluate the performance of CRT in this population. Elderly has been suggested as a subgroup less likely to benefit from CRT. This is an important issue that should be clarified, because most patients with heart failure are old. The present review discusses the available data concerning cardiac resynchronization therapy in the elderly, focusing on efficacy, indication, safety, and impact of co-morbidities
- Cardiac resynchronization therapy is effective even in elderly patients with comorbiditiesPublication . António, N; Lourenço, C; Teixeira, R; Saraiva, F; Coelho, L; Ventura, M; Cristovão, J; Elvas, L; Gonçalves, L; Providência, LAPURPOSE: The purpose of this study was to compare the effects of cardiac resynchronization therapy (CRT) in elderly patients (> or =65 years) with younger patients and to assess the impact of comorbidities in CRT remodeling response. METHODS: This is a prospective study of 87 consecutive patients scheduled for CRT who underwent clinical and echocardiographic evaluation before and 6 months after CRT. A reduction in left ventricular end-systolic volume (LVESV) > or =15% after CRT defined remodeling responders, and a reduction of at least one New York Heart Association class defined clinical responders. Multivariate analysis was used to identify independent predictors of non-response to CRT in terms of reverse remodeling. RESULTS: The mean age was 62 +/- 11 years, with 36 elderly patients (41%). The baseline QRS duration was 145 +/- 32 ms. After CRT, there were significant and similar improvements of left ventricular (LV) ejection fraction, LVESV, LV dP/dt, and mitral regurgitation jet area (JA) between elderly (> or =65 years) and younger (<65 years) patients. The number of clinical and remodeling responders was comparable, and we found no significant differences in unplanned cardiac hospitalizations at 6 months between groups. Independent predictors of lack of remodeling response to CRT were QRS duration <120 ms, LV diastolic diameter >74 mm, and JA >10 cm(2) before CRT, but not comorbidities. CONCLUSION: This work suggests that being elderly is not an impediment to CRT success even in the presence of comorbidities.
- Drug-Induced Acute Pancreatitis and Pseudoaneurysms: An Ominous CombinationPublication . Branquinho, D; Ramos-Andrade, D; Elvas, L; Amaro, P; Ferreira, M; Sofia, CRupture of pseudoaneurysms is rare but can be life-threatening complications of acute or chronic pancreatitis, usually due to enzymatic digestion of vessel walls crossing peripancreatic fluid collections. We report the case of a 40 year-old female, with multisystemic lupus and anticoagulated for prior thrombotic events, admitted for probable cyclosporine-induced acute pancreatitis. Hemodynamic instability occurred due to abdominal hemorrhage from two pseudoaneurysms inside an acute peri-pancreatic collection. Selective angiography successfully embolized the gastroduodenal and pancreatoduodenal arteries. The hemorrhage recurred two weeks later and another successful embolization was performed and the patient remains well to date. The decision to restart anticoagulants and to suspend cyclosporine was challenging and required a multidisciplinary approach. Despite rare, bleeding from a pseudoaneurysm should be considered when facing a patient with pancreatitis and sudden signs of hemodynamic instability.
- Haemodynamics during liver transplantation in familial amyloidotic polyneuropathy: study of the intraoperative cardiocirculatory data of 50 patientsPublication . Viana, JS; Bento, C; Vieira, H; Neves, S; Seco, C; Elvas, L; Coelho, L; Ferrão, J; Tomé, L; Perdigoto, R; Craveiro, AL; Providência, LA; Furtado, ALBACKGROUND: Circulatory instability frequently complicates liver transplantation for familial amyloidotic polyneuropathy (FAP) and may be a source of surgical morbidity and mortality. OBJECTIVE: To evaluate FAP intraoperative haemodynamic data and their relation to the duration of surgery, and need for anaesthetic drugs. RBC and sympathomimetic amines. SETTING: Clinical study during a four year period. PATIENTS (mean +/- SD): Group I included 50 consecutive FAP ATTR Met 30 recipients of first transplantation. Age was 35.3 +/- 7.1 years, neurological score 34.3 +/- 13 in 100 and time elapsed from first symptom 5.0 +/- 2.7 years. Group II (control), not different concerning age and sex, included 51 patients transplanted during the same period with other pathologies. METHOD: Anaesthetic protocol, monitoring and surgical techniques were similar in both groups. Data of the two groups were compared either by the Student's t-test or Fisher's exact test. RESULTS: Low values of systemic vascular resistance index were observed in both groups, with no differences between them. Systemic arterial pressures were usually lower in group I, because cardiac index and heart rate were also significantly lower, although within normal values. However, in group I, isoflurane (a vasodilator anaesthetic) was used during less time (p < 0.05) and in lower concentrations (p < 0.01) and phenylephrine was necessary in 26% of patients vs 0 patients in group II (p < 0.001). CONCLUSION: FAP patients presented a different intraoperative behaviour when compared to other patients submitted to liver transplantation. From a clinical point of view, the authors stress: 1--As a result of autonomic dysfunction, the administration of anaesthetic drugs to FAP patients always presents the risk of producing significant hypotension; even the use of ketamine does not prevent hypotension; 2--Safety is ensured by beat-to-beat surveillance of arterial pressures and the capacity to act immediately to support circulation; 3--These patients seem to be very sensitive to decreases in the pre-load; 4--Hypotension is also frequent with an adequate pre-load, usually as the result of low SVR; an infusion of a vasoconstrictor drug emerges as the most frequent treatment requested and our experience supports it as an effective one.
- Identification of 'super-responders' to cardiac resynchronization therapy: the importance of symptom duration and left ventricular geometryPublication . António, N; Teixeira, R; Coelho, L; Lourenço, C; Monteiro, P; Ventura, M; Cristovão, J; Elvas, L; Gonçalves, L; Providência, LAAIMS: Some patients show such an important clinical improvement and reverse remodelling after cardiac resynchronization therapy (CRT) that anatomy and function approach normal. These patients have been called 'super-responders'. The aim of our study was to identify predictors of becoming a super-responder after CRT. METHODS AND RESULTS: Eighty-seven consecutive patients who underwent CRT were prospectively studied. Before CRT and 6 months after, clinical and echocardiographic evaluation was performed. Patients with a decrease in New York Heart Association functional class >or=1, a two-fold or more increase of left ventricular ejection fraction (LVEF) or a final LVEF >45%, and a decrease in LV end-systolic volume >15% were classified as super-responders. There were 12% super-responders. At baseline, there were no significant differences between super-responders and the other patients, except for the fact that super-responders had significantly smaller mitral regurgitation and LV end-diastolic diameter (LVEDD) and a shorter duration of heart failure symptoms. Mitral regurgitation jet area, LVEDD, and duration of heart failure symptoms were correlated with this super-response. Moreover, an evolution of symptoms for <12 months was an independent predictor of super-response to CRT. CONCLUSION: Patients in earlier phases of the cardiomyopathy, with a less altered ventricular geometry, seem to have a greater probability of becoming super-responders.