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    Relationship-centred care: antidote, guidepost or blind alley? The epistemology of 21st century health care
    (Journal of Evaluation in Clinical Practice, 2014-06) Wyer, Peter; Silva, Suzana Alves da; Post, Stephen G; Quinlan, Patricia
    Contemporary health care is increasing in complexity and lacks a unifying understanding of epistemology, methodology and goals. Lack of conceptual consistency in concepts such as 'patient-centred care' (PCC) typifies system-wide discordance. We contrast the fragmented descriptions of PCC and related tools to its own origins in the writings of Balint and to a subsequent construct, relationship-centred care (RCC). We identify the explicit and elaborated connection between RCC and a defined epistemological foundation as a distinguishing feature of the construct and we demonstrate that this makes possible the recognition of alignments between RCC and independently developed constructs. Among these, we emphasize Schon's reflective practice, Nonaka's theory of organizational knowledge creation and the research methodology of realist synthesis. We highlight the relational principles common to these domains and to their common epistemologies and illustrate unsatisfying consequences of adherence to less adequate epistemological frameworks such as positivism. We offer RCC not as an 'antidote' to the dilemmas identified at the outset but as an example that illuminates the value and importance of explicit identification of the premises and assumptions underlying approaches to improvement of the health care system. We stress the potential value of identifying epistemological affinities across otherwise disparate fields and disciplines. Keywords: evidence-based medicine; patient-centred care; person-centred medicine.
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    Seven years of use of implantable cardioverter-defibrillator therapies: a nationwide population-based assessment of their effectiveness in real clinical settings
    (BMC Cardiovascular Disorders, 2015) Migowski, Arn; Ribeiro, Antonio Luiz; Carvalho, Marilia Sá; Azevedo, Vitor Manuel Pereira; Chaves, Rogério Brant Martins; Hashimoto, Lucas de Aquino; Xavier, Carolina de Aquino; Xavier, Regina Maria de Aquino
    Background: The efficacy of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) therapy has already been established in clinical trials but their effectiveness in several clinical settings remains undetermined. This study aimed to assess the effectiveness of ICD and CRT-D therapies within the Brazilian National Health System (SUS). Methods: All patients who underwent ICD or CRT-D implantation within the SUS from 2001 to 2007 were included in the study. We compared estimated Kaplan-Meier survival curves using the Peto’s test. Prognostic factors were selected using Cox’s models. Results: There were included 3,295 patients in the ICD group and 681 patients in the CRT-D group. Cardiac causes accounted for 79% of all deaths in both groups and Chagas’ heart disease accounted for 31% of these deaths. In the CRT-D group, survival significantly decreased around the fourth year of follow-up, with a decrease from 59.5% to 38.3% in 5.5 months. Transvenous implantation technique was used in 62% of CRT-D patients. In-hospital case-fatality rates were higher in those undergoing surgical implantation (5.3%) than those undergoing transvenous implantation (1.6%) (p = 0.02). Conclusions: The results show that short-term, medium-term and long-term effectiveness of ICD therapy appears to be similar to that evidenced in clinical trials. In the CRT-D group, in-hospital case-fatality and 30-day case-fatality were higher than those reported in other studies. Surgical epicardial implantation technique was performed in this group at a higher frequency than that reported in the literature and was associated with poorer short-term prognosis.
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    'One mission accomplished, more important ones remain': commentary on Every-Palmer, S., Howick, J. (2014) How evidence-based medicine is failing due to biased trials and selective publication. Journal of Evaluation in Clinical Practice, 20 (6), 908-914
    (Journal of Evaluation in Clinical Practice, 2015-06) Wyer, Peter; Silva, Suzana Alves da
    Every-Palmer and Howick suggest that evidence-based medicine (EBM) is failing in its mission because of contamination of research by manufacturer and researcher-motivated bias and self-interest. They fail to define that mission and to distinguish between the EBM movement and the research enterprise it was developed to critique. An educational movement, EBM accomplished its mission to simplify and package clinical epidemiological concepts in a form accessible to clinical learners. Its wide adoption within educational circles fostered critical literacy among several generations of practitioners. Illumination of bias, subterfuge and incomplete reporting of research has been a strength of EBM. Increased uptake and use of clinical research within the health care system properly defines the failing mission that eludes Every-Palmer and Howick. Responsibility for failure to make progress towards its achievement is shared by virtually all relevant streams within the system, including policy, clinical guideline development, educational movements and the development of approaches to evidence synthesis. Discordance between the epistemological premises pervading today’s research and health care community and the complex social processes that ultimately determine research use constitutes an important factor that must be addressed as part of a remedy. Enhanced emphasis on and demonstration of alternative approaches to research such as realism and realist synthesis and the momentum towards development of a learning health care system hold promise as guideposts for the rapidly evolving health care environment.
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    Aborted sudden cardiac death in A 12 old girl - a rare manifestation of a common disease
    (Cambridge University Press, 2023) Machado, Hérica Falci Ferreira; Araujo, Yasmin Farias Rodrigues; Innocenze, Adriana Macintyre; Malan, Iara Atié; Tzirulnik, Pedro Cunha; Soares, Viviane Xavier; Faria, Catharina de Almeida Serra; Marins, Marina Conrado Riedel; Silva, Renata Mattos
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    Impacto Clínico da Avaliação da Reserva de Fluxo Miocárdico na Identificação da Causa do Desconforto Torácico
    (Arquivos Brasileiros de Cardiologia, 2024) Lima, Ronaldo; Bezerra, André Luiz Ferreira; Daibes, Marianna; Domenico, Claudio; Lorenzo, Andrea de
    Fundamento: Gama-câmaras com detectores de telureto-cádmio-zinco (CZT) permitiram a quantificação da reserva de fluxo miocárdico (RFM), podendo aumentar a acurácia da cintilografia miocárdica de perfusão (CMP) para detectar a causa do desconforto torácico. Objetivo: Avaliar o impacto clínico da RFM para detectar a causa do desconforto torácico. Métodos: 171 pacientes com desconforto torácico que foram submetidos a coronariografia ou angiotomografia de coronárias também realizaram CMP e RFM num intervalo de tempo <30 dias. As aquisições das imagens dinâmicas de repouso e estresse foram iniciadas simultaneamente à injeção de 99mTc sestamibi (10 e 30mCi, respectivamente), ambas com duração de onze minutos, seguidas imediatamente pela aquisição das imagens de perfusão durante 5 minutos. O estresse foi realizado com dipiridamol. Uma RFM global ou por território coronariano <2,0 foi classificada como anormal. Resultados: A idade média foi de 65,9±10 anos (60% do sexo feminino). A avaliação anatômica mostrou que 115 (67,3%) pacientes apresentavam obstrução coronariana significativa, sendo que, 69 apresentavam CMP anormal e 91 apresentavam RFM anormal (60,0% vs. 79,1%, p<0,01). Dentre os pacientes sem obstrução (56 – 32,7%), 7 tinham CMP anormais e 23 tinham RFM global reduzida. A realização da RFM identificou a etiologia do desconforto torácico em 114 pacientes enquanto a CMP identificou em 76 (66,7% vs. 44,4%, p<0,001). Conclusão: A RFM é uma medida fisiológica quantificável que aumenta o impacto clínico da CMP na detecção da causa do desconforto torácico através de uma maior acurácia para detecção de DAC obstrutiva e ainda possibilita identificar a presença de doença microvascular.
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    TUBERCULOUS AORTITIS - A CATASTROPHIC PRESENTATION OF AN ANCIENT DISEASE IN A YOUNG PATIENT
    (Journal of the American College of Cardiology, 2024) Monteiro, Thaissa; Rocha, Isabella Lopes Nunes; Lopes, Priscilla Henrique De Moura; Magalhaes, Gabriela Carvalho Monnerat; Dantas, Carlos; Bech, Gregory; Pereira, Nelson Bonifacio; Carreiro, Ana Clara; Nishijuka, Fabio Akio
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    AORTIC DISSECTION DIAGNOSED DURING TREATMENT OF HYDATIDIFORM MOLE: A CASE REPORT
    (Journal of the American College of Cardiology, 2024) Monteiro, Thaissa; Deorsola, Breno; Leal, Stella; Brito, Izadora Bighetti; Velloso, Nathalia; Stockler, Márcia Olivares; Nishijuka, Fabio Akio
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    From bench to bedside: A review of the application and potential of microcirculatory assessment by hand-held videomicroscopy
    (International Journal of Cardiology, Heart & Vasculature, 2024) Lorenzo, Andrea de; Fernandes, Marcos; Tibirica, Eduardo
    In clinical practice, there is vast knowledge regarding the evaluation of macrocirculatory parameters, such as systemic blood pressure and cardiac output, for the hemodynamic monitoring of patients. However, assessment of the microcirculation has not yet been incorporated into the bedside armamentarium. Hand-held intravital video microscopy enables the direct, noninvasive, evaluation of the sublingual microcirculation at the bedside, offering insights into the status of the systemic microcirculation. It is easily performed and may be employed in several clinical settings, providing immediate results that may help guide patient management. Therefore, the incorporation of hand-held intravital video microscopy into clinical practice may lead to tremendous improve ments in the quality of care of critical, unstable patients or offer new data in the evaluation of patients with chronic diseases, especially those with microcirculatory involvement, such as occurs in diabetes.
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    Diretriz de Tomografia Computadorizada e Ressonância Magnética Cardiovascular da Sociedade Brasileira de Cardiologia e do Colégio Brasileiro de Radiologia – 2024
    (Arquivos Brasileiros de Cardiologia, 2024) Magalhães, Tiago Augusto; Carneiro, Adriano Camargo de Castro; Moreira, Valéria de Melo; Trad, Henrique Simão; Lopes, Marly Maria Uellendahl; Hadlich, Marcelo Souza
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    Cardiac and Liver Fibrosis Assessed by Multiparametric MRI in Patients with Fontan Circulation
    (Pediatric Cardiology, 2024) Innocenzi, Adriana; Rangel, Isabela; Póvoa‐Corrêa, Mariana; Parente, Daniella Braz; Perez, Renata; Rodrigues, Rosana Souza; Fukuyama, Lúcia Tomoko; Barroso, Julia Machado; Oliveira Neto, Jaime Araújo; Sousa, Andréa Silvestre de; Luiz, Ronir Raggio; Barbosa, Rosa Célia Pimentel; Camargo, Gabriel Cordeiro; Moll‐Bernardes, Renata
    The abnormal hemodynamics in Fontan circulation due to persistently increased systemic venous pressure results in hepatic venous congestion and Fontan-associated liver disease. Combined assessment of cardiac and liver fbrosis and cardiac remodeling using multiparametric MRI in this context have not been fully explored. To evaluate cardiac and liver fbrosis and cardiac remodeling using multiparametric MRI in patients who have undergone Fontan procedures. Thirty-eight patients and 23 controls underwent cardiac and liver MRI examinations in a 3.0-T scanner. Mann–Whitney, Fisher exact test, and Spearman’s correlation were applied to evaluate myocardial volumes, function, native cardiac and liver T1 mapping, ECVs and liver stifness. The mean native cardiac T1 value (p=0.018), cardiac ECV (p<0.001), liver native T1 (p<0.001), liver ECV (p<0.001), and liver stifness (p<0.001) were higher in patients than controls. The indexed end-diastolic volume (EDVi) correlated with the myocardial ECV (r=0.356; p=0.033), native liver T1 (r=0.571; p<0.001), and with liver stif- ness (r=0.391; p=0.015). In addition, liver stifness correlated with liver ECV (r=0.361; p=0.031) and native liver T1 (r=0.458; p=0.004). An association between cardiac remodeling and cardiac and liver fbrosis were found in this population. The usefulness of MRI to follow cardiac and liver involvement in these patients is critical to improve treatment strategies and to prevent the need for combined liver and heart transplantation.
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    Evaluation of myocardial contraction fraction in transcatheter aortic valve replacement
    (Heart, Vessels and Transplantation, 2024) Machado, Luana da Graça; Salgado, Angelo; Lorenzo, Andrea de
    Objective: Myocardial contraction fraction (MCF), a costless, easy-to-perform echocardiographic measure, which estimates cardiac function through the volumetric measurement of myocardial shortening, may be a useful prognostic indicator in patients undergoing transcatheter aortic valve replacement (TAVR). This study aimed to evaluate MCF in patients who underwent TAVR at a public hospital in Rio de Janeiro, Brazil. Methods: This was a retrospective cohort study. Clinical and echocardiographic data were obtained from medical records. MCF was calculated as FDV in mL/FSV in mL x100, where FDV= final diastolic volume and FSV= final systolic volume. These were derived from the dimensions of the left ventricle. The FDV was estimated as 4.5 x (final diastolic diameter of the left ventricle) and the FSV was estimated as 3.72 x (final systolic diameter of the left ventricle). Patients were followed for 66 months, and all-cause mortality was registered. Results: Overall, 78 patients were studied. Median age was 78 years. Mortality was 56.4% over 9 years, with 29% of deaths in the first year. Pre-TAVR median MCF (45.9%) was low, while mean left ventricular ejection fraction (LVEF) was normal (57.0%). In patients who survived after the procedure, MCF increased post-TAVR, but in those who died, it decreased (49.3% vs 45.1%). Conclusions: MCF may demonstrate left ventricular dysfunction unrecognized by LVEF measurement in patients undergoing TAVR, and may be a prognostic marker in this patient population.
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    Diretriz sobre Diagnóstico e Tratamento da Cardiomiopatia Hipertrófica – 2024
    (Arquivos Brasileiros de Cardiologia, 2024) Fernandes, Fabio; Simões, Marcus V.; Correia, Edileide de Barros; Marcondes-Braga, Fabiana Goulart; Coelho-Filho, Otavio Rizzi; Colafranceschi, Alexandre Siciliano
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    DNA damage and repair in patients undergoing myocardial perfusion single‐photon emission computed tomography
    (Scientifc Reports, 2024) Lorenzo, Andrea de; Fernandes, Maria Clara dos Santos; Romeiro, Francisco; Arpini, Anna Paula; Dias, Glauber Monteiro
    As patient exposure to ionizing radiation from medical imaging and its risks are continuing issues, this study aimed to evaluate DNA damage and repair markers after myocardial perfusion single-photon emission computed tomography (MPS). Thirty-two patients undergoing Tc-99m sestamibi MP were studied. Peripheral blood was collected before radiotracer injection at rest and 60–90 min after injection. The comet assay (single-cell gel electrophoresis) was performed with peripheral blood cells to detect DNA strand breaks. Three descriptors were evaluated: the percentage of DNA in the comet tail, tail length, and tail moment (the product of DNA tail percentage and tail length). Quantitative PCR (qPCR) was performed to evaluate the expression of fve genes related to signaling pathways in response to DNA damage and repair (ATM, ATR, BRCA1, CDKN1A, and XPC). Mann–Whitney’s test was employed for statistical analysis; p< 0.05 was considered signifcant. Mean Tc-99m sestamibi dose was 15.1 mCi. After radiotracer injection, comparing post-exposure to pre-exposure samples o each of the 32 patients, no statistically signifcant diferences of the DNA percentage in the tail, tail length or tail moment were found. qPCR revealed increased expression of BRCA1 and XPC, without any signifcant diference regarding the other genes. No signifcant increase in DNA strand breaks was detected after a single radiotracer injection for MPS. There was activation of only two repair genes, which may indicate that, in the current patient sample, the efects of ionizing radiation on the DNA were not large enough to trigger intense repair responses, suggesting the absence of signifcant DNA damage.
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    Diretriz Brasileira de Ergometria em População Adulta – 2024
    (Arquivos Brasileiros de Cardiologia, 2024) Carvalho, Tales de; Freitas, Odilon Gariglio Alvarenga de; Chalela, William Azem; Hossri, Carlos Alberto Cordeiro; Milani, Mauricio; Buglia, Susimeire; Precoma, Dalton Bertolim; Falcão, Andréa Maria Gomes Marinho; Mastrocola, Luiz Eduardo; Castro, Iran; Albuquerque, Pedro Ferreira de; Coutinho, Ricardo Quental; Brito, Fabio Sandoli de; Alves, Josmar de Castro; Serra, Salvador Manoel; Santos, Mauro Augusto dos; Colombo, Clea Simone Sabino de Souza; Stein, Ricardo; Herdy, Artur Haddad; Silveira, Anderson Donelli da; Castro, Claudia Lucia Barros de; Silva, Miguel Morita Fernandes da; Meneghello, Romeu Sergio; Ritt, Luiz Eduardo Fonteles; Malafaia, Felipe Lopes; Pena, José Luiz Barros; Almeida, Antônio Eduardo Monteiro de; Vieira, Marcelo Luiz Campos; Júnior, Arnaldo Laffitte Stier
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    LONG-TERM COMPLICATIONS OF ATRIAL SWITCH OPERATION IN PATIENT WITH TRANSPOSITION OF THE GREAT VESSELS
    (Journal of the American College of Cardiology, 2024) Monteiro, Thaissa; Binensztok, Beny; Ferraz, Aloan Carlos Lemos; Mattoso, Cíntia; Valle, Nathalia; Cola, Maria Carolina Terra; Teodoro, Bianca De Almeida; Santos, Maria Gabriela Pimenta Dos; Duarte, David; Ferreira, Lorreine; Nobre, Luiza; Oliveira, Regis; Innocenzi, Adriana Mancytire; Nishijuka, Fabio Akio
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    Peak oxygen uptake after the 80s as a survival predictor
    (European Geriatric Medicine, 2024) Braga, Fabricio; Milani, Mauricio; Fachetti, Ana; Espinosa, Gabriel; Moraes, Gabriel; Milani, Juliana Goulart Prata Oliveira; Mourilhe-Rocha, Ricardo
    Purpose: Peak oxygen uptake (VO2peak) is a crucial health marker, extensively studied in adults for its prognostic value. However, its significance in the older persons, especially octogenarians, remains underexplored due to limited representation in research. This study aims to assess the predictive power of VO2peak for survival in individuals aged 80 and above. Methods: We included individuals aged 80 or older who underwent cardiopulmonary exercise tests at a single center. Mortality rates were compared based on VO2peak relative to 80% of predicted values (%VO2peak). We employed three multivariate Cox regression models: Model 1 (unadjusted), Model 2 (adjusted for age) and Model 3 (adjusted for age and stroke). Results: Among 188 participants (mean age 83.3 ± 3 years, 68.9% male), 22 (11.7%) passed away during a median follow-up of 494 days. Non-survivors tended to be older with lower VO2peak and %VO2peak. All models demonstrated associations between %VO2peak ≤ 80% and mortality: HR = 3.19 (95% CI: 1.30-7.86, p = 0.011) for M1; HR = 3.12 (95% CI: 1.26-7.74, p = 0.013) for M2 and HR = 2.80 (95% CI: 1.11-7.06, p = 0.028) for M3. Conclusion: In the context of an aging population, this study underscores the enduring significance of VO2peak as a survival predictor among the older person, including octogenarians. These findings carry profound implications for tailoring healthcare strategies to address the evolving demographic landscape.
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    TACHYCARDIOMYOPATHY AND ATRIAL FIBRILLATION IN A PATIENT WITH TOTAL SITUS INVERSUS
    (Journal of the American College of Cardiology, 2024) Monteiro, Thaissa; Gutterres, Diogo Barros; Lynch, Rafaela; Carreiro, Ana Clara; Corvisier, Maurício; Nishijuka, Fabio Akio
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    Guide catheter extension use are associated with higher procedural success in chronic total occlusion percutaneous coronary interventions
    (Catheterization and Cardiovascular Interventions, 2024) Filho, Evandro M.; Araujo, Gustavo N.; Machado, Guilherme P.; Padilla, Lucio; Paula, João E. T. de; Botelho, Antonio C.; Campos, Carlos M.; Quesada, Franklin L. H.; Alcantara, Marco; Santiago, Ricardo; Santos, Félix D. de los; Oliveira, Marcos D.; Ribeiro, Marcelo H.; Perez, Luiz; Pinto, Mauro E.; Côrtes, Leandro A.; Piccaro, Pedro; Brilakis, Emmanouil S.; Quadros, Alexandre S.
    Background: Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications. Aim: Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all‐cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use. Results: From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J‐CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78–2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41–2.41, p = 0.986), in‐hospital death (OR: 1.39, 95% CI: 0.54–3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52–2.19, p = 0.850) were similar in both groups. Conclusion: In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes.
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    The Usefulness of Microcirculatory Assessment After Cardiac Surgery: Illustrative Case Report
    (Brazilian Journal of Cardiovascular Surgery, 2024) Fernandes, Marcos; Lorenzo, Andrea De; Tibiriçá, Eduardo
    Cardiac surgery causes a series of disturbances in human physiology. The correction of systemic hemodynamic variables is frequently ineffective in improving microcirculatory perfusion and delivering oxygen to the tissues. We present the case of a 52-year-old male submitted to mitral valve replacement (metallic valve) and subaortic membrane resection. Sublingual microcirculatory density and perfusion were evaluated using a handheld CytoCam camera before surgery and in the early postoperative period. In this case, systemic hemodynamic variables were compromised despite an actual improvement in the microcirculatory parameters in comparison to the preoperative evaluation, possibly due to the correction of the structural cardiac defects.