OBJETIVO: Mensurar e caracterizar a percepção dolorosa das puérperas primíparas submetidas à episiotomia. MÉTODOS: Trata-se de uma pesquisa descritiva com abordagem quantitativa, realizada com 40 puérperas primíparas submetidas ao parto normal com episiotomia. Para mensuração da dor foi utilizada a escala de categoria numérica e para caracterização a versão brasileira do questionário McGill - Br-MPQ. RESULTADOS: Os valores encontrados na avaliação da dor foram de média 4,2 e os descritores que melhor caracterizaram a dor foram: dolorida; que repuxa; incômoda; chata; ardida; pica como uma agulhada; latejante; em pressão. CONCLUSÃO: A intensidade da dor perineal foi considerada como moderada pelas puérperas. Na caracterização da queixa dolorosa os descritores mais citados foram da dimensão sensorial. Este estudo possibilitou observar a necessidade do reconhecimento dos aspectos qualitativos e quantitativos da dor na prática clinica obstétrica.

Background: Bicuspid aortic valve is the most common CHD. Its association with early valvular dysfunction, endocarditis, thoracic aorta dilatation, and aortic dissection is well established. Objective: The aim of this study was to assess the incidence and predictors of cardiac events in adults with bicuspid aortic valve. Methods: We carried out a retrospective analysis of cardiac outcomes in ambulatory adults with bicuspid aortic valve followed-up in a tertiary hospital centre. Outcomes were defined as follows: interventional -intervention on the aortic valve or thoracic aorta; medical -death, aortic dissection, aortic valve endocarditis, congestive heart failure, arrhythmias, or ischaemic heart disease requiring hospital admission; and a composite end point of both. Kaplan-Meier curves were generated to determine event rates, and predictors of cardiac events were determined by multivariate analysis. Results: A total of 227 patients were followed-up over 13 ± 9 years; 29% of patients developed severe aortic valve dysfunction and 12.3% reached ascending thoracic aorta dimensions above 45 mm. At least one cardiac outcome occurred in 38.8% of patients, with an incidence rate at 20 years of follow-up of 47 ± 4%; 33% of patients were submitted to an aortic valve or thoracic aorta intervention. Survival 20 years after diagnosis was 94 ± 2%. Independent predictors of the composite end point were baseline moderate-severe aortic valve dysfunction (hazard ratio, 3.19; 95% confidence interval, 1.35-7.54; p < 0.01) and aortic valve leaflets calcification (hazard ratio, 4.72; 95% confidence interval, 1.91-11.64; p < 0.005). Conclusions: In this study of bicuspid aortic valve, the long-term survival was excellent but with occurrence of frequent cardiovascular events. Baseline aortic valve calcification and dysfunction were the only independent predictors of events.

Objective: The role of right ventricular longitudinal strain for assessing patients with repaired tetralogy of Fallot is not fully understood. In this study, we aimed to evaluate its relation with other structural and functional parameters in these patients. Methods: Patients followed-up in a grown-up CHD unit, assessed by transthoracic echocardiography, cardiac MRI, and treadmill exercise testing, were retrospectively evaluated. Right ventricular size and function and pulmonary regurgitation severity were assessed by echocardiography and MRI. Right ventricular longitudinal strain was evaluated in the four-chamber view using the standard semiautomatic method. Results: In total, 42 patients were included (61% male, 32 ± 8 years). The mean right ventricular longitudinal strain was −16.2 ± 3.7%, and the right ventricular ejection fraction, measured by MRI, was 42.9 ± 7.2%. Longitudinal strain showed linear correlation with tricuspid annular systolic excursion (r = − 0.40) and right ventricular ejection fraction (r = − 0.45) (all p < 0.05), which in turn showed linear correlation with right ventricular fractional area change (r = 0.50), pulmonary regurgitation colour length (r = 0.35), right ventricular end-systolic volume (r = − 0.60), and left ventricular ejection fraction (r = 0.36) (all p < 0.05). Longitudinal strain (β = − 0.72, 95% confidence interval −1.41, −0.15) and left ventricular ejection fraction (β = 0.39, 95% confidence interval 0.11, 0.67) were independently associated with right ventricular ejection fraction. The best threshold of longitudinal strain for predicting a right ventricular ejection fraction of <40% was −17.0%. Conclusions: Right ventricular longitudinal strain is a powerful method for evaluating patients with tetralogy of Fallot. It correlated with echocardiographic right ventricular function parameters and was independently associated with right ventricular ejection fraction derived by MRI.

The benefits of patent foramen ovale (PFO) closure for cryptogenic stroke secondary prevention are still debated. The Risk of Paradoxical Embolism (RoPE) study developed a score to improve patient selection for this procedure. We proposed to assess the validity of this score to assess the prognostic impact of PFO closure.From 2000 to 2014, all consecutive patients submitted to PFO closure were included in a prospective registry in a university center. The primary endpoint was recurrent ischemic cerebrovascular events and the secondary endpoints were all-cause, neurological, and cardiac mortality rates and new-onset atrial fibrillation (NOAF) rates. In total, 403 patients were included in the study (women: 52.1%; mean age: 44.7 ± 10.9 years). The mean follow-up period was 6.4 ± 3.7 years. Immediate success was achieved in 97% patients. There were 23 (5.8%) ischemic cerebrovascular events, 8 (2.0%) deaths, and 17 (4.3%) NOAFs. The mean RoPE score was 6.10 ± 1.79. Smoker status, coronary artery disease, lower RoPE score, and higher left atrial dimensions were predictors of the primary endpoint. However, a lower RoPE score and coronary artery disease remained independent predictors in multivariate analysis.RoPE score was shown to be an independent predictor of recurrent ischemic cerebrovascular events, and a score of !6 was shown to identify patients with significantly higher risk of mortality and recurrent ischemic events. (Int Heart J 2018; 59: 1327-1332

PurposeNoninvasive ischemia testing (NIST) is recommended for most patients suspected to have stable coronary artery disease (CAD) before invasive coronary angiography (ICA). We sought to assess the diagnostic predictive ability of NIST over clinical risk profiling in a contemporary sample of patients undergoing the currently recommended diagnostic triage strategy.MethodsFrom 2006 to 2011, 2,600 consecutive patients without known CAD undergoing elective ICA in a single tertiary-care center were retrospectively identified and the prevalence of obstructive CAD determined. To understand the incremental value of frequently used clinical parameters in predicting obstructive CAD, receiver operating characteristic curves were plotted for six sequential models starting with Framingham risk score and then progressively adding multiple clinical factors and finally NIST results.ResultsAt ICA 1,268 patients (48.8%) had obstructive CAD. The vast majority (85%) were classified in an intermediate clinical pretest probability of CAD and NIST prior to ICA was used in 86% of the cohort. The most powerful correlate of obstructive CAD was the presence of severe angina (odds ratio (OR) = 9.1; 95% confidence interval (CI) 4.3-19.1). Accordingly, the incorporation of NIST in a sequential model had no significant effect on the predictive ability over that achieved by clinical and symptomatic status model (C-statistic 0.754; 95% CI 0.732-0.776, p = 0.28).ConclusionsLess than half the patients with suspect stable obstructive CAD referred to a tertiary-level center for elective ICA had the diagnosis confirmed. In this clinical setting, the results of NIST may not have the power to change the discriminative ability over clinical judgment alone.

PALAVRAS-CHAVEAngioplastia primária; Enfarte agudo do miocárdio com supradesnivelamento de ST; Sexo feminino ResumoObjetivos: A mortalidade na mulher após angioplastia primária (ICP-P) é superior à do homem. Contudo, permanece contraditório o papel do sexo poder ser fator de risco independente para mortalidade no contexto de enfarte agudo do miocárdio com supradesnivelamento de ST (EAMST). Com base no Registo Nacional de Cardiologia de Intervenção (RNCI), pretendemos avaliar como é que o género feminino influencia o prognóstico a curto prazo nos doentes com EAMST submetidos a ICP-P a nível nacional. Métodos: De 60 158 doentes incluídos prospetivamente no RNCI de 2002-2012, incluímos na análise 7544 doentes com EAMST tratados por ICP-P, dos quais 25% foram mulheres. Utilizámos modelos de regressão logística e ajustamento por propensity score para avaliar o impacto do sexo na mortalidade hospitalar. Resultados: As mulheres foram mais idosas (68 ± 14 versus 61 ± 13, p < 0,001), mais diabéticas (30 versus 21%, p < 0,001) e hipertensas (69 versus 55%, p < 0,001). Os homens foram revascularizados mais cedo (71 versus 63% nas primeiras 6 horas, p < 0,001). Choque cardiogénico foi mais frequente nas mulheres (7,1 versus 5,7%, p = 0,032). Estas apresentaram um pior prognóstico a curto prazo, com 1,7 x maior risco de morte intra-hospitalar (4,3 versus 2,5%; IC 95% 1,30-2,27; p < 0,001). Utilizando um modelo de regressão ajustado através de um propensity score, o sexo deixa de ser preditor de mortalidade hospitalar (OR 1,00; IC 95% 0,68-1,48; p = 1,00). Conclusões: No RNCI as mulheres com EAMST tratadas com ICP-P apresentaram maior risco cardiovascular, um acesso menos atempado a ICP-P e um pior prognóstico. Contudo, após ajustamento do risco, o género feminino deixa de ser preditor independente de mortalidade hospitalar. Documento descarregado de http://www.elsevier.pt el 29/07/2014. Cópia para uso pessoal, está totalmente proibida a transmissão deste documento por qualquer meio ou forma.

The impact of atrial dispersion of refractoriness (Disp_A) in the inducibility and maintenance of atrial fibrillation (AF) has not been fully resolved. Aim: To study the Disp_A and the vulnerability (A_Vuln) for the induction of self-limited (b 60 s) and sustained episodes of AF. Methods and results: Forty-seven patients with paroxysmal AF (PAF): 29 patients without structural heart disease and 18 with hypertensive heart disease. Atrial effective refractory period (ERP) was assessed at five sites -right atrial appendage and low lateral right atrium, high interatrial septum, proximal and distal coronary sinus. We compared three groups: group A -AF not inducible (n = 13); group B -AF inducible, self-limited (n = 18); group C -AF inducible, sustained (n = 16). Age, lone AF, hypertension, left atrial and left ventricular (LV) dimensions, LV systolic function, duration of AF history, atrial flutter/tachycardia, previous antiarrhythmics, and Disp_A were analysed with logistic regression to determine association with A_Vuln for AF inducibility. The ERP at different sites showed no differences among the groups. Group A had a lower Disp_A compared to group B (47 ± 20 ms vs 82 ± 65 ms; p = 0.002), and when compared to group C (47 ± 20 ms vs 80 ± 55 ms; p = 0.008). There was no significant difference in Disp_A between groups B and C. By means of multivariate regression analysis, the only predictor of A_Vuln was Disp_A (p = 0.04). Conclusion: In patients with PAF, increased Disp_A represents an electrophysiological marker of A_Vuln. Inducibility of both self-limited and sustained episodes of AF is associated with similar values of Disp_A. These findings suggest that the maintenance of AF is influenced by additional factors.

Cardiac tamponade occurring late after interventional closure of defects within the oval fossa is a very rare but life-threatening complication. We describe such an occurrence after use of a Cardioseal device to close an interatrial communication. Two arms of the device had perforated left atrial wall. The device was removed at surgery, and the defect closed uneventfully. All available means should be used to identify this complication.