SUMMARYIn order to assess left ventricular function in patients with rheumatic mitral stenosis, left ventricular function curves (plotting stroke work index vs left ventricular end-diastolic pressure) were June 20, 1975. tion curves were constructed by afterload elevation with angiotensin and reduction by nitroprusside. The over-all hemodynamic response of patients with mitral stenosis to these afterload changes was also examined.Methods Fourteen patients with isolated mitral stenosis were included in the study. Informed consent was obtained from all participants. Patients with other valvular disease were excluded by physical examination, echocardiography, and by the results of catheterization. Any patient exhibiting more than trivial mitral regurgitation at the time of left ventricular angiography was excluded.Resting cardiac catheterization was performed after premedication with 100 mg secobarbital intramuscularly. Wedge or NIH catheters with Statham P23Db transducers were employed for right-sided pressures, and 6.7 polyethylene end-hole catheters with Micron MP-15 transducers for left-sided pressures. Cardiac outputs were determined either by the direct Fick method or by duplicate indocyanine green dye dilution techniques. Pressures, mitral valve gradients, and stroke work indices were computerdetermined" and checked manually. Mitral valve area was calculated according to a modified Gorlin formula,7 using the mean pulmonary artery wedge-left ventricular pressure difference as the mitral valve gradient and an empirical constant of 44.5. The use of 44.5 reflects our reservations concerning the precision of constants derived from operative measurements of orifice size and preference for standardization with aortic valve measurements.Resting left ventricular angiography was performed using a 6.7F angiographic catheter passed retrogradely across the aortic valve, and with the patient in the 300 right anterior oblique position. End-diastolic and end-systolic left ventricular volumes and ejection fraction were determined by Circulation, Volume 52, November I975

RESUMO: Uma nova forma de síndrome pós perfusão, denominada síndrome vasoplégica, aparecendo no período pós-operatório imediato de cirurgias cardíacas com circulação extracorpórea (CEC) é apresentada. As manifestações dessa síndrome incluem hipotensão, débito cardíaco normal ou aumentado, resistência vascular sistêmica diminuída e pressões de enchimento baixas. ° exame físico mostra que, mesmo com hipotensão, os pacientes apresentam bom enchimento capilar de extremidades, mas com oligúria. Há necessidade de uso de vasoconstrictores potentes para manutenção da pressão arterial e, mesmo com altas doses de noradrenalina, não há o quadro clássico de extremidades frias. Doze pacientes que apresentaram sinais e sintomas compatíveis com a síndrome vasoplégica são mostrados. ° quadro da síndrome vasoplégica mostra semelhança com o observado no choque séptico. Na sepse , as alterações são mediadas pelas citocinas , entre elas o TNF-a, que também já foi demonstrado serem ativadas pela CEC. ° aparecimento da síndrome vasoplégica eleva a morbidade operatória, com conseqüente aumento de risco para o paciente. DESCRITORES: Circulação extracorpórea, síndromes pós perfusão. Síndromes pós perfusão, vasoplégica. Circulação extracorpórea, efeitos colaterais. INTRODUÇÃODesde a introdução da circulação extracorpórea (CEC), que viabilizou a correção cirúrgica de várias doenças cardíacas , ficou patente também a existência de efeitos colaterais decorrentes da utilização da máquina coração-Rulmão artificial 1. A síndrome pós perfusão, como ficou conhecido o conjunto desses efeitos, inclui os sinais clínicos de disfunção pulmonar e renal, alterações da coagulação, susceptibilidade a infecções, aumento do fluido intersticial, leucocitose, febre, vasoconstricção e hemólise 12. Apesar dos avanços ocorridos em téc-nicas e materiais de circulação extracorpórea, persistem a morbidade e mortalidade relacionadas com o aparecimento desses efeitos colaterais.Nos últimos anos, temos observado o aparecimento de um novo tipo de manifestação ocorrendo no período pós-operatório imediato de cirugias cardíacas com uso de circulação extracorpórea. É a chamada síndrome vasoplégica, que se manifesta com hipotensão, débito cardíaco normal ou aumentado, resistência vascular sistêmica diminuída e pressões de enchimento baixas, pouco ou não responsivas ao aumento da volemia por infusão de liqüidos 9. O aparecimento desta síndrome propicia o surgimento de complicações sistêmicas que con-

Purpose: NT-pro B-type natriuretic peptide (NT-proBNP) has predominantly ventricular origin, produced and released in response to increases in ventricular wall stress. It has been related both to systolic and diastolic left ventricular (LV) dysfunction. The purpose of this study was to investigate the correlations of NT-proBNP levels with echocardiographic measurements in patients with systolic heart failure. Methods: We prospectively investigated patients with symptoms/signs of CHF class II-IV and LV biplane ejection fraction (EF)<45%. After clinical evaluation an echocardiogram was done including M mode, 2D (ventricular dimensions and LV ejection fraction (EF)), conventional Doppler (LV inflow E wave, pulmonary artery systolic pressure (PASP), LV dP/dT). Early and late peak systolic myocardial velocity (Sm1 and Sm2), velocity time integral of Sm(SmVTI), early(Em) and late (Am) peak diastolic myocardial velocities were assessed by pulsed tissue Doppler of septal and lateral mitral annulus and tricuspid annulus. Blood was collected for NT-proBNP measurement. Results: Twenty patients were included 85% male, 71±9,5 years. Mean LV EF was 30±8%, dP/dT 557±164mmHg/s, NT-proBNP 7052±6314pg/mL. There was a trend toward higher NT-proBNP levels in those patients with lower inferior vena cava (IVC) colapse index (p=0,09) and a nonsignificant higher expiratory IVC diameter (p=0,15). Right ventricular end-diastolic dimension by 2D planimetry of four-chamber apical view showed a significant direct correlation to NT-pro-BNP levels (r 2 =0,24; p=0,03) as did PSAP (r 2 =0,37; p=0,009). No significant correlation was found with tissue Doppler measurements of tricuspid annulus. There was a trend to lower mitral E-wave deceleration time (r2=0,15; p=0,09) in patients with higher NT-pro BNP. No correlation was found to dP/dT and there was a nonsignificant trend to lower LV EF (p=0,07) in those with higher natriuretic peptides. Sm VTI of septal mitral annulus inversely correlated to 20; p=0,049). No other tissue Doppler measurements showed a signicant relation. PSAP was the only independent predictor of NT-proBNP in multiple regression analysis (p=0,029). Conclusion: NT-proBNP level relates to right ventricular dimention and PSAP in systolic heart failure patients. This relation sugests that right ventricular secretion of NT-proBNP may be an important contributor to serum levels of this natriuretic peptide in patients with systolic heart failure. Septal mitral annulus Sm VTI may be a more accurate estimate of global systolic function since it may be under influence of both the right and left ventricle.Background: Heart failure is characterized by neurohormonal activation that can be assessed with measurements of plasma brain natriuretic peptide (BNP). The purpose of this study was to assess changes in BNP levels after intravenous administration of levosimendan and their association with the extent of myocardial scar. Methods: We studied 14 patients (12 men, mean age 67.9±8.5 years) with a history of old myocardial infarction, left ven...