N° 01 - Cardiovascular Sciences Forum

Transcrição

ISSN 1809 - 3736
CARDIOVASCULAR
SCIENCES FORUM
CARDIOVASC SCI FORUM Jan. / Mar. 2009 Vol. 4/ NUMBER 1
EDITORIAL COORDINATION
Alexandre Ciappina Hueb
Carlos Henrique Marques Santos
Osvaldo Sampaio Netto
ASSOCIATED EDITORS
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Rafael Diniz Abrantes
Danton R. Rocha - Loures,
EDITORIAL SECRETARY:
Otoni Moreira Gomes
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São Francisco de Assis Truth is Jesus Cardiovascular Foundation
Fundación Cardiovascular San Francisco de Assis Jesus es la Verdad
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Scientific Coordination: Otoni M. Gomes
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International Scientific Board
Alberto J. Crottogini (Argentina)
Borut Gersak (Slovenia)
Celina Morales (Argentina)
Daniel Bia (Uruguay)
Calogerino Diego B. Cuzumano (Venezuela)
Diego A. Borzelino (Venezuela)
Domingos S. R. Souza (Sweden)
Eduardo Armentano (Uruguay)
Eduardo R. Migliaro (Uruguay)
Michael Dashwood (England)
Pascal Dohmen (Germany),
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Pawan K. Singal (Canadá)
Ricardo Gelpi (Argentina)
Ruben P. Laguens (Argentina)
Sylvain Chauvaud (França)
Tofy Mussivand (Canadá)
Tomas A. Salerno (EE.UU)
Verônica D’Annunzio (Argentina)
Scientific Co-sponsorship by: International College of Cardiovascular Sciences, South American Section of the
International Academy of Cardiovascular Sciences (IACS - SAS), Department of Experimental Research of the
Brazilian Society of Cardiovascular Surgery (DEPEX - SBCCV), SBCCV Department of Extracorporeal Circulation
and Mechanical Assisted Circulation (DECAM - SBCCV), SBCCV Department of Clinical Cardiology, Brazilian
Association of Intensive Cardiology, Brazilian Academy of Cardiology for the Family, SBCEC - Brazilian Society of
Extracorporeal Circulation.
JAN. / MAR. 2009 - VOL. 4 - NUMBER 1
CARDIOVASCULAR
SCIENCES FORUM
CARDIOVASC SCI FORUM Jan. / Mar. 2009 Vol. 4/ NUMBER 1
International College of Cardiovascular Research
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Cardiovasc Sci Forum Jan. /Mar. 2009 Vol. 4 / Number 1
CONTENTS
EDITORIAL
La Investigación Basica y Clínica en Cardiologia: Premios y Castigos
5
H.E. Cingolani
ARTIGO ESPECIAL / SPECIAL ARTICLE
The Criation Evolution
9
Otoni M. Gomes
ORIGINAL ARTICLE / ARTIGOS ORIGINAIS
1 - Assessments of the Inflamatory Reaction in Placing a Polypropylene Mesh at Different
Distances from the Aponeurotic Border.
Avaliação da Reação Inflamatória na Colocação da Tela de Polipropileno com Diferentes Afastamentos da Borda Aponeurótica.
Maria Raquel B. Massoti, Alexandre Ciappina Hueb, Eduardo Chibeni F. Ramos, Rogério Mendes
Grande, Félix Carlos Ocáriz Bazzano.
21
2 - Short -Term Analysis of Heart Rate Variability in Diabetic Patients.
33
E. R. Migliaro, P. Contreras.
CASE REPORT / RELATO DE CASO
Supraventricular Tachyarrhythmia in Fetus Experience and Treatment
39
G. C. Puentes.
UPDATING ARTICLE / ARTIGO DE ATUALIZAÇÃO
Life Style importance for Cardiovascular diseases prevention
A Importância do Estilo de Vida na Prevenção das Doenças Cardiovasculares
Pereira, S.N.; Pacheco; L. S.; Dias, D.; Barbosa, V.A.; Portela, L.O.C.;
43
HOW TO DO / COMO FAZER
Modified De Vega Tricuspid Valve Repair
Valvoplastia Tricúspide De Vega Modificada
Otoni M. Gomes, Márcio Pitchon
48
INSTRUCTIONS FOR AUTORS
51
UPCOMING MEETINGS
53
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EDITORIAL
*LA INVESTIGACIÓN BÁSICA Y CLÍNICA EN CARDIOLOGIA “Premios y Castigos”
“The Basic and Clinical Investigation in Cardiology: Prize and Punishment”
H. E. Cingolani
Director del Centro de Investigaciones Cardiovasculares - CONICET - UNLP
Aunque la mayor parte de los médicos
aceptamos que la investigación Básica es la hecha
con animales y la Clínica la realizada en pacientes,
Debemos reconocer, con las salvedades
anteriores, que generalmente se denomina investigación Clínica a la realizada en pacientes; puede
esta clasificación ha sido cuestionada. Para algunos especialistas en el tema, la especie utilizada
para probar una hipótesis no define qué clase de
investigación se realiza. Una clasificación mejor
sería posiblemente dividir la investigación en Básica y Aplicada. La investigación Básica está destinada a describir mecanismos aún no conocidos
sin pretender aplicación o rédito alguno (los investigadores saben que si el mecanismo es nuevo y la
investigación bien hecha, tarde o temprano, tendrá aplicación práctica). Esta investigación Básica
puede hacerse en animales o seres humanos.
¿Y la investigación Clínica? Alfredo Lanari decía que si hacíamos experimentos en la rata
diabética o hipertensa hacíamos investigación clínica, puesto que pretendíamos resolver problemas
de aplicación Clínica.
ser ésta Básica o Aplicada, pero en la mayoría de
los casos es Aplicada puesto que busca encontrar
una aplicación a un mecanismo muchas veces anteriormente descripto. Cuando se describe un mecanismo nuevo la investigación es Básica aunque
haya sido realizada en pacientes.
Bernardo Houssay escribía: “... la investigación Básica persigue hallar verdades nuevas aún
desconocidas, las cuales en general son inesperadas y tendrán consecuencias no siempre previsibles al principio...”.
Comroe y Drips analizaron retrospectivamente durante 1971-1977 qué hizo posible lo que
ellos consideraron los mayores diez adelantos de
la Ciencia Médica durante los últimos años. Analizaron 6.000 publicaciones científicas. Estos diez
adelantos fueron:
1. Antibióticos.
2. Prevención de la Poliomielitis.
3. Cirugía Cardíaca.
4. Transplantes.
5. Tratamiento de la hipertensión arterial.
6. Resucitación Cardíaca.
7. Tratamiento de las Arritmias.
8. Quimioterapia.
9. Unidades intensivas.
10. Tratamiento del infarto de miocardio.
* Republished from LA Arch Cardiovasc Sci 2001; 2(1): 5-8
Luego de este meticuloso estudio llegaron estos autores a la conclusión que los estudios
“clave” que posibilitaron estos diez adelantos provenían 62% de la investigación Básica y 38% de
la investigación Aplicada (observemos que no se
especifica la especie usada). Del 62% de investigación Básica, un 42% no pretendían solucionar
ningún problema ni tenían relación alguna con el
tema en cuestión que posibilitaron.
La investigación cardiológica (Básica y
Clínica) en Latinoamérica está subdesarrollada.
Así lo muestra el escaso número de publicaciones
o presentaciones en ambientes científicos en los
blicaciones científicas. Hay dos parámetros usados
comunmente para evaluar una publicación científica: 1) El “impacto”; este representa el porcentaje
de los trabajos publicados por esta revista que son
citados en los dos años posteriores a la publicación; 2) La “vida media” de los trabajos publicados.
Es decir un índice de por cuánto tiempo son citados estos trabajos luego de publicados. El primero
es el más conocido y usado de ellos. Combinando
los dos se obtiene el “doble producto”. Cuando
examinamos algunas pocas publicaciones científicas con este parámetro observamos que aparecen primero Circulation Research seguida luego
cuales existe una selección rigurosa. Hoy en día
en que todo parece que hubiese que convertirlo en
cifras y medirlo, también se han mensurado las pu-
de Circulation, Journal of the American College
of Cardiology, Cardiovascular Research y Journal
Molecular and Celular Cardiology.
Fig. 1: Se examina con este parámetro, “doble producto”, cinco publicaciones científicas cardiológicas durante 1996, 1997, 1998 y 1999.
La primer barra (la más alta) correspondió a Circulation Research, seguida de Circulation durante los 4 años examinados.
ISSN 1809 - 3736
Si tomamos la primera de estas publicaciones, Circulation Research, vemos que se recibieron para ser considerados para su publicación, desde 1-7-99 al 30-6-00, 1114 manuscritos; sólo 11 de
ellos fueron de Latinoamérica. Brasil, Argentina,
México y Chile fueron los países que enviaron
manuscritos. La figura 2 muestra la distribución
geográfica de los manuscritos recibidos por esta
publicación en el lapso anteriormente menciona-
do. Sería necesario aclarar que estos no fueron los
manuscritos publicados sino los que fueron enviados para ser considerados. Sólo un 20%, apróximadamente, de los manuscritos recibidos son publicados. Observemos que sólo un 1% provenían
de Latinoamérica. Cálculos similares podrían hacerse posiblemente en relación a otras prestigiosas
revistas científicas o a la presentación de trabajos
anuales a la American Heart Association.
Fig. 2: Distribución geográfica de los 1114 manuscritos recibidos para ser considerados para su publicación en Circulation Research
desde 1-7-99 al 30-6-00. Se observa que sólo el 1% de ellos provenía de Latinoamérica. Note que éstos son los manuscritos recibidos
para ser considerados para su publicación; sólo 20% de ellos fueron publicados
Las causas de este subdesarrollo en la investigación cardiológica hay que buscarla posiblemente en la falta de “premios y castigos”. Por otro
lado, el porcentaje del PBI que Latinoamérica dedica a la investigación está muy por debajo del de
los países desarrollados del resto del mundo.
Dado que la función principal de la cardio-
logía no sea posiblemente la de publicargeográfica
de los manuscritos recibidos por esta publicación
en el lapso anteriormente menciona trabajos sino
la de curar enfermos cardiológicos, uno podría
plantearse el interrogante si las otras dos “patas”
del trípode Asistencia – Docencia – Investigación
ayudan o son contraproducentes para la Asistencia.
Esto se ha mensurado y se llegó a establecer que en
aquellas instituciones académicas en las cuales se
hace investigación y docencia, a los pacientes les
va mejor (Do “America´s best hospitals” perform
better for acute myocardial infarction? Jersey Chen,
et al. New England Journal of Medicine 340:286292, 1999; Effects of admission to a teaching hos-
pital on the cost and quality of care for medicare
beneficiaries. Donald H Taylos, et al. New England
Journal of Medicine 340:293-2999, 1999.)
La Prestigiosa Universidad Norteamericana Jonhs Hopkins posee un logotipo que trata de
resumir estos tres principios en los cuales descansa la Educación Médica.
Fig. 2: Distribución geográfica de los 1114 manuscritos recibidos
para ser considerados para su publicación en Circulation Research
desde 1-7-99 al 30-6-00. Se observa que sólo el 1% de ellos
provenía de Latinoamérica. Note que éstos son los manuscritos
recibidos para ser considerados para su publicación; sólo 20% de
ellos fueron publicados
Volviendo a los “premios y castigos”, esto
aunque discutible para quiernes piensan en que la
Investigación Científica es una actividad creadora
que no puede estar sujeta a “premios y castigos”,
me ha hecho reflexionar en cuál sería la producción científica sa la Educación Médica en países
desarrollados si no hubiera exigencias sobre ésta
para subsistir académicamente. Por lo tanto, una
política agresiva, invirtiendo fondos y aplicando
“premios y castigos” ayudaría a impulsar la Investigación Cardiológica Latinoamericana.
*
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SPECIAL ARTICLES
THE CREATION EVOLUTION
Otoni M. Gomes
The antagonism between the concepts of
vation”. Therefore, the Holy Spirit’s presence and
creation and evolution of the human being is famous all over the world. However, at this moment,
we will review the undisputed evidence of the Creation evolution, an inescapable witness of the Father with His Son and the Holy Spirit’s work in the
beginning of time confronted with the scientific
facts that Darwin has used to compose his agnostic
conception of man’s evolution. Darwin attested in
his book “Descent of Man”, published in February, 1871, (not in the book “The Origin of Species”,
published in 1859) that ‘man is subject to the same
mutation laws as all other species are’, according
to “The Origin of Species” under the subtitle “by
Means of Natural Selection, or the Preservation of
Favoured Races in the Struggle for Life”.
It is important to recall Saint John’s, the
Baptist, saying “A man can receive nothing unless it has been given him from heaven.” (John
3:27) . Even the positivist philosopher, Emmanuel
Kant, having no Christian bonds whatsoever said,
in 1750, ‘human beings don’t possess innate ideas’. Darwin also quotes Milne-Edwards’ assertion
“nature is prodigal in variety, but niggard in inno-
will is embedded in all new ideas conceived for
the good.
Charles Darwin has done a priceless service to humankind culture when he presented his
findings and basic concepts of human development
that otherwise would be buried in time. Darwin
defied conventional thinking and approached the
problem with what at the time seemed an unscientific method. Although his concepts are pertinent
and incontestable to the adaptation phenomenon
of individuals from a particular species, they do
not apply to the transformation of one species into
another.
The first correlation between human body
development and animal development is attributed
to Karl Von Baer, in 1827. Defending the Theory
of Recapitulation, he said that ontogeny makes
him think of phylogeny. (Von Baer. Apud in Bruggen WW, Cardiac design in lower vertebrates:
what can phylogeny? Experientia 1988; 44: 91939 - Rodrigues TMA. Contribution to the compared study of the vascularization of the coronary arteries in vertebrate species with vinyl acetate tech-
New American Standard Bible (1995)
1
nique (vinilite) – Master Thesis/ São Francisco de
Assis Cardiovascular Foundation - ServCor, Belo
Horizonte, MG, 1998.)
Ontogeny describes the origin (genesis)
and development of a certain individual. Phylogeny describes the origin of beings that appeared
before the formation of the individual. This assertion defines Von Baer’s ingenious and comprehensive scientific knowledge because it entails a vast
knowledge about human being embryology and
about the anatomy and physiology of numerous
and different animals in the biological evolution
scale.
tween the aorta and the pulmonary artery.
This is the ontogeny description of our circulatory system formation. Ontogeny actually reminds phylogeny, this is why the aquamarine and
the sea anemones are examples of nutrition similar
to that of the trophoblasts. A cardiac tube with no
beatings exists in lancelets and in earthworms and
fishes themselves possess a beating cardiac tube.
There are no internal divisions in the anurans hearts and the reptiles have incomplete internal divisions. Having less evident variations, the hearts of
birds and mammals possess human like structure.
Therefore, even if environmental adversity
The development of human blood circulation study presents an enlightening example of this
phenomenon. Human conception has its origin in
the union of a spermatozoid, the male sex cell, with
an egg from the female ovary. The egg or zygote
forms the morula - a solid mass of blastomeres
formed by the zygote splitting - that is implanted
in the uterine mucosa. In that place, the maternal
blood feeds the morula that becomes an embryo
with a tube-shaped heart, namely the cardiac tube.
By the 21st day, it begins to contract as if starting
the future heartbeats. The cardiac tube assumes the
heart shape with the aorta that carries the blood all
over the body and the pulmonary artery that carries
the blood to the lungs where oxygen enriches it.
These are the phases that can be identified
in the process: the morula and the trophoblasts
phases when the nutrition is done by nutrients diffusion; the cardiac tube phase, the primitive heart
phase with its longitudinal chambers; the formation of a primitive heart with no separation between venous and arterial blood; the rising of septa or
partitions inside the heart and the separation be-
contributed to the acquisition or the loss of the proper physical resources for survival, as Wallace and
Darwin claimed, it would not be possible for a particular species heart to develop into another species
without Jesus’ will, hence that species either survive as the lancelets and the sharks or disappear.
In the Origin of Species2, page 158, Darwin claims, “If it could be demonstrated that any
complex organ existed, which could not possibly
have been formed by numerous, successive, slight
modifications, my theory would absolutely break
down. But I can find out no such case. No doubt
many organs exist of which we do not know the
transitional grades, more specially if we look to
much isolated species, round which, according to
my theory, there has been much extinction.”
Here we find a great scientific contradiction: how can one affirm the existence of something never proved to be, that is, the existence of
transitional forms by alleging they are extinct, if
his own theory claims that the transitional species
would be more capable to survive than the original
forms?
On the Origin of Species - By Means of Natural Selection or The Preservation of Favoured Races in the Struggle for Life,
London, John Murray, Albermale Street, 1859 - New York, Bantam Books Bantam Books, New York 1996.
2
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The passage from one kingdom to another
(crystal that can regenerate in form, plants that multiply and seek out better biological environments
for survival, intelligent animals, man that is able to
speak) is done by leaps. The remnants of all species are multiplying and there are no intermediate
forms between them. Creation has evolved by Our
Lord Jesus’ will and not by any accident (catastrophe) or by an environmental demanding; on the
contrary, evolution has evolved proportionally to
life better conditions in our planet. The adaptation
of the species to the environment, a real thing, happens according to different principles and evo-
created and reproducing in much more quantity
than we are.
Why couldn’t The Father Jesus and the
Holy Spirit create us isolatedly without links with
other living beings on the planet? I was discussing
this at home, years ago, while our book “Emmaus
Road” was being written, when my son Eros reasoned, “Dad, this is God’s greatest gift to our mortal life; we coexist emerged in all nature as His
most perfect work; if it wasn’t like that we would
live mechanically as robots, having only a superficial perception of all wonders of Creation without
the sublime poetry of its existence”. All my doubts
lution purposes, that is, the creation evolution is
very different from the adaptation evolution. No
thinking animal has appeared on Earth after man.
In Darwin’s own book title, “Origin of Species by Means of Natural Selection, or the Preservation of Favoured Races in the Struggle for Life”,
shows the verification on the evolution basic mistake, as proposed by Darwin himself, because the
species that came before us in the phylogenesis are
still surviving and multiplying themselves. One
can mention the algae, the lancelets that exist for
over 500 million years, the Sharks that exist for
over 350 million years, the frogs, the reptiles, the
birds and mammals, not to mention the ants, the
invertebrates, the plants and bacteria that appeared before all animals and exist in great numbers
until our days. De Baer’s scientific verification
about our gestation on how our circulatory system
evolves from an inferior animal structure while we
coexist with the survival of these same animals is
something crystal clear. That is, our ancestries are
still existing in the same form in which they were
went away!
However, how can one reconcile the perfect description of Creation, in Genesis, with the
scientific universe evolution concepts and the living beings on Earth? Since the cathecism of our
childhood, the Church has impressive information
about the creation of the world in seven days, as
said in Genesis, explaining that God has a different time from ours and that one day may represent
a billion years.
Saint John (21:25) teach us, “And there
are also many other things which Jesus did, which
if they were written in detail, I suppose that even
the world itself would not contain the books that
would be written.”
How could one describe the universe creation to the human race in the early days of the
scientific culture if until nowadays we do not even
know the basic natural phenomena like the black holes that hide more than 99% of the universe
substance we can observe with the most sophisticated telescopes? Including Einstein’s, all theo-
New American Standard Bible (©1995)
3
11
ries agree with an initial explosion (the Big Bang
theory) that projected the energy that formed the
celestial bodies. These theories are falling apart
before the fact of the speed in which the splitting
of the most distant galaxies are increasing. It can
be compared to a stone tossed in the air that grows
in speed, going far, and far instead of falling down
caused by the loss of the energy of the initial impulse, WITH AN IMPREDICTABLE DESTINY!
About Adam and Eve’s metaphor, how to
initiate humankind culture in the world creation
successfully, making it accessible to all peoples
including the illiterate and semi-illiterate persons
desert struggling to the survival of God’s chosen
people, having no investigation instruments or
related literature to help him. How could he describe with scientific precision – over 3.500 years
ago! – all phases about life on Earth and all phases
sequences of the Creation of the universe?! This
kind of knowledge was proved right only in the
last decades with the use of special ultra-telescopes help! Without the Divine Holy Spirit’s wisdom
presence, it would be impossible for St.Moses to
describe the sequences of the physical facts of the
universe, of life and of the humankind creation
perfectly.
all over the world with different accounts about
Genesis?
On the other hand, about the universe creation, the solar system, the Earth and life all around
the Earth, all sciences only confirm the Holy Spirit presence instructing St Moses in the writing of
Genesis, which we will discuss later step by step.
Before that, it is necessary to confirm the evidence
that is impossible to the human beings to enumerate just 13 unknown facts in a perfect and continuous sequence, once the odds are 1 to 5 billions!
It is a million of times more difficult to guess the
right numbers of the “quina” lottery as said by the
Christian scientist, Hugh Ross. (The Fingerprint
of God, 2ª Ed. Promise Publishing Co, California,
1991)
St. Moses’ intelligence knocks down all
agnostic theory of evolution versus creation by
Wallace, Edwards and Darwin’s own argumentation on the fact that nature makes no leaps! St.
Moses was found in a river and created as a prince
in Egypt. When he was 40, he began living in the
This is what Genesis says: 1.1 - “In the
beginning when God created the heavens and the
earth; 1.2 - the earth was a formless void and darkness covered the face of the deep, while a wind
from God swept over the face of the waters. 1.3
- Then God said, ‘Let there be light’; and there was
light. 1.4 - And God saw that the light was good;
and God separated the light from the darkness. 1.5
- God called the light Day, and the darkness he
called Night. And there was evening and there was
morning, the first day. 1.6 - And God said, ‘Let
there be a dome in the midst of the waters, and
let it separate the waters from the waters. 1.7 - So
God made the dome and separated the waters that
were under the dome from the waters that were
above the dome. And it was so. 1.8 - God called
the dome Sky. And there was evening and there
was morning, the second day. 1.9 - And God said,
‘Let the waters under the sky be gathered together
into one place, and let the dry land appear.’ And
it was so. 1.10 - God called the dry land Earth,
and the waters that were gathered together he cal-
A type of lottery in Brazil.
The New Revised Standard Version (Anglicized Edition), copyright 1989, 1995.
4
5
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led Seas. And God saw that it was good. 1.11 Then God said, ‘Let the earth put forth vegetation:
plants yielding seed, and fruit trees of every kind
on earth that bear fruit with the seed in it.’ And
it was so. 1.12 - The earth brought forth vegetation: plants yielding seed of every kind, and trees
of every kind bearing fruit with the seed in it. And
God saw that it was good. 1.13 - And there was
evening and there was morning, the third day. 1.14
- And God said, ‘Let there be lights in the dome of
the sky to separate the day from the night; and let
them be for signs and for seasons and for days and
years, 1.15 - and let them be lights in the dome of
waters under the sky be gathered together into one
place, and let the dry land appear”.) This single
continent existed until around 225 million years
ago. After that (200 – 150 million years ago) three
continents were formed and in 120 – 80 million of
years ago four continents appeared and began to
split one from another until they formed the continents as we know nowadays. (Lane TR. Life, The
Individual, The Species. Saint Louis, C.V. Mosby
Company, 1976).
This is the sequence established: 1- Creation of the physical universe (space, time, matter,
energy, galaxies, stars, planets, etc.). 2- The crea-
the sky to give light upon the earth.’ And it was so.
1.16 - God made the two great lights - the greater
light to rule the day and the lesser light to rule the
night - and the stars. 1.17 - God set them in the
dome of the sky to give light upon the earth, 1.18
- to rule over the day and over the night, and to
separate the light from the darkness. And God saw
that it was good. 1.19 - And there was evening and
there was morning, the fourth day”. Fifty day: God
created the great sea monsters and every winged
bird of every kind. Sixth day: First God made the
animals of the earth of every kind and finally he
created man.
Scientific events sequence: All advanced
scientific studies state that in its formation phase a
cosmic dust blocked the passage of all lights to the
Earth surface (“darkness covered the face of the
deep”). They also state that in the beginning all the
planet surface was covered by water and volcanic
lava; (“a wind from God swept over the face of the
waters”). Next moment the entire Earth surface
was split into two parts: a single ocean and a single
continent, which geology calls Pangaea; (“Let the
tion of the Milk Way. 3- The creation of the Earth’s
atmosphere from opaque into translucent. 4- The
formation of a continuous water cycle. 5- The
splitting up of the oceans and continents. 6- The
production of plants in the continent. 7- The atmosphere transformation from opaque into translucent, turning the sun, the moon and the stars visible for the first time. 8- The production of small
sea creatures. 9- The creation of the sea mammals.
10- The creation of the birds. 11- The formation of
the earth animals (wild, domestic and rodents animals). 12- Humankind creation. (Human species
- Adam).
Recently, in his book “The Universe in a
Nutshell”, Stephen Hawkins highlighted some astronomy facts that appointed to the existence of
several universes undergoing a different evolution
from ours. It is sublime that St.Moses knew this
fact and pointed to it in his first verses on the book
of Genesis, using the word heavens in the plural
form, “In the beginning when God created the HEAVENS and the earth, …”
Many of these universes have already im-
The Universe in a Nutshell (Published by Bantam Books, Copyright 2001, Stephen Hawking.)
6
13
ploded and others, like ours, are transforming and
expanding progressively. This fact casts a special mystery upon the present conceptions of the
physical laws about the universe creation (or the
universes), because, according to all formulation,
including Einstein’s theory, the galaxies and constellations should be slowing the speed in which
they are splitting up in relation to the initial explosion power of the Big Bang, but this splitting up
is increasing instead! Now, we are informed that
the Earth and the stars are going somewhere in the
space of which we have no idea. Our Lord Jesus
words comfort us, “I am the Light of the world; he
tory. Our first ancestries discovered fire and reproduced it, discovered the wheel and used it; there
is no intelligence surmounting but culture changes through the millenniums to our days. Darwin
did not realize that his intelligence on studying the
past and the future, therefore the Verb of Creation,
was his own agnosticism disqualification.
We shall remember that the Lord do traps
into the astuteness of the wises, and transforms
their wisdom into madness. (Saint Paul, Corinthians 3: 19, 20) It is possible to conclude that the
evolutionist theory apply to the circumstantial and
regional adaptation phenomenon of living beings
who follows Me will not walk in the darkness, but
will have the Light of life. … “he who walks in
the darkness does not know where he goes’. (Saint
John 8:12 and 12:35.)
The special issue now is to know when in
the Creation evolution time we have become God’s
image and likeness. The answer is in Jesus’ identity
as witnessed by Saint John (1: 1-5), “In the beginning was the Verb, and the Verb was with God, and
the Verb was God. He was in the beginning with
God. All things came into being through Him, and
apart from Him nothing came into being that has
come into being. In Him was life, and the life was
the Light of men. The Light shines in the darkness,
and the darkness did not comprehend it”. We were
created in God’s likeness at the very moment in
which we were physically prepared and received
from Him the Verb power, the greatest perfection
of evolution in all Universe. No other living being
possess it and without it, we would have no notion
about the existence of eternity and could not know
God. The Verb knowledge is the greatest leap in
animal intelligence, there are no antecedents of it
and it is perfect and immutable in humankind his-
on Earth and that science confirms the existence
and perfect coherence of all phenomena described
in the universe creation, including the Earth and
everything above it, mainly the gift of our creation
in God’s likeness and image with the Word Grace
that leads us to eternity. The Verb, Creation sublime leap, raised us above everything that appeared before us and made us into God’s image and
likeness making it possible for us to participate
with Him for all eternity. Without the Life from
the Verb, we would be like animal that perishes,
knowing nothing and understanding nothing about
the wonderful universe we live as the Priest Antonio Francisco da Silva highlighted on the Sunday
Mass, in Santa Monica Church, “He who does not
know the past cannot understand the present and
is not able to conceive the future”. So without the
Verb it would not be possible to understand and believe in Lord Jesus saying: “He who has seen Me
has seen the Father.” “I and the Father are one.”
– (The Lord Jesus in Saint John 10:30 and 14:9)
7
e 8 New American Standard Bible. (©1995)
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A EVOLUÇÃO DA CRIAÇÃO
Otoni M. Gomes
É de fato mundialmente notório o antago-
em toda idéia nova concebida para o bem está a
nismo entre os conceitos da criação e de evolução
do ser humano, contudo, neste momento, estaremos revendo as evidências incontestáveis da Evolução da Criação, que são testemunho inescusável
da obra do Pai com o Filho e o Espírito Santo no
princípio dos tempos e na inspiração dos fatos
científicos que Darwin usou para compor sua concepção agnóstica da evolução do homem, isto porque ele afirma, não no livro “A Origem das Espécies”, publicado em 1859, mas no livro “Descent
of Man”, publicado em fevereiro de 1871, que” o
homem está sujeito às mesmas leis de mutações de
todas as espécies” como na “Origem das Espécies”
que tem como subtítulo: “Por meio da seleção natural ou A sobrevivência das raças favorecidas na
luta pela vida”.
Antes de prosseguirmos é importante recordarmos a afirmação de São João Batista de que
“O homem não pode gerar nenhum bem que não
tenha antes recebido de Deus (São João 3- 27)” e
até Emanuel Kant, filósofo positivista sem vínculo
cristão afirmava em 1750 que “O ser humano não
possui idéias inatas”. Darwin também cita Mine
Edwards, afirmando que “a natureza é pródiga em
variedades, mas medíocre em inovações”. Assim,
presença e vontade do Divino Espírito Santo.
Charles Darwin prestou serviço inestimável para a cultura da humanidade trazendo a público descobertas e conceitos fundamentais do desenvolvimento humano que poderiam ficar sepultados
por séculos. Mas os conceitos de Darwin abordam
com vista desarmada e pouco científica a questão
da evolução sendo mais pertinentes, e nisto incontestáveis, aos fenômenos adaptativos de indivíduos de espécies já definidas e não da transformação
de uma espécie em outra, atributos próprios da
criação.
A primeira correlação entre o desenvolvimento do corpo humano em relação com o desenvolvimento dos animais coube Karl von Baer, em
1827, quando afirmou que a ontogenia recorda a
filogenia, defendendo a Teoria da Recapitulação.
(Von Baer. Apud In Bruggen WW, Cardiac design in lower vertebrates: what can phylogeny?.
Experientia 1988; 44: 919-39 - Rodrigues TMA.
Contribuição ao estudo comparativo da vascularização das artérias coronariana em espécies de vertebrados com técnica em acetato de vinil (vinilite)
– Tese de Mestrado/Fundação Cardiovascular São
Francisco deAssis-ServCor, Belo Horizonte, MG,
15
1998.
Ontogenia é a descrição da formação ou
gênese de um determinado indivíduo. Filogenia é
a descrição da origem dos seres familiares que antecederam a formação do indivíduo em questão.
Esta afirmação, por si mesma, define a genialidade e a extensão da cultura científica de Von
Baer, porque pressupõe conhecimentos vastos da
embriologia do ser humano e da anatomia e fisiologia de inúmeros e diferentes animais da escala
de evolução biológica.
O estudo do desenvolvimento da circulação sanguínea humana apresenta um exemplo
cimento de septos ou divisões dentro do coração e
a separação entre a aorta e a artéria pulmonar.
Esta é, pois a descrição da ontogenia da
formação de nosso sistema circulatório.
E a ontogenia de fato recorda a filogenia,
por isso encontramos na água marinha, ou anêmona, o exemplo de nutrição semelhante ao trofoblasto. O tubo cardíaco sem batimentos encontramos nos anfioxos e nas minhocas. O tubo cardíaco
com batimentos encontramos nos peixes. Os batráquios possuem corações sem as divisões internas, e nos répteis a divisão é incompleta. Já nas
aves e mamíferos o coração é normalmente com
muito esclarecedor desse fenômeno.
A concepção humana tem início na união
do espermatozóide, célula sexual masculina, com
o óvulo proveniente do ovário encontrado nas mulheres. Forma-se o ovo ou zigoto, que sofre multiplicação de suas células até constituir uma estrutura denominada mórula que se implanta na mucosa
uterina, nos primeiros dias após a fecundação. Ali,
alimentada pelo sangue materno, a mórula transforma-se no embrião que no 21°. dia já possui um
coração de forma tubular, ou tubo cardíaco que
começa a contrair, como iniciando os futuros batimentos do coração.
O tubo cardíaco, por sucessivas dobras
vai assumindo a forma definitiva do coração com
a aorta, que leva o sangue para todo o corpo, e
a artéria pulmonar, que levará o sangue para os
pulmões onde será enriquecido com o oxigênio.
As seguintes fases podem ser identificadas: a fase
da mórula e do trofoblasto onde a nutrição é feita
pela simples difusão dos nutrientes; a fase do tubo
cardíaco, a fase do coração primitivo com suas câmaras dispostas longitudinalmente, a formação de
um coração primitivo, onde não há separação entre
sangue venoso e arterial em suas câmaras; o apare-
estrutura semelhante ao humano, com variações
menos evidentes, evoluindo esta semelhança nos
mamíferos.
Assim, por mais que as adversidades ambientais tenham influído na aquisição ou perda de
recursos físicos de sobrevivência, como descrito
por Wallace e Darwin, não seria possível o coração
de uma espécie evoluir para outra sem a vontade
do Pai Jesus e a espécie ou sobreviveria como o
Anfioxo e o Tubarão de nossos dias, ou desapareceria.
Na página 158 de Origem das Espécies
(On the Origin of Species - By Means of Natural
Selection or The Preservation of Favoured Races
in the Struggle for Life, London, John Murray, Albermale Street, 1859 - New York, Bantam Books
Bantam Books, New York 1996), Darwin afirma:
“ If it could be demonstrated that any complex organ existed, which could not possibly have been
formed by numerous, successive, slight modifications, my theory would absolutely break down.
But I can find out no such case. No doubt many
organs exist of which we do not know the transitional grades, more specially if we look to much
isolated species, round which, according to my
16
ISSN 1809 - 3736
theory, there has been much extinction” (Se fosse possível demonstrar a existência de qualquer
órgão complexo, que não tenha sido formado por
seqüência numerosa de pequenas modificações a
minha teoria não teria sentido. Mas eu não encontrei nenhum caso. Não há dúvidas de que existem
muitos órgãos dos quais não conhecemos os graus
de transição, porque, segundo minha teoria –continua Darwin - tem ocorrido muita extinção). E
aqui está uma grande contradição científica: como
afirmar a existência do que nunca pode ser provado, ou seja, das formas de transição, simplesmente alegando que foram extintas, sendo que
por Darwin, porque as espécies que nos antecederam na filogênese estão praticamente todas sobrevivendo e multiplicando-se, desde algas marinhas,
o Anfioxo com 500 milhões de anos, os tubarões
com 350 milhões, os sapos, répteis aves e mamíferos, sem falar que ainda tem mais formiga e invertebrados do que nós na terra, e plantas e bactérias
que precederam a todos os animais e ainda predominam mais que todos. É cristalina a constatação
científica de De Baer de que em nossa gestação
nosso sistema circulatório evolui passando pela
estrutura dos animais inferiores enquanto convivemos com a sobrevivência dos mesmos animais na
pela própria teorias especies transicionais seriam
mais capazes para sobreviverem do que as formas
originais?
A passagem de um para outro reino (cristais que são regenerados na forma, plantas que
se multiplicam e se orientam buscando melhores
condições de sobrevivência biológicas, animais
com inteligência, homem com a fala e o verbo) é
toda feita por saltos. Os remanescentes de todas as
espécies estão em franca multiplicação e não existemas formas intermediárias entre elas. A Criação
evoluiu e evolui pela vontade do Senhor Jesus e
não por acidentes (catástrofes) ou exigências do
meio, ao contrário, a evolução progrediu proporcionalmente com a melhora das condições de vida
de nosso planeta. A adaptação de espécies ao
meio, que é real, atende a princípios e a finalidades de evolução absolutamente diferentes, ou seja,
a evolução da criação é absolutamente diferente
da evolução da adaptação. Nenhum animal novo
surgiu depois do homem.
No próprio título “Origem das Espécies Por meio da seleção natural ou a sobrevivência das
raças favorecidas na luta pela vida” está a constatação de erro básico na evolução como proposta
natureza ao nosso lado. Ou seja, nossos ancestrais
estão sobrevivendo igual quando foram criados e
reproduzindo-se muito mais do que nós.
Mas por que Jesus Pai Filho e Espírito Santo não nos criou isoladamente, sem vínculo com
outros seres no planeta? Estava comentando em
casa sobre esta dúvida durante a redação de nosso
livrinho “Estrada de Emaús”, anos atrás, quando
meu filho Eros argumentou: Pai, esta é a maior
dádiva de Deus para nossa vida mortal; nós convivemos inteiramente imersos em toda a natureza
sendo sua mais perfeita obra; se assim não fosse
viveríamos mecanicamente, como robôs, com percepção apenas superficial de toda a maravilha da
criação sem a poesia sublime de sua existência.
Dissiparam-se todas as minhas dúvidas!
Mas como conciliar a descrição perfeita da
criação, no gênesis, com os conceitos científicos
progressivos da evolução do universo e dos seres
na terra?
Uma informação de grande impacto está
no ensinamento da Igreja, desde nosso primeiro
catecismo de infância, sobre a criação do mundo
em sete dias, como no Gênesis, explicando que o
tempo para Deus é diferente, e que um dia pode ser
17
um bilhão de anos.
São João (21, 25) nos ensina: “Jesus fez
ainda muitos outros sinais, que se fossem escritos
um por um, penso que nem o mundo inteiro poderia conter os livros que se deveriam escrever”.
Como poderia ser descrita, então, a criação
do universo, para a raça humana, nos primórdios de
sua cultura científica, se até hoje não conhecemos
nem fenômenos naturais básicos, como os chamados buraco negros, que escondem mais de 99%
da matéria do universo que podemos ver, mesmo
com os mais sofisticados telescópios? Todas as
teorias, inclusive a de Einstein, concordando com
acertar a seqüência do que o necessário para ganhar a “quina lotérica” como afirmou o cientista
cristão Hugh Ross ( The Fingerprint of God, 2ª Ed.
Promise Publishing Co,, Califórnia, 1991).
A inteligência de São Moisés derruba toda
a teoria agnóstica da evolução x criação pelo próprio argumento de Wallace, Edwards e Darwin
de que a natureza não dá saltos! São Moisés foi
achado no rio e criado como príncipe no Egito.
Aos 40 anos de idade passou a viver no deserto
lutando arduamente pela sobrevivência do povo
escolhido, sem nenhum instrumento de investigação nem literatura correlata. Como escreveu com
uma explosão inicial (o chamado Big Bang) projetando a energia que constituiu os corpos celestes,
estão ruindo diante do fato de que a velocidade de
separação das galáxias mais distantes está aumentando. É como se uma pedra fosse atirada no ar, e
em vez de cair pela perda progressiva da energia
do impulso inicial, ela ganhasse cada vez mais velocidade e distância no espaço, COM DESTINO
IMPREVISÍVEL!
Então, sobre a metáfora de Adão e Eva,
como iniciar a cultura da humanidade na criação
do mundo, acessível a todos os povos em todas as
culturas, também analfabetas e semi-analfabetas e
em toda a face da terra, com tanto sucesso, com
um relato diferente do gênesis?
Por outro lado, sobre o fato da criação do
universo, do sistema solar, da terra e da vida na
terra, toda a ciência só faz confirmar a presença
do Divino Espírito Santo instruindo São Moisés na
redação do Gênesis, e isto veremos passo a passo.
Mas antes, precisamos confirmar a evidência lotérica de que é impossível ao ser humano enumerar
13, isto mesmo, “treze” fatos desconhecidos, em
seqüência perfeita e contínua, pois a chance é de
1 em 5 bilhões! Milhões de vezes mais difícil de
precisão científica - há mais de 3.500 anos atrás!todas as fases da vida sobre a terra e todas as fases
da seqüência de criação do universo e da terra?!
Conhecimentos que só puderam ser comprovados
nas últimas décadas com os ultratelescópios espaciais!! Sem a presença da sabedoria do Divino Espírito Santo em São Moisés, seria impossível sua
descrição absolutamente perfeita da seqüência dos
fatos físicos da criação do universo, da vida e da
humanidade.
Assim está no Gênesis: PRIMEIRO DIA 1.1 - No princípio. Deus criou os céus e a terra.
1.2 - A terra estava informe e vazia; as trevas cobriam o abismo e o Espírito de Deus pairava sobre
as águas. 1.3 - Deus disse: “Faça-se a luz!” E a
luz foi feita. 1.4 - Deus viu que a luz era boa, e
separou a luz das trevas. 1.5 - Deus chamou à luz
DIA, e às trevas NOITE. Sobreveio a tarde e depois a manhã: foi o primeiro dia. SEGUNDO DIA
- 1.6 - Deus disse: “Faça-se um firmamento entre
as águas, e separe ele umas das outras” 1.7 - Deus
fez o firmamento e separou as águas que estavam
debaixo do firmamento daquelas que estavam por
cima. 1.8 - E assim se fez. Deus chamou ao firmamento CÉUS. Sobreveio a tarde e depois a manhã:
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foi o segundo dia.
TERCEIRO DIA - 1.9 - Deus disse: “Que
as águas que estão debaixo dos céus se ajuntem
num mesmo lugar, e apareça o elemento árido”. E
assim se fez. 1.10 - Deus chamou ao elemento árido TERRA, e ao ajuntamento das águas MAR. E
Deus viu que isso era bom. 1.11 - Deus disse: “Produza a terra plantas,ervas que contenham semente
e árvores frutíferas que dêem fruto segundo a sua
espécie e o fruto contenha a sua semente”. E assim
foi feito. 1.12 - A terra produziu plantas, ervas que
contêm semente segundo a sua espécie,contendo o
fruto a sua semente. E Deus viu que isso era bom.
sobre as águas’!). Num momento seguinte toda a
superfície da terra ficou dividida em apenas duas
partes: Um só oceano e um só continente gigantescos, e ao continente único a Geologia denomina
de Pangea (“Reúnam-se as águas em um só lugar e
apareça a terra”!). Esse continente persistiu único
até cerca de 225 milhões de anos atrás. Depois
(200 – 150 milhões de anos atrás) formaram três
continentes, e, há 120 – 80 milhões de anos, a
divisão completou os quatro continentes, que foram separando-se uns dos outros, até definirem a
forma que conhecemos hoje (Lane TR. Life,The
Individual, The Species.Saint Louis, C.V.Mosby
1.13 - Sobreveio a tarde depois a manhã: foi o terceiro dia. QUARTO DIA - 1.14 - Deus disse: “Façam-se luzeiros no firmamento dos céus para separar o dia da noite; sirvam eles de sinais e marquem
o tempo, os dias e os anos; 1.15 - e resplandeçam
no firmamento dos céus para iluminar a terra”. E
assim se fez. 1.16 - Deus fez os dois grandes luzeiros: o maior para presidir o dia, e o menor para
presidir à noite; e fez também as estrelas. 1.17 Deus colocou-os no firmamento dos céus para que
iluminassem a terra, 1.18 - presidissem ao dia e à
noite, e separassem a luz das trevas. E Deus viu
que isso era bom. 1.19 - Sobreveio a tarde e depois
a manhã: foi o quarto dia. QUINTO DIA – Foram
criados os seres do mar e as aves. SEXTO DIA
– Foram criados primeiro os animais sobre a terra
e finalmente o homem.
SEQUÊNCIA CIENTÍFICA DE EVENTOS: Todos os estudos científicos, mais avançados hoje, atestam que na fase de sua formação a
poeira cósmica impedia a passagem de qualquer
luz para a superfície da terra (“as trevas cobriam o
abismo”!). Também é afirmado que no princípio,
toda a superfície do planeta era coberta pelas águas
e larvas vulcânicas (“E o Espírito de Deus pairava
Company, 1976). Constitui-se, então a seqüência:
1- Criação do universo físico (espaço, tempo, matéria, energia, galáxias, estrelas, planetas, etc.). 2Criação da via látea. 3 - Criação da atmosfera terrestre de opaca em translúcida. 4- Formação de um
ciclo estável de águas. 5- Separação entre oceanos
e continentes. 6- Produção de plantas no continente. 7- Transformação da atmosfera de translúcida
para transparente, com o sol, a lua e as estrelas
ficando visíveis pela primeira vez. 8- Produção
dos animais marinhos pequenos. 9- criação dos
mamíferos marinhos. 10- Criação dos pássaros.
11- Formação dos animais terrestres (Selvagens,
domésticos e roedores). 12- Criação da humanidade (Espécie humana – Adão)
Mais recentemente, Stephen Hawkins em
seu livro “O Universo numa Casca de Noz” (Editora Mandarim, São Paulo, 2001) ressalta fatos da
astronomia, que apontam para a existência de vários outros universos, com histórias de evolução
diferentes do nosso. É sublime, que São Moisés
soubesse desse fato e nos anunciasse, já nas primeiras palavras suas no primeiro versículo do Gênesis, quando afirma o termo céus, no plural: “No
princípio criou Deus OS CÉUS e aterra”
19
Muitos desses universos já implodiram e
outros, como o nosso, estão em transformações
com expansão em velocidade progressiva. Este
fato lança um mistério especial nas concepções
atuais das leis físicas para a criação do universo
(ou dos universos), porque segundo todas as formulações, inclusive pela teoria de Eistein, as galáxias e constelações deveriam estar diminuindo a
velocidade de separação uma das outras, em respeito à força de uma explosão inicial do Big Bang,
mas a velocidade de separação continua aumentando! Agora, estamos sendo informados de que
a terra e as estrelas estão caminhando no espaço,
ziu, que descobriu a roda e a utilizou, não tem superação de inteligência, mas apenas de cultura nos
milênios até hoje. Darwin não percebeu que sua
inteligência estudando passado e futuro, portanto
o Verbo da Criação era a própria desqualificação
de sua agnose.
Sem esquecermos de que o Senhor faz armadilhas na astúcia dos sábios e transforma em
loucura a sua sabedoria (São Paulo, Coríntios 319,20), é possível concluir pelo fato de que a teoria evolucionista aplica-se comprovadamente aos
fenômenos de adaptação circunstancial e regional
dos seres sobre a terra e de que a ciência confirma
e para onde vamos não sabemos. Neste particular
as palavras do Senhor Jesus chegam confortantes:
“Eu sou a luz do mundo. Todo o que crer em mim
não andará nas trevas, mas ao contrário terá a luz
da vida... Porque quem anda nas trevas não sabe
para onde vai – Jesus, em S. João 8, 12 e 12, 35”.
Agora a questão especial do quando na
evolução da criação nos tornamos imagem e semelhança de Deus. A resposta está na identidade
de Jesus testemunhada por São João (1. 1-5): “No
princípio era o Verbo. O Verbo estava com Deus.
Todas as coisas foram feitas por seu intermédio e
nada do que se fez sem ele se fez. A vida estava
nele e a vida é a luz dos homens. A luz resplandece
nas trevas e as trevas não prevaleceram sobre ela”.
Fomos criados à semelhança de Deus no momento
em que fisicamente por Ele preparados recebemos
o poder do Verbo, maior perfeição da evolução de
todo o Universo. Nem um outro ser vivo o possui e sem ele não teríamos noção da existência da
eternidade e não poderíamos conhecer a Deus. O
conhecimento do verbo é o maior salto da inteligência animal, não têm antecedentes e é perfeito
e imutável na história da humanidade. Nosso primeiro ancestral que descobriu o fogo e o reprodu-
a existência e perfeita coerência de todos os fenômenos descritos da Criação do universo, da terra
e de tudo que existe sobre ela, principalmente da
dádiva de nossa criação à imagem e semelhança
de Deus com a Graça do Verbo que nos conduz
à eternidade. Verbo, salto sublime da Criação que
nos elevou acima de tudo quanto nos precedeu, fazendo-nos à imagem e semelhança de Deus para
com ele participarmos em toda a eternidade. Sem
a Vida do Verbo seríamos como os animais que
perecem, nada conhecendo e nada entendendo do
maravilhoso universo em que vivemos porque,
como recordou e acentuou o Revdo. Padre Antônio
Francisco da Silva na Missa de domingo da Igreja
de Santa Mônica: “Quem não conhece o passado
não compreende o presente e não pode conceber
o futuro”. Portanto, sem o Verbo seríamos absolutamente incapazes de entender e crer no Senhor
Jesus dizendo: “Quem me vê, vê o Pai que me enviou. Eu e o Pai somos um – O Senhor Jesus em
São João 10,30 e 14,9).
20
ISSN 1809 - 3736
ORIGINAL ARTICLES
Assessments of The Inflammatory Reaction in Placing a Poly-propylene
Mesh at Different Distances from the Aponeurotic Border.
Avaliação da Reação Inflamatória na Colocação da Tela de Polipropileno com Dife-rentes
Afastamentos da Borda Aponeurótica.
Maria Raquel B. Massoti 1, Alexandre Ciappina Hueb 2, Eduardo Chibeni F. Ramos 3, Rogério Mendes Grande 4,
Félix Carlos Ocáriz Bazzano 3.
Summary
Objective: assess the acute and chronic
inflammatory response in experimental animals
implanted with polypropylene meshes at different
distances from the aponeurotic border.
Material: 48 Rattus novergicus albinus
specimens that were grouped as acute (24) and
chronic (24). They were subdivided into control
(8), 1 cm from the aponeurotic border (8) and 2
cm from the aponeurotic border. After preparation
the aponeurosis was sectioned and a polypropylene mesh used at different distances from the aponeurotic border. The histological assessment of the
aponeurosis was made after 3 or 28 days.
Results: no histological or microscopic alterations were observed in the acute group. Greater adhe-rence was observed in the acute group
with 2 cm distance than in the control (p= 0.026).
There was greater presence of lymphomononucle-
ar cells in the chronic 1 cm distance group than in
the 2 cm distance group (p<0.001). The presence
was observed of neutrofil cells in the acute control
(p= 0.010). A significant presence was observed
of gigantic cells and collagen in the chronic group
(p< 0.001). When the acute 2 cm distance group
was compared with the chronic 2 cm distance
group, the presence of lymphomononuclear cells
was observed in the acute group (p< 0.001) and
the presence of collagen in the chronic group (p=
0.026).
Conclusions: There was an inflammatory
response with the use of polypropylene mesh. The
initial phase was identified by the presence of neutrofil and lymphomononuclear cells the late phase by collagen and granulation tissue. Adherence
occurred with greater distance and time of mesh
use. Abdominal wall hernia was not observed at
greater distance from the aponeurotic border.
Trabalho Realizado no Departamento de Técnica Operatória da Faculdade de Medicina da Universidade do Vale do Sapucaí - UNIVAS
1- Residente de Cirurgia Geral do Hospital das Clínicas “Samuel Libânio” da Universidade do Vale do Sapucaí - UNIVAS
2- Cirurgião do Hospital das Clínicas “Samuel Libânio” da Universidade do Vale do Sapucaí – UNIVAS
3- Professor da Disciplina de Técnica Cirúrgica e Cirurgia Experimental da Faculdade de Ciência da Saúde “Dr. José Antonio Garcia Coutinho” da Universidade do Vale do Sapucaí – UNIVAS
4- Patologista do Hospital das Clínicas “Samuel Libânio” da Universidade do Vale do Sapucaí – UNIVAS
21
Resumo
Objetivo: avaliar a resposta inflamatória
aguda e crônica em animais de experimentação
submetidos ao implante de malhas de polipropileno com diferentes afastamentos da borda aponeurótica.
Material: 48 espécimes de rattus novergicus albinus que foram agrupados em agudo (24) e
crônico (24). Foram subdivididos em controle (8),
afastamento da borda aponeurótica 1cm (8) e afastamento 2cm (8). Após preparo a aponeurose foi
seccionada e utilizado tela de polipropileno com
diferentes afastamentos da borda aponeurótica.
Após 3 ou 28 dias houve avaliação histológica da
aponeurose.
Resultados: Não foram observadas alterações histológicas e macroscópicas no grupo agudo.
Obser-vou-se maior aderência no grupo agudo com
afastamento de 2cm que no controle (p= 0,026).
Houve presença mais intensa de linfomononucleares no crônico 1cm que no 2cm (p<0,001). Observou-se presença de aderência nos grupos com
afastamento 1 e 2cm (p= 0,007 e p= 0,026). Observou-se pre-sença de neutrófilos no controle agudo
(p= 0,010). Observou-se presença significativa de
células gigantes e colágeno no grupo crônico (p<
0,001). Comparando agudo 2cm com o crônico
2cm, observou-se presença de linfomononucleares no agudo (p< 0,001) e presença de colágeno no
crônico (p= 0,026).
Conclusões: Existe resposta inflamatória
com a utilização de tela de polipropileno. A fase
inicial é identificada pela presença de neutrófilos
e linfomononucleares a fase tardia por colágeno
e o tecido de granulação. Aderência ocorreu com
maior afastamento e tempo de utilização da tela.
Não obser-vou-se hérnia de parede com maior
afastamento da borda aponeurótica.
22
INTRODUCTION
Incision and suture of the abdominal wall is
one of the most common exercise in surgical practice (1). Ideally the main purpose in closing the
abdominal wall is to restore its functions after operational intervention and the ideal suture should be
sufficient to unite the parts, disappearing as soon
as healing starts, be free from infection and nonirritating, principles that until today guide the search for suitable techniques and materials for the
abdominal wall synthesis (2).
The abdominal wall suture in addition to
maintaining coaptation of the operational wound
borders should resist the extrinsic tensions until
the scar acquires its own tension forces (3).
The use of mesh prostheses that help abdominal wall synthesis has increased greatly recently, its main objective is to minimize tension
in the wall, relieve postsurgical pain and decrease
the occurrence of deiscences or abdominal wall
hernias (1,2,4).
Polypropylene meshes stand out because
they are inert in the presence of infection because of their tensile force characteristics and their
capacity to incorporate into the tissue. However,
these incorporation qualities cause a strong stimulus to the inflammatory response, and to adherence formation (5). Polypropylene was introduced to
Brazil in 1969 and is the material most used by
physicians, mainly when it is required to prevent
excessive tension in the stitching line at the aponeurotic border (6).
Most authors recommend the use of absorbable threads to fix the mesh in the aponeurosis,
although these cause problems in some patients,
such as foreign body granuloma and palpable threads in thin patients (7). To prevent complications
related to closing the wall technical faults should
ISSN 1809 - 3736
be avoided at the moment of synthesis such as
inadequate use of absorbable threads, breaking or
looseness in the suture thread and laceration of the
tissue that supports the thread (8).
Regardless of the technique or material
used, all sutures cause variable degrees of inflammatory reaction in the tissues in which they are
implanted, partly because of the trauma of insertion and partly because of their physical-chemical
properties. Furthermore, improper aponeurosis coapatation influences both the type and the intensity
of the inflammatory response (9).
Based on these assumptions, the objective
nio Garcia Coutinho“ College of Medical Sciences
at the University of Vale do Sapucaí (UNIVÁS)
- Pouso Alegre, Minas Gerais. The project was
carried out according to Federal Law 6.638 following the norms of the Brazilian College of Animal
Experimentation (COBEA). The project was approved by the Ethics Committee at UNIVÁS. A
pilot project was carried out on three specimens to
minimize the learning curve.
The procedures took place in the surgical
center of the UNIVÁS Animal House, in an environment with continuous air flow, without noise and at room temperature, following the ethical
of this study was to assess the acute and chronic
inflammatory response in experimental animals
implanted with polypropylene meshes at different
distances from the aponeurotic border.
principles of animal experimentation.
The animals were first divided into two
groups with 24 specimens each to characterize the
acute and chronic processes. The acute group was
subdivided into three further groups characterized
as the control group (8 specimens), group 1 cm
distance (8 specimens) and group 2 cm (eight specimens). The chronic group was subdivided in the
same way with the allocation of the same number
of specimens (Figure 1).
METHOD
Forty-eight specimens were used of male
rattus novergicus albinus, Rodentia mammalia,
Wistar line, average age 3 months and weighing
from 200 to 300 grams (average 230±30g); supplied by the Animal House at the “Dr. José Antô-
Fig. 1 - Organogram of the project.
23
Technique used for procedures:
After a three day period to adapt to the Animal House conditions, the specimens were anesthetized with a solution of 0.1 ml/100g Xilazin and Ketamine by intramuscular injection (Figure 2).
Fig. 2 - Induction of anesthesia.
The specimens were fixed on the operating table by containing the thoracic and pelvic members
in horizontal dorsal decubitus and the fur shaved from the ventral region with a disposable razor. Antisepsis was carried out next with a solution of 2% iodine polyvinyl pirrolydon (Figure 3).
Fig. 3 - Antisepsis 2% iodine polyvinyl pirrolydon.
The abdominal wall was opened with a 5 cm long median incision of the skin and subcutaneous
layers, followed by section of 2 cm in the Alba line, reaching the aponeurosis and peritoneum (Figure
4).
24
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Fig. 4 - Median incision
Control group
In the control group, the aponeurosis synthesis was performed with nylon non-absorbable monofilament threads with atraumatc needles using single separate stitches. Four stitches and three knots
each were used and then the skin and the subcutaneous cells were closed with single separate stitches,
using nylon monofilament 5.0 atraumatic needles.
1 cm distance group
In the 1 cm distance group, the aponeurosis was performed with non-absorbable nylon monofilament 5.0 atraumatic needles with separate single stitches, but a Marlex® polypropylene mesh was
placed the aponeurotic-peritoneal plane, taking care to keep the borders of the aponeurosis at 1 cm distance from each other after closing the skin and subcutaneous cells. (Figure 5).
Fig. 5 - Aponeurosis synthesis with polypropylene mesh.
25
2 cm distance group
In the 2 cm distance group, the procedure for the aponeurotic border synthesis was similar, Marlex® polypropylene mesh was placed over the aponeurotic border peritoneal plane, taking care to keep
the aponeurosis borders with 2 cm distance between each other after closing the skin and subcutaneous
cell. (Figure 6).
Fig. 6 - Aponeurosis synthesis with polypropylene mesh and 2 cm distance.
In the post surgery period, the specimens
of each group were kept in separate cages, with
chow and water ad libitum until the end of the observation period. Those that died or that presented
complications in the operation site were excluded
from the experiment.
The specimens in the acute group were
euthanized three days after the surgical procedure
and the chronic group was euthanized 28 days after the procedure. Euthanasia was carried out with
a solution of 10% potassium chloride in intercardiac injection after anesthesia.
A fragment of the abdominal wall was obtained including the whole laparotomy area are,
that included the peritoneum, aponeurosis, muscle, subcutaneous cells and skin. This material was
removed for histological study. (Figure 7). The
fragments obtained from the abdominal wall were
fixed in ALFAC solution (80% alcohol + 40%
26
formaldehyde + glacial acetic acid), at the ratio of
8.5: 1:2 for 24 hours. They were then dehydrated,
diaphanized and blocked in paraffin. The blocks
were cut with 0.5 mm thickness and stained with
hematoxylin-eosin. Three cuts from each block
were assessed by the same observer.
Fig. 7 - Obtaining the abdominal wall fragment.
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The histological analysis of the control
group was performed in the aponeurosis tissue
in the location that surrounded the suture wound,
while the in other groups it was carried out at the
intersection of the aponeurosis with the Marlex
mesh. The histological analysis assessed the following cell elements: neutrofil filtrate, lymph-monoplasmocytic infiltrates, collagen deposit, gigantocyte deposit, foreign body type cell deposits and
granulation tissue. The data obtained according to
the pathologist´s assessment were reported in the
following manner:
Absence: absence or traces of the cell ele-
control (A control) 8 specimens, 1 cm distance (A
1 cm distance) 8 specimens and 2 cm distance (A
2 cm distance) 8 specimens where the following
histological variables were assessed: neutrofils,
lymphomononuclear cells, gigantic cells, collagen
fibers and granulation tissue. Macroscopic variables related to the wound were also assessed such
as adherence and abdominal wall hernias.
The same variables were assessed in the
chronic group designated as the following groups:
chronic control (C control), 8 specimens, 1 cm
distance (C 1 cm distance) 8 specimens and 1 cm
distance (C 1 cm distance), eight specimens.
ment assessed;
Presence: moderate or intense presence of
the cell element assessed.
The variables of the acute and chronic
groups were compared considering the control
group, the 1 cm distance group and the 2 cm distance group. The data are shown in descriptive and
graphic form. Table 1.
Statistical Analysis
The various parameters analyzed were compared
by the analysis of variance of
one Factor, and the differences between the groups were
discriminated by the exact Fisher Test.
The data are presented
in mean and with and without
the standard deviation. The
level of significance was set
at 5%.
RESULTS
To analyze the data
obtained, the specimens from
the acute group (24 specimens) and the chronic group
(24 specimens) were placed
in the following groups: acute
27
A control: Control Acute Group, A 1 cm:
Acute Group with 1 cm distance, A 2 cm: Acute Group with 2 cm distance, C control: Control
Chronic Group, C 1 cm: Control Group 1 cm distance, C 2cm: Control Group With 2 cm distance,
LMN: lymphomononuclear cells.
Acute group
The animals in the A control, A 1 cm dis-
tance and A 2 cm distance groups were assessed.
Histological and macroscopic alterations were not
observed between the groups A control and A 1 cm
distance, nor between A 1 cm distance and A 2 cm
distance. (Figure 8). When A control group was
compared with A 2 cm distance, greater adherence
was observed in the A 2 cm distance group (p=
0.026).
Fig. 9 - Presence of these cell elements according to the group.
Fig. 10 - Presence of adherence
according to group
Chronic group
Animals from the C control, C 1 cm distance and C 2 cm distance groups were assessed. Histological difference was observed with greater presence of lymphomononuclear cells in the group C 1
cm distance compared to C 2 cm distance (p<0.001). (Figure 9). Adherence was observed in C control
group with statistical significance (p= 0.007 and p= 0.026, respectively).(Figure 10).
28
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Acute x chronic group
The acute and chronic groups were correlated. When the A control group was compared
with the C control group, the presence of neutrofils
was more significant in the A control group (p=
0.010). A more significant presence was observed
of gigantic cells and collagen in C control than in
A control (p< 0.001 and p< 0.001, respectively).
(Figure 11).
Fig. 11 - Presence of cell elements according to group. (Gigantic C: gigantic cells)
When A 2 cm distance was compared with C 2 cm distance, a greater presence of lymphomononuclear cells was observed in the acute group (p< 0.001) and greater presence of collagen in the chronic
group (p= 0.026). (Figure 12).
. 12 - To presence of cell elements according to group. (LMPH: Lymphomononuclear cells)
29
When the A 1 cm distance group was compared to the C 1 cm distance group, significant
presence of granulation in the chronic group was
observed compared to the acute group (p= 0.007),
and the presence of adherences that was greater in
C 1 cm distance (p= 0.041).
DISCUSSION
Closing the abdominal wall is a simple
anatomic technique, but there are situations where the tension under which this suture is made
damages the surgical result. Polypropylene mesh
is frequently used in peritoneostomies and in the
great advance in a hernia treatment and continues
to be the mesh most used today. Its characteristics include all properties necessary for biomaterials, because it is less reactive, resistant to traction, non-absorbable and microporous. This last
characteristic gives greater resistance to infection
and greater incorporation of the mesh to the host
tissue.
The objective of the present study was to
assess the type of inflammatory response and the
intensity of this response in experimental animals,
where situations of clinical difficulty were simulated such as those caused by acute abdominal
repair of abdominal hernias. The use of the mesh
prevents abdominal hypertension, facilitates intervention, prevents evisceration and minimizes the
damage to the abdominal wall (10).
Polypropylene is a synthetic material that
produces little tissue reaction and has good tensile resistance, a resistance that is maintained over
several years after its use in live organisms (6,11).
In spite of the low tissue reaction, polypropylene
mesh can trigger a granular reaction all of the foreign body type, chronic inflammatory reaction
and fibrosis(9), because the mesh surface is filled
with adipose tissue and a inflammatory response
triggered by operational trauma.
Experimental models of incision hernia
have been reported in several experimental animals(6,11). Abdominal hernias in rats are performed by a removing a fragment of the abdominal
wall and repairing it with prosthesis. This model
of abdominal hernia in rats has been used by several authors to study the correction of incision hernia with different types of processes, immediately
after the defect was produced (12).
Polypropylene mesh was introduced at the
end of the 1950s by Usher et al (13) and was a
surgery or abdominal infection with increase in
the intra-abdominal pressure. For this we implanted the experimental animals with polypropylene
mesh at different distances, 1 cm or 2 cm, from the
aponeurotic border.
The histological assessment of the tissue
was extremely important, because it identified the
type of inflammatory response and its intensity.
The presence of young cells such as neutrofils,
lymphomononuclear cells and gigantic cells suggested an acute inflammatory response while the
presence of collagen and granulation tissue identified a late healing reaction.
When the specimens in the acute groups
were compared amongst each other a greater presence of young cells was observed in those euthanized three days after the procedure, especially
neutrofils and lymphomononuclear cells.
Differences were not observed when the
control group was compared to the group with 1
cm distance and 2 cm distance from the aponeurotic border. In the chronic group The presence
of young and repair cells was observed in specimens euthanized 28 days after the procedure. The
presence of late response cells was evident in the
30
ISSN 1809 - 3736
three chronic groups, the control and 1 cm distance and 2 cm distance groups, but was greater in
the chronic 2 cm distance group. It is interesting
to note the increase in the lymphomononuclear
cells in the 1 cm distance group, compared to the
chronic 1 cm distance and 2 cm distance groups.
The lower tension may indicate a less intense late
healing response.
The within-group analysis, either the acute or chronic groups, showed that in the control
group the variable neutrofil cell presence was
greater in the acute group while that of gigantic cells and collagen was greater in the chronic
group. The same pattern of the presence of young
or repair cells was observed when the acute group
with 1 cm distance was compared with the chronic
group with the same distance. A greater presence
of lymphomononuclear cells was observed in the
acute group and a greater presence of collagen in
the chronic group.
Another interesting fact, that can be observed macroscopically, was the presence of adherence. The presence of adherence was observed in the
acute group 2 cm distance compared to the control
group, in the chronic group adherence was observed intensely in the two chronic groups compared
to the control and in the acute group 1 cm distance
acute group compared to the chronic group with
the same distance. These data suggested that the
more intense inflammatory response may be related to time and distance from the aponeurotic border and use of polypropylene mesh.
Regarding the various publications on abdominal wall hernia and the use of polypropylene
mesh, this study assessed the type and intensity of
the inflammatory response in an experimental model with different distances from the aponeurotic
border.
CONCLUSION
It was concluded that there was an inflammatory response with the use of polypropylene
mesh and that in the initial phases this response
was identified by the more intense presence of
neutrofil and lymphomononuclear cells and in the
later phase, collagen and granulation tissue were
greater. The adherences were more frequent in the
groups with greater distance from the aponeurotic
borders and longer time of polypropylene mesh
use. Prevalence of abdominal wall hernias was
not observed in the groups with greater distance
from the aponeurotic border.
REFERENCES
1. Goligher JC, Irvin TT, Johnston D, De Dombal
FT, Hill GL, Horrocks JC. Acontrolled clinical
trial of three methods of closure of laparotomy
wounds. Br. J. Surg. 1975;62:823-9.
2. Tognini JRF, Goldenberg S. Síntese da parede
abdominal: sutura contínua ou com pontos separados? revisão da literatura. Acta Cir. Bras.
1997;v.13 n.2.
3. Goldenberg A, Matone J, Marcondes W, Herbella FA, Farah JF. Comparative study of inflammatory response and adhesions formation
after fixation of different meshes for inguinal
hernia repair in rabbits. Acta Cir Bras. 2005;
20(5):347-52
4. Metzger J, Lutz N, Laidlaw I. Guidelines for
inguinal hernia repair in everyday practice. Ann
R Coll Surg Engl. 2001;83:209-14.
5. Bellón JM, Buján J, Contreras LA, Carrera-San
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Martín A, Jurado F. Comparison of a new type of
polytetrafluorethilene patch and polypropylene
prosthesis for repair of abdominal wall defects.
J Am Coll Surg. 1996;183:11-8.
6. Gianlupi A, Trindade, MRM. Comparação entre o uso de fio inabsorvível (polipropileno) e
fio absorvível (poliglactina 910) na fixação de
prótese de polipropileno em correção de defeitos músculo-aponeurótico da parede abdominal:
estudo experimental em ratos. Acta Cir. Bras
2004; v. 19, n. 2.
Santos AM, Santiago RR. Uso da peritoneostomia na sepse abdominal. Rev Bras. Colo-Proctol 2007 Sep; 27(3):278-283.
13. Usher FC, Cogan JE, Lowry TI. A new technique for the repair of inguinal and incisional
hernias. Arch Surg 1960; 81:847-54.
7. Condon RE. Ventral Abdominal Hernia. In: Fischer JD, editor. Mastery of Surgery. Thirth ed:
Little, rown and Company; 1997. p. 1877-81.
8. Sanders RJ, DiClementi D. Principles of abdominal wound closure. Arch. Surg. 1977;112:11891.
9. Mazzini DL; Mantovani M. Suture of the abdominal wall with partial approximation of
the borders of the aponeurosis using vicryl or
marlex meshes in rats. Acta Cir Bras 1999; Jan
Mar; 14:28-34.
10. Dinsmore RC, Calton WC, Harvey SB, Blaney
MW. Prevention of adhesions to polyproylene
mesh in a traumatized bowel model. J Am Coll
Surg 2000; 191:131-6.
11. Danilo NSP, Pereira FEL, Mata RF, Dauad FR,
Isabel CALP. Experimental models of longitudinal abdominal incisional hernia in rats. Acta
Cir. Bras.1997 Dec; 12(4): 235-239.
12. Torres Neto JR, Barreto AP, Prudente ACL,
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ORIGINAL ARTICLES
SHORT-TERM ANALYSIS OF HEART
RATE VARIABILITY IN DIABETIC ATIENTS
E. R. Migliaro, P. Contreras.
Departamento de Fisiologia. Facultad de Medicina. Montevideo, URUGUAY.
Summary
The aim of this work was to assess the
value of a short-term routine to measure the Heart
Rate Variability (HRV) and its parasympathetic
and sympathetic components. We studied a
group that was supposed to have low values of
HRV owing to their long-lasting type I diabetes
(n=15). None of these patients had symptoms of
autonomic neuropathy. This group was compared
with 13 healthy volunteers with similar gender
and age profile. An ECG was obtained from an
electrocardiograph and fed into a computer by
means of an analog to digital converter. R waves
were detected and visual inspection allowed the
elimination of the non-sinusal beats. The normal
R-R intervals (N-N) were measured and stored.
Using the N-N lists we calculated two timedomain indexes: the standard deviation of intervals
(SDNN) and the square root of the mean of the
squared differences between adjacent intervals
(rMSSD). Spectral analysis was done to study
HRV in the frequency domain. The spectrum
obtained was divided in different components: the
high frequency band (HF) from 0.15 to 0.4 Hz and
the low frequency band (LF) from 0.04 to 0.15 Hz.
The HF component is considered dependent on the
parasympathetic activity and the LF component
reflects both parasympathetic and sympathetic
drive. The total power of the spectrum and the LF/
HF ratio were also calculated. The results show a
clear diminution of HRV in the diabetic patients
in comparison with the control group. Such a
reduction seems to reflect a parallel decrease of the
sympathetic and parasympathetic flows.
Key Words: Heart rate variability, diabetic
neuropathy, autonomic nervous system.
Introduction
The duration of normal heart beat intervals
display subtle variations which lead to changes in
heart rate known as Heart Rate Variability (HRV).
The main determinants of HRV in healthy people
are the respiratory changes, resting heart rate and
age (1). All of them are related with the autonomic
nervous system (ANS) activity. The former is the
well-known respiratory sinus arrhythmia, the
normal variation of heart rhythm coupled with
respiration which is more evident in young people
(2). Resting heart rate expresses the sympathovagal balance, when it is shifted towards increments
of resting heart rate, HRV diminishes. Influence
33
of age could be related with autonomic aging
(HRV diminishes as age increases) (3). Besides
such physiological changes, many pathological
states also affect HRV. Among them,the most
wildly studied are: coronary disease (4)(5), heart
failure (6),(7), anxiety or phobias (8), and diabetes
mellitus (9),(10),(11). Diabetes delays neural
conduction as a consequence of either vascular
alteration (microangiopathy of the vasa nervorum)
or of metabolic or autoimmune changes in the
myelin sheath (12). Sensitive-motor dysfunctions
(somatic neuropathy) are found in the spinal nerves
of diabetic patients, while in the ANS this illness
causes alterations related to the denervation of the
viscera (autonomic neuropathy).
The cardiovascular autonomic neuropathy
may play a main role in causing arrhythmias and
sudden death (13),(14). The interest of studying
the cardiovascular modifications in the autonomic
neuropathy of diabetic patients is based on their
early appearance. Compared with other tests
used to diagnose autonomic neuropathy, HRV is
preferred by its simplicity, which explains why its
analysis has represented an important tool in the
study of this pathology (15).
Methods for HRV analysis.
The introduction of microcomputers
allowed the improvement of the recording method
and the measurement of HRV. In brief, HRV can be
measured in short-term recordings (few minutes) or
in long lasting ones (24 h Holter monitorization).
In each case, a list of successive R-R intervals is
obtained. Noise and non-sinusal beats are removed
and the resulting normal intervals (N-N) can be
processed in many ways, (statistical methods, nonlinear analysis, frequency domain studies). Here
we chose two of them:
34
Time-domain analysis.
The numeric expression of the dispersion
of data is the standard deviation of the N-N
intervals (SDNN) or the indexes that derive from
it (16). Another useful time-domain index is the
square root of the mean of the squared differences
between adjacent intervals (rMSSD) that evaluates
more accurately the beat to beat changes (17),(5).
Frequency-domain analysis.
The succession of intervals over time
(tachogram) can be analyzed as a new complex
signal, then its power spectral density can be
estimated.. In this work we computed the values
between 0.0033 and 0.50 Hz (referred as total
power). The analysis of HRV in the frequency
domain introduces a main aspect that refers to the
possibility of separating influences of both branches
of the ANS. Most researchers agree that the high
frequency band power (HF, 0.15 to 0.40 Hz) is
related to the modulation of the parasympathetic
branch (18),(11). The low frequency band power
(LF, from 0.04 to 0.15 Hz) represents both
autonomic branches and other non-autonomic
influences (11). The basis of the components of
frequencies below 0.04 Hz (“ultra low frequency”
and “very low frequency” bands) still remain
unclear (19). In addition, our short-term study do
not assess properly those frequencies.
The aim of the present work was the
evaluation of a short-term study as a diagnostic
tool for HRV in a group of patients that is supposed
to have low values of HRV owing to their longlasting type I diabetes.
3. Material and methods.
We studied 15 diabetic patients (7 men and
8 women) aged between 44 and 66 years (mean
ISSN 1809 - 3736
[± SD] 53.8 ± 7.4). All of them were insulindependent and had had diabetes mellitus for a
long time (mean [± SD] diabetes duration 38.33
± 8.5 years). They were allowed to receive their
usual medication (digitalis, calcium antagonists,
converting enzyme inhibitors).
The control group was composed by 13
healthy volunteers (5 men and 8 women) aged
between 45 and 70 years (mean [± SD] 55.8 ±
7.8 years). The volunteers were non-smokers and
were not receiving any medication. We excluded
for the study people who had arrhythmia in the
clinical examination or in the ECG or Holter
digital (A/D) converter. Such connection allowed
the acquisition of the entire ECG. The sampling
frequency was 500 Hz. In order to achieve a good
relaxation the subject lied for 20 min in supine
position in a quiet room. After that, we began the
recording period which lasted for 10 min. All the
studies were done between 4:00 and 6:00 PM.
In an off-line analysis, a special program
detected each R wave. A visual inspection routine
allowed the validation of the detected R waves,
correcting those related with premature beats and
movements (false positives). After that, we obtained
a train of N-N (normal to normal) intervals. Another
recording.
HRV was assessed measuring the intervals
between heart beats recorded in a conventional
ECG. The procedure for recording was the
following: Subjects were asked not to perform
heavy exercise or take coffee or alcohol 24 h prior
to the study. Electrodes for the ECG recording
were placed on the chest, two of them were used
to obtain a bipolar derivation. We connected the
ECG with the computer by means of an analog to
program measured the N-N intervals in ms. With
the lists obtained, a software calculated the indexes
for time domain HRV analysis: SDNN and rMSSD.
For the frequency domain analysis, graphs of the
total spectrum were plotted (Figure 1); then, we
computed the spectral density and calculated: total
power, LF power, HF power and LF/HF ratio 1 .
The statistical comparisons were done with
a non-parametric test (Mann-Whitney). Values of
p<0.05 were considered significant.
Fig 1 - Spectral analysis of two subjects matched by age and sex. The control has higher values of spectral density than the diabetic
patient in all frequencies.
- The original software for acquisition, visual inspe-ction, N-N measurements and calculus of HRV indexes were
developed by El. Eng. R. Canetti and El..Eng. M. Hackas from the Instituto de Ingeniería Eléctrica. Facultad de Ingeniería
Montevideo, Uruguay.
1
35
4. Results
As we mentioned earlier both groups are
similar in age and gender distribution. The values
of their mean (± SD) resting heart rate are: 73.9 ±
9.4 beats/min in the diabetic group and 69.7 ± 5.2
beats/min for the control group. Such figures are
not statistically different.
Time-domain analysis.
Mean values of SDNN and rMSSD in each
group, are shown in Figure 2. As we can see, values
for the diabetic group are significantly lower than
those for the controls.
Frequency-domain analysis.
The average values of spectral density are
shown in Table 1. The diabetic patients show a
significant reduction of the mean values of the total
power as well as HF and LF bands. Nevertheless,
values of LF/HF ratio are not statistically different.
Fig 2 - Time-domain indexes of HRV
Bar graphs show the comparison of SDNN (upper graph) and rMSSD (lower graph) between control group and diabetic patients. Figures
inside the boxes correspond to the mean values ± S.D. The symbol (*) indicates p<0.05. See text for discussion.
TABLE 1
TPSD
LF
HF
LF/HF
Diabetic
Mean
558.67
138.44
86.11
2.695
SD
637.24
187.70
124.92
1.838
Control
Mean
1801.50
501.48
263.68
2.849
SD
1263.40
410.53
311.88
2.056
P
0.0004
0.0004
0.007
N.S.
Table 1 - Frequency-domain indexes of HRV
Mean values (± S.D.) of: Total power spectrum density (TPSD), LF band, HF band LF/HF ratio. All values but the LF/HF ratio. are
statistically significant See text for discussion.
5. Comments
HRV is often studied by means of Holter
monitorization. This procedure has the advantage
that circadian variations of HRV are recorded. On
the other hand, its acquisition frequency is lower
than the one we use (128 vs. 500 Hz). In addition,
Holter studies are usually done using tape recorders
36
and small variations in tape speed can induce
abnormal HRV measurements.
On the contrary, short-term studies are
performed in control conditions, i.e. all subjects
are in the same environment without external
influences. The acquisition is performed with a
computer through an A/D converter, in this way
ISSN 1809 - 3736
tape speed changes are avoided and the acquisition
frequency can be increased. Using this short-term
procedure, our results agree with those of other
authors which point out the affectation of the ANS
in diabetes mellitus.
The concomitant reduction of LF and HF
bands and therefore, the non-significant variation
of the LF/HF ratio seems to show that the decrease
of HRV in the diabetic group is based on a similar
affectation of the sympathetic and parasympathetic
branches. Other authors have obtained evidence
about an early affectation of both branches of
the ANS in this pathology (20)(11). Meanwhile,
there are reports that states an increase (21) or a
decrease (22) in LF/HF ratio in diabetic compared
with controls.
In the earliest studies of diabetic neuropathy,
a rest taquicardia was described, which would
imply an premature parasympathetic affectation
(23). In our groups, the differences between the
mean values of heart rate is not significant, which
agrees with the parallel reduction of the HF and
LF components.
02. Marriot, H. J. L. and Myerburg, R. J. Recognition
and tratment of cardiac arrhythmias and conduction
disturbances. In: Hurst, J.W. eds.The Heart. Fourth
Edition. New York. McGraw Hill Company. 1978.
637-694.
6. Conclusions
Our short-term procedure is useful enough
to the diagnosis of the HRV impairment in diabetes.
In the present study, the diabetic patients show a
clear reduction of their HRV when compared with
the control volunteers. Such a reduction seems to
reflect a parallel affectation of the sympathetic and
parasympathetic branches.
06. Stein, P. K., Rich, M. W., Rottman, J. N., and Kleiger,
R. E,. Stability of index of heart rate variability in
patients with congestive heart failure. Am Heart J
(1995) 129:975-981.
Referências
01. Tsuji, H., Venditti, F. J., Manders, E. S., Evans, J.
C., Larson, M. G., Feldman, C. L., and Levy, D.
Determinants of Heart Rate Variability. J.Am.Coll.
Cardiol. (1996) 28:1539-1546.
08. Kawachi, I., Sparrow, D., Vokonas, P. S., and
Weiss, S. T. Decreased heart rate variability in men
with phobic anxiety (data from the Normative Aging
Study). Am J Cardiol (1995) 75:882-885.
03. Pfeifer, M. A., Weinberg, C. R, Cook, D., Reenan,
A., and Halter, J. B. Variaciones diferenciales de
la función del sistema nervioso autonómico con la
edad del varón. Am J Med (Spanish edition) (1983)
18:39-44.
04. Odemuyina, O., Malik, M., Farrell, T., Bashir, Y.,
Poloniecki, J., and Camm, J. Comparison of the
predictive characteristics of HRV index and left
ventricular ejection fraction for all cause mortality,
arrhytmic events and sudden death after acute
myocardial infarction. Am J Cardiol (1991) 68:434439.
05. Bigger, J. T., Kleiger, R. E., Fleiss, J. L., Rolnitzky,
L. M., Steinman, R. C., Miller, J. P. Multicenter
post-infarction research group,. Components of
heart rate variability measured during healing of
acute myocardial infarction. Am J Cardiol (1988)
61:208-215.
07. Woo, M. A., Stevenson, W. G., Moser, D. K.,
Trelease, R. B., and Harper, R. M. .Patterns of
beat-to-beat heart rate variability in advanced heart
failure. Am Heart J (1992) 123:704-710.
37
09. Malpas, S. C. and Maling, T. J. Heart rate variability
and cardiac autonomic function in diabetes. Diabetes
(1990) 39:1177-1181.
10. Thomaseth, K., Cobelli, C., Bellavere, F., Balzani,
I., De Masi, G., Bax, G., and Carenza, P. Heart rate
spectral analysis for assesing autonomic regulation
in diabetic patients. J Auton Nerv Syst (1990) 30:
S169-S172.
11. Malik, M. Heart Rate Variability. In: Zipes D., Jalife
J. Eds. Cardiac Electrophysiology. Third. Edition.
Philadelphia. W.B.Saunders Company. 1999. 753762.
12. Cotran , R. S., Kumar, V., and Robbins, S. T. El
páncreas. In: Robbins S.T. Ed. Patología estructural
y funcional. Madrid. McGraw-Hill - Interamericana.
1990. 1033-1062.
13. Rathmann, W., Ziegler, D., Jahnke, M., Haastert,
B., and Gries, F. A. .Mortality in diabetic patients
with cardiovascular autonomic neuropathy. Diabet
Med (1993) 10:820-48.
14. Ong, J. J., Sarma, J. S., Venkataraman, K., Levin,
S. R., and Singh, B. N.. Circadian rhythmicity of
heart rate and QTc interval in diabetic autonomic
neuropathy: implications for the mechanism of
sudden death.. Am Heart J (1993) 125:744-752.
15. Howorka, K., Pumprla, J., and Schabmann,
A. Optimal parameters of short-term heart rate
spectrogram for routine evaluation of diabetic
cardiovascular autonomic neuropathy. J Auton
Nerv Syst. (30-4-1998) 69:164-172.16 Kleiger, R.,
Stein, P., Bossner, M., and Rottman, J. Time domain
measurements of heart rate varibility. Cardiol Clin
(1992) 10:487-498.
Hart, B. I. The mean square succesive difference.
Ann Math Stat (1941) 12:153-162.
18. Appel, M. L., Berger, R. D., Saul, J. P., Smith, J.
M., and Cohen, R. J.,.Beat to beat variability in
cardiovascular variables: Noise or music? J Am
Coll Cardiol (1989) 14 nº 5:1139-1148.
19. Task Force of the European Society of Cardiology
and the North American Society of Pacing and
Electrophysiology. Heart rate Variability. Standards
of measurement, physiological interpretation, and
clinical use. Circulation (1996) 93:1043-1065.
20. Weise, F. and Heydenreich, F. A non-invasive
approach to cardiac autonomic neuropathy in
patients with diabetes mellitus. Clin Physiol (1990)
10:137-145.
21. Weston, PJ., James, MA., Panerai, RB., McNally,
PG., Putter, JF., and Thurson, E. Evidence of
defective cardiovascular regulation in insuline.
dependant diabetic patients without clinical
autonomic dysfunction. Diabetes Res Clin.Pract
(1998) 43:141-148.
22. Singh, JP, Larson, M. G., O´Donnell, CJ, Wilson,
PF, Tsuji, H., Lloyd-Jones, DM, and Levy, D.
Association of hyperglicemia with reduce heart
rate variability. (The Framinham heart study). Am J
Cardiol. (2000) 86:309-312.
23. Lloyod-Mostyn, R. and Watkins, P. Defective
inervation of heart in diabetic autonomic neuropathy.
BMJ (1975) 3:15.
17. von Neumann, J., Kent, R. H., Bellinson, R. H., and
38
ISSN 1809 - 3736
CASE REPORT
SUPRAVENTRICULAR TACHYARRHYTHMIA IN FETUS
- EXPERIENCE AND TREATMENT
Glicerio C. Puentes, MD.
Summary
Introduction: Cardiac arrhythmias in the
feturs are not seen frecuently; one can see premature
atrial beats (PAB) or premature ventricular beats
(VBP) isolated; others as sinus bradycardia (SB)
and sinus tachycardia (ST) are seen very often
without any consequence for the fetus. Among
supraventricular arrhythmias, supraventricular
tachycardia (SVT) and atrial flutter (AF) are the
arrhythmias that need some treatment as several
authors have described.
General Objectives: To report a case of
total tachyarrhythmia:
And (1): To recognize the behaviour of SVT
with echocardiographic follow up in the fetus (ECO)
after having done the diagnosis and to recognize
what will happen once the patient will be born.
And (2): To recognize what happened with
the treatment with digoxin and to support the opinion
that echocardiographic test is the best diagnostick
tool in face of all cardiac arrhythmias.
Method: We used a Combinson 310, Kretz
(M and B mode), in outpatients clinic, in order
to study all pregnants women with risk of heart
defects in their babies from the municipality of East
Havana.
Results: There was a good response after the
arrthythmia wa diagnosed and treated with digoxin
by maternal way.
We make a comment of what happened after
the baby was born.
Conclusions: It is emphasized that ECO is
the best diagnostic method among others. Digoxin
is the drug of first line and the maternal route, is a
good way.
Key Words: Cardiac Arrhythmia, Paediatric
Cardiology, Fetal Arrhythmia.
From Cardiocenter William Soler Hospital, Havana city Piti Fajardo Hospital, Havana, Cuba
39
Introduction
The use of ultrasound in the fetal world has
allowed to discover great unknown things of the
behaviour of the fetus and the world around it during
the nine months of pregnancy. Cardiac arrhythmias
are not isolated of this acquired knowing, and there
are a lot of authors which since a few years have
begun to speak about their experiences in Fetal
Medicine.
Fetal arrhythmias have received different
clasifications, one of them is Dr. Oberhansli’s(1):
Fetal Arrhythmias.
- Simple
- Premature atrial contraction (ACP)
- Premature ventricular contraction (VCP)
- Sinus tachycardia (ST)
- Sinus bradycardia (SB)
- Premature atrial contraction blocked.
- Potencially Mortal
- Supraventricular tachycardia (SVT)
- Atrial flutter (AF)
- Nodal tachycardia
- Atrioventricular block (A-V) of 2nd grade
- Atrioventricular complete block
- Complex arrhythmias
Echocardiography in their different forms
has permited to diagnose all of them. M mode is the
one that has been more used (2, 3, 4, 5).
The different treatments of choice in
arrhythmias depend on many factors but Digoxin
is the drug of first choice; several authors have
confirmed its benefit (6, 7, 8). Hydropis is a bad sign
and when it happens, it will determine the prognosis
of the fetus (9).
General Objectives:
To compare our findings with others
40
diagnostic methods used to diagnose arrhythmias in
fetal life and in the afterbirth period.
Specific Objetives:
To recognize the benefit of the treatment
with digoxin (slow treatment) and the value of its
use by maternal route.
Method
Our country has a programme of Prenatal
Diagnostic. The province of Havana inserted Fetal
echocardiography in 1989, as a pilot study, in the
east of the province. Since the beginning we have
used a Combinson 310 Kretz (M and B mode )
equipment.
Pregnants women are sent to receive our
service when they have some risk:
Maternal risk factors:
Extreme ages in life (<18 years and > 36
years). Some illness as: Sistemic Eritematous
Lupus, IDDM etc. Treatment with some drugs:
Dilatin, Ethanol, Retinoic acid etc.
Obstetrical risk factors:
Abnormal biometric profile. Amniotic liquid
abnormalities orchanges, etc.
Fetal risks factors: Fetal arrhythmias. Four
chambers abnormal view.
Pregnants women are selected according
to the risks by: the Family doctors, Obgyn. doctors
Genetist and others who treat the patients.
Case report:
MDF,38 years, white. G2P1. who was sent
to our Fetal echocardiographic service because she
was 36 years old.The first test was not possible
because of the position of the fetus. At 24 5/7
ISSN 1809 - 3736
weeks, we reoeated the test and found a fetal cardiac
frequency around of >200 BPM (M mode) without
atrial-ventricular(A-V) dissociation and without
heart defects and with a normal cardiotocographic
(CTG) test (Fig. 1). We began to treat the feto by
maternal route with digoxin (slow treatment)(0,125
mg/day), step by step and in the 3 er day, we raised
the treatment to 0,25 mg/day.
After 15 days with 0,25 mg/day, cardiac rate
in the fetus was normal (Fig. 2).
An echocardiographic control test was
done just as far as the cardic rate was normalized
and after that, every two weeks was done an
echocardiographic control until pregnancy was
finished. We never found any arrhythmia during the
treatment.
Since the beginning of the treatment and
until the end of pregnancy, the pregnant received a
close control by Obgyn. department. The fetus was
born without any problem (Apgar 9-9). They were
discharged from the hospital after 72 hours.
When the baby was 2 weeks old, he began
with tachycardia, polynea and cyanosis (Fig. 3).
We understood what happened when we knew that
the treatment was stopped when they went to his
house. We began again with digoxin 10 mcg/kg/
day and after 72 hours the symptoms and signs
Fig. 1
disappeared.
The baby did not have any other problem
in the first year of his life (ECO and ECG, normal).
Now, he is 1.2/1.3 year old and he is doing well
without any treatment.
Discussion:
The treatment with dogoxin in fetus with
SVT was reported in 1980 by Lingman(10), he
recommended digoxin, 0,25 mg every 12 hours in
the first day and later on digoxin 0,25 mg/day and
he also found no-correspondence between the CTG
test and transabdominal ECG in the fetus. All the
authors agree with the good response to digoxin.
In our case it was the first patient that we
have treated in 3000 test with 15 simple arrhythmias
which did not need any treatment.
We used the slow treatment with digoxin
because we could not dosify digoxin in blood. We
considered that there was a good response without
any bad secondary effects, so much to the mother
as to the fetus. The baby proved with his illness that
he needed digoxin all the time when he repeated the
arrhythmia. He finished the treatment 3 months ago
and he is very well.
In face of a fetal arrhythmia we should
always do an echocardiographic test.
Fig. 2
41
Fig. 3
References
1. Oberhanli-Weis, I. Afecciones cardiacas del feto.
Schweiz. Med. Wochenschr.1995, 125; 294-303.
transplacental therapy. Obstet. Gynecol. 1991,78;
523-25.
2. Allan,LD. Manual of fetal Echocardiography, 1986.
MTP Press Limited, Falcon House, Lancaster, England.
8. Perry,J.C. Fetal arrhythmias, pediatric arrhythmias,
and pediatric electrophysiology. Curr. Opin. Cardiol.
1995,10;52-57.
3. DeVore, G.R. et. al. Fetal echocardiography III. The
diagnosis of cardiac arrhythmias. Am.J.Obstet.Gynecol.1983. 146;792-99.
9. Copel, J.A. et.al. Management of fetal cardiac arrhythmias. Fet.Diag. Therap. 1997, 24; 1,201-11.
4. Friedman, D.M. et. al Benign fetal bradycardias diagnosed by echocardiography. Am.J .Perin.
1995,12;2,295-99.
10. Lingman, G. et.al. Intrauterine digoxin treatment of
fetal paroxismal tachycardia case report. Brit. J. Obstet.Gynecol. 1980,87; April, 340-43.
5. Kleimman, C.S. et. al. Fetal echocardiography. A tool
for evaluation of in utero cardiac arrhythmias and
monitoring of utero therapy. Am.J.Cardiol. 1983,51;
2,237-43.
6. Allan, L.D.Fetal tachycardia. Cardiol Young,
1996,6;197.
7. Hallak, M. et. al. Fetal supraventricular tachycardia
and hydrops fetalis: Combined intensive, direct and
42
ISSN 1809 - 3736
UPDATING ARTICLE
Life style importance for cardiovascular
diseases prevention
A Importância do Estilo de Vida na Prevenção
das Doenças Cardiovasculares
Pereira, S.N.; Pacheco; L.S.; Dias, D; Barbosa, V.A.; Portela, L.O.C.
A importância das doenças cardiovasculares
tanto do ponto de vista epidemiológico como
econômico é reconhecida em todo mundo. No
início do século XX elas representavam cerca de
10% do total de óbitos no mundo, porém, no inicio
do século XXI, já eram responsáveis por 50% das
mortes nos países desenvolvidos e 25% nos países
em desenvolvimento1. Este índice vem decaindo
em vários países, principalmente a partir da década
de 1960, no entanto, em paises em desenvolvimento
a taxa encontra-se em ascensão (3-9).
No Brasil, a Doença Cardiovascular (DCV)
é responsável por 32% dos óbitos e por um elevado
custo tanto para o paciente quanto para o sistema
de saúde (9). No Rio Grande do Sul e no municipio
de Santa Maria as DCV representam a principal
causa de óbito, atingindo percentuais de 31 a 33%
respectivamente (4,5,6).
Como bem documentado na literatura,
principalmenta após o estudo Framingham, o
desenvolvimento das DCV relaciona-se com a
presença de seus fatores de risco, sejam eles não-
modificáveis (idade, sexo e história familiar)
ou potencialmente modificáveis (tabagismo,
hipertensão arterial sistêmica - HAS, dislipidemia,
sedentarismo, Diabetes Mellitus - DM, sobrepeso
e obesidade) (1-10) . Estratégias de prevenção
primária em cardiologia baseadas em mudança de
estilo de vida, quando adequadamente executadas,
mostraram-se bastante eficazes (12), e aliados
aos grandes avanços de seus tratamentos são,
provavelmente, os responsáveis pela recente
redução da taxa de mortalidade por DCV observada
em alguns paises.
Em um trabalho de revisão, Castro e et al.
(13), evidenciaram como o exercício pode reduzir
vários fatores de risco, além de trazer outros
benefícios para o organismo em geral e para o
aparelho circulatório em particular. Entre estes
benefícios estão a redução do peso, elevação do
HDL colesterol, redução do LDL e triglicerídeos e
dos níveis de tensão arterial (14-20). Metanálises
de estudos de reabilitação cardíaca demonstraram
redução de 20-25% no risco de morte (14), podendo
Correspondência: Sérgio Nunes Pereira
Hospital Universitário de Santa Maria/Centro de Educação Física e Desporto - UFSM, Santa Maria, RS, Brasil.
Rua Venâncio Aires, 2086 / 803 - Santa Maria - RS - CEP: 97010-004 / Brazil
E-mail: [email protected]
43
chegar a cerca de 35 %, como aconteceu no estudo
das enfermeiras (7) .
Estudos epidemiológicos nos Estados
Unidos demonstraram aumento de cerca de 30% de
indivíduos com sobrepeso e obesidade, associados
com aumento também na prevalência de Diabete
Mellitus (DM) (11).
Em contraste, houve diminuição de
outros fatores de risco, tais como: o percentual de
indivíduos com hipercolesterolemia baixou de 34
para 17%, hipertensos de 31 para 15% e tabagistas
de 39 para 26% (11).
Em 1992 a AHA publicou as suas
contribui para:aumentar as taxas de HDL-colesterol
e reduzir os níveis de LDL-colesterol e VLDL, e
além disto, reduz a pressão arterial, a resistência
insulínica e melhora o desempenho cardiovascular.
Com base nestes fatos o NCEP recomendou a
prática regular de atividades físicas em pacientes
com hipercolesterolemia.
Estudos mais recentes demonstraram a
relação da inatividade física com o aumento das
doenças cardiovasculares (23-26) e também os
benefícios do exercício na prevenção e na redução
da morbi-mortalidade por estas doenças (27-30) .
Em nosso país a Sociedade Brasileira
recomendações sobre o exercício (21), partindo do
princípio de que a inatividade é um reconhecido
fator de risco para doença coronária. Baseouse também em metanálises que demonstraram
que o exercício supervisionado pode reduzir as
taxas de mortalidade por doença das coronárias e
recomenda um mínimo de 30-60 minutos por 3-4
vezes por semana. Adverte que os médicos têm a
responsabilidade de promover o assunto o exercício
para toda a sociedade.
Em maio de 2001 foi publicado o relatório
III NCEP/2001 com as diretrizes do Programa
Nacional de Educação sobre o Colesterol dos
Estados Unidos (22). Entre estas recomendações
está a orientação sobre a Sindrome Metabólica,
com resitência à insulina. Nela há excesso de
gordura corporal, principalmente às custas de
obesidade abdominal e iantividade física. Nestas
recomendações comentou-se que o sobrepeso e a
obesidade estão associados à resistência insulínica
e a síndrome metabólica. O manejo da síndrome
metabólica tem dois objetivos principais: Reduzir
a obesidade e inatividade física e tratar os fatores
de risco lipídicos e não lipídicos associados.
Demonstrou-se que a prática de exercícios físicos
de Cardiologia desenvolveu um grande estudo
epidemiológico sobre doenças cardiovasculares
e seus fatores de risco. Este projeto denominado
Corações do Brasil foi desenvolvido a partir de
2004, avaliando 2550 pessoas, de 74 cidades, da
cinco regiões geográficas do País. Este estudo
demonstrou taxas de mortalidade de 27,5% por
doenças cardiovasculares no Brasil e de 32 % na
região Sul (9).
Em 2006 realizamos um estudo sobre o
perfil clínico e laboratorial de 103 servidores da
Universidade Federal de Santa Maria, participantes
voluntários de um projeto de prevenção em
cardiologia baseado na mudança de estilo de vida.
Este grupo era constituído por 38 homens e 65
mulheres. Este estudo evidenciou uma prevalência
de 51,96 % de sobrepeso/obesidade. Encontramos
dislipidemia, com colesterol total maior do que 200
mg/dl em 58,42% e colesterol LDL superior a 130
mg/dl em 47,42% dos participantes. A prevalência
de hipertensão arterial foi de 28 %. O tabagismo
representou apenas 4,85% e a hiperglicemia (> 100
mg/dl) ocorreu em 5,82 dos participantes.
Nesta avaliação inicial dividimos os
participantes em ativos e sedentários conforme seu
44
ISSN 1809 - 3736
desempenho no teste ergoespirométrico, tomando
como referência a tabela de aptidão física da AHA
(baseada na medida do VO2 Max). Os resultados
desta análise demonstraram diferença significativa
nos seguintes indicadores: cintura masculina
superior a 94 cm, HDL feminino inferior a 50 mg/
dl e masculino inferior a 40 mg/dl, com prevalência
maior nos indivíduos sedentários em relação aos
ativos (p<0,02). Os indicadores colesterol total,
LDL, triglicerídeos e glicemia não mostraram
diferença significativa.
Estes resultados, embora com as limitações
do tamanho da amostra, sugeriram benefício da
Assim, cabe a nós, médicos a missão de
nos conscientizarmos para a gravidade da situação
e nos transformarmos em grandes divulgadores
da idéia, especialmente válida para as doenças
cardiovasculares, que mais vale prevenir do que
remediar.
Talvez o maior desafio desta atitude seja
a dificuldade na mudança de estilo de vida, pois
a doença cardiovascular se desenvolve lenta
e silenciosamente, de forma assintomática e
desapercebida, e quando se manifesta geralmente
já traz um dano muitas vezes irreparável. Mas
gradualmente estão surgindo as evidências de que
atividade física na redução de fatores de risco.
exercício na redução de alguns fatores de risco
conhecidos. Estes dados concordam com os da
literatura revisada e chamam a atenção para a
necessidade de se estimular com grande empenho a
mudança do estilo de vida na população.
É particularmente preocupante o amumento
da prevalência de sobrepeso e obesidade,
dislipidemia, síndrome metabólica, diabete e
tabagismo em população cada vez mais jovem e
também o aumento destes indicadores nos países
sub-desenvolvidos e em desenvolvimento, que
tem levado ao fenômeno denominado transição
epidemiológica com aumento das doenças crônicodegenerativas, em especial a doença cardiovascular
e redução das doenças infecciosas, antes mais
freqüentes.
Esta situação agrava-se ainda mais se
considerarmos os elevados custos dos tratamentos
de ponta, para os hospitais, a rede pública e,
especialmente, para os doentes, que se deparam com
tratamentos dispendiosos, muitas vezes inacessíveis
para a maioria da população que caminha,
inexoravelmente, para um grande aumento de sua
morbi-mortalidade por este tipo de doença.
as medidades de mudança de estilo de vida tem se
mostrado não só benéficas, mas tambem com custo/
benefício favoravel em relação às atuais medidas
terapêuticas existentes. Talvez, com a maior
divulgação destes resultados se possa mudar, nos
países em desenvolvimento, a tendência do perfil
evolutivo da doença cardiovascular.
REFERÊNCIAS
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Rio de Janeiro: Atheneu; 1999. p. 131-43.
2. Kuulasmaa K, Tunstall-Pedoe H, Dobson A, Fortmann S, Sans S, Tolonen H et al. Estimation of
contribution of changes in classic risk factors to
trends in coronary-event rates across the WHO
MONICA Project populations. Lancet 2000 Feb
26;355(9205):675-87.
3. McGovern P G, Pankow J S, Shahar E, Doliszny K
M, Folsom A R, Blackburn H et al. Recent trends in
acute coronary heart disease--mortality, morbidity,
medical care, and risk factors. The Minnesota Heart Survey Investigators. N Engl J Med 1996 Apr
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4;334(14):884-90.
4.Capewell S, Morrison C E, McMurray J J. Contribution of modern cardiovascular treatment and risk
factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994.
Heart 1999 Apr;81(4):380-6.
5.Capewell S, Beaglehole R, Seddon M, McMurray
J. Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand,
between 1982 and 1993. Circulation 2000 Sep
26;102(13):1511-6.
6. Cooper R, Cutler J, Desvigne-Nickens P, Fortmann
S P, Friedman L, Havlik R, Hogelin G et al. Trends
and disparities in coronary heart disease, stroke, and
other cardiovascular diseases in the United States:
findings of the national conference on cardiovascular disease prevention. Circulation, Dec 2000; 102:
3137 - 3147.
7. McGovern P G, Jacobs D R Jr, Shahar E, Arnett D
K, Folsom A R, Blackburn H et al. Trends in acute
coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the minnesota
heart survey. Circulation 2001 Jul 3;104(1):19-24.
8.Rothwell P M, Coull A J, Giles M F, Howard S C, Silver L E, Bull L M et al. Change in stroke incidence,
mortality, case-fatality, severity, and risk factors in
Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004 Jun 12;363(9425):1925-33.
9.Ministério da Saúde [homepage na Internet]. Secretaria Executiva. Datasus [citado 2005]. Informações
de Saúde. Morbidade e informações epidemiológicas. Disponível em: url: http://www.datasus.gov.br
10.Gus I; Fischmann A; Medina C. Prevalence of Risk
Factors for Coronary Artery Disease in the Brazilian
46
State of Rio Grande do Sul. Arq Bras Cardiol, volume 78 (5): 484 -90, 2002.
11.Gregg E W, Cheng Y J, Cadwell B L, Imperatore
G; Williams D E, Flegal K M et al. Secular trends in cardiovascular disease risk factors according
to body mass index in US adults. JAMA 2005 Apr
20;293(15):1868-74.
12.Rezende F A C, Rosado L E F P L, Ribeiro R C L,
Vidigal F C, Vasques A C J, Bonard I S et al. Índice de massa Corporal e circunferência Abdominal:
Associação com Fatores de Risco Cardiovasculares.
Arq. Brás Cardiol 2006;87(6):728- 734.
13.Castro, I; Bueno, N, Ramos, AM; Martini, R; Harter, K. - Importância do exercício físico na prevenção da aterosclerose e da cardiopatia isquêmica. Ver.
Med. IC-FUC, 2000; 3:248-259.
14.Miller, TD, Baladt, GJ, Fletcher GF – Exercise and
its role in the prevention and rehabilitation of cardiovascular disease. Ann. Behav Med. 1997: 19(3):
220-9
15.Manson, JE; Stampfer, MJ; Willett, WC; Colditz,
GA; Spelzer, FE; Hennekens, CH – Physical activity
and incidence of coronary heart disease and stroke
in women. Circulation 1995; 9:927
16.Stefanick ML, Mackey S, Sheehan M, Elsworth N,
Haskell WL, Wood PD – Effects of diet and exercises in men and postmenopausal women with low
levels of HDL cholesterol and high levels of LDL
Cholesterol. N. Engl. J. Med. 1998 2; 339(1): 12-20
17. King, AC; Haskell, WL; Young, DR; Oka, RK; Stefanick, ML – Long term effects, of varying intensities
and formats of physical activity on participation rates, fitness, and lipoproteins in men and women aged
50 to 65 years - Circulation. 1995; 91:2596-2604
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18. Paffenbarger, RS; Wing, AL; Hyde, RT. – Work activity and coronary heart mortality. N. Eng. J. Med.
292: 545, 1975
19.Wood, PD; Stefanick, ML; Dreon, DM; Frey-Hewitt,
Garay, SC; Williams, PT; Superko, HR; Fortmann,
SP; Albers, JJ; Vranizan, KM; Ellsworth, NM; Terry, RB; Haskell, WL. - Changes in plasma lipids,
and lipoproteins in overweight men during weight
loss through dieting and compared with exercise.
New Engl. J. Med. 1988,319(18): 1173-9
20. Wood PD, Stefanick ML, Williams PT, Haskell WL
- The effects on plasma lipoproteins of a prudent
weight-reducing diet, with or without exercise, in
overweight men and women. New England J. Med
325 (7): 461-66
21.Wood PD, Stefanick ML, Williams PT, Haskell WL
- The effects on plasma lipoproteins of a prudent
weight-reducing diet, with or without exercise, in
overweight men and women. New England J. Med
325 (7): 461-66
22. Fletcher, GF; Blair, SN; Blumenthal, J; Caspersen,
C; Chaitman, B; Epstein, S; Falls, H; Froelicher,
ESS; Froelicher, VF; Pina, IL. - Statement on Exercise - Benefits and Recommendations for physical
activity programs for all americans - A statement for
heath professionals by the Committee on Exercise
and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation 1992; 86(1): 340-343
24.Evenson, KR et. al. - Women’s Health Initiative Observational Cohort Study. Vigorous leisure activity
through womens’s adult life: the Women’s Health
Initiative Observational Cohort Study. Am. J. Epidemiol. 2002, 156 (10): 945-53.
25. Willams, PT - Phisical fitness and activity as separate heart disease risk factors: a metaanalysis. Med.
Sci. Sports Exerc. 2001, 33(5): 754-61.
26. Paffenbarger Jr., RS et. al. -– Physical activity, allcause mortlitiy, and logevity of college alumni. N.
Engl. J. Med. 1986, 314 (10):605-13.
27. Manson, JE et al. - A prospective study of walking
as compared with vigorous exercise in the prevention of coronary heart disease in women. N. Engl. J.
Med. 1999, 341 (9):650-8.
28. Manson, JE et al. - Walking compared with vigorous exercise in the prevention of cardiovascular events in women. N. Engl. J. Med. 1999, 347
(10):716-25.
29. Leon, AS et. al. - Leisure-time physical activity
levels and risk of coronary heart disease and death. The Multiple Risk Factor Interventional Trial.
JAMA 1987, 258 (17): 2388-95.
30.Nobre, MRC, Santos, LA; Fonseca, VR - Epidemiologia do risco cardiovascular associado à atividade física. In Cardiologia do Exercício - do atleta
ao cardiopata, Negrão CE & Barreto, ACP, Manole,
Barueri, SP, 2005, p.1.
23.III NCEP/2001 - Executive Summary on the Third
Report on National Cholesterol Education Program
(NCEP) Expert Panel on detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). JAMA 2001, 285
(19):2486-2497
47
HOW TO DO
Modified De Vega Tricuspid Valve Repair
Valvoplastia Tricúspide De Vega Modificada
Otoni Moreira Gomes, Márcio Pitchon
INTRODUÇÃO
De Vega, em 1972, demonstrou que o
tratamento da insuficiência valvar tricuspídea
poderia ser feito satisfatoriamente pela simples
constrição do contorno antero-lateral do anel da
valva tricúspide, praticamente excluindo a cirurgia
de implante valvar artificial nesta posição, mais
sujeita a tromboembolismo e endocardite que nas
demais.
O presente estudo descreve simplificação
da técnica original de De Vega, caracterizada
pela plicatura total apenas da metade posterior do
contorno ântero-lateral do anel valvar tricuspídeo.
CASUÍSTICA E MÉTODO
Foram estudados três pacientes portadores
de Cardiopatia Reumática, com dados gerais
descritos no Quadro I.
QUADRO I - DADOS GERAIS DOS PACIENTES
OBS.
N°
NOME
REG.
IDADE
/ ANOS
SEXO
DIAGNÓSTICO
GRUPO NYHA
DÉFICIT
MIOCÁRIDIO
1
RNP
160077
25
M
EM + INSUF. TRICÚSPIDE
IV
++++ / 4
2
RAO
154200
14
F
DLM + INSUF. TRICÚSPIDE
III
+++ / 4
3
SLS
190926
30
M
DLM + INSUF. TRICÚSPIDE
III
+++ / 4
Endereço para correspondência: Otoni M. Gomes
Fundação Cardiovascular São Francisco de Assis
Rua José do Patrocínio, 522 – Santa Mônica – 31525-160 – Belo Horizonte – MG / Brasil
E-mail: [email protected]
48
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As operações foram realizadas sob anestesia geral, toracotomia mediana anterior e com circulação
extracorpórea hipotérmica (Quadro II).
QUADRO II - DADOS GERAIS DA OPERAÇÃO
OBS.
N°
NOME
DATA
OPERAÇÃO
CEC
mm
T°C
CARDIOPLEGIA
OPERAÇÃO
PRÓTESE
1
RNP
20/04/83
39
29
HC UFMG-II
ANULOP. TRICÚSPIDE
COMISSUROTOMIA
MITRAL
____
2
RAO
12/09/84
101
26
HC UFMG-II
ANULOP. TRICÚSPIDE
TROCA MITRAL
PERICÁRDIO
FLVMEN
3
SLS
13/09/84
150
26
HC UFMG-II
ANULOP. TRICÚSPIDE
PERIACÁRDIO
FLVMEN
Estando os pacientes em circulação
extracorpórea, aberto o átrio direito e apresentada a
valva tricúspide, procedeu-se à plicatura da metade
posterior do contorno anterior do anel valvar,
empregando-se fio de poliester 3-0 com almofada
de dacron (Fig.1).
Fig.1
A correção da disfunção disfunção
tricúspide foi assim obtida, durante o tempo de
esfriamento corpóreo na CEC, estando o coração
ainda batendo.
Terminada a anuloplastia tricúspide e
atingida a temperatura corpórea desejada, a aorta
foi ocluída, a solução cardioplégica perfundida e as
demais valvas doentes tratadas.
RESULTADOS
O quadro III expõe os resultados obtidos,
concernentes à correção de valva tricúspide,
conforme observado na alta hospitalar e no último
controle ambulatorial.
Os pacientes RAO e SLS evoluíram sem
intercorrência e o paciente RNP recebeu alta do
CTI no 3º dia de pós-operatório, mas no 8º dia de
pós-operatório apresentou quadro compatível com
embolia pulmonar, complicada com pneumonia por
gram-negativo e necessitando de traqueostomia no
16º dia de pós-operatório. Recebeu alta no 45º dia de
pós-operatório em condições clínicas satisfatórias.
Além da disfunção das outras válvulas
corrigidas, notou-se completa recuperação clínica
das manifestações relativas à insuficiência tricúspide,
desaparecendo o pulso hepático, o sopro sistólico
característico e reduzindo-se significativamente o
éstase jugular.
49
QUADRO III - RESULTADOS
PRÉ-OPERATÓRIO
PÓS-OPERATÓRIO
OBS.
N°
SS-FT
GRUPO
NYHA.
FÍGADO
RCD
INGURGITAMENTO
JUGULAR
SS-FT
GRUPO
NYHA.
FÍGADO RCD
INGURGITAMENTO
JUGULAR
1
4/VI
IV
4,0cm
++++ /4
-
II
NÃO PALP.
____
2
4/VI
III
7,0cm
+++ /4
-
I
4,0cm
____
3
4/VI
III
7,5cm
+++/4
1/VI
II
4,0cm
____
COMENTÁRIOS
A correção da Insuficiência Tricúspide,
conforme proposta por De Vega, oferece resultados
eficientes, comprovados em vários centros
cardiológicos. Contudo, a preocupação com o
grau de constrição obtida, para evitar insuficiência
importante residual ou estenose por correção
excessiva, provavelmente tenha motivado as
modificações empregadas por CARPENTIER e por
DURAN, usando dispositivos semi-rígidos para
delimitar o diâmetro final da correção.
A técnica ora descrita, sendo eficaz, torna
mais simples e segura a operação, posto que a
plicadura sendo total, na extensão de 1/4 do anel,
prescinde de avaliações intra-operatórias do
diâmetro remanescente do orifício valvar.
50
ISSN 1809 - 3736
INSTRUCTIONS FOR AUTHORS
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No responsability is assumed by the Cardiovascular Sciences Forum Sponsor Institutions
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we recommend that the independent verification of diagnosis and drug dosages should be
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and drug dosages are the responsability of the
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Although all advertising material published in
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51
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Identify references in text in arabic numerals
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10.1
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10.1
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the chapter. Title of the chapter. In: Author (s)
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Edition (if not the first). City: Publisher, Year:
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10.1
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10.1
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ISSN 1809 - 3736
UPCOMING MEETINGS
53
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EDICOR Ltda.
John 1.1; 14.6; 17.17
60

N° 01 - Cardiovascular Sciences Forum

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