GERMANO EMILIO CONCEICAO SOUZA
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- Mode of Death on Chagas Heart Disease: Comparison with Other Etiologies. A Subanalysis of the REMADHE Prospective Trial(2013) AYUB-FERREIRA, Silvia M.; MANGINI, Sandrigo; ISSA, Victor S.; CRUZ, Fatima D.; BACAL, Fernando; GUIMARAES, Guilherme V.; CHIZZOLA, Paulo R.; CONCEICAO-SOUZA, Germano E.; MARCONDES-BRAGA, Fabiana G.; BOCCHI, Edimar A.Background: Sudden death has been considered the main cause of death in patients with Chagas heart disease. Nevertheless, this information comes from a period before the introduction of drugs that changed the natural history of heart failure. We sought to study the mode of death of patients with heart failure caused by Chagas heart disease, comparing with non-Chagas cardiomyopathy. Methods and results: We examined the REMADHE trial and grouped patients according to etiology (Chagas vs non-Chagas) and mode of death. The primary end-point was all-cause, heart failure and sudden death mortality; 342 patients were analyzed and 185 (54.1%) died. Death occurred in 56.4% Chagas patients and 53.7% non-Chagas patients. The cumulative incidence of all-cause mortality and heart failure mortality was significantly higher in Chagas patients compared to non-Chagas. There was no difference in the cumulative incidence of sudden death mortality between the two groups. In the Cox regression model, Chagas etiology (HR 2.76; CI 1.34-5.69; p = 0.006), LVEDD (left ventricular end diastolic diameter) (HR 1.07; CI 1.04-1.10; p<0.001), creatinine clearance (HR 0.98; CI 0.97-0.99; p = 0.006) and use of amiodarone (HR 3.05; CI 1.47-6.34; p = 0.003) were independently associated with heart failure mortality. LVEDD (HR 1.04; CI 1.01-1.07; p = 0.005) and use of beta-blocker (HR 0.52; CI 0.34-0.94; p = 0.014) were independently associated with sudden death mortality. Conclusions: In severe Chagas heart disease, progressive heart failure is the most important mode of death. These data challenge the current understanding of Chagas heart disease and may have implications in the selection of treatment choices, considering the mode of death.
- Hypertonic saline solution for prevention of renal dysfunction in patients with decompensated heart failure(2013) ISSA, Victor S.; ANDRADE, Lucia; AYUB-FERREIRA, Silvia M.; BACAL, Fernando; BRAGANCA, Ana C. de; GUIMARAES, Guilherme V.; MARCONDES-BRAGA, Fabiana G.; CRUZ, Fatima D.; CHIZZOLA, Paulo R.; CONCEICAO-SOUZA, Germano E.; VELASCO, Irineu T.; BOCCHI, Edimar A.Background: Renal dysfunction is associated with increased mortality in patients with decompensated heart failure. However, interventions targeted to prevention in this setting have been disappointing. We investigated the effects of hypertonic saline solution (HSS) for prevention of renal dysfunction in decompensated heart failure. Methods: In a double-blind randomized trial, patients with decompensated heart failure were assigned to receive three-day course of 100 mL HSS (NaCl 7.5%) twice daily or placebo. Primary end point was an increase in serumcreatinine of 0.3 mg/dL or more. Main secondary end point was change in biomarkers of renal function, including serum levels of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin-NGAL and the urinary excretion of aquaporin 2 (AQP(2)), urea transporter (UT-A(1)), and sodium/hydrogen exchanger 3 (NHE3). Results: Twenty-two patients were assigned to HSS and 12 to placebo. Primary end point occurred in two (10%) patients in HSS group and six (50%) in placebo group (relative risk 0.3; 95% CI 0.09-0.98; P=0.01). Relative to baseline, serum creatinine and cystatin C levels were lower in HSS as compared to placebo (P=0.004 and 0.03, respectively). NGAL level was not statistically different between groups, however the urinary expression of AQP2, UT-A1 and NHE3 was significantly higher in HSS than in placebo. Conclusions: HSS administration attenuated heart failure-induced kidney dysfunction as indicated by improvement in both glomerular and tubular defects, a finding with important clinical implications. HSS modulated the expression of tubular proteins involved in regulation of water and electrolyte homeostasis.
- Prognosis and risk stratification in patients with decompensated heart failure receiving inotropic therapy(2018) GOMES, Clara; TERHOCH, Caique Bueno; AYUB-FERREIRA, Silvia Moreira; CONCEICAO-SOUZA, Germano Emilio; SALEMI, Vera Maria Cury; CHIZZOLA, Paulo Roberto; JR, Mucio Tavares Oliveira; LAGE, Silvia Helena Gelas; FRIOES, Fernando; BOCCHI, Edimar Alcides; ISSA, Victor SarliObjectives The prognostic significance of transient use of inotropes has been sufficiently studied in recent heart failure (HF) populations. We hypothesised that risk stratification in these patients could contribute to patient selection for advanced therapies. Methods We analysed a prospective cohort of adult patients admitted with decompensated HF and ejection fraction (left ventricular ejection fraction (LVEF)) less than 50%. We explored the outcomes of patients requiring inotropic therapy during hospital admission and after discharge. Results The study included 737 patients, (64.0% male), with a median age of 58 years (IQR 48-66 years). Main aetiologies were dilated cardiomyopathy in 273 (37.0%) patients, ischaemic heart disease in 195 (26.5%) patients and Chagas disease in 163 (22.1%) patients. Median LVEF was 26 % (IQR 22%-35%). Inotropes were used in 518 (70.3%) patients. In 431 (83.2%) patients, a single inotrope was administered. Inotropic therapy was associated with higher risk of in-hospital death/urgent heart transplant (OR=10.628, 95% CI 5.055 to 22.344, p<0.001). At 180-day follow-up, of the 431 patients discharged home, 39 (9.0%) died, 21 (4.9%) underwent transplantation and 183 (42.4%) were readmitted. Inotropes were not associated with outcome (death, transplant and rehospitalisation) after discharge. Conclusions Inotropic drugs are still widely used in patients with advanced decompensated HF and are associated with a worse in-hospital prognosis. In contrast with previous results, intermittent use of inotropes during hospitalisation did not determine a worse prognosis at 180-day follow-up. These data may add to prognostic evaluation in patients with advanced HF in centres where mechanical circulatory support is not broadly available.
- Diretriz de Assistência Circulatória Mecânica da Sociedade Brasileira de Cardiologia(2016) AYUB-FERREIRA, Silvia Moreira; SOUZA NETO, Joao David de; ALMEIDA, Dirceu Rodrigues; BISELLI, Bruno; AVILA, Monica Samuel; COLAFRANCESCHI, Alexandre Siciliano; STEFANELLO, Bianca; CARVALHO, Braulio Matias de; POLANCZYK, Carisi Anne; GALANTINI, Danilo Ribeiro; BOCCHI, Edimar Alcides; CHAMLIAN, Eduardo Gregorio; HOJAIJ, Elaine Marques; GAIOTTO, Fabio Antonio; PINTON, Fabio Augusto; JATENE, Fabio Biscegli; RAMIRES, Felix Jose Alvarez; ATIK, Fernando Antibas; FIGUEIRA, Fernando; BACAL, Fernando; GALAS, Filomena Regina Barbosa Gomes; BRITO, Flavio de Souza; CONCEICAO-SOUZA, Germano Emilio; RIBEIRO, Gustavo Calado de Aguiar; PINHEIRO JUNIOR, Jairo Alves; SOUZA, Januario Manoel de; ROSSI NETO, Joao Manoel; LIMA, Jose Lindemberg da Costa; MEJIA, Juan Cosquillo; FERNANDES, Juliana Rolim; BAUMWORCEL, Leonardo; MOURA, Lidia Ana Zytynski; HAJJAR, Ludhmila Abrahao; BECK-DA-SILVA, Luis; ROHDE, Luis Eduardo Paim; SEGURO, Luis Fernando Bernal da Costa; PINHEIRO, Mabel Leite; PARK, Marcelo; FERNANDES, Marcelo Ramalho; MONTERA, Marcelo Westerlund; ALVES, Marco Stephan Lofrano; WANDERLEY JUNIOR, Mauro Rogerio de Barros; HOSSNE, Nelson; FERNANDES, Paulo Manuel Pego; LEMOS, Pedro; SCHNEIDEWIND, Rafael Otto; UCHOA, Ricardo Barreira; HONORATO, Ronaldo; MANGINI, Sandrigo; FALCAO, Sandra Nivea dos Reis Saraiva; LOPES, Sergio Augusto Veiga; STRABELLI, Tania Mara Varejao; GUIMARAES, Tereza Cristina Felippe; CAMPANILI, Ticiane Carolina Goncalves Faustino; ISSA, Victor Sarli
- Renal denervation in patients with heart failure secondary to Chagas' disease: A pilot randomized controlled trial(2019) SPADARO, Andre G.; BOCCHI, Edimar A.; SOUZA, Germano E.; FILHO, Antonio E.; MARIANI JR., Jose; CAMPOS, Carlos M.; LEMOS, Pedro A.Introduction Chagas disease is one of the most relevant endemic parasitic diseases in Latin America, affecting approximately 6 million people. Overt Chagas heart disease is an ominous condition, occurring in 20-30% of infected individuals, which has besides the persistent myocarditis a peculiar intracardiac ganglionic neuronal depletion and dysautonomy. This study aims to evaluate the safety and feasibility of renal denervation for patients with advanced symptomatic Chagas cardiomyopathy. Methods Open-label prospective pilot study that randomized patients with Chagas heart disease to either renal denervation or conservative treatment (2:1 ratio). The primary endpoint was the incidence of major adverse events at 9 months, defined as a composite of all-cause death, myocardial infarction, stroke, need for renal artery invasive treatment, or worsening renal function. Results A total of 17 patients were allocated for renal denervation (n = 11) or conservative treatment (n = 6). Included patients had severe symptomatic heart disease, with markedly depressed left ventricular function (average ejection fraction 26.7 +/- 4.9%). For patients randomized to renal denervation, the procedure was performed successfully and uneventfully. After 9 months, the primary endpoint occurred in 36.4% of patients in the renal denervation group and 50.0% in the control arm (p = .6). After 9 months, clinical, laboratory, functional, echocardiographic, and quality of life parameters were similar between groups. Conclusions This pilot study suggests that renal denervation is safe and feasible in patients with Chagas cardiomyopathy, warranting future studies to better evaluate the clinical efficacy of the interventional strategy in improving the prognosis of this high-risk population.
- Left cardiac sympathetic denervation for treatment of symptomatic systolic heart failure patients: a pilot study(2012) CONCEICAO-SOUZA, Germano Emilio; PEGO-FERNANDES, Paulo Manuel; CRUZ, Fatima das Dores; GUIMARAES, Guilherme Veiga; BACAL, Fernando; VIEIRA, Marcelo Luiz Campos; GRUPI, Cesar Jose; GIORGI, Maria Clementina Pinto; CONSOLIM-COLOMBO, Fernanda Marciano; NEGRAO, Carlos Eduardo; RONDON, Maria Urbana P.; MOREIRA, Luiz Felipe Pinho; BOCCHI, Edimar AlcidesTo evaluate the feasibility, safety, and potential beneficial effects of left cardiac sympathetic denervation (LCSD) in systolic heart failure (HF) patients. In this prospective, randomized pilot study, inclusion criteria were New York Heart Association (NYHA) functional class II or III, left ventricular ejection fraction (LVEF) 40, sinus rhythm, and resting heart rate 65 b.p.m., despite optimal medical therapy (MT). Fifteen patients were randomly assigned either to MT alone or MT plus LCSD. The primary endpoint was safety, measured by mortality in the first month of follow-up and morbidity according to pre-specified criteria. Secondary endpoints were exercise capacity, quality of life, LVEF, muscle sympathetic nerve activity (MSNA), brain natriuretic peptide (BNP) levels and 24 h Holter mean heart rate before and after 6 months. We studied clinical effects in long-term follow-up. Ten patients underwent LCSD. There were no adverse events attributable to surgery. In the LCSD group, LVEF improved from 25 6.6 to 33 5.2 (P 0.03); 6 min walking distance improved from 167 35 to 198 47 m (P 0.02). Minnesota Living with Heart Failure Questionnaire (MLWHFQ) score physical dimension changed from 21 5 to 15 7 (P 0.06). The remaining analysed variables were unchanged. During 848 549 days of follow-up, in the MT group, three patients either died or underwent cardiac transplantation (CT), while in the LCSD group six were alive without CT. LCSD was feasible and seemed to be safe in systolic HF patients. Its beneficial effects warrant the development of a larger randomized trial. Trail registration: NCT01224899.
- Clinical findings and prognosis of patients hospitalized for acute decompensated heart failure: Analysis of the influence of Chagas etiology and ventricular function(2018) TERHOCH, Caique Bueno; MOREIRA, Henry Fukuda; AYUB-FERREIRA, Silvia Moreira; CONCEICAO-SOUZA, Germano Emilio; SALEMI, Vera Maria Cury; CHIZZOLA, Paulo Roberto; OLIVEIRA JR., Mucio Tavares; LAGE, Silvia Helena Gelas; BOCCHI, Edimar Alcides; ISSA, Victor SarliAims Explore the association between clinical findings and prognosis in patients with acute decompensated heart failure (ADHF) and analyze the influence of etiology on clinical presentation and prognosis. Methods and results Prospective cohort of 500 patients admitted with ADHF from Aug/2013-Feb/2016; patients were predominantly male (61.8%), median age was 58 (IQ(25-75%) 47-66 years); etiology was dilated cardiomyopathy in 141 (28.2%), ischemic heart disease in 137 (27.4%), and Chagas heart disease in 113 (22.6%). Patients who died (154 [30.8%]) or underwent heart transplantation (53[10.6%]) were younger (56 years [IQ(25-75%) 45-64 vs 60 years, IQ(25-75%) 4967], P=0.032), more frequently admitted for cardiogenic shock (20.3% vs 6.8%, P<0.001), had longer duration of symptoms (14 days [IQ(25-75%) 4-32.8 vs 7.5 days, IQ(25-75%) 2-31], P=0.004), had signs of congestion (90.8% vs 76.5%, P<0.001) and inadequate perfusion more frequently (45.9% vs 28%, P<0.001), and had lower blood pressure (90 [IQ(25-75%) 80-100 vs 100, IQ(25-75%) 90-120], P<0.001). In a logistic regression model analysis, systolic blood pressure (P<0.001, OR 0.97 [95% CI 10.96-0.98] per mmHg) and jugular distention (P=0.004, OR 1.923 [95% CI 1.232-3.001]) were significant. Chagas patients were more frequently admitted for cardiogenic shock (15%) and syncope/arrhythmia (20.4%). Pulmonary congestion was rare among Chagas patients and blood pressure was lower. The rate of in hospital death or heart transplant was higher among patients with Chagas (50.5%). Conclusions A physical exam may identify patients at higher risk in a contemporaneous population. Our findings support specific therapies targeted at Chagas patients in the setting of ADHF.
- Clinical Usefulness of Coronary Angiography in Patients with Left Ventricular Dysfunction(2012) MELO, Rodrigo Morel Vieira de; MELO, Eduardo Franca Pessoa de; BISELLI, Bruno; SOUZA, Germano Emilio Conceicao; BOCCHI, Edimar AlcidesBackground: Performing a coronary angiography in patients with heart failure of unknown etiology is often justified by the diagnostic assessment of ischemic heart disease. However, the clinical benefit of this strategy is not known. Objective: To evaluate the prevalence of ischemic heart disease by angiographic criteria in patients with heart failure and reduced ejection fraction of unknown etiology, as well as its impact on therapy decisions. Methods: Consecutive outpatients with heart failure and systolic dysfunction, who had an indication for coronary angiography to clarify the etiology of heart disease were assessed from 1 January 2009 to December 31, 2010. Patients diagnosed with coronary artery disease, positive serology for Chagas disease, congenital heart disease, valve disease or patients undergoing cardiac transplantation were excluded from the analysis. The sample was divided into two groups according to the indication for catheterization. Group-1: Symptomatic due to angina or heart failure. Group-2: Presence of >= 2 risk factors for coronary artery disease Results: One hundred and seven patients were included in the analysis, with 51 (47.7%) patients in Group 1 and 56 (52.3%) in Group 2. The prevalence of ischemic heart disease was 9.3% (10 patients), and all belonged to Group 1 (p = 0.0001). During follow-up, only 4 (3.7%) were referred for CABG; 3 (2.8%) patients had procedure-related complications. Conclusion: In our study, coronary angiography in patients with heart failure and systolic dysfunction of unknown etiology, although supported by current guidelines, did not show benefits when performed only due to the presence of risk factors for coronary artery disease. (Arq Bras Cardiol 2012;98(5):437-441)
- Brazilian Guideline for Chronic and Acute Heart Failure(2018) ROHDE, Luis Eduardo Paim; MONTERA, Marcelo Westerlund; BOCCHI, Edimar Alcides; CLAUSELL, Nadine Oliveira; ALBUQUERQUE, Denilson Campos de; RASSI, Salvador; COLAFRANCESCHI, Alexandre Siciliano; FREITAS JUNIOR, Aguinaldo Figueiredo de; FERRAZ, Almir Sergio; BIOLO, Andreia; BARRETTO, Antonio C. Pereira; RIBEIRO, Antonio Luiz Pinho; POLANCZYK, Carisi Anne; GUALANDRO, Danielle Menosi; ALMEIDA, Dirceu Rodrigues; SILVA, Eneida Rejane Rabelo da; FIGUEIREDO, Estevao Lanna; MESQUITA, Evandro Tinoco; MARCONDES-BRAGA, Fabiana G.; CRUZ, Fatima Das Dores da; RAMIRES, Felix Jose Alvarez; ATIK, Fernando Antibas; BACAL, Fernando; SOUZA, Germano Emilio Conceicao; ALMEIDA JUNIOR, Gustavo Luiz Gouvea de; RIBEIRO, Gustavo Calado de Aguiar; VILLACORTA JUNIOR, Humberto; VIEIRA, Jefferson Luis; SOUZA NETO, Joao David de; ROSSI NETO, Joao Manoel; FIGUEIREDO NETO, Jose Albuquerque de; MOURA, Lidia Ana Zytynsky; GOLDRAICH, Livia Adams; BECK-DA-SILVA, Luis; DANZMANN, Luiz Claudio; CANESIN, Manoel Fernandes; BITTENCOURT, Marcelo Imbroinise; GARCIA, Marcelo Iorio; BONATTO, Marcely Gimenes; SIMOES, Marcus Vinicius; MOREIRA, Maria da Consolacao Vieira; SILVA, Miguel Morita Fernandes da; OLIVERA JUNIOR, Mucio Tavares de; SILVESTRE, Odilson Marcos; SCHWARTZMANN, Pedro Vellosa; BESTETTI, Reinaldo Bulgarelli; ROCHA, Ricardo Mourilhe; SIMOES, Ricardo; PEREIRA, Sabrina Bernardez; MANGINI, Sandrigo; ALVES, Silvia Marinho Martins; FERREIRA, Silvia Moreira Ayub; ISSA, Victor Sarli; BARZILAI, Vitor Salvatore; MARTINS, Wolney de Andrade
article Brazilian Guideline for Chronic and Acute Heart Failure (vol 111, pg 436, 2018)(2019) ROHDE, Luis Eduardo Paim; MONTERA, Marcelo Westerlund; BOCCHI, Edimar Alcides; CLAUSELL, Nadine Oliveira; ALBUQUERQUE, Denilson Campos de; RASSI, Salvador; COLAFRANCESCHI, Alexandre Siciliano; JUNIOR, Aguinaldo Figueiredo de Freitas; FERRAZ, Almir Sergio; BIOLO, Andreia; BARRETTO, Antonio C. Pereira; RIBEIRO, Antonio Luiz Pinho; POLANCZYK, Carisi Anne; GUALANDRO, Danielle Menosi; ALMEIDA, Dirceu Rodrigues; SILVA, Eneida Rejane Rabelo da; FIGUEIREDO, Estevao Lanna; MESQUITA, Evandro Tinoco; MARCONDES-BRAGA, Fabiana G.; CRUZ, Fatima das Dores da; RAMIRES, Felix Jose Alvarez; ATIK, Fernando Antibas; BACAL, Fernando; SOUZA, Germano Emilio Conceicao; JUNIOR, Gustavo Luiz Gouvea de Almeida; RIBEIRO, Gustavo Calado de Aguiar; JUNIOR, Humberto Villacorta; VIEIRA, Jefferson Luis; FERREIRA, Silvia Moreira Ayub; ISSA, Victor Sarli; NETO, Joao David de Souza; NETO, Joao Manoel Rossi; NETO, Jose Albuquerque de Figueiredo; MOURA, Lidia Ana Zytynsky; GOLDRAICH, Livia Adams; BECK-DASILVA, Luis; DANZMANN, Luiz Claudio; CANESIN, Manoel Fernandes; BITTENCOURT, Marcelo Imbroinise; GARCIA, Marcelo Iorio; BONATTO, Marcely Gimenes; SIMOES, Marcus Vinicius; MOREIRA, Maria da Consolacao Vieira; SILVA, Miguel Morita Fernandes da; JUNIOR, Mucio Tavares de Olivera; SILVESTRE, Odilson Marcos; SCHWARTZMANN, Pedro Vellosa; BESTETTI, Reinaldo Bulgarelli; ROCHA, Ricardo Mourilhe; SIMOES, Ricardo; PEREIRA, Sabrina Bernardez; MANGINI, Sandrigo; ALVES, Silvia Marinho Martins; BARZILAI, Vitor Salvatore; MARTINS, Wolney de Andrade