Marcelo Basso Gazzana

Pulmonary arterial hypertension (PAH) is a condition that predominantly affects the pulmonary arterial bed, leading to pulmonary vascular remodeling, progressive decrease in pulmonary arterial compliance, and increase in pulmonary vascular resistance. The symptoms of PAH are nonspecific, which often contributes to diagnostic challenges and significant delays in establishing the diagnosis. The investigation of PAH is extensive and involves thorough search for potential clinical conditions that may contribute to its development, as well as the exclusion of other causes of pulmonary hypertension. The proper hemodynamic definition of PAH requires right heart catheterization (RHC) and direct measurements of mean pulmonary artery pressure, pulmonary arterial wedge pressure, cardiac output, and pulmonary vascular resistance. Additionally, RHC allows the assessment of the severity of the disease and, in selected cases, the identification of patients with a positive pulmonary vascular vasoreactivity test. RHC also provides valuable longitudinal information for risk stratification and patient follow-up. In the current manuscript, we review the PAH diagnostic workup, including a detailed review of the most up-to-date recommendations for right RHC and patient risk stratification.

Background/Objectives: Venous thromboembolism (VTE) is a common and potentially fatal condition in hospitalized patients. Although appropriate risk assessment and prophylaxis reduce VTE events, preventive measures remain underutilized. This study aimed to evaluate the effectiveness of an electronic risk stratification tool within multifaceted interventions for implementing VTE prophylaxis protocols in adult clinical and surgical patients at Hospital Moinhos de Vento, Brazil. Methods: A prospective before-and-after hospital-based study was conducted from 2017 to 2019, including 772 patients admitted to clinical and surgical units for over 48 h. The electronic tool based on the Maynard risk assessment model classified patients’ VTE risk. Padua and Caprini scores served as reference standards for clinical and surgical patients, respectively. Prophylaxis was considered adequate if it complied with institutional protocols. Results: Globally, the Maynard model classified 0.9% as low risk, 76.4% intermediate, and 22.7% high risk, differing notably in orthopedic surgical patients. Overall prophylaxis adequacy was 69.3%, with no significant difference between phases. Orthopedic surgical patients showed a significant decrease in prophylaxis adequacy in phase 2 (p = 0.02). Conclusions: The Maynard model underestimated high-risk classification compared to Padua and Caprini scores, especially in orthopedic surgical patients. Implementation of the electronic tool alongside multifaceted interventions did not improve prophylaxis adequacy.

A insuficiência cardíaca direita (ICD) é uma condição grave caracterizada pela falência do ventrículo direito em gerar débito suficiente para a circulação pulmonar, resultando em congestão sistêmica e hipoperfusão. O manejo adequado da ICD é essencial para melhorar prognóstico e qualidade de vida, sendo necessário um tratamento individualizado baseado na avaliação hemodinâmica. Este artigo revisa fisiopatologia, diagnóstico e opções terapêuticas para a ICD, incluindo estratégias de otimização da pré-carga, redução da pós-carga e suporte circulatório avançado. Além disso, apresenta-se um caso clínico de uma paciente com ICD grave secundária a tromboembolismo pulmonar crônico e insuficiência tricúspide primária tratada com abordagem híbrida envolvendo angioplastia pulmonar por balão e tromboendarterectomia pulmonar associada a plastia valvar cirúrgica, resultando em melhora funcional significativa. Esta revisão reforça a importância de estratégias personalizadas e terapias combinadas na abordagem da ICD avançada.

Right heart failure (RHF) is a serious condition characterized by the inability of the right ventricle (RV) to generate sufficient output for pulmonary circulation, leading to systemic congestion and hypoperfusion. Proper management of RHF is essential to improve prognosis and quality of life, requiring individualized treatment based on hemodynamic assessment. This article reviews pathophysiology, diagnosis, and therapeutic options for RHF, including strategies for preload optimization, afterload reduction, and advanced circulatory support. Additionally, it presents a clinical case of a [...] Abstract Right heart failure (RHF) is a serious condition characterized by the inability of the right ventricle (RV) to generate sufficient output for pulmonary circulation, leading to systemic congestion and hypoperfusion. Proper management of RHF is essential to improve prognosis and quality of life, requiring individualized treatment based on hemodynamic assessment. This article reviews pathophysiology, diagnosis, and therapeutic options for RHF, including strategies for preload optimization, afterload reduction, and advanced circulatory support. Additionally, it presents a clinical case of a

Venous thromboembolism (VTE) is the third most common acute cardiovascular syndrome after acute myocardial infarction and stroke. In recent years, there has been an increase in the incidence of VTE, related to population aging and common comorbidities in the elderly, including chronic cardiorespiratory disease and cancer. On the other hand, disease-related mortality, particularly for pulmonary embolism (PE), shows a decreasing trend, which can be explained by improvements in diagnostic imaging, advances in available therapies, and greater adherence to patient management protocols. The guidelines presented here provide recommendations for the pharmacological treatment of PE in Brazil, on the basis of scientific evidence and with a focus on common practical issues. Six Patient, Intervention, Comparison, and Outcome questions were developed by a group of experts on the topic. Systematic reviews of randomized clinical trials were conducted for each question, with meta-analyses being performed when possible. The level of evidence and strength of recommendation were defined in accordance with the Grading of Recommendations Assessment, Development, and Evaluation approach. With these guidelines, we expect to provide relevant, up-to-date information on the pharmacological treatment of PE.

Objective: To assess the prevalence and type of residual lung abnormalities on chest computed tomography (CT) and pulmonary function testing (PFT) variables in patients with respiratory symptoms related to post-COVID-19 condition at 12 months of follow-up, and to analyze associations between CT findings and PFT parameters. Materials and Methods: The CT findings were evaluated by two radiologists, who calculated semiquantitative CT scores. The PFTs included spirometry, plethysmography, and the diffusing capacity of the lung for carbon monoxide. Results: Thirty-seven patients were included in the study. On CT scans of the chest acquired at 12 months of follow-up, 78.3% of the patients exhibited residual abnormalities, including reticular opacities, in 75.7%; traction bronchiectasis/bronchiolectasis, in 43.2%; and fibrosis-like findings, in 43.2%. The mean overall CT score was 9.30 ± 2.59. Patients with fibrosis-like findings had significantly lower total lung capacity (68.6% vs. 80.6% of the predicted value; p = 0.018). A moderate negative correlation was found between the overall CT score and total lung capacity (rs = −0.49; p = 0.003). Conclusion: It seems that a significant proportion of patients with respiratory symptoms related to post–COVID-19 condition demonstrate residual lung abnormalities on chest CT at 12 months of follow-up, with a substantial prevalence of fibrosis-like findings. Such abnormalities are associated with restrictive lung disease.

Objective: To investigate the impact of impaired pulmonary function on patient-centered outcomes after hospital discharge due to severe COVID-19 in patients without preexisting respiratory disease. Methods: This is an ongoing prospective cohort study evaluating patients (> 18 years of age) 2-6 months after hospital discharge due to severe COVID-19. Respiratory symptoms, health-related quality of life, lung function, and the six-minute walk test were assessed. A restrictive ventilatory defect was defined as TLC below the lower limit of normal, as assessed by plethysmography. Chest CT scans performed during hospitalization were scored for the presence and extent of parenchymal abnormalities. Results: At a mean follow-up of 17.2 ± 5.9 weeks after the diagnosis of COVID-19, 120 patients were assessed. Of those, 23 (19.2%) reported preexisting chronic respiratory diseases and presented with worse lung function and exertional dyspnea at the follow-up visit in comparison with their counterparts. When we excluded the 23 patients with preexisting respiratory disease plus another 2 patients without lung volume measurements, a restrictive ventilatory defect was observed in 42/95 patients (44%). This subgroup of patients (52.4% of whom were male; mean age, 53.9 ± 11.3 years) showed reduced resting gas exchange efficiency (DLCO), increased daily-life dyspnea, increased exertional dyspnea and oxygen desaturation, and reduced health-related quality of life in comparison with those without reduced TLC (50.9% of whom were male; mean age, 58.4 ± 11.3 years). Intensive care need and higher chest CT scores were associated with a subsequent restrictive ventilatory defect. Conclusions: The presence of a restrictive ventilatory defect approximately 4 months after severe COVID-19 in patients without prior respiratory comorbidities implies worse clinical outcomes.

Chronic unexplained dyspnea and exercise intolerance represent common, distressing symptoms in outpatients. Clinical history taking and physical examination are the mainstays for diagnostic evaluation. However, the cause of dyspnea may remain elusive even after comprehensive diagnostic evaluation-basic laboratory analyses; chest imaging; pulmonary function testing; and cardiac testing. At that point (and frequently before), patients are usually referred to a pulmonologist, who is expected to be the main physician to solve this conundrum. In this context, cardiopulmonary exercise testing (CPET), to assess physiological and sensory responses from rest to peak exercise, provides a unique opportunity to unmask the mechanisms of the underlying dyspnea and their interactions with a broad spectrum of disorders. However, CPET is underused in clinical practice, possibly due to operational issues (equipment costs, limited availability, and poor remuneration) and limited medical education regarding the method. To counter the latter shortcoming, we aspire to provide a pragmatic strategy for interpreting CPET results. Clustering findings of exercise response allows the characterization of patterns that permit the clinician to narrow the list of possible diagnoses rather than pinpointing a specific etiology. We present a proposal for a diagnostic workup and some illustrative cases assessed by CPET. Given that airway hyperresponsiveness and pulmonary vascular disorders, which are within the purview of pulmonology, are common causes of chronic unexplained dyspnea, we also aim to describe the role of bronchial challenge tests and the diagnostic reasoning for investigating the pulmonary circulation in this context.