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Marcapasso Cardíaco

Dra. Denise Hachul, Cardiologia
Publicado em 19/09/2017 - Atualizado em 10/12/2018



ENTENDENDO O FUNCIONAMENTO DO CORAÇÃO

As contrações do músculo cardíaco são determinadas por estímulos elétricos, que se originam em um grupamento de células especiais,  localizadas no átrio direito, às quais denominamos de Nó Sinusal.

Essas células têm propriedades especiais, pois são capazes de gerar impulsos elétricos espontaneamente, por meio de entrada e saída de íons (substâncias com cargas elétricas), através de suas membranas.  

O Nó Sinusal é o nosso “marcapasso natural”, ou seja, é a estrutura que determina a frequência cardíaca e a regularidade do ritmo do coração, de acordo com as necessidades de nosso organismo.  Está conectado ao cérebro por meio de um sistema de fibras nervosas, denominado Sistema Nervoso Autônomo.

O Sistema Nervoso Autônomo é automático, ou seja, responde aos comandos cerebrais independentemente de nossa vontade, acelerando ou desacelerando a frequência cardíaca, para garantir o bom funcionamento do organismo.

A partir do Nó Sinusal, fibras do sistema de condução espalham-se pelos átrios, entremeadas no músculo atrial e confluem-se numa outra estrutura denominada “Nó Átrio-ventricular”,  localizado entre os Átrios e Ventrículos.  A transmissão elétrica então prossegue, por meio de fibras entremeadas no músculo ventricular, promovendo a contração dos ventrículos.

No Nó Átrio-ventricular ocorre uma leve desaceleração da condução elétrica, para que os átrios contraiam-se alguns instantes antes dos ventrículos, garantindo que o sangue seja impulsionado para frente e as válvulas cardíacas possam abrir e fechar em sincronia. Quando os átrios estão contraídos, os ventrículos estão relaxados e vice-versa.

O MARCAPASSO

O Marcapasso Cardíaco Artificial foi inventado na década de 30, mas somente 28 anos depois, o primeiro ser humano pode experimentar seus benefícios. Era um aparelho de grande porte, ao qual o paciente tinha que ficar conectado por meio de fios elétricos.

A partir de então, com o desenvolvimento tecnológico, esses dispositivos foram aperfeiçoados, miniaturizados, suas funções aprimoradas de forma exponencial, atingindo, na atualidade, características eletrônicas muito próximas às do Sistema de Condução elétrico normal do coração.  Passaram a ser implantáveis, permitindo mobilidade total ao seu portador.

TIPOS DE MARCAPASSO

Há diferentes tipos de Dispositivos Cardíacos Eletrônicos Implantáveis (DCEI) na atualidade, com alta tecnologia para o reconhecimento e correção, não somente de bradicardias, mas também de taquicardias.

Os DCEIs constituem-se de um gerador de pequeno porte, ligado a cabos eletrodos (uma espécie de fios com uma ponta especial). O gerador é implantado embaixo da pele, na maioria das vezes logo abaixo da clavícula esquerda, por meio de uma incisão cirúrgica de poucos centímetros de largura, feita com bisturi. Os eletrodos são introduzidos através das veias adjacentes e suas pontas fixadas no interior das câmaras do coração.

 

MARCAPASSOS ANTI-BRADICARDIAS

As doenças do Nó Sinusal, do Nó Átrio-ventricular e do sistema de condução elétrico em geral, podem provocar lentificações inapropriadas ou mesmo pausas dos estímulos elétricos, as chamadas Bradicardias

Quando uma Bradicardia prejudica a oxigenação cerebral e dos demais órgãos do nosso corpo, podem provocar sintomas como cansaço desproporcional ao esforço realizado, desfalecimentos, falta de ar, fraqueza generalizada, desmaios e até morte súbita.

Os DCEI podem ser programados eletronicamente de acordo com a necessidade de cada paciente, por meio de sistemas de telemetria computadorizados. Atualmente podem até ser chamados de dispositivos “inteligentes”.

Caso haja uma falha na geração ou condução do impulso elétrico, os eletrodos dos DCEIs reconhecem a ausência desse estímulo, conduzem essa informação para o gerador que, por sua vez, envia um estímulo elétrico até o músculo  cardíaco, por meio do próprio cabo eletrodo. Esse estímulo artificial, faz o coração se contrair, restabelecendo o bombeamento de sangue.

Quando as falhas são intermitentes, a ocorrência de um estímulo normal vindo do Nó Sinusal imediatamente inibe o gerador artificial.  No entanto, o marcapasso continua monitorando o ritmo, para atuar em caso de necessidade.  São as chamadas funções de estimulação artificial por demanda.

Quando as doenças do sistema de condução são definitivas, o paciente torna-se dependente do marcapasso, que atua de forma constante, mantendo as contrações do coração.

Ainda, os marcapassos inteligentes são capazes de gravar as arritmias dos pacientes, são capazes de aumentar ou diminuir a frequência de geração do estímulo elétrico, pois têm sensores de movimento, temperatura, contração muscular, etc. 

Tudo isso torna o portador de marcapasso apto para suas atividades habituais, sem prejuízo de sua qualidade de vida.

MARCAPASSOS ANTI-TAQUICARDIA OU CARDIO-DESFIBRILADORES IMPLANTÁVEIS (CDI)

Taquicardias são acelerações inapropriadas da frequência cardíaca. Vários são os tipos de taquicardias. Os Marcapassos anti-taquicardia são dispositivos utilizados para indivíduos que apresentam risco de morte súbita por um tipo específico de taquicardia, a fibrilação ventricular (um ritmo caótico, muito rápido, originado nos ventrículos, que inviabiliza o bombeamento de sangue para o cérebro e corpo).

A fibrilação ventricular pode ocorrer em portadores de doenças do coração, como por exemplo: infarto do miocárdio, Doença de Chagas, inflamações, cicatrizes, dilatações, enfraquecimento muscular, doenças elétricas puras e geneticamente determinadas, entre outras.

O eletrodo do CDI, fixado no interior do ventrículo, “reconhece” uma arritmia ventricular e conduz essa informação, por meio do cabo, para o gerador.  Este, por sua vez,  libera estímulos elétricos bastante rápidos. Caso não consiga a reversão e o ritmo se degenerar em fibrilação ventricular, o gerador descarrega um “choque elétrico” de pequena voltagem diretamente sobre o músculo cardíaco, cujo objetivo é causar a interrupção da atividade caótica, para que o Nó Sinusal possa reiniciar o ritmo normal.

Os CDIs  são indicados para pacientes considerados de alto risco para morte súbita. Permanecem conectados continuadamente ao coração e possibilitando a reversão de arritmias malignas, antes que provoquem sequelas irreversíveis ou morte.  

RESSINCRONIZADORES CARDÍACOS

Os ressincronizadores cardíacos são DCEI indicados para pacientes com dilatação e enfraquecimento da força muscular do coração, que apresentam também bloqueios do sistema de condução elétrico. Esses bloqueios provocam dessincronia na contração dos dois ventrículos, o que agrava a disfunção da bomba cardíaca.

Cabos eletrodos são posicionados em ambos os ventrículos e, por meio de estímulos elétricos simultâneos, liberados pelo gerador, restabelecem  a sincronia da contração bi-ventricular, melhorando a efetividade do bombeamento do sangue.

Ainda, há DCEIs que contém as três funções: antibradicardia, de desfibrilação e de ressincronização, para pacientes portadores concomitantemente de bradiarritmias, disfunções musculares importantes, bloqueios de ramo e alto risco de morte súbita. 

O desenvolvimento crescente dos DCEI,  vem aumentando a sobrevida de portadores de insuficiência cardíaca, tem evitado muitas mortes súbitas e especialmente, melhorado a qualidade de vida dos pacientes.

Desde que bem indicados, adequadamente implantados e programados eletronicamente por profissionais qualificados, esses dispositivos tornaram-se nossos grandes aliados.

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