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



 
 
     
    
!
"   #"$   % 
&'


Botucatu - SP
2007
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FICHA CATALOGRÁFICA ELABORADA PELA SEÇÃO TÉCNICA DE AQUISIÇÃO E TRATAMENTO
DA INFORMAÇÃO
DIVISÃO TÉCNICA DE BIBLIOTECA E DOCUMENTAÇÃO - CAMPUS DE BOTUCATU - UNESP
Bibliotecária responsável: Selma Maria de Jesus
Zanati, Silméia Garcia.
Alterações estruturais e funcionais cardíacas em gestantes com hipertensão arterial
sistêmica / Silméia Garcia Zanati. - Botucatu : [s.n.], 2007.
Tese (doutorado) - Faculdade de Medicina de Botucatu, Universidade Estadual
Paulista, 2007.
Orientador: Beatriz B. Matsubara
Assunto CAPES: 40101002
1. Gravidez - Complicações e seqüelas 2. Hipertensão na gravidez
CDD 616.132
CDD 618.32
Palavras chave: Doppler-ecocardiograma; Função ventricular esquerda; Gestação;
Hipertensão arterial; Hipertrofia miocárdica.
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

  

  
      

    
   

   

  

  
 
  
 
 
     
 
! !   
 
 "#   $ 
    %  
   &  % !
'(       
%     
 )%  $   
 
 
*   + 
  %
,   (  
-
 
 (
     .
/& '0123+ 4 
  
       !
" #!   $  %     

    )% 
/  &   ' 0 123+ 4   &
'( !!) !! 
!*+ !$ 
(%
    . & 5 / 
& '0123+  * !!&
, -#
 5.6.
/& '4!
!!-*-
 (
 '* !.
) 
  1  7 8 
6  .  /  &   '
123+ 4) ! $

  +  -#8 
123+ # '4 , !   
 

 -#8.& 5
 
   /   

     -#8
/ . & 5  /  &  
'123+ 
%%'%/& 
'123+ 4   %

!  % 

     
     %
       ( 
 
  
$/4/ 3+ 
9::;<:=;>:#?
 


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*'+''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''',
-'.%/!''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(0
1''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(*
1'(''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(-
1'('( &2'''''''''''''''''''''''''''''''''''''''''''''''''(-
1'('* 32'''''''''''''''''''''''''''''''''''(-
1'('- $!''''''''''''''''''''''''''''''''''''''''''''''(1
1'('1 ''''''''''''''''''''''''''''''''''''''''''''''''(1
1'('4 5'''''''''''''''''''''''''''''''''''''''''''''''(4
1'* ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(6
1'*'( 7!'''''''''''''''''''''''''''''''''''''''''''''''''''''(6
1'*'* 7!%''''''''''''''''''''''''''''''''''''''''''''''(6
1'*'- 7!&38''''''''''''''''''''''''''(6
1'*'1 73'''''''''''''''''''''''''''''''''''''''''''''''''''*0
4'9''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''*(
4'(':3!38''''''''''''''''''''''**
4'*':3!8'''''''''''''''''''''''''''''''''''''''*-
4'-':3!8''''''''''''''''''''''''''''''''''''''''''''''-0
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;'<'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''1,
,' 9''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''40
='7%''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''4-
(0' 98>%38''''''''''''''''''''''''''''''''''''''''''''''''''''''''''46
((' 75'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''6;
!"
  

Lista de Tabelas

' :  !   !3!
38    ? 
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
*-

' :  !   !3!
8  %   
8
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
*4

' :   !   
8!?
%
  &
8!
?''''''''''''''''''''''''''''''''
-(

' :  !    
8   ! ? %
  &
8!
?''''''''''''''''''''''''''''''''
-1
    
Lista de Figuras
Figura 1.
Diâmetro diastólico médio do ventrículo esquerdo,
obtid
o nos diferentes grupos, por meio do
ecocardiograma ...........................................................
*6
Figura 2.
Índice de massa do ventrículo esquerdo nos quatro
grupos estudados ........................................................
*,
'):"8'
*=
Figura 4.
Freqüência de hipertrofia do ventrículo esquerdo, nos
quatro grupos estudados .............................................
*=
Figura 5. Coeficiente de correlação de Spearman ......................
-0
Figura 6.
Volume ejetado pelo ventrículo esquerdo, obtido nos
diferentes grupos, por meio do Doppler-ecocardio-
grama ...........................................................................
-*
Figura 7. Freqü
ência de disfunção diastólica nos quatro grupos
estudados (Painel A) e freqüência acumulada de
função diastólica preservada ou prejudicada, na
presença ou ausência de hipertrofia miocárdica
(Painel B) .....................................................................
-6
"#
     

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@B"?
@7
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!@&%
"@&A&:"?
#"@&A$:"?
!$@"
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"@/:"?
&'
@C!*;
$(@C+
$)@C#
(@+7
("@+8:"?
*+"@D:"?
@
+"@:"?
)$(@#@C+
)$)@#@C#
$*
@
@
#*"@$)!
@&"
,
@%5
"@:"?
"#@:$E"/F
χ
χχ
χ
@GG
$%&
  
) -5  
 @ 
 -  
A
       
  5  
1 ( - B:C  
 5       -   
9

  --
 - 5  %    
  %    
 %5         

D;

E   5 %  * % F 
   5   - 
       
         ( 
-% %
G 
;
 3     
     -#
     H
?
  %   
 
    /   4 I  5
      
J3  
  
 #       K%
       
%   F   
     L3.8M  
         
      

>

%        
   K *3
       5 N
   %   
       
O
B
$
P
 %
=
%
%% -
A:
   -
AA
 % 
A9
 
 L     OOM
AD
 
A;
 LM
A?
5
A>#AP

)       * 
@  $  5  @ 
 @  
- 3   $ 5      
  -   5   5  
      
A=
 3  
  
@     -$  
 % 
9:
   $  %
%   *
*
9A99

   % F  
     -   @ 
   % F  
9D
  (
      5%    
 5    6    #
       
9;
 3
@ G  #   - % 
    - 
5- 
        
          
 @ -    $    
    5      
@  -    N 
 
9?
  
  %    *
  
9>
   8
%
9B
     
         #
  
)% 
    -#   
<G   3 @ 
       (   
" %5 $ 
 @-
 &  %  $ -
        
 - 
9P
 +Q %
9=
%
*-
    #    (
  %    %
G - @
  -  
N% 
)5
  @ G  ( 
       
@FN 
-
D:
  5
(  @
@     3   
        
  
       $
%      # K 
 (       
  -
E    # 
 G  (     
% F      % F 
   
 #         3 
 G   * @ # 
-      
   
GG
 @   %  
&   (
     - 5 %  5#
G 5   $
G     
DA

.   (   5#G 
5 L 8O
9
M %
  %$ L"R
9
M < 8O
9
  
  
D9
 @  
        
  
       5#
G  5 %$    
 %         
N     -  
DD
 5
$*%F
     5#G    
  -#   
  $ @      $
N  (   $   - 
2        
      -
-
D;D?
3 5%
3 5( A::  
   -    F
     # ) 
        
  5      
- 99    

D>

'%
  
)   @    
%- 
     (
     
(-#
(%)"*#
! " # 
 
A        
        

9 
 5
+%, -
$ % &   ' (  
 
"     %  *  
.   S   /  &   '
L)/DP<9::;#.3 M "     
  %        
 -# 
4.1 Casuística
4.1.1 Desenho do estudo
/(
4.1.2 Cálculo do tamanho amostral



/ D?C
         
      )  
$ :P: TU::?. 
 ;:
$ % &   ' (  
 
4.1.3 Seleção de indivíduos



2( %9::D( %9::?
A=D 
   
     +  )% 
6./& '0123+ 
  
      %-  6
 3  6  .  /  &  
'0123+ 
    
 
  
5
4.1.4 Critérios de inclusão

Grupo gestante hipertensa (GHT, n= 57)4    
    D?  - 5 
      5 % 
OV('6
DB

$ % &   ' (  
 

Grupo gestante normotensa (GNT, n= 47)4
44
4    
 D?  

Grupo não gestante hipertensa (NGHT, n= 41)4
44
4    
 -        
5 

Grupo não gestante e normotensa (NGNT, n= 48)4
44
4  


4.1.5 Critérios de exclusão
    (  
   86" 286"    (   
W
   *   F 
86"W
 -
% 
 
 86"82"
$ % &   ' (  
 
4.2 Métodos
4.2.1 Avaliação clínica
"@ (
-   4
       
N
"     + 
)%/& '

4.2.2 Avaliação laboratorial
/       
    2   
 $   
 %  
4.2.3 Avaliação Doppler-ecocardiográfica
)$ # (
K $  (    + 9:::  6Q
X6O?:::+)2)."  %
$ % &   ' (  
 
F N  9:#D? & 6(    
        K%
    %    
% % 1    

  % #  @ 
 +Y  3Y
DP
   
#
%$4
M%%#$
  %  -
V3LV+V3M%$K-

%M -=:
%
$. V3
  K   * 
    L+OVM   
 2 %
 4G -LV3MG -
L+V3M-+OVV3
L M 3        
  %      % )  
$ % &   ' (  
 
*L3M
(   LM  %     
% G 33  @ 
(
D=
4

 V3 L& V3 MZ [\L+OV ] ] V3M
D
0 V3
D
^$ A:;_ #
AD>

`& V3
;:
LO& V3<
9B
MZ& V3<
9B

V3L/3V3MZ\LV3
D
#+V3
D
M<V3
D
^$A::

   -  G  
LC∆MZ\LV3#+V3M<V3^$A::

L37 MZ9$ <V3
M       %#    
G ($)
  
         
$V3#  G -$ 
( $ @
$ @.. 
#
;A
%#4

 $ $ L
3  <MW
$ % &   ' (  
 

 $ $ -
L  <MW

     3 L"3M  L M
 3
$%
M#    
%$-  %
  G  $       V3 )
 $-L 
-M    $   L%   M
 $  5V3L"7OVM

M-4(#?A<
9B
 
 
;:
 ( 
I JI J
#4 ( 3< L  TAM "7OV L
 5A:: M"3L A?:99: M
 ( I -JI 
-J
$ % &   ' (  

4.2.4 Análise Estatística
  $  5 
       2)V    
   %     
        5
   O& V3  %    
% * 5
O& V3 % % *
    +   - 
   # Lχ9M   
@         
 -  V3      
8  1(#      
 
 -  V3 3   (#   
GU::?
.%/
) *  

5.1 Variáveis demográficas dos grupos estudados
2 "% A      
 $
 L 5±4DD±:>
D:±:> W U :::AM     LZ
DA±:>   Z D9±:> W Z ::?=M 
LM3
        LU:::AM
   % LZ :;PAM O 5 
     L 5± 4
B=;±AB>?P±ABWU:::AM 
 L 5± 4 BB?±A>  >BB±APW U:::AM
       
- -       
" %5 N
 LZ :9;BM       
LU:::AM   LZ:B;?M
3?B86"A; #
 AA (  (  
%% 9> % # #  
) *  

 % 52286" #
   (  
Tabela 1
0V 5 

NGNT GNT NGHT GHT
Idade (anos)
30,5±5,5 29,3±5,7 34,2±5,9* 32,1±5,3*
Peso (Kg)
61,7±11,3 69,8±10,2† 73,6±17,8* 85,2±22,4*†
Altura (m)
1,62±0,06 1,55±0,06 1,60±0,06 1,58±0,06
PAS (mmHg)
112±6,4 112±8,6 139±20,9* 139±20,0*
PAD (mmHg)
75±6,3 74±8,0 93±12,7* 91±14,0*
FC (bpm)
72±9,3 86±10,5† 73±12,9 83±12,0†
PAS e PAD: pressão arterial sistólica e diastólica, respectivamente; FC: freqüência cardíaca; *:
p<0,05 - efeito da hipertensão; †: p<0,05 - efeito da gestação (ANOVA, duas vias, seguida do teste
de Tukey para as comparações múltiplas).
NG; G; NT; HT: não gestante; gestante; NT e HT: normotensa e hipertensa, respectivamente.
5.2 Variáveis morfométricas cardíacas
2     LU:::AM 
G      -  +OV 
L"%9M
  
          $
 
) *  

. #     
L 5 ±  M     %#
  3 LD=±::;  D?±::; W U:::AM  V3
L;=±::;  ;>±::; W U:::AM  +OV L:=D±::A9 
:B?±:A9 W U:::AM  L:=D±::A9  :B;±::A9 W
U:::AM %5   
   
   3 
 

2 3
)+
      O& V3  
G   3 L7Z:BA>W U:::AM L/ AM 6  
  V3 
    V3 L?:P±:;? M
L;>>±:;9 M 
L;B9±:D> M 3     %5
   G  -  L;?;±:9>
;B9±:D>  U::?M      
-  
    L;?;
±:9>  ;>>±:;9 
) *  

a::?M3  G 
(  
Tabela 20V 5      5
% 

NGNT GNT NGHT GHT
AE (cm)
3,28±0,24 3,62±0,40† 3,70±0,44* 4,11±0,40*†
DDVE (cm)
4,54±0,26 4,72±0,36† 4,66±0,42* 5,08±0,45*†#
DSVE (cm)
2,76±0,26 2,91±0,30† 2,82±0,41* 3,15±0,47*†
SIV (cm)
0,72±0,10 0,78±0,08† 0,89±0,16* 0,98±0,13*†
PP (cm)
0,71±0,08 0,78±0,07† 0,90±0,17* 0,95±0,12*†
HD/DDVE
0,31±0,04 0,33±0,04 0,39±0,07* 0,38±0,06*
AE: átrio esquerdo; DDVE e DSVE: diâmetros diastólico e sistólico do ventrículo esquerdo (VE),
respectivamente; SIV e PP: espessura diastólica do septo interventricular e da parede posterior
do VE; HD/DDVE: espessura relativa da parede ventricular; *: p<0,05 - efeito da hipertensão; †:
p<0,05 - efeito da gestação; #: interação significante entre os dois fatores (ANOVA, duas vias,
seguida do teste de Tukey para as comparações múltiplas).
NG; G; NT; HT: não gestante; gestante; normotensa; hipertensa, respectivamente.
) V3(
L/AM
) *  

DDVE (cm)
4.2
4.4
4.6
4.8
5,0
5.2
GEST- GEST+
HAS-
HAS+
†
#
*
NGNT
NGHT
GNT
GHT
DDVE (cm)
4.2
4.4
4.6
4.8
5,0
5.2
GEST- GEST+
HAS-
HAS+
†
#
*
DDVE (cm)
4.2
4.4
4.6
4.8
5,0
5.2
GEST- GEST+
HAS-
HAS+
†
#
*
NGNT
NGHT
GNT
GHT
Figura 1#G  - 5    % 
 
83+"#<]4   <W 6+ #<]4 
<
b4c4Wd4
L2)VWU::?M
)   *   
/ 9 D ; 8     
      V3
         ) 
L<
9B
M     #  
 4 82"Z ;:9
±B?W 286"Z ;A>±AAP 282"Z DA:±>> U::?M
O        
) *  

    L86"Z?PD±AAD <
9B

U::?282"86"286"M)N
       (
  ≥?A <
9B
 2      
     LN  9CM
   ABC     D;C
      BAC
L/;M"5 
   6   
G  -  3 O& V3 %     
+ L7Z:BA>WU:::AML/?M 
    
     6V3  *  L)74
=>;W O.
=?
4 AA>#P:;;W U::?M     %5
     6V3   L)74
9?D:WO.
=?
4DA?#9:D?:WU::?M36+
A99P( 6V3L)74A9APO.
=?
4;>P#DABAW
U::?M
6V3L)74;>;WO.
=?
4A=;#AA:=WU::?M
) *  

GRUPOS
GRUPOS
NGNT GNT NGH GH
0
20
40
60
80
100
120
140
IMVE (g/m
2,7
)
*
+§
GRUPOS
GRUPOS
NGNT GNT NGH GH
0
20
40
60
80
100
120
140
IMVE (g/m
2,7
)
*
+§
Figura 2#`       

b] e4 U::?  282" 82" 286"   282"4
 82"4 286"4
86"4L
 5M
) *  

MVEr (g/m
2,7
)
0
10
20
30
40
50
60
GEST- GEST+
HAS-
HAS+
§
NGNT
NGHT
GNT
GHT
MVEr (g/m
2,7
)
0
10
20
30
40
50
60
GEST- GEST+
HAS-
HAS+
§
NGNT
NGHT
GNT
GHT
*
*
*
*
0
10
20
30
40
50
60
70
80
Hipertrofia do VE (%)
NGNT GNT NGHT GHT
*
*
*
*
0
10
20
30
40
50
60
70
80
Hipertrofia do VE (%)
NGNT GNT NGHT GHT
Figura 3#&   O& V3   W 83+"#<]4 
 <W 6+ #<]4   
<e4U::?282"82"286"
Figura 4#/N       

b4 U::A 282"4    82"4
  286"4   86"4
L
χf8 M
) *  

Figura 5#.+



5.3 Variáveis funcionais cardíacas
)-"%
D2 
/3C∆.#
        .
LZ:::>M3 %5  LU:::AM
LZ::PBM
   .   (   
) *  

 F     V+  

     LZ::9>M   
  V+   L>:Bg=? h  >=?gAB? h
U::?M   L>:9gADA h ?=Pg=? h
a::?M       
LZ::A;MLZ:::BM
Tabela 30V 5-
   %    #

NGNT GNT NGHT GHT
FE
0,77±0,04 0,76±0,05 0,77±0,07 0,76±0,06
%D
39±3,8 38±4,0 40±6,1 38±5,5
DC (L/min)
4,24±0,54 5,08±0,95† 4,39±0,79* 5,70±1,25*†
VS (mL)
59,8±9,5 60,2±13,1† 60,7±9,5* 69,5±17,0*†#
DC: débito cardíaco; VS: volume ejetado; %D e FE : porcentagem de variação do diâmetro e
fração de ejeção do ventrículo esquerdo, respectivamente; *: p<0,05 - efeito da hipertensão; †:
p<0,05 - efeito da gestação; #: interação significante entre os dois fatores (ANOVA, duas vias,
seguida do teste de Tukey para as comparações múltiplas).
NG; G; NT; HT: não gestante; gestante; normotensa; hipertensa, respectivamente
.
)/>  V+(

) *  

VS (mL)
50
55
60
65
70
GEST- GEST+
HAS-
HAS+
*
#
†
VS (mL)
50
55
60
65
70
GEST- GEST+
HAS-
HAS+
*
##
††
Figura 6
#
##
#
V     %  
 #
83+"#<]4   <W 6+ #<]4 
<
b4c4Wd4
L2)VWU::?M
"% ; / B 5 '  
*-
2 
         $  
      2  
    $     *

) *  

   $  L??±A:P <  >D±AP;
<WU::?ML;D±A:: <>D±A?D <WU::?M
 $ L;D±A::??±A:P
<W U::?M    L>D±A?D < >D±AP;
<W a::?M .  N  @   
( 3<  *  *     
*
 LA;9±:9P  AD:±:?:W U::?M 
LA=>±:;9  A9P±:;BW U::?M     (
3<    LA=>±:;9  A;9±:9PW U::?M 
    LA9P±:;B  AD:±:?:W
a::?M6G 3
L7Z:;A>WU:::AM
)   $   5  
         
         
  L 5 ±  4 A::±9A  P>±99 W U::?M
8        
 3 
  "3
LAP9±;B 9:B±B? WU::?M.#
     
) *  

 LA=>±A; AP9±;B
Wa::?M
Tabela 40V 5-
   %    #

NGNT GNT NGHT GHT
E (cm/s)
81±12,4 81±15,7 76±18,7 76±21,8
A (cm/s)
43±10,0 55±10,8† 63±15,3* 63±18,4*†#
E/A
1,96±0,42 1,42±0,28† 1,28±0,47* 1,30±0,50*†#
TRIV (ms)
84±11 88±13 98±18* 101±25*
TDE (ms)
196±14 171±31 182±47 207±75#
E e A: pico de velocidade de fluxo na fase de enchimento ventricular rápido e durante a contração
atrial, respectivamente; E/A: razão entre E e A; TRIV: tempo de relaxamento isovolumétrico; TDE:
tempo de desaceleração da onda E; *: p<0,05 - efeito da hipertensão; †: p<0,05 - efeito da
gestação; #: interação significante entre os dois fatores (ANOVA, duas vias, seguida do teste de
Tukey para as comparações múltiplas).
NG, G, NT; HT: não gestante; gestante; normotensa; hipertensa, respectivamente.

-( 
 
#- 
6+ 
3   5  6+ 
- ?;>(LO.
=?
4BD#;:P?M
 $-    
/ B 5 ' N   - L M
  
) *  

286"86"L9=C;9C
a::?M 2  '   N  
 -       
 2#-
    86"  
286") F
-* 
) *  

*
*
*
0
5
10
15
20
25
30
35
40
45
Disfunção Diastólica (%)
NGNT GNT NGHT GHT
A
*
*
*
0
5
10
15
20
25
30
35
40
45
Disfunção Diastólica (%)
NGNT GNT NGHT GHT
*
*
*
0
5
10
15
20
25
30
35
40
45
Disfunção Diastólica (%)
NGNT GNT NGHT GHT
A
0%
20%
40%
60%
80%
100%
NGNT GNT NGHT GHT
disf.diast./HVE+
disf.diast./HVE-
diast nL/HVE+
diast nL/HVE-
B
Figura 7
#/N  -
L M N    -
      
 L'M
0%
+ ,  

)     
      @ 
  #$   
       $  

) $ 
  (    
   %$ 
  #  5   
  G
#       
%
 
 
     5     
  @  2 
-
 2- 
     
(    (  <
;9

 
%% 
+ ,  

 
;D#
;?
)  % 
    $  %#  
%  %    * 
      h 
      3 1  5
( D:   N  
% %$9:
D= 
;D
 3  %    
 %$ %$  D:
    $    ??C 
    %   
L;BCM)  
 $ $2
$  A9C D:D=
  
;>
 .    
 
  G  
* %%
3      
           
 OO     F  3
+ ,  

     *    *  
 O 5     #
 F      %  

;B
 1      $   
    
;P
 5  
 %   #   
 G    
;=
 )   
@ 5     5  
 2     %   
      ) 
 @ G   
%5 % @
9>
3
  
 5 $ )
  (    K% 
       
 
% 
 %  @ 
  K $
       5   
  
+ ,  

      $  
          
 - < -    
DB

        5
  3
#  
- A: )
  #
        
- 5?>C
?:

%/  %
 D9C $ 
 #   # -   
  )     ;:C  
         
-
?A
2
     5   $ $
      3     
(, ( %  9:
      #
@. $
 
?9

+ ,  

3  %  9;? 
     * 
%        
(    =AC     
# %
 D:C
?D

5
(  N  
#        
3 
   

D:
S( 
%25
 %     %  
  *
   
.  G 
%#
    -   -
           
      
 @
+ ,  

2     
 ( & V3     ) 5  
& V3     &  
        -
 
  $    G   2 
 -      
   G       
#$@ 

         
      @ 
  +%#   5
       
- 
>?;#?>
 5    
    
?B

3     
  
 
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25 @ 
F 
 @
  *  5    
+ ,  

N    @ 

D;D??P

2     @ 
 -@ 
(        G 
  *      
  
9>
 "#     
  -1 $@
 -$
( 
      & 
@   
     5%
 V 
 -  N 
      5  -  
 
?=
 3 5  
  *    
5% $
25*%F
  5    @  
   K     
+ ,  

 
9:
 S    
-  5
   %
9>9B>:
 % 
V+ 
  1      
( GO5*%F
     -  
  %$  5   (
2   %     
   
   %  -  V3
 N-
  #    
V     
     
- F  %  
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 "
-  
 
 O 5    F    
 3$
%K 

+ ,  

)     -   $
- G   
 -)

>;
$  
  %
@ %- 55
        
@  %   K 
    - 

>?>>
3 %-% 
  %
 G   #  @ 
    3     
  
 
  # 
     *     
     @  
 % F  
>B#>=
 2  
         
+   #  % 
      
+ ,  

      
   % -    #
  %
       
      3  5 
$ G     
% 3       5
    +   
  5  -
         
<         
5
1%
- %   .

AM 
       -
-
9M 6     5
        
5 -
2%/
/ * 

Zanati SG(0   1 2  
!$3

'9::B"LM0
/& '13 
Fundamento4
44
4  5  -  
L6M 5 - %  - -  
+#    @   
 
Objetivo4
44
4        
    6    
       5

Casuística E Métodos4
44
4 3    A=D
 486"LZ?BM
82" LZ;B  M 286" LZ;A #
M 282" LZ;P #  M " 
%  *  #  D?! DB!
  2)V
 W  #    
       L 
GU::?M
/ * 

Resultados4
44
4 6      
LZ::9>M 4   LV+M G  - 
LV3M V+
L>:Bg=?>=?gAB? U::?M 
 "  
V3 L M    L286"4 ;>>±:;9W82"4
;B9 ± :D>W 282"4 ;?; ± :9>M  #
     L86"4 ?:P ± :;?M
N-282"9C
82" 9=C   286" ;9C   86" LU::?M 
    #   
   L6V3M 5    6 L)74
9?D:W O.
=?
4 DA?#9:D?: U::?M 3     
 L)74;>;WO.
=?
4A=;#AA:=
U::?M
Conclusões4
44
4A 
 V3 -
 -  V3W 9  6# 
5   

Palavras chave4
44
4
    
# 
3%"
0   

Zanati SG   -  !  4 
  -  !  4   -  !  4 
  -  !  4 
4 ! !  %  
4 ! !  %  4 ! !  %  
4 ! !  %   '
''
' '
9::B " LM 0 ' &  + +  +
1Y
Background4
44
4 Y  Y  Q 
Y L6M   6Q %  $
Y   "   %
      
YYLhV6M
Objective4
44
4 YYYhV
Q Q  6 Q   Y 
Y   
Cases and Methods4
44
4 .#  Y  A=D
Q   :; 4 6 LZ?B Y 
Q M 2" LZ;B    Q M 62 LZ;A
Y#Q M2"2 LZ;P #
 Q M  Q Q %   #
Y D?#DB#QX   Y Q  
Q#QY2)V.# 
LU::?M
0   

Results4
44
4OLZ::9>MQ%
 L+VM LhVM
8Y+V YQ L>:Bg=?
>=?gAB? hU::?M% QQ 
YQYhVL M 
  L2"2 4 ;>> g :;9W 2" 4 ;B9 g :D>W 2"2 4 ;?; g :9>M
6Y#YL6 4?:Pg:;?
WU::? M "Y YQ
2"2 W9C2" W9=C62 ;9C6 LU::?M
&  Q  # Q
X  hV6      6 L)74 9?D:W O.
=?
4 DA?#
9:D?:U::?MOYQ XYY
YL)74;>;WO.
=?
4A=;#AA:=U::?M
Conclusions4
44
4 A 6Y    
YYQY
YW 9 "  6# $ Y 
 QX YYY
Key words4
44
4
YY YYY
# 
$4%/56"5
b O .   &  i 3 1
   %   %  
O& A==BWA9>4D>#;B
1 * 2 3 4 

A  h  H i 2#8 ' & YY Q 
i& ..9::9WD;4=A#A:?
9, % H" .  Y  
6Y9::AWDP4?PP#?=A
D8 H  ' &  i ' 3  
     Q  3 i
 Y) YA==PWB=4PP#=9
;h '6 .% ' h  YY4 
.9:::WA:94;B:#;B=
?H , ' h  YY X   
Y36iA==9WAD4P9#P
>/ 3 "   Y #  A==A Q
6YA==AWAP?4OOO>9#>P
B6Y , h 8 i&  ,  i6 3  
  %  Y    . A=P:W >94A:?;#
>A
P)X & 7 & i$7'H8
    YY 6Y
A==?W9?49;9#=
=8+$7'7 & i & 6hi67
%YYY 
Y6YA==;W9D4>::#>
1 * 2 3 4 
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A:&   hY 8 7i . ,  H , ' 7 
 X    4" /  +Y i
..A==AWAB4BAB#9A
AA+ & /68832('YX
       Y
.A=PPWBP4=?A#>
A96 V H6 + & /    
  Y %  Y 0 % 
.A==:WP94P;P#??
AD'Q j h%%Y  >
 $#%X  
9::A?:D#DD
A;$ 7' Y iO . +  ,  % Y
    YY  Y  Y i
.A=P;W?;4?=9#?
A?% h hY  8 7i O   
    Y  L
/  +YM i.A=P=W>;4A:>>#P
A>2( i, /HO   %5
  7
'69::AWP4;A;#9;
AB+ i YY    YY
& 9:::W99L;M49A?#9D
1 * 2 3 4 
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APh '6 .% ' h  YY 
.9:::WA:94;B:#=
A=.8'  YYY4Q
  7& A==BW;P4AD#9D
9:)8.3& 7h..E/7
YY.79:::W;?4>P#B?
9A&  63 .     . A==DW
PB?4OV;#>
99$ 7' "    (  
YY 6i9:::WAD=4+=#+A;
9D) i2 ' / +Y  3&   Y  
# (Y      
'i)%8YA=PAWPP4A9:;#A9A:
9;'Q& +& i+& 8Y3   
# Y
Y i)%8YA=P>WA??4D;=#D?D
9?.i2/7+2. #
 4      
 i ..9:::WD?4?>=#P9
9>+ h88i Y7, +
  Y i
Y#6.Y9::9W9PD46A>9B#6A>DD
1 * 2 3 4 
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9B8 " &  & ' +X h H ' X i&  3 
Y   Y    Y 
  6iA==BWADD4?D#?=
9P& & .+& & '8"  
YY.
.9::9W9?4A9;#ADA
9=+Q .&  j  " + &   8 & $ 7
+ '3h  YY   Y 
YQ .Y9::9W=B4BD#BP
D:. 3h . i/ .  Y  
Y i)%8YA=P=WA>A4A;;=#A;?D
DA/ +"Y727%i&  YY 
.A==AWAP4>>A#>P9
D9/ +   Q    
)%8YA=PPWBA4A99#ADB
DD)  &  i&  2 6 / 6) "Y 
% 'i)%8YA=P>W=D49D?#9D=
D;' & V 7% i 8 )  h  
  Y#Y i6Y9::AW
A;49BA#9B?
D?V628 V'7((87 & 3& 
& h8& 7 .8& 
1 * 2 3 4 
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Y Y
Y6Y9::AWDB4A9:=#A9A?
D> &  2. '% 7h ' V"&  i. & % ''
 #   
F'.9::9WB=4?BD#?BP
DB& i& .8 & & 2%/H )OV
( '  6   ' . 9::;W
P9OV4A#A;
DP+i& Hi, Y 7 
  & #  Y4 7  Y 
  .A=BPW?P4A:B9#A:PD
D=$ 7' 7 2 3Y    
  4     
.A=BBW??4>AD#>AB
;:+ 8$7'+7H& i& Y7hi6
3Q%Y 4 
 Y
X i.A==?W9?4A:?>#A:>9
;A7XQX 6  . . Hh   i8 6 8 i i 
.      
   Y  Y4 
     Y %Y
1 * 2 3 4 

Yi +3A==>W=4BD>#>:
;9+  3 hQ .3 .Y ih X hh 'X 8h ' 3
h  Y  Q Y "
.7O +Y .Y Y 7X   k 
+Yi& A==;W9BA4AB;B#AB?A
;D+ 7+ i7, /7%76, 
%  /  Y  A 
i& A=BPW9;:4A>:B#A>A:
;;,  , / l 7' + h  6 H , '
)Q  %Y     X "
/  3$O& 9::9WA>94AP>B#APB9
;?+  8 ,  H   V 6  ' 8 m 1
/Y / O% 6 i + H +3 h%#  )
h h6 2  & + ) X  ) + $ 7' 'Y
%  X    Y  
YY"hO/3Lh3
YM+Y.9::?WAAA4A=9;#A=DA
;>/& & 8/V'()& +& ++h i, )
  $     
%%$'.9::?WP;49=#DB
;B8 2/ Y 8h . + , Y i &  . Y 
 OO      Y i
1 * 2 3 4 

.OA=BDW?94D>P9#D>P=
;P82/, Y7i37'&  ..
 YHYOA=P:WAP49?D#9?P
;=.#3  &  i H8 &  h8 7 Y
%Y Y
iYA==AW9>A46AP;9#6AP;B
?:,  2 "X 8 /X ++ h 8i i% & O , Y ih
h     %Y  Y4
   Y %Y    $ 6 i
9::DWA;?4PPP#P=?
?AhY#i& 3i.h& 8hY" 
Y   Y4  Y 6Y
9::9W;:4>;:#>;>
?9, ( 83. 2 + i+ &6/  
     %  4
Y Qi6Y9::;W994AP;=#AP??
?D. 3' & Y5#2 &   7 . & .&  8 "i&
2% / 7   *  % 
 '.
9::?WP?4A?B#A>A
?;8 iH HX + . 7+ h k O    
YY   Y   %  Y
1 * 2 3 4 

Yi ..A==AWAB4A9BB#A9P9
??+ 73& /6O
      YYn i & 
A==9W=94+9P#+D;
?>$7'7 & ihi3, Y"Hh3"77/%(
776Q'V. 
Y#% 4"+6+Y
i.9:::WP>4A:=:#A:=>
?Bhk.7+& 8& 8hhYY
      Q   .
A==?W=94P:?#PA:
?P28 V6V'h8 / 
8 . ' 8    h  
 Y X    Y 6Y
9::DW;A4;>=#;B?
?= 7.)8EY Y
YQYY4Qi
..A=P>WB4AA;:#AA;=
>:3% &  7   & Y "k 7 6 , k " h
+ 3 &       YY
Y.79::?W=>4A9:P#A9A>
>A6 H +Q% H & & Y i 6  Q  
1 * 2 3 4 
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h# Y%Q
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