In this issue of the journal Arquivos Brasileiros de Cardiologia, important and original research work on rats is published. The work is important because pulmonary hypertension represents a serious pathology that is very difficult to treat. The only way to relieve patients is lung transplantation, but are very well known the difficulties and limitations of this treatment. The work is also original because a lot has been published about the beneficial effects of copaiba oil, such as its anti-inflammatory action, analgesic effect, and ability to prevent infections and improve the healing process. However, the beneficial effect of copaiba oil on pulmonary hypertension had not been described. In this sense, the group led by Adriane Belló Klein has been working for several years on this important issue of pulmonary hypertension in general,^– and the effects of copaiba oil on this particular pathology,^, which has made this research group an international benchmark on this theme.

It is important to mention that pulmonary hypertension induced in rats by monocrotaline produces vascular lesions very similar to those found in patients with this pathology.^, In essence, what the work published in this issue of the journal Arquivos Brasileiros de Cardiologia shows is that the administration of copaiba oil to a group of rats with pulmonary hypertension induced by monocrotaline produces a clear beneficial effect, through the decrease in peripheral blood indicators of oxidative stress, a reduction in pulmonary vascular resistance, and a favorable remodeling of the right ventricle, with a reduction in hypertrophy, which translates into a better systolic function of that ventricle. This finding is very important because it is well known that myocardial hypertrophy is one of the most important causes of heart failure and sudden death. The positive relationship between the degree of hypertrophy and the decrease in oxidative stress shown by the authors is clearly proven in this work by the high r-value obtained when these two variables were correlated. However, and beyond this important correlation, future studies should determine if the beneficial effect on the right ventricle is due to the reduction of oxidative stress or if there is also a direct effect of copaiba oil on myocardial fibers. Perhaps experiments that could be carried out on isolated hearts would make it possible to detect or not a direct impact of this natural agent. In this sense, it is important to mention that the authors of this study also published an interesting work previously where they showed that the administration of copaiba oil decreased apoptosis signals in the hypertrophic right ventricle and attributed the better remodeling to a possible decrease in the apoptosis mentioned above; obviously this same mechanism could be acting in the work that we are commenting now. Nevertheless, here it is important to make some clarifications that may allow a better understanding of what is happening in these hearts with hypertrophy secondary to pulmonary hypertension.

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Abstract

Background:

Mitral valve repair in paediatric patients with chronic rheumatic heart disease is superior to valve replacement and has been used with good results.

Objective:

To identify predictors of unfavourable outcomes in children and adolescents submitted to surgical mitral valvuloplasty secondary to rheumatic heart disease.

Methods:

Retrospective study of 54 patients under the age of 16 operated at a tertiary paediatric hospital between March 2011 and January 2017. The predictors of risk for unfavourable outcomes were: age, ejection fraction, degree of mitral insufficiency, degree of pulmonary hypertension, presence of tricuspid insufficiency, left chamber dilation, preoperative functional classification, duration of cardiopulmonary bypass, duration of anoxia, presence of atrial fibrillation, and duration of vasoactive drug use. The outcomes evaluated were: death, congestive heart failure, reoperation, residual mitral regurgitation, residual mitral stenosis, stroke, bleeding and valve replacement. For all analyzes a value of p < 0.05 was established as significant.

Results:

Of the patients evaluated, 29 (53.7%) were female, with an average of 10.5 ± 3.2 years. The functional classification of 13 patients (25%) was 4. There was no death in the sample studied. The average duration of extracorporeal circulation was 62.7±17.8 min, and anoxia 50 ± 15.7 min. The duration of use of vasoactive drug in the immediate postoperative period has an average of 1 day (interquartile interval 1-2 days). The logistic regression model was used to evaluate the predictive variables for each unfavourable outcome. The duration of use of vasoactive drug was the only independent predictor for the outcomes studied (p = 0.007). Residual mitral insufficiency was associated with reoperation (p = 0.044), whereas tricuspid insufficiency (p = 0.012) and pulmonary hypertension (p = 0.012) were associated with the presence of unfavourable outcomes.

Conclusion:

The duration of vasoactive drug use is an independent predictor for unfavourable outcomes in the immediate and late postoperative period, while residual mitral regurgitation was associated with reoperation, and both tricuspid regurgitation and pulmonary hypertension were associated with unfavourable outcomes.