Rheumatic Fever – ABC CARDIOL

ABCIC

Case Report

Importance of Echocardiography in the Differential Diagnosis of Rheumatic Mitral Regurgitation in Children and Adolescents

Camila Magalhães Silva et al. Maik Arantes Fátima Derlene da Rocha Araújo Adriana Furletti Machado Guimarães Zilda Maria Alves Meira

Introduction

Mitral regurgitation (MR) can be a result of abnormalities in different locations of the valve apparatus (cusps, annulus, tendinous cords and papillary muscles), being of acquired or congenital etiology. MR can be classified as primary, when resulting from a deformity in the valve structure, or secondary, when related to another heart or systemic disease. In our field, the main cause of MR in students and adolescents is the acquired one. Rheumatic fever (RF) is among the causes, as well as bacterial endocarditis, which should be considered in the differential diagnosis.^, However, congenital anomalies, such as mitral valve (MV) prolapse, mitral cleft (MC), parachute MV and, rarely, isolated cleft MV (ICMV) should be ruled out.^, The etiological diagnosis of MR is very important to determine the proper treatment, once it can be clinical or surgical, with definitive correction of the lesion.

We present the report of a student whose clinical and echocardiographic scenario was first diagnosed as acute RF, showing the importance of echocardiography in the posterior differential diagnosis of MR.

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ABCIC

Case Report

Rheumatic Mitral Valvopathy and Papillary Fibroelastoma An Unusual Association

Rafael Macedo Mustafé et al. Elinthon Tavares Veronesi Carlos Manuel Almeida Brandão Márcio Silva Miguel Lima

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Editorial

Thiol Homeostasis in Rheumatic Heart Disease: Biomarker or Risk Factor?

Ana Cecília de Almeida Valadares et al. Roney Orismar Sampaio

Rheumatic fever and rheumatic heart disease (RHD) lesions result from a complex network of several genes and proteins that control innate and adaptive immune responses following a Streptococcus pyogenes pharyngo-tonsillitis. The succeeding inflammatory process leads to the development of cardiac lesions with high production of inflammatory cytokines leading to calcification and valvular fibrosis. However, the cellular pathways beyond these immunoregulated phenomena have not been fully elucidated.

Oxidative stress is a biological condition marked by an imbalance between reactive oxygen species production and its reduction. Disturbances in this redox balance can cause the overproduction of peroxides and free radicals that damage all cellular components, including proteins, lipids and DNA.

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Original Article

Late Outcomes of Aortic Valve Replacement with Bioprosthesis and Mechanical Prosthesis

Larissa Ventura Ribeiro Bruscky et al. Carlos Gun Auristela Isabel de Oliveira Ramos Alice Lemos Morais

Abstract

Background

Despite constant improvement and refinement of the prostheses, the decision between mechanical and biological valves for aortic valve replacement is still controversial.

Objective

To compare outcomes of aortic valve replacement with bioprosthesis and mechanical prosthesis.

Methods

This was an observational, historical cohort study with review of medical records. A total of 202 patients who underwent heart valve replacement surgery between 2004 and 2008 were selected, with a mean follow-up of 10 years. The level of significance set at 5%.

Results

Mean age of patients was approximately 50 years; most patients were male (70%). Overall mortality- and reoperation-free survival was significantly higher in patients with mechanical prosthesis (HR=0.33; 95%CI=0.13-0.79; p=0.013). No difference was found in late mortality between the two groups. On the other hand, the risk of reoperation was significantly higher in patients with bioprosthesis than mechanical prosthesis (HR=0.062; 95%CI=0.008-0.457; p=0.006). The risk of composite adverse events – stroke, bleeding, endocarditis, thrombosis and paravalvular leak – was similar between the groups (HR=1.20; 95%CI= 0.74-1.93; p=0.44). The risk of bleeding was significantly higher in patients with mechanical prosthesis (HR=3.65; 95%CI= 1.43-9.29; p = 0.0064), although no case of fatal bleeding was reported.

Conclusion

No difference in 10-year mortality was found between the groups. The risk of reoperation significantly increases with the use of bioprosthesis, especially for patients younger than 30 years. Patients with mechanical prosthesis are at increased risk of nonfatal bleeding.

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Editorial

Mechanical Prosthesis X Biological Prosthesis: an Individualized and Shared Decision

João Ricardo C. Fernandes et al. Roney Orismar Sampaio

Surgical valve interventions are performed primarily in patients with severe valve heart disease, with associated symptoms and/or anatomical/hemodynamic consequences, and no contraindication to the procedure. The choice of prosthetic valve should be based on a shared decision-making process that must account for the trade-offs between durability (and the need for reintervention), bleeding, and thromboembolism.

The manuscript: “Late Outcomes of Aortic Valve Replacement with Bioprosthesis and Mechanical Prosthesis” is an observational retrospective study intended to evaluate the long-term follow-up of patients (n=202) who underwent aortic valve replacement, comparing biological (65.3%) and mechanical prostheses (34.7%). The patients were relatively young (mean age: 49 years), with predominantly degenerative aortic valve disease. On the other hand, 22% of the study population had rheumatic disease, the most prevalent etiology of valve disease in Brazil.

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Original Article

Histopathological Characterization of Mitral Valvular Lesions from Patients with Rheumatic Heart Disease

Nayana F. A. Gomes et al. Marcelo A. Pascoal-Xavier Livia S. A. Passos Thiago Mendonça Nunes Paula … João Marcelo de Souza Aguiar Felipe Vieira Guarçoni Maria Cecília Landim Nassif Claudio Leo Gelape Renato Braulio Paulo Henrique N. Costa Luiz Guilherme Passaglia Raquel Braga Martins Walderez O. Dutra Maria Carmo P. Nunes

Abstract

Background:

The underlying mechanisms by which rheumatic heart disease (RHD) lead to severe valve dysfunction are not completely understood.

Objective:

The present study evaluated the histopathological changes in mitral valves (MV) seeking an association between the pattern of predominant valvular dysfunction and histopathological findings.

Methods:

In 40 patients who underwent MV replacement due to RHD, and in 20 controls that underwent heart transplant, histological aspects of the excised MV were analyzed. Clinical and echocardiographic data were also collected. Histological analyses were performed using hematoxylin-eosin staining. Inflammation, fibrosis, neoangiogenesis, calcification and adipose metaplasia were determined. A p value<0.05 was considered to be statistically significant.

Results:

The mean age of RHD patients was 53±13 years, 36 (90%) were female, whereas the mean age of controls was 50±12 years, similar to the cases, with the majority of males (70%). The rheumatic valve endocardium presented greater thickness than the controls (1.3±0.5 mm versus 0.90±0.4 mm, p=0.003, respectively), and a more intense inflammatory infiltrate in the endocardium (78% versus 36%; p=0.004), with predominance of mononuclear cells. Moderate to marked fibrosis occurred more frequently in rheumatic valves than in control valves (100% vs. 29%; p<0.001). Calcification occurred in 35% of rheumatic valves, especially among stenotic valves, which was associated with the mitral valve area (p=0.003).

Conclusions:

Despite intense degree of fibrosis, the inflammatory process remains active in the rheumatic mitral valve, even at late disease with valve dysfunction. Calcification predominated in stenotic valves and in patients with right ventricular dysfunction.

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IJCS

Original Article

Mortality Trends from Cardiovascular Diseases in the State of Bahia, Brazil, between 2000 and 2015

Yana Mendonça Nascimento et al. Adriana Lopes Latado

Abstract

Background:

Mortality from cardiovascular diseases has reduced in Brazil in recent decades, but this phenomenon is not clear in the northeast region of the country.

Objectives:

To describe the mortality trends from cardiovascular disease in Bahia from 2000-2015, in total population and by sex and age groups, and by specific causes (ischemic heart disease, cerebrovascular diseases, rheumatic heart disease and heart failure).

Methods:

This was a time series study. Data were obtained from SIM-DATASUS and IBGE, and the 10th revision of the ICD used for disease classification. Mortality rates (per 100,000 inhabitants) were calculated from total cardiovascular disease and specific causes, by sex and age groups. Direct standardization was used to adjust for age, using the population of 2010 as reference. Linear regression models estimated percentage variation. The significance level of 5% was adopted.

Results:

In Bahia, crude mortality rates from cardiovascular disease increased in the period; however, after standardization by age, mortality rates became stable for the total and female populations, with a slight reduction for the male population. An increase in mortality rates from cardiovascular disease was found in the elderly groups. For ischemic heart disease, a progressive increase in adjusted mortality rates was observed: 43%, 24% and 29% for the total, male, and female population, respectively. There was a progressive reduction in crude and age-standardized mortality rates from heart failure in all groups, a modest reduction in age-adjusted mortality rates from cerebrovascular diseases, and a slight reduction in age-standardized mortality rate from rheumatic heart disease, especially in the subgroup <40 years.

Conclusions:

Mortality from cardiovascular disease in Bahia did not follow the decreasing trend of other Brazilian states, especially in relation to ischemic heart disease, which showed an increase in mortality rates.

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Original Article

Rheumatic Fever: A Disease without Color

Estevão Tavares de Figueiredo et al. Luciana Azevedo Marcelo Lacerda Rezende Cristina Garcia Alves

Abstract

Background:

Brazil has approximately 30.000 cases of Acute Rheumatic Fever (ARF) annually. A third of cardiovascular surgeries performed in the country are due to the sequelae of rheumatic heart disease (RHD), which is an important public health problem.

Objectives:

to analyze the historical series of mortality rates and disease costs, projecting future trends to offer new data that may justify the need to implement a public health program for RF.

Methods:

we performed a cross-sectional study with a time series analysis based on data from the Hospital Information System of Brazil from 1998 to 2016. Simple linear regression models and Holt’s Exponential Smoothing Method were used to model the behavior of the series and to do forecasts. The results of the tests with a value of p < 0.05 were considered statistically significant.

Results:

each year, the number of deaths due to RHD increased by an average of 16.94 units and the mortality rate from ARF increased by 215%. There was a 264% increase in hospitalization expenses for RHD and RHD mortality rates increased 42.5% (p-value < 0.05). The estimated mortality rates for ARF and RHD were, respectively, 2.68 and 8.53 for 2019. The estimated cost for RHD in 2019 was US$ 26.715.897,70.

Conclusions:

according to the Brazilian reality, the 1-year RHD expenses would be sufficient for secondary prophylaxis (considering a Benzatin Penicillin G dose every 3 weeks) in 22.574 people for 10 years. This study corroborates the need for public health policies aimed at RHD.

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IJCS

Original Article

Evolutive Study of Rheumatic Carditis Cases Treated with Corticosteroids in a Public Hospital

Fernanda Maria Correia Ferreira Lemos et al. Gesmar Volga Haddad Herdy Cristina Ortiz Sobrinho Valete Maria Eulália Thebit Pfeiffer

Abstract

Background:

Rheumatic carditis is a challenge for treatment and secondary prophylaxis, due to severe valve sequelae.

Objective:

To evaluate the cases of rheumatic carditis in patients under 18 years old treated with corticosteroids.

Methods:

An observational, longitudinal and retrospective study was carried out on the profile of patients, in the period of 2000-2015. We selected those who received corticosteroid therapy at immunosuppressive doses, for the treatment of carditis and were aged 5 to 18 years. Data were extracted from medical records. Calculations of: averages, standard deviations, medians and interquartile ranges, ratios and 95% confidence intervals were obtained. Chi-square and Wilcoxon tests were applied for comparisons. The level of significance was 5%.

Results:

Of the 93 cases, 93.53% developed moderate or severe carditis. Mitral regurgitation was detected in 100% of the sample. Pulse therapy was administered in 11.83%. Surgery was performed in 23.69% of patients: mitral, aortic and/or tricuspid valve repair or replacement. The evolution of the cases was favorable in 70.96%. There was a good response among those who received only clinical treatment and those who belonged to the surgical group. The comparison of the initial and posterior valve lesions to the corticoid use was statistically significant (p < 0.001). A difference between the ejection fraction medians was observed (p = 0.048). Hospitalization was required twice or more for 45.16% of the patients. The mortality rate was 5.38%.

Conclusions:

The patients showed significant clinical improvement. The treatment was effective, reducing trivalvular impairment.

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Original Article

Vimentin and Anti Vimentin Antibodies in Chagas' Disease

Marilda Savoia Nascimento et al. Anna Maria Simonsen Stolf Heitor Franco de Andrade Junior Ramendra Pati Pandey Eufrosina Setsu Umezawa

Abstract

Background:

Vimentin is a main structural protein of the cell, a component of intermediate cell filaments and immersed in cytoplasm. Vimentin is mimicked by some bacterial proteins and anti-vimentin antibodies occur in autoimmune cardiac disease, as rheumatic fever. In this work we studied vimentin distribution on LLC-MK2 cells infected with T. cruzi and anti-vimentin antibodies in sera from several clinical pictures of Chagas’ disease or American Trypanosomiasis, in order to elucidate any vimentin involvement in the humoral response of this pathology.

Objective:

We standardized an indirect immunofluorescence assay (IFI) to determine sub cellular expression in either parasites and host cells, and ELISA to evaluate anti-vimentin antibodies in sera fron chagasic patients.

Methods:

We analyzed the distribution of vimentin in culture cells using indirect fluorescent assays, using as external controls anti-T. cruzi sera, derived from chronic infected patients for identification of the parasites in the same model. After infection and growth of T.cruzi amastigotes, those cells express larger amounts of vimentin, with heavy staining of cytoplasm outside the parasitophorous vacuole and some particle shadowing patterns, suggesting that vimentin are associated with cell cytoplasm. Anti-vimentin antibodies were present in most American trypanosomiasis samples, but notably, they are much more present in acute (76, 9%) or clinical defined syndromes, especially cardiac disease (87, 9%). Paradoxically, they were relatively infrequent in asymptomatic (25%) infected patients, which had a clearly positive serological reaction to parasite antigens, but had low frequency of anti-vimentin antibodies, similar to controls (2,5%).

Conclusion:

Our current data revealed that anti-vimentin antibodies induced during T. cruzi infection could be a marker of active disease in the host and its levels could also justify drug therapy in American Trypanosomiasis chronic infection, as a large group of asymptomatic patients would be submitted to treatment with frequent adverse reactions of the available drugs. Anti-vimentin antibodies could be a marker of cardiac muscle cell damage, appearing in American Trypanosomiasis patients during active muscle cell damage.

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Original Article

Late Results of Cox Maze III Procedure in Patients with Atrial Fibrillation Associated with Structural Heart Disease

Gustavo Gir Gomes et al. Wagner Luis Gali Alvaro Valentim Lima Sarabanda Claudio Ribeiro da Cunha … Iruena Moraes Kessler Fernando Antibas Atik

Abstract

Background:

Cox-Maze III procedure is one of the surgical techniques used in the surgical treatment of atrial fibrillation (AF).

Objectives:

To determine late results of Cox-Maze III in terms of maintenance of sinus rhythm, and mortality and stroke rates.

Methods:

Between January 2006 and January 2013, 93 patients were submitted to the cut-and-sew Cox-Maze III procedure in combination with structural heart disease repair. Heart rhythm was determined by 24-hour Holter monitoring. Procedural success rates were determined by longitudinal methods and recurrence predictors by multivariate Cox regression models.

Results:

Thirteen patients that obtained hospital discharge alive were excluded due to lost follow-up. The remaining 80 patients were aged 49.9 ± 12 years and 47 (58.7%) of them were female. Involvement of mitral valve and rheumatic heart disease were found in 67 (83.7%) and 63 (78.7%) patients, respectively. Seventy patients (87.5%) had persistent or long-standing persistent AF. Mean follow-up with Holter monitoring was 27.5 months. There were no hospital deaths. Sinus rhythm maintenance rates were 88%, 85.1% and 80.6% at 6 months, 24 months and 36 months, respectively. Predictors of late recurrence of AF were female gender (HR 3.52; 95% CI 1.21-10.25; p = 0.02), coronary artery disease (HR 4.73 95% CI 1.37-16.36; p = 0.01) and greater left atrium diameter (HR 1.05; 95% CI 1.01-1.09; p = 0.02). Actuarial survival was 98.5% at 12, 24 and 48 months and actuarial freedom from stroke was 100%, 100% and 97.5% in the same time frames.

Conclusions:

The Cox-Maze III procedure, in our experience, is efficacious for sinus rhythm maintenance, with very low late mortality and stroke rates.

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Viewpoint

Rheumatic Fever: a neglected and underdiagnosed disease. New perspective on diagnosis and prevention

Carlos Eduardo de Barros Branco et al. Roney Orismar Sampaio Mario Maia Bracco Samira Saady Morhy … Marcelo Luiz Campos Vieira Luiza Guilherme Luiz Vicente Rizzo Flavio Tarasoutch

The Rheumatic fever (RF) and the rheumatic heart disease (RHD) remain important health problems among populations of developing countries. The number of studies is scarce, and public and private investments are practically inexistent. In addition, the cases of rheumatic fever are underdiagnosed, and are recognized only following permanent valve damage through the manifestation of carditis, more frequently represented by mitral stenosis.

In high-income countries, a tonsillitis is only a “throat infection”. However, in developing countries, or even those of average income, as it is the case of Brazil, it may be a harbinger of rheumatic heart disease, a disease that kills approximately 233,00 to 500,000 of RF/RHD sufferers per year globally. According to a projection by the World Health Organization (WHO) and the latest census by the Brazilian Institute of Geography and Statistics (“Instituto Brasileiro de Geografia e Estatística”, IBGE), it is estimated that annually in Brazil 10 million streptococcal pharygotonsillitis occur, totaling thirty Thousand new RF cases, of which up to half may evolve with cardiac involvement.

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Artigo Original

Effect of penicillin G every three weeks on oral microflora by penicillin resistant Viridans Streptococci

André Andrade de Aguiar et al. Roney Orismar Sampaio Jorge Luiz de Mello Sampaio Guilherme Sobreira Spina … Ricardo Simões Neves Luiz Felipe Pinho Moreira Max Grinberg

BACKGROUND: Benzathine penicillin G every 3 weeks is the standard protocol for secondary prophylaxis for recurrent rheumatic fever. OBJECTIVE: Assess the effect of Benzathine penicillin G on Streptococcus sanguinis and Streptococcus oralis in patients with cardiac valvular disease due to rheumatic fever receiving secondary prophylaxis. METHODS: Oral streptococci were evaluated before (baseline) and after 7 days (day 7) with Benzathine penicillin G in 100 patients receiving routine secondary rheumatic fever prophylaxis. Saliva samples were evaluated for colony count and presence of S. sanguinis and S. oralis. Chewing-stimulated saliva samples were serially diluted and plated onto both nonselective and selective 5% sheep blood agar containing penicillin G. The species were identified using conventional biochemical tests. Minimal inhibitory concentrations were determined with the Etest. RESULTS: No statistical differences were found in the presence of S. sanguinis comparing baseline and day 7 (p = 0.62). However, the existing number of positive cultures of S. oralis on day 7 after Benzathine penicillin G presented a significant increase compared to baseline (p = 0.04). No statistical difference was found between baseline and day 7 concerning the number of S. sanguinis or S. oralis CFU/mL and median minimal inhibitory concentrations. CONCLUSION: This study showed that Benzathine penicillin G every 3 weeks did not change the colonization by S. sanguinis, but increased colonization of S. oralis on day 7 of administration. Therefore, susceptibility of Streptococcus sanguinis and Streptococcus oralis to penicillin G was not modified during the penicillin G routine secondary rheumatic fever prophylaxis. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

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Case Report

Association between immunological diseases and their similar clinical manifestations

Alexandre de Matos Soeiro et al. Maria Carolina Feres de Almeida Tarso Augusto Duenhas Accorsi Guilherme Sobreira Spina … Carlos Vicente Serrano Jr Flávio Tarasoutchi

We report on a 30-year-old female patient, with biological mitral valve prosthesis due to symptomatic mitral stenosis and a history of acute myocardial infarction and generalized tonic-clonic seizure episodes, visual hallucinations, cerebral thromboembolic events and, at present, chorea and acute carditis. The patient was diagnosed with active rheumatic fever (RF), systemic lupus erythematosus (SLE) and Antiphospholipid syndrome (APS). The combination of three unusual diagnoses in the same patient makes this a unique case, modifying patient treatment and prognosis.

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Artigo Original

Amplification of the genes that codify endothelin-1 and its receptors in rheumatic mitral valves

Edmilson Bastos de Moura et al. Mariana Ribeiro Gomes Ricardo Barros Corso Cristiano Nicolleti Faber … Fabiana Pirani Carneiro Yolanda Galindo Pacheco

BACKGROUND: Cardiopathies are high prevalence conditions. Among them, rheumatic carditis is of high relevance in developing countries. Left cardiac chamber changes are associated to endothelial dysfunction and ET-1 levels increase. Pulmonary circulation is then affected, and not seldom leading to pulmonary hypertension (PH). However, the presence of ET-1 and its receptors in the mitral valve itself – promoting pulmonary vascular changes, with increased rheumatic valvular deformation – has not been discussed in the literature. OBJECTIVE: To determine the expression of endothelin gene and its receptors in rheumatic mitral valves through techniques of molecular genetics. METHODS: Twenty-seven patients submitted to mitral valve replacement had their valvular tissue examined to determine the presence of ET-1 genes and their A and B receptors. Histological and molecular analysis of the valves was performed (divided into M1, M2 and M3 fragments), with patients’ clinical and epidemiological data collected. Patients were divided into 3 groups (mitral valvopathy, mitroaortic valvopathy, and reoperation patients). RESULTS: The study showed endothelin-1 gene expression in 40.7% specimens and A receptor in all samples; receptor gene B had lower expression (22.2%). CONCLUSION: All patients showed A receptor gene expression. No statistically significant difference was observed in regard to condition severity, expressed according to functional class, and subgroups (mitral valvopathy, mitroaortic valvopathy, and reoperation patients).

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Artigo Original

Surgical mitral valve repair in children with rheumatic fever

Andréa Rocha e Silva et al. Gesmar Volga Haddad Herdy Alan Araujo Vieira Luiz Carlos Simões

BACKGROUND: Mitral repair is well accepted in children with rheumatic fever. OBJECTIVE: To analyze the outcomes of surgical mitral repair in children with rheumatic lesions after four years of follow-up. METHODS: Retrospective study of 40 patients younger than 18 years, who underwent surgery in the National Institute of Cardiology (Rio de Janeiro) between January 1998 and January 2003. The echocardiographic degree of mitral regurgitation; surgical technique used; pre and postoperative functional class; patient outcome; need for valve replacement; and deaths were analyzed. RESULTS: Twenty one patients (52.5%) were females. Severe mitral regurgitation was observed in 32 patients (80%) and moderate in eight (20%). Three immediate deaths occurred (7.5%). Three months after surgery, echocardiography showed no valve regurgitation or mild regurgitation in 35 of 37 cases (94.6%) patients, and severe regurgitation in two (5.2%). Thirty three cases (82.5%) were in functional class III or IV in the preoperative period, and three months after surgery all the 37 cases (100%) were in functional class I or II. The differences between the degree of mitral regurgitation and functional class in pre and postoperative periods were statistically significant (p<0.01). Seven (19%) patients underwent heart valve replacement before four years of follow-up. CONCLUSION: Mitral valve repair showed favorable results in most of the cases as regards the degree of mitral regurgitation and the pre and postoperative functional class. Only 19% of the patients required surgical valve replacement before four years of follow-up.

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Case Report

Atypical presentation of rheumatic carditis in pregnancy

Lurildo Cleano Ribeiro Saraiva et al. Aluísio Macedo Ana Elizabeth M. Batista

We report the case of a 31-year old woman presenting with atypical rheumatic disease in the 28th week of the second pregnancy. Questions related to prevention of the disease and its treatment during the pregnancy-puerperium cycle are discussed.

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Anatomopathological Session

Case 3/2008: severe and rapidly progressive dyspnea in a woman with mechanical mitral valve prosthesis

Adriano Freitas Ribeiro et al. Michele Tavares Abrantes Marcelo Vieira Vera Demarchi Aiello

ANATOMOPATHOLOGICAL SESSION

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Artigo Original

Comparison of the inoue and single balloon techniques during long term percutaneous balloon mitral valvoplasty follow-up: analysis of risk factors for death and major events

Ivana Picone Borges et al. Edison Carvalho Sandoval Peixoto Rodrigo Trajano Sandoval Peixoto Paulo Sergio de Oliveira … Mario Salles Netto Ricardo Trajano Sandoval Peixoto Marta Labrunie Pierre Labrunie Ronaldo de Amorim Villela Aristarco Gonçalves Siqueira-Filho

OBJECTIVE: To analyze the long term evolution of patients undergoing percutaneous balloon mitral valvoplasty comparing the Inoue and Balt single balloon methods, and to identify predictors of death and major events (death, repeat balloon mitral valvoplasty or mitral valve surgery). METHODS: The follow-up for the single and Inoue balloon groups were 54 ± 31 (1 to 126) months and 34 ± 26 (2 to 105) months, respectively (p 50 years and an echocardiographic score > 8 were independent predictors of death; and an echocardiographic score > 8 and post operative mitral valve area 50 years, echocardiographic score > 8 and mitral valve area < 1.50 cm² after the procedure.

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Artigo Original

Comparative study of clinical and Doppler echocardiographic evaluations of the progression of valve diseases in children and adolescents with rheumatic fever

Zilda Maria Alves Meira et al. Eugênio Marcos Andrade Goulart Cleonice de Carvalho Coelho Mota

OBJECTIVE: Compare clinical and Doppler echocardiographic evaluations in assessing valvular diseases in children and adolescents with rheumatic fever, as well as assess the progression of the disease in light of these assessments. METHODS: This is a longitudinal study of 258 children and adolescents diagnosed with rheumatic fever according to Jones’ criteria. The follow-up period ranged from 2-15 years. The presence and quantification of valve diseases were determined by means of clinical and Doppler echocardiographic evaluations performed during the acute and chronic phases. The Kappa statististics method was used to estimate the degree of agreement between clinical and Doppler echocardiographic evaluations. Comparisons between clinical and Doppler echocardiographic findings on the progress of carditis and valvulitis, respectively, were made using chi-square test or Fisher’s exact test, p< 0.05. RESULTS: Of the 109 patients who underwent Doppler echocardiographic evaluation during the acute phase, 31 did not present clinical evidence of carditis, but the Doppler echocardiograms of 17 (54.8%) of them showed valve lesions (subclinical valvulitis). During the chronic phase, 153 of the 258 patients had normal cardiovascular examination results; however, Doppler echocardiograms showed that 81 of them (52.9%) had valve lesions (subclinical chronic valvular diseases). Involution of the valvular lesions, as shown by Doppler echocardiographic evaluations, was less frequent and occurred in 10 (25.0%) patients with mild valvulitis, in only one (2.5%) patient with moderate valvulitis, and in none of the patients with severe valvulitis. CONCLUSION: The identification of rheumatic fever valve lesions can be enhanced when clinical evaluations are supplemented by Doppler echocardiographic examinations; also, clinical examinations are not as suitable to detect valvular lesion regression as the echocardiography. The diagnosis of subclinical valvulitis and valvulopathy influences the secondary prophylaxis of rheumatic fever and endocarditis.

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Artigo Original

Percutaneous mitral balloon valvotomy: long-term outcome and assessment of risk factors for death and major events

Ivana Picone Borges et al. Edison Carvalho Sandoval Peixoto Rodrigo Trajano Sandoval Peixoto Paulo Sergio de Oliveira … Mario Salles Netto Pierre Labrunie Marta Labrunie Ricardo Trajano Sandoval Peixoto Ronaldo de Amorim Villela

OBJECTIVE: To identify the factors that predict death and combined events, (death, new mitral balloon valvotomy, or mitral valve surgery) in long-term follow-up of patients undergoing percutaneous mitral balloon valvotomy. METHODS: Follow-up was 49.0±31.0 (1 to 122) months. Techniques used were the single-balloon (84.4%), Inoue-balloon (13.8%), and double-balloon techniques (1.7%). RESULTS: Included in the study were 289 patients 38.0±12.6 years of age (range, 13 to 83). Before the procedure, 244 patients had echocardiographic score 8. Females comprised 85%, and 84% patients were in sinus rhythm. During follow-up, survival of the total group was 95.5%, that of the group with 8 was 82.2% (P<0.0001), whereas combined event-free survival was 83.4%, 86.1%, and 68.9%, respectively (P 8 and the presence of severe valvular mitral regurgitation during the procedure. The events that predicted combined events were a previous history of mitral valvular commissurotomy and atrial fibrillation and the presence of severe mitral valvular regurgitation during the procedure, and postprocedure mitral valvular area < 1.5 m² (failure). CONCLUSION: Percutaneous mitral balloon valvotomy is an effective procedure, and over 2/3 of the patients were event-free at the end of follow-up. Survival in the group was high, even higher in the group with lower echocardiographic scores.

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Artigo Original

Clinical and demographic characteristics of 99 episodes of rheumatic fever in Acre, the Brazilian Amazon

Fátima Borges et al. Maria Luiza A. Barbosa Renata Beyruth Borges Olívia C. Pinheiro … Carlos Cardoso Claudilson Bastos Roque Aras

OBJECTIVE: To report clinical manifestations and demographic characteristics of patients with rheumatic fever treated in a public hospital in the state of Acre. METHODS: A cross-sectional study was conducted of patients consecutively seen in the Cardiology Ward at FUNDHACRE Demographic, clinical and laboratory data were assessed through a questionnaire. The diagnosis of rheumatic fever was made based on Jones’ criteria, associated with laboratory data, electrocardiography, chest X-ray, and bi-dimensional echocardiography. Patients with other heart diseases, diabetes, obesity, inflammatory disease, and infections were excluded. Those who smoked, were pregnant, or used anti-inflammatory medication or hormone therapy were also excluded. RESULTS: From July 2003 to February 2004, 99 patients with rheumatic fever were assessed (mean age, 11 years, SD= ± 10.18) with a predominance of females (59.6%), and a racial phenotype of a mixture of Caucasian and Indian (60.6%). Three individuals were excluded because they did not meet the diagnostic criteria. Mean age was 9.1 years old, and in 30.4% of the patients, the disease was diagnosed at the first episode of rheumatic fever. The most frequent clinical manifestations were carditis (69.7%), arthritis (21.4%), and chorea (6.1%). Mitral regurgitation was the most common lesion (36.4%) followed by the association of mitral regurgitation and aortic regurgitation (9.1%). CONCLUSION: Rheumatic carditis was the most common manifestation of rheumatic fever, predominant in the group with a racial mixture of Caucasian and Indian (60.6%). Low compliance with antibiotic therapy contributed to the recurrence of the disease and to cardiac sequelae.

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Artigo Original

Comparison of open commissurotomy and balloon valvuloplasty in mitral stenosis: a five-year follow-up

Luiz Francisco Cardoso et al. Max Grinberg Pablo Maria Alberto Pomerantzeff Miguel Antonio Neves Rati … Caio Cesar Jorge Medeiros Marcelo Luiz Vieira Luiz Virgen Flávio Tarasoutchi

OBJECTIVE: To compare clinical and laboratory data in patients with mitral stenosis undergoing open commissurotomy or balloon valvuloplasty, who were followed up for 5 years. METHODS: Eighty-one patients were prospectively assessed prior to the procedure (PRE) and immediately after the procedure, in the immediate postoperative period (IPO), and followed up yearly for 5 years (PO12M, PO24M, PO36M, PO48M, and PO60M). They were randomized into the following 2 groups: GC (group undergoing open commissurotomy): 37 patients (32.4 ± 7.2 years; 89.2% females); and GV (group undergoing balloon valvuloplasty): 44 patients (32.9 ± 9.5 years; 90.9% females). The patients’ assessment comprised the following items: functional class, occurrence of events, electrocardiography, and Doppler echocardiography. RESULTS: A significant improvement in functional class occurred in most patients. Three patients in GC and in GV were in functional class III in PO60M. No difference in the mitral gradient was observed between the groups. A difference in the mean mitral valve areas was observed between the groups during the entire evaluation. No patients died. In regard to the IPO of GC, 3 patients had moderate mitral insufficiency (MI), and 3 had bleeding (1 was reoperated upon). In the IPO of GV, 4 patients had moderate MI, 1 had severe MI, 2 had cardiac tamponade, and 1 patient required surgery due to severe MI. Over 60 months, 9 GV patients evolved to moderate or severe MI, while 6 GC patients evolved to moderate or severe MI, and 2 other GC patients required surgery due to double mitral dysfunction. CONCLUSION: The rate of success in open mitral commissurotomy and balloon mitral valvuloplasty was 100%, and the rate of complications was low. During follow-up, a mild elevation in mitral gradient and a drop in mitral valve area were observed in both groups.

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Original Article

Immediate and long term evolution of valve replacement in children less than 12 years old

Fernando Antibas Atik et al. Altamiro Ribeiro Dias Pablo M. A. Pomerantzeff Miguel Barbero-Marcial … Noedir Antonio Groppo Stolf Adib Domingos Jatene

OBJECTIVE: The aim of this work was the follow-up and evaluation of valve replacement in children under 12 years of age. METHODS: Forty-four children less than 12 years old were underwent valve replacement at INCOR-HCFMUSP between January 1986 and December 1992. Forty (91%) were rheumatic, 39 (88.7%) were in functional classes II or IV, 19 (43.2%) were operated upon on an emergency basis, and 6 (13.6%) had atrial fibrillation. Biological prostheses (BP) were employed in 26 patients (59.1%), and mechanical prostheses (MP) in 18 (40.9%). Mitral valves were replaced in 30 (68.7%), aortic valves in 8 (18.2%), a tricuspid valve in 1 (2.3%), and double (aortic and mitral) valves in 5 (11.4) of the patients. RESULTS: Hospital mortality was of 4.5% (2 cases). The mean follow-up period was 5.8 years. Re-operations occurred in 63.3% of the patients with BP and in 12.5% of those with MP (p=0.002). Infectious endocarditis was present in 26.3% of the BP, but in none of the cases of MP (p=0.049). Thrombosis occurred in 2 (12.5%) and hemorrhage in one (6.5%) of the patients with a MP. Delayed mortality occurred in 5 (11.9%) of the patients over a mean period of 2.6 years; four had had BP and one had a MP (NS). Actuarial survival and re-operation-free curves after 10 years were respectively, 82.5±7.7 (SD)% and 20.6±15.9%. CONCLUSION: Patients with MP required fewer re-operation, had less infectious endocarditis and lower late mortality rates compared with patients with bioprostheses. The former, therefore, appear to be the best valve replacement for pediatric patients.

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