Mitral stenosis in a girl of five years

Mitral stenosis(MS) detected below the age of 20 years is called juvenile mitral stenosis (JMS). JMS constitute 25-40 % of all cases of isolated mitral stenosis, though overall incidence of rheumatic fever and rheumatic heart disease (RHD) within mixed population is 7.5- 7.8 per thousand. The patient was 5 years old girl hailing from Modhupur, Tangail got herself admitted into CCU Mymensingh Medical College Hospital with the complaints of low grade fever, shortness of breath and also associated with failure to thrive. She was ill looking, mildly anaemic. Precordial examination revealed apex beat was in the left 5th intercostals space, tapping in nature, palpable P(2). There was left parasternal heave. 1st heart sound loud, pulmonary component of the 2nd heart sound was accentuated, opening snap with mid diastolic murmur with pre systolic accentuation. Routine blood examination reveals leucocytosis with raised ESR. C-reactive protein (CRP) and ASO titre were significantly raised. X-ray chest P/A view showing the features of mitral stenosis. Echocardiography showing MS (moderate) with pulmonary hypertension. She was treated with antibiotics and other relevant drugs and discharge with an advice for follow up and take preparation for cardiac intervention.

Giant Cell Tubulitis with Tubular Basement Membrane Immune Deposits: A Report of Two Cases after Cardiac Valve Replacement Surgery

This paper presents two elderly patients who had normal baseline renal function and had stenotic valvular lesions secondary to rheumatic fever and underwent aortic valve replacements with mechanical valves. Both patients developed acute renal failure after cardiac valve replacement procedures. The renal biopsies revealed acute granulomatous tubulointerstitial nephritis. The unique histologic features were tubular basement membrane (TBM) immune complex deposition detected by both immunofluorescence and electron microscopy and prominent multinucleated giant cells surrounding intact TBM. The temporal relationship to the surgical procedure and the subsequent recovery of the patients' renal functions upon therapy suggested that the renal failure may have been due to an allergic drug reaction from the perioperative exposure to unknown agents, such as prophylactic antibiotics and furosemide. The literature on TBM immune complex deposition was reviewed, and the pathophysiologic mechanisms that may account for the similarities between the clinicopathologic features of these two cases were examined. These two cases expand the histopathologic spectrum of previously described cases of putative drug-induced acute tubulointerstitial nephritis.

Rheumatic heart disease in children: from clinical assessment to therapeutical management

Rheumatic heart disease is still a relevant problem in children, adolescents and young adults. Molecular mimicry between streptococcal and human proteins has been proposed as the triggering factor leading to autoimmunity and tissue damage in rheumatic heart disease. Despite the widespread application of Jones' criteria, carditis is either underdiagnosed or overdiagnosed. Endocarditis leading to mitral and/or aortic regurgitation influences morbidity and mortality of rheumatic heart disease, whilst myocarditis and pericarditis are less significant in determining adverse outcomes in the long-term. Strategy available for disease control remains mainly secondary prophylaxis with the long-acting penicillin G-benzathine.

QT dispersion in acute rheumatic fever

BACKGROUND

Disturbances of conduction are well known in the setting of acute rheumatic fever. The aim of this study is to investigate the QT dispersion as seen in the surface electrocardiogram of children with acute rheumatic fever.

METHODS

QT dispersion was quantitatively evaluated in 88 children with acute rheumatic fever. Patients were divided into two groups based on the absence or presence of carditis. As a control group, we studied 36 healthy children free of any disease, and matched for age with both groups. Repeat echocardiographic examinations were routinely scheduled in all patients at 3 months after the initial attack to study the evolution of valvar lesions.

RESULTS

The mean QT dispersion was significantly higher in children with rheumatic carditis. But there was no statistical difference between children without carditis and normal children. Among the children with carditis, the mean dispersion was higher in those with significant valvar regurgitation. Dispersion of greater than 55 milliseconds had a sensitivity of 85%, and specificity of 70%, in predicting rheumatic carditis, while a value of 65 milliseconds or greater had sensitivity of 81% specificity of 85% in predicting severe valvar lesions in acute rheumatic carditis. At follow-up examination, a clear reduction on the QT dispersion was the main finding, reflecting an electrophysiological improvement.

CONCLUSIONS

These observations suggest that QT dispersion is increased in association with cardiac involvement in children with acute rheumatic fever.

Assessment of a register-based rheumatic heart disease secondary prevention program in an Australian Aboriginal community

OBJECTIVE

To assess specific performance indicators relating to a register-based acute rheumatic fever and rheumatic heart disease (ARF/RHD) prevention program in a remote Australian Aboriginal community in order to identify the most appropriate avenues for improvements in delivery of services.

METHODS

Information kept on the central ARF/RHD register was compared with an amalgamated dataset from three other sources. The community clinic charts of identified patients were reviewed for information regarding accuracy of diagnosis and the number of doses of benzathine penicillin received in the last year. Specific follow-up arrangements were assessed and compared with practice guidelines.

RESULTS

The central ARF/RHD register contained the names of 58 of the 72 (81%) people identified in the community as eligible for inclusion. Only 42% (22/52) of people receiving antibiotic prophylaxis had received 80% or more of the recommended doses in the previous year; service delivery was significantly better for females than males (p = 0.004). Individuals in priority category 1 (most severe disease) were found to be receiving follow-up and investigation according to guidelines. About half the people in categories 2 (moderate disease) and 3 (mild disease) had been inadequately investigated and/or missed out on follow-up appointments.

CONCLUSIONS

The ARF/RHD prevention program in this large remote Aboriginal community is struggling to deliver services to a substantial proportion of people who require them. Specific interventions, especially those related to men's health, may be required to correct the problems.

[Active rheumatic heart disease: findings from an 17-case series in the University Hospital Center of Dakar, Senegal]

This report is based on retrospective review of the charts of 18 patients with pre-existing active rheumatic heart disease compiled over a period of two years (January 2000 to December 2001). The purpose of this study was to determine the incidence of acute degenerative joint disease, to describe the clinical features and natural course of the disease, and to highlight the main points in the fight against degenerative joint disease and rheumatic heart disease. The prevalence of active rheumatic disease was 3.7%. Mean patient age was 15.5 years (range: 8 to 25 years). Female sex was predominant with 13 girls and 4 boys (sex ratio: 3.25). The most common clinical symptoms were migratory polyarthritis involving large joints in 14 cases (82.3%) and left heart insufficiency in 13 (76.4%). Additional clinical findings included oscillating fever in 8 cases (47.05%), tooth decay in 11 (73.3%), and poor buccodental hygiene in 14 (93.3%). Blood tests to evaluate inflammation demonstrated high values in all patients with mean ASLO titer of 950 UI/l, mean serum fibrin level of 7.8 g/l, and mean C-reactive protein level of 28.5 mg/l. The erythrocyte sedimentation rate was high in 15 cases (88.2%). In addition to showing heart valve disease, electrocardiography demonstrated first-degree atrioventricular block in 1 case. Chest x-ray revealed cardiomegaly in 15 cases (88.2%). Doppler ultrasonography of the heart showed isolated rheumatoid disease in 11 cases (64.7%). All patients responded favourably to treatment with corticosteroids and penicillin. The incidence of recurrence of active disease was high (70.5%) thus supporting use of high loading doses. Rheumatic heart disease is a public health problem in Africa and requires appropriate preventive measures.

[Asymptomatic myocarditis after infection of the upper respiratory tract]

HISTORY AND CLINICAL FINDINGS

A 20-year-old patient was hospitalized with persistent high fever after tonsillitis and swelling of the talocalcanean joint.

INVESTIGATIONS

The ECG showed a partial right bundle branch block pattern and pathological T inversions on the left precordial leads. Cardiac Troponin I levels were slightly elevated and echocardiography revealed a dyscinetic area at the right ventricular apex. The anti-streptolysin titer was elevated.

DIAGNOSIS

Post-streptococcal rheumatic myocarditis. THERAPY AND FOLLOW-UP: Antibiotic therapy for 2 weeks. The patient showed subjective full recovery after 6 weeks. The anti-streptolysin titer further increases. Nuclear spin tomography of the heart reveal postinflammatory alterations at the apex of the right ventricle.

CONCLUSION

Rheumatoid fever is a rare diagnosis in developed countries. This case, however, illustrates that the true prevalence of rheumatoid carditis might be underestimated in the presence of only minimal heart-and joint-specific symptoms.

Effects of long-term beta-blocker therapy on P-wave duration and dispersion in patients with rheumatic mitral stenosis

BACKGROUND

P-wave dispersion (PWD), has been defined as the difference between maximum and minimum P-wave duration. Prolonged P-wave duration and increased PWD have been reported to be related with increased risk for atrial fibrillation (AF). AF is the most common sustained arrhythmia encountered in patients with rheumatic mitral stenosis (MS). Beta-blockers are the mainstay of therapy in patients with rheumatic MS to control ventricular rate both during sinus rhythm and AF. In the present study, we aimed to evaluate the effect of long-term beta-blocker therapy on P-wave duration and PWD in patients with rheumatic MS.

METHOD

Study population includes 46 patients (group I, 8 men, 38 women, mean age = 34+/-8 years) with newly diagnosed moderate-to-severe rheumatic MS who have not taken any medication before and prescribed oral beta-blocker therapy and 46 healthy control subjects without any cardiovascular disease (group II, 8 men, 38 women, mean age = 35+/-7 years). Mitral valve area, maximum and mean diastolic mitral gradients, left atrial diameter, and systolic pulmonary artery pressure were evaluated by transthoracic echocardiography before initiation of beta blocker therapy and repeated at the end of the first month. Baseline maximum and minimum P-wave duration and PWD were determined on 12-lead electrocardiogram recorded for each patient and control subject and repeated at the end of the first month after initiation of beta-blocker therapy in patient group.

RESULTS

Maximum P-wave duration and PWD were found to be significantly higher in patients with MS than those in control subjects (Maximum P-wave duration: 128+/-7 ms vs. 104+/-4 ms and PWD: 52+/-6 ms vs. 27+/-3 ms, p < 0.001 for both). Both groups had comparable minimum P-wave duration (75+/-4 ms vs. 76+/-4 ms, p = 0.093). Maximum P-wave duration and PWD were found to be significantly decreased by long-term beta blocker therapy (Maximum P-wave duration; 128+/-7 ms vs. 122+/-6 ms, p < 0.001, PWD; 52+/-6 ms vs. 47+/-5 ms, p < 0.001). However, there was no significant difference between the values of minimum P wave duration measured before and at the end of the first month of beta-blocker therapy (75+/-4 ms vs. 75+/-3 ms, p = 0.678). Statistically significant decrease were detected on maximum and mean mitral gradient and systolic pulmonary artery pressure and resting heart rate at the end of the first month of beta-blocker therapy. However, only the change in resting heart rate was found to be significantly correlated with the decrease in maximum P-wave duration and PWD (Maximum P-wave duration: r = 0.327, p = 0.026, PWD: r = 0.378, p = 0.01).

CONCLUSION

We have shown for the first time that long-term beta-blocker therapy causes a significant decrease in maximum P-wave duration and PWD in patients with rheumatic MS.

Percutaneous Transluminal Mitral Valvuloplasty Reduces Circulating Vascular Cell Adhesion Molecule-1 in Rheumatic Mitral Stenosis

BACKGROUND

The circulating levels of adhesion molecules, such as vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1), have been demonstrated to be elevated in patients with rheumatic mitral stenosis (MS). However, the impact of percutaneous transluminal mitral valvuloplasty (PTMV) on the elevated circulating levels of VCAM-1 and ICAM-1 in patients with MS has never been investigated.

METHODS

and results: A total of 19 patients with symptomatic MS undergoing PTMV were studied (group 1) [15 patients in chronic atrial fibrillation, and 4 patients in sinus rhythm]. The plasma levels of soluble VCAM-1 and ICAM-1 in the femoral vein and artery, and right and left atria before PTMV, and those in the peripheral venous blood at the 1-week and 4-week follow-ups after PTMV were determined by solid-phase sandwich enzyme-linked immunosorbent assay. The mitral valve area was calculated by means of the Doppler pressure half-time method. In addition, we measured plasma concentrations of soluble VCAM-1 and ICAM-1 in the peripheral venous blood samples obtained from 22 control patients (including 14 healthy volunteers in sinus rhythm [group 2] and 8 patients in chronic lone atrial fibrillation [group 3]). The plasma level of soluble VCAM-1 was significantly elevated in group 1 patients (1,205.4 +/- 462.4 ng/mL [mean +/- SD]) compared with group 2 (580.9 +/- 208.0 ng/mL) and group 3 patients (716.4 +/- 221.6 ng/mL) [p < 0.0001]. In group 1 patients, the plasma levels of soluble VCAM-1 and ICAM-1 in the left atrium did not differ from those in the right atrium, femoral vein, or femoral artery (p = 0.668 for VCAM-1, and p = 0.232 for ICAM-1). The area of mitral valve increased significantly after PTMV (1.08 +/- 0.14 cm(2) vs 1.48 +/- 0.33 cm(2), p < 0.0001). The mean left atrial pressure fell significantly after PTMV (22.9 +/- 5.2 mm Hg vs 17.7 +/- 6.0 mm Hg, p < 0.0001). The peripheral venous plasma level of soluble VCAM-1 obtained before PTMV fell significantly after PTMV (before, 1,205.4 +/- 462.4 ng/mL; 1 week after PTMV, 915.7 +/- 280.2 ng/mL; 4 weeks after PTMV, 859.0 +/- 298.7 ng/mL; p < 0.0001).

CONCLUSIONS

In patients with moderate-to-severe MS, the venous plasma level of soluble VCAM-1 fell significantly after PTMV, and the elevated plasma soluble VCAM-1 concentration was associated with hemodynamic abnormality rather than with rheumatic activity.

Rheumatic fever and rheumatic heart disease: clinical profile of 550 cases in India

BACKGROUND

The aims and objectives of this paper were to analyze the clinical presentation of children with rheumatic fever (RF) and rheumatic heart disease (RHD), to determine the cardiac sequel of RF and valvular affection due to RF, and to study clinical manifestations in recurrences of RF.

METHODS

Our study, a retrospective analysis, was conducted at a tertiary-care teaching hospital with specialty follow-up clinic for patients with RF/RHD. This retrospective study was conducted to include a period of 31 years (from January 1971 through December 2001). Pre-completed case protocols of patients with RF/RHD were analyzed to record the following information: demographic data; clinical features on admission/presentation; relevant investigations; recurrences; cardiac valvular affection, and outcome. Modified Jones' criteria were used for diagnosis of RF.

RESULTS

The study included 550 patients. Mean age of presentation was 9.62 years and sex ratio was 1.15:1 favoring males. A total of 250 patients presented with initial/first attack of RF. Arthritis and carditis were seen in 169 (67.6%) and 105 cases (42%), respectively. Chorea was seen in 47 cases (18.8%) and erythema marginatum, in four. A total of 224 patients presented with recurrence of RF (with pre-existing RHD). Arthritis and carditis were seen in 109 (48.66%) and 178 cases (79.46%), respectively, in these patients; 76 cases presented with chronic RHD. Mitral regurgitation was the most common cardiac valvular lesion observed (150 cases) followed by a combination of mitral stenosis and mitral regurgitation (98 cases). Congestive cardiac failure was seen in 201 cases (36.54%) and infective endocarditis in 30 (5.45%). 2-D echocardiography and/or color Doppler was performed in 201 patients (36.54%). Average duration of follow-up was 3.19 years; 74.72% of cases were lost to follow-up. Benzathine penicillin prophylaxis was regular in 42.18% cases. Positive family history of RF/RHD was present in 2% of cases. Twenty three patients (4.18%) died.

CONCLUSIONS

Arthritis was the most common manifestation in the initial attack of RF, while carditis was the most common manifestation in patients presenting with rheumatic recurrences (with pre-existing RHD) and mitral regurgitation was the most common valvular lesion. Rate of patient dropout from penicillin prophylaxis was high. Clinical manifestations in initial/first attack of RF have not significantly changed in the last 31 years.

Effective regurgitant orifice area of rheumatic mitral insufficiency: response to angiotensin converting enzyme inhibitor treatment

OBJECTIVE

This study was designed for quantification of mitral regurgitation by echocardiographic measurements such as regurgitant volume (RV), regurgitant fraction (RF) and effective regurgitant orifice area (EROA), and to assess the effect of angiotensin converting enzyme inhibitor (ACEI) therapy on these measurements.

METHODS

Patients with rheumatic mitral insufficiency were divided into two groups: Study group (SG)-10 females, 2 males, aged 10-18 years, body surface area 1.49+/-0.05 m2, receiving digoxin therapy for at least one year and Control group (CG)-8 females, 4 males, aged 8-17 years, body surface area 1.38+/-0.07 m2, with no treatment. Patients in the two groups had no symptoms of cardiac failure. Angiotensin converting enzyme inhibitor therapy was given to SG patients on admission. Echocardiographic examinations were applied on admission and at the 20th day of therapy with ACEI and digoxin.

RESULTS

Study group's left ventricular end-diastolic volume (108.03+/-41.21 ml/m2), mitral stroke volume (510.37+/-321.58 ml/m2) and regurgitant volume (423.48+/-305.00 ml/m2) were significantly higher (p<0.05) on admission than in the CG (81.98+/-21.53 ml/m2, 315.34+/-207.38 ml/m2 and 245.77+/-179.84 ml/m2, respectively). Aortic stroke volume at the 20th day of therapy was significantly higher in SG than in the CG. Therapy with ACEI decreased significantly SG's left ventricular end-diastolic volume.

CONCLUSION

Angiotensin converting enzyme inhibitors should be started at an early stage of mitral regurgitation. The effective regurgitant orifice area is a feasible and easy method for the outpatient follow-up of mitral regurgitation.

[Study on protective effect of shenfu injection on cardiac function of patients undergoing valve replacement]

OBJECTIVE

To investigate the protective effect of Shenfu injection (SFI) on cardiac function of patients undergoing valve replacement operation under cardio-pulmonary bypass.

METHODS

One hundred and twenty patients undergoing valve replacement operation under cardio-pulmonary bypass were randomly divided into the SFI group and the control group, 60 in each group. Intravenous infusion of 1 ml/kg SFI was given to the SFI group, 30 min before anesthesia, and to the control group, equal volume of normal saline was given instead. The following indices were observed: (1) the hemodynamic changes occurred in the operational period; (2) the dosage of vaso-active drugs used during and after operation; (3) the post-operational recovery time of patients.

RESULTS

The mean arterial pressure and heart rate in the SFI group during operation were higher, while the central venous pressure was lower than those in the control group (P < 0.05). The dosage of vaso-active drugs, such as dopamine, dobutamine, sodium nitroprusside and lidocaine, used during and after operation was lower, and the extubation time and the intensive care unit (ICU) staying time were shorter in the SFI group when compared with those in the control group (P < 0.05).

CONCLUSION

SFI has certain protective effects on the cardiac function of patients undergoing valve replacement operation under cardio-pulmonary bypass.

[Present-day classification and nomenclature of rheumatic fever]

The paper presents a new classification of rheumatic fever, which has been adopted by the Plenary Session of the Association of Rheumatologists of Russia in May 2003. This classification envisages the abandonment of the term "rheumatism" in its former interpretation. The term "acute rheumatic fever" (ARF) appears to be more justified since it makes a physician elucidate its association with Group A streptococcal infection of the throat and prescribe antibiotics for eradication of this infection in its acute period (primary prophylaxis) and for prevention of repeated attacks (secondary prophylaxis). The current interpretation of the clinical syndromes/symptoms and laboratory parameters that enter into diagnostic criteria for ARF is presented. There are 2 types of outcome of the disease. In case of recovery, we are dealing with the complete regression of the clinical symptomatology of ARF, normalized laboratory parameters and no residual changes. Chronic rheumatic diseases of the heart are considered to mean a disease characterized by a cardiac valvular lesion as postinflammatory marginal fibrosis of valvular leaflets or cardiac abnormality (failure and/or stenosis) developed after prior ARF. Emphasis is laid on the significance of evidence of Group A streptococcal infection that precedes the development of the disease. Examples of clinical diagnosis in accordance with the terminology of the International Classification of Diseases, the 10th edition, are given in the paper.

Infective endocarditis: improving the diagnostic yield

INTRODUCTION

Isolating aetiological agents in patients with infective endocarditis (IE) remains problematical. We postulated that the high local incidence of culture-negative IE resulted from antibiotic exposure prior to blood cultures and that a structured delay in therapy in the subacute presentation would improve the diagnostic yield.

AIM

We aimed to prospectively observe the diagnostic approach and give an overview of supplementary laboratory tests.

STUDY DESIGN

Patients with suspected IE were enrolled into this analytical observational study and followed up for six months (n = 92). We compared the diagnostic yield and outcome in cases where antibiotics were withheld for 72 hours, with those cases who received early antimicrobials, despite being deemed safe for delayed therapy.

RESULTS

Definitive diagnoses (definite or excluded IE) were made in 92.8% of patients where antibiotics were delayed, compared to 60% of patients who received empirical treatment (p = 0.08). The mortality rates were 18.4% and 30.0% (p = 0.18). Twenty-three of 26 patients with definite culture-negative IE received antibiotics during the 48 hours preceding cultures, compared to eight of 21 culture-positive patients (P < 0.001). Screening for atypical bacteria did not improve the yield. C-reactive protein (CRP) had a sensitivity of 97.0% (negative predictive value 87.5%), whereas a positive rheumatoid factor (RF) had a specificity of 93.8% (positive predictive value 91.7%).

CONCLUSIONS

We observed tendencies towards a greater diagnostic yield and lower mortality where antibiotics were initially withheld. Antibiotic prior to blood cultures were an important cause of culture-negative IE. A normal CRP proved useful in excluding IE; a positive RF strongly favoured IE.

[Acute rheumatic fever: problems and outlooks]

The issue related with acute rheumatic fever still remains to be topical at the present stage, which is accentuated by a high prevalence of rheumatic heart diseases. The results of multiple studies point out at the presence of "rheumatogenetic" A-streptococcal strains possessing certain biological properties. Although there were no changes in the disease semiotics, the intensity degree of clinical signs went down, due to which an early diagnosis of the disease became more complicated. The issues related with the nosological classification of post-streptococcal reactive arthritis and with PANDAS syndrome need to be solved. There is also an urgent necessity in creating high-technological domestic benzathine-penicillins intended for secondary prevention of the disease.

Evaluation of subclinical valvar disease in patients with rheumatic fever

Carditis is the only manifestation of acute rheumatic fever that leads to permanent disability. Hence, its diagnosis is of paramount importance. Recently, it has been reported that Doppler echocardiography has disclosed subclinical valvar regurgitation in some patients with acute rheumatic fever manifested as isolated arthritis or pure chorea. The prognosis of such patients with acute rheumatic fever and subclinical valvitis is not clear. We aimed, therefore, prospectively to investigate the potential to diagnose patients with subclinical carditis. We examined 40 patients, aged from 7 to 16 years, with Doppler evidence of mitral and aortic regurgitation, but in the absence of any pathologic murmur. The major findings satisfying the Jones criterions were arthritis in 29 patients, chorea in 10 patients, and arthritis and erythema marginatum in one patient. Of the patients, 33 had mitral regurgitation, 6 patients had combined mitral and aortic regurgitation, and one patient had aortic regurgitation. The patients were followed over a mean period of 18.1 +/- 13.9 months, the valvar regurgitation disappearing in 23 (57.5%). No significant differences were observed in the resolution of the valvitis between those treated with acetylsalicylic acid, steroids, or those receiving no treatment. It is noteworthy, nonetheless, that patients treated with steroids were the fastest to recover from valvitis (p < 0.05). Based on our study, we suggest that subclinical valvitis demonstrated by echocardiography should now be accepted as adequate evidence for the diagnosis of carditis, and become a major diagnostic criterion for acute rheumatic fever. When managing this group of patients with subclinical disease, treatment with steroids seems to have a role in promoting early resolution of the valvitis.

The effects of lower intensity anticoagulation therapy on coagulation system in patients with mechanical prosthetic valves

To evaluate the effect of lower intensity anticoagulation therapy in patients with mechanical prosthetic valves, laboratory-based hematological assays including prothrombin time (PT), activity of factor X, antithrombin III (AT III), D-dimer, fibrinogen (Fg) and platel et al pha-granular membrane protein (GMP-140) were performed in 65 patients who had been on warfarin treatment for over one month. The patients were assigned to 3 groups on the basis of their International Normalized Ratios (INR), ranging from 2.00 to 2.50; 2.51 to 3.00; 3.01 to 4.50, respectively. The results showed that the D-dimer, Fg, GMP-140 levels were higher after mechanical valve replacement than those before operation, indicating the activation of coagulation and fibrinolysis system and the damage of platelets. Lower intensity anticoagulation therapy (INR 2.00 to 2.50) could effectively inhibit the activity of factor X and increase the level of AT III. There were no appreciable differences among D-dimer, Fg, GMP-140 and AT III in the 3 anticoagulation intensity groups. These results suggest that in patients with new generation mechanical prosthetic valves, target anticoagulation level (INR 2.00 to 2.50) may result in good protection from thrombo-embolism.

Prevalence of left atrial thrombus in rheumatic mitral stenosis with atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study

BACKGROUND

The frequency of occurrence of left atrial thrombi, and the effect of anticoagulation in patients with rheumatic mitral stenosis and atrial fibrillation is not well established. This study was conducted to evaluate the occurrence of left atrial body and left atrial appendage clots in patients with rheumatic mitral stenosis and atrial fibrillation, and to document the effect of long-term anticoagulation on clot dissolution.

METHODS AND RESULTS

Consecutive patients with severe rheumatic mitral stenosis and atrial fibrillation were assessed by transesophageal echocardiography. Those with left atrial body or left atrial appendage clots were anticoagulated with oral nicoumalone. Transesophageal echocardiography was then repeated in patients on anticoagulation who were on regular follow-up, and in whom percutaneous transvenous mitral commissurotomy could be considered. Of the 490 patients studied, 163 had left atrial body or left atrial appendage clots. A repeat transesophageal echocardiographic examination was done in 50 patients who had optimal anticoagulation for a period of 6 months. Only 2 of the 17 patients who had left atrial body clots had successful clot dissolution after long-term anticoagulation, while the left atrial appendage clots disappeared in 31 of 33 patients (p<0.001).

CONCLUSIONS

Left atrial clots are present in a third of patients with severe rheumatic mitral stenosis and atrial fibrillation. Isolated left atrial appendage clots in patients with rheumatic mitral stenosis and atrial fibrillation can disappear with long-term anticoagulation, while thrombi that extend into the left atrial body may persist despite optimal anticoagulation.

[Modern views on rheumatic fever]

Submitted in the paper are modern conceptions on etiology, pathophysiology, diagnosis and treatment of acute inflammatory rheumatism (IR). Some aspects of IR course in different age groups are highlighted, high informative value of new laboratory methods of diagnosis of its latent forms are validated. The place of interferons and selective inhibitors of COG-2 in the treatment of IR is determined.

Is pentoxifylline therapy effective for the treatment of acute rheumatic carditis? A pilot study

OBJECTIVE

The aim of the present study was to determine whether pentoxifylline has a beneficial effect on the treatment of rheumatic carditis.

METHODS

A total of 33 children between the ages 6 and 16 were studied in two groups. The first group (5 boys, 10 girls, mean age: 12.2 +/- 2.9 years) was treated with steroid plus pentoxifylline and the second group (6 boys, 12 girls, mean age; 11.6 +/- 2.8 years) was treated with steroid only for 3-6 weeks until the acute-phase reactants became normal. At admission and on the 7th, 30th, and 90th days of the treatment, laboratory studies including white blood cell count, erythrocyte sedimentation rate, C-reactive protein, throat culture and cytokines (interleukin-1alpha, tumour necrosis factor-alpha) were performed. Cardiac evaluation with chest X-ray, electrocardiography and echocardiography was performed in all patients. In the control group (12 boys, 3 girls, mean age; 10.7 +/- 3.2 years) all parameters were evaluated once only.

RESULTS

In both groups, the similar white blood cell count was significantly decreased on the 90th day, and there was no significant difference between the two groups. C-reactive protein, erythrocyte sedimentation rate and interleukin-1alpha were significantly decreased on the 30th and 90th days. In the first group (treated with steroid plus pentoxifylline), the cardiothoracic index was significantly greater at the beginning of the therapy. In the first group, tumour necrosis factor-alpha became normal on the 30th day and in the second group, tumour necrosis factor-alpha became normal on the 7th day of therapy. For all parameters, there was no significant difference between the two groups with respect to the type of therapy used.

CONCLUSION

The present study showed that pentoxifylline plus steroid treatment has no beneficial effects on the treatment of acute rheumatic carditis when compared with steroid alone.

Atrial natriuretic peptide levels in rheumatic mitral regurgitation and response to angiotensin-converting enzyme inhibitors

BACKGROUND

Rheumatic mitral regurgitation (MR) causes heart failure by volume overload and an increase in atrial natriuretic peptide (ANP) levels by atrial stretching. Symptoms of heart failure improve with ANP treatment. Angiotensin-converting enzyme inhibitors (ACEI) and ANP have similar effects, such as vasodilation, natriuresis and diuresis.

OBJECTIVE

To determine ANP levels and response to ACEI treatment in children with rheumatic MR.

PATIENTS AND METHODS

Patients with rheumatic MR were divided into two groups: the digoxin group (10 girls, two boys; age range 10 to 18 years, mean 14 +/- 0.72 years; taking digoxin for at least one year) and the control group (eight girls, four boys; age range eight to 17 years, mean 13.5 +/- 0.81 years). None of the patients in either group had symptoms of heart failure. Serum ANP levels, left ventricular systolic functions, and mitral and aortic stroke volumes of both groups were evaluated on admission. The digoxin group was given ACEI and re-evaluated on the 20th day of treatment.

RESULTS

At baseline, ANP levels were higher in the digoxin group (27.3 +/- 6.5 pg/100 microL) than in the control group (6.9 +/- 0.9 pg/100 microL) (P<0.05). On the 20th day of treatment, there were no significant differences in the ANP levels of the digoxin (13.2 +/- 6.1 pg/100 microL) and control groups. There was a significant decrease in ANP levels in the digoxin group between baseline and the 20th day of therapy. Mitral stroke volumes (510.4 +/- 92.8 mL/m2) and left ventricular diastolic volume (108 +/- 12 mL/m2) in the digoxin group at baseline were higher than those in the control group (315.3 +/- 59.9 mL/m2 and 82 +/- 6.5 mL/m2, respectively) on admission; on the 20th day of treatment, there were no significant differences in these values. At baseline, aortic stroke volume in the digoxin and control groups were 86.9 +/- 59.1 and 82.9 +/- 28.3 mL/m2, respectively (P>0.05). On the 20th day of therapy, the aortic stroke volume of digoxin group had increased to 104.7 +/- 70.1 mL/m2, significantly higher than that of the control group.

CONCLUSION

ANP levels are a good indicator of volume overload. ACEI should be introduced at an early stage of rheumatic MR because, even if patients are taking digoxin, their heart failure may progress silently.