[Postoperative course of left ventricular function in aortic insufficiency]

PURPOSE

To analyze the follow-up of left ventricular function (LVF) after surgical correction of severe chronic aortic insufficiency (AI).

METHODS

Twenty-one out of 68 patients with AI, initially asymptomatic and that developed symptoms during the follow-up period of 24-36 months, were studied. Relationship between symptoms and LVF by echocardiogram and radioisotopic ventriculography at rest and in isotonic exercise were studied. Three clinical moments (CM) were assumed: CM-0- at the beginning of the study, when all patients were asymptomatic; CM-1- manifestation of the symptoms during 24-36 months; CM-2- corresponding to the late post-operative period of 8 months of 20 out of 21 patients (one refused the surgery). The analysis did not show any significant differences between the mean values of all echocardiographic variables (diastolic and systolic diameters, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and the ejection fraction of the left ventricle (EF) obtained by the radioisotope ventriculography at rest and, including exercise, between clinical moments 0 and 1.

RESULTS

In the CM-2, involution was verified for functional class I/II in all cases and absence of expressive complications or immediate or late postoperative mortality. Comparison between CM-2 and 0 showed expressive regression of the diameters at rest in the postoperative period and with significant improvement in the means mainly the percentual variation of the EF and total time of effort.

CONCLUSION

Symptoms assembled patients with more advanced eccentric hypertrophy and did not coincide with any immediate change in findings studied at rest and at exercise. It represented a point of reference for surgical indication compatible with late postoperative involution of chronic adaptation of AI.

[Clinico-morphological dissociation in patients with mitral valve stenosis]

PURPOSE

To study characteristics of the natural history of mitral stenosis (MS) in patients that have no correlation between mitral valve areas (MVA) and symptoms.

METHODS

We studied 18 patients with MS, that presented no correlation between MVA and functional class (FC), 16 (89%) were female and two (11%) men, with age ranging from 16 to 54 (mean 33) years. Patients assigned to group A (8 cases) had FC III and MVA > or = 1.5 cm2 and group B (10 cases) FC I/II and MVA < 1.1 cm2. FC and MVA at the start (initial time-It) and after 12 months or before surgical correction (SC) or percutaneous mitral balloon valvuloplasty (PBV) (final time-Ft) were compared. All patients with predict O2 uptake (%PRED VO2) at It were evaluated.

RESULTS

Five (63%) patients of group A, that maintained MVA > or = 1.5 cm2, changed to FC I/II but three (38%) needed a SC or PBV (2 with lesser MVA at Ft). At group B, six (60%) patients needed SC or PBV.

CONCLUSION

MS patients with MVA > or = 1.5 and FC III, providing MVA do not decrease, improves their FC, becoming it more compatible with MVA %PRED VO2. The cases of group B presented the greatest probability of needing SC or PVB.

[Preoperative erythrocytopheresis in a patient with SC hemoglobinopathy and mitral stenosis]

Hemoglobinopathies are associated with thrombotic complications, when exposed to cardiopulmonary bypass. A 54-year old, black woman with hemoglobinopathy SC and severe mitral stenosis was submitted to eritrocytopheresis 48 hours before mitral commissurotomy surgery. The therapeutic determined appearance of the percentual hemoglobin A of 68% with reduction the hemoglobin S of 48% to 15% and the hemoglobin C of 51% to 17%. No complications occurred during postoperative period. To best of our knowledge, that is the first report about application the eritrocytopheresis in the pre operative extra corporeal circulation care in surgical treatment of patients with chronic rheumatic heart disease and hemoglobinopathy SC.

Maternal and fetal outcome in pregnant women with Eisenmenger's syndrome

Interruption of pregnancy is usually recommended for pregnant women with Eisenmenger's syndrome. We studied 13 pregnancies in 12 women with this syndrome, who decided to carry on with their pregnancy despite recommendation for therapeutic abortion. The mean age was 27 years. Five patients had ventricular septal defect; two, persistent ductus arteriosus; one, a combination of both; two, atrial septal defect; one, atrioventricular septal defect and one patient a combination of ventricular and atrial septal defects. Mean systolic and diastolic arterial pulmonary pressures were 112.7 and 61.7, mmHg, respectively. There were three spontaneous abortions, one premature labour at 23 weeks of gestation and two maternal deaths during the 23 and 27 weeks of gestation. Seven patients who reached the end of the second trimester were hospitalized until delivery and received heparin (20,000 to 40,000 units per day) and oxygen therapy. Caesarean section was performed in all patients as a result of worsening maternal or fetal clinical condition during the third trimester of gestation. all the mothers were discharged from hospital but one of them died on the 30th day post-partum. Five of the eight infants were premature, three were small babies for gestational age and all were discharged from hospital with the exception of one who died 48 h after birth. In conclusion, although pregnancy should be discouraged in women with Eisenmenger's syndrome, it can be successful. In this study, prolonged bed rest, the use of heparin and oxygen therapy presumably positively influenced maternal and infant outcomes.

[The relationship between left ventricular function and the precipitation of symptoms in severe chronic aortic insufficiency]

PURPOSE

To study the relationship between symptoms and left ventricular function in 68 patients with severe chronic aortic regurgitation using echocardiogram and radionuclide left ventriculography at rest.

METHODS

Three stages of natural history are assumed: the 1st, at the beginning of the study, when all patients were asymptomatic (clinical stage 0); the 2nd, at the end of 36 month persistence of asymptomatic (clinical stage 1), consisting of 45 patients (group AA); the 3rd, on occasion of manifestation of the symptoms during this period of time (clinical stage 2), consisting of 21 patients (group AS-PRE), with two fatalities not related to valvopathy.

RESULTS

The comparison between the groups resulted in similarities in the mean ages, mean time of knowledge of the disease, predominance of males and rheumatic etiology. The profile analysis showed that the significant initial differences between the average of all echocardiographic variables (diastolic diameter, systolic diameter, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and of the ejection fraction of the left ventricle obtained by the radionuclide ventriculography at rest, remained during the study.

CONCLUSION

Development of symptoms grouped patients with more advanced excentric hypertrophy, did not coincide with any immediate change in the laboratory markers studied at rest and it was used as a referential for surgical therapy.

[Mitral stenosis correction by double catheter-balloon valvuloplasty technique]

PURPOSE

To evaluate long-term efficacy of double balloon percutaneous mitral valvuloplasty technique (PMV2B).

METHODS

Sixty-eight patients (76% female), mean-age 32 (15-69) years who had been submitted to PMV2B, that completed clinical and echodopplercardiographic one year follow-up (PO12M). Admission criteria were: exertional dyspnoea, no thromboembolism antecedent up to three months before the procedure, absence of other cardiac disease requiring correction, an admissible echodopplercardiographic score, absence of intracavitary thrombus and mitral regurgitation absent or minor.

RESULTS

The patients were divided in two groups: group A of 7 (11%) patients that have a cardiac event in this period, and group B of 61 patients that completed the follow-up without a cardiac event. In group A three patients have had a severe mitral regurgitation, one case was unsuccessful and other one had a re-stenosis. There were two deaths, not related to the intervention. In group B, haemodynamic results before and immediately after PMV2B (POI) showed a significant improvement, except in relation to cardiac index. There was an increase in the grade of mitral regurgitation in 17 (28%) patients and in two cases this regurgitation became moderate. The mitral valvar area (MVA) variation between PRE x POI x PO12M presented, comparing MVA between POI and PO12M, a significant reduction. Two (3%) patients with a reduction greater than 50% of the initial increase, 33 (54%) between 10 and 50% and 26 (42%) less that 10% remained in functional class I/II.

CONCLUSION

PMV2B is an attractive treatment to select symptomatic mitral stenosis patients, with a low incidence of complications, symptomatic effective improvement that was maintained in one year follow-up, although there was a reduction in MVA.

[Chronic rheumatic cardiopathy in a patient with of hemophilia successfully treated with surgery]

A 52 year-old man, with rheumatic cardiopathy and hemophilia was admitted to the hospital for aortic valve replacement and mitral valve commisurotomy. He had a history of allergic reaction to cryoprecipitate, and to undergo to the cardiac surgery, the ideal level of factor VIII was estimated to be 100%. To reach this level he first received 2,500UI of the factor VIII:C increasing the factor VIII:C level from 20 to 58%. During the surgery he received an additional dose of 1,500UI of factor VIII plus 3,500,000UI of aprotinin (Trasylol), which was started at the beginning of the anaesthesia and maintained during the surgical procedure, increasing the factor VIII level to 220%. The patient was discharged 11 days after the surgery without any hemorrhagic complication.

[Aneurysms of the left and non coronary sinus of Valsalva associated to mitral and aortic rheumatic valves and obstructive coronary disease]

A 30 years old, male, patient with rare multiple aneurysms of sinus of Valsalva associated to mitral and aortic regurgitation and total occlusion of circumflex artery had the clinical diagnosis made accidentally. The multiple aneurysms were detected by transesophageal echodopplercardiography and hemodynamic study. The diagnosis were confirmed at surgery and the patient underwent correction of the aneurysms through the use of pericardial patches and mitral and aortic valve replacement.

[Acquired ventricular septal defect during infective endocarditis]

We studied five patients with acquired ventricular septal defect during the course of an infective endocarditis. All patients were male and had a previous aortic valve disease associated with an aortic ring abscess. Clinical examination was useful for the diagnosis of 4 cases, emphasizing the following findings: systolic murmur and/or left paraesternal thrill and right-heart failure. Incidence of congestive heart failure was 60%, while 40% of all patients died during the in-hospital course. No specific etiologic agent was detected. Therefore, acquired ventricular septal defect should be suspected in patients with infective endocarditis of the aortic valve that evolve with a systolic murmur and/or paraesternal thrill and right-heart failure. Immediate surgical treatment is mandatory in these cases.

[Neurological events in infective endocarditis]

PURPOSE

The study of frequency, modalities and course of neurological complications of infective endocarditis (IE), as well as the current indication and value of supplementary examinations.

METHODS

Sixty-three patients with IE, 39 with native valve and 24 with valvar prosthesis, were prospectively studied; the mean age was 42 years and 45 (71.4%) were males. Two groups were formed: A) 41 patients without neurological events and B) 22 patients who presented 28 neurological events before or during hospitalization: ischemic cerebrovascular accident 20, hemorrhagic cerebrovascular accident 2, meningeal hemorrhage 2, meningitis 2, brain abscess 1 and seizure 1. All patients were submitted to neurological clinical examination; 57 computerized tomographies of the cranium, 28 arteriographies and 32 cerebrospinal fluid analysis were performed.

RESULTS

The incidence of neurological events corresponded to 34.92% of IE patients, with a clear predominance (85.71%) of vascular as compared to infectious manifestations. Mortality was 2.32 times higher in group B patients (22.73% x 9.76%), albeit p = 0.256, and was not related to staphylococcal etiology. The neurological events were not related to sex, age and presence of valvar prosthesis. The presence of neurological complications was greater (p = 0.047) in patients with simultaneous infections in two valves (mitral and aortic) and also (p = 0.00884) in those with IE in prosthesis implanted for less than three months. All supplementary neurological examinations in group A were normal.

CONCLUSION

1) Occurrence of neurological events is a factor which influences the prognosis of IE; 2) supplementary neurological examinations did not reveal subclinical neurological complications; 3) neurological complications were significantly more frequent in patients with simultaneous mitral and aortic valve IE; 4) IE in prosthesis implanted for less than 3 months has a greater probability to develop a neurological picture as compared to IE in prosthesis implanted for more than 3 months.

[Comparison between the use of unifoil double balloon and bifoil balloon in successful mitral valvuloplasty by balloon catheter]

PURPOSE

To compare immediate and long term results balloon mitral valvuloplasty (BMV) using double balloon or bifoil balloon.

METHODS

One hundred and thirteen consecutive cases of BMV used aleatory double balloon (group DB--55 cases) or bifoil balloon (group BF--16 cases). Patients were similar regarding to age, sex, valvopaty etiology, functional class and echocardiographic score. Seventy one (63%) patients achieved 12 months follow-up.

RESULTS

In group DB there were 2 (4%) insuccess, 2 (4%) cardiac tamponade and 2 (4%) deaths, 91% patients had immediate criteria of success. Mitral valve area (MVA) increased from 0.8 to 1.69cm2 and mitral gradient (G) by echodopplercardiographic (ECHO) decreased from 17.9 to 4.8mmHg. Three (5%) patients developed severe mitral regurgitation (MR) and needed surgical intervention. At follow-up 2 (4%) developed mitral restenosis. MVA estimated by ECHO study after one year follow-up was inferior to 1.15cm2 in 15 (32%) cases, between 1.5 and 2.0cm2 in 17 (37%) and superior to 2.0cm2 in 14 (31%). In group BF there were 2 (12.5%) insuccess, 4 (25%) developed severe MR occurring 1 death immediate post-operative mitral valve replacement. Among 14 (87%) success cases, MVA increased from 0.8 to 1.89cm2 and G decreased from 18 to 6.4mmHg. Lately 2 (12.5%) needed surgical intervention because significative MR. At 12th month follow-up the ECHO study showed that in one (10%) case MVA was < 1.5cm2, and in 3 (27%) cases was between 1.5 and 2.0cm2.

CONCLUSION

There were similar good results in both groups, however group DB had more restenosis, cardiac tamponade and vascular complications and group BF had more severe MR.

[Mitral catheter-balloon valvuloplasty in surgical high risk patients]

PURPOSE

To evaluate percutaneous mitral balloon valvuloplasty (PMBV) in surgical high risk patients.

METHODS

Twenty (12%) patients out of 172 submitted to a PMBV were considered high surgical risk cases; 17 (85%) were women and mean age was 43 (18-69). Thirteen (65%) were in acute pulmonary edema (3 were pregnant, 2 had previous cerebrovascular event, 1 had pulmonary thromboembolism and other had chronic renal failure), and 7 (35%) were in functional class (CF) III (2 had coronary artery disease, 2 severe obesity, 1 pulmonary neoplasia, 1 cardiac cachexia and one with previous cerebrovascular event). All patients underwent PMBV through transseptal technique. Double balloon was used in 10 (50%) patients; Inoue balloon in 5 (25%), mono-foil in 3 (15%) and bi-foil in 2 (10%).

RESULTS

Seventeen (85%) obtained success and 2 (10%) had clinical improvement. The hemodynamic results pre versus post-PMBV showed: left atrium pressure (LAP) mmHg 28.2 +/- 10.0 x 15.2 +/- 9.2 (n = 20) (p < 0.001), mitral medium gradient (G) mmHg 21.2 +/- 10.7 x 10.7 +/- 6.7 (n = 18) (p < 0.001), mitral valve area (MVA) cm2 0.73 +/- 0.3 x 1.73 +/- 0.6 (n = 11) (p < 0.001), pulmonary artery pressure mmHg 52.0 +/- 18.2 x 40.1 +/- 14.7 (n = 18) (p < 0.001) and cardiac index L/min/m2 2.1 +/- 0.4 x 2.5 +/- 0.6 (n = 14) (p < 0.001). Comparative echocardiography results pre, post and 6 months after PMBV showed: MVA 1.06 +/- 0.39 x 1.92 +/- 0.51 x 1.65 +/- 0.5 and G 13.8 +/- 4.7 x 7.3 +/- 3.6 x 7.3 +/- 4.4. There were two immediate deaths (pulmonary thromboembolism and multiple organs failure) and other after hospital discharge. The complications were: 2 (10%) patients with neurological complications, 1 (5%) atrial septal defect and other right atrium perforation (5%).

CONCLUSION

PMBV offers an alternative to surgical treatment in high risk surgical patients and the results are maintained in the 6 month follow-up.

[Randomized study comparing mitral valve replacement with and without preservation of mitral ring chordae tendinae papillary continuity]

PURPOSE

To demonstrate the importance of the preservation of mitral annulus-chordae tendineae-papillary muscles continuity in mitral valve replacement.

METHODS

We studied 21 patients who were submitted to mitral valve replacement, divided in two randomized groups: group 1, 12 cases who undergone mitral valve replacement, with preservation of the posterior leaflet and correspondent chordae tendineae; and group 2-9 cases who undergone conventional mitral valve replacement, excising the mitral valve apparatus. The left ventricular function was studied both, in the pre and post operative period, by echocardiography, cardiac catheterization, and radioisotopic study. The statistical analysis was done by the Wilcoxson's test.

RESULTS

There were no early post operative deaths. Analyzing the results of the ejection fraction by the radioisotopic study we found a significant difference (p = 0.03) between the percentual decrease of the two groups. The results of the fractional shortening were higher in group 1 than in group 2, however not significant. The left ventricular diastolic diameters average was lower in group 1 than in group 2, so as the left atrium diameter. We found a decrease in left ventricular end-diastolic pressure in group 1, however there was an increase in group 2, by the cardiac catheterization. There was a proportional increase in group 1 both in lung artery and lung capillary pressures. There was a significant difference (p = 0.05) between the average values of right ventricular diastolic pressure.

CONCLUSION

There is better preservation of left ventricular function in group 1.

[Infective endocarditis: analysis of 300 episodes]

PURPOSE

Study of clinical features and etiologic agents, treatment and mortality of patients with infective endocarditis (IE).

PATIENTS AND METHODS

300 episodes of IE occurring in 288 patients, ages ranged between 0.2 and 78 (mean 30.76) years; 185 (62%) episodes occurred in males.

RESULTS

a) etiologic agents: viridans group streptococci in 93 (31%) episodes, enterococci en 21 (7%), group D-non enterococci in 19 (6%) (13 S. bovis), other streptococci in 14 (5%), Staphylococcus aureus in 59 (20%), Staphylococcus epidermidis in 14 (5%), gram-negative bacteria in 16 (5%), gram-positive bacteria other than streptococci and staphylococci and staphylococci in 8 (3%), fungi in 4 (1%). The etiologic agents were not identified in 52 (17%) episodes; b) underlying cardiac diseases: valvular heart disease in 119 (40%) episodes, congenital heart disease in 37 (12%), prosthetic heart valves in 69 (23%), other heart diseases in 6 (2%). There was no evidence of previous heart disease in 69 (23%); c) treatment: surgical treatment was undertaken in 102 (34%) episodes. The frequency of surgical treatment in relation to the etiologic agents ranged between 1% (non-group D streptococcus) and 62% (negative blood cultures). The frequency of operation in relation to underlying heart disease ranged between 17% (other heart diseases), 19% (congenital heart disease) and 54% (prosthetic heart valve); d) mortality: 78 (26%) patients died, 56 (28%) of the 198 submitted to medical treatment and 22 (21%) of the 102 submitted also to surgical treatment. The mortality in the different groups of etiologic agents ranged between 5% (non group D streptococcus) and 62% (gram-positive bacteria other than streptococci ans staphylococci); in relation to the underlying with other heart disease, 19% in valvular heart disease patients, 21% in patients with congenital heart disease, 23% in patients without known heart disease and 43% in patients with prosthetic heart valves.

CONCLUSION

The mortality associated with IE remains still high in spite of modern treatment; the mortality is different in relation to the cardiac status before the IE.