[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.

[Valvular surgical treatment concurrent with myocardial revascularization]

PURPOSE

To study the morbidity and mortality due to valvar surgical treatment performed concomitantly to myocardial revascularization.

METHODS

From 1650 patients submitted to mitral or aortic valve surgical treatment, 103 (6.24%) had it associated to myocardial revascularization. Coronary insufficiency was associated to aortic valvar lesion in 66 (64.0%) patients, group I, with mean age of 62.3 +/- 8 years; and in 37 (35.9%) patients with mitral valve lesion, group II, with mean age of 57.8 +/- 5.8 years. Diagnosis was based upon the anamnesis, physical examination and confirmed by cine-coronarographic findings.

RESULTS

I-Complications at the immediate postoperative; a) mortality 11 (10.6%) patients, 6 (9.09%) from group I: by low cardiac output 3, uncontrolled arrhythmia 1, mediastinitis 1; acute infarction with cardiogenic shock 1, and 5 (134.5%) of group II: uncontrolled hemorrhage 2, sudden death 1, saphenous vein graft occlusion, respiratory insufficiency and sepsis 2; b) controlled intercurrences that increased the time of hospitalization: mental disorder 5 patients; CVA 7, diabetes decompensation 2, worsening of chronic renal insufficiency 1, upper level digestive hemorrhage 1 and respiratory insufficiency 3 patients. II-late postoperative complications of 77 (83.6%) patients which could be followed up during a period of 60 months: 1) mortality: 3 (3.89%) patients; 2 due to cardiomyopathy and 1 by acute myocardial infarction; 2) late evolution-functional capacity III (NYHA) by cardiomyopathy 6; I/II 68 patients; mild angina 6 patients, 2 underwent revascularization at the end of final 36-42 months.

CONCLUSION

The clinical improvement and mortality indexes statistically similar to the isolate surgical acts stimulate us to keep up with such associate procedures.

[Course of pregnancy and puerperium in women with mitral valve stenosis]

PURPOSE

To study pregnancy, delivery, puerperium and the newborn in cases of mitral valve stenosis, asymptomatic at conception.

METHOD

Sixty-two pregnant women, 30 with mitral valve stenosis (GE group) and 32 without cardiac disease (GN group) had their functional class, kind of delivery, anesthetic technique and newborn characteristics evaluated during gestation.

RESULTS

In GE group 16 (53.3%) patients changed from functional class (FC) I/II to FC III and 10 (33.3%) to FC IV. In GN group 18 (56.2%) changed from FC I to II during the gestation. Delivery was vaginal in 21 patients (70%); anesthetic technique was regional block in 17 (56.6%). These findings were not statistically different between (p > 0.1) the groups. Premature (20.0%) and small babies for gestational age (36.7%) were higher (p > 0.001) in GE group. There were no cases of maternal death.

CONCLUSION

The majority of GE women who started pregnancy in FC I/II changed to FC III/IV during gestation. Probably adequate medical treatment and valvoplasty in one case allowed fetal viability; but we had higher incidence of pre-term and small for gestation age babies in the GE group.

[Aortic dissection associated with systemic lupus erythematosus]

A 33-year-old female patient, with a 4-year history of hypertension plus a 3-year history of systemic lupus erythematosus, who had been taking high dosages of corticosteroids, has shown repetitive respiratory infections and congestive heart failure for the past 8 months. Angiocardiography confirmed the diagnosis of aortic insufficiency with aneurysmatic dilation of Valsalva's posterior sinus, ascending aorta of normal diameter and normal coronary arteries. Aortic dissection causing aortic insufficiency due to collapse of aortic leaflets was spotted during the surgery and was corrected by a bovine pericardial tube and suspension of aortic valve. The postoperative (PO) period was complicated by left-sided seizures followed by left hemiparesis and respiratory infection. She was discharged on the 25th PO day with mild left hemiparesis and in functional class I (NYHA), using medicines. We emphasize the need to consider the diagnosis of aortic dissection in patients with systemic lupus erythematosus and aortic insufficiency, specially in those who have a history of systemic arterial hypertension and long-term corticosteroid therapy.

[Mitral valvuloplasty by balloon catheter. Early results and one-year follow-up]

PURPOSE

To evaluate percutaneous mitral balloon valvuloplasty (PMBV) results immediately and one year follow-up.

METHODS

One hundred and four procedures in 103 patients, 89 (87%) were women and mean age was 33. Ninety five (91%) had mitral stenosis, 7 (7%) mitral restenosis and 2 (2%) stenotic bioprosthesis. Twelve (10%) patients were in functional class (FC) II (NYHA), 73 (70%) in FC III and 19 (18%) in FC IV. Ninety three (89%) were in sinusal rhythm, 10 (10%) had atrial fibrillation and 1 (1%) junctional rhythm. In 99% cases the transseptal access was used.

RESULTS

The comparative haemodynamic results late x immediately after-PMBV were mitral valve area (cm2) 0.75 +/- 0.27 x 1.68 +/- 0.48 (p < 0.0001), gradient AE-VE average (mmHg) 19.52 +/- 8.03 x 5.44 +/- 4.38 (p < 0.0001); average pressure AE (mmHg) 24.72 +/- 8.76 x 9.63 +/- 6.11 (p < 0.0001), cardiac index (L/min/m2) 2.55 +/- 0.69 x 2.92 x 0.77 (p < 0.0001); average pressure PA (mmHg) 40.17 +/- 16.52 x 25.65 +/- 13.77 (p < 0.0001). The echocardiography results pré-PMBV, post-PMBV, 6 and 12 months after PMBV were respectively: mitral valve area (cm2) 0.89 +/- 0.23 x 1.87 +/- 0.41 x 1.72 +/- 0.43 x 1.64 +/- 0.44 and mitral transvalvar gradient (mmHg) 13.12 +/- 4.66 x 6.44 +/- 2.93 x 7.72 +/- 3.24 x 8.30 +/- 4.17. There was one death immediately after-PMBV in a patient with pulmonary thromboembolism. Four (4%) had severe mitral regurgitation and went to surgery (1 death). There were 2 mitral reestenosis.

CONCLUSION

For selected patients PMBV is a safe method and the good results are maintained in 1 year follow-up.