Ventricular function by radionuclide ventriculography in malignant hypertension

Malignant hypertension is a unique and natural model for the study of abnormalities of left ventricular function due to arterial hypertension, because the development and regression of these abnormalities can be observed in a short period. Studies of ventricular function by radionuclide ventriculography, either before or after therapy, have not been previously reported in malignant hypertensive patients. We used this methodology to study left ventricular function in 17 malignant/accelerated hypertensive patients at the time of admission to the hospital and 3, 6, and 9 months after discharge. Seventy percent of patients (12 of 17) had symptoms of congestive heart failure at admission. We compared these data with those obtained in 12 normotensive subjects and 13 mild-to-moderate untreated hypertensive patients. Blood pressure of malignant hypertensive patients was 213 +/- 26/140 +/- 17 mm Hg at admission and 165 +/- 23/101 +/- 15 after 9 months of therapy. Radionuclide ventriculography at admission showed that peak filling rates of malignant hypertensive patients (2.13 +/- 0.21 end-diastolic volume [counts] [EDV]/sec) were significantly lower than those in normotensive subjects (2.40 +/- 0.41) and in mild-to-moderate hypertensive patients (2.46 +/- 0.21). In contrast, peak ejection rates were significantly higher in malignant hypertensive patients (3.44 +/- 0.38 EDV/sec) than in the two control groups (3.01 +/- 0.32 and 3.10 +/- 0.43, respectively). Ejection fractions were similar in the three groups of patients. After 9 months of therapy, peak filling rates of malignant hypertensive patients increased to 2.38 +/- 0.35 EDV/sec, whereas peak ejection rates decreased to 2.89 +/- 0.43 EDV/sec, both not significantly different from data in controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute aortic dissections. Hospital outcome of 186 cases]

PURPOSE

To determine in hospital outcome acute aortic dissection patients.

METHODS

We revised 186 consecutive cases (up to 14 days of dissection), in a period of 6 years. The patients were divided according to Daily's classification (types A and B).

RESULTS

Type A--127 cases: a) 75 were surgically treated (37 died); b) 2 were medically treated (both died); c) 39 died before the definitive treatment could be initiated; d) 11 died misdiagnosed or undiagnosed. The total mortality was 70.0%. Type B--59 cases: a) 11 complicated cases were surgically treated (6 died); b) 40 were medically treated (8 died); c) 7 died before the definitive treatment could be initiated; d) one died misdiagnosed. The total mortality was 37.25%. In summary, 41.4% of the patients survived. 28.4% died despite the definitive treatment, 24.7% died before the definitive treatment could be initiated and 6.4% died without the correct diagnosis.

CONCLUSION

The acute aortic dissection is a dramatic situation, mainly type A. In this type of dissection many patients (41%) died misdiagnosed, undiagnosed or without enough time to surgical therapy. So, an earlier diagnosis and treatment are imperative.

Role of arterial hypertension in left ventricle hypertrophy in hemodialysis patients: an echocardiographic study

To assess the role of arterial hypertension in left ventricle (LV) hypertrophy among hemodialysis patients, echocardiographic evaluation was performed in 10 hypertensive and 13 normotensive hemodialysis subjects matched for age, sex, race, duration of dialysis treatment and degree of interdialytic volume expansion. We excluded from the latter group patients with previous hypertension since hypertensive heart disease may persist after adequate blood pressure control. We also studied 17 normal controls and 10 non-uremic patients with essential hypertension. Comparisons between the two uremic groups showed that the hypertensive patients had a higher mass index (222 +/- 74 x 108 +/- 26, p = 0.0001) and posterior wall thickness (12 +/- 2 x 9 +/- 2, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 5.8 +/- 1, p = 0.0001). There were no significant echocardiographic differences between normal controls and normotensive uremics. In contrast, compared to controls, hypertensive uremic patients showed an increased LV mass index (222 +/- 74 x 83 +/- 21, p = 0.0001) and posterior wall thickness (12 +/- 2 x 7 +/- 1, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 6.5 +/- 1.1, p = 0.001), characterizing concentric hypertrophy. They also had ventricular dilation with larger LV dimensions than in controls (53 +/- 5 x 47 +/- 4, p = 0.004). In patients with essential hypertension, the mass index (135 +/- 22), wall thickness (11 +/- 1) and LV radius/wall thickness ratio (4.3 +/- 0.7) significantly differed (p = 0.0001) from those in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mapping with Technetium-99 methoxy-isobutyl isonitrile at the bedside after coronary thrombolysis]

PURPOSE

To evaluate the feasibility of bedside Technetium99-methoxy-isobutyl-isonitrile (99mTc-MIBI) cardiac imaging to assess perfusion after thrombolytic therapy (TT) for myocardial infarction (MI).

METHODS

We studied 9 patients (mean age 59 +/- 9 years) submitted to TT with 100 mg of rt-PA in 90 minutes within the 6 hours of the onset of MI with subsequent angiography. 99mTc-MIBI was injected intravenously in a doses of 740 MBq immediately before TT start. Imaging was performed in three moments: study 1--as soon as the TT finished, study 2--3-18 hours after TT; study 3--7-10 days after TT. A perfusion score was established in each study and then compared to determine the perfusion patterns after TT. We compared through linear regression, the perfusion score with left ventricle ejection fraction, and with CKMB enzymatic peak.

RESULTS

All patients had a patent infarct related artery. The perfusion score of study 1 varied from 12 to 22, mean 15.8 +/- 3.7, and correlated with ejection fraction (r = 0.9, p < 0.01) and peak CKMB (r = 0.78, p = 0.03). Four (44%) patients presented perfusion score improvement in study 2 (varied from 12 to 23, mean 16.8 +/- 4.3) and 8 (88%) in study 3 (varied from 12 to 28, mean 19.0 +/- 4.3).

CONCLUSION

Bedside 99mTc-MIBI cardiac imaging is useful to quantify myocardial area under risk before TT, and to identify the late (7 to 10 days) benefit of TT.

Acute myocardial infarction with diffuse endarteritis, contraction bands, and distal thrombosis of the coronary arteries in a heart transplant patient

The case history of a heart transplant patient who died of an acute myocardial infarction 6 months after the procedure is described. The finding of contraction bands and thrombosis associated with endarteritis suggests that coronary vasospasm may have contributed to the acute myocardial infarction during an episode of vascular rejection.

[Diet with usual quantity of salt in hospital treatment of congestive heart insufficiency]

PURPOSE

To study the consequences of a diet with usual salt quantity (non salt-restricted) on hospital treatment of congestive heart failure (CHF), in behalf of a better food intake.

METHODS

Thirty-two patients admitted to compensation of class III or IV CHF, randomly allowed to group I (2 g salt per day diet) or II (10 g salt). Hypertensive, renal failure or restrictive syndrome cases were excluded. Oral medication and water intake were standardized; furosemide dosage was adjusted on a daly basis, allowing the study of this drug's requirements in each group. Compensation of CHF was defined as a return to classes I or II without edema.

RESULTS

Group I included 14 and group II 18 patients. There was no significant difference between groups respective to the time needed for compensation of CHF (7.5 x 6.6 days, mean) percentual weight loss (12.2 x 10.0%), cumulative furosemide dosage (568 x 599 mg), mean daily furosemide dosage per kilogram of lean weight (1.43 x 1.58 mg/kg/day), and to 24-hour urinary excretion of sodium (241 x 254 mEq) and potassium (38.8 x 53.9 mEq). Small elevations of blood urea and potassium were an uniform trend. There was no significant alteration of plasmatic sodium. Food intake was adequate. There was one death for each group, from causes not directly related to CHF.

CONCLUSION

Dietary salt intake did not adversely influence in-hospital compensation of severe CHF in studied group. In selected cases, adoption of a more liberal diet in this aspect may allow the patient a better ingestion of food.

[Ergospirometry as a method for predicting the clinical course of ischemic, Chagas and idiopathic myocardiopathy]

PURPOSE

To compare and evaluate the modifications variables obtained through spyroergometry in groups of patients with ischemic cardiomyopathy (IS), Chagas' disease (CH), and idiopathic cardiomyopathy (ID). To study tolerance to anaerobic conditions of patients from the above groups who died.

METHODS

A study was carried with 50 male patients, 10 of which were found in normal conditions whereas 40 presented cardiomyopathy with compensated heart failure. We observed that from the 40 patients from the cardiomyopathy groups, nine died, subgroups OB--during the study period of 1.005 days. These were compared to subgroups NOB--the remaining 31 patients. These patients were evaluated under 4 conditions--Rest (Rep), anaerobic threshold (LA), power peak of the exercise (P) and in the fourth minute recovery (REC). The investigation was based on data collected by means of spyroergometry: oxygen consumption (MET), production of CO2-(VCO2), respiratory equivalent of oxygen (VE/VO2), oxygen pulse (VO2/FC) and the time elapsed between LA and P.

RESULTS

There were significant differences when the three pathological groups (IS, CH, ID) were compared with the control groups (N). There were no significant differences when the three pathological groups compared among themselves. In relation to tolerance to anaerobic conditions significant differences were found among the patients of subgroup OB--1.33 min--who died when compared to subgroup NOB--3.26 min (time elapsed between LA and P).

CONCLUSION

The authors conclude that the variables studied, obtained through spyroergometry may indicate important data towards the prognosis with heart failure.

[Coronary-cavitary fistula after resection of vascularized left atrial myxoma]

A 52-year-old man with left atrial myxoma, in whom postoperative angiographic control revealed a coronary-cavitary fistula originated from a previous atrial branch from the circumflex coronary artery. These fistulas should be considered in cases of revascularized atrial myxoma.

[Myocardial infarction: comparison of anatomo-pathological findings from hearts with and without severe coronary atherosclerosis in 194 necropsy cases]

PURPOSE

To compare morphological features of myocardial infarction (MI) from patients with any epicardial coronary artery narrowed at some point more than 70% (severe coronary atherosclerosis--SCA) with those from patients with either no coronary atherosclerosis or only mild (less than 70%) atherosclerosis.

METHODS

Necropsy findings from 194 patients who died due to MI, 174 patients with and 20 without SCA. Ages ranged from 21 to 82 (mean 60) years.

RESULTS

Mean age was 60 years in the cases with SCA and 56 in the case without it; nevertheless, age distribution was different (p = 0.023), due to the existence of more patients under age 40 in the group without SCA. There was no significant difference concerning sex (31.0% of female patients in the group with SCA and 35.0% in the other group, p = 0.718), mean heart weight (500 g and 506 g), distribution of cases according to time of evolution of MI in recent only, old only or both (cases with SCA--36.2%, 28.2% and 35.6%; cases without SCA--45.0% and 20%; p = 0.666), left ventricular wall committed by the MI (p = 0.715), incidence of hemorrhagic infarction (with SCA--8.6%; without SCA--15.0%; p = 0.406), left ventricular rupture (with SCa--5.17%, without SCA--10.0%; p = 0.719) and left ventricular aneurysms (with SCA--12.1%, without SCA--15.0%; p = 0.316). An association was found between coronary atherosclerosis and recent (p = 0.046) and recanalized (p less than 0.001) thrombosis, but absent when only recent thrombosis and non-operated cases with recent MI were considered (p = 0.091).

CONCLUSION

Necropsy of fatal cases of MI were not significantly different in the presence or absence of severe atherosclerotic narrowing (greater than 70%) of epicardial coronary arteries, suggesting that this factor does not modify the natural history of MI.

[Spontaneous variability of ventricular extrasystole in chronic Chagas cardiopathy]

PURPOSE

To study the spontaneous variability of single (VPCs) and coupled (CVPCs) in patients with chronic Chagas' disease (CCD).

PATIENTS AND METHODS

Twenty patients with CCD, 14 male, in class I and II NYHA, with frequent VPCs and VCPCs, free of drug therapy were studied. 21 hour Holter monitoring was done for 4 subsequent days. The data analysis assessed the variation in the frequency of VPCs and CVPCs between patients, seven hour periods one hour periods in a hierarchical model by a Poisson process.

RESULTS

a) the frequency of VPCs follows a circadian rhythm, closely related to the hourly variations of the mean heart rate; b) disregarding the heart rate influence on the variability of the ventricular arrhythmia, its behavior was at random and unpredictable; c) the minimal percentual reduction in VPCs/h that discriminated between antiarrhythmic effect and spontaneous between antiarrhythmic effect and spontaneous between antiarrhythmic effect and spontaneous variability was 121.86% for seven-hour, 58.42% for 21-hour and 38.45% for 42-hour electrocardiographic monitoring periods; d) the same approach for the VCPCs revealed values of 133.6%, 63.21% and 41.3% respectively.

CONCLUSION

The large variability of ventricular arrhythmia in CCD during a 24 hour period makes necessary observations always longer. The minimal percentual reduction in VPCs/h that discriminated between antiarrhythmic effect and spontaneous variability might be 58.42% for two 21-hour electrocardiography monitoring periods.

Mycotic aneurysm of the celiac trunk and superior mesenteric artery in a case of infective endocarditis

Mycotic aneurysms of the celiac artery are extremely rare, and in our review of the literature we found that in only one case was it due to infective endocarditis. In our case a 19-year-old female patient with culture-negative infective endocarditis presented with pain in the epigastric area. A celiac artery aneurysm was diagnosed by ultrasonography and confirmed on CT scan and angiography, which also demonstrated an associated aneurysm of the superior mesenteric artery. Since excellent collateral circulation was present, simple ligation of the two aneurysms was performed. The patient presented no major complications in the postoperative course.

Incessant ectopic atrial tachycardia and sudden death

A patient with refractory and incessant ectopic atrial tachycardia (IEAT) is reported in whom it was possible to document, during ECG (Holter) the occurrence of aborted sudden death by spontaneous ventricular fibrillation (VF). Following the second of two attempts at surgical ablation of the origin of the IEAT, the patient has been asymptomatic without antiarrhythmic drugs and in sustained sinus rhythm for 24 months. Although we cannot exclude the residual action of amiodarone and flecainide (proarrhythmia) or the residual peripartum cardiomyopathy it is probable that the observed VF was a true complication of a cardiomyopathy induced by a chronically increased heart rate (HR). Although unclear, this VF might be considered as a form of adrenergic-dependent long QT syndrome due to early afterdepolarization in the presence of predisposing myocardial conditions.

[Clinical and Doppler echocardiographic follow-up of elderly patients subjected to aortic balloon valvuloplasty]

PURPOSE

To evaluate the evolution of patients with critical aortic stenosis (AS) submitted to balloon aortic valvuloplasty (BAV).

PATIENTS AND METHODS

sixteen patients (mean age 74.0 +/- 5.1 years), 11 (68.7%) women. The study periods consisted during the 3 rd (post-1) and 15th month (post-2) after dilatation.

RESULTS

The functional class of angina and dyspnea persisted in all patients during period post-1, in 75% of the patients, during period post-2 in relation to intra-hospital evaluation. However, in period post-1, 53% of the patients had significant reduction of aortic valve area, trend which remained in period post-2. Simultaneously, progressive (insignificant) elevation of the left ventricular aortic peak to peak gradient was noticed in the periods post-1 and post-2. Two deaths and two aortic valve replacements occurred during the study.

CONCLUSION

BAV is associated to maintenance of functional class improvement obtained immediately after dilatation despite the aortic valve restenosis registered by echodopplercardiography.

[Use of intravenous hydralazine in treatment of hypertensive crisis]

PURPOSE

To evaluate the efficacy and safety of intravenous hydralazine in arterial hypertension.

PATIENTS AND METHODS

12 patients, mean age 45.33 +/- 15.82.8 men and 4 women all of them with systolic (S) arterial pressure (AP) greater than or equal to 180 and or diastolic (D) greater than or equal to 126 mmHg with symptoms like headache, in characteristic thoracic pain and others but without an hypertensive emergency neither acute manifestation of hypertensive encephalopathy through fundi examination were studied. The AP was taken 10 minutes after rest (initial) and 5, 15, 30 and 60 min (final) after intravenous administration of hydralazine-HCL (5 mg) which was repeated when at least 20% AP reduction was not achieved.

RESULTS

The initial and final SAP, DAP and heart rate (HR) were 208 +/- 19.4 and 176 +/- 17.2 (p less than 0.0001), 133 +/- 11.3 and 112 +/- 11.5 (p less than 0.001) and 72 +/- 12.9 and 80 +/- 15.5 (NS), respectively. Side effects related to the drug were observed in 3 (25%) patients. One had symptomatic orthostatic hypotension, the second had precordial pain with ST-T changes compatible with myocardial ischemia and the third presented a thorax and abdominal cutaneous erythema, but all of them reversible.

CONCLUSION

Intravenous hydralazine-HC1 is an alternative when rapid arterial pressure reduction is needed.

[Effect of ticlopidine and dipyridamole on platelet aggregation and count in patients with chronic stable angina pectoris]

PURPOSE

To compare the ticlopidine and dipyridamole effects on platelets count and aggregation in patients with stable coronary artery disease.

PATIENTS AND METHODS

Eighty patients with stable coronary artery disease and mean of 58.3 +/- 5.8 years were studied. They were divided into two equal groups of 40 patients and each one treated with ticlopidine or dipyridamole. Platelets count and aggregation were examined before treatment and at first and fourth weeks of treatment.

RESULTS

At the end of fourth week of treatment, spontaneous, induced by ADP or by adrenalin platelet aggregation inhibition was observed, respectively, in 82.5%, 72.5% e 67.5% of the patients in ticlopidine group. The spontaneous, induced by ADP or by adrenalin, platelet aggregation inhibition in the patients of dipyridamole group was, respectively, 40%, 30% e 27.5% (p less than 0.001). The platelets count did not change in both groups.

CONCLUSION

The ticlopidine effect is much more evident in platelet aggregation inhibition than dipyridamole, and maybe a choice in the prevention of cardiovascular events.

Usefulness of T-cell phenotype characterization in endomyocardial biopsy fragments from human cardiac allografts

The mean numbers of cytotoxic/suppressor (CD8+) and helper/inducer (CD4+) T cells were determined in 111 successive endomyocardial biopsy fragments from eight cardiac allograft patients in an attempt to define their significance in the rejection process. Endomyocardial fragments from autopsy or donor hearts without myocarditis were evaluated as controls. The mean numbers of CD8+ and CD4+ T cells in the control group were 0.8 and 0.5 cells/field at x400 magnification, respectively. The mean numbers of CD8+ T cells per field in the cardiac allograft biopsies were 2.4, no rejection group; 5.4 mild rejection group; 11.1, moderate rejection group; and 4.9, resolving rejection group. The mean numbers of CD4+ T cells per field for the same groups were slightly lower than those of the CD8+ T cells. The number of CD8+ T cells per field reliably indicated the severity of rejection. Patients with normal numbers of CD8+ T cells and no evidence of rejection had better long-term outcomes (two or fewer moderate rejection episodes) than those with higher numbers. Analysis of the data suggests that the presence of two or fewer CD8+ T cells/field may be considered normal in the myocardial interstitium. The diagnosis of no evidence of rejection should be coupled to the presence of a normal number of CD8+ T cells. High numbers (greater than 10) of CD8+ T cells, even in absence of myocytolysis, should be treated more assertively, including the use of high doses of prednisone, because all our cases with high numbers showed a worse histologic picture at the subsequent biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral valve aneurysm associated with mitral insufficiency in absence of aortic insufficiency]

Two 31 year old patients were interned with cardiac insufficiency (functional class III). Case number one infective endocarditis with mitral valve 8 months before. Case number two had previous rheumatic disease. Both had severe mitral insufficiency and were submitted to replacement of mitral valve. Surgical findings included the presence of aneurysm mitral leaflet (posterior in case one and both in case two). The pathologic study showed mitral valve prolapse and signs of previous endocarditis in case one and rheumatic lesion in the other case.

[Mitral valve prolapse and panic disorder]

PURPOSE

To determine the incidence of mitral valve prolapse (MVP), using echocardiographic and auscultatory criteria, in cases of panic disorder (complicated or not with agoraphobia).

PATIENTS AND METHODS

Sixty-five patients (37 women) with panic disorder and without known cardiac disease, mean age 39.8 years (range 19-67) were studied. MVP was diagnosed when there was a typical auscultatory click or when the echocardiographic study (echo) registered one mitral lacinea 2 mm behind the C-D line at the "M" study or a systolic billowing of mitral leaflets in two views to the two-dimensional study.

RESULTS

MVP was found in 29 (44.6%) of the patients, 12 (42.7) men and 17 (49.5%) women. A click was found in 19 (24%) of the cases and the Echo was positive in 24 (39.6%) of the patients. Click and a positive Echo finding were identified in 14 patients.

CONCLUSION

MVP was found in panic cases, in incidence greater than in the general population.

Usefulness of high-frequency analysis of signal-averaged surface electrocardiograms in acute myocardial infarction before and after coronary thrombolysis for assessing coronary reperfusion

The incidence of late potentials on the signal-averaged electrocardiogram before and after coronary thrombolysis was studied in 54 patients with an acute myocardial infarction of less than or equal to 5 hours' duration and with an angiographically documented total occlusion of the infarct-related coronary artery on admission. A significant (p = 0.038) 50% relative reduction in the incidence of late potentials was observed in the group of 35 patients who underwent reperfusion: from 16 of 35 (46%) before to 8 of 35 (23%) at 120 minutes after the start of thrombolytic treatment. No significant reduction was seen in the 19 patients in whom thrombolysis was unsuccessful: from 8 of 19 (42%) before to 7 of 19 (37%) afterward. Despite successful recanalization, late potentials persisted or newly developed after thrombolytic therapy in 8 of 54 patients (15%). It is concluded that successful thrombolysis reduces the incidence of late potentials on the signal-averaged electrocardiogram but that the sensitivity and specificity of this finding are not high enough to allow reliable monitoring of coronary reperfusion at the bedside.

[Systemic lytic state as marker of therapeutic success after rt-PA in bolus in myocardial infarction]

PURPOSE

Evaluate the lytic state (LS) expressed by the level of plasmatic fibrinogen (PF) after rt-PA "in bolus" infusion for acute myocardial infarction (MI) and its relation to coronary reperfusion.

PATIENTS AND METHODS

Fifty-one patients (38 men, mean age of 53.0 +/- 9.8 years) with demonstrated occlusion of the infarct related artery (IRA) received an intravenous bolus infusion of 70 mg of rt-PA, PF was assessed before and 90 minutes after the treatment and the levels were compared in patients with (group 1) and without (group 2) reperfusion of the IRA.

RESULTS

Basal levels of PF were within the normal range in all patients. There was a decrement of 35.1% in the PF dosed at 90 minutes, from 276.8 +/- 55.5 mg/dl to 168.0 +/- 68.2 mg/dl. Both groups were similar in the levels of PF 90 after treatment (145.1 +/- 95.7 mg/dl in group 1 versus 187.0 +/- 53.7 mg/dl in group 2).

CONCLUSION

"In bolus" rt-PA treatment for MI significantly reduces the PF, but the LS obtained was similar in patients with or without reperfusion of the IRA.

[ST segment as an arterial recanalization indicator after thrombolytic therapy in myocardial infarction]

PURPOSE

To evaluate the importance of the segment ST in the identification of coronary recanalization in patients submitted to intravenous thrombolysis during acute myocardial infarction (MI).

PATIENTS AND METHODS

Seventy four patients with MI, 62 male with mean age of 52.6 +/- 10 years. All patients had angiographically demonstrated occlusion of the infarct-related artery (IRA) before the thrombolytic treatment with intravenous "in bolus" infusion of 50 mg, 60 mg and 70 mg of rt-PA. The recanalization of the IRA was assessed 90 minutes later. The real status of the IRA in the angiograms was compared with the ST segment changes between the ECGs obtained before and after the thrombolytic therapy.

RESULTS

Fifty six (75.6%) patients presented a significant reduction in the ST segment elevation (groups I and II). Of these, 47 possessed an opened IRA. From the 18 patients who did not show ST segment decrement (group III), 13 had an occluded IRA, and 5 an opened one. The method presented sensitivity of 90.3% and a specificity of 59.1%, positive predictive value of 83.9% and negative predictive value of 72.2%.

CONCLUSIONS

The ST segment is an important marker of coronary recanalization or not following intravenous thrombolytic therapy.

[Endomyocardial fibrosis. Course in patients undergoing clinical and surgical treatment]

PURPOSE

To follow-up a group of patients during a period of time after either clinical or surgical approach.

PATIENTS AND METHODS

A hundred and twenty-one patients were studied retrospectively with endomyocardial fibrosis (EMF) for a period that varied from one month to 11 years (mean = 32 months). Upon entrance, patients had from 5 to 64 years of age (mean = 30), being 41 male and 80 female. Biventricular involvement were present in 70 cases, whereas 36 showed pure left and 15 pure right ventricular involvement. The patients were divided in two groups: 62 treated clinically, and 59 surgically, the latest defined as fibrosis resection added to atrioventricular valve rebuilding or replacement. All surgical cases had a prior III to IV functional class (NYHA).

RESULTS

In the clinical group there were 24 fatalities, 21 who were in class IV, 1 in class III, and 2 in class II. In the surgical group there were 18 fatalities, 12 early and 6 late.

CONCLUSIONS

(1) All the patients who survived the operation showed functional class improvement; (2) surgical mortality decreased in the latest years; (3) clinical treatment is indicated to patients in classes I and II, groups with low mortality rates; (4) surgical treatment is indicated to patients in classes III and IV, provided that clinical mortality is high in these groups of patients.