Coronary bilateral ostial enlargement using the saphenous vein in a patient with syphilitic aortitis

A patient with tertiary syphilis presenting with bilateral coronary ostial lesions and aortic regurgitation underwent surgical reconstruction of the coronary ostia by the anterior approach with autogenous saphenous vein grafting and substitution of the aortic valve with a bovine bioprosthesis. The procedure was easily performed and had good outcomes both early and late. The rarity of the association of a lesion in both coronary ostia with aortic regurgitation in syphilis and the surgical technique employed are discussed.

A study of infectious endocarditis in Ribeirão Preto, SP - Brazil. Analysis of cases occurring between 1992 and 1997

OBJECTIVE: To analyze the epidemiology, diagnosis, clinical aspects causes and evolution of infectious endocarditis. METHODS: The patients analyzed were treated at the University Hospital of the Faculdade de Medicina of Ribeirão Preto-USP and had a diagnosis of infectious endocarditis defined by Duke's criteria, which classifies infectious endocarditis as native, prosthetic valve or that occurring in intravenous drug users. RESULTS: One hundred and eighty episodes of infectious endocarditis in 168 patients were observed. Echocardiograms in 132 (73.3%) provided a diagnosis of infectious endocarditis in 111 (84%) patients; mitral valves were affected in 55 (30.5%), tricuspid valves in 30 (16.6%) and the aortic valve in 28 (15.5%) patients. Hemocultures were performed in 148 (93.8%) episodes of IE. The most commonly isolated infectious organisms were Staphylococcus aureus in 46 (27.2%) patients and Streptococcus viridans in 27 (15.9%). Complications occurred in 116 (64.4%) patients and 73 (40.5%) of the patients died. CONCLUSION: The general profile of the observed infectious endocarditis was similar to that reported in studies performed in other countries and included users of intravenous drugs. The high degree of mortality observed is not compatible with progress in diagnosis and treatment of infectious endocarditis and is probably due to the absence of diagnostic suspicion. The high frequency of fatal cases of septicemia (45.1% of deaths) in the patients studied indicates that unnoticed cases of infectious endocarditis had only been diagnosed at necropsy.

Peripheral arterial embolism. Report of hospitalized cases

OBJECTIVE: We analyzed the frequency of peripheral embolisms, the underlying heart disease,triggering factors, the sites of the emboli, and evolution of the patients. METHODS: We analyzed 29 cases of peripheral arterial embolism out of a total of 20,211 hospitalizations in a cardiology center in the city of São Paulo. The age was 51.89±18.66 years, and 15 were males. RESULTS: Embolism in the right lower limb occurred in 18 patients (62.0%),in the left lower 11(37.9%) and right upper 3 (10.3%) limbs, and in the left arm (1). Four patients had embolism in two limbs. The heart disease, mitral valvar heart disease (9 patients - 31.0%); infective endocarditis (7- 24.1%); dilated cardiomyopathy (6 - 20.6%); ischemic coronary heart disease (6 patients - 20.6%); and one patient with cor pulmonale. Atrial fibrillation was observed in 20 patients (68.9%), chronic in 12 patients (41.3% ) and acute in 8 (27.5%). All patients with mitral valvar heart disease had atrial fibrillation, chronic in 8 patients (88.8%); patients with cardiomyopathy and coronary heart disease, 4 in each group had atrial fibrillation, acute in 60% of the patients.Patients with infective endocarditis, 3 had staphylococcus and 2 Gram-negative bacteria. In the follow-up, 2 patients (6.8%) required limbs amputation, and 5 (17.2%) died due to embolism. CONCLUSION: Most of the time, embolism does not cause permanent complications. Our data highlight the importance of anticoagulation for patients acute atrial fibrillation in myocardial dysfunction and for patients with chronic atrial fibrillation in cases of mitral valvar heart disease to prevent peripheral embolism.

Structural and functional characteristics of rat hearts with and without myocardial infarct. Initial experience with doppler echocardiography

OBJECTIVE: To assess by Doppler echocardiography the structural and functional alterations of rat heart with surgical induced extensive myocardial infarction. METHODS: Five weeks after surgical ligature of the left coronary artery, 38 Wistar-EPM rats of both sexes, 10 of them with extensive infarction, undergone anatomical and functional evaluation by Doppler echocardiography and then euthanized for anatomopathological analysis. RESULTS: Echocardiography was 100% sensible and specific to anatomopathological confirmed extensive miocardial infarction. Extensive infarction lead to dilatation of left ventricle (diastolic diameter: 0.89cm vs.0.64cm; systolic: 0.72cm vs. 0.33cm) and left atrium (0.55cm vs. 0.33cm); thinning of left ventricular anterior wall (systolic: 0.14cm vs. 0.23cm, diastolic: 0.11cm vs. 0.14cm); increased mitral E/ A wave relation (6.45 vs. 1.95). Signals of increased end diastolic ventricle pressure, B point in mitral valve tracing in 62.5% and signs of pulmonary hypertension straightening of pulmonary valve (90%) and notching of pulmonary systolic flow (60%) were observed in animals with extensive infarction. CONCLUSION: Doppler echocardiography has a high sensitivity and specificity for detection of chronic extensive infarction. Extensive infarction caused dilatation of left cardiac chambers and showed in Doppler signals of increased end diastolic left ventricular pressure and pulmonary artery pressure.

Corrected transposition of the great arteries with several associated anomalies in a 68-year-old patient

Few patients with corrected transposition of the great arteries survive past 50 years of age because of the association with congenital defects, development of total atrioventricular block, and right ventricular dysfunction. We report the case of a male patient with dextrocardia in situs solitus and corrected transposition of the great arteries associated with a wide atrial septal defect and severe pulmonary valvar and subvalvar stenoses. The patient also developed a large aneurysm on the pulmonary artery, total atrioventricular block diagnosed 8 years earlier, symptoms of dysfunction of the systemic ventricle in the previous 2 years, insufficiency of the left atrioventricular valve, and aortic regurgitation. Despite all these associated anomalies, the patient developed class III cardiac decompensation only at the age of 68 years, which makes this case a rarity. The patient was clinically treated, and was discharged from the hospital in good condition.

Multiple Embolism in a Female Patient with Infective Endocarditis: Low Back Pain and Hematuria as the Initial Clinical Manifestations

A 59-year-old female patient with mitral valve prolapse and a previous history of lumbosacral spondyloarthrosis and lumbar disk hernia had an episode of infective endocarditis due to Streptococcus viridans, which evolved with peripheral embolism to the left kidney, spleen, and left iliac artery, and intraventricular cerebral hemorrhage. Her clinical manifestations were low back pain and hematuria, which were initially attributed to an osteoarticular condition. Infective endocarditis is a severe polymorphic disease with multiple clinical manifestations and it should always be included in the differential diagnosis by clinicians.

Neonate Aortic Stenosis: Importance of Myocardial Perfusion in Prognosis

OBJECTIVE: To analyze our experience with percutaneous aortic balloon valvuloplasty in newborn infants with aortic stenosis, emphasizing the extraordinary importance of myocardial perfusion.METHODS: Over a 10-year-period, 21 neonates underwent percutaneous aortic balloon valvuloplasty. Age ranged from 2 to 27 days, weight ranged from 2.2 to 4.1 kg and 19 were males. All patients presented with congestive heart failure that could not be treated clinically. The onset of symptoms in the first week of life occurred in 9 patients considered as having critical aortic stenosis. Severe aortic stenosis occurred in 12 patients with the onset of symptoms in the second week of life.RESULTS: Mortality reached 100% in the patients with critical aortic stenosis. The procedure was considered effective in the 12 patients with severe aortic stenosis. Vascular complications included the loss of pulse in 12 patients and rupture of the femoral artery in 2 patients. Cardiac complications included acute aortic regurgitation in 2 patients and myocardial perforation in one. In an 8.2±1.3-year follow-up, 5 of the 12 patients died (2 patients due to septicemia and 3 patients due to congestive heart failure). Five of the other 7 patients underwent a new procedure and 2 required surgery.CONCLUSION: Percutaneous aortic valvuloplasty in neonates is not an effective procedure in the 1st week of life, because at this age the common presentation is cardiogenic shock. It is possible that, in those patients with critical aortic stenosis, dilation of the aortic valve during fetal life may change the prognosis of its clinical outcome.

Short- and midterm follow-up results of valvuloplasty with balloon catheter for congenital aortic stenosis

OBJECTIVE: To report short and midtem follow-up results of balloon aortic valvuloplasty to treat congenital aortic stenosis. METHODS: Seventy-five patients (median age: 8 years) underwent the procedure through the retrograde femoral or carotid route. RESULTS: The procedure was completed in 74 patients (98.6%). The peak-to-peak systolic gradient dropped from 79.6±27.7 to 22.3±17.8 mmHg (P<0.001), the left ventricular systolic pressure dropped from 164±39.1 to 110±24.8 mmHg (P<0.001), and the left ventricular end diastolic pressure dropped from 13.3±5.5 to 8.5±8.3 mmHg (P< 0.01). Four patients (5.3%) died due to the procedure. Aortic regurgitation (AoR) appeared or worsened in 27/71 (38%) patients, and no immediate surgical intervention was required. A mean follow-up of 50±38 months was obtained in 37 patients. Restenosis and significant AoR were observed in 16.6% of the patients. The estimates for being restenosis-free and for having significant AoR in 90 months were 60% and 50%, respectively. CONCLUSION: Aortic valvuloplasty was considered the initial palliative method of choice in managing congenital aortic stenosis, with satisfactory short- and midterm results.

Fibrinolytic therapy for thrombosis in cardiac valvular prosthesis short and long term results

OBJECTIVE: To assess the short- and long-term results of the use of streptokinase (SK) for the treatment of thromboses in cardiac valvular prostheses. METHODS: Seventeen patients with cardiac prosthetic thrombosis diagnosed by clinical, echocardiographic, and radioscopic findings underwent fibrinolytic treatment with a streptokinase bolus of 250,000 U followed by 100.000 U/hour. Short- and long-term results were assessed by radioscopy and echocardiography. RESULTS: Of the 17 patients, 12 had mechanical double-disk prostheses (4 aortic, 6 mitral, 2 tricuspid), 4 had single-disk prostheses (2 aortic, 1 mitral, and 1 tricuspid), and 1 had a tricuspid bioprosthesis. The success rate was 64.8%, the partial success rate was 17.6%, and the nonsuccess rate was 17.6%. All patients with a double-disk prosthesis responded, completely or partially, to the treatment. None of the patients with a single-disk prosthesis had complete resolution of the thrombosis. The time of streptokinase infusion ranged from 6 to 80 hours (mean of 56 h). The mortality rate due to the use of streptokinase was 5.8% and was secondary to cerebral bleeding. During streptokinase infusion, 3 (17.6%) embolic episodes occurred as follows: 1 cerebral, 1 peripheral, and 1 coronary. The rethrombosis index was 33% in a mean follow-up of 42 months. CONCLUSION: The use of fibrinolytic agents was effective and relatively safe in patients with primary thrombosis of a double-disk prosthesis. A fatal hemorrhagic complication occurred in 1 (5.8%) patient, and embolic complications occurred in 3 (17.6%) patients. In a mean 42-month follow-up, 67% of the patients were free from rethrombosis.

Intrauterine ductus arteriosus constriction: analysis of a historic cohort of 20 cases

OBJECTIVE: To describe the relative incidence, presentation, and evolvement of fetuses with early ductus constriction. METHODS: Twenty fetal echocardiograms indicating ductus constriction were reviewed in a population of 7000 pregnants. RESULTS: The cases were divided into group A (related to maternal use of cyclooxygenase inhibitors [n=7] and group B (idiopathics [n=13]). Mean gestational age was 32.5±3.1 (27-38) weeks and maternal age was 28.2±8.5 (17-42) years. Mean systolic velocity in the ductus was 2.22±0.34 (1.66-2.81) m/s, diastolic velocity 0.79±0.28 (0.45-1.5) m/s, and pulsatility index 1.33±0.36 (0.52-1.83). Two cases of ductal occlusion were noted. In 65% of the cases, an increase occurred in the right cavities; in 90% of the cases, tricuspid or pulmonary regurgitation, or both, occurred, with functional pulmonary atresia in 1 case. Diastolic velocity was greater in group A (1.13±0.33) than in group B (0.68±0.15) (P=0.008). The other data were similar in the 2 groups. The evolvement was not favorable in 4 patients from group B, including 1 death and 2 cases of persistent pulmonary hypertension. CONCLUSION: The high incidence of idiopathic constriction of the ductus arteriosus suggests that its diagnosis is underestimated and that many cases of persistence of fetal circulation in newborns may be related to constriction of the ductus arteriosus not diagnosed during intrauterine life. Group B had a lower severity but a risk of an unfavorable evolvement, suggesting a distinct alteration.

Right ventricular structure and function as possible determinants of surgical outcome 30 years after repair of tetralogy of Fallot

OBJECTIVE: To identify the variables that may be involved in the persistence of symptoms (functional class II, III, or IV vs. I) in patients being followed up for 30 years after surgical repair of tetralogy of Fallot. METHODS: Fifty-three patients (27 women), who underwent corrective surgery for tetralogy of Fallot between 1960 and 1970, were studied. Their ages ranged from 7 months to 26 years. At the end of follow-up, 13 patients were asymptomatic and the remaining were in functional class II (N=24), III (N=15), and IV (N=1). To differentiate asymptomatic from symptomatic patients, the following variables were analyzed: age at surgery, need for widening the pulmonary ring and trunk, need for a second (2nd OP) or 3rd operation, residual defect of the interventricular septum, residual regurgitation of the pulmonary valve, systolic gradient through the right ventricular outflow tract, right ventricular dilation or hypertrophy (RVH), cardiothoracic index (CTI), right and left ventricular ejection fraction (RVEF/LVEF), and arrhythmias. RESULTS: The univariate analysis showed an association between the presence of symptoms and the 2nd OP (P=0.03), an increase in the CTI (P=0.0001), moderate to severe RVH (P=0.002), and dilation (P=0.0003). In the logistic regression model, the combination of the 2nd OP (P=0.008), the RVH (P=0.002), and the reduction in RVEF (P=0.01) determined the presence of symptoms. CONCLUSION: Despite the surgical treatment, right ventricular remodeling and performance were the major determinants in the late follow-up of tetralogy of Fallot.

Williams-Beuren syndrome: cardiovascular abnormalities in 20 patients diagnosed with fluorescence in situ hybridization

OBJECTIVE: To evaluate the cardiovascular findings and clinical follow-up of patients with Williams-Beuren syndrome. METHODS: We studied 20 patients (11 males, mean age at diagnosis: 5.9 years old), assessed for cardiovascular abnormalities with electrocardiography and Doppler echocardiography. Fluorescence in situ hybridization (FISH) was used to confirm the diagnosis of the syndrome. RESULTS: Elastin gene locus microdeletion was detected in 17 patients (85%) (positive FISH), and in 3 patients deletion was not detected (negative FISH). Sixteen patients with a positive FISH (94%) had congenital cardiovascular disease (mean age at diagnosis: 2,3 years old). We observed isolated (2/16) supravalvular aortic stenosis and supravalvular aortic stenosis associated (11/16) with pulmonary artery stenosis (4/11); mitral valve prolapse (3/11); bicuspid aortic valve (3/11); aortic coarctation (2/11), thickened pulmonary valve (2/11); pulmonary valvular stenosis (1/11); supravalvular pulmonary stenosis (1/11); valvular aortic stenosis (1/11); fixed subaortic stenosis (1/11); pulmonary artery stenosis (2/16) associated with pulmonary valvar stenosis (1/2) and with mitral valve prolapse (1/2); and isolated mitral valve prolapse (1/16). Four patients with severe supravalvular aortic stenosis underwent surgery (mean age: 5.7 years old), and 2 patients had normal pressure gradients (mean follow-up: 8.4 years). CONCLUSION: A detailed cardiac evaluation must be performed in all patients with Williams-Beuren syndrome due to the high frequency of cardiovascular abnormalities.

Endocardite de Libmann-Sacks e anticoagulação oral

Paciente de 34 anos, com lúpus eritematoso sistêmico e síndrome de anticorpo antifosfolípide secundária, evoluiu com crises convulsivas, parcialmente controladas com anticonvulsivante, e ausculta de sopro cardíaco, cuja propedêutica mostrou a presença de vegetação em valva mitral. Diante do diagnóstico de endocardite de Libman-Sacks foi iniciada terapia com warfarina sódica, e após seis meses de anticoagulação oral, a paciente apresentava controle total das crises convulsivas e desaparecimento da vegetação valvar ao ecocardiograma. São discutidas a ocorrência da endocardite de Libman-Sacks no lúpus eritematoso sistêmico, sua associação com a síndrome de anticorpo antifosfolípide e a terapêutica anticoagulante, e feita uma revisão da literatura.

Quilopericárdio isolado após cirurgia cardíaca

Quilopericárdio como complicação de cirurgia cardíaca é raro. Pode ser causado por lesão no ducto torácico, de tributárias do ducto ou pela trombose da confluência das veias jugular e subclávia esquerda, obstruindo a drenagem do ducto torácico. O tratamento pode ser conservador ou cirúrgico, dependendo da duração e do volume drenado. Apresentamos o caso de uma mulher de 24 anos que no pós-operatório tardio de troca da valva mitral (bioprótese) foi internada com quadro de tamponamento cardíaco devido à presença de quilopericárdio. São comentados os aspectos clínicos e o tratamento instituído.

Como o ecocardiograma pode ser útil em predizer a morte em crianças com cardiomiopatia dilatada idiopática?

OBJETIVO: Determinar os fatores preditores ecocardiográficos de morte em crianças com cardiomiopatia dilatada idiopática. MÉTODOS: Estudo retrospectivo de 148 crianças com cardiomiopatia dilatada idiopática diagnosticadas entre setembro/1979 a março/2003. Critérios para inclusão: insuficiência cardíaca e redução da contratilidade no ecocardiograma, na ausência de cardiopatia congênita ou secundária. Foram analisados 470 exames, durante 244,8 meses de evolução. Parâmetros analisados: dimensão do átrio esquerdo (DAE), relação átrio esquerdo/aorta (DAE/Ao), dimensão sistólica (DSVE) e diastólica (DDVE) do VE, massa do VE (massa), dimensão do ventrículo direito (DVD), fração de ejeção do VE (FE), percentagem de encurtamento do VE (%EC), gravidade da insuficiência das valvas atrioventriculares e da valva pulmonar e medida da pressão sistólica (PsVD) e diastólica (PdVD) do VD. Foi considerado significativo erro alfa <0,05. RESULTADOS: Idade média de 2,37 anos, ocorridos 35 óbitos (23,7% - IC95=17,1% a 31,2%). ANOVA demonstrou: DAE (p<0,0001), DAE/Ao (p<0,0001), DSVE (p=0,0061), DDVE (p=0,0086), massa (p<0,0001), FE (p=0,0074), %EC (p=0,0072) e DVD (p<0,0001). O agravamento da insuficiência mitral (IM) (p=0,0113) e tricúspide (IT) (p=0,0044) foram marcadores de óbito e a presença de IM, IT e insuficiência pulmonar moderada/grave foram deletérias à sobrevida. A análise de Cox demonstrou como preditores independentes da morte: DAE/Ao (p=0,0487), FE (<0,0001) e presença de IM moderada/grave (p=0,0419). CONCLUSÃO: Os pacientes com aumento progressivo da DAE/Ao, redução da FE e agravamento progressivo da IM, a despeito do tratamento clínico, devem ser considerados precocemente em programa de transplante cardíaco.