Spectrum of cardiac lesions associated with Isolated Cleft Mitral Valve and their impact on therapeutic choices

Abstract Background: Isolated cleft mitral valve (ICMV) may occur alone or in association with other congenital heart lesions. The aim of this study was to describe the profile of cardiac lesions associated with ICMV and their potential impact on therapeutic management. Methods: We conducted a descriptive study with data retrieved from the Congenital Heart Disease (CHD) single-center registry of our institution, including patients with ICMV registered between December 2008 and November 2014. Results: Among 2177 patients retrieved from the CHD registry, 22 (1%) had ICMV. Median age at diagnosis was 5 years (6 days to 36 years). Nine patients (40.9%) had Down syndrome. Seventeen patients (77.3%) had associated lesions, including 11 (64.7%) with accessory chordae in the left ventricular outflow tract (LVOT) with no obstruction, 15 (88.2%) had ventricular septal defect (VSD), three had secundum atrial septal defect, and four had patent ductus arteriosus. Thirteen patients (59.1%) required surgical repair. The decision to proceed with surgery was mainly based on the severity of the associated lesion in eight patients (61.5%) and on the severity of the mitral regurgitation in four patients (30.8%). In one patient, surgery was decided based on the severity of both the associated lesion and mitral regurgitation. Conclusion: Our study shows that ICMV is rare and strongly associated with Down syndrome. The most common associated cardiac abnormalities were VSD and accessory chordae in the LVOT. We conclude that cardiac lesions associated with ICMV are of major interest, since in this study patients with cardiac lesions were diagnosed earlier. The decision to operate on these patients must take into account the severity of both mitral regurgitation and associated cardiac lesions.

Chagas heart disease: pathophysiologic mechanisms, prognostic factors and risk stratification

Chagas heart disease (CHD) results from infection with the protozoan parasite Trypanosoma cruzi and is the leading cause of infectious myocarditis worldwide. It poses a substantial public health burden due to high morbidity and mortality. CHD is also the most serious and frequent manifestation of chronic Chagas disease and appears in 20-40% of infected individuals between 10-30 years after the original acute infection. In recent decades, numerous clinical and experimental investigations have shown that a low-grade but incessant parasitism, along with an accompanying immunological response [either parasite-driven (most likely) or autoimmune-mediated], plays an important role in producing myocardial damage in CHD. At the same time, primary neuronal damage and microvascular dysfunction have been described as ancillary pathogenic mechanisms. Conduction system disturbances, atrial and ventricular arrhythmias, congestive heart failure, systemic and pulmonary thromboembolism and sudden cardiac death are the most common clinical manifestations of chronic Chagas cardiomyopathy. Management of CHD aims to relieve symptoms, identify markers of unfavourable prognosis and treat those individuals at increased risk of disease progression or death. This article reviews the pathophysiology of myocardial damage, discusses the value of current risk stratification models and proposes an algorithm to guide mortality risk assessment and therapeutic decision-making in patients with CHD.

The performance of laboratory tests in the management of a large outbreak of orally transmitted Chagas disease

Orally transmitted Chagas disease (ChD), which is a well-known entity in the Brazilian Amazon Region, was first documented in Venezuela in December 2007, when 103 people attending an urban public school in Caracas became infected by ingesting juice that was contaminated with Trypanosoma cruzi. The infection occurred 45-50 days prior to the initiation of the sampling performed in the current study. Parasitological methods were used to diagnose the first nine symptomatic patients; T. cruzi was found in all of them. However, because this outbreak was managed as a sudden emergency during Christmas time, we needed to rapidly evaluate 1,000 people at risk, so we decided to use conventional serology to detect specific IgM and IgG antibodies via ELISA as well as indirect haemagglutination, which produced positive test results for 9.1%, 11.9% and 9.9% of the individuals tested, respectively. In other more restricted patient groups, polymerase chain reaction (PCR) provided more sensitive results (80.4%) than blood cultures (16.2%) and animal inoculations (11.6%). Although the classical diagnosis of acute ChD is mainly based on parasitological findings, highly sensitive and specific serological techniques can provide rapid results during large and severe outbreaks, as described herein. The use of these serological techniques allows prompt treatment of all individuals suspected of being infected, resulting in reduced rates of morbidity and mortality.

Variáveis de acidez em função da mineralogia da fração argila do solo

A acidez do solo e variáveis associadas são muito importantes nos manejos dos solos, especialmente nas regiões tropicais e subtropicais. Com o objetivo de estudar algumas variáveis da acidez do solo e verificar a influência da mineralogia da fração argila sobre a relação entre pH em CaCl2 e grau de saturação por bases (V), amostraram-se os horizontes B e C de diferentes classes de solo no Estado do Paraná: Latossolo Bruno ácrico húmico (LBw-1), Latossolo Bruno distrófico húmico (LBw-2), Latossolo Vermelho distroférrico húmico (LVdf), Cambissolo Háplico alumínico típico (CXa) e Cambissolo Húmico distroférrico típico (CHd). A fração argila foi estudada por difratometria de raios X, análise termodiferencial, análise termogravimétrica e análises químicas. As amostras de solo foram incubadas por 60 dias, após terem recebido doses crescentes de óxido de cálcio, para atingir valores preestabelecidos do grau de saturação por bases (natural, 25, 45, 60, 70, 125 e 150 %). Em seguida, determinaram-se os teores de cátions trocáveis e os valores de pH em H2O e solução de CaCl2 1 mol L-1. Os solos apresentaram o seguinte comportamento quanto à mineralogia da fração argila: mais esmectítico/vermiculítico - CXa; mais oxídico, principalmente óxidos de Fe - LVdf e óxidos de Al - LBw1; mais caulinítico, com menores teores de óxidos de Fe e Al - CHd e LBw2. Essa diversidade mineralógica foi determinante na relação pH em CaCl2 e grau de saturação por bases (V) dos solos. As curvas que mostraram essa relação foram não lineares, o que significa poder tamponante diferenciado ao longo da faixa de pH em CaCl2 estudada; formato convexo dos solos mais oxídicos e côncavo dos solos cauliníticos e com argila 2:1. O formato convexo das curvas foi conseqüência da formação de cargas negativas e dissociação de H+ preferencialmente a valores elevados de pH em CaCl2 (acima de 5), devido à menor acidez (PCZ mais alto) dos radicais Fe-OH e Al-OH. O formato côncavo foi atribuído a cargas permanentes e a maior dissociação de H+ a valores menores de pH em CaCl2 (abaixo de pH 5), uma vez que o radical Si-OH é considerado um ácido forte (PCZ baixo). Para um mesmo pH em CaCl2 verificou-se a seguinte seqüência nos valores de V em função da mineralogia da fração argila: solos com predomínio de óxidos de Fe e Al < solos com predomínio de caulinita < solos cauliníticos com minerais 2:1.

Soil tillage systems: changes in soil structure and crop response

The introduction and intensification of no-tillage systems in Brazilian agriculture in recent decades have created a new scenario, increasing concerns about soil physical properties. The objective of this study was to assess the effects of different tillage systems on some physical properties of an Ultisol previously under native grassland. Five tillage methods were tested: no-tillage (NT), chiseling (Ch), no-tillage with chiseling every two years (NTCh2), chiseling using an equipment with a clod-breaking roller (ChR) and chiseling followed by disking (ChD). The bulk density, macroporosity, microporosity and total porosity, mechanical resistance to penetration, water infiltration into the soil and crop yields were evaluated. The values of soil bulk density, mechanical resistance to penetration and microporosity increased as macroporosity decreased. Soil bulk density was lower in tillage systems with higher levels of tillage/soil mobilization; highest values were observed in NT and the lowest in the ChD system. The water infiltration rate was highest in the ChR system, followed by the systems ChD, NT and NTCh2, while crop yields were higher in systems with less soil mobilization.

Dinâmica oscilatória em sistemas contendo bromato e 1,4-ciclo-hexanodiona em meio ácido: I. Efeito da temperatura

We present in this work the influence of temperature on the dynamics of homogeneous chemical systems containing bromate and 1,4-cyclohexanedione (1,4-CHD) in acidic media. In particular, the following systems were studied: bromate/1,4-CHD/acid, bromate/1,4-CHD/ferroin/acid and bromate/1,4-CHD/trisbipyridine ruthenium/acid. Investigations were carried out by means of an electrochemical probe, at five temperatures between 5 and 45 °C. Activation energies (Ea) were estimated in different ways for the pre-oscillatory and oscillatory regimes. In any case, the Ea was found to depend on the catalyst, composition and initial concentrations. In addition, it was observed that ferroin and trisbipyridine ruthenium act as catalysts only during the transition between the induction period and oscillatory regime.

Resistência de populações de capim-colchão (Digitaria ciliaris) aos herbicidas inibidores da Acetil Co-A Carboxilase

O objetivo do presente trabalho foi avaliar as populações com suspeita de ocorrência de biótipos resistentes de Digitaria ciliaris aos herbicidas inibidores da AcetilCoA Carboxilase (ACCase), por meio de curvas de dose-resposta, bem como estabelecer o grau de resistência cruzada aos herbicidas cicloexanodionas (CHD) e ariloxifenoxipropionatos (APP) desses biótipos. O experimento foi conduzido em casa de vegetação, utilizando-se quatro populações com suspeita de resistência (R1, R2, R3 e R4) e uma população suscetível (S). O delineamento experimental adotado foi o de blocos ao acaso, com quatro repetições, sendo os tratamentos resultado da interação fatorial entre cinco populações, três herbicidas (fluazifop-p-butil, sethoxydim e tepraloxydim) e oito doses de herbicidas (0C, 0,06C, 0,125C, 0,5C, 1C, 2C, 4C e 10C), em que C é a dose comercial recomendada para cada produto. Foram realizadas avaliações de porcentagem de controle aos 28 dias após a aplicação (DAA). A partir dos resultados obtidos, conclui-se que as populações R1, R2, R3 e R4 apresentaram-se como biótipos resistentes aos herbicidas inibidores da ACCase, com diferentes níveis de resistência cruzada aos herbicidas com esse mecanismo de ação.

Lack of a relationship between serum ferritin levels and coronary atherosclerosis evaluated by coronary arteriography

Many clinical and epidemiological studies have demonstrated the relationship between serum ferritin and ischemic heart disease. In the present study we evaluated the relationship between coronary heart disease (CHD) and serum ferritin levels in patients submitted to coronary arteriography. We evaluated 307 patients (210 (68.7%) males; median age: 60 years) who were submitted to coronary angiography, measurement of serum ferritin and identification of clinical events of ischemic heart disease. Serum ferritin is reported as quartiles. Ninety-six patients (31.27%) had normal coronary angiography (group 1) and 211 (68.73%) had coronary heart disease (group 2). Of the patients with CHD, 61 (28.9%) had serum ferritin levels higher than 194 ng/ml (4th quartile), as opposed to only 14 (14.58%) of those without CHD (P = 0.0067). In the 2nd quartile, 39 patients (18.48%) had CHD, while 35 patients (36.46%) had normal coronary arteries (P = 0.00064). Multivariate analysis of the data showed that the difference between groups was not statistically significant (P = 0.33). We conclude that there is no independent relationship between coronary heart disease and increased levels of serum ferritin.

Estrogen replacement therapy and cardioprotection: mechanisms and controversies

Epidemiological and case-controlled studies suggest that estrogen replacement therapy might be beneficial in terms of primary prevention of coronary heart disease (CHD). This beneficial effect of estrogens was initially considered to be due to the reduction of low density lipoproteins (LDL) and to increases in high density lipoproteins (HDL). Recent studies have shown that estrogens protect against oxidative stress and decrease LDL oxidation. Estrogens have direct effects on the arterial tissue and modulate vascular reactivity through nitric oxide and prostaglandin synthesis. While many of the effects of estrogen on vascular tissue are believed to be mediated by estrogen receptors alpha and ß, there is evidence for `immediate non-genomic' effects. The role of HDL in interacting with 17ß-estradiol including its esterification and transfer of esterified estrogens to LDL is beginning to be elucidated. Despite the suggested positive effects of estrogens, two recent placebo-controlled clinical trials in women with CHD did not detect any beneficial effects on overall coronary events with estrogen therapy. In fact, there was an increase in CHD events in some women. Mutations in thrombogenic genes (factor V Leiden, prothrombin mutation, etc.) in a subset of women may play a role in this unexpected finding. Thus, the cardioprotective effect of estrogens appears to be more complicated than originally thought and requires more research.

Effects of chronic heart disease on skeletal muscle fiber size

Size changes in muscle fibers of subjects with chronic heart disease (CHD) have been reported, although a consensus has not been achieved. The aims of the present study were to investigate a possible association between CHD and fiber size changes in the brachial biceps compared to subjects without heart disease. Forty-six muscle samples were obtained in autopsies of individuals (13 to 84 years) without neuromuscular disorders, 19 (10 males and 9 females) with, and 27 (14 males and 13 females) without CHD. In all cases muscle sections were stained with hematoxylin and eosin and processed for the visualization of myofibrillar ATPase activity. The lesser diameter of type 1 and type 2 fibers was obtained tracing their outlines (at least 150 fibers of each type per sample) onto an image analyzer connected to a computer. The results were analyzed statistically comparing males and females with and without CHD. Type 1 fiber mean lesser diameters were 51.51 and 54.52 µm in males (normal range 34-71 µm) and 45.65 and 55.42 µm in females (normal range 34-65 µm) without and with CHD, respectively; type 2 fibers measured 54.31, 58.23, 41.15, and 49.57 µm, respectively (normal range 36-79 µm for males and 32-59 µm for females). No significant difference in fiber size was detected in 24 males with and without CHD, while in 22 females there was a significant increase in size in those with cardiomyopathy. We concluded that CHD does not determine significant changes in fiber size. However, in females, there is some hypertrophy which, despite within normal range, may reflect morphologic heterogeneity of the sample, or the daily life activities in the upper limbs as a compensatory mechanism to fatigability that affect predominantly the lower limbs in subjects with CHD.

The impact of short daily hemodialysis on anemia and the quality of life in Chinese patients

Anemia is a frequent complication in hemodialysis patients. Compared to conventional hemodialysis (CHD), short daily hemodialysis (sDHD) has been reported to be effective in many countries except China. The aim of the present study was to determine whether sDHD could improve anemia and quality of life (QOL) for Chinese outpatients with end-stage renal disease. Twenty-seven patients (16 males/11 females) were converted from CHD to sDHD. All laboratory values were measured before conversion (baseline), at 3 months after conversion (sDHD1), and at 6 months after conversion (sDHD2). The patient's QOL was evaluated at baseline and 6 months after conversion using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Hemoglobin concentration increased significantly from 107.4±7.9 g/L at baseline to 114.4±6.8 g/L (P<0.05) at sDHD1, and 118.3±8.4 g/L (P<0.001) at sDHD2 (Student paired t-test). However, the dose requirement for erythropoietin decreased from 6847.8±1057.3 U/week at baseline to 5869.6±1094.6 U/week (P<0.05) at sDHD2. Weekly stdKt/V increased significantly from 2.05±0.13 at baseline to 2.73±0.20 (P<0.001) at sDHD1, and 2.84±0.26 (P<0.001) at sDHD2. C-reactive protein decreased from baseline to sDHD1 and sDHD2, but without statistically significant differences. Physical and mental health survey scores increased in the 6 months following conversion to sDHD. sDHD may increase hemoglobin levels, decrease exogenous erythropoietin dose requirements, and improve QOL in Chinese hemodialysis patients compared to CHD. A possible mechanism for improvement of clinical outcomes may be optimized management of uremia associated with the higher efficiency of sDHD.

Associations between CD36 gene polymorphisms and susceptibility to coronary artery heart disease

Associations between polymorphisms of the CD36 gene and susceptibility to coronary artery heart disease (CHD) are not clear. We assessed allele frequencies and genotype distributions of CD36 gene polymorphisms in 112 CHD patients and 129 control patients using semi-quantitative polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis. Additionally, we detected CD36 mRNA expression by real-time quantitative PCR, and we quantified plasma levels of oxidized low-density lipoprotein (ox-LDL) using an enzyme-linked immunosorbent assay (ELISA). There were no significant differences between the two groups (P>0.05) in allele frequencies of rs1761667 or in genotype distribution and allele frequencies of rs3173798. The genotype distribution of rs1761667 significantly differed between CHD patients and controls (P=0.034), with a significantly higher frequency of the AG genotype in the CHD group compared to the control group (P=0.011). The plasma levels of ox-LDL in patients with the AG genotype were remarkably higher than those with the GG and AA genotypes (P=0.010). In a randomized sample taken from patients in the two groups, the CD36 mRNA expression of the CHD patients was higher than that of the controls. In CHD patients, the CD36 mRNA expression in AG genotype patients was remarkably higher than in those with an AA genotype (P=0.005). After adjusted logistic regression analysis, the AG genotype of rs1761667 was associated with an increased risk of CHD (OR=2.337, 95% CI=1.336-4.087, P=0.003). In conclusion, the rs1761667 polymorphism may be closely associated with developing CHD in the Chongqing Han population of China, and an AG genotype may be a genetic susceptibility factor for CHD.