Pregnancy in Women with Complex Congenital Heart Disease. A Constant Challenge.

BACKGROUND: The improvement in surgical techniques has contributed to an increasing number of childbearing women with complex congenital heart disease (CCC). However, adequate counseling about pregnancy in this situation is uncertain, due to a wide variety of residual cardiac lesions. OBJECTIVES: To evaluate fetal and maternal outcomes in pregnant women with CCC and to analyze the predictive variables of prognosis. METHODS: During 10 years we followed 435 consecutive pregnancies in patients (pts) with congenital heart disease. Among of them, we selected 42 pregnancies in 40 (mean age of 25.5 ± 4.5 years) pts with CCC, who had been advised against pregnancy. The distribution of underlying cardiac lesions were: D-Transposition of the great arteries, pulmonary atresia, tricuspid atresia, single ventricle, double-outlet ventricle and truncus arteriosus. The surgical procedures performed before gestation were: Fontan, Jatene, Rastelli, Senning, Mustard and other surgical techniques, including Blalock, Taussing, and Glenn. Eight (20,0%) pts did not have previous surgery. Nineteen 19 (47.5%) pts had hypoxemia. The clinical follow-up protocol included oxygen saturation recording, hemoglobin and hematocrit values; medication adjustment to pregnancy, anticoagulation use, when necessary, and hospitalization from 28 weeks, in severe cases. The statistical significance level considered was p < 0.05. RESULTS: Only seventeen (40.5%) pregnancies had maternal and fetal uneventful courses. There were 13 (30.9%) maternal complications, two (4.7%) maternal deaths due to hemorrhage pos-partum and severe pre-eclampsia, both of them in women with hypoxemia. There were 7 (16.6%) stillbirths and 17 (40.5%) premature babies. Congenital heart disease was identified in two (4.1%) infants. Maternal and fetal complications were higher (p < 0.05) in women with hypoxemia. CONCLUSIONS: Pregnancy in women with CCC was associated to high maternal and offspring risks. Hypoxemia was a predictive variable of poor maternal and fetal outcomes. Women with CCC should be advised against pregnancy, even when treated in specialized care centers.

Effect of enalapril on left ventricular diameters and exercise capacity in asymptomatic or mildly symptomatic patients with regurgitation secondary to mitral valve prolapse or rheumatic heart disease.

The effects of 12 months of therapy were evaluated in 47 mildly symptomatic patients with moderate to severe mitral valve regurgitation; 26 patients received enalapril and 21 received a placebo. Enalapril was associated with a significant reduction in left ventricular diameter and mitral regurgitation volume, with no evidence of change in systolic function indexes. However, enalapril did not hinder progressive aerobic impairment to effort.

Pregnancy in patients with heart disease: experience with 1,000 cases.

BACKGROUND: Previously, the high maternal mortality in cardiac patients who became pregnant prompted the assertion: Women with an abnormal heart should not become pregnant. This long-standing notion needs to be revised today. HYPOTHESIS: The study was undertaken to ascertain the experience with a large series of pregnant women with cardiac disease cared for in the same referral center. METHODS: From 1989 to 1999, 1,000 pregnant women with heart disease were followed by the same clinical and obstetric team. The cardiac diseases included rheumatic heart disease (55.7%), congenital heart disease (19.1%), Chagas' disease (8.5%), cardiac arrhythmias (5.1%), cardiomyopathies (4.3%), and others (7.3%). RESULTS: Of the pregnant women studied, 765 (76.5%) experienced no cardiovascular events during the study; 235 (23.5%) patients had the following cardiovascular complications: congestive heart failure (12.3%), cardiac arrhythmias (6%), thromboembolism (1.9%), angina (1.4%), hypoxemia (0.7%), infective endocarditis (0.5%), and other complications (0.7%). Clinical treatment allowed adequate management in 161 (68.8%) patients; however, 46 (19.6%) patients underwent interventional procedures because of refractory complications. The general maternal mortality rate was 2.7%. Of the 915 (91.5%) infants who were discharged, 119 (13%) were premature. CONCLUSION: Pregnancy in women with heart disease is still associated with considerable morbidity and mortality rates, which strongly correlate to maternal underlying disease. Strict prenatal care and early risk stratification during gestation are fundamental measures to improve the prognosis of pregnancy in women with heart disease.

Pregnancy and peripartum cardiomyopathy. A comparative and prospective study.

OBJECTIVE: To assess pregnancy outcome in women with peripartum cardiomyopathy and to compare it with idiopathic cardiomyopathy. METHODS: Twenty-six pregnant women, aged 28.4+/-6.1 years, with dilated cardiomyopathy were followed. Eighteen patients had peripartum cardiomyopathy [11 with persistent left ventricular systolic dysfunction (EF=45.2+/-2) and 7 with recovered ventricular function (EF=62.3+/-3.6)]. The 8 remaining patients had idiopathic cardiomyopathy (EF= 43.5+/-4.1). During the prenatal period, limited physical activity and a low-sodium diet were recommended, and hospitalization was recommended when complications occurred. RESULTS: Of the 26 patients, 11 (42.3%) had a normal delivery; 9(35.5%) had cardiac complications, 6 (22.2%) had obstetric complications. Two patients (7.7%) died. Two preterm pregnancies occurred, with 26 health newborns (2 sets of twins). Two miscarriages took place. The cardiac complication rate during pregnancy was lower (p<0.009) in the peripartum cardiomyopathy group without ventricular dysfunction and greater (p=0.01) in the idiopathic group when compared with the peripartum group with ventricular dysfunction. Changes in left ventricular ejection fraction were not observed (p<0.05) in the postpartum period, when compared with that during pregnancy in the 3 groups. CONCLUSION: Pregnancy in patients with dilated cardiomyopathy is associated with maternal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when counseling patients with peripartum cardiomyopathy about a new pregnancy.

Pregnancy in Women with Complex Congenital Heart Disease. A Constant Challenge / Gravidez em Portadoras de Cardiopatias Congênitas Complexas: Um Constante Desafio

Abstract Background: The improvement in surgical techniques has contributed to an increasing number of childbearing women with complex congenital heart disease (CCC). However, adequate counseling about pregnancy in this situation is uncertain, due to a wide variety of residual cardiac lesions. Objectives: To evaluate fetal and maternal outcomes in pregnant women with CCC and to analyze the predictive variables of prognosis. Methods: During 10 years we followed 435 consecutive pregnancies in patients (pts) with congenital heart disease. Among of them, we selected 42 pregnancies in 40 (mean age of 25.5 ± 4.5 years) pts with CCC, who had been advised against pregnancy. The distribution of underlying cardiac lesions were: D-Transposition of the great arteries, pulmonary atresia, tricuspid atresia, single ventricle, double-outlet ventricle and truncus arteriosus. The surgical procedures performed before gestation were: Fontan, Jatene, Rastelli, Senning, Mustard and other surgical techniques, including Blalock, Taussing, and Glenn. Eight (20,0%) pts did not have previous surgery. Nineteen 19 (47.5%) pts had hypoxemia. The clinical follow-up protocol included oxygen saturation recording, hemoglobin and hematocrit values; medication adjustment to pregnancy, anticoagulation use, when necessary, and hospitalization from 28 weeks, in severe cases. The statistical significance level considered was p < 0.05. Results: Only seventeen (40.5%) pregnancies had maternal and fetal uneventful courses. There were 13 (30.9%) maternal complications, two (4.7%) maternal deaths due to hemorrhage pos-partum and severe pre-eclampsia, both of them in women with hypoxemia. There were 7 (16.6%) stillbirths and 17 (40.5%) premature babies. Congenital heart disease was identified in two (4.1%) infants. Maternal and fetal complications were higher (p < 0.05) in women with hypoxemia. Conclusions: Pregnancy in women with CCC was associated to high maternal and offspring risks. Hypoxemia was a predictive variable of poor maternal and fetal outcomes. Women with CCC should be advised against pregnancy, even when treated in specialized care centers.

Resumo Fundamento: A contínua habilidade na conduta das cardiopatias congênitas complexas (CCC) tem permitido o alcance da idade fértil. Contudo, a heterogeneidade das lesões cardíacas na idade adulta limita a estimativa do prognóstico da gravidez. Objetivo: Estudar a evolução materno-fetal das gestantes portadoras de CCC e analisar as variáveis presumíveis de prognóstico. Método: No período de 10 anos, 435 gestantes portadoras de cardiopatias congênitas foram consecutivamente incluídas no Registro do Instituto do Coração (Registro-InCor). Dentre elas, foram selecionadas 42 gestações em 40 mulheres com CCC (24,5 ± 3,4 anos) que haviam sido desaconselhadas a engravidar. As cardiopatias de base distribuíram-se em: transposição das grandes artérias, atresia pulmonar, atresia tricúspide, ventrículo único, dupla via de saída de ventrículo direito, dupla via de entrada de ventrículo esquerdo e outras lesões estruturais. As cirurgias realizadas foram Rastelli, Fontan, Jatene, Senning, Mustard e outros procedimentos combinados, como tunelização, Blalock Taussing e Glenn. Oito pacientes (20%) não haviam sido operadas, e 19 (47,5%) apresentavam hipoxemia. O protocolo de atendimento incluiu: registro da saturação de oxigênio, hemoglobina sérica, hematócrito, ajuste das medicações, anticoagulação individualizada e hospitalização a partir de 28 semanas de gestação, em face da gravidade do quadro clínico e obstétrico. Na análise estatística, o nível de significância adotado foi de 0,05. Resultado: Somente 17 gestações (40,5%) não tiveram complicações maternas nem fetais. Houve 13 problemas maternos (30,9%) e 2 mortes (4,7%) causadas por hemorragia pós-parto e pré-eclâmpsia grave, ambas em pacientes que apresentavam hipoxemia. Houve 7 perdas fetais (16,6%), 17 bebês prematuros (40,5%) e 2 recém-nascidos (4,7%) com cardiopatia congênita. As complicações materno-fetais foram significativamente maiores em pacientes que apresentavam hipoxemia (p < 0,05). Conclusão: O alcance da idade reprodutiva em pacientes com CCC é crescente; contudo, a má evolução materno-fetal desaconselha a gravidez, particularmente nas pacientes que apresentam hipoxemia.

Influence of pregnancy on clinical course and fetal outcome of women with hypertrophic cardiomyopathy.

OBJECTIVES: To study clinical evolution of women with HCM during pregnancy; the influencing factors of gestation on natural course of HCM and the frequency of HCM in their children in early childhood. METHODS: A prospective study was conducted in 35 women with HCM; there were 23 pregnant women (PG group) and 12 nonpregnant control patients (NP group), matched for age and functional class (FC). Clinical monthly evaluations were carried out and electrocardiogram and transthoracic echocardiography tests were performed. The offspring endpoints included stillbirth and prematurity rates and investigation of HCM during childhood. RESULTS: No deaths occurred in either group. Cardiac arrhythmias were significantly (p< 0.05) more frequent in the NP group (33.3% vs. 13.4%), and no differences were observed between the groups (p>0.05) in heart failure (30.3% vs. 16.6%) or ischemic stroke (4.3% vs. 8.3%) rates. In the PG group, required hospitalization for treatment of cardiac complication was more frequent (p=0.05) in patients with family history of HCM (71.4% vs. 25.0%). Cesarean section was performed in 12 (52%) patients, for obstetrical reasons; there were 7 (30.4%) premature babies and 1 (4.3%) neonatal death. One child was clinically diagnosed as having HCM, and his genetic study identified a mutation in the beta myosin heavy chain gene, located on chromosome 14. CONCLUSION: Heart failure is a frequent cardiac complication in women with HCM during pregnancy, particularly in patients with family history of the disease, but this did not influence the natural course of HCM. In one child, clinical examination allowed HCM identification during early childhood.

Influência da gestação na evolução clínica materno-fetal de portadoras de cardiomiopatia hipertrófica / Influence of pregnancy on clinical course and fetal outcome of women with hypertrophic cardiomyopathy

OBJETIVOS: Estudar a evolução clínica de gestantes com CMH, a influência da gestação sobre o curso natural da CMH e a freqüência da doença nos filhos dessas mulheres no início da infância. MÉTODOS: Foi realizado um estudo prospectivo em 35 portadoras de CMH com a mesma idade e classe funcional (CF). Vinte e três estavam grávidas (grupo G), e 12 pacientes que não estavam grávidas serviram como controle (grupo NG). Foram realizadas avaliações clínicas mensais, bem como eletrocardiograma e ecocardiograma transtorácico Os desfechos para os filhos foram taxas de natimortalidade e prematuridade e investigação de CMH durante a infância. RESULTADOS: Não houve mortes em nenhum dos dois grupos. A ocorrência de arritmias cardíacas foi significantemente maior (p< 0,05) no grupo NG (33,3 por cento vs. 13,4 por cento), e não foram observadas diferenças nos índices de insuficiência cardíaca (30,3 por cento vs. 16,6 por cento) ou acidente vascular cerebral isquêmico (4,3 por cento vs. 8,3 por cento) entre os grupos (p > 0,05). No grupo NG, a necessidade de hospitalização para tratamento de complicações cardíacas foi mais freqüente (p = 0,05) em pacientes com história familiar de CMH (71,4 por cento vs. 25,0 por cento). Doze pacientes (52 por cento) foram submetidas à cesariana por razões obstétricas, sete bebês (30,4 por cento) nasceram prematuramente e um bebê (4,3 por cento) teve morte neonatal. Uma criança teve diagnóstico clínico de CMH, e seu estudo genético identificou mutação no gene da cadeia pesada da b-miosina, situado no cromossomo 14. CONCLUSÃO: Insuficiência cardíaca é uma complicação freqüente em portadoras de CMH durante a gravidez, principalmente em pacientes com antecedentes familiares da doença, mas não altera o curso natural da CMH. Em uma criança, o exame clínico identificou HMC no início da infância.

OBJECTIVES: To study clinical evolution of women with HCM during pregnancy; the influencing factors of gestation on natural course of HCM and the frequency of HCM in their children in early childhood. METHODS: A prospective study was conducted in 35 women with HCM; there were 23 pregnant women (PG group) and 12 nonpregnant control patients (NP group), matched for age and functional class (FC). Clinical monthly evaluations were carried out and electrocardiogram and transthoracic echocardiography tests were performed. The offspring endpoints included stillbirth and prematurity rates and investigation of HCM during childhood. RESULTS: No deaths occurred in either group. Cardiac arrhythmias were significantly (p< 0.05) more frequent in the NP group (33.3 percent vs. 13.4 percent), and no differences were observed between the groups (p>0.05) in heart failure (30.3 percent vs. 16.6 percent) or ischemic stroke (4.3 percent vs. 8.3 percent) rates. In the PG group, required hospitalization for treatment of cardiac complication was more frequent (p=0.05) in patients with family history of HCM (71.4 percent vs. 25.0 percent). Cesarean section was performed in 12 (52 percent) patients, for obstetrical reasons; there were 7 (30.4 percent) premature babies and 1 (4.3 percent) neonatal death. One child was clinically diagnosed as having HCM, and his genetic study identified a mutation in the beta myosin heavy chain gene, located on chromosome 14. CONCLUSION: Heart failure is a frequent cardiac complication in women with HCM during pregnancy, particularly in patients with family history of the disease, but this did not influence the natural course of HCM. In one child, clinical examination allowed HCM identification during early childhood.

Spontaneous closure of ventricular septum rupture after acute myocardial infarction / Fechamento espontâneo de comunicação interventricular após infarto agudo do miocárdio

Spontaneous closure of ventricular septal defect due to acute anterzor myocardial infarction was demonstrated angiographically 20 months later in a 55-year-old female patient.

Mulher de 55 anos apresentou infarto agudo do miocárdio de parede anterior e ruptura do septo interventricular, o qual fechou espontaneamente. O fechamento foi demonstrado angiograficamente depois de 20 meses do infarto.

Rotura do septo interventricular pós-infarto agudo do miocárdio na ausência de sintomas típicos e de alteraçöes eletrocardiográficas: relato de caso / Rupture of the interventricular septum after acute myocardial infarction in the abscence of typical symptoms and electrocardiographic changes: a case report

Indivíduo do sexo masculino, de 79 anos de idade, com dispnéia súbita, síncope e bloqueio atrioventricular total, que persistiu com os sintomas mesmo após implante de marca-passo. Após três dias do procedimento detectou-se sopro holossistólico em precórdio, com suspeita de comunicaçäo interventricular como complicaçäo do implante do marca-passo. Diagnosticou-se, através de estudo hemodinâmico, infarto agudo do miocárdio de parede inferior por suboclusäo da artéria coronária direita e rotura do septo interventricular. Näo se demonstrou, em nenhum dos ECG realizados, qualquer alteraçäo sugestiva de áreas isquêmicas e/ou de área eletricamente inativa. Comenta-se a extrema raridade desta associaçäo na ausência, tanto de alteraçöes eletrocardiográficas, quanto de manifestaçöes clínicas sugestivas

Prolapso da valva mitral em endocardite infecciosa: incidência e características / Mitral valve prolapse in infectious endocarditis: incidence and characteristics

Avaliar características de casos de prolapso de valva mitral (PVM) complicados pela ocorrência de endocardite infecciosa (EI), atendidos em hospital de cardiologia de referência. Casos de PVM, integrantes de um conjunto de 276 portadores de El, näo previamente submetidos a tratamento cirúrgico, selecionados através de critérios clínico-ecocardiográficos. Foram estudados: a) incidência; b) distribuiçäo das idades e sexo; c) fatores de risco para EI; d) dados clínico-bacteriológicos; e) aspectos ecocardiográficos; f) aspectos terapêuticos e g) evoluçäo e complicaçöes. a) identificados 40 (14,4%) casos de PVM; b) média etária de 40,6 (17-78) anos; maior em relaçäo à média geral, sendo 29 (72,5%) homens; c) tratamento dentário recente sem antibioticoprofilaxia em sete (17,5%), presença de insuficiência mitral em 33 (82,5%), redundância mitral em seis (15%) casos; d) febre constatada em todos (100%), emagrecimento em oito (20%), poliartrite em seis (15%), insuficiência cardíaca expressiva em seis (15%), sopro sistólico mitral em todos (100%); estalido meso-sistólico em quatro pacientes (10%); cultivo de estreptococos em 30 (75%), estafilococos em três (7,5%), Haemophyllus sp em três (7,5%), Peptostreptococcus productus em um (2,5%) e hemoculturas negativas em três (7,5%) casos; e) sinais ecocardiográficos de vegetaçäo em 23 (57,5%), insuficiência mitral em 33 (82,5%), rotura de corda em 11 (27,5%) e redundância mitral em seis (15%) casos; f) tratamento clínico isolado aplicado a 37 (92,5%)...

Purpose­To determine characteristics of mitral valve prolapse (MVP) cases, complicated with infective endocarditis (IE), seen at a cardiologic reference hospital. Methods­The MVP cases were diagnosed within a series of 276 cases of IE without previous cardiac surgery with clinical-echocardiographic criteria. We emphasised in our study; a) incidence; b) age and sex distribution; c) risk factors for IE; d ) clinical-bacteriological data; e) echocardiographic features; f) therapeutic aspects; g) evolution and complications. Results­a) We diagnosed 40 (14,4%) cases of MVP; b) mean age of 40,6 years, with 29 men (72,5%); c) dental procedures without prophylactic antibioticotherapy in seven patients (17,5%), mitral regurgitation in 33 (82,5%), mitral valve redundancy in six (15%); d) fever was found in all patients (100%), caquexia was diagnosed in eight (20%), poliarthritis in six (15%) and congestive heart failure in six (15%). A systolic murmur of mitral regurgitation was found in all the patients and a nonejective click was encountered in four (10%), a Streptococcus was cultivated in 30 (75%), Staphylococcus in three (7,5%) Haemophyllus sp in three (7,5%) Peptostreptococcus products in one (2,5%) and negative in three (7,5%) patients; e) echocardiographic signs of vegetation in 23 (57,5%), mitral regurgitation in 33 (82,5%), rupture of mitral chordae in 11 (27,5%) and mitral redundance in six (15,2%); f) 37 (92,5% )

Avaliação comparative entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral / Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis

PURPOSE: To compare immediate and late (12 months) follow-up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2 +/- 5.8 to 5.80 +/- 2.7 (p < 0.001) in commissurotomy group (CG) and from 11.7 +/- 6.1 to 5.0 +/- 2.4 (p < 0.001) in the balloon valvuloplasty group (VG). Mitral valve are (cm2) increased from 0.98 +/- 0.21 to 2.52 +/- 0.46 in CG and from 1.05 +/- 0.25 to 2.18 +/- 0.40 in VG (p < 0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however, there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

Gravidez em portadoreas de cardiomiopatia periparto. Estudo prospectivo e comparativo / Pregnancy and peripartum cardiomyopathy. A comparative and prospective study

OBJECTIVE - To assess pregnancy outcome in women with peripartum cardiomyopathy and to compare it with idiopathic cardiomyopathy. METHODS - Twenty-six pregnant women, aged 28.4±6.1 years, with dilated cardiomyopathy were followed. Eighteen patients had peripartum cardiomyopathy [11 with persistent left ventricular systolic dysfunction (EF=45.2±2) and 7 with recovered ventricular function (EF=62.3±3.6)]. The 8 remaining patients had idiopathic cardiomyopathy (EF= 43.5±4.1). During the prenatal period, limited physical activity and a low-sodium diet were recommended, and hospitalization was recommended when complications occurred. RESULTS - Of the 26 patients, 11 (42.3 percent) had a normal delivery; 9(35.5 percent) had cardiac complications, 6 (22.2 percent) had obstetric complications. Two patients (7.7 percent) died. Two preterm pregnancies occurred, with 26 health newborns (2 sets of twins). Two miscarriages took place. The cardiac complication rate during pregnancy was lower (p<0.009) in the peripartum cardiomyopathy group without ventricular dysfunction and greater (p=0.01) in the idiopathic group when compared with the peripartum group with ventricular dysfunction. Changes in left ventricular ejection fraction were not observed (p<0.05) in the postpartum period, when compared with that during pregnancy in the 3 groups. CONCLUSION - Pregnancy in patients with dilated cardiomyopathy is associated with maternal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when counseling patients with peripartum cardiomyopathy about a new pregnancy

Obstruçäo da via de saída do ventrículo esquerdo após implante de bioprótese em posiçäo mitral: uma causa de síndrome de baixo débito reversível por reoperaçäo imediata; relato de caso / Obstruction of left ventricular autflow after bioprosthesis implantation in mitral position: a case of low cardiac output reversible by immediate reoperation; a case report

Mulher de 36 anos, branca, submetida a troca de valva mitral por prótese de pericárdio bovino de alto perfil, veio a apresentar síndrome de baixo débito no pós operatório imediato. Estudo hemodinâmico comprovou obstruçäo da via de saída do ventrículo esquerdo pela prótese. O quadro foi revertido pela troca da bioprótese por prótese de baixo perfil

Insuficiência mitral rapidamente progressiva no decorrer de manifestaçäo inicial de lupus eritematoso sistêmico: correlaçäo anátomo - clínico - ecocardiográfia; relato de caso / Rapidly progressive mitral insufficiency during initial manifestation of systemic lupus erythematosus: anatomo - clinical - echocardiographic correlation; a case report

Paciente do sexo feminino, 26 casos, desenvolveu insuficiência mitral severa como manifestaçäo inicial de lupus eritematoso disseminado (LES). O estudo ecocardiográfico permitiu, de maneira näo observada na literatura, proceder a uma análise de fases distintas anátomo-funcionais do comprometimento do endocárdio. A ocorrência de insuficiência cardíaca congestiva refratária motivou a indicaçäo de tratamento cirúrgico da disfunçäo valvar mitral. No ato operatório, constatou-se que a insuficiência mitral era conseqüente ao acolamento do folheto posterior, bem como do músculo papilar posterior ao endocárdio ventricular pelo processo inflamatório imune-induzido, em ausência de rotura de corda tendínea. Procedeu-se à substituiçäo da valva mitral bioprótese porcina. Näo houve complicaçöes pós-operatórias e, após seis meses da operaçäo, a paciente estava em classe funcional I. Concluiu-se que a correçäo cirúrgica da disfunçäo mitral deve ser cogitada em casos de insuficiência mitral de grande repercussäo hemodinâmica, rapidamente progressiva, mesmo no decorrer da manifestaçäo inicial do LES

Cardiotocologia: análise de 327 casos / Cardiac pregnant woman: analysis of 327 cases

Foram estudadas clinicamente 327 mulheres matriculadas no Programa de Atendimentos à Gestante Cardiopata, no INCOR, no período de 1983 a 1986. Os principais eventos maternos analisados, na evoluçäo do ciclo gravídico-puerperal, foram insuficiência cardíaca (ICC), tromboembolismo, disritmias cardíacas, endocardite infecciosa (El) e mortalidade. A ICC esteve presente em 50 (15,0%) casos afetando 27 (54,0%) portadoras de valvulopatia reumática näo operada e 19 (38,0%) miocardiopatas o tromboembolismo foi encontrado em 10 (3,0%) pacientes, das quais, 3 (30,0%) portadoras de próteses metálicas. Disritmias cardíacas foram registradas em 61 (18,0%) pacientes. Näo registramos nenhum caso de EI, mesmo considerando até o puerpério tardio. Ocorreram 14 (4,2%) óbitos. Os autores destacaram certas peculiaridades de evoluçäo clínica de mulheres portadoras de cardiopatias durante a gestaçäo, parto e puerpério, bem como enfatizam as principais complicaçöes maternas e sua relaçäo com o tipo de cardiopatia presente

Dissociação clínico-morfológica em portadores de estenose mitral / 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.

Comparaçäo entre uso de duplo balão unifoil e baläo bifoil no sucesso da valvoplastia mitral por cateter balão / 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 per cent ) patients achieved 12 months follow-up. RESULTS--In group DB there were 2 (4 per cent ) insuccess, 2 (4 per cent ) cardiac tamponade and 2 (4 per cent ) deaths, 91 per cent 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 per cent ) patients developed severe mitral regurgitation (MR) and needed surgical intervention. At follow-up 2 (4 per cent ) developed mitral restenosis. MVA estimated by ECHO study after one year follow-up was inferior to 1.15cm2 in 15 (32 per cent ) cases, between 1.5 and 2.0cm2 in 17 (37 per cent ) and superior to 2.0cm2 in 14 (31 per cent ). In group BF there were 2 (12.5 per cent ) insuccess, 4 (25 per cent ) developed severe MR occurring 1 death immediate post-operative mitral valve replacement. Among 14 (87 per cent ) success cases, MVA increased from 0.8 to 1.89cm2 and G decreased from 18 to 6.4mmHg. Lately 2 (12.5 per cent ) needed surgical intervention because significative MR. At 12th month follow-up the ECHO study showed that in one (10 per cent ) case MVA was < 1.5cm2, and in 3 (27 per cent ) 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

Plástica da valva mitral. Ressecçäo quadrangular da cúspide posterior em portadores de degeneraçäo mixomatosa / Mitral valve repair. Quadrangular resection of the posterior leaflet in patients with myxomatous degeneration

Objetivo - Analisar os resultados imediatos e tardios da plástica da valva mitral com ressecção quadrangular da cúspide posterior, sem a utilização de anuloplastia com anel protético. Métodos - Com esta técnica foram estudados 118 portadores de prolapso da valva mitral submetidos à plástica da valva mitral, de janeiro/84 a dezembro/96. A idade variou de 30 a 86 (média de 59,1 + 11,8) anos, e 62,7 por cento eram do sexo masculino. Cirurgia associada foi realizada em 22 por cento dos pacientes, sendo a mais freqüente a revascularização do miocárdio em 15 (12,7 por cento). Em 20 (16,9 por cento) pacientes, foram utilizadas técnicas associadas de plástica da valva mitral, sendo a mais freqüente o encurtamento de cordas alongadas (6 pacientes). Resultados - A mortalidade imediata foi de um paciente (0,9 por cento). As taxas linearizadas para tromboembolismo, endocardite, reoperação e óbito no pós operatório tardio foram respectivamente 0,4 por cento, 0,4 por cento, 1,7 por cento e 2,2 por cento paciente/ano. A curva actuarial de sobrevida é de 83,8 + 8,6 por cento em 12 anos, livre do evento reoperação, 91,8 + 4,3 por cento, endocardite 99,2 + 0,8 por cento e tromboembolismo 99,2 + 0,8 por cento. No pós-operatório tardio, 93,8 por cento dos pacientes se encontram em classe funcional I (NYHA), com um seguinte completo de 89,7 por cento. Conclusão - Os portadores de prolapso da valva mitral submetidos a plástica mitral com esta técnica, apresentaram uma evolução satisfatória em 12 anos.