Endocardite infecciosa em adolescentes: análise dos fatores de risco de mortalidade intra-hospitalar / Infective endocarditis in adolescents: analysis of risk factors for in-hospital mortality

OBJETIVO - Estudar os aspectos epidemiológicos, clínicos, terapêuticos e evolutivos da endocardite infecciosa (EI) em grupo de paciente com idade entre 12 e 20 (média de 15,5) anos. MÉTODOS - Foram estudados, retrospectivamente, 33 pacientes consecutivos (14 do sexo masculino e 19 do feminino), admitidos com diagnóstico de EI. RESULTADOS - A mortalidade da EI foi de 42 'por cento'. A cardiopatia reumática predominou como condição predisponente (63 'por cento' dos casos), seguida das cardiopatias congênitas (24 'por cento') e próteses cardíacas (12 'por cento'). A maioria dos pacientes (78 'por cento') encontrava-se na admissão em CF III e IV e apresentava mortalidade significativamente maior do que os que se encontravam na CF I e II (p=0,001). Complicaçöes embólicas foram detectadas em 51 'por cento' e determinaram maior mortalidade (p=0,05). O agente etiológico mais isolado foi o Staphylococcus aureus (em 42 'por cento' das hemoculturas positivas), seguido do Staphylococcus viridans (21 'por cento'). A análise multivariada mostrou que a contagem global de leucócitos acima de 10.000/mmü, e a CF referidos na admissão (p=0,001 e p=0,04), e a ocorrência de embolias (p=0,03) eram preditores independentes de mortalidade intra-hospitalar. CONCLUSÄO - A cardiopatia reumática permanece, semelhante à população adulta, como principal fator predisponente da EI nos adolescentes, tendo como principal agente etiológico o S.aureus, semelhante à população pediátrica. A mortalidade é elevada e representam preditores de mortalidade intra-hospitalar a CF na admissão, a ocorrência da fenômenos embólicos e a leucocitose.

[Infective endocarditis in adolescents. Analysis of risk factors for hospital mortality]. / Endocardite infecciosa em adolescentes. Análise dos fatores de risco de mortalidade intra-hospitalar.

PURPOSE: To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old (mean 15.5). METHODS: Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied. RESULTS: Infective endocarditis mortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p = 0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm3 and functional class, both at admission (p = 0.01 and p = 0.004, respectively), and the occurrence of embolic complications (p = 0.03) as independent predictors of in-hospital mortality. CONCLUSION: Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S. aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.

[Coronary fistula associated with severe pulmonary stenosis and cianosis]. / Fístula coronariana associada à estenose pulmonar grave e cianose.

A 17 year old male adolescent was admitted to the hospital due to dyspnea and cyanosis, since the age of 6 years. On physical examination, it was found a continuous murmur over the left esternal border at the 4th and 5th intercostal spaces suggesting a coronary fistula. A color-echocardiogram associated with an angiography confirmed the diagnosis of coronary fistula and severe pulmonary stenosis. The functional consequence was a right to left shunt with cyanosis. A surgical repair was performed with closure of the fistula at the point where it drained into the right ventricle plus a pulmonary commissurotomy. The patient had an uneventful recovery.

Fístula coronariana associada à estenose pulmonar grave e cianose / Coronary Fistula Associated with Severe Pulmonary Stenosis and Cianosis

Adolescente do sexo masculino, 17 anos, com queixa de dispnéia e cianose desde os 6 anos, apresentava ao exame fisíco sopro contínuo nos quarto e quinto espaços intercostais esquerdos, sugestivo de fístula coronariana. O eco-color e a angiografia confirmaram a hipótese de fístula coronariana associada a estenose pulmonar valvar grave e shunt direito-esquerdo, o que provocava a cianose. Foi submetido a correçäo cirúrgica para fechamento da fístula ao nível do seu sítio de drenagem e realizaçäo de cosurotomia pulmonar, permanecendo assintomático até o momento.

[Beta-hemolytic streptococcus endocarditis in an adolescent with hypertrophic cardiomyopathy]. / Endocardite por estreptococo beta-hemolítico em adolescente portador de cardiomiopatia hipertrófica.

A 15 year-old male adolescent was hospitalized in a severe septic condition, due to infectious endocarditis which abided for 20 days. The admittance echocardiogram displayed a mitral valve vegetation in conjunction to a hypertrophic cardiomyopathy. In spite of applied antibiotics the patient expired. The authors emphasize the diagnostic difficulties of this compound entity and stress the need of antibiotic prophylaxis for patients who bear a hypertrophic cardiomyopathy, even in those with a non-obstructive disposition.

[Clinical and hemodynamic aspects of non-obstructive coronary lesions. A comparative retrospective study]. / Aspectos clínicos e hemodinâmicos das lesões coronárias não-obstrutivas. Estudo retrospectivo comparativo.

PURPOSE: To study the clinical and hemodynamic aspects of a group of patient presenting non-obstructive coronary lesions. METHODS: We reviewed 963 coronary angiographies performed at a same institution. The 52 patients presenting only stenosis < or = 50% after semi-quantitative measurement composed group I, which was compared with two other groups consisted of 52 patients each: one, with patients presenting univascular lesion > 50% (group II) and the other with normal coronary arteriographies (group III). RESULTS: Mean age was similar in groups I and II (49.4 +/- 6.89 and 51.3 +/- 7.86, p > 0.05) and significantly higher than that of group III (44.8 +/- 6.81, p < 0.05). Risk factors did not discriminate group I (GI) from groups II (GII) and III (GIII). During a follow-up period of 63 months, the number of hospital admissions due to cardiac events and repetitions of coronary arteriography were similar in GI and GII, being significantly less frequent in GIII (p < 0.00001 and 0.001; p < 0.01 and 0.05, respectively). By the end of the follow-up period, though angina and heart failure functional classes had been similar in the three groups, patients in groups I and II were using more medications than those in group III (p < 0.0001 and 0.00001). Mean ejection fractions (%) were lower in GI and GII (67.04 +/- 10.13 and 68.90 +/- 11.32) than in GIII (74.69 +/- 6.40, p < 0.01). Lesions were predominantly proximal in GI when compared with GII (p < 0.05). Length, simmetry, ulceration, thrombus and proximal shoulder showed no difference between GI and GII. CONCLUSION: Patients with non-obstructive coronary lesions were similar to those with univascular lesion > 50% regarding several aspects and were considerably different from those with normal coronary arteries.