Antemortem case of atrioventricular valve insufficiency in bearded dragon (Pogona vitticeps) - a case report / Caso antemortem de insuficiência valvar atrioventricular em dragão barbudo (Pogona vitticeps) - relato de caso

An atrioventricular valve insufficiency is a common form of cardiac disorder in mammals, whereas it has rarely been reported in reptiles. A two-year-old male bearded dragon (Pogona vitticeps) was presented with acute onset of lethargy, inappetence and general weakness, increased respiratory effort, dark skin color, and arched back. A gastrointestinal foreign body was suspected, but radiography showed coelomic fluid accumulation. Ultrasound heart examination revealed turbulent blood flow at the level of the atrioventricular valves. Electrocardiography by modified Einthoven lead system (lead configuration 1) as described for Squamata, did not show significant changes. A tentative diagnosis of congestive heart failure as a result of valvulopathy was made. Treatment consisted of parenteral furosemide and fluid administration and assisted feeding with appropriate food intended for adult bearded dragons. The patient was weekly evaluated and successfully recovered over the four months. Echocardiography and electrocardiography were repeated 12 months later. The prescribed treatment was successful with complete resolution of clinical signs, and long-term surveillance of the bearded dragon (Pogona vitticeps)

Uma insuficiência da válvula atrioventricular é uma forma comum de distúrbio cardíaco em mamíferos, enquanto que em répteis raramente é relatada. Um dragão barbudo macho de dois anos de idade (Pogona vitticeps) apresentou início agudo de letargia, inapetência e fraqueza geral, aumento do esforço respiratório, cor de pele escura e dorso arqueado. Suspeitou-se de corpo estranho gastrointestinal, mas a radiografia mostrou acúmulo de líquido celômico. O exame ultrassonográfico do coração revelou fluxo sanguíneo turbulento ao nível das válvulas atrioventriculares. O eletrocardiograma pelo sistema de derivações de Einthoven modificado (configuração de derivações 1), conforme descrito para Squamata, não mostrou alterações significativas. Foi feito um diagnóstico provisório de insuficiência cardíaca congestiva como resultado de valvulopatia. O tratamento consistiu em furosemida parenteral, administração de fluidos e alimentação assistida com alimentos apropriados destinados a dragões barbudos adultos. O paciente foi avaliado semanalmente e se recuperou com sucesso ao longo dos quatro meses. Ecocardiograma e eletrocardiograma foram repetidos 12 meses depois. O tratamento prescrito foi bem-sucedido, com resolução completa dos sinais clínicos e supervisão a longo prazo do dragão barbudo (Pogona vitticeps)

La edad avanzada en forma aislada no constituye una limitación para el reemplazo valvular aórtico quirúrgico / Old Age Alone is not a Limitation for Surgical Aortic Valve Replacement

RESUMEN Introducción: El reemplazo quirúrgico de la válvula aórtica (REEAO) en pacientes con valvulopatía aórtica grave sintomática, es el tratamiento definido como el de referencia. Sin embargo, el implante valvular aórtico transcatéter (TAVI) se posiciona actualmente como una alternativa en pacientes de diferentes riesgos según los scores internacionales. Algunas guías consideran al TAVI como el procedimiento preferible en los pacientes añosos. Objetivos: Conocer el riesgo y resultados de morbimortalidad del REEAO en pacientes adultos clasificados según la edad en mayores de 75 años, o de 75 años o menos. Material y métodos: Estudio retrospectivo sobre 228 pacientes consecutivos intervenidos mediante REEAO entre el 1 de enero de 2011 y el 31 de diciembre de 2020 por valvulopatía aórtica grave sintomática. Del total de pacientes operados, 46 (16%) eran mayores de 75 años (Grupo 1, G1) y 182 pacientes (84%) tenían 75 años o menos (Grupo 2, G2). Se excluyeron pacientes con enfermedad coronaria concomitante, endocarditis bacteriana u otras valvulopatías asociadas. Resultados: Los pacientes del G1 tenían mayor riesgo de morbimortalidad quirúrgica analizado por scores de riesgo validados: ArgenSCORE de 1,55 (RIC 0,99-3,33) vs 1,08 (RIC 0,68-2,23), p = 0,02 y STS score de 2,33 (RIC 1,57-3,23) vs. 0,94 (RIC 0,721,44), p = 0,0001, con respecto al G2; no se encontraron en cambio diferencias significativas en el EuroSCORE II : 2,37 (RIC 1,19-3,61) vs. 1,83 (RIC 1,16-3,04), p = 0,2. La mortalidad registrada global fue del 1,7% (G1: 2,1% vs. G2: 1,6% , p NS); no se observaron accidente cerebrovascular (ACV) ni infarto agudo de miocardio (IAM) perioperatorios. Conclusiones: La escasa presentación de muerte, ACV e IAM sugiere que el tratamiento seleccionado para estos pacientes fue adecuado, con excelentes resultados sin diferencias entre los dos grupos etarios.

ABSTRACT Background: Surgical aortic valve replacement (SAVR) is the reference treatment in patients with symptomatic severe aortic valve disease. However, according to international scores, transcatheter aortic valve implantation (TAVI) is currently an alternative in different risk patients, and some guidelines consider TAVI as a preferable procedure in elderly patients. Objectives: The aim of this study was to assess SAVR morbidity and mortality risk and results in adult patients, classified according to age as >75 years or ≤75 years. Methods: A retrospective study was performed on 228 consecutive patients undergoing SAVR between January 1, 2011 and December 31, 2020 for symptomatic severe aortic valve disease. Among the total number of patients operated on, 46 (16%) were >75 years (Group 1, G1) and 182 (84%) were ≤75 years (Group 2, G2). Patients with concomitant coronary heart disease, bacterial endocarditis or other associated valve diseases were excluded from the analysis. Results: Group 1 patients had greater risk of surgical morbidity and mortality analyzed by validated risk scores: ArgenSCORE 1.55 (IQR 0.99-3.33) vs 1.08 (IQR 0.68-2.23), p = 0.02 and STS score 2.33 (IQR 1.57-3.23) vs. 0.94 (IQR 0.72-1.44), p = 0.0001, with respect to G2, while no significant differences were found for EuroSCORE II: 2.37 (IQR 1.19-3.61) vs. 1.83 (IQR 1.163.04), p = 0.2. Overall mortality was 1.7% (G1: 2.1% vs. G2: 1.6%, p=NS), with no perioperative stroke or acute myocardial infarction (AMI). Conclusions: The low number of deaths, stroke and AMI observed suggests that the selected treatment for these patients was adequate, with excellent results and without significant differences between these two age groups.

Supervivencia a los cinco años en pacientes con valvulopatías izquierdas operados de cirugía cardíaca valvular / Five-year survival of patients with left-side heart valve disease who underwent heart valve surgery

RESUMEN Introducción: La supervivencia a mediano y largo plazo es un parámetro necesario para evaluar los resultados de la cirugía valvular cardíaca. Objetivos: Determinar la supervivencia a los cinco años de los pacientes operados de cirugía cardíaca valvular aórtica, mitral o ambas, y las variables que pueden pronosticar de manera independiente una peor sobrevida en el seguimiento. Método: Se realizó un estudio de cohorte que evaluó a los 139 pacientes operados de cirugía cardíaca valvular en el trienio 2010-2012, en el Instituto de Cardiología y Cirugía Cardiovascular de La Habana, Cuba, y que fueron egresados vivos del postoperatorio, hasta un período de cinco años posteriores a la intervención. Se realizó una curva de Kaplan Meier para determinar la supervivencia al final del seguimiento, así como un análisis multivariable de Cox para determinar las variables que se asociaron a una menor supervivencia. El nivel de significación estadística empleado fue p<0,05. Resultados: La muestra resultó homogénea según las variables clínicas y demográficas. La supervivencia al término del seguimiento, que tuvo una media de 5,8 años, fue de un 93%. El incremento de la edad (HR=1,15; p=0,001) y el haber sufrido bajo gasto cardíaco durante el perioperatorio (HR=3,54; p=0,037) se asociaron de manera independiente a una peor sobrevida en el seguimiento. Conclusiones: La supervivencia de los pacientes al concluir el seguimiento fue elevada. El incremento de la edad y el bajo gasto cardíaco perioperatorio fueron las variables asociadas de manera independiente a una menor sobrevida.

ABSTRACT Introduction: The mid and long term survival rate is a necessary parameter to evaluate the outcomes of heart valve surgery. Objectives: To determine the five-year survival of patients who underwent aortic and/or mitral valve surgery, and the variables that could independently predict a lower survival in the follow-up. Method: A cohort study was conducted for evaluating 139 patients who underwent a heart valve surgery, in the period 2010-2012, at the Instituto de Cardiología y Cirugía Cardiovascular of Havana, Cuba, all of which survived the postoperative period, and were followed up to five years after the surgery. A Kaplan-Meier curve was performed to determine the survival after surgery. Also, a multivariate Cox regression was carried out to determine the variables that were independently associated with a lower survival rate. The statistical significance level used was p<0.05. Results: The sample was homogeneous according to clinical and demographic variables. The overall survival rate was 93% at the end of the study, with a mean follow up of 5.8 years. The older age (HR=1.15; p=0.001) and the history of perioperative low cardiac output syndrome (HR= 3.54; p=0.037) were the variables independently associated to lower survival in the follow-up. Conclusions: The patients' survival when concluded the follow-up was high. The older age and the perioperative low cardiac output syndrome were the variables independently associated to lower survival.

Assessment of left atrial function in dogs with myxomatous mitral valve disease by biplane simpson's method / Avaliação da função atrial esquerda em cães com degeneração mixomatosa de valva mitral pelo método Simpson biplanar

The relationship between the diameter of the left atrium (LA) and aorta (Ao) is considered as a prognostic factor in chronic mitral valve disease. As the left atrium is a three-dimensional structure, methods based on measurement of the chamber volume can be more accurate than linear methods.The aim of this study was to assess the feasibility of measuring LA volume with 2D echocardiography using the biplane modified Simpson (SIMP) method in 33 dogs with various classes of myxomatous mitral valve disease (MMVD), as well as to present values of LA function using the atrial diastolic and systolic volume indices (ADVI and ASVI), cardiac index (ACI) and atrial ejection fraction (AEF). We observed agreement among the LA/Ao ratio and the atrial volume indices (ADVI and ASVI) and the ACI, suggesting that the values of the variables increase as the LA/Ao ratio increases due to atrial remodeling that accompanies MMVD progression. The data demonstrated a good assessment of atrial function, allowing a better understanding of LA's role in the pathophysiology of MMVD.(AU)

A relação entre o diâmetro átrio esquerdo (AE) e da aorta (Ao) é considerada como fator prognóstico na doença crônica de valva mitral. Como o átrio esquerdo é uma estrutura tridimensional, os métodos baseados na mensuração de volume da câmara podem ser mais precisos que os métodos lineares. O objetivo deste estudo foi avaliar a viabilidade da mensuração do volume do AE com a ecocardiografia bidimensional, sendo usado o método Simpson biplanar em 33 cães com diversas classes da degeneração mixomatosa de valva mitral (DMVM), bem como apresentar valores de função do AE utilizando-se os índices de volumes atriais diastólico e sistólico (iVdA e iVsA), o índice cardíaco atrial (iCA) e a fração de ejeção atrial (FEA). Observou-se uma concordância entre a relação AE/Ao e os índices de volume atrial (iVdA e iVsA) e o iCA, o que sugere que os valores das variáveis aumentam à medida que a relação AE/Ao aumenta, devido à remodelação atrial que acompanha a progressão da DMVM. Os dados demonstram uma boa avaliação da função atrial e permitem uma melhor compreensão do papel do AE na fisiopatologia da DMVM.(AU)

Assessment of left atrial function in dogs with myxomatous mitral valve disease by biplane simpson's method / Avaliação da função atrial esquerda em cães com degeneração mixomatosa de valva mitral pelo método Simpson biplanar

The relationship between the diameter of the left atrium (LA) and aorta (Ao) is considered as a prognostic factor in chronic mitral valve disease. As the left atrium is a three-dimensional structure, methods based on measurement of the chamber volume can be more accurate than linear methods.The aim of this study was to assess the feasibility of measuring LA volume with 2D echocardiography using the biplane modified Simpson (SIMP) method in 33 dogs with various classes of myxomatous mitral valve disease (MMVD), as well as to present values of LA function using the atrial diastolic and systolic volume indices (ADVI and ASVI), cardiac index (ACI) and atrial ejection fraction (AEF). We observed agreement among the LA/Ao ratio and the atrial volume indices (ADVI and ASVI) and the ACI, suggesting that the values of the variables increase as the LA/Ao ratio increases due to atrial remodeling that accompanies MMVD progression. The data demonstrated a good assessment of atrial function, allowing a better understanding of LA's role in the pathophysiology of MMVD.(AU)

A relação entre o diâmetro átrio esquerdo (AE) e da aorta (Ao) é considerada como fator prognóstico na doença crônica de valva mitral. Como o átrio esquerdo é uma estrutura tridimensional, os métodos baseados na mensuração de volume da câmara podem ser mais precisos que os métodos lineares. O objetivo deste estudo foi avaliar a viabilidade da mensuração do volume do AE com a ecocardiografia bidimensional, sendo usado o método Simpson biplanar em 33 cães com diversas classes da degeneração mixomatosa de valva mitral (DMVM), bem como apresentar valores de função do AE utilizando-se os índices de volumes atriais diastólico e sistólico (iVdA e iVsA), o índice cardíaco atrial (iCA) e a fração de ejeção atrial (FEA). Observou-se uma concordância entre a relação AE/Ao e os índices de volume atrial (iVdA e iVsA) e o iCA, o que sugere que os valores das variáveis aumentam à medida que a relação AE/Ao aumenta, devido à remodelação atrial que acompanha a progressão da DMVM. Os dados demonstram uma boa avaliação da função atrial e permitem uma melhor compreensão do papel do AE na fisiopatologia da DMVM.(AU)

La cirugía mínimamente invasiva de la válvula mitral a través de toracotomía derecha es un procedimientoseguro y eficaz a corto y largo plazo. Estudio de cohortes ajustadas por nivelación del riesgo de propensión / Minimally-invasive mitral valve surgery via right thoracotomy is a safe an efficient procedure in the short and long term. Cohort study adjusted by propensity score matching

Resumen Introducción: La cirugía cardiaca mínimamente invasiva sobre la válvula mitral ha crecido en popularidad. El objetivo del estudio es valorar la morbilidad y eficacia de la técnica a medio plazo en una serie inicial. Material y métodos: 212 pacientes fueron sometidos a cirugía sobre la válvula mitral entre los años 2009 y 2013; 44 mediante cirugía mínimamente invasiva por toracotomía y 168 por esternotomía media. Se realizó un emparejamiento estadístico para la obtención del grupo control por regresión logística y nivelación del grado de propensión considerando las principales variables de riesgo. Se registró la morbilidad y calidad de la reparación o sustitución. Se realizó un análisis univariante y multivariante para un evento compuesto de morbimortalidad, eficacia y requerimientos de hemoderivados. Resultados: Fueron incluidos 44 pacientes por grupo. La media de seguimiento fue de 26,6 (14,6) y 28,4 (1,1) meses en el grupo de estudio y control, respectivamente. Se realizó reparación de la válvula mitral en el 70,5% en el grupo estudio y en el 68,2% en el grupo control. No se encontraron diferencias en la morbimortalidad perioperatoria. El número de pacientes que desarrollaron insuficiencia mitral moderada o severa durante el seguimiento fue del 9,1% en el grupo estudio y 11,4% en el control (p = 1,0). Tanto en el análisis univariante como multivariante la cirugía mínimamente invasiva fue un predictor independiente de menor transfusión. Conclusión: La cirugía mínimamente invasiva no es inferior a la esternotomía en morbilidad hospitalaria, ni en la calidad de la técnica quirúrgica en un programa de iniciación.

Abstract Introduction: Minimally-invasive mitral valve cardiac surgery has become increasingly popular. The objective of this study is to assess morbidity and efficiency of the technique in the médium run in an initial series. Material and methods: 212 patients underwent mitral valve surgery between 2009 and 2013; 44 with minimally-invasive thoracotomy and 168 via median sternotomy. Statistical pairing was conducted to obtain the control group by means of logistic regression and propensity score matching considering the main risk variables. Morbidity and repair or replacement quality were registered. A univariate and multivariate analysis was carried out for an event comprising morbidity and mortality, efficiency and blood component requirements. Results: Each group included 44 patients. Average follow-up time was 26.6 (14.6) and 28.4 (1.1) months in the study group and control group respectively. Mitral valve repair was performed in 70.5% of patients in the study group and in 68.2% of patients in the control group. No differences were found in perioperative morbidity and mortality. The number of patients who developed moderate or severe mitral insufficiency during follow-up was 9.1% in the study group and 11.4% in the control group (p = 1.0). Minimally-invasive surgery was an independent predictor for lower transfusion in both the univariate and multivariate analyses. Conclusion: Minimally-invasive surgery is not inferior to sternotomy in hospital morbidity or in the quality of surgical technique in an initial program.

Valvulopatía cardiaca asociada al uso de agonistas dopaminérgicos en pacientes con hiperprolactinemia / Valvular heart disease associated with use of dopaminergic agonists in patients with hyperprolactinemia

La cabergolina y la bromocriptina son fármacos agonistas dopaminérgicos utilizados para tratar la hiperprolactinemia, así como la enfermedad de Parkinson. Entre sus efectos adversos considerados como muy raros se ha descrito la capacidad de inducir cambios fibróticos en el aparato valvular cardiaco, inicialmente descritos en pacientes con enfermedad de Parkinson, en quienes se emplean dosis superiores a las que de manera habitual se emplean en el tratamiento de la hiperprolactinemia. Varios estudios han señalado la evidencia de estos hechos y de los posibles mecanismos por los cuales la afectación valvular ocurre. Existen hasta el momento pocas investigaciones sobre el asunto en pacientes con hiperprolactinemia, pero la mayoría de ellos indican que su empleo en este tipo de pacientes no produce afectación valvular clínicamente relevante, hecho que pudiera estar en relación con las dosis empleadas (como promedio 10 veces inferiores a las usadas en la enfermedad de Parkinson); sin embargo, se han detectado algunas anomalías subclínicas en el aparato valvular. Dado lo novedoso del tema y la poca evidencia de estos hechos en pacientes tratadas por hiperprolactinemia se ofreció una amplia revisión sobre el tema(AU)

Cabergoline and bromocriptine are dopaminergic agonists drugs used in hyperprolactinemia treatment, as well as in patients with Parkinson's disease. Among its adverse effects considered as very inusual is included the ability to induce fibrotic changes in cardiac valvular tract first described in patients with Parkinson disease using doses higher than those usually used in hyperprolactinemia treatment. Some studies have mentioned the evidence on these facts and of the possible mechanisms causing the valvular affection. Until now, there are not much researches on this subject in patients with hyperprolactinemia, but most indicated that its use in this kind of patient can not to produce a clinically relevant valvular afection, fact tha may to be related to the dose used (on average 10 times lower than those used in Parkinson's disease); however, some subclinical anomalies have been detected in valvular tract. Due to this novel subject and the scarce evident of these facts in patients treated by hyperprolactinemia, we offered an review of the subject(AU)

Infiltração gordurosa em valvas cardíacas de cães (Canis familiares, Linneu 1758) / Greasy infiltration in heart valves of dogs (Canis familiars, Linneu 1758)

As válvulas cardíacas são formadas por tecido conjuntivo denso, revestidas por endotélio e suas ba¬ses são ligadas aos aneis do esqueleto fibroso do coração. Essas estruturas podem ser acometidas por um distúrbio do metabolismo das gorduras denominado infiltração gordurosa. Neste estudo foram utilizados 30 corações de cães. Avaliou-se a presença de infiltração gordurosa de válvulas cardíacas atrioventricular por meio de análise histopatológica. Em conclusão, foi observado que 70% das valvas mitrais e 83,3 % das valvas tricúspides examinadas apresentaram algum grau de infiltração gordurosa

The heart valves are formed by dense connective tissue, lined by endothelium and its bases are at¬tached to rings of fibrous heart skeleton. Heart valves can be affected by a disorder on fat metabo¬lism, called greasy infiltration. In this study were used hearts of 30 dogs to evaluate the presence of atrioventricular valve’s greasy infiltration through histopathological analysis. In conclusion, it was observed that 70% of mitral valves and 83.3% of tricuspide valves examined showed some degree of that infiltration

Infiltração gordurosa em valvas cardíacas de cães (Canis familiares, Linneu 1758) / Greasy infiltration in heart valves of dogs (Canis familiars, Linneu 1758)

As válvulas cardíacas são formadas por tecido conjuntivo denso, revestidas por endotélio e suas ba¬ses são ligadas aos aneis do esqueleto fibroso do coração. Essas estruturas podem ser acometidas por um distúrbio do metabolismo das gorduras denominado infiltração gordurosa. Neste estudo foram utilizados 30 corações de cães. Avaliou-se a presença de infiltração gordurosa de válvulas cardíacas atrioventricular por meio de análise histopatológica. Em conclusão, foi observado que 70% das valvas mitrais e 83,3 % das valvas tricúspides examinadas apresentaram algum grau de infiltração gordurosa(AU)

The heart valves are formed by dense connective tissue, lined by endothelium and its bases are at¬tached to rings of fibrous heart skeleton. Heart valves can be affected by a disorder on fat metabo¬lism, called greasy infiltration. In this study were used hearts of 30 dogs to evaluate the presence of atrioventricular valves greasy infiltration through histopathological analysis. In conclusion, it was observed that 70% of mitral valves and 83.3% of tricuspide valves examined showed some degree of that infiltration(AU)

Valvulopatía cardiaca asociada al uso de agonistas dopaminérgicos en pacientes con hiperprolactinemia / Valvular heart disease associated with use of dopaminergic agonists in patients with hyperprolactinemia

La cabergolina y la bromocriptina son fármacos agonistas dopaminérgicos utilizados para tratar la hiperprolactinemia, así como la enfermedad de Parkinson. Entre sus efectos adversos considerados como muy raros se ha descrito la capacidad de inducir cambios fibróticos en el aparato valvular cardiaco, inicialmente descritos en pacientes con enfermedad de Parkinson, en quienes se emplean dosis superiores a las que de manera habitual se emplean en el tratamiento de la hiperprolactinemia. Varios estudios han señalado la evidencia de estos hechos y de los posibles mecanismos por los cuales la afectación valvular ocurre. Existen hasta el momento pocas investigaciones sobre el asunto en pacientes con hiperprolactinemia, pero la mayoría de ellos indican que su empleo en este tipo de pacientes no produce afectación valvular clínicamente relevante, hecho que pudiera estar en relación con las dosis empleadas (como promedio 10 veces inferiores a las usadas en la enfermedad de Parkinson); sin embargo, se han detectado algunas anomalías subclínicas en el aparato valvular. Dado lo novedoso del tema y la poca evidencia de estos hechos en pacientes tratadas por hiperprolactinemia se ofreció una amplia revisión sobre el tema(AU)

Cabergoline and bromocriptine are dopaminergic agonists drugs used in hyperprolactinemia treatment, as well as in patients with Parkinson's disease. Among its adverse effects considered as very inusual is included the ability to induce fibrotic changes in cardiac valvular tract first described in patients with Parkinson disease using doses higher than those usually used in hyperprolactinemia treatment. Some studies have mentioned the evidence on these facts and of the possible mechanisms causing the valvular affection. Until now, there are not much researches on this subject in patients with hyperprolactinemia, but most indicated that its use in this kind of patient can not to produce a clinically relevant valvular afection, fact tha may to be related to the dose used (on average 10 times lower than those used in Parkinson's disease); however, some subclinical anomalies have been detected in valvular tract. Due to this novel subject and the scarce evident of these facts in patients treated by hyperprolactinemia, we offered an review of the subject(AU)

Determinación de la densidad y heterogeneidad de la angiogénesis en la valvulitis crónica reumática

En los países en desarrollo la fiebre reumática constituye aún, un problema de salud. La valvulopatía reumática es grave porque amerita en la mayoría de los casos, reemplazo valvular afectando inclusive a pacientes adolescentes y en la edad media de la vida. La evolución de la lesión valvular es progresiva con remodelado fibroso de sus estructuras. Histológicamente, la densidad de la neovascularización es variable y heterogénea dependiente de diferentes factores de crecimiento. El objetivo fue determinar la densidad y heterogeneidad de la angiogénesis o neovascularización en tres etapas de progresión de la valvulitis crónica reumática y su relación con la fibrosis e inflamación. Se realizó análisis histopatológico e inmunohistoquímico de 60 biopsias de pacientes con reemplazo valvular mitral, de ambos sexos divididos en tres grupos que caracterizan etapas de progresión de la valvulitis crónica. Se estimó la densidad de cada tipo de neovasos en las valvas y su relación con el grado de inflamación y fibrosis de la valva. Los promedios de edades de los grupos 1, 2 y 3 fueron: 15,3 ± 0,6; 31 ± 1,5 y 49,7 ± 1,4 años, respectivamente. La densidad total (vasos/mm2) de la angiogénesis fue decreciente desde el grupo 1 al 3; 14,78 ± 1,92, 5,98 ±1,08 y 3,55 ± 0,76, respectivamen te. (P< 0,001. ANOVA F=19,162). El neovaso predominante fue el “vaso madre”, estructura transitoria que evoluciona a las formas intermedias y a las más estables (vasos “hijos” y vasos con pared muscular). La presencia de la variabilidad de la densidad neovascular y la heterogeneidad de los neovasos en la etapa crónica de la valvulopatía reumática en relación con el proceso inflamatorio y de cicatrización, puede ser explicada por la acción de diferentes factores de crecimiento

In the developing countries the rheumatic fever still constitutes a health problem. The rheumatic valvulopathy is serious because in most of the cases replacement of the affected valve is needed, including adolescent patients and in the average age of the life. The evolution of the valvular lesions is progressive with fibrous remodeling of the structures. Histologically the angiogenesis density is variable and heterogeneous depending on different growth factors. The objective was to determine the angiogenesis density and heterogeneity in three stages of progression of the rheumatic chronic valvulitis and their relation with the fibrosis and inflammation. Histopathologic and immunohisthochemical analysis of 60 biopsies was done on patients with replacement of the mitral valve, of both sexes, divided in three groups that characterize stages of progression of the chronic valvulitis. Each type of neovasculature’s valvular density and its relation to the inflammation and fibrosis degree was estimated. The age averages of groups 1.2 and 3, were: 15.3 ± 0.6; 31 ± 1.5 and 49.7 ± 1.4 years, respectively. The total angiogenesis, density (vasos/mm2) decreassed from group 1 to the 3; 14.78 ± 1.92; 5.98 ± 1.08 and 3.55 ± 0.76 (P< 0.001), ANOVA, F=19.162. The predominant angiogenesis was the “mother-vase”, transitory structure that evolves to the intermediate and most stable forms: (“children vases” and “vases with muscular walls”). The presence of the neovascular density’s variability and the heterogeneity in the chronic stage of the rheumatic valvulopathy in relation to the inflammatory and of healing process could be explained as the effect of different growth factors

Clínica de enfermedad valvular cardíaca del Centro Cardiovascular Regional-Ascardio: Barquisimeto-Estado Lara / Clinic of valvular heart disease of the Regional Cardiovascular Center-Ascardio: Barquisimeto-Lara State

La enfermedad valvular cardíaca es un importante problema de salud que requiere programas de atención especializada. Este artículo señala la justificación de una consulta de patologías valvulares y presenta la consulta organizada en el Centro Cardiovascular Regional Ascardio, su estructura, sus objetivos, protocolo de trabajo, requisito para el ingreso de pacientes y los vínculos que tiene con otras unidades y servicios. Se concluye que la consulta de enfermedad vascular cardíaca representa una experiencia positiva que puede servir de referencia para otros centros similares que tengan la iniciativa de organizar consultas especializadas.

Valvular heart disease poses a critical health problem requiring specialized medical care programs. This article highlights why a valvular heart disease clinic is justified and presents the clinic set up at Ascardio Regional Cardiovascular Center, as well as its structure, objectives, work protocol, requirements for patients´enrollment, and links with other units and services. In conclusion, the valvular heart disease clinic is a positive experience and a useful reference for other similar centers who may be taking the initiative in setting up specialized clinics.

Enfermedad reumática cardiovascular: observaciones anatomopatológicas en biopsias valvulares de jóvenes con menor e igual a 20 años de edad / Cardiovascular rheumatic disease: pathologic´s observations in biopsies valvulares of young people minor and equal 20 years of age

La fiebre reumática es una enfermedad endémica en los países en desarrollo como Venezuela y es causa importante de valvulopatía crónica progresiva, siendo primeramente afectado el aparato valvular mitral. Evaluar el aspecto morfológico de la valvulitis crónica en su etapa inicial, en individuos quienes han sido sometidos a reemplazo valvular mitral o mitro-aórtico. Se seleccionaron 20 biopsias de válvulas mitrales y mitro/aórticas diagnosticadas como valvulopatía crónica reumática, representativas de la etapa inicial, en pacientes con edad igual o menos de 20 años. Los diagnósticos pre-operatorios fueron: disfunción valvular severa mitral (insuficiencia (60%), doble lesión (10%) y estenosis (5%) y mitro-aórtica (25%). Las biopsias (valvas y aparatos valvulares mitrales) fueron evaluadas macroscópicamente. El estudio histológico se hizo con secciones teñidas con Hematoxilina-eosina e inmunomarcadas con anticuerpos CD 34 y antimúsculo liso. Todos los casos mostraron lesiones morfológicas propias de la valvulitis crónica reumática inicial: inflamación grado 1 (81,6%), con nódulos de Aschoff (35%), fibrosis de grado 2 (40%) y 3 (60%) Con una alta densidad de neovascularización (14,78 ± 1,92). Se hizo el análisis de los hallazgos morfológicos y se consideró que este trabajo puede servir de base para investigaciones comparativas con casos de etapas más avanzadas de la enfermedad valvular en relación a la inflamación, remodelado colágeno y angiogénesis.

Rheumatic fever is an endemic disease in developing countries such as Venezuela and is an important cause of progressive chronic valve disease, the mitral valve apparatus being affected in the first place. To evaluate the morphologic aspect of chronic valvulitis in its initial stage among individuals that have gone through mitral and mitro-aortic valve replacement. Twenty (20) biopsies of mitral and mitro-aortic valves diagnosed with rheumatic chronic valvulopathy in its initial stage were selected from patients aged 20 years or younger. Preoperating diagnoses were as follows: severe mitral valve dysfunction (insufficiency: 60%, double injury: 10%, stenosis: 5%, and mitro-aortic: 25%). The biopsy material (valve apparatuses) was macroscopically evaluated. A histological study was made on haematoxylin-eosin stained and CD34 antibody immunomarked sections and smooth antimuscle. All cases showed morphologic lesions typical of initial chronic rheumatic valvulitis: grade 1 inflammation (81,6%), with Aschoff's bodies or nodules (35%), grade 2 fibrosis (40%), and grade 3 fibrosis (60%) with high density neovascularization (14,78 ± 1,92). Morphologic findings were analyzed, thus concluding that this work can serve as a basis for comparative investigations on case of valvular disease at more advanced stages in terms of inflammation, collagen remodeling and angiogenesis.

Ecocardiografía en la valvulopatía mitral / Echocardiography in mitral valve disease

La ecocardiografía se ha convertido en el método principal para la evaluación de las enfermedades valvulares. En el caso de la valvulopatía mitral, el ecocardiograma provee información detallada acerca de la anatomía y función ventricular. El uso de este método nos ha permitido el ahondar en el conocimiento de los mecanismos que participan en la génesis de insuficiencia mitral. El eco no sólo nos permite detectar la presencia de insuficiencia mitral sino también cuantificar su severidad, la cual contribuye al pronóstico del paciente. La ecocardiografía intraoperatoria ha servido para guiar los procedimientos quirúrgicos de reparación y mejorar sus resultados. Las nuevas técnicas dirigidas al tratamiento percutáneo de la insuficiencia mitral se apoyan fuertemente en la ecocardiografía para el monitoreo en tiempo real de estos procedimientos.

Echocardiography has become the premier method for the evaluation of valvular heart disease. In mitral valve disease, echo provides detailed anatomic and functional information. Using echo has allowed us to increase our understanding of the mechanisms that play a role in mitral regurgitation. Echocardiography not-only detects the presence of mitral regurgitation (MR) but also allows quantification of its severity. The importance of quantitative data forthe prognosis of patients with MR has been shown recently. Intraoperative echo has been very helpful in guiding surgical repair and improving its results. The new techniques for percutaneous treatment of mitral regurgitation strongly rely on echo for on-line monitoring of device deployment and immediate results. (Arch Cardiol Mex 2005; 75:188-196).

El procedimiento de Ross para reemplazo valvular aórtico / The Ross procedure for aortic valve replacement

La valvulopatía Aórtica es común en la población y el substituto valvular óptimo no ha sido encontrado. Las válvulas mecánicas necesitan anticoagulación de por vida y las válvulas tisulares tienen limitada durabilidad. El reemplazo de la válvula aórtica por un autoinjerto pulmonar produce excelentes resultados en la mayoría de los pacientes. Se evaluó las condiciones postoperatorias tales como: mortalidad, complicaciones, estancia hospitalaria de los 32 pacientes operados por el procedimiento de Ross en el hospital Jackson Memorial y se comparó esos resultados con los de la literatura médica existente. El promedio de seguimiento fue de un año y 11 meses postcirugía. El 6.2 por ciento de los operados fallecieron. Las mayores complicaciones tempranas fueron síndrome postpericardiotomía, derrame pericárdico y atelectasias. El promedio de estancia hospitalaria fue de 10.8 días para los pacientes pediátricos y de 13.1 días para los adultos. Los seguimientos ecocardiográficos revelaron ausencia de gradientes significativos de presión a través del autoinjerto pulmonar. El autoinjerto pulmonar podría ser el mejor substituto disponible en niños y en todo paciente con valvulopatía aórtica y expectativa de vida mayor a 20 años.

Aortic valve disease is a common entity in the general population. The optimal substitute has not been found. Mechanical valves need life-long anticoagulation. Tissue valves have a limited durability. The replacement of the aortic valve by a pulmonary autograft produces excellent results in the majority of patients. The postoperatory conditions (Mortality, Complications, Hospital stay) of 32 patients who underwent the Ross procedure at Jackson Memorial Hospital were evaluated and the results compared to the ones existing in the medical literature. The average follow-up was one year and 11 months. Six percent of the patients died. The major complications were: post-pericardiotomy syndrome, pericardial effusion and atelectasis. The average pediatric and adult hospital stays were 10.8 and 13.1 days respectively. Echocardiography follow-ups showed absence of any significant pressure gradient through the pulmonary autograft. The pulmonary autograft might be the most suitable substitute available for children and for every patient with aortic valve disease and a life expectancy longer than 20 years.