Plastia mitral en endocarditis infecciosa: reporte de un caso / Mitral valve repair in infective endocarditis: a case report / Plastia mitral em endocardite infecciosa: relato de um caso

La endocarditis infecciosa es una patología heterogénea con una alta mortalidad y requiere tratamiento quirúrgico en al menos la mitad de los casos. Cuando asienta en posición mitral, la reparación valvular en lugar de su sustitución, si bien representa un desafío técnico, ha ido ganando terreno en los últimos años. Describimos el caso de un paciente que se presentó con una endocarditis sobre válvula nativa mitral en quien se realizó una plastia valvular exitosa. Revisaremos la evidencia acerca de su beneficio.

Infective endocarditis is a heterogeneous disease with a high mortality and that requires surgical treatment in at least half of cases. When seated in mitral position, valve repair rather than replacement, while technically challenging, has been gaining popularity in recent years. We describe the case of a patient who presented with a mitral valve endocarditis in whom a successful valve repair was performed. Evidence supporting its use will be reviewed.

A endocardite infecciosa é uma doença heterogênea com alta mortalidade que requer tratamento cirúrgico em pelo menos metade dos casos. Quando sentado na posição mitral, o reparo da válvula, em vez da substituição da válvula, embora seja um desafio técnico, tem ganhado espaço nos últimos anos. Descrevemos o caso de um paciente que apresentou endocardite valvar mitral nativa, no qual foi realizada plastia valvar com sucesso. Vamos revisar as evidências sobre o seu benefício.

Advantages of early replacement therapy for mucopolysaccharidosis type VI: echocardiographic follow-up of siblings.

Mucopolysaccharidosis type VI (Marateaux-Lamy syndrome) is an autosomal recessive disorder caused by deficient activity of the enzyme N-acetylgalactosamine-4-sulphatase (arylsulphatase B). Cytoplasmic vacuoles full of dermatan sulphate are observed in endothelial cells, myocyte, and fibroblasts, compromising the function of cardiovascular structures and contributing significantly towards morbidity and mortality. The primary objective of this study was to assess the advantages of early replacement therapy with recombinant human arylsulphatase B through the echocardiographic follow-up of sisters who started treatment at quite different ages: one at 9 years and the other at 1 year and 7 months. The older sibling showed striking mitral and aortic valve compromise when she was only 2 years old and finally needed cardiac surgery at the age of 8, even before starting enzyme replacement. Differently, the younger one has developed only mild mitral and aortic lesions throughout the follow-up period of 3 years. The two siblings had left ventricle cardiomyopathy, but partial reverse remodelling was induced by enzyme replacement therapy in both cases. The younger sibling has never received any cardiovascular drugs, whereas the older one has been using ß-blockers and diuretics in addition to enzyme therapy to cope with heart failure. Comparing the outcomes of these two sisters with a very aggressive phenotype of mucopolysaccharidosis type VI, the conclusion was that early onset of therapy may slow down the disease progression and prevent severe cardiac lesions to be established. Moreover, patients' compliance is essential for the success of treatment, as sequential echocardiographic evaluation demonstrated worsening of some cardiac lesions whenever infusions were missed.

Mitral valve regurgitation: paradoxical behavior of dobutamine stress cardiac magnetic resonance imaging.

A 62-year-old woman with mitral regurgitation (MR) underwent cardiac magnetic resonance (CMR) and dobutamine stress CMR imaging, a widely used method to analyze left ventricular function and MR volumes. During dobutamine provocation at escalating doses, the left ventricular end-diastolic diameter (LVEDD) decreased, with a corresponding decrease in MR. At peak dobutamine dose, the LVEDD further decreased, with near complete relief of MR. Upon cessation of dobutamine provocation, the MR returned to predobutamine level. This case thereby demonstrates that MR may be reversible under certain conditions.

Papillary squamous cell carcinoma of the uterine cervix, high-risk human papilloma virus infection and p16(INK4a) expression: a case report.

BACKGROUND: Papillary squamous cell carcioma is rare form of squamous cell carcinoma of the uterine cervix occurring in women in the sixth decade of life and is frequently misdiagnosed as high-grade intraepithelial lesion. Few reports with cytologic study have been performed, especially with cytology in liquid-based specimens. CASE: A 58-year-old woman who had 8 gestations (no abortions) and mitral cardiopathy treated with coumarin medication was referred for transvaginal bleeding of 20 days' duration. Specular examination showed an exophytic, easily bleeding lesion occupying all of the uterine cervix and superior third of the vagina. Liquid-based cytology showed squamous cells, mostly basaloid but some bizarre or in fiber, with clearly atypical nuclei. Second-generation hybrid capture for high-risk human papillomavirus was positive, with a viral load of 404 relative light unit/positive control B, and the tumor expressed p16(INK4a). CONCLUSION: This report adds further experience with liquid-based cytology to the existing conventional and liquid-based cytologic findings, particularly in the Brazilian female population.

Effects of carvedilol treatment in dogs with chronic mitral valvular disease.

BACKGROUND: Stimulation of the sympathetic nervous system occurs during the development of heart failure in dogs with chronic mitral valvular disease (CMVD). HYPOTHESIS: The use of beta-blockers to modulate the activation of the sympathetic nervous system would be useful in dogs with CMVD. ANIMALS: Group A included 13 dogs who received the conventional treatment (digoxin, benazepril, a reduced sodium diet, and codeine, and a diuretic when indicated), and group B included 12 dogs who received the protocol above plus carvedilol (0.3 mg/kg q12h). METHODS: Blinded, placebo, controlled study. RESULTS: The main echodopplercardiographic variables, heart rate, biochemical data, functional classification (FC) (New York Heart Association) and quality of life score (functional evaluation of cardiac health questionnaire) were assessed at baseline (TO) and after 3 months (T1). Only group B showed improvement in score of quality of life (13.8 +/- 8.8 versus 6.0 +/- 6.3; P < .001), in FC (2.4 - 0.9 versus 1.8 +/- 0.7; P = .032) and a reduction in systolic blood pressure (151.2 +/- 18.3 versus 124.5 +/- 23.4; P = .021). Two deaths from group A and 1 from B were related to CMVD. CONCLUSION: The studied dose of carvedilol in this group did not improve the sympathetic activation and echocardiographic variables over 3 months of chronic oral treatment. However, the results suggested a beneficial effect on the quality of life score, functional classification, and a reduction on systolic blood pressure.

Mitral valvular heart disease in the adults.

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the first of a series of two that will discuss valvular problems in the adults in concise and practical form. Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this first article we will discuss mitral valve disorders including mitral valve prolapse (MVP).

[Valve repair surgery in infectious endocarditis]. / Cirugía valvular reparadora en endocarditis infecciosa.

BACKGROUND: Valve replacement has been the treatment of choice for patients with valvular complications of infectious endocarditis (IE). However, excellent results with valve repair allowed it to become a new therapeutic alternative for these patients. AIM: To evaluate the results of valve repair in patients with valvular complications of IE. PATIENTS AND METHODS: From January 1991 to December 2000, 14 patients with valvular complications of IE underwent valve repair. Mean age was 37.9 +/- 14.9. RESULTS: New York Heart Association (NYHA) class was 2.8 +/- 0.9. IE was located in the aortic in 6 (42%), in the mitral valve in 4 (29%) and in both valves in 4 cases (29%). Surgical indication was hemodynamic in 50% of the cases, echocardiographic in 29% and septic in 21%. Five aortic valves were bicuspid, 3 mitral valves were myxomatous and the rest were normal. The most common septic lesions were vegetations and leaflet perforations. A total of 23 aortic and 21 mitral valve repair procedures were performed. There were no deaths. Only 1 patient had a surgical complication (renal failure and prolonged mechanical ventilation). Follow-up was 100% complete. There was not late mortality. One patient with bone marrow aplasia required reoperation for a new episode of IE 19 months later. At the end of the follow-up NYHA class was 1.3 +/- 0.6 and echocardiography showed a mild or absence of valve regurgitation in most patients. CONCLUSIONS: Valve repair surgery in IE has good results, with advantages over valve replacement.

Mildly symptomatic chronic mitral regurgitation. Analysis of left ventricular systolic function and mitral regurgitation fraction under pharmacological influence. Echocardiographic study.

OBJECTIVE: To study echocardiographic parameters of left ventricular systolic function and valvar regurgitation under pharmacological influence in mildly symptomatic patients with chronic mitral regurgitation (MR). METHODS: We carried out a double-blind placebo controlled study in 12 patients with MR, mean aged 12.5 years old, who were randomized in 4 phases: A) digoxin; B) enalapril; C) digoxin + enalapril; D) placebo. The medication was administered for 30 days in each phase, and the following variables were analyzed: shortening and ejection fractions, wall stress index of left ventricle, left ventricular meridional end-systolic wall stress, Doppler-derived mean rate of left ventricular pressure rise (mean dP/dt), stroke volume and MR jet area. The clinical variables analysed were heart rate and systemic arterial pressure. RESULTS: No significant variation was observed in the clinical variables analysed. The shortening and ejection fraction, the mean dP/dt and stroke volume significantly increased and the wall stress index of left ventricle, the meridional left ventricular end systolic wall stress and the mitral regurgitation jet area decreased in the phases with medication as compared with that in the placebo phase. CONCLUSION: The parameters of left ventricular systolic function improved significantly and the degree of MR decreased with the isolated administration of digoxin or enalapril in mildly symptomatic patients with chronic MR. The combination of the drugs, however, did not show better results.

Gaucher's disease with myocardial involvement in pregnancy.

CONTEXT: Described originally in 1882, Gaucher's disease is the most prevalent of storage disorders. This autosomal recessive disease is caused by a defective gene responsible for coding the beta-glucosidase enzyme, essential in the hydrolysis of glucosylceramide in glucose and ceramide. The accumulation of glucosylceramide in the lysosomes of the reticuloendothelial system produces a heterogeneous clinical picture with neurological involvement, liver and spleen enlargement, hematological disorders and bone lesions. CASE REPORT: Two pregnancies of a patient with Gaucher's disease are presented. The patient, who had been asymptomatic following earlier splenectomy, developed congestive heart failure due to myocardial involvement at the beginning of her first pregnancy, and responded to conservative treatment. In spite of this complication and also chronic anemia, hepatomegaly and ascites due to portal hypertension, the patient had two successful pregnancies with good perinatal results. No hemorrhagic complications were observed.

La digoxina es efectiva en el tratamiento de pacientes con insuficiencia cardíaca y ritmo sinusal / Digoxin is effectiveness in the treatment of cardiac failure and sinus rhythm patients

Due to differences in treatment effect in studies on the effectiveness of digoxin in patients with congestive heart failure in sinus rhythm, a cross-over placebo-controlled randomized double blind clinical trial was performed. Thirty one patients, without previous treatment with digoxin, in New York Heart Association (NYHA) functional class II to IV, with a dilated left ventricle and/or ventricular systolic dysfunction were included. Patients received digoxin, adjusted for blood levels, or placebo, during an 8 week period, prior to crossing over to the other treatment for another 8 weeks. The order of tretments was randomly allocated. Outcome measurement were performed at the end of each 8 week period. Digoxin, compared with placebo, improved NYHA class, 6,9 por ciento vs 41.4 por ciento (p=0.013) and increased the treadmill exercise time, 406 ñ 204 s vs 484 ñ 185 s (p=0.003). During the digoxin treatment the left ventricular and systolic diameter was reduced from 52.9 ñ 8.9 to 50.1 ñ 9.7 mm (p=0.009). No significant difference was observed in the left ventricular end diastolic diameter (LVED) of the left ventricle and in a estimation of quality of life. In conclusion, digoxin treatment produced a significant improvement in functional capacity, exercise time and left ventricular performance

Anticoagulantes / Anticoagulants

La trombosis es un evento vascular que se evidencia por la disfunción del órgano afectado. Por esa razón los fármacos anticoagulantes tienen un amplio espectro de indicaciones en diversas circunstancias patológicas. Como sus efectos no están exentos de riesgos, existe considerable controversia acerca de sus reales indicaciones, dosificación, asi como sobre la duración de las terapias. En la presente revisión, se presenta en forma muy resumida el uso de estos medicamentos en algunos de los cuadros patológicos de mayor interes para el médico internista general. Entre ellos destacan las trombosis venosas profundas, la embolia pulmonar, la cardiopatía coronaria, las valvulopatías, las prótesis valvulares, la arritmia completa por fibrilación auricular, etc