MINOCA por mixoma atrial esquerdo: relato de caso / Left atrial myxoma MINOCA: case report

INTRODUÇÃO: O termo MINOCA (Myocardial Infarction with Nonobstrutive Coronary Arteries) é utilizado para se referir aos casos de infarto agudo do miocárdio (IAM) em que na angiografia as artérias coronárias são normais. A MINOCA representa 14% de todas as causas de IAM, sendo mais frequente em mulheres jovens. Os mixomas são os tumores benignos primários do coração mais frequentes (40-50%). RELATO DE CASO: VMF, 49 anos, sexo feminino, apresentando dispneia aos esforços há 4 meses. O eletrocardiograma evidenciou área eletricamente inativa anterior extensa (figura 1) e o ecocardiograma (figura 2), fração de ejeção de ventrículo esquerdo (VE) de 55% (método Simpson), acinesia do ápice e dos segmentos apicais de todas as paredes e presença de imagem sugestiva de massa homogênea, com contornos regulares, localizada no interior do átrio esquerdo, medindo 25x28mm. Foi submetida à ressecção tumoral, com anatomopatológico confirmando mixoma atrial esquerdo. Paciente manteve seguimento ambulatorial, onde realizou angiotomografia de coronárias com escore de cálcio de zero, sem placas ateroscleróticas ou redução luminal. A ressonância magnética cardíaca (RMC), figura 3, mostrou fibrose miocárdica difusa, transmural, poupando apenas os segmentos anterolateral e inferolateral basais, com áreas de fibrose microvascular. A paciente evoluiu com disfunção ventricular, recebendo o tratamento medicamentoso recomendado. DISCUSSÃO: O diagnóstico de MINOCA na evolução deste caso pode ser bem estabelecido pelas alterações eletrocardiográficas, ecocardiográficas e, principalmente pelas alterações da RMC com a comprovação de realce tardio transmural de padrão coronariano. Foram afastadas lesões coronárias estruturais pela angiotomografia coronária. A presença de massa tumoral atrial esquerda levanta a possibilidade de embolização coronária, seja por fragmentos da massa ou por trombos formados pela sua presença, ou ainda por estado de hipercoagulabilidade induzida pelo tumor. A presença de embolização sistêmica em portadores de mixoma de átrio esquerdo é bem conhecida, embora o diagnóstico de embolia coronária seja extremamente rara. CONCLUSÃO: Massas tumorais cardíacas devem ser lembradas diante de casos de MINOCA, e um ecocardiograma e RMC são métodos diagnósticos importantes para confirmação deste diagnóstico. O tratamento cirúrgico precoce e possivelmente anticoagulação devem ser considerados para prevenção desta ocorrência

[Surgical treatment of infective endocarditis]. / Tratamento cirúrgico na endocardite infecciosa.

PURPOSE: To analyse, retrospectively, 83 patients with infective endocarditis (IE) that were operated during the acute phase of the disease and to identify possible subgroups with distinct mortality. METHODS: Between 1985 to 1990, 83 patients comprised the subject of this analysis. Fifty-one (61%) were male, aged between 3 months to 71 years, mean of 31.4 +/- 16.7 years. RESULTS: We could identify two subgroups that were most frequently operated on: the left side IE and the Staphylococcus aureus; and 77 (43%) had left sided IE (p < 0.001). When discriminated accordingly to the specifically etiologic agent (Staphylococcus aureus) this difference continues to be statistically significant: of 29 left sided IE by this agent 13 (45%) were operated on, whereas from 22 right sided IE by the same agents, just 3 (14%) were operated on (p < 0.05). The two major etiologic agents did not show any statistically significant difference in the number of patients that needed to be operated on: on those 51 patients with Staphylococcus aureus IE, 16 (31%) were treated surgically, while from the 60 patients with Streptococcus viridans, 22 (37%) underwent to surgical procedure (p- NS). The mortality in the patients treated by surgery was 32%, and those with Staphylococcus aureus IE were responsible for 46% of the total surgical deaths. CONCLUSION: Surgical treatment were most frequently used in the patient with left sided IE independently of the etiologic agent.

[Infective endocarditis associated with pregnancy]. / Endocardite infecciosa relacionada à gravidez.

PURPOSE: To report the intra-hospitalar and late follow-up of patients with infective endocarditis (IE) acquired in the pregnancy or puerperium. METHODS: Eleven patients, between 1984-1992 according to the beginning of the IE episode (fever and other signals) were studied. Patients were divided in two groups: IE of pregnancy (7 cases), and puerperal IE (4 cases). RESULTS: In the pregnancy IE group, mitral valve was affected in 6 (85%), and aortic valve in 1 (15%). During the course of the treatment, two patients had to be operated on, respectively, in the 24th and 28th week of the pregnancy. The 1st one had a successfully mitral valve replacement by a biological prosthesis but 48 h later she aborted, and the 2nd presented neurological complication (intracerebral hemorrhage) in the immediate post-operative period of a successfully mitral valve replacement by biological prosthesis. She was undergone to a cesarean but the fetus remained alive for 24 h only. If we look at the newborns (fetus), only 4 of them survived. Out of 3 fetal deaths, 2 had close association with mother cardiac surgeries. In the pregnant period acquired IE, 3 (47%) mothers died. In the puerperium group, 2 mitral valves and 2 aortic valves had IE. Two of them had to be operated on due to an important aortic regurgitation and cardiac failure. There were no deaths in this group. CONCLUSION: During pregnancy, IE showed a high morbi-mortality for mother and concept. The mother's neurological complications played a major role in the poor outcome during the pregnancy period.

[Infective endocarditis in children and adolescents]. / Endocardite infecciosa na infância e adolescência.

PURPOSE: To assess infective endocarditis (IE) predisposing factors, etiologic agents and hospital course in infants and adolescents. METHODS: We Studied 222 patients admitted under compatible IE diagnosis, from 1985 to 1990. The population of this study is fifty patients (23%) under 16 years of age. RESULTS: Rheumatic valvular disease, as predisposing cardiopathy was proeminent within 9 to 16 years of age, markedly Statistical difference when compared to age range of 0 to 8 years (p < 0.05). Among congenital cardiopathies, the most frequent were: interventricular septal defect (26.0%) and tetralogy of Fallot (21.7%). Blood cultures, surgical material or emboli cultures were positive in 35 (70.0%) assessed patients. Streptococcus viridans (45.7%) and Staphylococcus aureus (42.8%) were the etiologic agents most often isolated. It was found that endocarditis by Staphylococcus aureus had mortality rate of 53.3% [(clinical (66.6%) and surgical (44.4%)], (p < 0.05) when compared to those by Streptococcus viridans; with total mortality of 6.2% (no clinical death and 16.6% in the surgical group). Total in-hospital mortality (clinical and surgical) was 26.0% (13 deaths). CONCLUSION: IE in infants and adolescents in this studied population presented Streptococcus viridans responsible for 46.7% of patients with endocarditis and the Staphylococcus aureus for 42.8% were the etiologic agents most often found. Total, clinical and surgical mortality was greater in patients with endocarditis by Staphylococcus aureus when compared with those by Streptococcus viridans. Among the congenital cardiopathies, whether operated on or not, ventricular septal defect and of Fallot's tetralogy were the most involved ones; rheumatic cardiopathy Still remains a significant predisposing factor to infective IE in our country.

[Endocarditis due to Mycobacterium chelonei in a valvular prosthesis]. / Endocardite por Mycobacterium chelonei em prótese valvar.

Male aged 40 year, with infective endocarditis in valvular prosthesis caused by Mycobacterium chelonei. This agent is unusual in this situation and rarely identified by the blood cultures.

[Infective endocarditis in patients with permanent pacemaker]. / Endocardite infecciosa em pacientes com marcapasso definitivo.

Five patients who had permanent pacemaker and infective endocarditis were analyzed. Diagnose was confirmed by a positive blood cultures in all patients and 2 of them had identifiable vegetation in the echocardiogram too. The etiologic agent was Staphylococcus aureus in 3, Staphylococcus epidermidis in 1 and Staphylococcus viridans in 1. Three patients were treated with antibiotics alone: one had no clinical conditions to be operated, one died before surgery and one had good response to antimicrobial therapy alone. Two patients were submitted to antibiotic therapy and surgical removal of the pacemaker system, without complications. It was concluded that the surgical removal of the pacemaker system, as soon as possible, is the choice's therapy.

[Radiologic signal of dehiscence of Starr-Edwards aortic prosthesis]. / Sinal radiológico de deiscência de prótese aórtica de Starr-Edwards.

A male 54 years-old patient with infective endocarditis through Staphylococcus aureus with prosthesis of Starr-Edwards aortic with clinical and echocardiographic signs compatible with dysfunction classified as severe. The x-ray images presented double silhouette of the prosthesis, thus suggesting its partial dehiscence. This case report points out that the detailed analysis of the X-ray may supply relevant data for the diagnosis of one of this complication thus influencing on management and prognosis.

[Myocardial infarction in infective endocarditis]. / Infarto do miocárdio na endocardite infecciosa.

Two patients with chronic valvular heart disease and myocardial infarction were assisted at our hospital. Both of them were febrile and only one had petechiae associated with signs of valvular involvement led to suspicion of infective endocarditis. Although blood cultures were negative, echocardiographic, surgical and anatomopathologic findings were compatible with infective endocarditis. They required cardiac surgery during the acute phase of the infection because they presented progressive hemodynamic deterioration and no satisfactory response to antimicrobial regimen too. One patient died at late follow-up (two weeks after the hospital discharge) and the other survived, but with signs of cardiac failure (class II of NYHA) one year after the procedure.

[Embolomycotic pseudoaneurysm of the common femoral artery in infective endocarditis]. / Pseudoaneurisma embolomicótico da artéria femoral comum na endocardite infecciosa.

A male patient, six years old, with mitral valve endocarditis presented with pseudoaneurysm of the right femoral artery. He was submitted to surgical treatment with reconstruction of the artery with good outcome.

[Infectious endocarditis in a drug addict]. / Endocardite infecciosa em toxicômanos.

PURPOSE: To compare two groups of patients with infective endocarditis, the drug addicts and non-drug addicts. We attempted to set particularities among the various aspects that involve the patient with endocarditis, due to the concurrent chronic use of cocaine intravenously. METHODS: Twenty nine patients, group B, whose clinical diagnose was compatible with infective endocarditis, with risk factor of parenteral toxicomania by cocaine were treated at Institute "Dante Pazzanese de Cardiologia" and Hospital "Emilio Ribas" in São Paulo, from 1984 to 1990. The data obtained for etiological agents, previous cardiac pathology, affected heart structures, affected heart side and clinical-surgical evolutions of group B were compared to group A (193 patients), which was also composed of patients with endocarditis, without chronic endovenous use of cocaine antecedent. The data obtained were analysed comparatively according to the chi square with Yates correction. RESULTS: Male gender (89.7%) was predominate in group B towards group A (57.0%); (p < 0.01). Previous cardiopathy, either congenital or acquired, as antecedent proning to endocarditis, was found in 89.1% of patients in group A, significantly higher than 17.2% of patients group B (p < 0.001). Staphylococcus aureus was the most frequent agent, which accounted for endocarditis of group B in 86.4% of the cases, significantly higher when compared to 23.9% of cases of group A (p < 0.01). Streptococcus viridans was the most frequent etiological agent for endocarditis of group A (44.8%), significantly higher than group B (4.5%), (p < 0.01). In concern to the affected structures, the tricuspid valve was most affected in group B (65.5%), significantly higher than group A (4.7%) p < 0.001. The mitral valve was significantly more affected in group A (45.1%) in comparison to group B (6.9%), (p < 0.05). In group A 82 patients (42.5%) required surgical treatment and this occurred in 3 patients of group b (10.3%), (p < 0.05). No significant statistical difference was found as for the general mortality (clinical and surgical) in both groups. CONCLUSION: a) presence of previous cardiac disease was lower suggesting permanent contamination blood flow by pathologic agents, mainly of those found in the skin as S. aureus; b) right side of the heart is most frequently affected, specially the tricuspid valve even without previous damage.

[Meningitis and other neurological complications in infectious endocarditis]. / Meningite e outras complicações neurológicas na endocardite infecciosa.

PURPOSE: To study the localization, etiological agents and the respective prognosis in patients with infective endocarditis with or without neurological complications, with emphasis on the association of endocarditis and meningitis. METHODS: 222 patients with clinical, echocardiographic and laboratory diagnosis of infective endocarditis were treated at Instituto Dante Pazzanese de Cardiologia from 1985 to 1990. They were classified in two groups: group A-116 patients without neurological complications, ages 4 months-76 (mean 30) years old and 66.3% males. group B-56 patients with neurological complication, ages 1-71 (mean 31) years old and 46.4% males. A third group, group C, comprised 17 patients, ages 8-51 (mean 23.7) years old and 9 patients (52.9%) male, assisted at Hospital Emilio Ribas, which is specialized at infectious diseases, which presented meningitis as the unique manifestation of neurological complication associated to the diagnosis of infective endocarditis (IE). In all patients the diagnosis of IE was based on the presence of at least two of three essential findings: echocardiogram with vegetations or valvar dysfunctions, positive hemocultures and the compatible clinical picture. For the comparative analysis among the groups was employed through the chi-square test corrected according to Yates. RESULTS: No differences of sex and age of the patients were found among the three groups. Predominated the Staphylococcus aureus as etiological agent. The localization of cardiac lesions was similar in the three groups, except for the tricuspid valve affected in 16.3% of patients of group A and 2.3% of group B. There was a greater association of the structures on the left side of the heart with IE of group B (p < 0.05). Group B and C showed a general mortality rate greater than group A (p < 0.001). CONCLUSION: Meningitis and other neurological complications showed interrelationship between the presence of "Staphylococcus aureus" as etiological agent of endocarditis and the association with infection of the left heart side.

[The importance of the early diagnosis of infectious endocarditis in an aortic prosthesis by transesophageal two-dimensional Doppler echocardiography]. / Importância do diagnóstico precoce de endocardite infecciosa em prótese aórtica pela ecodopplercardiografia bidimensional transesofágica.

A female patient, 21 years old, was submitted to surgical treatment of severe aortic insufficiency. She was doing well until the 9th postoperative day, when she presented sepsis and an embolic cerebrovascular attack. The transesophageal echo-Doppler-cardiogram showed paraprosthetic abscess and vegetations, that were not seen on the transthoracic echo-Doppler-cardiogram performed one day before. We are convinced that the findings on the echocardiogram were very important for the good results obtained by the prompt surgical procedure.

[Surgical management of the aortic valve in patients older than 70 years of age]. / Manuseio cirúrgico da valva aórtica em pacientes acima de 70 anos.

PURPOSE: To assess the short and long-term benefits of patients who were submitted to isolated aortic valve replacement or valve replacement (VR) concomitant myocardial revascularization (MR); to evaluate the incidence of postoperative complications, hospital mortality and late mortality. METHODS: From January 1985, through December 1989, 20 consecutive patients underwent surgical intervention, 15 male (75%) and 5 female (25%), the mean age was 74.8% (ranging from 70 to 86 years old), and the aortic valve gradient ranged between 78 and 180 mmHg (mean = 97 mmHg). They presented preoperative diagnosis to have either isolated aortic stenosis (AS) or As and coronary artery disease (CAD). No patient was in NYHA functional class I; 3 patients (15%) were in class II, 14 (70%) in class III and 3 (15%) in class IV. RESULTS: The most frequent post-operative complications found were: extended intubation in 7 patients (35%), bleeding in 4 (20%), acute renal failure in 3 (15%) and ventricular arrhythmia in 3 (15%). Hospital mortality occurred in 2 patients (10%) who had been submitted to VR and concomitant MR. Late mortality occurred in 1 patient (5%). Through December 1989, 11 patients (64%) were in functional class I (NYHA), 3 (18%) in class II, 3 (18%) in class III and none in class IV. CONCLUSION: We concluded that the surgical treatment is indicate to elderly patients with isolated AS os with AS and concomitant CAD. There was a significant post-operative improvement of the functional class (NYHA) to the surviving patients.

[Mitral valvuloplasty with double balloon catheter. Analysis of 200 cases]. / Valvoplastia mitral com duplo cateter-balão. Análise de 200 casos.

PURPOSE: To study the immediate clinical, echocardiographic and hemodynamic results of 200 patients who underwent percutaneous mitral balloon valvotomy (PMV) with double balloon technique. METHODS: Two hundred patients were submitted to PVM for treatment of congestive heart failure secondary to severe mitral stenosis, between August 1987 to July 1991. Their mean age was 35.2 years, and 86.5% were female patients: 81% of them was in functional class, New York Heart Association (NYHA) III or IV; 4% was in atrial fibrilation and 4% had previous surgical commissurotomy. RESULTS: PMV was successfully performed in 89% of the patients. The mitral valve area, by pressure half time method, increased from 0.91 +/- 0.27 to 2.10 +/- 0.47 cm2, p < 0.001; the mean mitral gradient decreased from 20.86 +/- 6.16 to 4.26 +/- 3.13 mmHg, p < 0.001; the left atrium and mean pulmonary artery pressure decreased from 22.3 +/- 7.1 to 11.9 +/- 8.3 and 36.47 +/- 12.93 to 24.56 +/- 9.98 mmHg, p < 0.001, respectively. Complications related to transeptal technique occurred in 12 patients, which resulted in cardiac tamponade in 5 and death in 1. In 19 patients the punction of the atrial septum could not be performed. Mitral regurgitation (MR) immediately after PMV appeared 1+ or more grade in 50 patients, increased in 8 patients and remained unchanged in 11 patients. Ten patients needed mitral valve replacement in the first 48h after PMV, for treatment of severe MR. CONCLUSIONS: PMV produces excellent immediate results and can be considered an alternative to surgery for the relief of mitral stenosis.

[Technical modification of total cavo-pulmonary connection]. / Modificação técnica da conexão cavo-pulmonar total.

A variation of total cavopulmonary connection without anastomosing the superior vena cava to the right pulmonary artery branch is presented. Both vena cava flow go through an intra atrial tunnel to the right atrial appendage, which is anastomosed to the right pulmonary artery, in anatomical eligible cases.

[Syphilitic aneurysm communicating with an aortic sinus of Valsalva. A case report]. / Aneurisma sifilítico comunicando-se com um seio de Valsalva aórtico. Relato de caso.

The authors present the case of a 27-year old woman with an aneurysm, possibly originating from an ectopic coronary sprout and communicating with the right anterior sinus of Valsalva. Secondary syphilitic lesions were observed. By virtue of its great size and localization, this aneurysm produced obstruction of the outlet of the right ventricle and dislocation of the left coronary artery. The authors conclude that this aneurysm was a congenital anomaly because of its great volume, configuration, the way it opened in the aortic right anterior sinus of Valsalva, the normal aortic wall and valve, and normal sinuses of Valsalva, observed at surgery. The follow-up was uneventful.