Dysregulation of macrophage PEPD in obesity determines adipose tissue fibro-inflammation and insulin resistance.

Resulting from impaired collagen turnover, fibrosis is a hallmark of adipose tissue (AT) dysfunction and obesity-associated insulin resistance (IR). Prolidase, also known as peptidase D (PEPD), plays a vital role in collagen turnover by degrading proline-containing dipeptides but its specific functional relevance in AT is unknown. Here we show that in human and mouse obesity, PEPD expression and activity decrease in AT, and PEPD is released into the systemic circulation, which promotes fibrosis and AT IR. Loss of the enzymatic function of PEPD by genetic ablation or pharmacological inhibition causes AT fibrosis in mice. In addition to its intracellular enzymatic role, secreted extracellular PEPD protein enhances macrophage and adipocyte fibro-inflammatory responses via EGFR signalling, thereby promoting AT fibrosis and IR. We further show that decreased prolidase activity is coupled with increased systemic levels of PEPD that act as a pathogenic trigger of AT fibrosis and IR. Thus, PEPD produced by macrophages might serve as a biomarker of AT fibro-inflammation and could represent a therapeutic target for AT fibrosis and obesity-associated IR and type 2 diabetes.

Risk assessment of in vitro cytotoxicity, antioxidant and antimicrobial activities of Mentha piperita L. essential oil.

The objective of this study was to determine the chemical composition as well as antioxidant, antibacterial, and cytotoxic properties of the essential oil of Mentha piperita L. (peppermint). Fifteen chemical constituents were identified in the essential oil, for a total of 99.99% of the compounds. The essential oil exhibited antimicrobial activity against two Gram-positive bacteria Staphylococcus aureus and Listeria monocytogenes. The minimum inhibitory concentration (MIC) of essential oil of Mentha piperita L. for Staphylococcus aureus and Listeria monocytogenes was 1.84 µg/ml, whereas the minimum bactericidal concentration (MBC) values were 3.7 and 7.43 µg/ml, respectively. The oil displayed potent antioxidant activity inhibiting up to approximately73% of 2,2'-azinothiobis (3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) radicals. In the cytotoxicity assay, the highest essential oil concentration (100 µg/ml) resulted in viability of approximately 90% human epidermal keratinocyte (HaCaT) cells. With respect to antitumor activity in C6 rat glioma cells, there was significant reduction in cell viability: 56-74% in 24 hr, and 71-77% in 48 hr. Data suggest that in presence of the essential oil of Mentha piperita L. antioxidant, antibacterial, antitumor and non-cytotoxic properties were noted.

Erratum to: One-level step section histological analysis is insufficient to confirm complete pathological response after neoadjuvant chemoradiation for rectal cancer.

Unfortunately, one of the author name was wrongly published in the original publication. The complete correct name should read as follows "Beatriz Camargo Azevedo". The original article was updated.

One-level step section histological analysis is insufficient to confirm complete pathological response after neoadjuvant chemoradiation for rectal cancer.

BACKGROUND: Neoadjuvant chemoradiation therapy (nCRT) for rectal cancer may lead to cure. As we currently lack reliable methods to clinically confirm the absence of disease, some patients undergo radical resection and have pathological complete response (pCR) still undergo surgery. Furthermore, it is uncertain if conventional one-level histopathological analysis is accurate enough to determine complete response. Confirming pCR is essential to determine the prognosis and to consider the patient's inclusion in trials of adjuvant therapy. The aim of this study was to determine whether the current 1-level approach is sufficient to confirm pCR. METHODS: Four hundred and thirty-five patients with rectal cancer who received nCRT followed by radical resection were analyzed. All cases identified as pCR by 1-level step section histological evaluation were reassessed with 3-level step sections and immunohistochemical analysis to verify the presence of residual disease. RESULTS: Out of 435 patients, 75 (17.2%) were staged as ypT0. Of these, 6 had lymph node involvement and 1 had distant metastasis, leaving 68 (15.6%) who had pCR. After the additional step sections, residual tumor was detected in 12 (17.6%) of these 68. The final pCR rate was 12.9%. Distant recurrence was detected in 7.1% of real-pCR patients compared to 16.7% in the false-pCR group (p = 0.291). Sensitivity of clinical assessment for detecting pCR was 35.7%, and the accuracy of 1-section histological evaluation to identify pCR was 82.4%. CONCLUSIONS: Histopathological analysis with 1-level step section is insufficient to determine complete tumor eradication. The 3-level sections methodology revealed residual tumor cells in patients initially classified as ypT0. Further studies with larger sample size are required to verify the clinical relevance of these residual tumor cells. Caution should continue to be applied to watch and wait strategies following nCRT.

Correction of iatrogenic injury of the obturator nerve during pelvic laparoscopic lymphadenectomy by the use of sural nerve grafts.

•Intraoperative injury of the obturator nerve is not an infrequent complication of gynecological surgeries.•This injury can occur in association with pelvic lymphadenectomy for uterine or cervical cancer.•This manuscript demonstrates an alternative technique for the obturator nerve repair, when primary end to end anastomosis is not possible.

Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon.

AIM: Chagas' disease is an endemic parasitosis found in Latin America. The disease affects different organs, such as heart, oesophagus, colon and rectum. Megacolon is the most frequent long-term complication, caused by damage to the myoenteric and submucous plexus, ultimately leading to a functional barrier to the faeces. Patients with severe constipation are managed surgically. The study aimed to analyse the 10-year minimum functional outcome after rectosigmoidectomy with posterior end-to-side anastomosis (RPESA). METHOD: A total of 21 of 46 patients were available for follow up. Patients underwent clinical, radiological and manometric evaluation, and the results were compared with preoperative parameters. RESULTS: Of the 21 patients evaluated, 81% (17) were female, with a mean age of 60.6 years. Good function was achieved in all patients, with significant improvement in defaecatory frequency (P < 0.0001), usage of enemas (P < 0.0001) and patient satisfaction. Barium enema also showed resolution of the colonic and rectal dilatation in 19 cases evaluated postoperatively. CONCLUSION: Minimal 10-year follow up of RPESA showed excellent functional results, with no recurrence of constipation.

Synchronous collision malignant melanoma and adenocarcinoma of the rectum.

"Collision tumors" consist of two independent but coexisting tumors. This uncommon situation might be easily mistaken for a composite tumor where one histogenetic event originates from two apparently distinct neoplasms. Colorectal collisions are particularly unusual; here, we report the exceedingly rare case of a 61-year-old man with malignant melanoma and adenocarcinoma colliding in the rectum. Collision tumors have an idiopathic pathophysiology and in fact "accidental meeting" is accepted by many authors. This article discusses the concepts about cancer development, which are overlooked by this hypothesis, another theory to explain that this rare occurrence involves microenvironment changes.

Resposta tecidual ao compósito 50 por cento hidroxiapatita: 50 por cento poli-hidroxibutirato para substituição óssea em coelhos / Tissue response to the composite 50 percent hydroxyapatite: 50 percent polyhydroxybutyrate for bone substitution in rabbits

Avaliaram-se a biocompatibilidade, a osseointegração, a osseocondução e a biodegradação de compósitos de 50 por cento hidroxiapatita (HAP-91®) e 50 por cento poli-hidroxibutirato. O compósito foi implantado em defeitos ósseos em 12 coelhos (grupo experimental), sendo comparado a defeitos não preenchidos (grupo-controle, de igual número). Os parâmetros clínicos dor, claudicação, infecção, deiscência e edema foram avaliados nos primeiros oito dias após a cirurgia e aos 45 e 90 dias. Radiografias foram realizadas aos oito, 45 e 90 dias após a cirurgia em quatro animais por grupo que, em seguida, foram submetidos à eutanásia para coleta de amostras destinadas a análises histológica e histomorfométrica. Não ocorreram diferenças entre os grupos para todos os parâmetros clínicos. Radiografias demonstraram um compósito com radiopacidade semelhante à do osso vizinho e contato direto entre osso e compósito aos 45 e 90 dias. Diferença significativa foi observada entre a porcentagem dos tecidos ósseo e conjuntivo dentro do defeito nos dias oito, 45 e 90, assim como na interface aos 45 e 90 dias. Foram observadas projeções dos tecidos ósseo e conjuntivo no interior do compósito e sinais de biodegradação na ausência de infiltrado inflamatório. Pode-se concluir que o compósito é biocompatível, osseocondutor, biodegradável e se integra ao tecido ósseo.

The biocompatibility, osseointegration, osseoconductivity, and biodegradation of a 50-50 percent hydroxyapatite (HAP-91®)-polyhydroxybutyrate were evaluated. The composite was implanted in bone defects of 12 rabbits (experimental group), being compared to unfilled defects (control group, 12 animals). The clinical parameters of pain, lameness, infection, dehiscence, and edema were evaluated during the first eight days and on the 45th and 90th days after surgery. Radiographs were taken in four animals per group at 8, 45, and 90 days after surgery, when animals were euthanized to collect samples for histology and histomorphometry. Significant differences between groups for all clinical parameters were not observed. Radiographs showed a similar radiopacity of the composite and bone and their direct contact. More bone than connective tissue was found within the defect at 8, 45, and 90 days and at the interface on the 45th and 90th days. Projections of bone and connective tissue were seen inside the composite. Biodegradation signs became evident, with absence of inflammatory infiltrate. Data support that such composite is biocompatible, osseoconductive, biodegradable, and integrate to bone.

[Grey platelet disease]. / Síndrome da plaqueta cinzenta.

Grey Platelet disease is a rare disease characterized by morphologic changes in platelets alpha-granules. These proteins are essential for the homeostasis, so the patients with this blood defect present hemorrhagic disturbs. The blood discrasia is usually mild, however some patients could present more serious manifestations, usually after a severe trauma. The authors present the following clinical report about a patient that was admitted in a Medical Department with a severe bleeding and mild thrombocytopenia. The patient was submitted to an extensive study to determine the etiology (autoimmunity serology, myelogram, coagulation study) that were all normal. The diagnosis of Idiopathic Thrombocytopenic Purpura was considered. Six months after a worsening of the hemorrhagic discrasia and thrombocytopenia the patient was assisted. Corticotherapy was initiated without improvement. The morphology of the platelets was revised and the blood smear with Wright coloration revealed the presence of large, pale and grey platelets. The electronic microscopy confirmed the diagnosis of Grey Platelet disease. The family of the patient was studied and we found that two direct relatives were affected with the same disease. In these family these syndrome probably has autossomic dominant inherence.

Conjugated equine estrogen, raloxifene and arterial stiffness in postmenopausal women.

METHODS: We analyzed the influence of conjugated equine estrogen (CEE) and raloxifene on arterial stiffness. Sixty-seven healthy, normotensive women 1-10 years into menopause were assigned to receive oral placebo, conjugated equine estrogen 0.625 mg, or raloxifene 60 mg. Arterial stiffness was evaluated by measuring the carotid-femoral and femoral-dorsalis pedis pulse wave velocity (CF PWV, FP PWV). Systolic pressure augmentation index (AI) at the carotid artery was obtained with applanation tonometry. RESULTS: Arterial stiffness was not affected by any treatment regimen: placebo (CF PWV before vs. after: 644 vs. 626 cm/s, p = 0.09; FP PWV before vs. after: 1006 vs. 1012 cm/s,p = 0.77; AI before vs. after = 30 vs. 29%, p = 0.55), CEE (CF PWV before vs. after: 642 vs. 600 cm/s, p = 0.11; FP PWV before vs. after: 952 vs. 971 cm/s, p = 0.66; AI before vs. after: 25 vs. 32%, p = 0.82), and raloxifene (CF PWV before vs. after: 636 vs. 601 cm/s, p = 0.12; FP PWV before vs. after: 964 vs. 941 cm/s, p = 0.62; AI before vs. after: 25 vs. 25%, p = 0.65). A correlation occurred between basal stiffness and the degree of reduction in indexes measured, indicating that the higher the basal stiffness, the greater the degree of reduction, particularly in the CEE group: CF PWV (r = - 0.602, p = 0.001); FP PWV (r = - 0.455, p = 0.022); AI (r = - 0.410, p = 0.042). CONCLUSIONS: Conjugated equine estrogen and raloxifene do not seem to affect arterial stiffness of healthy normotensive women less than 10 years since menopause. Reduction in arterial stiffness seems related to its basal level.

A calcified foreign body in the bladder after laparoscopic inguinal hernia repair.

In this paper, we report an exceedingly rare complication after laparoscopic inguinal hernioplasty. A 57-year-old man was submitted to transurethral resection of the prostate followed by laparoscopic "bikini mesh" hernia repair. One year later, he presented with miccional irritative symptoms. Ultrasonography showed a vesical intraluminal foreign body and computerized tomography revealed a calcified foreign body on the anterior bladder wall. On reoperation, it was noted that there occurred mesh transfixation of the bladder. The lateral segments were removed and the patient recovered uneventfully. This is a, thus far, unpublished complication of this technique.

Does caffeine modify corticomotor excitability?

AIMS: To test the influence of caffeine on the lower and upper motor neuron excitability. METHODS: In Experiment A, 18 healthy subjects received 200 mg of caffeine or placebo, in a randomized, double-blind, placebo-controlled design protocol. Mean F-waves amplitude, amplitude of the motor response evoked by magnetic stimulation (MEP), MEP duration, cortical silent period (CSP), central conduction time, and cortical threshold were evaluated. In Experiment B, 6 healthy controls received 400 mg of caffeine, the peripheral silent period (PSP) and CSP were evaluated. CSP was recorded bilaterally in biceps brachii (intensity 10% above threshold) and abductor digiti minimi (ADM) (intensity at 10% and 50% above threshold). Muscle contraction was above 50% of the maximum force in both experiments. Latencies were defined by a technician who was not aware of this investigation. Serum caffeine level was evaluated. RESULTS: In Experiment A, only the CSP, recorded in both ADM with intensity at 10% above threshold showed a significant change after caffeine (decrease of 17.1+/-34.0 ms, about 12% reduction). In Experiment B, PSP did not change, but CSP tested with intensities 10% above threshold was significantly decreased by 20.8+/-34.4 ms in ADM and 13.5+/-13.8 ms in biceps (about 13 and 16%, respectively). Serum caffeine level clearly increased after consumption but no correlation could be found between these levels and CSP reduction. CONCLUSIONS: In our investigation, caffeine elicited a consistent decrease of the CSP, suggesting that caffeine increases cortical neuronal excitability.

Effects of conjugated equine estrogens or raloxifene on lipid profile, coagulation and fibrinolysis factors in postmenopausal women.

OBJECTIVES: To compare the effect of conjugated equine estrogens (CEE) and raloxifene on lipid profile and hemostasis. MATERIALS AND METHODS: A double-blind, randomized and parallel study was performed with 90 healthy postmenopausal women, aged 54 +/- 5 years, divided into three groups and submitted to daily therapy with either CEE 0.625 mg, raloxifene 60 mg or placebo for 4 months. The lipid profile, coagulation and fibrinolytic factors were analyzed. RESULTS: CEE increased the levels of high density lipoprotein cholesterol (HDL-C) from 49.0 to 56.8 mg/dl (p < 0.001), very low density lipoprotein cholesterol (VLDL-C) from 17.2 to 22.3 mg/dl (p < 0.001), and triglycerides from 86.0 to 111.7 mg/dl (p < 0.001), and decreased the levels of low density lipoprotein cholesterol (LDL-C) from 121.0 to 106.5 mg/dl (p < 0.001). The only significant effect of raloxifene was an increase in the levels of HDL-C from 46.0 to 47.8 mg/dl (p = 0.019). There was no significant reduction in LDL-C, from 115.5 to 110.2 mg/dl (p = 0.06), VLDL-C, from 21.7 to 20.0 mg/dl (p = 0.201), and triglycerides, from 108 to 100 mg/dl (p = 0.201). CEE decreased the levels of fibrinogen, from 370.5 to 326.8 g/l (p = 0.039) and the levels of antithrombin III, from 99.5 to 93.2% (p < 0.001). Raloxifene decreased the levels of fibrinogen, from 354.7 to 302.0 g/l (p = 0.009) and the levels of antithrombin III, from 102.4 to 98.5% (p = 0.039). CEE increased levels of protein C from 103.7 to 115.3 mg/l (p < 0.001) and raloxifene did not change the levels of protein C (107.9 to 105.1 mg/l; p = 0.158). CEE decreased the antigen levels of tissue plasminogen activator (t-PA) from 8.8 to 6.8 U/ml (p < 0.001), and of plasminogen activator inhibitor (PAI-1) from 30.8 to 21.6 U/ml (p < 0.010), whereas raloxifene had no significant effect on either t-PA, from 9.6 to 9.2 U/ml (p = 0.235) or PAI-1 antigen levels, from 32.1 to 30.4 U/ml (p = 0.538). CONCLUSION Both CEE and raloxifene exert significant effects on the lipid and coagulation profile. CEE had a more significant effect on fibrinolysis than raloxifene. These effects may have a significant impact on the cardiovascular risk that needs to be confirmed in larger studies.

Chlorobis(dimethylamido)(eta5-2,5-dimethylpyrrolyl)titanium(IV), [Ti(NMe2)2(DMP)Cl].

The structure of the title compound, [Ti(C2H6N)2(C6H8N)Cl], displays a eta5-coordination mode for the pyrrolyl ring, confirmed by the values of the slip parameter [0.073 (9) A] and the fold angle [4.6 (6) degrees ]. This coordination is confirmed by NMR data, which point to the involvement of the complex in a fluxional process in solution above 285 K, passing through an intermediate involving simultaneously a metal-azaallyl and a metal-olefin bond.

Inclusion of lidocaine in cardioplegic solutions provides additional myocardial protection.

AIM: Lidocaine inhibits depolarization by blocking sodium and calcium influx and potassium release, abolishing the action potentials of cells in the Hiss-Purkinje system and myocit cells. As it can directly influence cardiac electric and mechanical activities, this study evaluated the efficacy of lidocaine in providing myocardial protection during normothermic blood cardioplegia. METHODS: Twenty-six dogs were randomly assigned to groups based on the cardioplegic induction solution they were to receive. Group I dogs (n=10) received a solution consisting of lidocaine (5 mg/kg), KCL (41.6 mEq/L) and 180 ml of normothermic blood. Group II dogs (n=10) received the same solution, except for the lidocaine and group III dogs (n=6) received only normothermic blood. In addition, 120 ml of normothermic blood was reinfused every 20 min. All dogs underwent cardiopulmonary bypass, 2 hours of global myocardial ischemia and 3 hours of reperfusion. Statistical differences were determined with the chi squared test, the two-way analysis of variance and Bonferroni's test. RESULTS: There were no deaths in group I. The survival rate in group II was 60%, and no dogs in group III survived (p=0.025). No difference in lactate liberation or left ventricular function (i.e., cardiac outflow and ejection fraction) was observed between groups. However, animals in group I demonstrated less enzymatic releases (troponin I, p=0.049 and CK, p=0.026) and less mitochondrial ultrastructural changes (p=0.022). CONCLUSIONS: Lidocaine offers myocardium additional protection against ischemia during cardiopulmonary bypass.

Histoplasma capsulatum inhibits apoptosis and Mac-1 expression in leucocytes.

Histoplasma capsulatum is a fungus found intracellularly in neutrophils and peripheral blood mononuclear cells (PBMCs), suggesting that it is capable of evading damage and survives inside these cells. In this study, we report that neutrophils from H. capsulatum-infected mice, and human neutrophils and mononuclear cells exposed to H. capsulatum presented less apoptosis than those from noninfected animals or cells exposed to medium only. Moreover, cells harvested from infected animals are resistant to apoptosis induced by dexamethasone - a proapoptotic stimulant. We also show that neutrophils harvested from infected mice and PBMCs from humans exposed to the fungus had a greatly decreased Mac-1 expression. We conclude that H. capsulatum induces an antiapoptotic state on leucocytes, which correlates with decreased cell-surface Mac-1 expression. These facts may represent an escape mechanism for the fungus by delaying cell death and allowing the fungus to survive inside leucocytes.

Mini-sternotomy for the treatment of aortic valve lesions.

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous 1/4-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided more comfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.

Downmodulation of CD18 and CD86 on macrophages and VLA-4 on lymphocytes in experimental tuberculosis.

Development and evaluation of new vaccines and immunotherapy against tuberculosis demand a better understanding of the immune mechanisms in this disease. Costimulatory signals and intercellular contact seem to be pivotal in determining whether recognition of antigen by T cells leads to activation or anergy. In this paper, we show that virulent M. tuberculosis H37Rv downmodulates the ex vivo expression of CD18 and CD86 on peritoneal macrophages and VLA-4 on lymphocytes but does not disturb the in vitro production of interleukin (IL)-12 and interferon (IFN)-gamma after intraperitoneal infection. In addition, splenocytes from infected mice produce IL-10, while the expression of cell surface receptors is unchanged. The interplay among IL-12, IFN-gamma and IL-10 in vivo and the downmodulation of cell-surface receptors during the infection at the inflammatory site may contribute to the explanation of the maintenance of infection.

Immediate and long term evolution of valve replacement in children less than 12 years old.

OBJECTIVE: The aim of this work was the follow-up and evaluation of valve replacement in children under 12 years of age. METHODS: Forty-four children less than 12 years old were underwent valve replacement at INCOR-HCFMUSP between January 1986 and December 1992. Forty (91%) were rheumatic, 39 (88.7%) were in functional classes II or IV, 19 (43.2%) were operated upon on an emergency basis, and 6 (13.6%) had atrial fibrillation. Biological prostheses (BP) were employed in 26 patients (59.1%), and mechanical prostheses (MP) in 18 (40.9%). Mitral valves were replaced in 30 (68.7%), aortic valves in 8 (18.2%), a tricuspid valve in 1 (2.3%), and double (aortic and mitral) valves in 5 (11.4) of the patients. RESULTS: Hospital mortality was of 4.5% (2 cases). The mean follow-up period was 5.8 years. Re-operations occurred in 63.3% of the patients with BP and in 12.5% of those with MP (p=0.002). Infectious endocarditis was present in 26.3% of the BP, but in none of the cases of MP (p=0.049). Thrombosis occurred in 2 (12.5%) and hemorrhage in one (6.5%) of the patients with a MP. Delayed mortality occurred in 5 (11.9%) of the patients over a mean period of 2.6 years; four had had BP and one had a MP (NS). Actuarial survival and re-operation-free curves after 10 years were respectively, 82.5+/-7.7 (SD)% and 20.6+/-15.9%. CONCLUSION: Patients with MP required fewer re-operation, had less infectious endocarditis and lower late mortality rates compared with patients with bioprostheses. The former, therefore, appear to be the best valve replacement for pediatric patients.

[Ischemic mitral valve insufficiency. Incidence, diagnosis and surgical treatment]. / Insuficiência valvar mitral isquêmica. Incidência, diagnóstico e tratamento cirúrgico.

PURPOSE: To study the incidence of ischemic mitral regurgitation (MR) and the mortality. METHODS: One-hundred-five cases of acute myocardial infarction (AMI) with MR were reviewed. Patients were divided in two groups: group A-59 (56.2%) necropsied patients without previous surgical procedures to correlate clinical pictures with the aim to determine the cause of death; group B-46 (43.8%) patients were submitted to surgical treatment. This group was subdivided in mild, moderate and severe forms of MR, and studied comparatively the type of surgical treatment and its evolution. RESULTS: Group A-23 (39%) patients with mild forms and predominant ischemic heart disease, responsible for death; 18 (30.5%) patients without previous diagnosis, masked by myocardial failure and 18 (30.5%) with severe MR and coronary heart disease; group B-14 (30.4%) patients died at the immediate post-operatory period. Higher mortality associated to ejection fraction (EF) below 35% (47.6%; p = 0.022), severe MR (41.7%; p = 0.044) and cardiogenic shock (52.9%; p = 0.14). In 41 (89.1%), the mitral valve repair was combined to coronary artery bypass grafting operation (CABG), in 4 (8.7%) this last procedure was made without mitral repair and in the remaining patients the surgery was limited to the valve. Mitral valvuloplasty was performed in 23 (50%) patients with 3 (13%) deaths, and in 19 (42.3%) the mitral valve was replaced with 9 (47.4%) deaths. CONCLUSION: The prognosis is related to the grade of EF and to the severity of MR. In mild to moderate forms, the surgical indication is due to the associated coronary heart disease and the valvuloplasty is preferred, in this instance. In severe forms, surgical intervention must be performed as soon as possible, before cardiogenic shock appears.