Long-term evolution of mitral commissurotomy in rheumatic patients with low echocardiographic score.

INTRODUCTION: The good results of open mitral commissurotomy are well known and there is a hypothesis that it could provide better results in patients selected by echocardiographic score. OBJECTIVE: The purpose of this study is to analyze the late results with open mitral commissurotomy in patients selected by score and to identify variables influencing these results. METHODS: From January 1990 to August 1994, 50 patients were submitted to open mitral commissurotomy due to rheumatic mitral stenosis in Heart Institute of University of Sao Paulo Medical School. Patients with age < 60 years, in functional class II, III or IV (New York Heart Association) and echocardiographic score 9 were included. The mean age was 32.7 ± 8.3 years and 41 patients (82%) were female. The functional class was II in three patients (6%), III in 46 (92%) and IV in one (2%). Forty six patients (92%) were in sinus rhythm and four (8%) were in atrial fibrillation. The mean mitral valve area was 0.9 ± 0.2 cm². RESULTS: There was no hospital mortality. There were two late deaths, one related to valve disease. Actuarial survival was 95.5 ± 3.1 %, freedom from reoperation was 62.3 ± 11,8% and freedom from tromboembolism was 88,2 ± 5,0% in 18 years. There was no endocarditis. The grade of the echocardiographic score had no significant influence on the reoperations in late evolution. CONCLUSION: Open mitral commissurotomy presented excelent long term results in rheumatic patients with low echocardiographic score.

Evolução tardia da comissurotomia mitral em pacientes reumáticos com baixo escore ecocardiográfico / Long-term evolution of mitral commissurotomy in rheumatic patients with low echocardiographic score

INTRODUÇÃO: Os bons resultados da comissurotomia mitral a céu aberto são bem conhecidos e existe a hipótese de que se poderiam obter melhores resultados em pacientes selecionados pelo escore ecocardiográfico. OBJETIVO: Analisar os resultados tardios da comissurotomia mitral em pacientes selecionados pelo escore ecocardiográfico e identificar variáveis com influência nesses resultados. MÉTODOS: De janeiro de 1990 a agosto de 1994, 50 pacientes com estenose mitral reumática foram submetidos à comissurotomia mitral a céu aberto no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foram incluídos pacientes com idade < 60 anos, classe funcional II, III ou IV (New York Heart Association) e escore ecocardiográfico 9. A idade média foi de 32,68 ± 8,29 anos, sendo 41 (82%) pacientes do sexo feminino. Três (6%) pacientes estavam em classe funcional II, 46 (92%) em III e um (2%) em IV. Quarenta e seis (92%) pacientes apresentavam ritmo sinusal e quatro (8%), fibrilação atrial. A área valvar mitral média foi de 0,9 ± 0,2 cm². RESULTADOS: Não houve mortalidade hospitalar. Ocorreram dois óbitos tardios, um relacionado à valvopatia. A sobrevida actuarial foi de 95,5 ± 3,1%, sobrevida livre de reoperação, 62,3 ± 11,8%, e sobrevida livre de tromboembolismo, 88,2 ± 5,0% em 18 anos. Não houve endocardite. O escore ecocardiográfico não teve influência significante em reoperações na evolução tardia. CONCLUSÃO: A comissurotomia mitral a céu aberto obteve resultados tardios excelentes nos pacientes com baixo escore ecocardiográfico.

INTRODUCTION: The good results of open mitral commissurotomy are well known and there is a hypothesis that it could provide better results in patients selected by echocardiographic score. OBJECTIVE: The purpose of this study is to analyze the late results with open mitral commissurotomy in patients selected by score and to identify variables influencing these results. METHODS: From January 1990 to August 1994, 50 patients were submitted to open mitral commissurotomy due to rheumatic mitral stenosis in Heart Institute of University of Sao Paulo Medical School. Patients with age < 60 years, in functional class II, III or IV (New York Heart Association) and echocardiographic score 9 were included. The mean age was 32.7 ± 8.3 years and 41 patients (82%) were female. The functional class was II in three patients (6%), III in 46 (92%) and IV in one (2%). Forty six patients (92%) were in sinus rhythm and four (8%) were in atrial fibrillation. The mean mitral valve area was 0.9 ± 0.2 cm². RESULTS: There was no hospital mortality. There were two late deaths, one related to valve disease. Actuarial survival was 95.5 ± 3.1 %, freedom from reoperation was 62.3 ± 11,8% and freedom from tromboembolism was 88,2 ± 5,0% in 18 years. There was no endocarditis. The grade of the echocardiographic score had no significant influence on the reoperations in late evolution. CONCLUSION: Open mitral commissurotomy presented excelent long term results in rheumatic patients with low echocardiographic score.

Perfuração tardia de ventrículo direito em portador de cardioversor desfibrilador implantável / Delayed right ventricular perforation in patient with implantable cardioverter - defibrillator / Perforación tardía de VD en portador de DCI

Descrevemos o caso de uma paciente de 62 anos que retornou para avaliação nove meses após implante de cardioversor desfibrilador implantável (CDI) com sinais de perfuração tardia do ventrículo direito. São discutidos os sinais clínicos que permitem o diagnóstico dessa apresentação tardia, assim como as condutas e a frequência dessa complicação na literatura.

We describe the case of a 62-year-old patient who returned for evaluation nine months after receiving an implantable cardioverter-defibrillator (ICD) with signs of delayed right ventricular (RV) perforation. The clinical signs that allowed the diagnosis of this late presentation to be achieved are discussed herein, as well as the conduct and the frequency of this complication in the literature.

Describimos un caso de una mujer de 62 años que regresó para evaluación nueve meses después de implantación de un desfibrilador cardiaco implantable (DCI) con signos de perforación tardía del ventrículo derecho. Se discuten los signos clínicos que permitan el diagnóstico de esta presentación tardía, así como el comportamiento y la frecuencia de esta complicación en la literatura.

Delayed right ventricular perforation in patient with implantable cardioverter - defibrillator.

We describe the case of a 62-year-old patient who returned for evaluation nine months after receiving an implantable cardioverter-defibrillator (ICD) with signs of delayed right ventricular (RV) perforation. The clinical signs that allowed the diagnosis of this late presentation to be achieved are discussed herein, as well as the conduct and the frequency of this complication in the literature.

Evaluating the adequacy of cardiovascular risk factor control after myocardial revascularization surgery / Avaliação da adequação do controle de fatores de risco cardiovascular após cirurgia de revascularização miocárdica

FUNDAMENTO: Os fatores de risco cardiovascular (FR) são responsáveis pela ocorrência de eventos cardiovasculares. OBJETIVO: Estimar o porcentual de pacientes submetidos a cirurgia de revascularização miocárdica (RM) que conseguem controle adequado de fatores de risco (FR) modificáveis, pelo menos seis meses após o procedimento. MÉTODOS: O estudo incluiu 88 pacientes, no qual se realizaram análise de prontuários e entrevista clínica, entre seis e 12 meses após a realização de cirurgia de RM em hospital de referência para doenças cardiovasculares, no período de janeiro a dezembro de 2004. RESULTADOS: A média de idade foi 63,1±9,9 anos: 51 (58 por cento) eram do sexo masculino, 86 (97,7 por cento), hipertensos, 38 (43,2 por cento), diabéticos, 85 (96,6 por cento), dislipidêmicos e 10 (11,4 por cento), tabagistas. O controle da hipertensão (PA < 140x90 mmHg) foi atingido em 24,4 por cento dos pacientes. Para o colesterol (colesterol LDL < 100 mg/dl) e para o diabete melito (glicemia < 110), os níveis de controle foram, respectivamente, 30,6 por cento e 31,6 por cento. O uso de anti-hipertensivos, agentes hipoglicemiantes (orais ou insulina) e estatinas, quando indicado, foi, respectivamente, 96,5 por cento, 92,1 por cento, 78,8 por cento. Entretanto, analisando-se a tríade hipertensão, diabete e hipercolesterolemia, apenas 14,8 por cento do total de pacientes apresentavam níveis de pressão arterial, glicemia e colesterol LDL dentro dos limites aceitáveis. CONCLUSÃO: Apesar do uso freqüente de medicações para controle da hipertensão, diabete e hipercolesterolemia, o controle de fatores de risco ainda é realizado de forma insuficiente nos pacientes revascularizados, o que sugere grande potencial para a melhoria da prática clínica.

BACKGROUND: Cardiovascular risk factors (RF) for coronary artery disease (CAD) are responsible for the occurrence of cardiovascular events. OBJECTIVE: To estimate the percentage of patients submitted to myocardial revascularization surgery (MRS) that attains adequate control of modifiable RF at least six months after the surgery. METHODS: Data collection was based on the review of medical records and a clinical interview of 88 patients submitted to MRS between January and December of 2004 at a reference hospital for cardiovascular diseases. The patients were interviewed in the follow-up period, between six and twelve months after the surgical revascularization. RESULTS: Mean age was 63.1 ± 9.9 years; 51 patients (58 percent) were males, 86 (97.7 percent) were hypertensive, 38 (43.2 percent) were diabetic, 85 (96.6 percent) had hypercholesterolemia and 10 (11.4 percent) were smokers. Hypertension control (PA < 140 x 90 mmHg) was attained by 24.4 percent of the patients; cholesterol (LDL cholesterol < 100 mg/dl) and diabetes control (blood glucose levels < 110 mg/dl) levels were 30.6 percent and 31.6 percent, respectively. The use of antihypertensive drugs, hypoglycemic agents and statins, when indicated, were 96.5 percent, 92.1 percent and 78.8 percent, respectively. However, only 14.8 percent patients had their blood pressure, glucose and cholesterol levels within the limits accepted as adequate control. CONCLUSION: Despite the frequent use of drugs to control hypertension, diabetes and hypercholesterolemia, a high proportion of patients still do not achieve the target levels of risk factor control recommended by current guidelines at least six months after revascularization surgery, which suggests there is a great potential for improvement in clinical practice.

Evaluating the adequacy of cardiovascular risk factor control after myocardial revascularization surgery.

BACKGROUND: Cardiovascular risk factors (RF) for coronary artery disease (CAD) are responsible for the occurrence of cardiovascular events. OBJECTIVE: To estimate the percentage of patients submitted to myocardial revascularization surgery (MRS) that attains adequate control of modifiable RF at least six months after the surgery. METHODS: Data collection was based on the review of medical records and a clinical interview of 88 patients submitted to MRS between January and December of 2004 at a reference hospital for cardiovascular diseases. The patients were interviewed in the follow-up period, between six and twelve months after the surgical revascularization. RESULTS: Mean age was 63.1 +/- 9.9 years; 51 patients (58%) were males, 86 (97.7%) were hypertensive, 38 (43.2%) were diabetic, 85 (96.6%) had hypercholesterolemia and 10 (11.4%) were smokers. Hypertension control (PA < 140 x 90 mmHg) was attained by 24.4% of the patients; cholesterol (LDL cholesterol < 100 mg/dl) and diabetes control (blood glucose levels < 110 mg/dl) levels were 30.6% and 31.6%, respectively. The use of antihypertensive drugs, hypoglycemic agents and statins, when indicated, were 96.5%, 92.1% and 78.8%, respectively. However, only 14.8% patients had their blood pressure, glucose and cholesterol levels within the limits accepted as adequate control. CONCLUSION: Despite the frequent use of drugs to control hypertension, diabetes and hypercholesterolemia, a high proportion of patients still do not achieve the target levels of risk factor control recommended by current guidelines at least six months after revascularization surgery, which suggests there is a great potential for improvement in clinical practice.

Late evolution of mitral commissurotomy in patients with low echocardiographic score.

OBJECTIVE: The purpose of this study was to analyze the late results with open mitral commissurotomy in patients with low echocardiographic scores and to identify variables influencing these late results. METHODS: We studied 50 patients who underwent open mitral commissurotomy due to rheumatic mitral stenosis at the Heart Institute University of São Paulo Medical School. Enrolled patients had a Wilkins echocardiographic score

Evolução tardia de pacientes com baixo escore ecocardiográfico submetidos a comissurotomia mitral / Latee evolution of patients with low ecocardiographic score submitted to mitral comissurotomy

A comissurotomia mitral a céu aberto tem bons resultados imediatos em pacientes com baixo escore ecocardiográfico. Nosso objetivo é analisar os resultados tardios. Foram operados 50 pacientes com escore  9 e área valvar mitral (AVM) de 0,940,2cm2. Não houve óbito hospitalar. Com seguimento de 383,58 pacientes/ano, a sobrevida actuarial, a sobrevida livre de reoperação e de tromboembolismo foram respectivamente: / Open mitral comissurotomy has good immediate results in patients with low echocardiographic score. Our purpose is to analyse the late results. Fifthy patients were operated with score  9 and 0.940.2cm2 mitral valve area (MVA). There was no hospital death. With a 383.58 patients/year follow-up, actuarial survival, freedom from reoperation and thromboembolism were respectively...

Multivariate analysis of risk factors for hospital mortality in valvular reoperations for prosthetic valve dysfunction.

OBJECTIVES: The purpose of the study was to analyze risk factors for hospital mortality in patients undergoing valvular reoperations for prosthetic valve dysfunction. METHODS: We performed a prospective analysis of 146 patients who underwent valvular reoperations for prosthetic valve dysfunction between July 1995 and June 1999 at the Heart Institute of the University of São Paulo Medical School. Multivariate statistical analysis with logistic regression was used to analyze preoperative and intraoperative variables to determine risk factors for hospital mortality. RESULTS: The overall hospital mortality was 10.9% (16 patients). Univariate analysis showed that the following variables were associated with higher mortality rates: advanced New York Heart Association (NYHA) functional class, increased creatinine level, prolonged extracorporeal circulation time and treatment of annular abscess. Logistic multivariate analysis identified advanced NYHA functional class and a creatinine level higher than 1.5 mg/dl as independent predictors of hospital mortality. CONCLUSIONS: Advanced NYHA functional class and higher creatinine levels were independent predictors of hospital mortality in patients submitted for valvular reoperations for prosthetic valve dysfunction.

Risk factors to hospital mortality in valvar reoperations

OBJETIVO: Identificar fatores de risco para mortalidade hospitalar em reoperações valvares. MÉTODO: Foi realizada análise prospectiva de 194 pacientes submetidos a reoperações valvares no período entre julho de 1995 e junho de 1999. As variáveis estudadas foram: sexo, idade, classe funcional, número e tipo de operações prévias, intervalo entre as operações, caráter da operaçäo, creatinina sérica, fraçäo de ejeçäo do ventrículo esquerdo, diâmetros diastólico e sistólico do ventrículo esquerdo, pressäo sistólica de ventrículo direito, atividade de protrombina, relaçäo do tempo de tromboplastina parcial ativada, contagem de plaquetas, tempo de circulaçäo extracorpórea, tempo de pinçamento aórtico, posiçäo e número de valvas, tipo de procedimento, operações associadas e volume de sangramento intra-operatório. Análise univariada e multivariada foi realizada para determinar os fatores de risco para mortalidade hospitalar. RESULTADOS: A mortalidade hospitalar foi de 8,8 porcento (17 pacientes). A análise univariada identificou as seguintes variáveis associadas a maior mortalidade: classe funcional avançada, fraçäo de ejeçäo do ventrículo esquerdo baixa, atividade de protrombina baixa, creatinina elevada, tempo de circulaçäo extracorpórea prolongado, tempo de pinçamento aórtico prolongado, procedimentos associados e volume de sangramento intra- operatório elevado. Na análise multivariada foram significativas: classe funcional IV, creatinina > 1,5 mg/dl e tempo de circulaçäo extracorpórea > 120 minutos. CONCLUSÕES: As variáveis classe funcional IV, creatinina > 1,5 mg/dl e tempo de circulaçäo extracorpórea > 120 minutos säo fatores de risco independentes para mortalidade hospitalar nas reoperações valvares.

Fatores de risco para mortalidade hospitalar nas reoperações valvares / Risk factors in the Hospital mortality and heart valves

OBJETIVO: Identificar fatores de risco para mortalidade hospitalar em reoperações valvares. MÉTODO: Foi realizada análise prospectiva de 194 pacientes submetidos a reoperações valvares no período entre julho de 1995 e junho de 1999. As variáveis estudadas foram: sexo, idade, classe funcional, número e tipo de operações prévias, intervalo entre as operações, caráter da operação, creatinina sérica, fração de ejeção do ventrículo esquerdo, diâmetros diastólico e sistólico do ventrículo esquerdo, pressão sistólica de ventrículo direito, atividade de protrombina, relação do tempo de tromboplastina parcial ativada, contagem de plaquetas, tempo de circulação extracorpórea, tempo de pinçamento aórtico, posição e número de valvas, tipo de procedimento, operações associadas e volume de sangramento intra-operatório. Análise univariada e multivariada foi realizada para determinar os fatores de risco para mortalidade hospitalar. RESULTADOS: A mortalidade hospitalar foi de 8,8 por cento (17 pacientes). A análise univariada identificou as seguintes variáveis associadas a maior mortalidade: classe funcional avançada, fração de ejeção do ventrículo esquerdo baixa, atividade de protrombina baixa, creatinina elevada, tempo de circulação extracorpórea prolongado, tempo de pinçamento aórtico prolongado, procedimentos associados e volume de sangramento intra-operatório elevado. Na análise multivariada foram significativas: classe funcional IV, creatinina > 1,5 mg/dl e tempo de circulação extracorpórea > 120 minutos. CONCLUSÕES: As variáveis classe funcional IV, creatinina > 1,5 mg/dl e tempo de circulação extracorpórea > 120 minutos são fatores de risco independentes para mortalidade hospitalar nas reoperações valvares