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1.
BMC Infect Dis ; 20(1): 907, 2020 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33256617

RESUMO

BACKGROUND: Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis. CASE PRESENTATION: A 21-year-old male cocaine drug abuser presented to the emergency department with a 1-week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of antimicrobial treatment. CONCLUSION: Despite the effectiveness of toxoid-based vaccines, recent global outbreaks of invasive C. diphtheriae infectious related to non-toxigenic strains have been described. These infectious could be highly invasive as demonstrated in this case. Interdisciplinary work with an institutional "endocarditis team" is essential to achieve favorable clinical outcomes in such defiant scenarios.

5.
Arq. bras. cardiol ; 115(4): 720-775, out. 2020. tab, graf
Artigo em Português | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1131346
6.
Interact Cardiovasc Thorac Surg ; 31(4): 461-466, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32901288

RESUMO

OBJECTIVES: Concomitant valvular heart valve disease is a frequent finding, with higher morbidity and mortality among patients undergoing redo surgical procedures. Our goal was to report our initial experience with combined transcatheter Inovare bioprosthesis implants for severe valve dysfunction. METHODS: Among 300 transcatheter procedures, a total of 6 patients had concurrent simultaneous transcatheter bioprosthesis implants for severe mitral bioprosthesis failure (valve-in-valve), with a second valve procedure that included native aortic (n = 2) or degenerated bioprostheses in the aortic position (n = 4). During the procedures, all patients were treated with a balloon-expandable Inovare transcatheter valve, using the transapical approach. RESULTS: Patients were highly symptomatic [New York Heart Association (NYHA) functional class IV: 100%], with a mean age of 62 ± 5 years, yielding a mean European System for Cardiac Operative Risk II (EuroSCORE II) of 24.0 ± 10.1%. There was a mean of 1.6 ± 0.4 prior valve operations/patient, with a median time from prior mitral bioprosthesis surgery of 13.0 (9.2-20.0) years. Device success was 100% according to the Mitral Valve Academic Research Consortium and the Valve Academic Research Consortium-2 criteria. During the hospital stay, only 1 patient required dialysis, and the median intensive care unit and hospital lengths of stay were 5.0 (3.2-6.7) days and 16.0 (12.2-21.2) days, respectively. No deaths occurred at 30 days; at a median follow-up of 287 (194-437) days, 1 patient died of a non-cardiac cause and the rest of patients were in NYHA functional class I or II, with normofunctioning bioprostheses. CONCLUSIONS: Transcatheter double valve interventions using the Inovare bioprosthesis in this initial series were shown to be a reasonable alternative to redo surgical operations. The short- and mid-term clinical and echocardiographic outcomes demonstrate promising results, although future studies with a larger number of patients and longer follow-up are warranted.

7.
Interact Cardiovasc Thorac Surg ; 30(2): 229-235, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31713609

RESUMO

OBJECTIVES: Our goal was to analyse the initial results of the first 50 transapical transcatheter mitral valve-in-valve procedures performed in a single Latin American centre. METHODS: A prospective, single centre, database analysis was conducted to evaluate immediate, 30-day and 1-year postoperative results of 50 consecutive patients who had a transcatheter mitral valve-in-valve procedure from May 2015 to June 2018. All patients were operated on in a hybrid operating room and received a balloon-expandable valve via the transapical approach. Preoperative and postoperative characteristics were analysed and compared between the first 25 and the second 25 patients to evaluate the impact of the learning curve. Twenty patients had a follow-up examination at 1 year. RESULTS: There was a 98% device success rate. The patients had a mean age of 64.8 years; 72% were women; 80% were in New York Heart Association functional class ≥III preoperatively; and 36% of the procedures were urgent. The mean Society of Thoracic Surgeons scores and EuroSCORE II were 8.3% and 12.4%, respectively. Patients had a median of 2 previous operations; valve durability was 12.1 years; and 64% mitral valve disease of rheumatic fever aetiology. Echocardiography showed decreases in the maximum and mean mitral gradients from 23.5 to 14.6 and 11.5 to 6.4 mmHg postoperatively; the overall mean hospitalization period was 15 days. The overall mortality rate at 30 days was 14%, with 1 intraprocedural death. Further subanalyses between the first and the second half of the cases showed a drop in the mortality rate from 20% to 8% (P < 0.01). CONCLUSION: The transcatheter mitral valve-in-valve procedure was shown to be a safe and effective procedure to treat bioprosthetic dysfunction, with potential benefits in patients with rheumatic disease.


Assuntos
Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Valva Mitral/cirurgia , Ecocardiografia , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Humanos , América Latina , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Estudos Prospectivos , Desenho de Prótese , Fatores de Tempo , Resultado do Tratamento
13.
Int J Infect Dis ; 77: 48-52, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30248465

RESUMO

OBJECTIVE: To compare the clinical and epidemiological features, treatments, and outcomes of patients with isolated right-sided and left-sided fungal endocarditis and to determine the risk factors for in-hospital mortality in patients with Candida sp endocarditis. METHODS: A retrospective review of all consecutive cases of fungal endocarditis from five hospitals was performed. Clinical features were compared between patients with isolated right-sided and left-sided endocarditis. In the subgroup of fungal endocarditis due to Candida species, binary logistic regression analysis was performed to determine variables related to in-hospital mortality. RESULTS: Seventy-eight patients with fungal endocarditis were studied. Their median age was 50 years; 55% were male and 19 patients (24%) had isolated right-sided endocarditis. Overall, cardiac surgery was performed in 46 patients (59%), and in-hospital mortality was 54%. Compared to patients with left-side fungal endocarditis, patients with isolated right-sided endocarditis had lower mortality (32% vs. 61%; p=0.025) and were less often submitted to cardiac surgery (37% vs. 66%; p=0.024). The most frequent etiology was Candida spp (85%). In this subgroup, acute heart failure (odds ratio 5.0; p=0.027) and exclusive medical treatment (odds ratio 11.1; p=0.004) were independent predictors of in-hospital death, whereas isolated right-sided endocarditis was related to a lower risk of mortality (odds ratio 0.13; p=0.023). CONCLUSIONS: Patients with isolated right-sided fungal endocarditis have particular clinical and epidemiological features. They were submitted to cardiac surgery less often and had better survival than patients with left-sided fungal endocarditis. Isolated right-sided endocarditis was also a marker of a less harmful illness in the subgroup of Candida sp endocarditis.


Assuntos
Endocardite/mortalidade , Insuficiência Cardíaca/mortalidade , Micoses/mortalidade , Adulto , Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Candida/efeitos dos fármacos , Candida/isolamento & purificação , Equinocandinas/uso terapêutico , Endocardite/tratamento farmacológico , Feminino , Fluconazol/uso terapêutico , Seguimentos , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/microbiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Micoses/tratamento farmacológico , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
14.
Echocardiography ; 35(9): 1342-1350, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29920772

RESUMO

BACKGROUND: The identification of predictors of mitral valve (MV) repair results is important for quality improvement in cardiac surgery. The aim of this study was to evaluate the relationship between MV morphological quantification by three-dimensional (3D) transesophageal echocardiography and mitral repair results. METHODS: Fifty-four patients with MV prolapse who were submitted to surgical repair were divided into 2 groups according to their postoperative mitral regurgitation (MR) degree (group 1, grade 0-I MR; group 2, ≥grade II MR). Morphological parameters related to the mitral ring, dimension of leaflets and prolapse, coaptation line, distance from papillary muscles to the leaflet border and valve angles were analyzed by 3D MV quantification. Cardiac remodeling and MR quantitative parameters were also evaluated. RESULTS: There was no correlation between 3D MV quantification and surgical results; a multivariate analysis did not show an association between morphological parameters and surgical outcome. The distance from the posteromedial papillary muscle to the leaflet border was higher (P = .038) in patients with ≥grade II postoperative MR. The left atrial diameter, left ventricular end-systolic diameter, left ventricular end-diastolic and end-systolic volumes were larger in patients with a significant residual MR (P < .05). CONCLUSION: Three-dimensional MV quantification did not predict the postoperative MR grade; however, the distance from the posteromedial papillary muscles to the leaflet border may be related to suboptimal repair results. Furthermore, excessive cardiac remodeling was related to postoperative MR ≥ grade II, what could suggest a potential benefit of early surgical treatment.


Assuntos
Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Prolapso da Valva Mitral/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Resultado do Tratamento
16.
Int J Infect Dis ; 67: 3-6, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28935245

RESUMO

OBJECTIVE: To determine the annual incidence of prosthetic valve endocarditis (PVE) and to evaluate its current classification based on the epidemiological distribution of agents identified and their sensitivity profiles. METHODS: Consecutive cases of PVE occurring within the first year of valve surgery during the period 1997-2014 were included in this prospective cohort study. Incidence, demographic, clinical, microbiological, and in-hospital mortality data of these PVE patients were recorded. RESULTS: One hundred and seventy-two cases of PVE were included, and the global annual incidence of PVE was 1.7%. Most PVE cases occurred within 120days after surgery (76.7%). After this period, there was a reduction in resistant microorganisms (64.4% vs. 32.3%, respectively; p=0.007) and an increase in the incidence of Streptococcus spp (1.9% vs. 23.5%; p=0.007). A literature review revealed 646 cases of PVE with an identified etiology, of which 264 (41%) were caused by coagulase-negative staphylococci and 43 (7%) by Streptococcus spp. This is in agreement with the current study findings. CONCLUSIONS: Most PVE cases occurred within 120days after valve surgery, and the same etiological agents were identified in this period. The current cut-off level of 365days for the classification of early-onset PVE should be revisited.


Assuntos
Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/etiologia , Próteses Valvulares Cardíacas/efeitos adversos , Infecções Relacionadas à Prótese/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Endocardite Bacteriana/microbiologia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções Relacionadas à Prótese/microbiologia , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/etiologia , Adulto Jovem
19.
PLoS One ; 12(1): e0170191, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28121998

RESUMO

Autoimmune inflammatory reactions leading to rheumatic fever (RF) and rheumatic heart disease (RHD) result from untreated Streptococcus pyogenes throat infections in individuals who exhibit genetic susceptibility. Immune effector mechanisms have been described that lead to heart tissue damage culminating in mitral and aortic valve dysfunctions. In myxomatous valve degeneration (MXD), the mitral valve is also damaged due to non-inflammatory mechanisms. Both diseases are characterized by structural valve disarray and a previous proteomic analysis of them has disclosed a distinct profile of matrix/structural proteins differentially expressed. Given their relevance in organizing valve tissue, we quantitatively evaluated the expression of vimentin, collagen VI, lumican, and vitronectin as well as performed immunohistochemical analysis of their distribution in valve tissue lesions of patients in both diseases. We identified abundant expression of two isoforms of vimentin (45 kDa, 42 kDa) with reduced expression of the full-size protein (54 kDa) in RHD valves. We also found increased vitronectin expression, reduced collagen VI expression and similar lumican expression between RHD and MXD valves. Immunohistochemical analysis indicated disrupted patterns of these proteins in myxomatous degeneration valves and disorganized distribution in rheumatic heart disease valves that correlated with clinical manifestations such as valve regurgitation or stenosis. Confocal microscopy analysis revealed a diverse pattern of distribution of collagen VI and lumican into RHD and MXD valves. Altogether, these results demonstrated distinct patterns of altered valve expression and tissue distribution/organization of structural/matrix proteins that play important pathophysiological roles in both valve diseases.


Assuntos
Doenças Autoimunes/patologia , Prolapso da Valva Mitral/patologia , Cardiopatia Reumática/patologia , Adulto , Doenças Autoimunes/imunologia , Doenças Autoimunes/metabolismo , Colágeno Tipo VI/análise , Matriz Extracelular/química , Feminino , Perfilação da Expressão Gênica , Humanos , Lumicana/análise , Masculino , Pessoa de Meia-Idade , Valva Mitral/química , Prolapso da Valva Mitral/etiologia , Prolapso da Valva Mitral/imunologia , Prolapso da Valva Mitral/metabolismo , Domínios Proteicos , Proteômica , Cardiopatia Reumática/imunologia , Cardiopatia Reumática/metabolismo , Vimentina/análise , Vitronectina/análise
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