Caracterização Histológica das Lesões da Valva Mitral de Pacientes com Cardiopatia Reumática / Histopathological Characterization of Mitral Valvular Lesions from Patients with Rheumatic Heart Disease

Resumo Fundamentos: Os mecanismos subjacentes pelos quais a doença cardíaca reumática (DCR) levam à disfunção valvar grave não são totalmente compreendidos. Objetivo: O presente estudo avaliou as alterações histopatológicas nas valvas mitrais (VM) buscando uma associação entre o padrão de disfunção valvar predominante e os achados histopatológicos. Métodos: Em 40 pacientes submetidos à troca da VM devido a DCR e em 20 controles submetidos a transplante cardíaco, foram analisados os aspectos histológicos da VM excisada. Dados clínicos e ecocardiográficos também foram coletados. As análises histológicas foram realizadas usando coloração com hematoxilina-eosina. Determinou-se inflamação, fibrose, neoangiogênese, calcificação e metaplasia adiposa. Valores de p<0,05 foram considerados estatisticamente significativos. Resultados: A idade média dos pacientes com DCR foi de 53±13 anos, sendo 36 (90%) do sexo feminino, enquanto a idade média dos controles foi de 50±12 anos, semelhante aos casos, sendo a maioria do sexo masculino (70%). O endocárdio valvar reumático apresentou espessura maior que os controles (1,3±0,5 mm versus 0,90±0,4 mm, p=0,003, respectivamente), e infiltrado inflamatório mais intenso no endocárdio (78% versus 36%; p=0,004), com predominância de células mononucleares. Ocorreu fibrose moderada a acentuada mais frequentemente em válvulas reumáticas do que em válvulas controle (100% vs. 29%; p<0,001). Ocorreu calcificação em 35% das valvas reumáticas, principalmente entre as valvas estenóticas, associada à área valvar mitral (p=0,003). Conclusões: Apesar do intenso grau de fibrose, o processo inflamatório permanece ativo na valva mitral reumática, mesmo em doença tardia com disfunção valvar. A calcificação predominou em valvas estenóticas e em pacientes com disfunção ventricular direita.

Abstract Background: The underlying mechanisms by which rheumatic heart disease (RHD) lead to severe valve dysfunction are not completely understood. Objective: The present study evaluated the histopathological changes in mitral valves (MV) seeking an association between the pattern of predominant valvular dysfunction and histopathological findings. Methods: In 40 patients who underwent MV replacement due to RHD, and in 20 controls that underwent heart transplant, histological aspects of the excised MV were analyzed. Clinical and echocardiographic data were also collected. Histological analyses were performed using hematoxylin-eosin staining. Inflammation, fibrosis, neoangiogenesis, calcification and adipose metaplasia were determined. A p value<0.05 was considered to be statistically significant. Results: The mean age of RHD patients was 53±13 years, 36 (90%) were female, whereas the mean age of controls was 50±12 years, similar to the cases, with the majority of males (70%). The rheumatic valve endocardium presented greater thickness than the controls (1.3±0.5 mm versus 0.90±0.4 mm, p=0.003, respectively), and a more intense inflammatory infiltrate in the endocardium (78% versus 36%; p=0.004), with predominance of mononuclear cells. Moderate to marked fibrosis occurred more frequently in rheumatic valves than in control valves (100% vs. 29%; p<0.001). Calcification occurred in 35% of rheumatic valves, especially among stenotic valves, which was associated with the mitral valve area (p=0.003). Conclusions: Despite intense degree of fibrosis, the inflammatory process remains active in the rheumatic mitral valve, even at late disease with valve dysfunction. Calcification predominated in stenotic valves and in patients with right ventricular dysfunction.

Associated clinical and laboratory markers of donor on allograft function after heart transplant

Abstract Introduction: Primary graft dysfunction is a major cause of mortality after heart transplantation. Objective: To evaluate correlations between donor-related clinical/biochemical markers and the occurrence of primary graft dysfunction/clinical outcomes of recipients within 30 days of transplant. Methods: The prospective study involved 43 donor/recipient pairs. Data collected from donors included demographic and echocardiographic information, noradrenaline administration rates and concentrations of soluble tumor necrosis factor receptors (sTNFR1 and sTNFR2), interleukins (IL-6 and IL-10), monocyte chemoattractant protein-1, C-reactive protein and cardiac troponin I. Data collected from recipients included operating, cardiopulmonary bypass, intensive care unit and hospitalization times, inotrope administration and left/right ventricular function through echocardiography. Results: Recipients who developed moderate/severe left ventricular dysfunction had received organs from significantly older donors (P =0.020). Recipients from donors who required moderate/high doses of noradrenaline (>0.23 µg/kg/min) around harvesting time exhibited lower post-transplant ventricular ejection fractions (P =0.002) and required longer CPB times (P =0.039). Significantly higher concentrations of sTNFR1 (P =0.014) and sTNFR2 (P =0.030) in donors were associated with reduced intensive care unit times (≤5 days) in recipients, while higher donor IL-6 (P =0.029) and IL-10 (P =0.037) levels were correlated with reduced hospitalization times (≤25 days) in recipients. Recipients who required moderate/high levels of noradrenaline for weaning off cardiopulmonary bypass were associated with lower donor concentrations of sTNFR2 (P =0.028) and IL-6 (P =0.001). Conclusion: High levels of sTNFR1, sTNFR2, IL-6 and IL-10 in donors were associated with enhanced evolution in recipients. Allografts from older donors, or from those treated with noradrenaline doses >0.23 µg/kg/min, were more frequently affected by primary graft dysfunction within 30 days of surgery.

Doenças neuromusculares raras: um retrato da judicialização no Tribunal Regional Federal da 1a Região / Rare neuromuscular diseases: a portrait of the judicial decisions in Federal Regional Court of the first region / Enfermedades neuromusculares raras: la judicialización en el Tribunal Regional Federal de la 1a región

Introdução: o estudo aborda a judicialização da saúde promovida pelos portadores de doenças neuromusculares raras em face da Política Nacional de Atenção Integral às Pessoas com Doenças Raras. Metodologia: tratou-se de pesquisa exploratória, descritivo-analítica, quali-quantitativa e de base documental secundária. A coleta de dados foi realizada no sítio eletrônico do Tribunal Regional Federal da 1a região. Resultados: foram selecionados 17 julgados entre os anos de 2007 a 2015. Pacientes com Doença de Pompe, Distrofia Muscular e Esclerose Lateral Amiotrófica compreenderam o universo da amostra. A maioria (94,11%), dos dados encontrados, solicitava medicamento não padronizado pelo Sistema Único de Saúde e 76,5% dos processos judiciais foram julgados procedentes pelo tribunal. Conclusão: concluiu-se que a política específica constituída deve mitigar o número de ações judiciais, porém os resultados demonstraram que o paciente portador de doença neuromuscular rara ainda recorre ao Poder Judiciário para a obtenção de seu tratamento.

Introduction: the study analyzes lawsuits about health, promoted by people with rare neuromuscular diseases in the face of the National Assistance Care Policy for People with Rare Diseases. Methods: it was an exploratory, descriptive and analytical, qualitative and quantitative study of secondary database. The research was performed on the Federal Regional Court of the 1st region website. It was selected 17 judicial decisions between 2007 and 2015. Results: the patients with Pompe disease, Muscular Dystrophy and Amiotrophyc Lateral Sclerosis were the sample. The majority (94.11%) of the data found, requested medication which is not standardized by the Unified Health System and 76.5% of claims have been upheld by the court. Conclusion: it was concluded that incorporated specific policy must mitigate the number of lawsuits, but the results showed that obtain treatment.

Introducción: el estudio trató de la judicialización de la salud promovida por las personas con enfermedades neuromusculares raras y su relación con la Política Nacional de Atención Integral a Personas con Enfermedades Raras. Metodología: se trata de estudio exploratorio, descriptivo y analítico, cualitativa y cuantitativa de base secundaria. La recolección de datos se llevó a cabo en el sitio web del Tribunal Regional Federal de la 1a región. Resultados: fueron seleccionados 17 decisiones judiciales entre 2007 y 2015. La amuestra comprendió los pacientes con enfermedad de Pompe, Distrofia Muscular y Esclerosis Lateral Amiotrofica. La mayoría (94,11%), de los datos encontrados, solicitaba medicación que no tenía registro en el Sistema Único de Salud y en 76,5% de las reclamaciones se han confirmado por el tribunal. Conclusión: se concluyó que la política especial debe para mitigar el número de demandas, pero los resultados mostraron que el paciente con enfermedad neuromuscular rara todavía recurre a los tribunales para obtener su tratamiento.

Scintigraphic imaging with technetium-99M-labelled ceftizoxime is a reliable technique for the diagnosis of deep sternal wound infection in rats

PURPOSE:To evaluate whether scintigraphy with technetium-99m-labeled ceftizoxime (99mTc-CFT) can differentiate mediastinitis from aseptic inflammation associated with sternotomy.METHODS:Twenty female Wistar rats were randomly distributed into four groups: S (control) -partial upper median sternotomy with no treatment; SW (control) - sternotomy and treatment of sternal wounds with bone wax; SB - sternotomy and infection with Staphylococcus aureus; SWB - sternotomy with bone wax treatment and bacterial infection. Scintigraphy with 99mTc-CFT was performed eight days after surgery and images were collected 210 and 360 min after infusion of the radiopharmaceutical.RESULTS: No animals exhibited clinical signs of wound infection at the end of the experiment, although histological data verified acute inflammatory response in those experimentally infected with bacteria. Scintigraphic images revealed that tropism of 99mTc-CFT to infected sternums was greater than to their non-infected counterparts. Mean counts of radioactivity in bacteria-infected sternal regions (SB and SWB) were significantly higher (p = 0.0007) than those of the respective controls (S and SW).CONCLUSION:Scintigraphy with technetium-99m-labeled ceftizoxime is a method that can potentially detect infection post sternotomy and differentiate from aseptic inflammation in animals experimentally inoculated with S. aureus.

Indicators of surgical treatment of patent ductus arteriosus in preterm neonates in the first week of life / Indicadores para o tratamento cirúrgico na persistência do ducto arterial em neonatos prematuros na primeira semana de vida

OBJECTIVE: To identify clinical and echocardiographic indicators of the necessity for early surgical closure of patent ductus arteriosus in preterm neonates. METHODS: The prospective study was conducted at the Neonatal Unit of Hospital Municipal Odilon Behrens between 2006 and 2010. The study population comprised 115 preterm neonates diagnosed with patent ductus arteriosus in the first week after birth, of whom 55 (group S) were submitted to clinical and or surgical closure and 60 (group NS) received non-surgical treatment. The parameters analyzed were birth weight, diameter of the ductus arteriosus (DAD), left atrial-to-aortic root diameter ratio (LA:Ao), the quotient of DAD² and birth weight (mm²/kg), and ductal shunting. RESULTS: The study population comprised 58 males and 57 females. The average birth weight of group S (924 ± 224.3 g) was significantly (P=0.049) lower than that of group NS (1012.3 ± 242.8 g). The probability of the preterm neonates being submitted to surgical closure was 62.1% (P=0.006) when the DAD2/birth weight index was > 5 mm²/kg, 72.2% (P=0.001) when the LA:Ao ratio was > 1.5, and 61.2% when ductal shunting was high (P=0.025). CONCLUSION: The parameters DAD²/birth weight index > 5 mm²/kg, LA:Ao ratio > 1.5 and high ductal shunting were statistically significant indicators (P<0.05) of the need for surgical closure of patent ductus arteriosus in low birth weight preterm neonates. Moreover, when an LA:Ao ratio > 1.5 was associated with the occurrence of shock, the probability of surgical closure increased to 78.4%.

OBJETIVO: Identificar parâmetros clínicos e ecocardiográficos para a indicação do tratamento cirúrgico precoce da persistência do ducto arterial. MÉTODOS: Esse estudo prospectivo foi conduzido na Unidade Neonatal do Hospital Municipal Odilon Behrens entre 2006 e 2010. A população estudada compreendeu 115 neonatos prematuros diagnosticados com persistência do ducto arterial na primeira semana após o nascimento, dos quais 55 (grupo S) foram submetidos ao tratamento clínico e ou cirúrgico e 60 (grupo NS) ao tratamento clínico. Os parâmetros analisados foram peso ao nascer, diâmetro do ducto arterial (DAD), relação diâmetro do átrio esquerdo pelo diãmetro da aorta (AE/Ao), índice DAD2/peso ao nascer e fluxo no ducto. RESULTADOS: O estudo abrangeu 58 pacientes do sexo masculino e 57 do feminino. O peso médio ao nascer do grupo S (924 ± 224,3 g) foi significativamente (P=0,049) menor do que do grupo NS (1012,3 ± 242,8 g). A probabilidade dos neonatos prematuros serem submetidos à cirurgia foi 62.1% (P=0,006) quando o índice DAD2/peso ao nascer era > 5 mm2/kg, 72,2% (P=0,001) quando a razão LA:Ao era > 1,5 e 61,2% (P=0,025) quando o fluxo no ducto era alto. CONCLUSÃO: Os parâmetros DAD²/peso ao nascer > 5 mm²/kg, razão LA:Ao > 1,5 e alto fluxo no ducto foram preditores estatisticamente significativos (P<0,05) da necessidade de fechamento cirúrgico do persistência do ducto arterial em neonatos prematuros com baixo peso ao nascer. Adicionalmente, quando a razão LA:Ao > 1,5 estava associada ao choque, a probabilidade de tratamento cirúrgico aumentou para 78,4%.

Tratamento percutâneo combinado: implante de stent coronário e embolização com micromolas para ablação de miocardiopatia hipertrófica obstrutiva / Combined percutaneous treatment: coronary stent implantation and microcoil embolization for ablation of hypertrophic obstructive cardiomyopathy

O tratamento usual para pacientes sintomáticos com cardiomiopatia hipertrófica obstrutiva (CMHO) e doença arterial coronária (DAC), que requerem revascularização do miocárdio, tem sido a cirurgia combinada (revascularização e miectomia). Entretanto, esta abordagem aumenta significativamente o risco cirúrgico. O objetivo deste relato é mostrar a possibilidade e a eficácia da embolização da artéria septal com micromolas, associada a implante de stent na artéria descendente anterior, como modalidade alternative de tratamento em casos selecionados de pacientes com CMHO e DAC.

Symptomatic patients with HOCM and coronary artery disease (CAD) that require revascularization, surgery – simultaneous myectomy and bypass – has usually been performed. However, the procedure significantly increases surgical risk. The aimof our report is to show the feasibility and efficacy of septal artery embolization with microcoils and simultaneous coronary dilation and stenting in the anterior descending as an alternative therapy to selected patients with HOCM and CAD.

Tratamento cirúrgico da embolização de coil para artéria pulmonar após tentativa de fechamento percutâneo do canal arterial / Surgical treatment of coil embolization to the pulmonary artery after an attempt at percutaneous closure of patent ductus arteriosus

A embolização de uma das três molas de Gianturco usadas para o fechamento de grande canal arterial, em criança de 5 anos e 6 meses, alojada na artéria pulmonar esquerda, requereu intervenção operatória 6 meses após, em face da diminuição da perfusão para esse pulmão. Foi realizada secção e sutura do canal arterial e, sob hipotermia profunda através a arteriotomia pulmonar esquerda, foi retirada a mola obstrutiva, localizada na artéria lobar inferior, aderida à parede arterial e coberta por endotélio. Não havendo trombo no local, a perviabilidade arterial pulmonar foi totalmente restabelecida.