Acute heart failure as an initial symptom of pediatric rheumatic carditis: clinical analysis of 10 cases / 中华实用儿科临床杂志

Objective:To investigate the clinical manifestations, pathological characteristics, treatment and prognosis of pediatric rheumatic carditis with the initial symptom of acute heart failure, and to improve the clinical understanding of the disease.Methods:The clinical data, laboratory examination results, imaging findings, treatment and prognosis data of 10 cases with acute rheumatic carditis were collected and analyzed retrospectively.The patients pre-sented with acute heart failure as the first symptom and were treated in Shenzhen Children′s Hospital from January 2015 to February 2022.Results:There were 4 males and 6 females in this study.The mean age was 9.1 years (3 years and 1 month to 11 years and 3 months), and the average onset age was (9.3 ± 3.2) days (4-14 days). All the 10 cases had circulation symptoms.Besides, 4 cases were also complicated with joint symptoms, 3 cases with neurological symptoms and 2 cases with skin symptoms.Echocardiography revealed mitral valve diseases in all cases.More specifically, combined valve diseases were found in 5 cases, pure mitral regurgitation in 3 cases, and mixed mitral valve diseases (mitral regurgitation complicated with mitral stenosis) in 2 cases.After receiving antibiotic therapy, anti-infection treatment and anti-heart failure therapy, symptoms improved in all patients and valve lesions were alleviated.All patients were followed up for 6 months to 6 years.Six cases had persistent rheumatic heart disease during the follow up.Conclusions:Pediatric rheumatic carditis with the initial symptom of acute heart failure is characterized by early onset and the typical manifestation of rheumatic fever.Mitral valve disease is the commonest lesion.Echocardiography is of great value for the early diagnosis of the disease.Medical treatment is effective, but the incidence of chronic rheumatic heart disease is still high.

Propensity matching study of mitral valve management strategy during coronary artery bypass grafting in patients with moderate ischemic mitral insufficiency / 中华胸心血管外科杂志

Objective:To explore the surgical strategy of coronary artery bypass grafting(CABG) for moderate ischemic mitral regurgitation(IMR), and to clarify the impact of mitral valve surgical intervention(MVS) on the long-term prognosis of such patients.Methods:The clinical data of 234 consecutive patients with moderate IMR who received CABG from January 2013 to December 2018 were retrospectively included, with 184 males and 50 females. The age ranged from 29 to 78 years, with a mean of(61.5 ± 8.7) years old. According to whether MVS was performed at the same time, they were divided into CABG group(108 cases, CABG alone) and CABG+ MVS group(126 cases, CABG+ MVS at the same time). The long-term cardiac events, all-cause deaths, major cardiovascular and cerebrovascular adverse events(MACCE) and other end events were followed up. A matching queue was established by propensity matching score for statistical analysis.Results:After propensity matching score, a matching queue was established, including 78 pairs of patients. Survival analysis showed that the incidence of long-term cardiac events and postoperative new onset atrial fibrillation in CABG+ MVS group was significantly higher( P<0.05). However, there was no significant difference between the two groups in all-cause mortality, cardiogenic mortality, and the incidence of MACCE events( P>0.05). Cox regression analysis showed that simultaneous CABG+ MVS was a risk factor for long-term cardiac events and new postoperative atrial fibrillation. The results of subgroup studies showed that for patients without tricuspid regurgitation before operation, left ventricular end diastolic diameter>55 mm, and left ventricular ejection fraction(LVEF) ≤0.55, the probability of cardiac events after MVS at the same time of CABG was higher( P<0.05). However, patients with no tricuspid regurgitation before operation, left ventricular end diastolic diameter>55 mm, LVEF≤0.55, and left atrial diameter≥40 mm had a higher probability of atrial fibrillation after MVS at the same time of CABG( P<0.05). Conclusion:CABG can improve left ventricular remodeling in patients with moderate IMR, whether MVS intervention is performed at the same time or not, and the long-term survival rate of both is similar. CABG+ MVS in the same period can maintain a low residual reflux, but the incidence of long-term cardiac events and arrhythmias is high. The longer-term prognosis needs to be further studied. The surgical strategy of such patients should be selected individually according to the specific situation and the surgical quality in medical centers.

Síndrome coronario agudo e insuficiencia mitral-aórtica grave en un paciente con rubeola congénita / Acute coronary syndrome and mitral-aortic insufficiency in a patient with congenital rubella

Resumen La rubeola es una enfermedad exantemática que se produce en la infancia. En caso de que se presente durante la gestación y hubiera afectación del producto, este puede desarrollar el síndrome de rubeola congénita, el cual incluye malformaciones cardiacas que se presentan en el 67% de los pacientes, de las cuales la más común es la persistencia del conducto arterioso, seguida de la estenosis valvular pulmonar y la comunicación interauricular. Se presenta el caso de un hombre de 20 años con diagnóstico de síndrome de rubeola congénita, quien desarrolló glaucoma congénito, insuficiencia aórtica grave, insuficiencia mitral grave y enfermedad miocárdica isquémica. Se realizó procedimiento quirúrgico de revascularización coronaria y recambio valvular mitral y aórtico. Los estudios encontrados durante el proceso de investigación mencionan el daño de los vasos sanguíneos y del miocardio producido por el virus. Con los datos obtenidos se corrobora la baja incidencia de presentación con compromiso coronario y valvular, por lo cual se hace énfasis en la importancia de este caso.

Abstract Rubella is an exanthematous disease that occurs in childhood. If it occurs during pregnancy and there is an effect on the product, it can develop congenital rubella syndrome. The congenital rubella syndrome includes cardiac malformations, which occur in 67% of patients, of which the most common is patent ductus arteriosus, followed by pulmonary valvular stenosis and atrial septal defect. We present the case of a 20-year-old man with a diagnosis of congenital rubella syndrome, presenting with congenital glaucoma, severe aortic insufficiency, severe mitral regurgitation and ischemic myocardial disease. In which a surgical procedure is performed by a coronary revascularization and mitral and aortic valve replacement. Studies found during the research process mention the damage to the blood vessels and myocardium produced by the virus. With the required data, the low incidence of presentation with coronary and valvular involvement is corroborated, which is why the importance of the present case is emphasized.

Resultados de la cirugía de reparación valvular mitral en el Hospital Guillermo Grant Benavente de Concepción (2009-2020) / Results of surgical mitral valve repair at Guillermo Grant Benavente Hospital, Concepción, Chile

Resumen: Objetivo: Describir las características clínicas, resultados operatorios inmediatos y a 5 años de la cirugía de reparación valvular mitral. Material y métodos: Estudio retrospectivo de la cohorte de pacientes operados de reparación valvular por insuficiencia mitral (IM) en el Hospital Guillermo Grant Benavente desde el 2009 hasta marzo 2020 (N=206). Se comparan los pacientes con IM primaria y secundaria en sus características clínicas, ecocardiográficas, técnicas quirúrgicas empleadas, cirugías asociadas, morbimortalidad operatoria, sobrevida y reintervenciones hasta el 30 de mayo de 2020. Resultados: 124(60,2%) hombres. Edad media 62,6±10,5 años. La IM fue primaria en 134 y secundaria en 72. En comparación con los pacientes portadores de IM primaria, aquellos con IM secundaria tuvieron más enfermedad coronaria (69,4% versus 11,9%; p<0,001) y mayor riesgo operatorio (EuroSCORE logístico 7,7±6,7 versus 5,2±7,3; EuroSCORE II 3,4±4,8 versus 2,4±4,7; p<0,001). El mecanismo más frecuente de IM primaria fue tipo II (65,7%) y en las secundarias fue el tipo III (48,6%) seguido del tipo I (30,6%). Las IM primarias se corrigieron principalmente con procedimientos para disminuir el prolapso (76,1%). En las secundarias la técnica más utilizada fue el implante de un anillo exclusivo (76,4%). Hubo 116 cirugías asociadas y 10 (4,9%) conversiones a reemplazo valvular. Hubo 57 complicaciones operatorias y fallecieron 12 (5,8%) pacientes, 5 (3,7%) con IM primaria y 7(9,7%) con IM secundaria. La sobrevivencia global a 5 años fue 83,5% (90% en las primarias y 78% en las secundarias) y hubo 6 reintervenciones. Conclusiones: La cirugía de reparación valvular, tanto en pacientes con IM primaria como secundaria, tuvo una baja mortalidad operatoria y excelentes resultados a 5 años.

Abstract: Aim: To describe the clinical characteristics, operative and long term results of surgical mitral valve repair. Material and methods: Retrospective study of the cohort of patients undergoing valve repair due to mitral regurgitation (MR) at the Guillermo Grant Benavente Hospital from 2009 to March 2020 (N = 206). Patients with primary and secondary MR were compared on clinical and echocardiographic characteristics, surgical techniques, associated surgeries, operative morbidity and mortality, survival and reinterventions up to May 30, 2020. Results: 124 (60.2%) were men. The average age was 62.6±10.5 years. Type of MR was primary in 134 and secondary in 72. Compared to patients with primary MR, those with secondary MR had more coronary artery disease (69.4% versus 11.9%; p <0.001) and greater operative risk (logistic EuroSCORE 7.7±6, 7 versus 5.2±7.3; EuroSCORE II 3.4±4.8 versus 2,4±4.7; p<0.001). The most frequent mechanism of MR was type II in primary (65.7%) and type III (48.6%) followed by type I (30.6%) in secondary MR. Primary MR was corrected mainly with procedures to decrease prolapse (76.1%). In secondary MR the main technique used was the implantation of an exclusive ring (76.4%). There were 116 associated surgeries and 10(4.9%) conversions to valve replacement. There were 57 operative complications and 12(5.8%) patients died, 5 (3.7%) with primary MR and 7 (9.7%) with secondary MR. Overall survival at 5 years was 83.5% (90% in primary MR and 78% in secondary MR) and there were 3 reoperations. Conclusions: Valve repair surgery in both primary and secondary MR patients was associated to a low operative mortality and excellent results at 5 year post surgery.

Enfermedad reumática cardiaca: ¿Estamos realmente haciendo lo necesario? / Rheumatic heart disease: are we really doing what is necessary?

Resumen Objetivo: Revisar las características demográficas, clínicas y ecocardiográficas, así como el abordaje quirúrgico de pacientes con fiebre reumática menores de 18 años, durante un periodo de diez años. Materiales y métodos: Estudio descriptivo, retrospectivo, en el cual se incluyeron pacientes menores de 18 años, con diagnóstico de fiebre reumática entre los años 2006 a 2016. Resultados: Se incluyeron 22 niños con edades entre los 10 a los 14 años, de los cuales 59% (13/22) eran mujeres; 13,6% (3/22) provenían de Arauca y el 18,1% (4/22) eran indígenas. Se diagnosticó carditis en el 63,6% (14/22) seguido de poliartralgia y fiebre en un 59% (13/22) y 54% (12/22) respectivamente; así mismo, se detectó corea de Sydenham y eritema marginado 4,5% (1/22). Se determinó compromiso severo de válvula mitral en el 72,7% (16/22). 15 pacientes fueron llevados a cirugía; se realizó reemplazo valvular mitral en 13,3% (2/15), plastia mitral y tricúspide en el 40% (6/15), plastia mitral, tricúspide y aórtica en el 6,66%(1/15) y reemplazo aórtico en el 5,2% (1/15). Un paciente requirió oxigenación por membrana extracorpórea. La mortalidad fue del 0% (0/22). Conclusiones: Se observó que la fiebre reumática ocasionó grave compromiso cardiaco, que requirió un alto grado de intervención quirúrgica. Las poblaciones rurales e indígenas se beneficiarían notablemente de una prevención primordial, primaria y secundaria, al igual que de un diagnóstico y tratamiento oportunos.

Abstract Objective: The aim of this study is to review the demographic, clinical, and cardiac ultrasound characteristics, as well as the surgical approach, of patients less than 18 years-old with rheumatic fever. Materials and methods: A descriptive, retrospective study was conducted that included patients less than 18 years-old diagnosed with rheumatic fever between the years 2006 to 2016. Results: The study included a total of 22 children with ages between 10 and 14 years, of whom 59% were female. It was recorded that 13.6% (3/22) were from Arauca Department (Colombia), and 18.1% (4/22) were indigenous. Carditis was diagnosed in 63.6% (14/22), followed by polyarthralgia and fever in 59% (13/22) and 54% (12/22), respectively. Sydenham's chorea and marginal erythema was also detected in 4.5% (1/22). The severity of mitral valve involvement was determined in 72.7% (16/22). Of the 15 patients that had surgery, 13.3% (2/15) had a mitral valve replacement, mitral and tricuspid repair in 40% (6/15), mitral, tricuspid, and aortic repair in 6.66%, respectively (1/15), and aortic replacement in 5.2% (1/15). One patient required extracorporeal membrane oxygenation. There was no mortality. Conclusions: It was observed that rheumatic fever led to serious cardiac compromise that required a high rate of surgical interventions. Rural and indigenous population would notably benefit from basic, primary, and secondary prevention, as well as a timely diagnosis and treatment.

Clinical analysis of on-pimp mitral valve repair combined with off-pump coronary artery bypass graft surgery: 32 cases report / 解放军医学杂志

Objective To review the clinical experience with on pimp mitral valve repair (MVP) and off-pump coronary artery bypass grafting (OPCABG) for coronary atherosclerotic heart disease (CAD). Methods From April 2017 to March 2018, a total of 32 patients received MVP combined with OPCABG in Beijing Anzhen Hospital. The echocardiographic results before and after the operation were compared and SPSS 20.0 statistical software was used to analyze the clinical data of these patients. Results There were 3.69 grafts per case. Artificial ring forming was performed in 26 cases, quadrangular resection in 4, chordal replacement in 2. No death of these patients occurred in the hospital. Thirty patients were followed up from 6 months to 30 mouths with improved heart function. Heart function was class in 26 and class Ⅱ in 4. The postoperative cardiac ultrasonography for reexaminations indicated that 8 with slight mitral regurgitation, 20 with mild regurgitation and 2 with moderate regurgitation. Patients' cardiac function and size of heart (LVESD, LVEDD and LVEF) were remarkably improved. Conclusions OPCABG and MVP should be performed concomitantly when CAD and mitral insufficiency disease present simultaneously. OPCABG operation at the same time line for the treatment of MVP effect is better. The patients' quality of life could be significantly improved.

Prognostic value of plasma big endothelin-1 in patients with moderate to severe chronic ischemic mitral insufficiency after mitral valvuloplasty / 中华胸心血管外科杂志

Objective Big endothelin-1(big ET-1) is associated with the prognosis of various cardiovascular diseases. This study is to explore the predictive value of plasma big ET-1 level for long-term outcome after mitral valvuloplasty in patients with moderate to severe chronic ischemic mitral insufficiency .Methods A total of 142 consecutive patients with moderate to severe chronic ischemic mitral regurgitation who underwent coronary artery bypass grafting and mitral valvuloplasty were enrolled at our center from January 2009 to December 2015.The clinical baseline data were collected and recorded.All patients were followed up.The mortalities and major adverse cardiovascular and cerebrovascular events during the follow-up period were re-corded.Results A total of 142 patients were enrolled, with mean age of(59.4 ±8.3) years.During(51.9 ±22.6) months follow-up, 19 cases(13.4％) died and 35 cases(24.6％) had major adverse cardiovascular and cerebrovascular events.Uni-variate and multivariate Cox regression analysis showed that big ET-1 was an independent risk factor for all-cause mortality (HR=3.970, 95％CI:1.535-10.268) and major adverse cardiovascular and cerebrovascular events(HR=2.754, 95％CI:1.238-6.129).In addition, left ventricular ejection fraction, pulmonary hypertension and stroke history were independent risk factors for all-cause mortality , while left ventricular ejection fraction , stroke history were independent risk factors for major adverse cardiovascular and cerebrovascular events.Conclusion Long-term outcomes of simultaneous coronary artery bypass grafting and mitral valvuloplasty for moderate to severe ischemic mitral insufficiency are satisfactory and big ET-1 is an inde-pendent risk factor for long-term outcomes of these patients.

Reporte de un caso de ruptura del músculo papilar anterior debido a infarto agudo de miocardio / Anterior papillary muscle rupture due to an acute myocardial infarction: A case report

Resumen La ruptura del músculo papilar anterolateral es una complicación del síndrome coronario agudo poco frecuente, en especial porque este músculo usualmente tiene doble irrigación sanguínea al comparar con el músculo papilar posteromedial que, por lo general, solo tiene una irrigación. Se presenta el caso de un paciente que consultó por signos y síntomas de falla cardiaca aguda precedidos de dolor de pecho, en quien se documentó insuficiencia mitral grave por ruptura del músculo papilar anterolateral debido a enfermedad coronaria isquémica de múltiples vasos.

Abstract The rupture of the anterior-lateral papillary muscle is an uncommon complication of acute coronary syndrome. This is particularly relevant as this has double blood irrigation compared to that of the posteromedial papillary muscle that generally only has single irrigation. The case is presented on a patient that consulted due to having signs and symptoms of acute heart failure preceded by chest pains. Severe mitral insufficiency was observed due to a rupture of the anterior-lateral papillary muscle caused by a multiple vessel ischaemic coronary disease.

Utilidad de la ecocardiografía en la detección de la insuficiencia cardiaca en un adulto joven con síndrome de origen anómalo de la arteria coronaria izquierda del tronco de la arteria pulmonar y válvula mitral asimétrica similar al paracaídas / Use of echocardiography in the detection of heart failure in a young adult with anomalous left coronary artery from the pulmonary artery syndrome andparachute-like asymmetric mitral valve

Resumen Objetivo: describir un caso de un paciente joven con insuficiencia cardiaca, secundaria a dos malformaciones cardiacas infrecuentes, síndrome de ALCAPA y válvula mitral asimétrica, parecida al paracaídas, resaltando la utilidad de la ecocardiografía. Métodos: se analiza el caso a la luz de la literatura médica. Conclusiones: El origen anómalo de la arteria coronaria izquierda del tronco de la arteria pulmonar y la válvula mitral asimétrica parecida al paracaídas, son malformaciones raras, asociadas a insuficiencia mitral severa e insuficiencia cardiaca. No se encontraron reportes en la literatura acerca de la coexistencia de las dos patologías en un paciente.

Abstract Objective: To describe a case of a young adult with heart failure, secondary to two rare cardiac malformations, anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome and parachute-like asymmetric mitral valve, highlighting the use of echocardiography. Material and methods: A case is analysed along with a search in the medical literature. Conclusions: The anomalous origin of left coronary artery from the pulmonary artery and parachute-like asymmetric mitral valve are rare malformations associated with severe mitral insufficiency and heart failure. No reports were found in the literature as regards the existence of these two diseases in a patient.

Complicaciones mecánicas del infarto agudo de miocardio: aunque infrecuentes, potencialmente letales / Mechanical complications of acute myocardial infarction: common but potentially fatal

Resumen Aunque la incidencia de complicaciones mecánicas en el infarto agudo de miocardio ha descendido después de la era de la intervención coronaria percutánea, la mortalidad sigue siendo significativa. La ruptura septal ventricular, la regurgitación mitral aguda y la ruptura de la pared libre del ventrículo izquierdo conforman el espectro de complicaciones mecánicas posteriores al infarto agudo de miocardio. La reparación quirúrgica es el pilar del tratamiento; sin embargo, como puente para la cirugía, el manejo médico permite estabilizar al paciente.

Abstract Although the incidence of complications in acute myocardial has decreased since the percutaneous coronary intervention era, there is still a significant mortality rate. Ventricular septal rupture, acute mitral regurgitation, and left ventricular free wall rupture, are part of the spectrum of mechanical complications after an acute myocardial infarction. Surgical repair is the key to their treatment, but, as a bridge for the surgery, medical management helps to stabilise the patient.

Prevalence and Risk Factors of Mitral Regurgitation in the Population Aged ≥ 35 Years / 中国循环杂志

Objective: To explore the prevalence and risk factors of mitral regurgitation (MR) in the population ≥35 years in China in order to provide prevention reference for high risk crowd. Methods: The residents ≥35 years were taken by a stratified multistage sampling method. General information of crowd was collected by predesigned questionnaire and physical examination including life style, disease history, body weight and height. Echocardiography was conducted, fasting blood glucose and blood lipid levels were measured. Results: A total of 28814 subjects were enrolled. The overall MR detection rate was 18.4%, the detection rate in male and female were both 18.4%. The detection rates of moderate and severe MR were 0.3% in the paticipants at (35-50) years, 0.9% at (51-64) years and 2.2% at ≥65 years. MR prevalence showed an increasing trend with aging. Multivariate Logistic regression analysis indicated that age, systolic blood pressure, urban and rural, district, left atrial front and back diameter, left ventricular end diastolic front and back diameter, left ventricular ejection fraction, stroke, atrial fibrillation and heart failure were the risk factors for MR occurrence. Conclusion: MR detection rate was rather high in China. Specific prevention action should be taken for those with theabove risk factors.

MitraClip para el reparo de insuficiencia mitral severa / MitraClip for the repair of severe mitral insufficiency

Resumen Objetivo: Reportar el primer caso de implante de MitraClip realizado en la costa atlántica. Material y métodos: Paciente femenina de 69 años de edad, con diagnóstico de: cardiopatía dilatada de 10 años de evolución con aumento progresivo de deterioro funcional. Ha presentado edema pulmonar recidivante. Resultados: Se realiza procedimiento de implante del dispositivo. Mediante cateterismo transeptal, se procede a introducir el MitraClip con maniobras del sistema de posicionamiento pasando la válvula mitral guiado por el ETE 3 D y se realiza la captura de ambos bordes de la válvula en el sitio de mayor regurgitación A2/P2 sujetando los bordes por él. Se observa persistencia de la insuficiencia moderada por lo que se coloca un segundo MitraClip en forma satisfactoria. Se realizan las medicines Doppler observando una insuficiencia residual mínima. Se corrobora por la angiografía y el ETE su adecuada implantación. Se considera un éxito pudiendo realizar el implante del dispositivo en forma rápida, adecuada y sin complicaciones. Conclusiones: Se reporta el primer caso de implante de MitraClip para el manejo de la IM severa, en la ciudad de Barranquilla, siendo la segunda ciudad de Colombia, después de Cali, donde se implanta este tipo de dispositivos para el reparo de la insuficiencia mitral severa.

Abstract Objective: To report the first case if MitraClip implantation performed in the Atlantic coast. Material and methods: 69 year-old female patient diagnosed with dilated cardiomyopathy with a 10-year course suffering from gradual functional deterioration. She developed relapsing pulmonary edema. Results: Device implantation is performed. By means of a transseptal catheterization MitraClip is inserted with positioning system operations below the mitral valve guided by 3 D TEE and captures both vale leaflets on the place where most A2/P2 regurgitation is located, thus holding the leaflets. Mild insufficiency is still observed, so a second MitraClip is implanted succesfully. Doppler measurements reveal minimal residual insufficiency. Angiography and TEE confirm correct implantation. Procedure is considered a success, being able to conduct device implantation in a fast, proper and uncomplicated way. Conclusions: The first case of MitraClip implant for management of severe MI in Barranquilla is presented, this being the second Colombian city after Cali where this type of device is implanted for the repair of severe mitral insufficiency

Síndrome de insuficiencia cardíaca aguda como presentación clínica de anomalía congénita de las arterias coronarias: ALCAPA (origen anómalo de la arteria coronaria izquierda desde la arteria pulmonar) / Acute heart failure syndrome as clinical presentation of congenital anomaly of the coronary arteries: ALCAPA (anomalous origin of the left coronary artery from the pulmonary artery) / Síndrome de insuficiência cardíaca aguda como apresentação clínica da anomalia congênita das artérias coronárias: ALCAPA (origem anômala da artéria coronária esquerda a partir da artéria pulmonar)

El nacimiento anómalo de la arteria coronaria izquierda en la arteria pulmonar es una entidad poco frecuente. Presentamos el caso clínico de un paciente masculino de 44 años que ingresó por síndrome de insuficiencia cardíaca aguda, con hallazgo por ecocardiograma de insuficiencia mitral severa por calcificación del músculo papilar posterior. Durante el estudio hemodinámico se constató el nacimiento anómalo de la arteria coronaria izquierda desde la arteria pulmonar, llenándose por circulación heterocoronaria. Las arterias coronarias no presentaban lesiones angiográficamente significativas. Durante la evolución, se realizó un estudio de perfusión miocárdica que evidenció isquemia severa apical, anteroapical y lateroapical. El paciente fue sometido a cirugía de reemplazo valvular mitral y revascularización miocárdica en el mismo tiempo quirúrgico, con buena evolución.

The anomalous origin of the left coronary artery from the pulmonary artery is a rare entity. We report a case of a 44 year old male patient was admitted for acute heart failure syndrome with echocardiographic finding of severe mitral regurgitation due to calcification of the posterior papillary muscle. During the hemodynamic study the anomalous origin of the left coronary artery from the pulmonary artery found, filled by heterocoronary circulation. The coronary arteries showed no angiographically significant lesions. During evolution, a myocardial perfusion study showed severe apical ischemia, anteroapical and lateroapical was performed. The patient underwent surgery for mitral valve replacement and coronary artery bypass graft in the same surgical time, with good results.

A origem anômala da artéria coronária esquerda do tronco pulmonar é uma entidade rara. Nós relatamos o caso de um paciente de 44 anos do sexo masculino que foi admitido com uma síndrome de insuficiência cardíaca aguda com achado ecocardiográfico de insuficiência mitral severa devido à calcificação do músculo papilar posterior. Durante o estudo hemodinâmico foi constatado a origem anômala da artéria coronária esquerda do tronco pulmonar, preenchido por circulação heterocoronaria. As artérias coronárias não mostraram lesões angiograficamente significativas. Durante a evolução, um estudo de perfusão miocárdica mostrou isquemia grave apical, anteroapical e lateroapical. O paciente foi submetido à cirurgia para substituição da válvula mitral e revascularização do miocárdio no mesmo tempo cirúrgico, com bons resultados.

Insuficiencia mitral causada por cuerpo extraño / Foreing body mitral valve insufficiency

Introducción: Hombre de 21 años con antecedentes de una valvuloplastía aórtica transventricular a los 3 meses de edad y de una aortoventriculoplastía anterior (operación de Konno-Rastan) con reemplazo valvular aórtico con prótesis de St Jude número 17, a los 10 meses de edad. En el año 2006, a los 16 años, fue re-operado por una estenosis subvalvular aórtica, efectuándose una ampliación del Konno con pericardio bovino y un reemplazo de la prótesis aórtica St Jude 17 por una número 23. Asintomático hasta 3 meses previo a su ingreso en que inicia disnea progresiva. Se efectuó en esta oportunidad un ecocardiograma transesofágico el que demostró una regurgitación periprostética aórtica severa y la presencia de un catéter que entraba a la aurícula izquierda a través de la vena pulmonar superior derecha, dirigiéndose a la válvula mitral (Fig 1-A, flechas). El velo mitral anterior y el aparato subvalvular mitral estaban retraídos alrededor del catéter, lo que originaba una insuficiencia mitral moderada (Fig 1-B, flechas).Al momento de la cirugía se confirmaron los hallazgos ecocardiográficos, encontrándose este catéter completamente adherido al velo mitral anterior, cuerdas tendíneas y músculo papilar, como se puede observar en la pieza quirúrgica (Fig 1-C y D, flechas). En esta cuarta operación se reconstruyó el Konno con Dacron y se reemplazó la válvula mitral con una prótesis de St Jude número 27. En su último control el paciente estaba asintomático.

A 21 year-old man presented with a 3-month history of progressive dyspnea . He had undergone transventricular aortic valvuloplasty at age 3 months and at age 10 months a Konno operation with implantation of a 17- St Jude prosthesis. In 2006, at age 16 years-old, he was reoperated due to subvalvular stenosis. A Konno amplification with bovine pericardiumwas was performed and the 17-St Jude valve replaced by a size 23 valve. Transesophagueal ecocardiography showed severe peri-prosthetic aortic regurgitation and a catheter entering the left atrium through the right superior pulmonary vein toward the mitral valve (Fig 1-A, arrows). The anterior leaflet and the subvalvular apparatus were retracted around the catheter, causing moderate mitral regurgitation (Fig 1-B, arrow). At surgery, echocardiography findings were confirmed, the catheter being completely adhered to the anterior leaflet, chordae tendinae and papillary muscle, as can be seen in the surgical specimen (Fig 1-C and D, arrows). The Konno was reconstructed with Dacron and the mitral valve replaced with a 27-St Jude prosthesis. At last follow-up, the patient was asymptomatic.

Ecocardiografía en infarto agudo del miocardio / Echocardiography in acute myocardial infarction

La ecocardiografía es la primera línea de diagnóstico en la fase aguda del infarto agudo del miocardio. Provee información invaluable sobre la estratificación de riesgo, valoración a corto y largo plazo, características hemodinámicas y utilidad en el reconocimiento de la mayoría de complicaciones mecánicas relacionadas con dicho evento. En este artículo se describen algunos parámetros ecocardiográficos que han mostrado evidencia para detectar pacientes en riesgo de pobre pronóstico así como para determinar el tratamiento y las intervenciones de los síndromes coronarios agudos. En conclusión, la ecocardiografía brinda información pronóstica significativa en el manejo de pacientes con infarto agudo del miocardio y debería emplearse en la evaluación rutinaria de este tipo de pacientes.

Echocardiography is the first line of diagnosis in the acute phase of myocardial infarction. It provides invaluable information about risk stratification, assessment of short and long term prognosis, hemodynamic features, and helps to identify the most common mechanical complications related to acute myocardial infaction. In this article, some of the echo cardiographic parameters are decribed that have provided evidence for the detection of those patients at risk of a poor prognosis, and equally important to determine the treatment and interventions in acute coronary syndromes. In conclusion, echocardiography provides strong prognostic information in the management of patients with recent myocardial infarction and should be used always in the routine evaluation of these patients.

Cardiopatía valvular en un paciente con granulomatosis de Wegener / Valvular cardiopathy in a patient with Wegener's granulomatosis

La granulomatosis de Wegener es una vasculitis necrotizante autoinmune cuya prevalencia reportada es de 3/100.000 habitantes. Tiene compromiso multisistémico, principalmente el tracto respiratorio superior e inferior, y el sistema nervioso central y renal. La frecuencia del compromiso cardiaco varía según las series estudiadas, pero oscila alrededor de 6%; sin embargo, las manifestaciones clínicas son poco frecuentes. El compromiso valvular se reporta como insuficiencia aórtica o mitral, secundaria a infiltración de las valvas o dilatación de la raíz aórtica. El tratamiento se basa en el control de la enfermedad, el manejo de la falla cardiaca y la intervención quirúrgica de la válvula comprometida según la indicación.

Wegener's granulomatosis is an autoimmune necrotizing vasculitis with a reported prevalence of 3/100.000 inhabitants. It is a multisystemic disease, involving mainly the upper and lower respiratory tract, the central nervous system and the kidneys. The frequency of cardiac involvement varies depending on the series studied, but oscillates around 6%; however, the clinical manifestations are rare. The valvular involvement is reported as aortic or mitral insufficiency secondary to infiltration of the leaflets, or as aortic root dilatation. Treatment is based on the control of the disease, the management of heart failure and surgical intervention of the involved valve, as directed. Palabras clave: granulomatosis de Wegener, insuficiencia mitral, insuficiencia aórtica, cardiopatía, vasculitis.

Insuficiencia mitral isquémica: utilidad de la ecocardiografía en su evaluación y tratamiento / Ischemic mitral regurgitation: utility of echocardiography in evaluation and treatment

La regurgitación mitral isquémica (RMI) es una complicación común de la enfermedad arterial coronaria que produce insuficiencia cardíaca en un alto porcentaje de pacientes. Puede presentarse como una verdadera emergencia cuando es causada por un infarto del miocardio con ruptura del músculo papilar asociada a shock cardiogénico. La insuficiencia mitral isquémica crónica es una complicación frecuente trasel infarto agudo del miocardio, aparece aproximadamente en 20% de los casos y es mucho más probable en el infarto agudo del miocardio de localización inferior (38%) que en el anterior (10%). Es producida por una integración de varios mecanismos que influyen en su desarrollo y que básicamente están relacionados con remodelado local o global del ventrículo izquierdo, con disfunción y disincronía del mismo. Su evaluación adecuada y rápida puede influir en el éxito de su tratamiento y en el mejor pronóstico de los pacientes. Una indicación quirúrgica precoz, actuando sobre ventrículos menos remodelados, y la innovación en el arsenal de dispositivos y técnicas quirúrgicas permitirán una corrección exitosa y duradera con baja mortalidad hospitalaria. En este sentido, las nuevas exploraciones desarrolladas por la ecocardiografía han adquirido una gran importancia al permitir evaluar la severidad de la insuficiencia mitral, el grado de disfunción local o global del ventrículo izquierdo y el estado del aparato valvular mitral lo que ha hecho del método la exploración más confiable y necesaria en estos pacientes. Revisamos la utilidad y el papel del ecocardiograma en el estudio de la insuficienciamitral isquémica.

Ischemic mitral regurgitation is a common complication of coronary heart disease that leads to heart failure in a high percentage of patients. It can present as a real emergency when it is caused by a myocardial infarction with rupture of a papillary muscle resulting in cardiogenic shock. Chronic ischemic mitral regurgitation is a frequent complication after a myocardial infarction in 20% of cases and it is even more frequent when the myocardial infarction is localized in the inferior wall (38%) than the anterior wall (10%). This complication is the result of the interaction of several mechanisms that are related to local or global remodeling of the left ventricle and associated left ventricle dysfunction and desynchronization. Prompt and precise evaluation can be of vital importance for successful treatment and a better prognosis. Early surgery in less remodeled ventricles, and innovation in devices and surgical techniques will lead to long-lasting successful correction with low in-hospital mortality. Therefore, new developments in echocardiography have acquired substantial significance for the evaluation of the severity of mitral insufficiency, the grade of local or global dysfunction of the left ventricle and the state of the mitral valve apparatus, rendering this method more reliable and indispensable for these patients. We reviewed the utility and role of echocardiography in the evaluation ofischemic mitral regurgitation.

Enfermedad reumática cardiovascular: observaciones anatomopatológicas en biopsias valvulares de jóvenes con menor e igual a 20 años de edad / Cardiovascular rheumatic disease: pathologic´s observations in biopsies valvulares of young people minor and equal 20 years of age

La fiebre reumática es una enfermedad endémica en los países en desarrollo como Venezuela y es causa importante de valvulopatía crónica progresiva, siendo primeramente afectado el aparato valvular mitral. Evaluar el aspecto morfológico de la valvulitis crónica en su etapa inicial, en individuos quienes han sido sometidos a reemplazo valvular mitral o mitro-aórtico. Se seleccionaron 20 biopsias de válvulas mitrales y mitro/aórticas diagnosticadas como valvulopatía crónica reumática, representativas de la etapa inicial, en pacientes con edad igual o menos de 20 años. Los diagnósticos pre-operatorios fueron: disfunción valvular severa mitral (insuficiencia (60%), doble lesión (10%) y estenosis (5%) y mitro-aórtica (25%). Las biopsias (valvas y aparatos valvulares mitrales) fueron evaluadas macroscópicamente. El estudio histológico se hizo con secciones teñidas con Hematoxilina-eosina e inmunomarcadas con anticuerpos CD 34 y antimúsculo liso. Todos los casos mostraron lesiones morfológicas propias de la valvulitis crónica reumática inicial: inflamación grado 1 (81,6%), con nódulos de Aschoff (35%), fibrosis de grado 2 (40%) y 3 (60%) Con una alta densidad de neovascularización (14,78 ± 1,92). Se hizo el análisis de los hallazgos morfológicos y se consideró que este trabajo puede servir de base para investigaciones comparativas con casos de etapas más avanzadas de la enfermedad valvular en relación a la inflamación, remodelado colágeno y angiogénesis.

Rheumatic fever is an endemic disease in developing countries such as Venezuela and is an important cause of progressive chronic valve disease, the mitral valve apparatus being affected in the first place. To evaluate the morphologic aspect of chronic valvulitis in its initial stage among individuals that have gone through mitral and mitro-aortic valve replacement. Twenty (20) biopsies of mitral and mitro-aortic valves diagnosed with rheumatic chronic valvulopathy in its initial stage were selected from patients aged 20 years or younger. Preoperating diagnoses were as follows: severe mitral valve dysfunction (insufficiency: 60%, double injury: 10%, stenosis: 5%, and mitro-aortic: 25%). The biopsy material (valve apparatuses) was macroscopically evaluated. A histological study was made on haematoxylin-eosin stained and CD34 antibody immunomarked sections and smooth antimuscle. All cases showed morphologic lesions typical of initial chronic rheumatic valvulitis: grade 1 inflammation (81,6%), with Aschoff's bodies or nodules (35%), grade 2 fibrosis (40%), and grade 3 fibrosis (60%) with high density neovascularization (14,78 ± 1,92). Morphologic findings were analyzed, thus concluding that this work can serve as a basis for comparative investigations on case of valvular disease at more advanced stages in terms of inflammation, collagen remodeling and angiogenesis.

Cardiomyopathy and secondary mitral insufficiency: Surgical possibilities in the end-stage phase / Cardiomiopatia e insuficiência mitral secundária: Possibilidades cirúrgicas na fase avançada / Miocardiopatía e insuficiencia mitral secundaria: Posibilidades quirúrgicas en la etapa final

Background. Secondary mitral insufficiency is a strong risk factor for death in end stage cardiomyopathies. The possible correction of mitral regurgitation is now been accepted as an alternative to cardiac transplantation in a special subset of patients. We proposed a surgical approach that consists of implantation of a mitral prosthesis smaller than the annulus and preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. Methods. Between December 1995 and March 2008, 132 cardiomyopathies were operated on including the following etiologies: ischemic (78), idiopathic (49), Chaga's disease (3), viral (1), and postpartum (1). The patients were analyzed according to clinical criteria, echocardiographic findings and morphology of left ventricle. Results. All patients were in an end-stage phase, requiring >2 hospital admissions over the past 3 months, despite receiving full medication. Furthermore, 8 were in intensive care unit receiving intravenous drugs or intra-aortic balloon counterpulsation, and one was in cardiogenic shock. Hospital mortality was 14.4% (19/132) yet midterm follow-up showed a relatively flat late survival curve, with evidence of improved clinical status, better echocardiographic parameters, and reduction ventricular sphericity. Conclusions. The high early mortality rate is related to other clinical conditions at the time of surgery. However, the resultant flat survival after this early interval offers a promising long-term therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy that is associated to moderate or severe secondary mitral regurgitation.

Introdução. A insuficiência mitral secundária é um importante fator de risco de morte na fase inicial de cardiomiopatias. A possibilidade de correção do refluxo mitral é aceito na atualidade como uma alternativa cirúrgica ao transplante em um grupo especial de pacientes. Propomos uma abordagem cirúrgica que consiste na implantação de uma prótese valvular, menor que o anel e a preservação e tração dos músculos papilares para reduzir a esfericidade do ventrículo esquerdo. Método. Entre dezembro de 1995 até março de 2008, 132 cardiomiopatias foram operadas incluindo as seguintes etiologias: isquêmicas (78), idiopática (49), Chaga's (3), viral (1) e pós-parto (1). Os pacientes foram analisados de acordo com critérios clínicos, ecocardiográficos e morfologia do ventrículo esquerdo. Resultados. Todos os pacientes estavam em fase final de insuficiência cardíaca, exigindo 2 admissões hospitalares nos últimos 3 meses a despeito de medicação plena. Ainda, 8 estavam em uso de drogas vasoativas em UTI ou sob auxilio do balão intra-aórtico. Um paciente se apresentava em choque cardiogênico. A mortalidade hospitalar foi de 14,4% (19/132). No seguimento a médio prazo a curva de sobrevivência se mostrou estável com evidencias de melhora clínica, melhores parâmetros ecocardiográficos e redução da esfericidade do ventrículo esquerdo. Conclusões. A alta mortalidade hospitalar esteve relacionada com precárias condições clínicas pré-operatórias, no entanto a estabilidade da curva de sobrevivência oferece uma expectativa boa neste grupo de pacientes com insuficiência mitral secundária nas miocardiopatias em fase final.

Introducción. La insuficiencia mitral secundaria es un fuerte factor de riesgo de muerte en la etapa final de las miocardiopatías. La posible corrección de la regurgitación mitral es actualmente aceptada como una alternativa al trasplante cardíaco en un subconjunto especial de pacientes. Propusimos un enfoque quirúrgico que consiste en la implantación de una prótesis mitral más pequeña que el anillo valvular, y la preservación y tracción de los músculos papilares para reducir la esfericidad del ventrículo izquierdo. Métodos. Entre Diciembre de 1995 y Marzo de 2008, se operaron 132 miocardiopatías que incluían las siguientes etiologías: isquémica (78), idiopática (49), chagásica (3), viral (1) y postparto (1). Se analizaron a los pacientes de acuerdo a los criterios clínicos, resultados ecocardiográficos y morfología del ventrículo izquierdo. Resultados. Todos los pacientes se encontraban en la etapa final de la enfermedad, y requirieron más de 2 hospitalizaciones en los 3 últimos meses, a pesar de recibir medicación completa. Además, 8 se encontraban en la unidad de cuidados intensivos, recibiendo drogas intravenosas o balón de contrapulsación intraaórtico, y uno estaba en shock cardiogénico. La mortalidad hospitalaria fue del 14,4% (19/132) y el seguimiento a mediano plazo (trimestral) mostró una curva de sobrevida tardía relativamente aceptable, con evidencia de un estado clínico mejorado, mejores parámetros ecocardiográficos, y reducción de la esfericidad ventricular. Conclusiones. La alta tasa de mortalidad temprana está relacionada a otras condiciones clínicas a la hora de la cirugía. De todas maneras, la sobrevida resultante luego de este temprano intervalo, ofrece una prometedora alternativa terapéutica a largo plazo para el tratamiento de pacientes en insuficiencia cardíaca refractaria con miocardiopatía asociada a regurgitación mitral secundaria moderada o severa.