Tolerância ao exercício, função pulmonar, força muscular respiratória e qualidade de vida em crianças e adolescentes com cardiopatia reumática / Exercise tolerance, pulmonary function, respiratory muscle strength, and quality of life in children and adolescents with rheumatic heart disease

RESUMO Objetivo: Apesar da alta prevalência de cardiopatia reumática no nosso país, a ocorrência de prejuízos funcionais em crianças e adolescentes com cardiopatia reumática não está esclarecida. Este estudo visou avaliar tolerância ao exercício, força muscular respiratória, função pulmonar e qualidade de vida de crianças e adolescentes com cardiopatia reumática. Métodos: Estudo transversal, realizado de agosto a dezembro de 2014, com portadores de cardiopatia reumática de 8 a 16 anos de idade. Os participantes, após preenchimento dos questionários socioeconômico, clínico e de qualidade de vida, foram submetidos a espirometria, manovacuometria e teste de caminhada de seis minutos. As variáveis e seus valores de referência foram comparados pelo teste t de Student pareado. Para comparar as diferenças entre as distâncias percorridas prevista e observada, considerando-se as categorizações dos participantes, foi utilizado o teste t de Student. Correlações entre essas diferenças e as variáveis quantitativas foram feitas pelo coeficiente de Pearson, sendo significante p<0,05. Resultados: Os 56 participantes obtiveram distância percorrida inferior à prevista (p<0,001). As diferenças entre as distâncias prevista e observada mostraram correlação positiva com a frequência cardíaca basal (r=0,3545; p=0,007). A força muscular expiratória também foi inferior à prevista (p<0,001). A qualidade de vida foi de 70; 77 e 67%, respectivamente, nos domínios geral, físico e psicossocial. Conclusões: Crianças e adolescentes com cardiopatia reumática apresentam tolerância reduzida ao exercício, a qual está relacionada com uma maior frequência cardíaca basal; eles também demonstram prejuízo na força expiratória e na qualidade de vida.

ABSTRACT Objective: Despite the high prevalence of rheumatic heart disease in Brazil, the occurrence of functional impairment in children and adolescents with rheumatic heart disease is not clear. The aim of this study was to evaluate exercise tolerance, respiratory muscle strength, lung function, and quality of life of children and adolescents with rheumatic heart disease. Methods: Cross-sectional study, conducted from August to December 2014 with children and adolescents with rheumatic heart disease aged 8 to 16 years. The participants, after completing the socioeconomic, clinical, and quality of life questionnaires were tested by spirometry, manovacuometry and in a 6-minute walk test. The variables and their reference values were compared using the paired Student's t-test. Comparisons between predicted and observed walking distance were done also by Student's t-test, consdiering the categorization of the participants. Correlations between these differences and quantitative variables were assessed by Pearson's coefficient, being significant p<0.05. Results: All 56 participants had a walked distance lower than predicted (p<0.001). The differences between predicted and observed distances were positively correlated with the baseline heart rate (r=0.3545; p=0.007). Expiratory muscle strength was also lower than the predicted values (p<0,001). Regarding quality of life assessment, the mean scores were 70, 77 and 67% for general, physical, and psychosocial aspects, respectively. Conclusions: Children and adolescents with rheumatic heart disease have reduced exercise tolerance, which is related to their higher baseline heart rate; they also show impaired expiratory strength and quality of life.

Surgical treatment of atrial fibrillation in patients with rheumatic valve disease

Abstract Objective: To assess heart rhythm and predictive factors associated with sinus rhythm after one year in patients with rheumatic valve disease undergoing concomitant surgical treatment of atrial fibrillation. Operative mortality, survival and occurrence of stroke after one year were also evaluated. Methods: Retrospective longitudinal observational study of 103 patients undergoing rheumatic mitral valve surgery and ablation of atrial fibrillation using uni- or bipolar radiofrequency between January 2013 and December 2014. Age, gender, functional class (NYHA), type of atrial fibrillation, EuroSCORE, duration of atrial fibrillation, stroke, left atrial size, left ventricular ejection fraction, cardiopulmonary bypass time, myocardial ischemia time and type of radiofrequency were investigated. Results: After one year, 66.3% of patients were in sinus rhythm. Sinus rhythm at hospital discharge, lower left atrial size in the preoperative period and bipolar radiofrequency were associated with a greater chance of sinus rhythm after one year. Operative mortality was 7.7%. Survival rate after one year was 92.3% and occurrence of stroke was 1%. Conclusion: Atrial fibrillation ablation surgery with surgical approach of rheumatic mitral valve resulted in 63.1% patients in sinus rhythm after one year. Discharge from hospital in sinus rhythm was a predictor of maintenance of this rhythm. Increased left atrium and use of unipolar radiofrequency were associated with lower chance of sinus rhythm. Operative mortality rate of 7.7% and survival and stroke-free survival contribute to excellent care results for this approach.

Simplifying proximal isovelocity surface area as an assessment method of mitral valve area in patients with rheumatic mitral stenosis by fixing aliasing velocity and mitral valve angle

We aimed to test the ability of a simple equation using proximal isovelocity surface area method [PISA], created by fixing the angle to 100° and the aliasing velocity to 33 cm/s, to calculate mitral valve area [MVA] and assess severity in patients with rheumatic mitral stenosis [MS]. In a series of 51 consecutive patients with rheumatic MS, MVA was assessed by four methods, conventional PISA equation PISA[conventional], simple PISA equation PISA[simple], pressure half time [PHT], and planimetry [PLN] which was taken as the reference method. All methods correlated significantly with PLN with the highest correlation found in case of PISA[conventional] and PISA[simple] [r = 0.97, 0.96, p < 0.001], while the correlation in case PHT was relatively weaker [r = 0.69, p < 0.001]. Bland-Altman analysis revealed that the level of agreement with PLN was better in case of both PISA methods than PHT and, moreover, were close to each other. The number of cases that showed agreement of severity grade with planinetry was better in case of PISA[conventional] [42 cases] and PISA simple [44 cases] than that in case of PHT [34 cases, p = 0.037]. Finally, the measure of agreement with Cohen's Kappa test was better in case of PISA[conventional] and PISA[simple] than that in case of PHT. Provided that aliasing velocity is fixed at 33 cm/s, PISA can effectively predict mitral valve area and severity of MS by a simple equation, with the advantage of easy and accurate calculation over other methods

Efficacy of echocardiographic criteria for diagnosis of carditis in acute rheumatic fever.

Background: There is a great need forECHOcriteria for accurate diagnosis of carditis in acute rheumatic fever. Aim: To propose and test the efficacy of ECHO criteria for accurate diagnosis of carditis. Material and Methods: The 333 cases underwent detailed clinical examination, laboratory tests and meticulous Echocardiographic study.Vijay’s ECHO criteria for the diagnosis of carditis / subclinical valvulitis was used. 220 (66.06%) cases were both Jones’ positive and ECHO positive [True +ve], 52 cases (15.61%), probably had subclinical carditis as murmur was not heard (Jones’-ve) but ECHO was positive [False - ve]. Four cases, clinically diagnosed as carditis were Jones’+ve ,but ECHO showed congenital heart disease [False +ve]. 57 cases (17.11%) were clinically , echocardiographically and Jones’ negative were taken as control (True –ve). Sensitivity is81%and specificity is 93%. Conclusions: Precise diagnosis of both carditis /subclinical valvulitis is possible with Vijay’s ECHO criteria. ECHO should be included as a major criterion in Jones’criteria.

Monitorização materno-fetal durante procedimento odontológico em portadora de cardiopatia valvar / Maternal-fetal monitoring during dental procedure in patients with heart valve disease / Monitoreo maternofetal durante procedimiento odontológico en portadora de cardiopatía valvular

FUNDAMENTO: Os efeitos da anestesia local em odontologia com lidocaína e epinefrina, sobre parâmetros cardiovasculares de gestantes portadoras de valvopatias e seus conceptos, não estão esclarecidos. OBJETIVO: Avaliar e analisar parâmetros da cardiotocografia, de pressão arterial e eletrocardiográficos da gestante portadora de doença valvar reumática, quando submetida à anestesia local com 1,8 ml de lidocaína 2 por cento sem vasoconstritor e com epinefrina 1:100.000, durante procedimento odontológico restaurador. MÉTODOS: Realizamos monitorização ambulatorial da pressão arterial, eletrocardiografia ambulatorial materna e cardiotocografia de 31 portadoras de cardiopatia reumática, entre a 28ª e 37ª semana de gestação, divididas em dois grupos conforme presença ou não do vasoconstritor RESULTADOS: Demonstrou-se redução significativa dos valores de frequência cardíaca materna nos dois grupos, durante o procedimento, quando comparado aos demais períodos (p < 0,001). Houve ocorrência de arritmia cardíaca em 9 (29,0 por cento) pacientes, das quais 7 (41,8 por cento) pertencentes ao grupo de 17 gestantes que recebeu anestesia com adrenalina. A pressão arterial materna não apresentou diferença quando comparamos períodos ou grupos (p > 0,05). O mesmo ocorreu (p > 0,05) com número de contrações uterinas, nível e variabilidade da linha de base e número de acelerações da frequência cardíaca fetal. CONCLUSÃO: O uso de 1,8 ml de lidocaína 2 por cento associado à adrenalina mostrou-se seguro e eficaz em procedimento odontológico restaurador durante a gestação de mulheres com cardiopatia valvar reumática.

BACKGROUND: The effects of local dental anesthesia with lidocaine and epinephrine on cardiovascular parameters of pregnant women with heart valve diseases and their fetuses are not fully understood. OBJECTIVES: To assess and analyze cardiotocographic, blood pressure and electrocardiographic parameters of pregnant women with rheumatic heart valve disease undergoing local anesthesia with 1.8mL of lidocaine 2 percent with or without epinephrine 1:100,000 during restorative dental treatment. METHODS: Maternal ambulatory blood pressure and electrocardiographic monitoring as well as cardiotocography of 31 patients with rheumatic heart disease were performed between the 28th and 37th week of gestation. The patients were divided into two groups, those with or without vasoconstrictor. RESULTS: A significant reduction in maternal heart rate was shown in both groups during the procedure in comparison with the other periods (p<0.001). Cardiac arrhythmia was observed in nine (29.0 percent) patients, of which seven (41.8 percent) were from the group of 17 pregnant women who received anesthesia plus epinephrine. No difference in maternal blood pressure was observed when periods or groups were compared (p>0.05). The same occurred (p>0.05) with the number of uterine contractions, baseline level and variability, and number of accelerations of fetal heart rate. CONCLUSION: The use of 1.8mL of lidocaine 2 percent in combination with epinephrine was safe and efficient in restorative dental procedures during pregnancy in women with rheumatic heart valve disease.

FUNDAMENTO: Los efectos de la anestesia local en odontología con lidocaína y epinefrina, sobre los parámetros cardiovasculares de gestantes portadoras de valvulopatías y sus conceptos, no son claros. OBJETIVO: Evaluar y analizar parámetros de la cardiotocografía, de la presión arterial y electrocardiográficos de la gestante portadora de enfermedad valvular reumática, al someterse a anestesia local con 1,8 ml de lidocaína 2 por ciento sin vasoconstrictor y con epinefrina 1:100.000, durante procedimiento odontológico restaurador. MÉTODOS: Realizamos monitoreo ambulatorio de la presión arterial, electrocardiografía ambulatoria materna y cardiotocografía de 31 portadoras de cardiopatía reumática, entre la 28ª y la 37ª semana de gestación, divididas en dos grupos según la presencia o no del vasoconstrictor. RESULTADOS: Se observó reducción significativa de los valores de frecuencia cardíaca materna en los dos grupos, durante el procedimiento, al compararlo con los demás períodos (p < 0,001). Se registró ocurrencia de arritmia cardíaca en 9 (29,0 por ciento) pacientes, de las cuales 7 (41,8 por ciento) pertenecían al grupo de 17 gestantes que recibió anestesia con adrenalina. La presión arterial materna no presentó diferencia al comparar períodos o grupos (p > 0,05). Lo mismo ocurrió (p > 0,05) con el número de contracciones uterinas, nivel de variabilidad de la línea de base y número de aceleraciones de la frecuencia cardíaca fetal. CONCLUSIÓN: El uso de 1,8 ml de lidocaína 2 por ciento asociado a la adrenalina se mostró seguro y eficaz en procedimiento odontológico restaurador durante la gestación de mujeres con cardiopatía valvular reumática.

Determinants of left atrial pressure in rheumatic mitral stenosis: role of left atrial compliance and "atrial stiffness".

BACKGROUND: A wide range of left atrial pressures exist in rheumatic mitral stenosis despite similar mitral valve area. Left atrial compliance may be an important determinant of left atrial pressure in mitral stenosis. Data regarding left atrial compliance in rheumatic mitral stenosis and changes following balloon mitral valvotomy are scarce. METHODS AND RESULTS: Left atrial compliance and predictors of left atrial pressure were analyzed in 85 patients with mitral stenosis undergoing balloon mitral valvotomy. The stroke volume was divided by systolic rise in left atrial pressure to calculate the left atrial compliance. Systolic rise in left atrial pressure was computed as difference between amplitudes of left atrial "v" wave and "x" descent. The mean left atrial compliance prior to balloon mitral valvotomy was 2.62+/-1.20 cm3/mmHg. Following successful balloon mitral valvotomy there was a significant fall in pulmonary artery pressure, mean left atrial pressure, transmitral gradient, and significant increase in cardiac output, stroke volume and mitral valve area. There was a marked increase in left atrial compliance from 2.62+/-1.20 to 6.1+/-3.16 cm3/mmHg. On univariate analysis pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary artery mean pressure, mean transmitral gradient, mitral valve area and left atrial compliance were the only correlates of left atrial pressures, while no correlation was noted with age, gender, left atrial size, cardiac output and stroke volume. Those with higher pulmonary artery pressure, higher transmitral gradient, lower mitral valve area and lower left atrial compliance had higher left atrial mean pressure, and the strongest negative correlation was noted with left atrial compliance. On multivariate analysis the strongest predictors of left atrial mean pressure were transmitral gradient and left atrial compliance. CONCLUSIONS: Patients with rheumatic mitral stenosis have markedly depressed left atrial compliance and hence have "stiff" left atria. Left atrial compliance is an important determinant of left atrial pressure, and improves immediately after successful balloon mitral valvotomy, irrespective of pre-balloon mitral valvotomy left atrial pressures.

Percutaneous transvenous mitral commissurotomy: hemodynamic and initial outcome differences between atrial fibrillation and sinus rhythm in rheumatic mitral stenosis patients.

BACKGROUND: Atrial fibrillation (AF) occurs frequently in severe rheumatic mitral stenosis (MS) and has been reported to be a predictor of poor outcome after percutaneous transvenous mitral commissurotomy (PTMC). Nevertheless, according to observations in our catheterization laboratory, patients with sinus rhythm (SR) seem to have a higher pulmonary artery pressure than AF. PURPOSE: To determine 1) the hemodynamic differences between MS patients with AF and SR before and after PTMC and 2) the success rate and difference in outcome between both groups. METHOD: A total of 145 patients who had undergone PTMC with the Inoue balloon technique in King Chulalongkorn Memorial Hospital between 1993 and 1997 were enrolled. The data were presented as mean +/- SD. Student t-test was used to compare the difference in hemodynamic and outcome between the AF and SR groups. RESULTS: Fifty-six patients (38.6%) were in the AF group. The AF patients were older (42.0 +/- 11.3 vs 32.4 +/- 8.7 yr., p < 0.0001), had a larger left atrium (49.2 +/- 6.1 vs 45.3 +/- 4.9 mm, p < 0.001) and a higher valvular calcification score (1.8 +/- 0.6 vs 1.5 +/- 0.6, p = 0.02) than the SR group. There was no significant difference between baseline heart rate and overall MV score index. The hemodynamic data showed that the SR group had higher systolic (59.9 +/- 26.0 vs 47.4 +/- 16.8 mmHg, p < 0.05), diastolic (28.1 +/- 12.8 vs 22.7 +/- 9.2 mmHg, p < 0.05) and mean (40.1 +/- 17.1 vs 32.7 +/- 11.8 mmHg, p < 0.05) pulmonary artery (PA) pressure than the AF group. After successful PTMC, the SR group exhibited a more favorable change in all PA pressures and the transmitral valvular gradient (10.0 +/- 6.5 vs 6.7 +/- 6.5 mmHg, p < 0.01) than the AF group. Procedural success rates were 98 per cent in the AF and 96 per cent in the SR group (p = ns). Transthoracic colour-flow echocardiographic imaging detected atrial septal defects in 18.2 per cent and 7.5 per cent (p = 0.08) of the AF and SR groups, respectively. There was no systemic embolization, peri-procedural death or emergency surgery in both groups. CONCLUSION: Patients with MS and AF were older, had a larger LA and lower pre-PTMC PA pressure than the patients who had MS and SR. In addition, patients with SR had a more favourable PA and LA pressure reduction than patients with AF.

Fatores prognósticos da estenose mitral reumática durante o período da gravidez e puerpério / Prognostic factors of rheumatic mitral stenosis during pregnancy and puerperium

OBJECTIVE: To identifity characteristics associated with complications during pregnancy and puerperium in patients with rheumatic mitral stenosis. METHODS: Forty-one pregnant women (forty-five pregnancies) with mitral stenosis, followed-up from 1991 to 1999 were retrospectively evaluated. Predictor variables: the mitral valve area (MVA), measured by echocardiogram, and functional class (FC) before pregnancy (NYHA criteria).Maternal events: progression of heart failure, need for cardiac surgery or balloon mitral valvulotomy, death, and thromboembolism. Fetal/neonatal events: abortion, fetal or neonatal death, prematurity or low birth weight (<2,500g), and extended stay in the nursery or hospitalization in newborn ICU. RESULTS: The mean + or - SD of age of the patients was 28.8 + or - 4.6 years. The eventful and uneventful patients were similar in age and percentage of first pregnancies. As compared with the level 1 MVA, the relative risk (RR) of maternal events was 5.5 (95 per cent confidence interval (CI) =0.8-39.7) for level 2 MVA and 11.4 (95 per cent CI=1.7-74.5) for level 3 MVA. The prepregnancy FC (FC > or = II and III versus I) was also associated with a risk for maternal events (RR=2.7; 95 per cent CI=1.4-5.3).MVA and FC were not importantly associated with these events, although a smaller frequency of fetal/neonatal events was observed in patients who had undergone balloon valvulotomy. CONCLUSION: In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but are not associated with fetal/neonatal events. Balloon mitral valvulotomy could have contributed to reducing the risks of fetal/neonatal events in the more symptomatic patients who had to undergo this procedure during pregnancy.

Reversibility of mitral regurgitation following rheumatic fever: clinical profile and echocardiographic evaluation.

The clinical disappearance of the murmur of rheumatic mitral regurgitation after period of time has been documented by many researchers. However no studies have related the disappearance of the murmur with the functional or anatomical state of the mitral valve. This study was done to elucidate the mitral valve status using doppler and color coded echocardiography among those children who have lost their apical pansystolic murmur on auscultation following a documented attack of rheumatic fever. The study sample consisted of 51 patients including 31 patients in whom the murmur has disappeared (group I), and 20 patients with persistent isolated mitral regurgitation (group II). Patients of group I had significantly lower grades of murmur intensity, lower incidence of cardiomegaly, and had no heart failure in the initial attack. They were more compliant with prophylaxis and had less recurrences than patients of group II. The murmur disappeared in patients of group I from 1/2 to 14 years after the initial attack. Echocardiography revealed that such patients had a normal mitral valve apparatus, and a normal heart size and function. Only 5 patients of this group had a significant regurgitant jet demonstrated by colour doppler. We concluded that recovery of the mitral valve and return of cardiac functions to normal is possible in patients who had mitral regurgitation following rheumatic fever. Some of them may still have an inaudible mild regurgitation. Patients who have lost their murmur may be allowed to exercise freely, yet penicillin prophylaxis should not be discontinued.

Left ventricular volume overload in isolated rheumatic mitral stenosis.

Having shown the absence of chronic preload insufficiency as the mechanism of modestly depressed left ventricular ejection performance in patients with rheumatic mitral stenosis in our previous work, we sought to characterise a subset of patients with left ventricular volume overload. Echocardiographically determined ventricular load, ejection and contractile performance and left ventricular geometry were studied in 19 patients with mitral stenosis having left ventricular volume overload (end-diastolic volume > 90 ml/m2, Group I) and in 83 patients with normal volume (end-diastolic volume < 90 ml/m2, Group II). The two groups were well matched for age, gender, body size and mitral valve area. Left ventricular ejection fraction was similar in the two groups; however, the patients in Group I had higher end-diastolic volume (101 +/- 15 vs 58 +/- 18 ml/m2, p < 0.0001), end-systolic wall stress (81.7 +/- 17 vs 64 +/- 22 Kdynes/cm2, p < 0.0001), left ventricular mass (109 +/- 20 vs 82 +/- 19 gm/m2, p < 0.001) but lower relative wall thickness (26 +/- 6 vs 34 +/- 9%, p = 0.007), mass/volume ratio (1.1 +/- 0.23 vs 1.49 +/- 0.46 gm/ml, p < 0.001) and wall stress/end-systolic volume ratio (2.07 +/- 0.58 vs 2.65 +/- 0.92, p = 0.016). Of these 19 patients in Group I, seven had isolated volume overload while 12 had associated eccentric hypertrophy. Wall stress correlated well with fractional shortening in Group II (r = 0.75, p < 0.001) but not in Group I (r = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)

Valvoplastia mitral com duplo cateter-baläo, avaliaçäo hemodinâmica de 52 casos um ano depois do procedimento / Mitral Valvoplasty by Double Balloon. Hemodynamic Evaluation of 52 Cases One Year After the Procedure

Objetivo - Avaliar os resultados hemodinâmicos e angiográficos tardios da valvoplastia mitral por duplo cateter-baläo, para tratamento da estenose mitral reumática. Métodos - Cinquenta e dois pacientes foram submetidos à avaliaçäo, sendo 84,6// do sexo feminino, com idade média de 21,9 anos. Oitenta e um por cento estavam na classe funcional I (NYHA), e 5,7// exibiam fibrilaçäo atrial, 18 meses após dilataçäo. Todos foram submetidos a estudo ecocardiográfico e cateterismo cardíaco com angiografia, 1 ano após o procedimento. Resultados - quarenta e seis pacientes (88,5//) exibiram, imediatamente após a valvoplastia, áerea valvar > 1,50cm². Em 6(11,5//), a área da valva mitral foi ó 1,50cm². Os casos em que se obteve área valvar ò 1,50cm², tiveram boa evoluçäo clínica, sem perda dos bons resultados hemodinâmicos e ecocardiográficos iniciais, incluindo o gradiente de pressäo diastólica mitral, as pressöes médias do átrio esquerdo e da artéria pulmonar e a área valvar mitral. Nos 6 casos em ques e obteve area valvar ó 1,50cm², 2 tiveram evoluçäo favorável, 2 foram redilatados, 1 aguarda tratamento cirúrgico e outro mantém-se em tratamento clínico a despeito do resultado hemodinâmico insatisfarório. Em 3 dos 52 casos (5,7), demonstrou-se, após o procedimento, a existência de comunicaçäo interatrial, em 2 sem repercussäo hemodinâmica, e, no 3º, com repercussäo, foi indicada a correçäo cirúrgica do defeito. A insuficiência mitral ocorreu em 16 casos (30,7//), sendo de grau + em 8 e de + a ++, nos demais, sem nenhum agravamento neste período evolutivo. Conclusäo - A valvoplastia mitral por duplo cateter-baläo é método eficaz para tratamento da estenose mitral reumática, havendo boa evoluçäo tardia, nos casos que apresentam área ò 1,50cm² imediatamente após a dilataçäo

Purpose - To evaluate the late hemodynamic and angiographic results of 52 patients who underwent mitral valvoplasty by the double balloon technique in the treatment of the rheumatic mitral stenosis. Methods - The mean follow-up was of 18 months and the patients had a Doppler-echocardiogram and cardiac catheterization one year after dilatation. Of the 52 patients 84.6% were femule and the mean age was 21.9% years. Eighty one percent were in NYHA class I whereas 5.7% had atrial fibrillation at the end of 18 months. Results Immediatly after valvoplasty 46 patients (88.5%) had a valvar area larger, and 6 (11.5%) smaller than 1.5 cm2 . The first group had a good clinical outcome with maintenance of the clinical, echocardiographic and angiographic results in the late followup, including the dyastolic gradient and the valvar area. Of the 6 cases with mitral area smaller than 1.5 cm2, 2 had a good clinical evolation, 2 were redilated, I was scheduled for surgery and the last one is under clinical management but with poor hemodynamic results. Three (5.7%) cases developed an atrial septal defect after the procedure, with hemodynamic repercussion in 1. Mitral regurgitation developed in 16 cases (+ in 8, +/++ in 8) without changes during the follow-up period. Conclusion - Double balloon mitral valvoplasty is a safe effective method in the treatment of the rheumathic mitral stenosis, and offers a better evolution in patients with a valvar area larger than 1.5 cm2 after the dilatation

Trombosis en la auricula izquierda: su expresión en la coronariografía en pacientes portadores de valvulopatía reumática / Thrombosis in left auricula: it expresion in coronariography of patients with rheumathic valvulopathy

En 26 pacientes portadores de valvulopatía mitral reumática, sometidos a cateterismo cardiáco como parte de su estudio preoperatorio, se evaluaron sus coronariografías con el fin de establecer la presencia de un ovillo vascular auricular izquierdo que además fistuliza a dicha cavidad (TAI). Se demostró que dicho hallazgo estaba presente en un 23% de los pacientes, todos los cuales tenían como ritmo de base una fibrilación o un flutter auricular. Al comparar el grupo con TAI con el sin TAI se demuestra que no hay diferencias significativas en parámetros obtenidos con eco-Doppler contemporáneo como: el tamaño de la aurícula izquierda (4.8ñ0.6 vs 4.93ñ0.65), el AVM (1.05ñ0.28 vs 1.15ñ0.29) y las mediciones del ventrículo izquierdo. Al comparar estos grupos en cuanto a sus parámetros hemodinámicos se demuestran diferencias significativas en la presión sistólica de arteria pulmonar (60.83ñ28.11 vs 39.40ñ14.95, p<0.02), la presión diastólica de arteria pulmonar (30.17ñ16.28 vs 15.13ñ6.85, p<0.01) y la presión de capilar pulmonar (23.83ñ7.34 vs 14.89ñ6.89, p<0.02). Se concluye que el TAI es un hallazgo relativamente frecuente en la coronariografía del VR y que esta información se obtiene al efectuar la coronariografía convencional, siempre que se obtiene al efectuar al efectuar imágenes tardías de los vasos que se dirigen hacia la aurícula izquierda. El TAI está asociado a presiones de arteria y capilar pulmonar significativamente mayores que el grupo sin TAI a pesar de que ambos grupos tienen un AVM similar utilizando la técnica de Doppler

Fiebre reumatica: cardiopatia reumatica: revision de la experiencia del Instituto Nacional de Torax / Rheumatic fever: cardiopaty experience at the national Thorax Institute

Se analiza la experiencia del Instituto Nal. del Torax en relacion a la Fiebre reumatica y Cardiopatia reumatica, que constituyen la causa nosologica de mayor frecuencia con una incidencia del 17 por ciento . La fiebre reumatica se presenta a una edad promedio de 15,7 anos con una alta incidencia de carditis 72 por ciento . Entre las lesiones valvulares residuales destacan por su frecuencia la valvulopatia mitral y la valvulopatia mitrotricuspidea, en la mayoria de casos con lesiones importantes y asociadas a una alta incidencia de complicaciones cardiologicas destacando la insuficiencia cardiaca (50 por ciento ) y la fibrilicion auricular (32 por ciento ). El Departamento de Cardiologia del INT, dispone de los medios suficientes para el diagnostico cardiologico de la Fiebre reumatica/Cardiopatia Reumatica. Las normas de tratamiento estan basadas en las recomendaciones del Comite Nacionalde Prevencion y Control de la Fiebre Reumatica. La mortalidad por Fiebre reumatica es de 6 por ciento con una cifra similar para la cardiopatia reumatica. La mortalidad quirurgica para la comisurotomia mitral es de 0 por ciento y aun no se disponen de datos de importancia estadistica en relacion a la mortalidad por cambio valvular. En el seguimiento el 36 por ciento de los pacientes abandonan sus controles y el indice de desercion de la prevencion secundaria es alto alcanzando 24,4 por ciento en el ano 1986.