Válvula aórtica bicúspide: ¿qué debo conocer? Revisión actualizada de sus aspectos clínicos y fisiopatológicos / Bicuspid aortic valve: what should I know? Updated review of its clinical and pathophysiological aspects

Resumen La válvula aórtica bicúspide es la cardiopatía congénita más frecuente en la población general. Lejos de ser solo una malformación valvular inocua, supone una enfermedad compleja y heterogénea. A menudo es identificada como un hallazgo incidental en personas sanas, cursando de manera asintomática. Sin embargo, en un alto porcentaje de pacientes conduce a lo largo de su vida a complicaciones valvulares (estenosis, insuficiencia, endocarditis) o aórticas (dilatación o disección). Con frecuencia estas manifestaciones suceden a una edad temprana y causan una elevada morbimortalidad. A pesar de que en los últimos años se ha producido una intensa investigación en este campo, la fisiopatogenia de la enfermedad no es del todo conocida y muchas preguntas siguen abiertas. En este artículo se revisan de forma actualizada los aspectos clínicos y fisiopatológicos más novedosos y relevantes sobre esta cardiopatía congénita.

Abstract The most common congenital heart disease in the general population is the bicuspid aortic valve. Far from being just a harmless valve malformation, it is a complex and heterogeneous disease. It is often identified as an incidental finding in healthy people. However, in a high percentage of patients it leads throughout their life towards valvular (stenosis, insufficiency, endocarditis) or aortic (dilatation or dissection) complications. Frequently, manifestations occur at an early age, being responsible for high morbidity and mortality. Even though in recent years intense research has been carried out in this field, the pathophysiogenesis of the disease is not fully known and many questions remain open. In this article, we review the most innovative and relevant clinical and pathophysiological aspects of this congenital heart disease.

Caracterización de las enfermedades valvulares congénitas en la edad pediátrica / Characterization the pediatric patients with diagnostic of illnesses congenital valvulares

Introducción: Las valvulopatías congénitas son un grupo de entidades en las cuales la principal alteración anatomofuncional está en las válvulas cardiacas. Objetivo: Caracterizar los pacientes pediátricos nacidos vivos con diagnósticos de valvulopatías congénitas. Métodos: Se realizó una investigación descriptiva retrospectiva a partir de los registros de valvulopatías congénitas del Servicio de Cardiología del Hospital Pediátrico Universitario José Luis Miranda en Santa Clara, Cuba, en el periodo de 2005 a 2016. La población estuvo conformada por los 147 niños nacidos vivos con diagnóstico de valvulopatías congénitas. Se empleó un muestreo no probabilístico intencional por criterios y la muestra quedó conformada por 143. La recogida de la información se realizó a través de la revisión documental de las historias clínicas. Resultados: La tasa de incidencia de la valvulopatías congénitas fue de 1,5 x 1 000 nacidos vivos, predominó la estenosis pulmonar que agrupó el 70,6 por ciento de los diagnosticados. Se encontró predominio del sexo masculino con 50,3 por ciento, se determinó que 45,5 por ciento de los casos se diagnosticaron antes de los 29 días de nacido, período que incluye un diagnóstico prenatal. Conclusiones: El desarrollo del diagnóstico prenatal de las cardiopatías congénitas ha posibilitado la disminución de la incidencia de las malformaciones más complejas. El conocimiento de las enfermedades congénitas del corazón contribuye a operar de forma segura y con resolución anatómica completa a muchos de estos niños en el período prenatal o cuando son lactantes pequeños, para evitar el deterioro global de estos cuando la cardiopatía no está resuelta(AU)

Introduction: The congenital valvulopatías is a group of entities in which the main alteration anatomofuncional is in the heart valves. Objective: To characterize the pediatric patients with diagnostic of born congenital valvulopatías. Methods: He/she was carried out a retrospective descriptive investigation starting from the registrations of congenital valvulopatías of the service of Cardiology of the Hospital Pediatric University student José Luis Miranda in the period of 2005 at the 2016. The population was conformed by the 147 alive born children with diagnostic of congenital valvulopatías, a sampling was not used intentional probabilístico by approaches, being conformed the sample by 143. The collection of the information was carried out through the documental revision of the clinical histories. Results: The rate of incidence of the congenital valvulopatías was of 1,5 x 1000 born alive, the lung estenosis prevailed containing to 70,6 percent of those diagnosed he/she was prevalence of the masculine sex in 50,3 percent, it was determined that 45,5 percent of the cases was diagnosed before the 29 days where a prenatal diagnosis is included. Conclusions: The development of the prenatal diagnosis of the congenital cardiopatías has facilitated the decrease of the incidence of the most complex malformations. The knowledge of the congenital illnesses of the heart contributes to operate in a sure way and with complete anatomical resolution to many of these children in the prenatal period or when they are small nurslings, to avoid the global deterioration of these when the cardiopatía is not resolved(AU)

Prevalence and Prediction of Obstructive Coronary Artery Disease in Patients Undergoing Primary Heart Valve Surgery / Prevalência e Predição de Doença Arterial Coronariana Obstrutiva em Pacientes Submetidos a Cirurgia Valvar Primária

Abstract Background: The prevalence of coronary artery disease (CAD) in valvular patients is similar to that of the general population, with the usual association with traditional risk factors. Nevertheless, the search for obstructive CAD is more aggressive in the preoperative period of patients with valvular heart disease, resulting in the indication of invasive coronary angiography (ICA) to almost all adult patients, because it is believed that coronary artery bypass surgery should be associated with valve replacement. Objectives: To evaluate the prevalence of obstructive CAD and factors associated with it in adult candidates for primary heart valve surgery between 2001 and 2014 at the National Institute of Cardiology (INC) and, thus, derive and validate a predictive obstructive CAD score. Methods: Cross-sectional study evaluating 2898 patients with indication for heart surgery of any etiology. Of those, 712 patients, who had valvular heart disease and underwent ICA in the 12 months prior to surgery, were included. The P value < 0.05 was adopted as statistical significance. Results: The prevalence of obstructive CAD was 20%. A predictive model of obstructive CAD was created from multivariate logistic regression, using the variables age, chest pain, family history of CAD, systemic arterial hypertension, diabetes mellitus, dyslipidemia, smoking, and male gender. The model showed excellent correlation and calibration (R² = 0.98), as well as excellent accuracy (ROC of 0.848; 95%CI: 0.817-0.879) and validation (ROC of 0.877; 95%CI: 0.830 - 0.923) in different valve populations. Conclusions: Obstructive CAD can be estimated from clinical data of adult candidates for valve repair surgery, using a simple, accurate and validated score, easy to apply in clinical practice, which may contribute to changes in the preoperative strategy of acquired heart valve surgery in patients with a lower probability of obstructive disease.

Resumo Fundamento: A prevalência de doença arterial coronariana (DAC) nos pacientes valvares é semelhante à da população geral, com associação usual aos fatores de risco tradicionais. Ainda assim, a busca por DAC obstrutiva é mais agressiva nos valvulopatas em pré-operatório, determinando a angiografia coronariana invasiva (ACI) a praticamente todos os pacientes adultos, uma vez que se acredita que a cirurgia de revascularização miocárdica deva ser associada à troca valvar. Objetivos: Avaliar a prevalência de DAC obstrutiva e identificar fatores a ela associados em adultos candidatos à cirurgia cardíaca primariamente valvar entre os anos de 2001 a 2014 no Instituto Nacional de Cardiologia (INC) e elaborar um modelo preditivo de DAC obstrutiva através de escore derivado de análise multivariada. A partir da estimativa da probabilidade pré-teste de DAC obstrutiva, espera-se melhor estratégia pré-operatória para cada paciente. Métodos: Estudo transversal avaliando 2.898 pacientes com indicação de cirurgia cardíaca por qualquer etiologia. Desses, foram estudados 712 pacientes valvopatas submetidos à ACI nos 12 meses anteriores à cirurgia. Diferenças com valor de p < 0,05 foram consideradas estatisticamente significativas. Resultados: A prevalência de DAC obstrutiva foi de 20%. Um modelo preditivo de DAC obstrutiva foi criado a partir de regressão logística multivariada, utilizando as variáveis idade, dor torácica, história familiar de DAC, hipertensão arterial sistêmica, diabetes mellitus, dislipidemia, tabagismo e sexo masculino. O modelo demonstrou excelente correlação e calibração (R2 = 0,98), além de ótima acurácia (ROC de 0,848; IC95% 0,817 - 0,879) e validação em diferente população valvar (ROC de 0,877; IC 95%: 0,830 - 0,923). Conclusões: É possível estimar DAC obstrutiva a partir de dados clínicos com elevada acurácia, o que pode vir a permitir estabelecer estratégias pré-operatórias de acordo com a probabilidade pré-teste individual, evitando a indicação indiscriminada de procedimentos desnecessários e invasivos, principalmente nos grupos de menor probabilidade de DAC obstrutiva. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Influência das características sociodemográficas e clínicas no impacto da doença em valvopatas / Influencia de las características sociodemográficas y clínicas en el impacto de la enfermedad en válvulas del corazón / Influence of sociodemographic and clinical characteristics at the impact of valvular heart disease

RESUMO Objetivo: analisar as características sociodemográficas e clínicas dos pacientes com valvopatia e verificar a influência dessas variáveis no impacto da valvopatia no cotidiano. Método: participaram do estudo 86 pacientes em seguimento ambulatorial. A coleta de dados foi realizada em duas etapas - entrevista presencial para caracterização sociodemográfica e clínica e por meio de contato telefônico para aplicação do Instrumento para Mensuração do Impacto da Doença no Cotidiano do Valvopata (IDCV). Os dados foram analisados através de estatística descritiva e análise de regressão múltipla. Resultados: constatou-se que o escore total do IDCV e seus domínios foram influenciados pela idade, escolaridade, presença ou não de sintomatologia, uso ou não de diurético. Conclusão: o impacto da doença foi influenciado por variáveis sociodemográficas e clínicas. Os resultados fornecem subsídios para o delineamento de intervenções de enfermagem com vistas à redução do impacto da doença no cotidiano do paciente com valvopatia.

RESUMEN Objetivo: analizar las características sociodemográficas y clínicas de los pacientes con enfermedad de las válvulas del corazón y verificar la influencia de esas variables en el impacto de la enfermedad en la vida cotidiana. Método: participaron del estudio 86 pacientes con seguimiento ambulatorio. La recolección de datos fue realizada en dos etapas - entrevista presencial para caracterización sociodemográfica y clínica y por medio de contacto telefônico para aplicación del Instrumento para Medición del Impacto en lo Cotidiano de la Enfermedad de Válvula (IDCV). Los datos fueron analizados a través de estadística descriptiva y análisis de regresión múltiple. Resultados: se constató que la puntuación total del IDCV y sus dominios fueron influenciados por la edad, escolaridad, presencia o no de sintomatología, uso o no de diurético. Conclusión: el impacto de la enfermedad fue influenciado por variables sociodemográficas y clínicas. Los resultados otorgan subsidios para el delineamiento de intervenciones de enfermería con vistas a la reducción del impacto de la enfermedad en lo cotidiano del paciente con enfermedad de válvula.

ABSTRACT Objective: to analyze the sociodemographic and clinical characteristics of patients with valvular heart disease and to verify the influence of these variables on the impact of valve disease in daily life. Method: the study involved 86 outpatients. Data collection was performed in two stages - face-to-face interview for sociodemographic and clinical characterization and through telephone contact for the application of the Instrument to Measure the Impact of Valvular Heart Disease on Patient's Everyday Life (IDCV). Data were analyzed through descriptive statistics and multiple regression analysis. Results: it was noticed that the total score of IDCV and its domains were influenced by age, schooling, presence or absence of symptoms, use or not of diuretic. Conclusion: The impact of the disease was influenced by sociodemographic and clinical variables. The results provide subsidies for the design of nursing interventions aimed at reducing the impact of the disease on the patient's daily life with valve disease.

Propensity-matched analysis of association between preoperative anemia and in-hospital mortality in cardiac surgical patients undergoing valvular heart surgeries.

Introduction: Anaemia is associated with increased post-operative morbidity and mortality. We retrospectively assess the relationship between preoperative anaemia and in-hospital mortality in valvular cardiac surgical population. Materials and Methods: Data from consecutive adult patients who underwent valvular repair/ replacement at our institute from January 2010 to April 2014 were collected from hospital records. Anaemia was defined according to WHO criteria (hemoglobin <13g/dl for males and <12g/dl for females). 1:1 matching was done for anemic and non-anemic patients based on propensity for potentially confounding variables. Logistic regression was used to evaluate the relationship between anaemia and in-hospital mortality. MatchIt package for R software was used for propensity matching and SPSS 16.0.0 was used for statistical analysis. Results: 2449 patients undergoing valvular surgery with or without coronary artery grafting were included. Anaemia was present in 37.1% (33.91% among males & 40.88% among females). Unadjusted OR for mortality was 1.6 in anemic group (95% Confidence Interval [95% CI] – 1.041-2.570; p=0.033). 1:1 matching was done on the basis of propensity score for anaemia (866 pairs). Balancing was confirmed using standardized differences. Anaemia had an OR of 1.8 for mortality (95% CI- 1.042 to 3.094, P=0.035). Hematocrit of < 20 on bypass was associated with higher mortality. Conclusion: Preoperative anaemia is an independent risk factor associated with in-hospital mortality in patients undergoing valvular heart surgery.

Clinical and epidemiological profile of patients with valvular heart disease admitted to the emergency department / Aspectos clínicos e epidemiológicos de portadores de doença valvar atendidos em unidade de pronto atendimento

Objective To evaluate the clinical and epidemiological profile of patients with valvular heart disease who arrived decompensated at the emergency department of a university hospital in Brazil. Methods A descriptive analysis of clinical and echocardiographic data of 174 patients with severe valvular disease, who were clinically decompensated and went to the emergency department of a tertiary cardiology hospital, in the State of São Paulo, in 2009. Results The mean age of participants was 56±17 years and 54% were female. The main cause of valve disease was rheumatic in 60%, followed by 15% of degenerative aortic disease and mitral valve prolapse in 13%. Mitral regurgitation (27.5%) was the most common isolated valve disease, followed by aortic stenosis (23%), aortic regurgitation (13%) and mitral stenosis (11%). In echocardiographic data, the mean left atrial diameter was 48±12mm, 38±12mm for the left ventricular systolic diameter, and 54±12mm for the diastolic diameter; the mean ejection fraction was 56±13%, and the mean pulmonary artery pressure was 53±16mmHg. Approximately half of patients (44%) presented atrial fibrillation, and over one third of them (37%) had already undergone another cardiac surgery. Conclusion: Despite increased comorbidities and age-dependent risk factors commonly described in patients with valvular heart disease, the clinical profile of patients arriving at the emergency department represented a cohort of rheumatic patients in more advanced stages of disease. These patients require priority care in high complexity specialized hospitals. .

Objetivo Avaliar o perfil clínico e epidemiológico dos pacientes com doença valvar que chegaram descompensados no pronto atendimento de um hospital universitário de referência nacional. Métodos Análise descritiva de dados clínicos e ecocardiográficos de 174 pacientes consecutivos portadores de doença valvar grave, que apresentaram descompensação clínica e procuraram atendimento no pronto-socorro de um hospital terciário de cardiologia do Estado de São Paulo no ano de 2009. Resultados Dos 174 pacientes avaliados, a média etária foi de 56±17 anos e 54% eram do gênero feminino. A principal etiologia da doença valvar foi a reumática (60%), seguida pela doença degenerativa aórtica (15%) e pelo prolapso mitral (13%). A valvopatia mais comumente observada de forma isolada foi a insuficiência mitral (27,5%), seguida por estenose aórtica (23%), insuficiência aórtica (13%) e estenose mitral (11%). Nos dados ecocardiográficos, a média do diâmetro do átrio esquerdo foi de 48±12mm, do ventrículo esquerdo na sístole foi de 38±12mm, e diástole foi de 54±12mm; a média da fração de ejeção foi de 56±13% e a pressão pulmonar média foi de 53±16mmHg. Aproximadamente metade dos pacientes (44%) estava em fibrilação atrial, e mais de um terço dos pacientes (37%) já havia sido submetido a outra cirurgia cardíaca. Conclusão Apesar do aumento das comorbidades e dos fatores de risco idade dependentes comumente descritos nos portadores de cardiopatia valvar, o perfil clínico dos sujeitos que chegaram ao pronto atendimento representou uma coorte de pacientes reumáticos em estágios mais avançados de doença. Esses pacientes requerem atendimento prioritário em serviço ...

Enfoque diagnóstico y terapéutico de la estenosis aórtica / Aortic stenosis: diagnosis and treatment

La estenosis aórtica es la valvulopatía más frecuente de la población adulta. En las últimas décadas, se ha puesto de manifiesto un incremento significativo de su prevalencia, y esto se relaciona principalmente con la mayor expectativa de vida poblacional. Este hecho impone actualmente un constante desafío para el abordaje clínico-quirúrgico de esta enfermedad, dado que el aumento de los riesgos en este grupo de pacientes está dado no sólo por su edad avanzada sino también por las importantes comorbilidades asociadas. El objetivo de este trabajo es revisar los fundamentos fisiopatológicos, las manifestaciones clínicas y los predictores evolutivos de esta enfermedad, así como realizar una actualización de los métodos diagnósticos utilizados en la detección y seguimiento de estos pacientes para, finalmente, realizar un análisis de las nuevas intervenciones terapéuticas aplicadas al manejo global de la estenosis aórtica.

Tratamento cirúrgico da raiz da aorta: é possível preservar a valva aórtica? / Surgical treatment of the aortic root, is it possible to preserve the aortic valve

O tratamento cirúrgico convencional para os pacientes portadores de aneurisma da raiz da aorta é a sua substituição completa por um conduto valvulado associado ao reimplante dos óstios coronários. Este é um procedimento de baixo risco, duradouro e principalmente utilizado naqueles pacientes que se recusam a imaginar a necessidade de outra operação, apesar da necessidade de utilização do anticoagulante oral em definitivo. Alternativamente, é possível a reconstrução deste seguimento da aorta com preservação valvar. Muita controvérsia existe em relação à longevidade deste complexo tratamento alternativo, apesar dos resultados imediatos, em muitas séries, melhores até que os obtidos com a operação convencional. A literatura sugere que a síndrome de Marfan, a valva aórtica bivalvulada, os grandes aneurismas, os anéis aórticos dilatados, a ausência de fixação do anel aórtico e a necessidade de plastia de um ou mais folhetos aórticos sejam os principais preditores de reoperação no seguinte tardio dos pacientes que tiveram a valva aórtica preservada...

The conventional surgical treatment for patients with aortic root aneurysm has been the replacement of the entire root and valve with a composite valve graft and the reimplantation of the coronary ostium. It has become a low risk operation although its effects are long-standing. It is usually used in patients who do not wish to accept the risk of another operation, despite the indefinite anticoagulation needs. Alternatively, the valve sparing aortic operation is a practical possibility. Despite its immediate results in many series, even better by those obtained by a conventional operation, the longetivity of this complex alternative treatment is still controversial. Many papers suggest that Marfan syndrome, bicuspid aortic valve, large aneurysms, large aortic rings, the absence of aortic ring fixation and the need of aortic leaflets plasty are predictors of reoperation during the follow up. There is no doubt, however, that the aortic root reconstruction can be performed with low hospital mortality and high freedom from aortic valve-related reoperation, however the choice of the best procedure must be individualized for each patient and the valve sparing operation it is neither a procedure that can be performed by all surgeons nor applied to all patients.

Anemia, disfunção renal e desnutrição associadas à insuficiência cardíaca em pacientes valvopatas / Anemia, renal dysfunction and malnutrition associated with heart failure in patients with valvulopathy

FUNDAMENTO: A doença valvar pode cursar com insuficiência cardíaca (IC), anemia e disfunção renal (DR), aumentando o risco nutricional e piorando o prognóstico dos pacientes. OBJETIVO: Avaliar a prevalência de anemia e DR em pacientes portadores de valvopatias com ou sem IC, bem como estabelecer correlação com o estado nutricional. MÉTODOS: Foram avaliados 104 pacientes internados na enfermaria de valvopatias do PROCAPE/UPE, no período de ago-out/2008. Os dados foram obtidos das fichas de acompanhamento nutricional e dos prontuários. As variáveis coletadas foram: sexo, idade, estado nutricional segundo o índice de massa corpórea (IMC), presença de IC, anemia, DR. Considerou-se como anemia valores de hemoglobina < 13 g/dl nos homens e < 12 g/dl nas mulheres. A DR foi estabelecida de acordo com a taxa de filtração glomerular (TGF), sendo calculada pela fórmula proposta por Cockcroft e Gault. RESULTADOS: A prevalência de anemia e DR em pacientes com IC foi de 71,1 por cento e de 68,8 por cento, e nos pacientes sem IC foi de 48,1 por cento e de 60,0 por cento, respectivamente, com diferença estatisticamente significativa para anemia (p = 0,022). Dos pacientes, 48,1 por cento estavam eutróficos, 26,9 por cento com excesso de peso e 25,0 por cento com algum grau de desnutrição. Os pacientes com IC apresentaram uma frequência maior de baixo peso (p = 0,020). O estado nutricional não apresentou associação com anemia (p = 0,117), mas apresentou associação com DR, sendo a função renal diminuída mais frequente nos pacientes com baixo peso (p = 0,000). CONCLUSÃO: Houve significância estatística quando comparamos as prevalências de desnutrição, anemia e DR entre pacientes com e sem IC.

BACKGROUND: Valvular disease can course with heart failure (HF), anemia and renal dysfunction (RD), increasing the nutritional risk and worsening patient prognosis. OBJECTIVE: To evaluate the prevalence of anemia and RD in patients with valvulopathy with or without HF, as well as establish a correlation with the nutritional status. METHODS: A total of 104 patients admitted at the Clinic of Valvulopathy of PROCAPE/UPE, during the period of Aug-Oct/2008. The data were obtained from the nutritional and medical follow-up files. The collected variables were: sex, age, nutritional status according to the body mass index (BMI), presence of HF, anemia and RD. Anemia was considered when hemoglobin values were < 13 g/dl in men and < 12 g/dl in women. RD was established according to the glomerular filtration rate (GFR) and it was calculated through the formula proposed by Cockcroft and Gault. RESULTS: The prevalence of anemia and RD was 71.1 percent and 68.8 percent, and 48.1 percent and 60.0 percent, in patients with and without HF, respectively, with a statistically significant difference for anemia (p = 0.022). Of the patients, 48.1 percent were eutrophic, 26.9 percent had excess weight and 25.0 percent presented some degree of malnutrition. The patients with HF presented a higher frequency of low weight (p = 0.020). The nutritional status was not associated with anemia (p = 0.117), but it was associated with RD, with renal function being decreased more often in patients with low weight (p = 0.000). CONCLUSION: When the prevalence of malnutrition, anemia and RD was compared between patients with and without HF, it showed statistical significance.

Valvopatias / Valvular heart disease

A doença valvar apresenta particularidades relacionadas ao sexo. A identificação dessas diferenças é fundamental para o manejo clínico adequado. Com o declínio da doença reumática nos países desenvolvidos, a doença valvar degenerativa tornou-se a etiologia preponderante. Entretanto, nos países em desenvolvidos, a doença cardíaca reumática com comprometimento valvar é ainda bastante comum. A prevalência de insuficiência mitral resultante de prolapso da valva mitral é semelhante em ambos os sexos, porém aumenta nos homens com mais de 50 anos de idade. A estenose mitral ocorre quase que exclusivamente no sexo feminino, e no países em desenvolvimento é comum o aparecimento dos primeiros sintomas na gestação, ao contrário do que ocorre nos países desenvolvidos, em que a afecção se manifesta na quinta e na sexta década da vida. Nas gestantes muito sintomáticas, portadoras de estenose mitral, a valvotomia mitral percutânea é o tratamento mais indicado, com resultado clínico favorável imediato. A insuficiência aórtica predomina nos homens e os parâmetros ecocardiográficos de gravidade foram direcionados para eles. As mulheres são encaminhadas para cirurgia sobretudo pelos sintomas, pois dificilmente atingem os diâmetros ventriculares recomendados pelas diretrizes do American College of Cardiology/Americam Heart Association (ACC/AHA). Na estenose aórtica...

Valvular heart disease has gender-related peculiarities. The identification of these differences is essential for adequate clinical management. With the decrease of rheumatic disease in developed countries, degenerative valvular disease has become the most prevalent etiology. Nevertheless in developing countries, rheumatic heart disease with valvular commitment is still very common. The prevalence of mitral valve insufficiency as a consequence of mitral valve prolapse is similar in both genders, however it increases in men over 50 years of age. Mitral stenosis occurs almost exclusively in women and in developing countries the onset of symptoms is usually observed during pregnancy, whereas in developed countries it is manifested in the 5th and 6th decades of life. Percutaneous mitral valvulotomy is the most indicated treatment, with immediate favorable clinical results in very symptomatic pregnant women with mitral stenosis. Aortic insufficiency is prevalent in men and the echocardiographic severity parameters were developed for them. Women are referred to surgery especially because of their symptoms since they rarely achieve the ventricular diameters recommended by the guidelines of the American College of Cardiology/American Heart Association (ACC/AHA). There is a differentiated gender-related response to ventricular hypertrophy in aortic stenosis. Women develop more hypertrophy than men. All of these evidences affect the course of women with valvular heart disease.

Validação de um novo escore de risco cirúrgico para cirurgia valvar: VMCP / Validación de un nuevo score de riesgo quirúrgico para cirugía valvular: VMCP / Validation of a new surgical risk score for heart valve surgery: VMCP

FUNDAMENTO: Alguns estudos desenvolveram escores para avaliar o risco cirúrgico, particularmente o EuroSCORE que, entretanto, é complexo e trabalhoso. Sugerimos um escore novo e simples, mais adequado para a prática clínica e para a avaliação de risco cirúrgico em pacientes valvopatas. OBJETIVO: Este estudo foi realizado para criar e validar um escore simples e prático para predizer mortalidade e morbidade em cirurgia valvar. MÉTODOS: Coletamos dados hospitalares de 764 pacientes e realizamos a validação do escore, utilizando dois modelos estatísticos: óbito (= mortalidade) e tempo de internação hospitalar (TIH) > 10 dias (= morbidade). O escore foi composto de quatro índices (V [lesão valvar], M [função miocárdica], C [doença arterial coronariana] e P [pressão da artéria pulmonar]). Estabelecemos um valor de corte para o escore, e foram utilizadas análises uni e multivariada para confirmar se o escore seria capaz de predizer mortalidade e morbidade. Também estudamos se havia associação com outros fatores de risco. RESULTADOS: O escore foi validado, com boa consistência interna (0,65), e o melhor valor de corte para mortalidade e morbidade foi 8. O escore com valor > 8 pode predizer TIH > 10 dias (odds ratio (OR) = 1,7 p=0,006), e um maior risco de óbito ao menos na análise univariada (p=0,049). Entretanto, o risco de óbito não foi previsível na análise multivariada (p=0,258). CONCLUSÃO: O escore VMCP > 8 pode predizer TIH > 10 dias e pode ser usado como uma nova ferramenta para o seguimento de pacientes portadores de valvopatia submetidos a cirurgia.

BACKGROUND: Some studies have developed scores for the assessment of surgical risk, particularly the EuroSCORE, which, however, is complex and difficult to apply. We suggest a new and simpler score, which is more appropriate for the clinical practice and for the assessment of surgical risk in patients with heart valve diseases. OBJECTIVE: This study was conducted to create and validate a simple and practical score to predict mortality and morbidity related to heart valve surgery. METHODS: Hospital data from 764 patients were collected, and the score was validated using two statistical models: death (= mortality) and length of hospital stay (LHS) > 10 days (= morbidity). The score was composed by four indexes (V [heart valve lesion], M [myocardial function], C [coronary artery disease], and P [pulmonary artery pressure]). A cut-off point was set for the score, and uni and multivariate analyses were performed to confirm whether the score would be able to predict mortality and morbidity. The existence of association with other risk factors was also studied. RESULTS: The score was validated with good internal consistency (0.65), and the best cut-off point for mortality and morbidity was 8. Scores > 8 can predict LHS > 10 days (odds ratio [OR] = 1.7; p = 0.006) and a higher death risk, at least in the univariate analysis (p = 0.049). However, the death risk could not be predicted in the multivariate analysis (p=0.258). CONCLUSION: VMCP scores > 8 can predict LHS > 10 days and may be used as a new tool for the follow-up of patients with heart valve disease undergoing surgery.

FUNDAMENTO: Algunos estudos desarrollaron scores para evaluar el riesgo quirúrgico, particularmente el EuroSCORE que, sin embargo, es complejo y de difícil aplicación. Sugerimos una puntuación nueva y sencilla, más adecuada para la práctica clínica y para la evaluación de riesgo quirúrgico en pacientes con valvulopatías. OBJETIVO: Se realizó este estudio con el objetivo de crear y validar un score sencillo y práctico para predecir mortalidad y morbilidad en cirugía valvular. MÉTODOS: Recoleccionamos datos hospitalarios de 764 pacientes y realizamos la validación del score, con la utilización de dos modelos estadísticos: óbito (= mortalidad) y tiempo de internación hospitalaria (TIH) > 10 días (= morbilidad). El score estaba conpuesto por cuatro índicadores (V [lesión valvular], M [función miocárdica], C [enfermedad arterial coronaria] y P [presión de la arteria pulmonar]). Establecemos un valor de corte para el score, y utilizamos el análisis uni y multivariado para confirmar si la puntuación sería capaz de predecir mortalidad y morbilidad. También investigamos si había asociación con otros factores de riesgo. RESULTADOS: Se validó el score, con satisfactoria consistencia interna (0,65). El mejor valor de corte para mortalidad y morbilidad fue 8. El score con valor > 8 es adecuado para predecir tanto el TIH > 10 días (odds ratio (OR) = 1,7 p=0,006), como un mayor riesgo de óbito, por lo menos en el análisis univariado (p=0,049). No obstante, el riesgo de óbito no se mostró previsible en el análisis multivariado (p=0,258). CONCLUSIÓN: El score VMCP > 8 es adecuado para predecir TIH > 10 días, y se puede utilizarlo como una nueva herramienta para el seguimiento de pacientes portadores de valvulopatía sometidos a cirugía.

Comportamiento de las enfermedades crónicas no transmisibles en adultos mayores / Behavior of non-communicable chronic diseases in older adults

Con el incremento de la expectativa de vida y el consecuente aumento de la proporción de personas de 60 años y más, también se eleva el porcentaje de la población que padece de enfermedades crónicas no transmisibles, las que representan las primeras causas de muerte en los países desarrollados y en Cuba. Se presenta un estudio descriptivo de corte transversal, realizado en el período comprendido entre marzo de 2007 y marzo de 2008 en pacientes de 65 años y más en el Policlínico 27 de Noviembre del municipio Marianao, con el objetivo de identificar el comportamiento de estas enfermedades. Se estudiaron 300 ancianos, la información se obtuvo de las bases de datos del estudio de investigación en demencias 10/66, con las tasas de prevalencia de las principales enfermedades no transmisibles que afectan a este grupo poblacional. La hipertensión arterial constituyó la enfermedad de mayor frecuencia con un 55 por ciento, seguida de las enfermedades del corazón (32,3 por ciento) y la diabetes mellitus (18,3 por ciento). La primera fue más frecuente en el sexo masculino, mientras que las otras predominaron en el femenino. El síndrome demencial presentó una frecuencia del 12 por ciento, y la depresión estuvo presente en el 6,7 por ciento de los pacientes estudiados.

With the increase of life expectancy and the consequent rise of the number of persons aged 60 and over, the percentage of the population suffering from non-communicable chronic diseases, which are the first causes of death in the developed countries and in Cuba, also grows. A descriptive cross-sectional study was conducted among patients aged 65 and over at 27 de Noviembre Polyclinic from March 2007 to March 2008 aimed at identifying the behavior of these diseases. 300 elderly were studied. The information was obtained from the databases of the research on dementias 10/66, with the rates of prevalence of the main non-communicable diseases affecting this population group. Arterial hypertension was the most common disease (55 percent), followed by heart diseases (32.3 percent) and diabetes mellitus (18.3 percent). The first was the most frequent in males, whereas the others predominated among females. The demential syndrome presented a frequency of 12 percent and depression was observed in 6.7 percent of the studied patients.

Doença arterial coronariana em pacientes com valvopatia reumática e não-reumática acompanhados em hospital público do Rio de Janeiro / Coronary artery disease in patients with rheumatic and non-rheumatic valvular heart disease treated at a public hospital in Rio de Janeiro

OBJETIVO: Avaliar a prevalência de doença arterial coronariana (DAC) na valvopatia de etiologia reumática e não-reumática, examinando possíveis fatores preditivos da presença da doença. MÉTODOS: Estudo transversal, de série de casos obtidos em população pré-definida. Foram avaliados 1.412 pacientes com indicação de cirurgia cardíaca por qualquer etiologia. Destes, foram encontrados e estudados 294 casos com valvopatia primária de etiologias reumática e não-reumática, com idade > 40 anos, submetidos a coronariografia. RESULTADOS: Os valvopatas reumáticos apresentaram menor prevalência de DAC (4 por cento) que os não-reumáticos (33,61 por cento) (p < 0,0001). O modelo de regressão logística evidenciou que idade, dor torácica típica, hipertensão arterial sistêmica (HAS), diabete melito e dislipidemia estavam significativamente relacionados à DAC, e que a etiologia reumática não era determinante da doença. Tabagismo e sexo revelaram-se de importância clínica na DAC, embora sem significância estatística. No grupo total, o modelo de análise Log linear demonstrou que, independentemente da etiologia, sexo, idade > 55 anos, HAS, dor torácica típica, diabete e dislipidemia se relacionavam diretamente com a DAC, sendo as três últimas as variáveis de maior peso para a doença. CONCLUSÃO: A prevalência de DAC é baixa entre valvopatas reumáticos e mais alta entre não-reumáticos; a etiologia reumática não parece exercer efeito protetor sobre a prevalência de DAC; e as variáveis sexo, idade, HAS, dor torácica típica, dislipidemia e diabete melito foram identificadas como fortemente associadas à presença de DAC. É possível definir critérios de indicação de coronariografia pré-operatória nas trocas valvares, podendo-se evitar a indicação rotineira a partir dos 40 anos.

OBJECTIVE: to estimate the prevalence of coronary artery disease (CAD) in valvular heart disease of rheumatic (RVHD) and non-rheumatic (NVHD) etiology, assessing possible predictive factors for the presence of CAD. METHODS: This is a cross-sectional study of a series of cases obtained from a pre-defined population, wherein 1,412 patients referred for heart surgery of any etiology were evaluated. Of these, 294 primary heart disease patients aged >40 submitted to cinecoronary arteriography (CA) were identified and studied. RESULTS: patients with RVHD presented lower prevalence of CAD (4 percent) when compared to NVHD (33.61 percent), p<0.0001. The logistic regression analysis showed that age, typical angina-like chest pain (TACP), systemic arterial hypertension (SAH), diabetes and dyslipidemia were significantly related to CAD, and that the rheumatic etiology was not a disease determinant. Smoking and gender were clinically important in CAD, although not statistically significant. In the whole group, the Log-linear analysis showed that, regardless of the etiology, gender, age >55, SAH, TACP, diabetes and dyslipidemia were all related directly to CAD, with the latter three being the most important variables for the disease. CONCLUSION: the prevalence of CAD among RVHD patients is low, whereas it is high among NVHD patients; the rheumatic etiology does not seem to have any beneficial effects on the prevalence of CAD; gender, age, SAH, TACP, dyslipidemia and diabetes were identified as being strongly associated with the presence of CAD. It is possible to define the criteria that indicate the need for pre-surgical CA in heart valve replacements, so that the standard indication after the age of 40 years can be avoided.

Estudio retrospectivo de la endocarditis infecciosa en diferentes grupos de riesgo / Infective endocarditis in an internal medicine ward

Background: Due to the increasing number of intravenous drug users, subjects with immune deficiencies or with prosthetic valves, infective endocarditis (IE) continues to be prevalent and to have a high mortality. Aim: To review all cases of infective endocarditis diagnosed in an Internal Medicine Service. Material and methods: Retrospective review of medical records of all patients with infective endocarditis, hospitalized in an Internal Medicine ward, between 1989 and 2003. Dukes criteria were used to define definitive, possible and less probable cases of IE. Results: Eighty seven patients with definite IE were identified (66 males, age range 19-84 years), with a mean incidence of 5.3 per 1000 hospitalizations. IE in intravenous drugs users was usually caused by Staphylococcus aureus and presented high risk of embolism (RR: 3,21). Subjects aged over 70 years had a relative risk of mortality of 5.5. Hospital acquired IE was associated with advanced age and IV catheters appeared as the only predisposing factor. Patients with prosthetic valves were also older, their main complication was abscess formation and their mortality was higher. Conclusions: A closer approach to differential conditions of patients, according to age, intravenous drug use or the presence of prosthetic valves, is necessary

Rheumatic and nonrheumatic valvular heart disease: epidemiology, presentation and management

Valvular disease ranks among the major cardiovascular afflictions in Africa. Acute rheumatic fever and chronic rheumatic valvular disease in their most virulent form are still commonly encountered and impose a huge burden on the limited healthcare resources. There is scarce published data from the Sudan, although open heart surgery and interventional cardiology was re-established as a program in the Sudan in the country since1998. The aim of this study was to investigate the epidemiology and the presentations of patients with valvular lesions as well as the type of procedure expected to help them. The files of 235 patients presented at Ahmed Gasim Cardiac Centre during 1999-2000 were retrospectively reviewed. The study was based on echocardiographic assessment. 235 patients were enrolled; Patients with secondary MR, TR, PR or complex congenital lesions were excluded. Out of the 235 Pts assessed, 182 were young < 40 yrs of age and 185 [78%] had Rheumatic origin, which is preventable. 153 patients 65% were recommended for prosthetic valve replacement with the hazard of long term anticoagulant therapy, 49 patients [23%] with MS, were suitable for PTMC, with a possible risk of restenosis in 10 to 15 years, while 33 patients [12%] only has expected good long term results [patients with PS and elderly, patients for tissue valves or patients for valve repair or excision of a sub-aortic membrane. In conclusion, to launch a nation wide and a sustainable control program for rheumatic fever, the provision of a reliable anticoagulant monitoring and to continue the search for an ideal valve

Pregnancy and valvular heart disease

To review all cases of valvular heart disease during pregnancy in a regional Saudi-Arabian population between 1993-1997, determine its incidence, contributing factors and its effect on the outcome of pregnancy. A retrospective study of 33,200 cases between 1993-1997 performed over a period of 5 years in the Department of Obstetrics and Gynecology in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Most patients were Saudi nationals [83.4%]. Evidence of heart disease was detected in 166 pregnant women, an incidence of 0.5%. Valvular heart disease was present, either as a single valve involvement or in combination, in 76% of the patients. The remaining 24% were a miscellaneous group including patients with cardiomyopathies, or pulmonale and septal defects. The data collected was analyzed using Gold Stat Software Package. As a single valve disease, mitral valve involvement was predominant [94.5%], compared to aortic valve [5.5%]. The most common condition involving mitral valve was the valve prolapse [39.2%], followed by mitral regurgitation [19.9%] and mitral stenosis [16.9%]. Twenty-four percent of the pregnant women with valve disease had multiple valve involvement. Forceps were applied in 8.4% of the patients and ventouse deliveries in 1.2%. Cesarean section was performed in 3.6% of the cases, out of which 2.4% were emergency lower segment cesarean section and 1.2% were elective. No maternal or infant mortality occurred. All infants were normal and healthy with mean infant weight of 3.24 +/- 0.52 kg. Prophylactic antibiotics were administered in 83% of the patients. None of the patients, whether treated with antibiotics or not, developed infective endocarditis, Presence of valvular heart disease in our study did not appear to affect the outcome of pregnancy, but its accurate diagnosis and management dem and a greater underst and ing of cardiovascular physiology and its pathophysiology in pregnancy, labor and the puerperium. The successful management of the woman with valvular heart disease in pregnancy required complete cooperation between the patient herself, the obstetrician, cardiologist, anesthetist and other supporting medical staff, to optimize the outcome for both the mother and her baby