Sudan Rheumatic Heart Disease Control Initiative: achievements and challenges: 2012-2017. Sudan RHD Control Committee

NA

Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression / Parâmetros indicativos de persistência de patologia valvular no diagnóstico inicial de cardite reumática aguda: o papel da albumina e da expressão de CD19

Abstract Objective: The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC). Methods: Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement. Results: During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6 ± 0.48 g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1. Conclusion: The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.

Resumo Objetivo: Definir os preditores da cardite crônica em pacientes com cardite reumática aguda (CRA). Métodos: Os pacientes diagnosticados com CRA entre maio de 2010 e maio de 2011 foram incluídos no estudo. Foram feitos os testes de ecocardiografia, eletrocardiograma, uma análise do subgrupo de linfócitos, provas de fase aguda, níveis de albumina plasmática, antiestreptolisina-O (ASO) na manifestação inicial. As avaliações ecocardiográficas foram repetidas no 6º mês de acompanhamento. Os pacientes foram divididos em dois grupos de acordo com a persistência da patologia valvular no 6º mês como Grupo 1 e Grupo 2 e todos os parâmetros clínicos e laboratoriais na internação foram comparados entre dois grupos de comprometimento valvular. Resultados: Durante o período do estudo de um ano, 22 pacientes apresentaram doença valvular; 17 (77,2%) apresentaram regressão da patologia valvular. Houve desaparecimento de regurgitação moderada inicial em oito pacientes (36,3%). Entre sete (31,8%) pacientes com regurgitação moderada inicialmente, a regurgitação desapareceu em três e quatro apresentaram melhoria para regurgitação leve. Dois pacientes com regurgitação grave inicialmente apresentaram melhoria para regurgitação moderada (9,1%). Em cinco (22,8%) pacientes o grau de regurgitação (regurgitação moderada em um [4,6%] e regurgitação grave em quatro [18,2]) continuou inalterado. O nível de albumina foi significativamente menor no diagnóstico no Grupo 2 (2,6 ± 0,48 gr/dL). A análise do subgrupo de linfócitos mostrou uma redução significativa no percentual de CD8 e um aumento significativo no percentual de CD19 no Grupo 2 em comparação com o Grupo 1. Conclusão: O nível de albumina no sangue e o percentual de linfócitos CD8 e CD19 (+) no diagnóstico podem ajudar a prever risco de doença valvular crônica em pacientes com cardite reumática aguda.

Impacto da Etiologia sobre a Função Atrial Esquerda em Pacientescom Refluxo Mitral Importante / Impact of Etiology on the Left Atrial Function in Patients with Severe Mitral Regurgitation

A adaptação à sobrecarga crônica de volume na insuficiência mitral (IM) tende a aumentar o átrioesquerdo (AE), predispondo a disfunção atrial e arritmias. Embora as dimensões do AE tragam importante informação prognóstica, a função contrátil atrial não tem sido estudada consistentemente na IM. Objetivo: O objetivo deste estudo foi analisar a função atrial em pacientes com IM por cardiopatia reumática (CR) eprolapso valvar mitral (PVM). Métodos: Foram estudados 54 pacientes com IM importante, com área do orifício regorgitante efetivo (ERO) ≥ 0,40 cm2,sendo 23 com CR e 31 com PVM, em ritmo sinusal, com fração de ejeção do ventrículo esquerdo (VE) > 60%. Foram medidos diâmetros e massa do VE, volumes do VE e AE (máximo, mínimo e pré-A), fração de esvaziamento total (FEsv.TAE), passiva (FEsv.P AE) e ativa (FEsv.A AE) do AE, para avaliar função. Medidas de Doppler transmitral e tecidual foram obtidas. Resultados: Comparados ao PVM, pacientes com CR eram mais jovens (35 ± 11 versus 55 ± 13 anos; p < 0,05) e do sexo feminino (17 versus 7 mulheres; p < 0,05); o índice de massa do VE foi maior no grupo PVM. O volume atrial máximo foiigual para os grupos, com maior volume mínimo (56,9 ± 30 versus 41,6 ± 17 mL; p = 0,02) e consequentemente menor FEsv.A AE (0,41 ± 0,11 versus 0,47 ± 0,07; p = 0,03) e FEsv.A AE (0,20 ± 0,08 versus 0,27 ± 0,07; p < 0,001) para o grupo CR. Conclusão: Embora mais jovens, pacientes com IM de etiologia reumática apresentam maior comprometimento da função atrial comparados a pacientes com PVM, possivelmente refletindo o acometimento do miocárdio atrial peladoença...

Adaptation to chronic volume overload in patients with mitral insufficiency (MI) tends to increase left atrium (LA), leading to LA dysfunction and arrhythmias. Though LA dimension is a well-known cardiovascular risk predictor, LA contractile function has not been thoroughly assessed in patients with MI of distinct etiologies. Objective: We aimed to assess LA structure and function in patients with MI due to rheumatic heart disease (RHD) and mitral valve prolapse (MVP). Methods: We assessed 54 patients with severe MI, defined by an effective regurgitant orifice (ERO) ≥ 0.40 cm2, 23 with RHD and 31 with MVP, all in sinus rhythm and with left ventricular (LV) ejection fraction > 60%. We measured LV diameters and mass, and also volumes (Simpson) to assess function, including maximal, minimal and pre-atrial contraction volumes, and total (TLAEF), passive (PLAEF) and active (ALAEF) LAemptying fraction. Transmitral and tissue Doppler measurements were obtained. Results: Compared to MVP, patients with RHD were younger (35 ± 11 versus 55 ± 13 years) and mainly female (17 versus 7 female; p < 0.05);LV mass index was higher for MVP patients. Although LA maximal volume was similar for both groups, patients with RHD had higher minimal LA volumes (56.9 ± 30 versus 41.6 ± 17 ml; p = 0.02), resulting in lower TLAEF (0.41 ± 0.11versus 0.47 ± 0.07; p = 0.03) and ALAEF (0.20 ± 0.08versus 0.27 ± 0.07; p < 0.001). Conclusion: Although younger, patients with MI due to RHD present with more severe LA dysfunction compared to MVP, possibly reflecting direct atrial impairment from rheumatic heart disease...

Dilatación aneurismática de la aurícula izquierda / Giant left atrium

Mujer de 48 años con síntomas progresivos de disnea, fatiga, disfagia, edema de miembros inferiores, palpitaciones y disminución de su capacidad física que le obligan a buscar atención médica. La radiografía de tórax muestra cardiomegalia grave o <

Woman 48 years old with progressive dyspnea, fatigue, dysphagia, lower limb edema, palpitations and decreased physical ability that made her to seek medical attention. The chest film showed severe cardiomegaly or <

In-hospital Mortality in Patients with Rheumatic Heart Disease Undergoing Double Valve Replacement / Mortalidade Intra-Hospitalar em Pacientes com Cardiopatia ReumáticaSubmetidos a Dupla-Troca Valvar

A cardiopatia reumática é um importante problema de saúde pública. Há escassez de dados sobreinfluência de variáveis cirúrgicas na mortalidade de pacientes reumáticos submetidos dupla-troca valvar (DTV).Objetivo: Identificar possíveis variáveis cirúrgicas associadas à mortalidade de pacientes reumáticos submetidos à DTV.Métodos: Estudo retrospectivo de corte transversal, incluindo 104 pacientes >18 anos, com diagnóstico prévio devalvopatia reumática, submetidos à cirurgia de DTV no período de janeiro de 2007 a dezembro de 2011. A coletade dados utilizou os prontuários de pacientes do Hospital Ana Nery, Salvador, BA, Brasil.Resultados: Observou-se diferença estatística significativa entre os grupos do desfecho (óbito intra-hospitalar/alta hospitalar) em relação às variáveis, respectivamente: tempo de anoxia (minutos) de 149,17±40,99 e 123,99±24,12(p=0,001); tempo de CEC 185,53±54,59 e 157,34±34,62 (p=0,006); e o tempo cirúrgico total 350,29±56,69 e 295,23±63,98(p=0,002). Os pacientes que realizaram outro procedimento associado à DTV, no mesmo tempo cirúrgico,apresentaram maior mortalidade (n=10; 31,2%), em relação aos que realizaram apenas a DTV (n=9; 12,8%) (p=0,027).Houve também associação significativa na comparação de pacientes com reabordagem cirúrgica com aqueles querealizaram única abordagem (p<0,001). Não houve diferença estatística quando se comparou desfecho hospitalare os tipos de próteses utilizadas (p=0,219). Conclusões: As variáveis cirúrgicas que tiveram influência na mortalidade foram: tempos de anoxia, de CEC, de cirurgia total, com possíveis pontos de corte, respectivamente, de 150 min, 100 min e 300 min. A necessidade de reabordagemno pós-operatório hospitalar e a realização de outro procedimento no mesmo ato também mostraram significância...

Rheumatic heart disease is a major public health issue. Data on the influence of surgical variables in mortality in rheumatic patients undergoing double valve replacement (DVR) are scarce. Objective: Identify potential surgical variables associated with mortality in rheumatic patients undergoing DVR. Methods: Retrospective cross-sectional study including 104 patients over 18 years, previously diagnosed with rheumatic heart-valve disease, and undergoing DVR surgery from January 2007 to December 2011. Data collection: medical records of patients from HospitalAna Nery, Salvador, Brazil.Results: Outcome groups (in-hospital death vs. hospital discharge) had a significant statistical difference in relation to variables, respectively:anoxia time (in minutes) of 149.17±40.99 and 123.99±24.12 (p=0.001); CPB time 185.53±54.59 and 157.34±34.62 (p=0.006); and totalsurgical time 350.29±56.69 and 295.23±63.98 (p=0,002). Patients who underwent another procedure associated with DVR for the same surgical time showed higher mortality rates (n=10; 31.2%) compared to those who underwent DVR only (n=9, 12.8%) (p=0.027). There was also a significant association when comparing patients with surgical rapprochement with those who underwent one surgery only(p<0.001). There was no statistical difference between hospital outcome and the types of prostheses used (p=0.219). Conclusions: The surgical variables that influenced mortality were: anoxia, CPB and total surgical times, with potential cutoff points of 150, 100 and 300 minutes, respectively. The need for rapprochement during the in-hospital postoperative period, and the performance of another associated procedure in the same surgery were also significant...

Mouth - A Diagnostic Mirror of Various Diseases.

The mouth is a unique site, due to the presence of hard and soft tissues in close approximation. It serves in various purposes of speech, mastication and digestion. It is an important entry point for many pathogens in the body. Many systemic diseases manifest in the oral cavity and mouth can show early signs or the only signs of a disease process at a site elsewhere. As the mouth is an easily accessible site, the indicators it shows of various diseases should not be overlooked. A dentist thus can frequently be exposed to such conditions and play a key role in the diagnostic procedure of various systemic diseases. Appropriate knowledge of these oral manifestations is essential for early diagnosis, treatment and referral of cases.

Aspectos atuais da doença reumática / Current aspects of the rheumatic fever

O autor faz revisão sobre a Doença Reumática, frente à sua permanência nas regiões mais pobres do país. Da análise da tríade produtora da enfermidade, discute aspectos ligados aos aspectos imunitários envolvidos, a possibilidade de cepa estreptocócica de grande virulência na gênese de formas graves e, sobretudo, aspectos ligados à pobreza e ausência de saneamento nos locais em que vivem os enfermos. Sob o ângulo clínico, mostra a contradição entre "aspectos atuais da doença", quando eles apenas reproduzem a apresentação que existia nos países centrais nos séculos 18 e 19. Enfatiza a relevância do uso do Ecodopplercardiograma no estudo de populações, o que depõe por prevalência bem maior que estudos realizados apenas com o estetoscópio. Salienta a supremacia da prevenção da doença e a necessidade que seja ela incluída entre as doenças negligenciadas, na base de políticas de combate a essas enfermidades.

The author's review of the Rheumatic Fever, outside hispersistence in the poorest regions of the our country. Analysis of the epidemiological triad of the disease, the aspects immunological are argued, also the possibility of large strain streptococcus virulence in the genesis of serious issues and especially the relevance of the poverty and lack of sanitation inplaces where the sick live. Under the clinical angle shows the contradiction between "current aspects of the disease" when they merely reproduce the presentation that existed in the central countries in the 18th and 19th centuries. Emphasizes the importance of using Doppler echocardiogram in study populations, which argues for much greater prevalence than studies only with the stethoscope. Underlines the primacy of disease prevention and the need to be included it among the neglected diseases, on the basis of policies to combat these diseases.

Prevalence of Rheumatic Fever and Rheumatic Heart Disease Among School Children.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns in the developing countries like India. A total number of 10330 school children were examined clinically for evidence of acute rheumatic fever and rheumatic heart disease . Those suffering with the disease were subjected to electrocardiographic, rontgenographic and echocardiographic examination. Prevalence of acute rheumatic fever and rheumatic heart disease was found to be 0.87 per 1000.

Reducción de la aurícula izquierda y reemplazo de válvula mitral mediante técnica de autotransplante en paciente con aurícula izquierda gigante / Left atrial reduction and mitral valve replacement through autotransplant technique in giant left atrium

El 19% de los pacientes con patología mitral reumática presenta aurícula izquierda gigante (diámetro mayor a 65mm), esta patología ha sido asociada con incremento del riesgo de stroke y de muerte súbita. La indicación de reducción auricular se establece cuando existe compresión de las extructuras vecinas, antecedentes de fenómenos tromboembólicos o en pacientes asintomáticos para restablecer el ritmo sinusal (Cirugía de Maze). Se presenta el caso de una mujer de 63 años con estenosis e insuficiencia mitral reumáticas severas, atrio izquierdo gigante (diámetro mayor a 90 mm) y fibrilación auricular permanente, a quien se le realizó mediante técnica de autotrasplante, reemplazo de válvula mitral y reducción de aurícula izquierda. En el postoperatorio la paciente presentó insuficiencia renal que requirió diálisis y soporte ventilatorio con intubación orotroqueal por tres semanas. Sin embargo al tercer mes del postoperatorio la paciente se encontraba en Clase funcional I (NYHA) y en ritmo sinusal. (AU)

19% of patients with rheumatic mitral valve disease have giant left atrium (diameter greater than 65mm), this condition has been associated with increased risk of stroke and sudden death. The indication for atrial reduction are established when there are compression of neighboring extructura, history of thromboembolic events and in asymptomatic patients for restore sinus rhythm (Maze surgery). We report the case of a patient of 63 years old with rheumatic mitral disease, giant left atrium (diameter greater than 90 mm ) and permanent atrial fibrillation, we performed mitral valve replacement and left atrial reduction. Postoperatively, the patient had renal failure requiring dialysis and ventilatory support with intubation orotroqueal for three weeks. However at the third postoperative month the patient was in functional class I (NYHA) and sinus rhythm. (AU)

Endocarditis infecciosa: características clínicas, complicaciones y mortalidad en 506 pacientes y factores pronósticos de sobrevida a 10 años (1998-2008). Estudio cooperativo nacional en endocarditis infecciosa en Chile (ECNEI-2) / Clinical characteristics, complications and mortality in 506 patients with infective endocarditis and determinants of survival rate at 10 years

Background: Rates ofmorbidity and mortality in Infective Endocarditis (IE) remain high and prognosis in this disease is still difficult and uncertain. Aim: To study IE in Chile in its active phase during inpatient hospital stay and long term survival rates. Material and Methods: Observational prospective national cohort study of 506 consecutive patients included between June 1,1998 and July 31, 2008, from 37 Chilean hospitals (secondary and tertiary centers) nationwide. Results: The main findings were the presence of Rheumatic valve disease in 22.1 % of patients, a history of intravenous drug abuse (IVDA) only in 0.7%, the presence of Staphylo-coccus aureus in 29.2% of blood cultures, negative blood cultures in 33.2%, heart failure in 51.7% and native valve involvement in 86% ofpatients. Echocardiographic diagnosis was achieved in 94% of patients. Hospital mortality was 26.1% and its prognostics factors were persisting infection (Odds ratio (OR) 6.43, Confidence Interval (CI) 1.45-28.33%), failure of medical treatment and no surgical intervention (OR 48.8; CI 6.67-349.9). Five and 10 years survival rates were 75.6 and 48.6%, respectively. The significant prognostic factors for long term mortality, determined by multivariate analysis were the presence of diabetes, Staphylococcus aureus infection, sepsis, heart failure, renal failure and lack of surgical treatment during the IE episode. Conclusions: The microbiologic diagnosis of IE must be urgently improved in Chile. Mortality rates are still high (26.1%) partly because of a high incidence of negative blood cultures and the need for more surgical valve interventions during in-hospital period. Long term prognostic factors for mortality should be identified early to improve outcome.

Presença de anti-RO prediz aparecimento de lesão valvar em artrite reumatoide / Presence of anti-RO predicts onset of valve lesions in rheumatoid arthritis

JUSTIFICATIVA E OBJETIVOS: Alguns autoanticorpos são associados com achados clínicos peculiares. Pacientes com artrite reumatoide (AR) podem apresentar autoanticorpo anti-RO. O objetivo deste estudo foi estudar a prevalência e associações clínicas do anticorpo anti-RO em pacientes com AR. MÉTODO: Foram estudados 385 pacientes diagnosticados com AR e que possuíam teste Elisa para anti-RO. Também foram analisadas informações referentes ao perfil do paciente, avaliação funcional, DAS-28, manifestações extra-articulares, função tireoidiana, perfil de autoanticorpos e de tratamento.RESULTADOS: A prevalência do anticorpo anti-RO foi de 8,31%. Não houve diferença significativa em relação ao sexo, HAQ, DAS-28, classificação funcional em pacientes com anti-RO positivo (p = ns). Pacientes com anti-RO apresentaram idade menor ao diagnóstico (p = 0,02). Em relação às manifestações extra-articulares, encontrou-se maior prevalência de lesões valvares cardíacas (p < 0,001) em pacientes com anticorpo anti-RO.Não foram encontradas diferenças significativas na análise de outras desordens extra-articulares, associação com hipotireoidismo,amiloidose, tratamentos indicados, presença de fator reumatoide (FR) e anticorpo antipeptídeo cíclico citrulinado (anti-CCP). CONCLUSÃO: Pacientes com AR que apresentam o anticorpo anti-RO tem um início de doença mais precoce. O anticorpoanti-RO é um fator de risco para o desenvolvimento de lesões valvares. Não foram encontradas relações do anti-RO com tireoidopatias, amiloidose secundária e escolha de tratamento.

BACKGROUND AND OBJECTIVES: Some auto antibodies are associated with peculiar clinical findings. Patients with rheumatoid arthritis (RA) may have anti-RO antibodies. The objective of this study was to investigate the prevalence and clinical associations of anti-RO antibodies in RA patients. METHOD: We studied 385 patients with RA for anti-RO by Elisa testing and for clinical profile, functional assessment, DAS-28, extra-articular manifestations, thyroid function, auto antibodies and treatment. RESULTS : The prevalence of anti-RO was 8.31%. There was no significant difference in sex distribution, HAQ, DAS-28,functional classification in patients with positive anti-RO (p = ns). Patients with anti-RO were younger at diagnosis (p = 0.02).Analyzing extra-articular disorders we found a greater prevalence of cardiac valve lesions (p < 0.001) in patients with anti-RO antibodies. No differences were found in other extra-articular manifestations, associated hypothyroidism, amyloidosis, treatment requirements, presence of rheumatoid factor (RF) and anti citrullinated protein antibodies (ACPA). CONCLUSION : RA patients with anti-RO have disease onset at earlier age. Anti-RO is a risk factor for the development of valve lesions. There is no association between this antibody and thyroid disease, amyloidosis and treatment needs.

Anestesia para gestante cardiopata / Anaesthesia for the obstetric patient with cardiac disease

A doença cardíaca permanece como causa frequente de morte durante a gravidez. A cardiopatia mais frequente durante a gravidez é a reumática, seguida pela congênita. No Brasil, a cardiopatia chagásica é a terceira causa de doença cardíaca durante a gravidez. As alterações cardiovasculares da gravidez associadas às doenças cardíacas têm significativo impacto no binômio materno-fetal, resultando em comprometimento tanto para a mãe como para o feto. Essas alterações acentuam-se durante o trabalho de parto, parto e puerpério imediato, acarretando interações importantes com a anestesia. A anestesia peridural contínua e o bloqueio combinado raqui-peridural utilizando soluções de bupivacaína ou ropivacaina associada a fentanil ou sufentanil são técnicas seguras para parto vaginal. Para cesariana, tanto o bloqueio combinado como a anestesia peridural contínua, com indução lenta em bolus, são técnicas seguras. A anestesia geral deve ser reservada para as pacientes graves com classe funcional IV, hipertensão pulmonar grave, coarctação da aorta, e estenose aórtica e mitral grave. O período de pós-parto imediato é o período de maior risco. As pacientes graves devem permanecer monitorizadas e sob vigilância, independentemente da via do parto e da técnica anestésica.

Surgical treatment of primary cardiac rhabdomyosarcoma / Tratamento cirúrgico de rabdomiosarcoma primário do coração

The authors report a case of a 16-year-old man who presented progressive dyspnea. At that time the diagnosis of rheumatic fever with mitral valve involvement was performed. The bidimensional echocardiogram showed presence of mobile mass inside the left atrium. The tumor presented lobules, projecting into the left ventricle during the diastole and provoking turbulence. The patient underwent surgical resection with postoperative course needing re-operation for mitral valve replacement. Histopathology has proven that such tumor was a primary cardiac rhabdomyosarcoma and the early clinical diagnosis of rheumatic mitral valve disease was very difficult.

Os autores reportam caso de jovem de 16 anos, o qual apresentou dispnéia progressiva. No momento do atendimento foi feito diagnóstico de febre reumática com comprometimento da valva mitral. Ecocardiograma bidimensional demonstrou a presença de massa móvel dentro do átrio esquerdo. O tumor apresentava lobos, se projetando para o interior do ventrículo esquerdo durante a diástole, provocando turbulência. O paciente foi submetido a ressecção cirúrgica, complicada com reoperação e troca valvar mitral. A histopatologia demonstrou tratar-se de rabdomiosarcoma primário e o diagnóstico clínico diferencial com febre reumática e doença valvar mitral foi muito difícil desde o seu início.

Auscultation versus echocardiography for assessment of patients with acute rheumatic fever and rheumatic heart disease

Rheumatic fever is a major health problem in many countries, and RHD, a sequelae of RF, is a very common cause of cardiovascular mortality and morbidity especially in developing countries as in Egypt. Due to many factors like tachycardia, an untrained ear and low intensity of the murmur, many murmurs in the cardiovascular system are missed clinically. It has been seen in many studies that the echo is much more sensitive in picking up the lesions which are easily missed on clinical examination. This study was designed to determine the effectiveness of auscultation in detecting valvular affection in cases with acute rheumatic fever [ARF] and in those with established RHD and to assess the usefulness of echocardiographic examination in such cases. The study included sixty patients with RHD [mean age 1 +/- 4.2 years] who came for follow up in the RF outpatient clinic of the Children hospital of Cairo University and 64 children with ARF [mean age 9.8 +/- 2.9 years] who were admitted to the inpatient wards of the same hospital. Each patient underwent detailed clinical evaluation and relevant investigations including echocardiography. The most common lesion was mitral regurgitation [MR] both by auscultation and by echo. Mixed lesions were seen more often than pure lesions. In the whole studied patients, MR had the highest sensitivity while tricuspid regurgitation [TR] had the highest specificity. TR showed the highest positive predictive value and MS showed the highest negative predictive value. Sensitivity of aortic regurgitation [AR] was very low. There was a statistically significant difference between echo diagnosis and clinical auscultation diagnosis of MR, TR and AR [p < 0.05 in MR, <0.001 in TR and AR]. Clinical auscultation skills were noticed to be suboptimal regarding AR and MS murmurs. Clinical auscultation alone can miss various lesions, especially when the lesions are mild or when multiple lesions are present, so it is recommended that echocardiography be done routinely for the diagnosis of cardiac lesions in patients of ARF and RHD

Gustav Mahler: aspectos médicos y psicológicos que influenciaron la vida y obra del gran músico / Gustav Mahler: medical and psychological aspects

Gustav Mahler es considerado en la actualidad uno de los más importantes músicos que vivieron al final del siglo XIX. A pesar de tener en vida sólo un parcial reconocimiento como compositor, Mahler sufrió de complicaciones de una fiebre reumática, desarrollando un corea de Sydenham, manifestaciones obsesivas y compromiso valvular cardíaco. Gran importancia tuvieron en su vida y obra, aspectos psicológicos de su infancia revelados después de una estrevista terapéutica con Freud. Mahler lamentablemente falleció en el período más productivo y de madurez de su obra, debido a una endocarditis bacteriana subaguda.

A proposito de un caso clínico: infarto simultaneo cardiaco y cerebral, en el curso de endocarditis infecciosa / Purposely of s case report: simultaneous cardiac and cerebral infarction, in the course of infectious endocarditis

Se trata de un caso de paciente masculino, de 58 años de edad, atendido de emergencia en el Intituto Nacional de Torax por presentar un cuadro clínico inusual de Infarto Agudo de Miocardio asociado contemporáneamente a infarto cerebral como complicación de embolismo séptico procedente de vegetaciones de la válvula mitral en el curso de Endocarditis Infecciosa, no diagnosticada previamente. Es un caso de alto riesgo de mortalidad que evolucionó satisfactoriamente mediante estrategia de tratamiento combinado de Antibioticoterapia parenteral, tratamiento invasivo con cateterismo cardiaco y Angioplastia Coronaria Primaria, y tratamiento quirúrgico con circulación extracorpórea de Cambio Valvular Mitral.

A clinical case of a 58 years old patient is described, the patient wasadmitted as an Emergency to the Instituto Nacional de Tórax, with anunusual presentation of both Acute myocardial Infarction and CerebralEmbolic Stroke as a complication of septic embolism associated withmitral valve vegetations in the course of Infective Endocarditis thatwas not previously diagnosed. This is a high mortality risk clinicalcase, that evolved to full recovery with combined treatment strategyincluding full antibiotic therapy, cardiac catheterization and primarycoronnary angioplasty, and surgical mitral valve replacement.

Pattern of rheumatic heart disease in Southern Yemen

To determine the pattern of rheumatic heart disease in Aden city and surrounding areas by assessing its frequency distribution, severity and complications. We conducted this research in a sole regional echocardiographic department for Southern Yemen governorates at a referral hospital located in Aden city, from January 1999 to December 2003. It was a retrospective study focused on echocardiographic findings in 805 patients affected by rheumatic heart disease. Out of 805 patients, 383 [47.6%] were male and 422 [52.4%] were female [age range, 4-70 years; mean age, 28.6 +/- 14.5]. Heart valve damage was distributed among patients as follow: mitral 459 [57.1%], aorta 70 [8.7%] and both valves 276 [34.2%]; isolated lesions 55.2% and multiple 44.8%; mitral regurgitation 464 [57.6%], mitral stenosis 405 [50.3%], aortic regurgitation 327 [40.6%] and aortic stenosis 54 [6.7%]. All children aged less than 10 years had regurgitation. Stenosis and multiple valve lesions predominated in adolescents and young adults. Complications were detected in 20.8% of cases. Pulmonary hypertension was the most common complication [80.4%]. Lesions with moderate and severe degree were detected in 51% cases. Only 34.8% of patients at severe stage were operated. Rheumatic heart disease takes an aggressive course in Southern Yemen. Children, adolescents and young adults of both gender are the victims. Complications appear early with scanty opportunity to reach advanced age. There is a little chance for palliative treatment

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

Profilaxia da febre reumática / Rheumatic fever prophylaxis

A prevenção de surtos iniciais de febre reumática depende do reconhecimento e do tratamento rápidos da faringoamidalite. A erradicação do estreptococo do grupo A da orofaringe é essencial. Na seleção de um regime terapêutico, vários fatores devem ser considerados, incluindo eficácia bacteriológica e clínica, e facilidade de aderência à terapêutica recomendada. A penicilina é o agente antimicrobiano de escolha para o tratamento da estreptococcia, exceto em pacientes com história de alergia à penicilina. Para os pacientes que já apresentam o diagnóstico de febre reumática é indicada a profilaxia secundária para a prevenção de novos surtos de febre reumática. Ressalta-se a necessidade do diagnóstico correto, e a melhor ferramenta para fazê-lo é a história clínica detalhada e o exame físico minucioso. Assim, em nosso meio, a profilaxia secundária deve ser realizada com aplicações de penicilina G benzatina com intervalo máximo de três semanas.