Nova contribuição ao estudo do remodelamento ventricular e dos anéis valvares na cardiomiopatia dilatada: avaliação anátomo-histopatológica / New contribution to the study of ventricular remodeling and valve rings in dilated cardiomyopathy: anatomical and histological evaluation

Introdução: A cardiomiopatia dilatada idiopática (CMDId) é causadora de grande impacto, porém aspectos de sua fisiopatologia são desconhecidos. Objetivo: Avaliar aspectos anatomo-histológicos de corações com CMDId comparando-os a corações normais, com medidas perimetrais dos anéis atrioventriculares direito (AVD) e esquerdo (AVE) e dos ventrículos direito (VD) e esquerdo (VE) e a porcentagem de fibras colágenas e elásticas dos anéis. Métodos: Foram avaliados 13 corações de cadáveres portadores de CMDId e 13 corações normais, que foram dissecados mantendo-se os anéis atrioventriculares e a massa ventricular, com laminação em segmentos correspondentes a 20%, 50% e 80% da distância entre o sulco atrioventricular e o ápice ventricular. Os cortes foram submetidos à digitalização fotográfica, sendo comparadas as medidas. Os anéis foram dissecados, medidos e enviados ao laboratório de anatomia patológica, sendo realizadas colorações por meio de hematoxilina-eosina, picrossírius e resorcina fuccina oxidada. Resultados: Com relação aos ventrículos, no grupo CMDId ocorre dilatação nos segmentos apical, equatorial e basal. A medida do AVD foi maior no grupo CMDId, não havendo diferença no AVE entre os grupos. Com relação ao percentual de fibras colágenas, há diminuição no grupo CMDId em relação ao grupo normal. Com relação às fibras elásticas, não houve diferença entre os grupos. Conclusão: Ocorre alteração da geometria ventricular com dilatação no grupo CMDId. Na CMDId observou-se aumento no perímetro do AVD. Não se observou aumento do perímetro do AVE. Houve diminuição percentual na área total de colágeno tanto no AVD quanto no AVE em corações com CMDId. .

Introduction: Idiopathic dilated cardiomyopathy causes great impact but many aspects of its pathophysiology remain unknown. Objective: To evaluate anatomical and histological aspects of hearts with idiopathic dilated cardiomyopathy and compare them to a control group, evaluating the behavior of the perimeters of the atrioventricular rings and ventricles and to compare the percentage of collagen and elastic fibers of the atrioventricular rings. Methods: Thirteen hearts with cardiomyopathy and 13 normal hearts were analysed. They were dissected keeping the ventricular mass and atrioventricular rings, with lamination of segments 20%, 50% and 80% of the distance between the atrioventricular groove and the ventricular apex. The sections were subjected to photo scanning, with measurement of perimeters. The atrioventricular rings were dissected and measured digitally to evaluate their perimeters, later being sent to the pathology laboratory, and stained by hematoxylin-eosin, picrosirius and oxidized resorcin fuccin. Results: Regarding to ventricles, dilation occurs in all segments in the pathological group, and the right atrioventricular ring measurement was higher in idiopathic dilated cardiomyopathy group, with no difference in the left side. With respect to collagen, both sides had lower percentage of fibers in the pathological group. With respect to the elastic fibers, there was no difference between the groups. Conclusion: There is a change in ventricular geometry in cardiomyopathy group. The left atrioventricular ring does not dilate, in spite of the fact that in both ventricles there is lowering of collagen. .

Síndrome carcinoide y compromiso valvular cardíaco / Carcinoid syndrome anf heart valve involvemen

El carcinoide es un tumor neuroendocrino raro que se origina típicamente en el tracto gastrointestinal y que puede resultar en un amplio espectro de síntomas mediado por sustancias vasoactivas. La enfermedad carcinoide con compromiso cardíaco es caracterizada por el depósito de tejido fibroso en forma de placas, afectando más frecuentemente las válvulas cardíacas derechas y el endocardio. El compromiso valvular izquierdo ocurre en menos del 10 por ciento de los casos y es casi siempre asociado a un cortocircuito de derecha a izquierda o a un carcinoide bronquial primario. Los pacientes con falla cardíaca derecha sintomáticos tienen limitadas opciones terapéuticas diferentes a la cirugía cardíaca. El reemplazo valvular cardíaco es el único tratamiento efectivo para la enfermedad valvular carcinoide y debiese ser considerada en pacientes sintomáticos, en los cuales la enfermedad metastásica y los síntomas del síndrome carcinoide se encuentran bien controlados. Por estos motivos, se recomienda un enfoque multidisciplinario en un centro de experiencia para este tipo de pacientes. El presente artículo es una revisión actualizada de la literatura al respecto, tratando de clarificar las principales dudas con respecto al manejo de estos pacientes.

Carcinoid is a rare neuroendocrine tumor typically originating in the gastrointestinal tract and which may result in a broad spectrum of symptoms mediated by vasoactive substances. Carcinoid heart disease is characterized by plaque-like deposits of fibrous tissue, most frequently affecting the right heart valves and endocardium. Left-sided valve disease occurs in less than 10 percent of patients with cardiac involvement and is almost always associated with an atrial right-to-left shunt or a primary bronchial carcinoid. Patients with symptomatic right heart failure have limited therapeutic options other than cardiac surgery. Cardiac valve replacement is the only effective treatment for carcinoid heart disease and should be considered for symptomatic patients whose metastatic carcinoid disease and symptoms of carcinoid syndrome are well controlled. A multidisciplinary approach at an experienced center is recommended for the care of these patients.

Análisis numérico de una prótesis endobronquial utilizada para el tratamiento de cáncer pulmonar / Numerical analysis of intrabronchial prosthesis used for the treatment of lung cancer

En México, la mortalidad debido a enfermedades bronco-respiratorias se ubica en el sexto lugar según datos estadísticos dados por el Instituto Nacional de Enfermedades Respiratorias (INER). Esto genera la necesidad de incrementar la eficiencia en la aplicación de los tratamientos usados para este tipo de patología. Algunos de los métodos utilizados con mayor frecuencia para el tratamiento de estas dolencias hacen uso de micro dispositivos, también conocidos como válvulas endobronquiales. Este es un sistema alternativo que evita cirugías invasivas y logra prolongar e incrementar la calidad de vida de los pacientes. En este trabajo se presenta el análisis del desempeño de la válvula IBV®. Para el desarrollo del estudio numérico se determinaron las dimensiones y propiedades mecánicas del modelo a partir de catálogos del fabricante. Se desarrolló un modelo para el cual se consideraron las propiedades del Nitinol® y Silastic®. Asimismo, se propusieron dos condiciones de operación para la válvula, una anclada en el bronquio y la otra en la condición en la que se encuentra plegada dentro del broncoscopio. Se utilizó el Método del elemento finito (MEF) para simular las condiciones de trabajo de la válvula. Los resultados encontrados muestran el funcionamiento estructural y el nivel de los esfuerzos generados en el implante durante el ciclo de respiración forzada del individuo. Además, se proporcionan las bases para generar un nuevo dispositivo que pueda emular el funcionamiento de este tipo de implantes y aumente la eficiencia del tratamiento de dicha patología.

In Mexico, the mortality rate due to bronchial respiratory sickness is placed in the sixth position, according to statistics from the National Institute of Breathing Sickness (INER), so it is convenient to increment the efficiency of treatments for those pathologies. The intrabronchial valve is a recommended alternative method; being it main objective to avoid invasive surgery and increase the time and quality of patient´s life. Within this work a biomechanical analysis of an IBV® valve is carried out. Regarding the numerical analysis, the dimensions and mechanical properties of the valve were proposed based on catalogues published by the manufacturer as more reliable information was not available in the open literature. As a result, a new model was developed in which both materials Nitinol® and Silastic® are considered as the main valve materials. The proposed working conditions assume that the valve is implanted in folded form at the bronchus and then anchored when it is unfolded. Finite Element Method (FEM) was used to simulate the proposed working conditions. Results obtained show the structural performance and the level of stress generated in the implant during the breathing cycle. In addition, it provides the knowledge to generate a new device that could emulate the performance of these implants and develop a more efficient treatment this disease.

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

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

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

HLA Profile in Iraqi rheumatic valvulitis patients

Human leukocyte antigen [LILA] is the most polymorphic genetic system in man. The genes of this region influence susceptibility to certain disease. This study was established to shed light on the possible association of HLA class I and II antigens with RV patients. Lymphocvtotoxicity assay for HLA for class I and II typing had been done for [100] iraqi patients suffering from rheumatic valvulitis [RV] the control groups consisting of [75 healthy individuals and 35 non rheumatic heart disease [NRHD] patients]. The results showed a significant association of A33-Ag with these patients as compared with healthy and cardiac controls [P=0.005][P=0.033] respectively. Another interesting finding was the low frequency of AI in RI patients when compared with heal/he control [p=0.002], suggesting that Al allele may confer protective effect against this disease. In addition significant association between blood group B and RV was evident [p=0.04] An interesting observation was a strong association of blood group B and A33 among those patients [P < 0.001]. The present results are consistent with hypothesis that susceptibility to RV is genetically linked and in turn may be associated mainly with A33 in Iraqi patients

Valvular vegetations? Cardiac amyloidosis is a possibility.

Cardiovascular system is a frequent target for the deposition of amyloid, specially in the primary type. Patients with this condition can present with myocardial dysfunction due to heavy interstitial myocardial deposits. We report a case of primary cardiovascular amyloidosis in a male with sudden cardiac death. The distribution of amyloid was remarkable for exclusive deposition in the pulmonary and systemic arterial adventitia and more strikingly over all valves, specially the mitral valve. These were large enough to simulate vegetations.

Válvula de Eustaquio que simula un mixoma atrial / Eustachian valve that simulates atrial myxoma

Se presenta un caso de válvula de Eustaquio que simula ecocardiográficamente un mixioma atrial derecho, en un paciente con sospecha clínica de tromboembolismo pulmonar. La válvula de Eustaquio es un remanente embrionario de la porción derecha del seno venoso, cuya función consiste en permitir el paso de sangre oxigenada desde la vena cava inferior, a la circulación sistémica. Su presencia constituye parte del diagnóstico diferencial de otras masas intracavitarias cardíacas, como los mixiomas, trombos, metástasis tumorales, o tumores primarios del corazón. Descriptores: Válvula Eustaquio, mixoma, exocardiografía.

Aspectos anátomo-patológicos e histológicos en el corazón de pacientes con endocarditis infecciosa / Anatomopathological and hystological aspects of the heart of patients with infectious endocarditis

Se discute aquellos aspectos anatomopatológicos e histológicos del corazón considerando la patogénesis, bacteremia, patología valvular previa y la morfología de las vegetaciones.

Rheumatic heart disease in the past decade: an autopsy analysis.

BACKGROUND: Rheumatic heart disease continues to be an important cardiac problem, afflicting the young population of India. Though prophylaxis and various treatment modalities are available for the valvar pathology, mortality and morbidity continue to be high. Autopsy data are scarce. METHODS AND RESULTS: This is an autopsy analysis of rheumatic heart disease as seen at a large teaching hospital over a period of 5 years in the past decade. Four hundred thirty-four cases were autopsied in a five-year period from 1993 to 1997. The majority of cases were between 16 and 40 years of age. Fifty cases showed the presence of Aschoff bodies indicating a recent attack of rheumatic carditis. One hundred seventy-eight valves were examined in detail--in 174, the mitral valve was involved. In 4 cases, only the aortic valve was affected. The mitral valve showed significant disease with a severe degree of subvalvar pathology. One hundred thirty-eight patients had already undergone some form of previous surgery and presented with valve dysfunction. Most of these patients were in the third and fourth decades of life. The most frequent cause of death in operated and unoperated cases was congestive cardiac failure. CONCLUSIONS: There is no decrease in the incidence or severity of rheumatic heart disease over a period of 25 years as seen at our institute. The pattern of the disease has changed, with patients who had a previous surgery now returning with valve dysfunction or related problems.

Comparison of th immediate and intermediate term results of percutaneous balloon mitral valvuloplasty [inoue single - balloon versus double - balloon technique]

This study aimed to compare between the immediate-and intermediate- term results of two modalities of balloon dilatation [the Inoue single-balloon and the double-balloon techniques]. Fifty patients with significant rheumatic mitral stenosis [MS] were enrolled in this study from 1993 to 1996. They were randomly chosen and assigned to either one of the two treatment modalities. Both groups were statistically comparable and identical as regards the clinical examination, ECG, chest X-ray, color Doppler echocardiography and invasive hemodynamic data. After dilatation, the patients were followed up immediately, three and >/ six months later by clinical and echo-Doppler evaluation. An invasive hemodynamic study was also done immediately post-dilatation. Both techniques gave a highly significant improvement in the hemodynamics of both patient groups. They equally improved the mitral valve area [MVA] and the functional status of the patients, which was maintained during the follow-up period

Endocarditis infecciosa tricuspidea por Estreptococo bovis / Streptococcus Bovis tricuspidal infectious endocarditis

La endocarditis infecciosa (EI) en valvulas cardiacas derechas es una afeccion poco frecuente, correspondiendo al 10 por ciento de todas las EI; si bien su incidencia viene en aumento, debido al frecuente uso de dispositivos intravasculares (cateteres, marcapasos) y la drogadiccion. Comentaremos el caso de un EI en valvula tricuspidea en un paciente sin los factores predisponentes mencionados y que se presento como fiebre prolongada de dificil diagnostico

Demanda hospitalaria, manifestaciones clínicas y prevención de fiebre reumática y cardiopatía en el Instituto de Salud del Niño 1989-1993 / Hospital demand, clinical sign and prevention of rheumatic fever and rheumatic cardiopathy in the Instituto de Salud del Niño 1989-1993

Se estudiaron retrospectivamente 66 pacientes hospitalizados en el Servicio de Cardiología del Instituto de Salud del Niño-entre 1989 y 1993- con el diagnóstico de fiebre reumática y cardiopatía reumática. Se encontró un aumento significativo en los 3 últimos años. El promedio en días de hospitalización se duplicó en 1993 respecto a 1989. El grupo etáreo más afectado fue entre los 11-15 años, con 39 pacientes (59 por ciento). El 74.5 por ciento tuvieron clase funcional III o IV, el 98 por ciento compromiso cardíaco; la lesión valvular más encontrada fue de insuficiencia aórtica (41 por ciento); la complicación más frecuente fue endocarditis infecciosa en 15 pacientes (23 por ciento). Fueron operados 8 pacientes sin mortalidad quirúrgica, 4 pacientes (6 por ciento) fallecieron de complicaciones clínicas. El severo compromiso cardiovascular mostrado en nuestra casuística se debe a una recurrencia elevada de carditis reumática por una ineficaz prevención. Ello hace imprescindible la implementación de un programa ampliado de prevención que considere la administración de fármacos y las condiciones sociales del enfermo para mejorar sus condiciones de vida.

Estudio morfológico de 23 corazones con anomalía de Ebstein / Morphologic study of 23 hearts with ebstein's anomaly

Los trabajos publicados sobre malformación de Ebstein han presentado poca atención al estudio de la porción trabecular del vertículo derecho. Por eso estudiamos morfológicamente veintitrés corazones portadores de esta cardiopatía, empleando el método secuencial segmentario y determinando especialmente la extensión del adosamiento y la displasia valvular, las características de la porción trabeculada del ventrículo derecho y las anomalías asociadas. Las tres valvas de la trícuspide presentaron adosamiento, siendo menos frecuente en la anterior aunque en nuestro material ocurrió en el 43 por ciento, cifra alta comparada con lo referido en la literatura. La porción trabecular presentó múltiples bandas anómalas y dicha zona estuvo recubierta por las valvas adosadas. El descenso del orificio funcional fue directamente proporcional al adosamento valvar. Las alteraciones estructurales del ventrículo derecho, correlacionadas con la malformación valvular, permiten suponer que el daño primario conducente a esta cardiopatía ocurrió en el ventrículo derecho durante el desarrollo embrionario alterando la morfogénesis de dicha válvula

Tratamiento de la enfermedad valvular mitral y aórtica / Treatment of the valvular mitral and aortic disease

El presente trabajo constituye una revisión y actualización del tratamiento médico e intervención de la estenosis valvular mitral, insuficiencia valvular mitral, estenosis valvular aórtica e insuficiencia valvular aórtica. Se describen las indicaciones y limitaciones de esas modalidades de tratamiento para cada una de las lesiones valvulares referidas. Del mismo modo se precisan las contraindicaciones de las distintas alternativas y se elaboraron tablas con el esquema del tratamiento intervencionista y quirúrgico para cada valvulopatía