Epidemiology and Management of the 2013-16 West African Ebola Outbreak.

The 2013-16 West African Ebola outbreak is the largest, most geographically dispersed, and deadliest on record, with 28,616 suspected cases and 11,310 deaths recorded to date in Guinea, Liberia, and Sierra Leone. We provide a review of the epidemiology and management of the 2013-16 Ebola outbreak in West Africa aimed at stimulating reflection on lessons learned that may improve the response to the next international health crisis caused by a pathogen that emerges in a region of the world with a severely limited health care infrastructure. Surveillance efforts employing rapid and effective point-of-care diagnostics designed for environments that lack advanced laboratory infrastructure will greatly aid in early detection and containment efforts during future outbreaks. Introduction of effective therapeutics and vaccines against Ebola into the public health system and the biodefense armamentarium is of the highest priority if future outbreaks are to be adequately managed and contained in a timely manner.

[Diastolic intraventricular gradient detected with Doppler echocardiography in hypertrophic cardiomyopathy. Report of a case]. / Detecção com ecocardiografia Doppler de um gradiente intraventricular diastólico na cardiomiopatia hipertrófica. A propósito de um caso.

It has recently been reported the rare existence of intraventricular diastolic gradients in patients with hypertrophic cardiomyopathy. This proves the great disturbance of diastolic function that exists in these patients. We report the case of a patient with this disease, in whom a significant diastolic intraventricular gradient was detected with color Doppler echocardiography. In the end we make a summing up of its most probable physiopathology.

[Changes in coronary angiography in young patients with myocardial infarction]. / Alterações coronariográficas em doentes jovens com enfarte do miocárdio.

OBJECTIVE: To assess the coronariographic changes and left ventricular function of a group of young patients (pts) (less than 40 years) with myocardial infarction. DESIGN: Retrospective analysis on clinical data and cineangiography. SETTING: Patients studied in the Cardiology Department and Cardiothoracic Department of the Santa Marta Hospital in Lisbon. PATIENTS AND INTERVENTIONS: Sequential sample of 40 pts 39 male and one female submitted to coronariography after an acute myocardial infarction (mean age--34 +/- 3 years). MEASUREMENTS AND RESULTS: Twenty one pts had one vessel disease, 6 pts two vessel disease, 3 pts three vessel disease, 1 left main disease (2.5%) and 9 normal coronary arteries. More than a half (22) had a lesion on the left anterior descending artery (proximal in 12-30%), 13 a lesion on the right coronary artery (proximal in 3) and 8 on the circunflex coronary artery. There were 22 (55%) total occlusions (3 of the circunflex, 9 of the left anterior descending artery and 10 of the right coronary artery). Of these 8 were proximal. We divided the pts according to the regional contractility score in three groups. Most of them had a moderate decrease in contractility. Three pts had an apical aneurysm and 8 pts had apical discinesia. Three of these 11 pts had no significant coronary lesions, six had one vessel disease and 6 had a proximal lesion of the left anterior descending artery. The mean ejection was 53% and none was less than 30%. There was a statistical difference of score and ejection fraction between anterior and inferior myocardial infarctions (6.5 +/- 1.8 versus 7.8 +/- 1.6 e 48 +/- 11.6 versus 55.4 +/- 10.8), p less than 0.05 and between those with and without a proximal lesion of the anterior descending coronary artery (5.5 +/- 1.5 versus 7.9 +/- 1.5 and 41.4 +/- 7.9 versus 56.3 +/- 9.9), p less than 0.0005. Neverthless, when we tried to separate the pts with or without atherosclerotic lesions (6.9 +/- 1.7 versus 7.9 +/- 2.2 and 50.4 +/- 11 versus 54.8 +/- 14.3) or with and without multivessel disease (7.2 +/- 1.8 versus 6.7 +/- 1.9 and 52.9 +/- 12.2 versus 46.6 +/- 8.7), no statistical difference of score and ejection fraction was found. CONCLUSION: Young patients with myocardial infarction are predominantly males; - There is an important number of one vessel disease and in many patients no coronary significant lesions were found; - The functional changes depended more on the proximal location than on the number of diseased vessels.

[Regurgitation jets in mitral prosthesis studied using transesophageal echocardiography]. / Estudos dos fluxos de regurgitação de próteses mitrais obtidos por ecocardiografia transesofágica.

STUDY OBJECTIVE: To analyze the regurgitant jets of mitral valve prostheses studied by transesophageal echocardiography. DESIGN: Prospective study of patients with mitral prostheses with or without suspicion of dysfunction. SETTING: Patients referred to the Echocardiology Department of the Instituto de Cardiologia in Madrid, some as outpatients. PATIENTS AND INTERVENTIONS: Twenty five patients with mitral valve prostheses (5 biological, 7 St Jude, 12 Bjork Shiley and 1 Hall Kaster). Ten male patients and fifteen female, mean age 50 years. Five also had aortic valve prostheses. In only 5 there was a suspicion of dysfunction. The transthoracic echos were done with phased array transducers and the transthoracic with 2.5 (18 patients) or 5 MHz (7 patients) transducers coupled to a commercial echocardiographer. The presence of regurgitant jets was looked for, as well as their origin, maximal area and length, their type and degree of turbulence. MAIN RESULTS: Only 3 mitral regurgitations were noticed by transthoracic echocardiography. All the mechanical prostheses and 80% of the biological ones had regurgitant jets by transesophageal echocardiography. The tilting disc prostheses had two physiological jets, the St. Jude 2, 3, or exceptionally only one central jet. The biological prostheses had one central regurgitant jet, that was smaller than those from the mechanical prostheses (p less than 0.05). There were ten malfunctioning prostheses (5 Bjork Shiley, 3 St Jude and 2 biological). The diagnosis of dysfunction was based on the abnormal origin of the jet (9 cases) or just simply on the characteristics of the regurgitation (turbulence). Four patients were submitted to surgery, all with dysfunctioning prostheses. CONCLUSIONS: Transthoracic echocardiography has a low sensitivity for detecting the regurgitant jets of mitral prostheses. All mechanical prostheses and 80% of biological ones have regurgitation by transesophageal echocardiography. The area and length of the jets are not so different between normal and malfunctioning prostheses in order to separate them. The abnormal jets are recognised because of their abnormal origin and/or their characteristics, with formation of mosaic in color coded Doppler echocardiography.

[Ebstein's anomaly. Clinical aspects and surgical therapy]. / Anomalia de Ebstein. Clínica e terapêutica cirúrgica.

OBJECTIVE: We reviewed the clinical findings and surgical results of Ebstein's anomaly in adult and adolescent age. DESIGN: Retrospective analysis on clinical data, surgery and follow up. SETTING: Patients (pts) studied in the Cardiology and Cardiothoracic Surgery Departments of the Santa Marta Hospital, Lisbon. PATIENTS: All pts in whom Ebstein's anomaly was diagnosed by cardiac catheterization or echocardiography or both, between 1875 and 1989 were included. RESULTS: There were 8 cases (4 female and 4 male). The age varied from 15 and 53 years. Cyanosis and dyspnoea were the presenting features in 7 pts. One of the youngest pts had asymptomatic murmurs. Late appearance of cyanosis had no relation with prognosis. Three pts had pulmonary tuberculosis. One woman had no deterioration in cardiac function during two pregnancies. Clinical findings were variable and ranged from absent murmur with third and fourth sounds to systolic murmurs of high intensity. The ECG was abnormal in all pts. A case with delta wave and normal PQ interval was noted. On the chest X-ray we found cardiomegaly in all pts. Echocardiograms were recorded in 6 pts. The delay of tricuspid valve closure on mitral closure was not always diagnostic. Uncomplicated catheter studies were done in 6 pts. Two pts had associated cardiac lesions: ventricular septal defect (VSD) with pulmonary hypertension and mild pulmonary valve stenosis. Right ventricular angiographies were diagnostic in all cases. During medical follow up from 1 year to 10 years (mean-4) one death occurred in one pt with VSD. In the remaining 4 cases no deterioration in cardiac function or cyanosis was noted. Three pts were operated. The indications for surgery were: severe heart failure and/or increasing cyanosis. Two pts had tricuspid valve replacement with biological prosthesis. One pts had Danielson's tricuspid annuloplasty. During surgical follow up from 2 to 15 years (mean-7) functional class improved and cyanosis disappeared in 2 pts and it decreased in the other. CONCLUSION: In our series of pts with Ebstein's anomaly clinical findings were variable. The indications for surgery were heart failure and cyanosis. The 3 pts operated are alive and have mild symptoms.

[Surgery for infectious endocarditis]. / Cirurgia na endocardite infecciosa.

OBJECTIVE: to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results. DESIGN: retrospective analysis on clinical data, surgery and follow up. SETTING: patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon. PATIENTS AND INTERVENTIONS: sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis. MEASUREMENTS AND RESULTS: the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals. CONCLUSION: the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

[Transesophageal Doppler echocardiography in the evaluation of cardiac pathology]. / A ecocardiografia Doppler transesofágica na avaliação da patologia cardíaca.

Transesophageal echocardiography is one of the most important innovations that have lately turned up for the evaluation of the cardiac patient. This technical approach consists not only of the study of the two dimensional image but of the cardiac flows obtained with pulsed and color Doppler as well, using a gastroscopic probe to which an ultrasonic transducer has been adapted. In this paper we make a revision of the methodology used in our laboratory. We discuss the utility of this technical approach not only for the study of the ambulatory patient but also for the critically ill patient.

[Hypertrophic non-obstructive cardiomyopathy associated with interauricular communication. Report of a case]. / Cardiomiopatia hipertrófica não obstrutiva associada a comunicação interauricular. Apresentação de um caso.

It is unusual the association between hypertrophic cardiomyopathy and atrial septal defect. We present in this paper the results of the tests done to one patient with these two diseases and profit to make an update of the bibliography on this subject.

[Infective endocarditis of pulmonary valve. Considerations apropos of a case associated with interventricular communication and aortic insufficiency ]. / Endocardite infecciosa da válvula pulmonar. Considerações a propósito de um caso associado a comunicação interventricular e insuficiência aórtica.

We report the case of a 23 year old patient in whom heart disease was detected in childhood. He began to have suddenly fever and symptoms of right side heart failure. There were signs of aortic regurgitation, a systodiastolic murmur in the left parasternal region and a diastolic murmur in the left 4th intercostal space. The bidimensional and Doppler Echocardiogram showed a saccular dilatation in the right ventricular outflow tract. He was submitted to catheterisation which confirmed aortic regurgitation and detected ventricular septal defect and pulmonary hypertension. During surgery, a subaortic ventricular septal defect was seen as well as a dilatation of the right coronary aortic cusp which prolapsed through the defect to the right ventricular outflow tract. Vegetations were seen in the pulmonary valve. The aortic valve and a pulmonary cusp were excised and a Björk Shiley aortic prosthetic valve was inserted. The septal defect was closed. The patient is still alive, symptomless, with 40 months of follow up. We discuss some problems related to this case, particularly the surgical indication and the rarity of the morphology discovered.

[Isolated hypoplasia of the right ventricle--apropos of a case]. / Hipoplasia isolada do ventrículo direito--a propósito de um caso.

OBJECTIVE: To report one case of a rare heart disease (Isolated Hypoplasia of the Right Ventricle) and discuss the methodology used to propose surgery with goal. Good follow up results. DESIGN: To report a case. SETTING: One patient studied in the Cardiology Department of the Santa Marta Hospital, Lisbon, and submitted to surgery in the Cardiothoracic Surgery Department of the same Hospital. PATIENT: A 22 years old woman, who had cyanosis since birth, normal cardiac auscultatory findings, pulmonary oligohemia in the chest Roentgenogram and right atrial strain on the Electrocardiogram. INTERVENTIONS: She had an echocardiogram (M1 Mode and 2D) and catheterised, with pressure and oximetry measurements. During the latter procedure, the atrial septal defect was occluded for 20 minutes with a Fogarty catheter and pressure and oximetries were reevaluated. She was later operated. MEASUREMENTS AND RESULTS: The Echocardiogram showed right ventricular hypoplasia, with a normally inserted tricuspid valve and a dilated right atrium. The hemodynamic study confirmed the presence of an atrial septal defect with right to left shunt, normal pulmonary artery pressure, no gradients and giant "a" wave in the right auriculogram. The right ventriculography showed right ventricular inflow hypoplasia. The occlusion of the atrial septal defect with the balloon catheter decreased the peripheral insaturation, without a significant increase in the right ventricular pressure. With this information, surgery was proposed (closure of the atrial septal defect), with good results (4 years of follow-up). CONCLUSION: The interruption of the shunt with a balloon allows us to see if the right ventricle can handle properly the volume load. With this information surgery can be suggested. It may be rather simple as in this case.