Antonio Sergio de Santis Andrade Lopes

Clinically manifested myocarditis in acute rheumatic fever.

The development of acute myocarditis in the postoperative period of cardiac surgery is a challenge for the doctor who treats this type of patient. In most cases, myocarditis can be only a consequence of procedural-related inflammation. However, differential diagnoses must be observed. Among them, rheumatic fever must be considered as an important mechanism. Although its cardiac manifestation is predominantly related to the involvement of the valvular apparatus, its diagnosis is essentially clinical and it can acutely impair the myocardium. In this context, the occurrence of acute rheumatic myocarditis is rare and its immunosuppressive treatment remains uncertain.

Feminization of medicine

Dear Editor, Data from the year 2011 on more than 370,000 practicing physicians in Brazil reveal that female physicians account for approximately 20% of those aged 60 years or more and about 50% (≤ 29 years = 53.3% - the majority!) in the age range younger than 40 years1. Regarding Cardiology, in 2008 women represented 27.3% of those approved by the Examination Board to obtain the title of Specialist by SBC, of which percentage increased to 35.4% in 2012. The increasing feminization of medical practice, on the one hand, helps to establish the confidence in female doctors, recalling that they did not have the trust of most of the Brazilian population 40 years ago. On the other hand, it brings about new provisions on being a Brazilian physician2, regarding the distribution of the number of hours between the professional activity (part-time work among women has been expanding in the U.S. since 20053) and womens view about themselves, family and home life.

Paradoxical Aortic Stenosis: Simplifying the Diagnostic Process

DOI: 10.5935/abc.20180075 Figure 1 – Algorithm proposed for the diagnosis of paradoxical aortic stenosis. * In patients with BMI above 30 kg/m2, we must use 0.5 cm2/m2 value as reference for iAVA. AS: aortic stenosis; AVA: aortic valve area; Vel: jet velocity; Grad: gradient; EF: ejection fraction; iAVA: indexed aortic valve area; sBP: systolic blood pressure; CT: computed tomography. Paradoxical AS Recognition AVA ≤ 1.0 cm2 Vel < 4 m/s ou Grad médio < 40 mmHg EF ≥ 50%

Recommendation of Early Surgery in Primary Mitral Regurgitation: Pros and Cons

DOI: 10.5935/abc.20160107 Primary mitral valve regurgitation is the most frequent valvular pathology, affecting approximately 1.7% of the population, with prolapsed mitral as the highlighted etiology.1 In developing countries, such as Brazil, rheumatic fever is still widely prevalent (18.6/1000), and affects about 15.6 million people worldwide.2,3 Currently, the recommendation of mitral surgery for asymptomatic patients is very controversial, since the indication of valvular intervention for symptoms, left ventricular disfunction and dilatation, recent onset atrial fibrillation or pulmonary arterial hypertension is well consolidated in literature (Table 1).4-6 One strand defends the concept of “watchful waiting”, highlighting operative risks and morbi-mortality in early implantation of a bioprosthesis, as well as the benign history of asymptomatic mitral regurgitation. On the other hand, a second group advocates for the indication of early surgery, showing, through literature, that mitral valve repair, in these conditions, reduces surgical mortality and increases survival for these patients.7-11

Patient Management with Metallic Valve Prosthesis during Pregnancy and Postpartum Period.

Prosthetic thrombosis is a rare complication, but it has high mortality and morbidity. Young women of childbearing age that have prosthetic heart valves are at increased risk of thrombosis during pregnancy due to changes in coagulation factors. Anticoagulation with adequate control and frequent follow-up if pregnancy occurs must be performed in order to prevent complications related to anticoagulant use. Surgery remains the treatment of choice for prosthetic heart valve thrombosis in most clinical conditions. Patients with metallic prosthetic valves have an estimated 5% risk of thrombosis during pregnancy and maternal mortality of 1.5% related to the event. Anticoagulation with vitamin K antagonists during pregnancy is related to varying degrees of complications at each stage of the pregnancy and postpartum periods. Warfarin sodium crosses the placental barrier and when used in the first trimester of pregnancy is a teratogenic agent, causing 1-3% of malformations characterized by fetal warfarin syndrome and also constitutes a major cause of miscarriage in 10-30% of cases. In the third trimester and at delivery, the use of warfarin is associated with maternal and neonatal bleeding in approximately 5 to 15% of cases, respectively. On the other hand, inadequate anticoagulation, including the suspension of the oral anticoagulants aiming at fetal protection, carries a maternal risk of about 25% of metallic prosthesis thrombosis, particularly in the mitral valve. This fact is also due to the state of maternal hypercoagulability with activation of coagulation factors V, VI, VII, IX, X, platelet activity and fibrinogen synthesis, and decrease in protein S levels. The Registry of Pregnancy and Cardiac Disease (ROPAC), assessing 212 pregnant women with metal prosthesis, showed that prosthesis thrombosis occurred in 10 (4.7%) patients and maternal hemorrhage in 23.1%, concluding that only 58% of patients with metallic prosthesis had a complication-free pregnancy.

Giant Left Atrial Thrombus with Double Coronary Vascularization

Rheumatic valvular disease, especially mitral stenosis (MS) and atrial fibrillation (AF), are the main factors related to the formation of left atrial (LA) thrombi1-6. Its incidence can range from 16 to 64%, and the most affected site is the left atrial appendage1,7. Systemic embolism is responsible for 10 to 45% of the complications, being the most frequent clinical presentation1. Despite being rare, the mechanical mitral valve obstruction caused by thrombus may be considered as potentially severe, especially among those patients with previous MS. The clinical manifestations of this condition are variable, presenting from worsened functional class (NYHA) to cardiogenic shock2. The left atrial thrombus related to MS, even if rarely, may present as a large and organized mass with undistinguishable characteristics from vascularized tumors, especially the atrial myxoma. Clinical and echocardiographic aspects may not be sufficiently specific to distinguish one from the other safely, and additional examinations are often required7. This is the case of a patient with moderate rheumatic MS and no anticoagulation for AF, with a large thrombus organized in LA mimicking an atrial tumor, with difficult clinical differentiation by complementary examinations.

Paternalism, Autonomy and Ontology

The bond with the patient, in the asymptomatic phase of natural history of the rheumatic heart valve disease (RHVD), provided certain lessons for the communication physician-patient that respects both beneficent paternalism of Medicine (guidelines, for example), and values and preferences of the human being (principle of autonomy).

Needs and preferences of the patient with valvular heart disease

A decision regarding the conduct aiming at good quality of life of patients with chronic valvular heart disease during the natural history of the disease is supported by four good clinical practice pillars1,2: 1 Identification of the patient’s clinical need; 2 useful and effective recommendation selection according to the stateof-the-art; 3 – Strictly ensured organic harmony when applying the conceptual benefit; 4 Realities of the patient’s preference.