Cleonice de Carvalho Coelho Mota

Assessing pre-clinical ventricular dysfunction in obese children and adolescents: the value of speckle tracking imaging

AIMS Obesity has become a major health problem worldwide. Cardiovascular abnormalities have been described not only in obese adults but also in obese children and adolescents. The aim of the present study was to investigate left and right, systolic and diastolic ventricular dysfunction in obese paediatric patients without comorbidities using 2D speckle tracking longitudinal strain. METHODS AND RESULTS Doppler echocardiogram was performed on 50 obese children and adolescents with body mass index (BMI) above the 95th percentile (OG) and 46 non-obese sex- and age-matched controls (CG). Systolic and diastolic functions of both ventricles were investigated through conventional Doppler echocardiography. Tissue Doppler imaging (TDI), colour Doppler myocardial imaging (CDMI), and two-dimensional (2D) speckle tracking were also used to analyse ventricular performance in both groups. Left-ventricular (LV) ejection fraction was similar between groups (68.2 ± 6.2 vs. 68.3 ± 5.3, P = 0.931). Left-ventricular diastolic parameters did not differ between groups, except for a lower mitral A wave (61.6 ± 13.0 vs. 51.9 ± 10.0 cm/s, P > 0.001) and higher E/A ratio (1.8 ± 0.5 vs. 2.1 ± 0.4, P = 0.007) in the controls. Left-ventricular global strain was lower in the OG by both methods (CDMI: 22.0 ± 2.8 vs. 24.6 ± 2.7%, P = 0.020; 2D speckle tracking: 18.4 ± 1.6 vs. 20.4 ± 1.7%, P < 0.001). In multivariate analysis, 2D longitudinal global strain correlated negatively with BMI, r = -0.433, p = 0.002. CONCLUSION Although EF was not different between the two groups, LV 2D speckle tracking longitudinal strain was lower in the obese group, even in the absence of other comorbidities, indicating that obesity effects on LV function is an early finding in obesity.

Presentation of congenital heart disease diagnosed at birth: analysis of 29,770 newborn infants

OBJECTIVE To estimate the prevalence rate and study the clinical presentation and associated factors of congenital heart diseases diagnosed at birth between August 1990 and December 2003, at the Maternity Unit of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Brazil. METHODS A retrospective, database driven study, part of the Latin-American collaborative study of congenital malformations. Records were reviewed on all live born (LB) and stillborn (SB) infants with congenital heart diseases diagnosed by postnatal echocardiogram or by autopsy. Data on birth weight, sex, age and parity were collected for the LB and studied for associations. The statistical analysis employed Pearsons chi-square test and multinomial logistic regression. RESULTS During the period studied there were 29,770 births (28,915 LB and 855 SB). The prevalence of heart disease among the LB was 9.58:1,000 (277/28,915) while among SB the rate was 87.72:1,000 (75/855). Heart disease occurred isolated in 37.2% of LB cases and 18.7% of SB cases; was associated with anomalies of other organs and systems, but without a syndromic diagnosis in 31.4% of LB cases and 48.0% of SB cases; and in 23.1% of the LB cases and 32.0% of the SB cases the heart disease was a feature of a syndrome. Multivariate analysis demonstrated an association between heart disease and birth weight <or= 2,500 g in all types of clinical presentation, between maternal age >or= 35 years and heart disease in syndromic heart disease and between female sex and isolated heart disease. CONCLUSIONS It was found a high prevalence, which is an alert to the medical significance of heart disease. There was association between birth weight <or= 2,500 g and all forms of presentation, between increased maternal age and syndromic heart disease besides between female sex and isolated congenital heart disease.

Subclinical rheumatic valvitis: a long-term follow-up.

In order prospectively to investigate the frequency and evolution of subclinical valvitis, we selected 40 consecutive patients suffering their initial attack of rheumatic fever, seen in our clinic from 1992 to 1994, and followed-up until 2001, with a mean period of follow-up of 8.1 years, and a standard deviation of 0.6 year. We also assembled a matched control group of 37 healthy children and adolescents. We discovered a murmur of mitral regurgitation in 28 (70.0%) of the patients. In 3 (7.5%) of these patients, there was also a murmur of aortic regurgitation. In the group of 28 symptomatic patients, Doppler echocardiography showed mitral regurgitation in all, and aortic regurgitation in 17. In the group of 12 patients without clinical evidence of cardiac involvement, Doppler echocardiography identified mitral regurgitation in 2, isolated in one and associated with aortic regurgitation in the other. Thus, the frequency of subclinical valvitis was 16.7%. In patients with subclinical valvitis only the aortic regurgitation regressed during the period of follow-up. In the group of 28 symptomatic patients, mitral regurgitation disappeared in 6 (21.4%), aortic regurgitation in 7 of the 17 having this feature (41.2%), while 2 patients (7.1%) developed mitral stenosis. The sensitivity and specificity of cardiac auscultation were, respectively, 93.3%, with 95% confidence intervals between 72.3% and 97.4%, and 100%, with 95% confidence intervals between 65.5% and 100%, for the diagnosis of mitral regurgitation, and 16.7%, with 95% confidence intervals between 4.4% and 42.3%, and 100%, with 95% confidence intervals between 81.5% and 100%, for that of aortic regurgitation. We conclude that the Doppler echocardiogram is an important means of diagnosing and assessing the evolution of subclinical rheumatic valvar lesions, which are not always transient. We suggest that Doppler echocardiography should be performed in all patients with acute rheumatic fever. Subclinical valvitis should be considered as mild carditis, provided that strict criterions are observed in the differential diagnosis from physiological regurgitation, and Doppler echocardiographic findings are analyzed in the context of the other manifestations of the disease.

Evaluation of secondary prophylactic schemes, based on benzathine penicillin G, for rheumatic fever in children

Serum concentrations of penicillin were measured in children with rheumatic fever. The adequacy of the values after administration of 1.2 million units of benzathine penicillin G every 2 or 3 weeks was confirmed; the adequacy of a 4-week regimen was questionable. The administration of 0.6 million units every 3 weeks was found to be inadequate to maintain serum levels high enough for the secondary prophylaxis of rheumatic fever.

Apresentação das cardiopatias congênitas diagnosticadas ao nascimento: análise de 29.770 recém-nascidos

OBJECTIVE: To estimate the prevalence rate and study the clinical presentation and associated factors of congenital heart diseases diagnosed at birth between August 1990 and December 2003, at the Maternity Unit of the Hospital das Clinicas, Universidade Federal de Minas Gerais, Brazil. METHODS: A retrospective, database driven study, part of the Latin-American collaborative study of congenital malformations. Records were reviewed on all live born (LB) and stillborn (SB) infants with congenital heart diseases diagnosed by postnatal echocardiogram or by autopsy. Data on birth weight, sex, age and parity were collected for the LB and studied for associations. The statistical analysis employed Pearsons chi-square test and multinomial logistic regression. RESULTS: During the period studied there were 29,770 births (28,915 LB and 855 SB). The prevalence of heart disease among the LB was 9.58:1,000 (277/28,915) while among SB the rate was 87.72:1,000 (75/855). Heart disease occurred isolated in 37.2% of LB cases and 18.7% of SB cases; was associated with anomalies of other organs and systems, but without a syndromic diagnosis in 31.4% of LB cases and 48.0% of SB cases; and in 23.1% of the LB cases and 32.0% of the SB cases the heart disease was a feature of a syndrome. Multivariate analysis demonstrated an association between heart disease and birth weight £ 2,500 g in all types of clinical presentation, between maternal age ³ 35 years and heart disease in syndromic heart disease and between female sex and isolated heart disease. CONCLUSIONS: It was found a high prevalence, which is an alert to the medical significance of heart disease. There was association between birth weight £ 2,500 g and all forms of presentation, between increased maternal age and syndromic heart disease besides between female sex and isolated congenital heart disease.

Frequency and significance of vocalizations in Sydenham's chorea.

Sydenhams chorea (SC) is a complication of Streptococcus infection characterized by a combination of motor and non-motor features. We have investigated the presence of vocalizations in 89 consecutive patients with SC evaluated during a one-year period in the UFMG Movement Disorders Clinic. Seven (4/3 M/F) of the 89 patients (29/60 M/F) presented with simple vocalizations not preceded by premonitory sensations but in association with facial chorea in five patients. These findings suggest that vocalizations are not a common feature in SC and their phenomenology is quite distinct from the characteristics of vocal tics in tic disorders.

Doppler echocardiographic assessment of subclinical valvitis in the diagnosis of acute rheumatic fever.

almost 200 years after the initial descriptions of the cardiac involvement by Wells in 1812, and by Jean-Baptiste Bouillaud in 1836, rheumatic fever remains a significant challenge to those involved in providing health care.1 Although impressive data have been gathered by studies in several areas of investigation, all this knowledge has been unable to explain the pathogenesis of the condition. In many parts of the world, the origin of relevant problems in the cardiovascular area is still related to rheumatic fever, with significant rates of morbidity and mortality. In developing countries, the disease is a risk because of its cardiac sequels, being the most important cause of acquired heart disease in the young. Its potential resurgence now emphasises its burgeoning significance in the developed world. Several factors, nonetheless, have contributed to a changing pattern of rheumatic fever. The decline in frequency and seriousness during the last decades has been attributed to changes in the host and environment, besides possible modifications in virulence of the streptococcus. Other factors influencing the changes include the increased ability to diagnose the disease through the establishment of stricter diagnostic criterions, as well as the strategies of primary and secondary prophylaxis for controlling recurrences. Furthermore, procedures to assess damage to the heart, and to improve the cardiac performance, have resulted in more effective health care by the introduction of technological advances, mainly Doppler echocardiography, valvoplasty, and surgical valvar replacement and repair.

Cardiovascular dysfunction in obesity and new diagnostic imaging techniques: the role of noninvasive image methods.

Obesity is a major public health problem affecting adults and children in both developed and developing countries. This condition often leads to metabolic syndrome, which increases the risk of cardiovascular disease. A large number of studies have been carried out to understand the pathogenesis of cardiovascular dysfunction in obese patients. Endothelial dysfunction plays a key role in the progression of atherosclerosis and the development of coronary artery disease, hypertension and congestive heart failure. Noninvasive methods in the field of cardiovascular imaging, such as measuring intima-media thickness, flow-mediated dilatation, tissue Doppler, and strain, and strain rate, constitute new tools for the early detection of cardiac and vascular dysfunction. These techniques will certainly enable a better evaluation of initial cardiovascular injury and allow the correct, timely management of obese patients. The present review summarizes the main aspects of cardiovascular dysfunction in obesity and discusses the application of recent noninvasive imaging methods for the early detection of cardiovascular alterations.

Estudo comparativo das avaliações clínica e ecocardiográfica Doppler na evolução das lesões valvares em crianças e adolescentes portadores de febre reumática

OBJECTIVE Compare clinical and Doppler echocardiographic evaluations in assessing valvular diseases in children and adolescents with rheumatic fever, as well as assess the progression of the disease in light of these assessments. METHODS This is a longitudinal study of 258 children and adolescents diagnosed with rheumatic fever according to Jones criteria. The follow-up period ranged from 2-15 years. The presence and quantification of valve diseases were determined by means of clinical and Doppler echocardiographic evaluations performed during the acute and chronic phases. The Kappa statistics method was used to estimate the degree of agreement between clinical and Doppler echocardiographic evaluations. Comparisons between clinical and Doppler echocardiographic findings on the progress of carditis and valvulitis, respectively, were made using chi-square test or Fishers exact test, p< 0.05. RESULTS Of the 109 patients who underwent Doppler echocardiographic evaluation during the acute phase, 31 did not present clinical evidence of carditis, but the Doppler echocardiograms of 17 (54.8%) of them showed valve lesions (subclinical valvulitis). During the chronic phase, 153 of the 258 patients had normal cardiovascular examination results; however, Doppler echocardiograms showed that 81 of them (52.9%) had valve lesions (subclinical chronic valvular diseases). Involution of the valvular lesions, as shown by Doppler echocardiographic evaluations, was less frequent and occurred in 10 (25.0%) patients with mild valvulitis, in only one (2.5%) patient with moderate valvulitis, and in none of the patients with severe valvulitis. CONCLUSION The identification of rheumatic fever valve lesions can be enhanced when clinical evaluations are supplemented by Doppler echocardiographic examinations; also, clinical examinations are not as suitable to detect valvular lesion regression as the echocardiography. The diagnosis of subclinical valvulitis and valvulopathy influences the secondary prophylaxis of rheumatic fever and endocarditis.

Enhancing longevity of pacemakers through reprogramming. Underutilization and cost-effectiveness

OBJECTIVE This study was performed to observe the number of pacemakers that had never been reprogrammed after implantation, and the effect of optimised output programming on estimated longevity of pulse generators in patients with pacemaker METHODS Sixty patients with Teletronics Reflex pacemakers were evaluated in a pacemaker clinic, from the time of the beginning of its activities, in June 1998, until March 1999. Telemetry was performed during the first clinic visit, and we observed how many pulse generators retained nominal output settings of the manufactures indicating the absence of reprogramming until that date. After evaluation of the capture threshold, reprogramming of pacemakers was performed with a safety margin of 2 to 2.5:1, and we compared the estimated longevity based on battery current at the manufacturers settings with that based on settings achieved after reprogramming. RESULTS In 95% of the cases, the original programmed setting was never reprogrammed before the patients attended the pacemaker clinic. Reprogramming the pacemaker prolonged estimated pulse generator life by 19.7+/-15.6 months (35.5%). CONCLUSION The majority of the pacemakers evaluated had never been reprogrammed. Estimated pulse generator longevity can be prolonged significantly, using this simple, safe, efficacious, and cost-effective procedure.