Eduardo Giusti Rossi

Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology.

OBJECTIVES This study was designed to assess the feasibility and the long-term results of a symptom-based strategy of aortic valve replacement in a Brazilian population with predominant rheumatic etiology. BACKGROUND Optimal criteria for valve replacement in aortic regurgitation (AR) are still not entirely clear. The appearance of symptoms is an indication for surgery, but may be associated with myocardial damage. Although cardiac imaging data have provided a safer guide for such decisions, the use of symptom-based surgical indication has not been validated and might conceivably be better in populations with predominant rheumatic etiology and younger age. METHODS Echocardiography and rest-exercise radionuclide ventriculography were performed in 75 patients with severe AR, age 28 +/- 9 years, over a period of 10 +/- 0.69 years. Thirty-seven patients developed symptoms and underwent aortic valve replacement surgery within six months. Thirty-eight patients remained asymptomatic and were managed medically. RESULTS Survival was 100% in asymptomatic patients and 82% in symptomatic. Surgical treatment caused marked ventricular remodeling, with ventricular diameter involution and an improvement of rest-exercise ejection fraction percent variation. Multivariate analysis showed that the probability of developing symptoms within 10 years was 58% for a patient with a left ventricular end-diastolic diameter > or =70 mm and 76% for a patient with left ventricular end-systolic (LVESD) > or =50 mm. Logistic regression identified LVESD and age as the most predictive and specific, but not sensitive, indicators of symptom development. CONCLUSIONS Application of a standardized therapeutic strategy to patients with severe AR and predominant rheumatic etiology resulted in 90.6% survival after 10 years of follow-up.

Pregnancy and peripartum cardiomyopathy: a comparative and prospective study

OBJECTIVE To assess pregnancy outcome in women with peripartum cardiomyopathy and to compare it with idiopathic cardiomyopathy. METHODS Twenty-six pregnant women, aged 28.4+/-6.1 years, with dilated cardiomyopathy were followed. Eighteen patients had peripartum cardiomyopathy [11 with persistent left ventricular systolic dysfunction (EF=45.2+/-2) and 7 with recovered ventricular function (EF=62.3+/-3.6)]. The 8 remaining patients had idiopathic cardiomyopathy (EF= 43.5+/-4.1). During the prenatal period, limited physical activity and a low-sodium diet were recommended, and hospitalization was recommended when complications occurred. RESULTS Of the 26 patients, 11 (42.3%) had a normal delivery; 9(35.5%) had cardiac complications, 6 (22.2%) had obstetric complications. Two patients (7.7%) died. Two preterm pregnancies occurred, with 26 health newborns (2 sets of twins). Two miscarriages took place. The cardiac complication rate during pregnancy was lower (p<0.009) in the peripartum cardiomyopathy group without ventricular dysfunction and greater (p=0.01) in the idiopathic group when compared with the peripartum group with ventricular dysfunction. Changes in left ventricular ejection fraction were not observed (p<0.05) in the postpartum period, when compared with that during pregnancy in the 3 groups. CONCLUSION Pregnancy in patients with dilated cardiomyopathy is associated with maternal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when counseling patients with peripartum cardiomyopathy about a new pregnancy.

Influência da gestação na evolução clínica materno-fetal de portadoras de cardiomiopatia hipertrófica

OBJECTIVES To study clinical evolution of women with HCM during pregnancy; the influencing factors of gestation on natural course of HCM and the frequency of HCM in their children in early childhood. METHODS A prospective study was conducted in 35 women with HCM; there were 23 pregnant women (PG group) and 12 nonpregnant control patients (NP group), matched for age and functional class (FC). Clinical monthly evaluations were carried out and electrocardiogram and transthoracic echocardiography tests were performed. The offspring endpoints included stillbirth and prematurity rates and investigation of HCM during childhood. RESULTS No deaths occurred in either group. Cardiac arrhythmias were significantly (p< 0.05) more frequent in the NP group (33.3% vs. 13.4%), and no differences were observed between the groups (p>0.05) in heart failure (30.3% vs. 16.6%) or ischemic stroke (4.3% vs. 8.3%) rates. In the PG group, required hospitalization for treatment of cardiac complication was more frequent (p=0.05) in patients with family history of HCM (71.4% vs. 25.0%). Cesarean section was performed in 12 (52%) patients, for obstetrical reasons; there were 7 (30.4%) premature babies and 1 (4.3%) neonatal death. One child was clinically diagnosed as having HCM, and his genetic study identified a mutation in the beta myosin heavy chain gene, located on chromosome 14. CONCLUSION Heart failure is a frequent cardiac complication in women with HCM during pregnancy, particularly in patients with family history of the disease, but this did not influence the natural course of HCM. In one child, clinical examination allowed HCM identification during early childhood.

Mixoma de átrio direito com origem na veia cava inferior: uma localização rara com implicações diagnósticas e terapêuticas

The myxomas are the most frequent primary cardiac tumors. They are usually located in the left atrium but can be found in other places. This is a case report of a 71 year old patient with diagnosis of a tumor arising from the right atrium, submitted to a surgical resection of the tumor. The operation was realized and the diagnosis confirmed. Resection was successful and the procedure uneventful. Four months postoperatively a standard two-dimensional echocardiogram revealed a residual mass that seemed to arise from the inferior vena cava. He was reoperated and the myxoma originating from the inferior vena cava and extending to the interior of the right atrium was resected. At the basis of the tumor implantation, a portion of the inferior vena cave was resected. The present report shows an unusual location of the myxoma as well as the complications regarding the diagnosis and the approach to surgical treatment.

Avaliação comparativa entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral

PURPOSE: To compare immediate and late (12 months) follow up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2±5.8 to 5.80±2.7 (p<0.001) in commissurotomy group (CG) and from 11.7±6.1 to 5.0±2.4 (p<0.001) in the balloon valvuloplasty group (VG). Mitral valve area (cm2) increased from 0.98±0.21 to 2.52±0.46 in CG and from 1.05±0.25 to 2.18±0.40 in VG (p<0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

O vínculo droga valvopatia

Metisergida 2-5,8 Nas decadas de 60/70, o derivado do ergot metisergida era o mais eficaz profilatico para enxaqueca. Na ocasiao, estimava-se o consumo em 500 mil pessoas. Em 1964, John Graham, entao diretor da Headache Research Foundations, em Boston, foi alertado sobre a ausculta de sopros de insuficiencia mitral ou aortica durante uso continuo da droga. Uma primeira avaliacao, compreendendo 27 pacientes com casos de fibrose retroperitonial induzida pela metisergida, revelou sete (26%) casos com sopro cardiaco. Em periodo de dois anos, o pesquisador pode observar o desenvolvimento sem outra causa aparente de sopro cardiaco expressivo em 16 de seus pacientes. Dez anos apos a constatacao original, revisao publicada pelo mesmo Servico incluiu nao mais do que 48 casos de vinculo da droga com sopro cardiaco. Este numero restrito de casos foi suficiente para incorporar as seguintes observacoes ao conhecimento sobre cardiopatia valvar: 1) taxa de 3,6% dos pacientes sob uso continuado de metisergida desenvolve sopro cardiaco. Devemos conjecturar que lesoes valvares subclinicas, atualmente identificaveis pela ecocardiografia, possam ter ficado a margem desta proporcao; 2) a maioria dos pacientes nao apresentava sopro cardiaco previamente ao uso; 3) nao havia outra causa de sopro cardiaco; 4) a intensidade do sopro cardiaco mostrou-se inicialmente crescente; 5) a suspensao da droga associou-se a regressao total (46%) ou parcial (12%) do sopro cardiaco em 58% dos casos; 6) os sopros reveladores de estenose e/ou insuficiencia tinham origem nas valvas mitral, aortica e tricuspide; 7) sopro cardiaco superpos-se em 26% ao desenvolvimento de fibrose retroperitonial, condicao tambem, potencialmente, reversivel com a suspensao da droga; 8) o exame anatomopatologico das valvas que vieram a ser operadas ou estudadas a necropsia revelou caracteristicas similares entre si de comprometimento de folhetos valvares, cordas tendineas e musculos papilares; 9) o aspecto patologico fundamental e um processo fibroproliferativo, que se desenvolve como uma camada de revestimento de tecido colageno. Nao ha destruicao da estrutura valvar subjacente. Este aspecto o diferencia da doenca reumatica; 10) o processo fibrotico da valva aortica pode se estender para a parede ventricular esquerda, aorta e ostio de arteria coronaria (causa documentada de infarto do miocardio). A orientacao clinica para uso da metisergida passou a se restringir a: 1) formas graves de enxaqueca; 2) pacientes confiaveis para cumprir rigorosamente a orientacao de suspender, periodicamente, o medicamento e se submeter a exames de controle; 3) acrescimo das seguintes contra-indicacoes as vigentes: lesoes valvares, descompensacao cardiaca de qualquer causa, doencas associadas a estados de fibrose. Estima-se que 1000-1200 pacientes estejam sob uso de metisergida, atualmente, no Brasil, droga praticamente reservada para casos de cefaleia em salva.