Fátima Derlene da Rocha Araújo

Prognostic value of clinical and Doppler echocardiographic findings in children and adolescents with significant rheumatic valvular disease

Introduction: The diagnosis of acute rheumatic fever (RF) is based on clinical findings. However, during the chronic phase of the disease, the clinical approach is not sufficient for the follow-up of the patients and the Doppler echocardiography is a tool for the diagnosis of cardiac involvement. Prognostic variables that influence long-term outcomes are not well known. Methods: 462 patients with RF according to Jones criteria were studied, and followed-up from the initial attack to 13.6 ± 4.6 years. All patients underwent clinical assessment and Doppler echocardiography for the detection of heart valve involvement in the acute and chronic phases. Multivariate logistic regression analysis was used to identify the factors influencing long-term heart valve disease. Results: Carditis occurred in 55.8% and subclinical valvulitis in 35.3% patients. In the chronic phase, 33% of the patients had significant valvular heart disease. No normal Doppler echocardiography exam was observed on patients who had severe valvulitis, although heart auscultation had become normal in 13% of these. In the multivariate analysis, only the severity of carditis and the mitral and/or aortic valvulitis were associated with significant valvular heart disease. Chorea or arthritis were protective factors for significant valvular heart disease, odds ratio 0.41 (95% C.I. 0.22 – 0.77) and 0.43 (95% C.I. 0.23 – 0.82), respectively. Conclusions: Our study suggests that the use of Doppler echocardiography during RF helps to identify prognostic factors regarding the development of significant valvular heart disease. Initial severe carditis is an important factor in the long-term prognosis of chronic RHD, whereas arthritis and chore during the initial episode of RF appears to be protective. Strict secondary prophylaxis should be mandatory in high risk patients.

Rheumatic Fever prevention program: long-term evolution and outcomes.

This investigation aims to analyze the profile of long-term evolution of rheumatic fever in children and adolescents and outcomes after the control of recurrences. The cohort involved 702 patients followed from 1.3 to 16.9 years covering the two periods, before and after the implementation of a prevention program. Besides the establishment of the Reference Center in the State of Minas Gerais and the implementation of strategies to promote the compliance to prophylaxis, a project for education of health professionals was carried out in 23 cities. In addition to the clinical and epidemiological profile, the severity of the disease was analyzed. Mixed lesions were found in 27.1%, valvar regurgitation in 72.9%, and complete regression of the valvar lesions was seen in 34.4% of the patients, mostly presenting mild dysfunctions. The recurrence rate per patient-year was 0.058 and out of a total of 85 recurrences, 21.4% occurred in the first and 7.5% in the second period. More severe degrees of carditis and significant valvar sequels presented a higher prevalence in patients with recurrences. The comparative analysis between the two periods showed no changes regarding the age at the primary attack, gender, type, and site of valvar lesions and affected joints; however, important modifications in the indices of severity were observed after the control of recurrences. A significant decrease in the prevalence of severe carditis, obstructive valvar sequels, hospital admissions, surgical approach, and deaths was seen. This investigation showed that although the clinical profile of presentation remains unchanged, the control of repeated attacks can improve the morbimortality rates. In this context, the secondary prophylaxis should be the first priority in the control of the disease in developing countries, taking into account the difficulties found for effective primordial and primary prevention.

Indicators of surgical treatment of patent ductus arteriosus in preterm neonates in the first week of life

Objective To identify clinical and echocardiographic indicators of the necessity for early surgical closure of patent ductus arteriosus in preterm neonates. Methods The prospective study was conducted at the Neonatal Unit of Hospital Municipal Odilon Behrens between 2006 and 2010. The study population comprised 115 preterm neonates diagnosed with patent ductus arteriosus in the first week after birth, of whom 55 (group S) were submitted to clinical and or surgical closure and 60 (group NS) received non-surgical treatment. The parameters analyzed were birth weight, diameter of the ductus arteriosus (DAD), left atrial-to-aortic root diameter ratio (LA:Ao), the quotient of DAD2 and birth weight (mm2/kg), and ductal shunting. Results The study population comprised 58 males and 57 females. The average birth weight of group S (924 ± 224.3 g) was significantly (P=0.049) lower than that of group NS (1012.3 ± 242.8 g). The probability of the preterm neonates being submitted to surgical closure was 62.1% (P=0.006) when the DAD2/birth weight index was > 5 mm2/kg, 72.2% (P=0.001) when the LA:Ao ratio was > 1.5, and 61.2% when ductal shunting was high (P=0.025). Conclusion The parameters DAD2/birth weight index > 5 mm2/kg, LA:Ao ratio > 1.5 and high ductal shunting were statistically significant indicators (P<0.05) of the need for surgical closure of patent ductus arteriosus in low birth weight preterm neonates. Moreover, when an LA:Ao ratio > 1.5 was associated with the occurrence of shock, the probability of surgical closure increased to 78.4%.

Doppler Echocardiographic Follow-Up of Mitral and Aortic Regurgitation in Children and Adolescents with Subclinical and Mild Rheumatic Carditis

Fundamento: As cardites reumaticas leve e subclinica se diferenciam basicamente pela ausculta de sopro regurgitativo mitral. A evolucao destas formas nao esta bem estabelecida na literatura. Objetivo: Avaliar a evolucao das cardites reumaticas leve e subclinica, considerando as valvites mitral e/ou aortica (fase aguda) e a regressao, manutencao ou piora delas ao final do seguimento (fase cronica). Metodos: Estudo retrospectivo, longitudinal, incluindo pacientes com cardites reumaticas leve e subclinica. A evolucao ecocardiografica das valvites mitral e/ou aortica foi comparada nos dois grupos, considerando a analise ao final do seguimento. Foram utilizados o teste qui quadrado e as curvas de sobrevida de Kaplan-Meier, com nivel de significância p < 0,05. Resultados: Foram incluidos 125 pacientes, sendo 69 (55,2%) com cardite reumatica subclinica e 56 (44,8%) com cardite reumatica leve, com media de idade na fase aguda de 10,4 ± 2,6 anos e, ao final do estudo, de 19,9 ± 4,6 anos. O tempo de seguimento variou de 2 a 23 anos (media: 9,38 ± 4,3 anos). Na fase aguda, a regurgitacao mitral leve/moderada ou moderada foi mais frequente nos pacientes com cardite reumatica leve (p = 0,001). A regurgitacao aortica leve ou leve/moderada tambem foi mais comum no grupo de cardite reumatica leve (p = 0,045). Na fase cronica, observou-se que tanto a regurgitacao mitral (p < 0,0001) quanto a regurgitacao aortica (p = 0,009) foram mais frequentes nos pacientes com cardite reumatica leve, e a sobrevida livre de valvopatia residual foi maior no grupo de cardite reumatica subclinica (p = 0,010). A regurgitacao mitral residual foi maior no grupo de cardite reumatica leve p < 0,0001), e a regurgitacao aortica residual foi semelhante nos dois grupos (p = 0,099). Conclusao: A resolucao da regurgitacao mitral foi maior nos pacientes com cardite reumatica subclinica, e a involucao da regurgitacao aortica foi menos frequente e semelhante nos dois grupos.

Prognosis of Dilated Cardiomyopathy with Severe Heart Failure according to Functional Classification Scales in Childhood

Fundamento: A insuficiencia cardiaca e principal manifestacao da cardiomiopatia dilatada na infância, e a avaliacao sistematizada dos sinais e sintomas permite acompanhar o resultado do tratamento. Objetivo: Avaliar o uso de tres escalas de classificacao funcional da insuficiencia cardiaca na evolucao de criancas e adolescentes com cardiomiopatia dilatada. Metodos: Estudo longitudinal e observacional incluindo pacientes de zero a 18 anos com cardiomiopatia dilatada e insuficiencia cardiaca inicial grave. Todos foram acompanhados por meio das escalas New York Heart Association (NYHA), The New York University Pediatric Heart Failure Index (The NYU PHFI) e Ross versao 2012. As analises estatisticas foram feitas com uso do Statistical Package for Social Science, versao 14.0, com teste de Mann-Whitney, teste qui quadrado ou de Fisher, aplicacao da Curva Caracteristica de Operacao, teste de Wilcoxon e coeficiente de Kappa, para comparacao das escalas, e curva Kaplan-Meier, para avaliacao da sobrevida. O nivel de significância adotado foi de 5%. Resultados: Foram incluidos 57 pacientes, com idade de 1 a 200 meses (media de 48,7 ± 55,9) e seguimento de 6 a 209 meses (media de 63,6 ± 48,4). Houve substancial concordância das escalas Ross 2012 e The NYU PHFI com a NYHA (Kappa = 0,71 e 0,82, respectivamente). A analise pareada pelo teste de Wilcoxon, comparando as escalas antes e apos o tratamento, foi significativa (p < 0,0001). A sobrevida maior foi encontrada nos pacientes com classes I/II pela NYHA ou pontuacao menor que 11 pontos nas outras. Conclusao: O uso das escalas de avaliacao funcional da insuficiencia cardiaca se mostrou util no seguimento e na avaliacao da resposta terapeutica. Pacientes que permaneceram em classes funcionais III ou IV de NYHA, ou com pontuacao igual ou maior que 11 na Ross 2012 ou na The NYU PHFI tiveram pior prognostico.

Enfermedad de takayasu con grave compromiso cardíaco y arterial en pre-escolar

Neste artigo os autores descrevem um caso de arterite de Takayasu em uma crianca de apenas 3 anos de idade, ressaltando-se a raridade dessa doenca nessa faixa etaria. A crianca foi atendida em servico de urgencia em estado pos-comicial de convulsao tonico-clonica generalizada. Apos exame clinico detalhado, vasta propedeutica e evolucao do quadro clinico, fez-se o diagnostico de doenca de Takayasu com grave envolvimento cardiaco e arterial. O relato desse caso alerta pediatras e cardiologistas para o reconhecimento dessa entidade em criancas de baixa idade, nos paises em que ela e pouco diagnosticada.The authors describe a case of Takayasus arteritis in a child of only 3 years of age, emphasizing the rarity of this disease in this age group. The child was admitted to the emergency room in a post-convulsive state after a tonic-clonic seizure. After a detailed clinical examination, extensive diagnostic tests, and observation of the clinical evolution, the diagnosis was Takayasus disease with severe cardiac and arterial involvement. The report warns pediatricians and cardiologists to awareness of the possibility of this disease in very small infants, in countries where it is underdiagnosed.

Doença de Takayasu com grave envolvimento cardíaco e arterial em pré-escolar

Neste artigo os autores descrevem um caso de arterite de Takayasu em uma crianca de apenas 3 anos de idade, ressaltando-se a raridade dessa doenca nessa faixa etaria. A crianca foi atendida em servico de urgencia em estado pos-comicial de convulsao tonico-clonica generalizada. Apos exame clinico detalhado, vasta propedeutica e evolucao do quadro clinico, fez-se o diagnostico de doenca de Takayasu com grave envolvimento cardiaco e arterial. O relato desse caso alerta pediatras e cardiologistas para o reconhecimento dessa entidade em criancas de baixa idade, nos paises em que ela e pouco diagnosticada.The authors describe a case of Takayasus arteritis in a child of only 3 years of age, emphasizing the rarity of this disease in this age group. The child was admitted to the emergency room in a post-convulsive state after a tonic-clonic seizure. After a detailed clinical examination, extensive diagnostic tests, and observation of the clinical evolution, the diagnosis was Takayasus disease with severe cardiac and arterial involvement. The report warns pediatricians and cardiologists to awareness of the possibility of this disease in very small infants, in countries where it is underdiagnosed.

Takayasu's disease with severe heart and arterial involvement in a preschool-age child

Neste artigo os autores descrevem um caso de arterite de Takayasu em uma crianca de apenas 3 anos de idade, ressaltando-se a raridade dessa doenca nessa faixa etaria. A crianca foi atendida em servico de urgencia em estado pos-comicial de convulsao tonico-clonica generalizada. Apos exame clinico detalhado, vasta propedeutica e evolucao do quadro clinico, fez-se o diagnostico de doenca de Takayasu com grave envolvimento cardiaco e arterial. O relato desse caso alerta pediatras e cardiologistas para o reconhecimento dessa entidade em criancas de baixa idade, nos paises em que ela e pouco diagnosticada.The authors describe a case of Takayasus arteritis in a child of only 3 years of age, emphasizing the rarity of this disease in this age group. The child was admitted to the emergency room in a post-convulsive state after a tonic-clonic seizure. After a detailed clinical examination, extensive diagnostic tests, and observation of the clinical evolution, the diagnosis was Takayasus disease with severe cardiac and arterial involvement. The report warns pediatricians and cardiologists to awareness of the possibility of this disease in very small infants, in countries where it is underdiagnosed.