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Objective Infective endocarditis (IE) may cause devastating complications with high morbidity and mortality rates. The aim of the present study was to study the demographic, cardiological, microbiologic, and dental profiles of patients with oral bacteria–related IE. Study Design We present a retrospective study of patients with oral bacteria–related IE treated at Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil, between January 2009 and December 2019. Results Of the 100 patients included, 70% were male with a mean age of 45.4 years at diagnosis. The most affected sites were aortic and mitral valves, 60% in prosthetic heart valves, 34% in native valves, and 3% in pacemakers. The most common cause of valvular disease was rheumatic cardiopathy (51.9%), and the most frequent complications were valvular and perivalvular damage (26%). Streptococcus viridans was the most common species (96%), dental caries were present in 57% of the patients, 78% had tooth loss, 45% had apical periodontitis, and 77% were at high/moderate risk for periodontal disease. Conclusion Oral bacteria–related IE among Brazilians was predominant in the prosthetic heart valves of young male adults previously affected by rheumatic cardiopathy. Streptococcus viridans was the main cause of IE, which was linked to patients with a poor oral health status.

International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

1. Introducao O Departamento de Cardiologia da Mulher (DCM) apresenta este documento, elaborado de acordo com as normas estabelecidas pela Sociedade Brasileira de Cardiologia (SBC), com a finalidade de discutir sobre as patologias cardiovasculares mais prevalentes que acometem a mulher durante o ciclo gravidico-puerperal e para as quais nao existem evidencias substanciais ou ensaios clinicos randomizados. Com o apoio da SBC, o entao Departamento de Cardiopatia e Gravidez publicou, em 1999, o 1° Consenso sobre Cardiopatia e Gravidez e Planejamento [...]

In due time, the Brazilian Society of Cardiology decided to create a guideline on telemedicine applied to cardiology, also known as telecardiology. According to the Pan American Health Organization (PAHO) and the World Health Organization (WHO), telemedicine is “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” Such a seemingly simple and altruistic definition carries a wide range of potential implications at various levels, from an ethical point of view to a potential impact on clinical practice and outcomes. Hence, the importance of guidelines, organized by the medical community through scientific societies, in offering to all of those involved in the process a reference based, as much as possible, on expert opinion, current scientific evidence, and on respect for medical ethical and deontological values. Oportunamente, a Sociedade Brasileira de Cardiologia decidiu criar uma diretriz sobre a telemedicina aplicada à cardiologia, também conhecida como telecardiologia. Segundo a Organização Pan-Americana da Saúde (OPAS) e a Organização Mundial da Saúde (OMS), a telemedicina é “A prestação de serviços de saúde, onde a distância é um fator crítico, por todos os profissionais de saúde que utilizam tecnologias de informação e comunicação para a troca de informações válidas para diagnóstico, tratamento e prevenção de doenças e lesões, pesquisa e avaliação, e para a educação continuada dos profissionais de saúde, tudo no interesse do avanço da saúde dos indivíduos e de suas comunidades”. Tal definição aparentemente simples e altruísta carrega uma ampla gama de implicações potenciais em vários níveis, desde um ponto de vista ético até um potencial impacto na prática clínica e nos resultados. Daí a importância das diretrizes, organizadas pela comunidade médica por meio das sociedades científicas, em oferecer a todos os envolvidos no processo uma referência baseada, tanto quanto possível, na opinião de especialistas, nas evidências científicas atuais e no respeito à ética médica e valores deontológicos.

BACKGROUND The identification of predictors of mitral valve (MV) repair results is important for quality improvement in cardiac surgery. The aim of this study was to evaluate the relationship between MV morphological quantification by three-dimensional (3D) transesophageal echocardiography and mitral repair results. METHODS Fifty-four patients with MV prolapse who were submitted to surgical repair were divided into 2 groups according to their postoperative mitral regurgitation (MR) degree (group 1, grade 0-I MR; group 2, ≥grade II MR). Morphological parameters related to the mitral ring, dimension of leaflets and prolapse, coaptation line, distance from papillary muscles to the leaflet border and valve angles were analyzed by 3D MV quantification. Cardiac remodeling and MR quantitative parameters were also evaluated. RESULTS There was no correlation between 3D MV quantification and surgical results; a multivariate analysis did not show an association between morphological parameters and surgical outcome. The distance from the posteromedial papillary muscle to the leaflet border was higher (P = .038) in patients with ≥grade II postoperative MR. The left atrial diameter, left ventricular end-systolic diameter, left ventricular end-diastolic and end-systolic volumes were larger in patients with a significant residual MR (P

A prescricao de um farmaco diretamente ao paciente, a captacao do voluntario para uma pesquisa clinica, a palestra em um congresso da especialidade, a participacao em um comite elaborador de uma diretriz clinica, a supervisao em uma visita clinica com residentes, a opiniao para os colegas em um cafezinho. Todas essas situacoes se caracterizam como interacao humana, maior ou menor assimetria de conhecimento e influencia de multiplos interesses, em que o eventual privilegio de um pode provocar prejuizo de algum [...]

SummaryObjectivesWe studied the clinical characteristics, in-hospital mortality, and long-term prognosis of patients with culture-negative endocarditis.MethodsIn total, 221 episodes of definite endocarditis were studied (2004–2009). We compared the clinical, laboratory, and echocardiography characteristics and the survival rates of patients with culture-negative and culture-positive endocarditis. Survival after hospital discharge was evaluated using the Kaplan–Meier method and coefficient of mortality comparisons.ResultsCulture-negative endocarditis occurred in 51/221 (23.1%) episodes. Compared with the culture-positive endocarditis patients, the time elapsed between admission and initiation of antibiotic therapy was longer in patients with culture-negative endocarditis (p

Drug interaction studies selecting patients in a real-life setting are scarce, and most studies to date are characterized by a small sample size.To evaluate the effect of amiodarone on warfarin maintenance dose and adverse events in an anticoagulation cohort from a tertiary cardiovascular service.This study recruited 866 patients, and oral anticoagulant therapy was monitored by the prothrombin time expressed as the international normalized ratio (INR). Genotyping of CYP2C9*2, CYP2C9*3, and VKORC1 3673 polymorphisms was performed.Of the 866 patients, 111 (12.8%) were taking amiodarone and warfarin simultaneously, and 514 (59.4%) reached the therapeutic target dose. The warfarin maintenance dose was significantly lower in patients simultaneously using amiodarone (23.8 ± 11.3 mg/wk) compared with other patients (29.5 ± 14.3 mg/wk; P0.001). Patients taking amiodarone had higher INR/current dose ratios (0.83 ± 0.04 per mg) compared with patients not using amiodarone (0.71 ± 0.02 per mg, P = 0.001). Adverse event frequency was not different between the groups (P = 0.40). No genotype effect was noted on the odds of bleeding associated with amiodarone use.Simultaneous use of amiodarone influences warfarin maintenance dose, but is not associated with adverse events.

La auricula izquierda tiene importancia clinica en pacientes con estenosis de la valvula mitral. El objetivo de este estudio es analizar los efectos de la valvuloplastia percutanea con balon en los volumenes auriculares izquierdos y la fraccion de vaciado auricular izquierdo en pacientes con estenosis de valvula mitral sintomatica, mediante el empleo de ecocardiografia transtoracica bidimensional y tridimensional en tiempo real. Metodos Se llevo a cabo un estudio prospectivo de 28 pacientes consecutivos, 24 de ellos mujeres (85,6%), de 22-72 (media, 39 ± 11,5) anos de edad, con estenosis de valvula mitral sintomatica a los que se practico una valvuloplastia percutanea con balon entre marzo de 2009 y mayo de 2011. Se realizaron exploraciones de ecocardiografia transtoracica bidimensional y tridimensional y transesofagica (fibrilacion auricular) y una medicion invasiva del area de valvula mitral. Se efectuo un analisis ecocardiografico antes de la valvuloplastia percutanea con balon y a las 72 h y los 12 meses de realizada. Se analizaron los siguientes parametros: a) area de valvula mitral (planimetria bidimensional, semitiempo de presion, ecocardiografia tridimensional, medicion invasiva de parametros hemodinamicos); b) volumenes indexados maximo y minimo de la auricula izquierda, y c) fraccion de vaciado auricular izquierdo. Resultados Los parametros tridimensionales de los pacientes con estenosis de valvula mitral antes y 72 h y 12 meses despues de la valvuloplastia con balon percutanea fueron los siguientes: a) area de valvula mitral, 0,9 ± 0,1 cm2, 1,8 ± 0,2 cm2 (p < 0,001) y 1,7 ± 0,2 cm2 (p < 0,001); b) volumenes maximos de la auricula izquierda, 49,9 ± 12; 42 ± 11,4 (p < 0,001) y 40,3 ± 10,2 ml/m2 (p < 0,001), y c) fraccion de vaciado auricular izquierdo, 30,1 ± 9,4%; 40,6 ± 7,4% (p < 0,001) y 44,1 ± 8% (p < 0,001) respectivamente. Conclusiones En los pacientes con estenosis de valvula mitral sintomatica tratados con valvuloplastia percutanea con balon, el analisis mediante ecocardiografia bidimensional y tridimensional mostro una mejora del remodelado inverso de la auricula izquierda y de la fraccion de vaciado auricular izquierdo a las 72 h y a los 12 meses de la intervencion.

Background Balloon aortic valvuloplasty (BAV) is used as a palliative strategy in patients who are not eligible for valve replacement surgery, transcatheter aortic valve implantation, or as a bridge to these treatment modalities. The impact of BAV as a salvage procedure for patients in extreme clinical conditions ( in extremis ) is unknown. Methods Patients with severe degenerative aortic stenosis undergoing BAV between July 2008 and January 2013 were evaluated. Patients were divided into the in - extremis group (defined by the presence of two or more of the following organ dysfunctions: mechanical ventilation, hemodynamic instability, dialysis, coagulopathy or severe hepatic dysfunction) and the control group, which included the remaining patients. Results A total of 19 patients underwent BAV. The clinical condition in - extremis was present in 42.1% of them. Patients from the in - extremis group had a higher EUROSCORE II (41.1 ± 24.7 vs. 15.9 ± 14.0; P = 0.001) and LV ejection fraction lower than the control group (33.9 ± 17.3% vs. 49.0 ± 12.5; P = 0.04). None of the patients in the in - extremis group survived past the hospitalization period, whereas the control group mortality was 27.3% (P Conclusions BAV has an unfavorable result in patients with severe degenerative aortic stenosis with two or more organ dysfunctions, that is, patients in extremis .

A B S T R A C T Introduction and objectives: The left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3-dimensional transthoracic echocardiography. Methods: We carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 (11.5)) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72 h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemody- namic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction. Results: The 3-dimensional parameters of the mitral valve stenosis patients before and 72 h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm 2 ; 1.8 (0.2) cm 2 (P

Background Host factors and complications have been associated with higher mortality in infective endocarditis ( IE ). We sought to develop and validate a model of clinical characteristics to predict 6‐month mortality in IE . Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ ICE ]–Prospective Cohort Study [ PCS ], 2000–2006, n=4049), a model to predict 6‐month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry ( ICE ‐ PLUS , 2008–2012, n=1197). The 6‐month mortality was 971 of 4049 (24.0%) in the ICE ‐ PCS cohort and 342 of 1197 (28.6%) in the ICE ‐ PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE , causative organism, left‐sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6‐month mortality, and surgery was associated with a lower risk of mortality (Harrell's C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell's C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62–0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six‐month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE .

FUNDAMENTO: Penicilina G benzatina a cada 3 semanas é o protocolo padrão para a profilaxia secundária para febre reumática recorrente. OBJETIVO: Avaliar o efeito da penicilina G benzatina em Streptococcus sanguinis e Streptococcus oralis em pacientes com doença valvular cardíaca, devido à febre reumática com recebimento de profilaxia secundária. MÉTODOS: Estreptococos orais foram avaliados antes (momento basal) e após 7 dias (7º dia) iniciando-se com penicilina G benzatina em 100 pacientes que receberam profilaxia secundária da febre reumática. Amostras de saliva foram avaliadas para verificar a contagem de colônias e presença de S. sanguinis e S. oralis. Amostras de saliva estimulada pela mastigação foram serialmente diluídas e semeadas em placas sobre agar-sangue de ovelhas seletivo e não seletivo a 5% contendo penicilina G. A identificação da espécie foi realizada com testes bioquímicos convencionais. Concentrações inibitórias mínimas foram determinadas com o Etest. RESULTADOS: Não foram encontradas diferenças estatísticas da presença de S. sanguinis comparando-se o momento basal e o 7º dia (p = 0,62). No entanto, o número existente de culturas positivas de S. oralis no 7º dia após a Penicilina G benzatina apresentou um aumento significativo em relação ao valor basal (p = 0,04). Não houve diferença estatística existente entre o momento basal e o 7º dia sobre o número de S. sanguinis ou S. oralis UFC/mL e concentrações inibitórias medianas. CONCLUSÃO: O presente estudo mostrou que a Penicilina G benzatina a cada 3 semanas não alterou a colonização por S. sanguinis, mas aumentou a colonização de S. oralis no 7º dia de administração. Portanto, a susceptibilidade do Streptococcus sanguinis e Streptococcus oralis à penicilina G não foi modificada durante a rotina de profilaxia secundária da febre reumática utilizando a penicilina G. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0) BACKGROUND: Benzathine penicillin G every 3 weeks is the standard protocol for secondary prophylaxis for recurrent rheumatic fever. OBJECTIVE: Assess the effect of Benzathine penicillin G on Streptococcus sanguinis and Streptococcus oralis in patients with cardiac valvular disease due to rheumatic fever receiving secondary prophylaxis. METHODS: Oral streptococci were evaluated before (baseline) and after 7 days (day 7) with Benzathine penicillin G in 100 patients receiving routine secondary rheumatic fever prophylaxis. Saliva samples were evaluated for colony count and presence of S. sanguinis and S. oralis. Chewing-stimulated saliva samples were serially diluted and plated onto both nonselective and selective 5% sheep blood agar containing penicillin G. The species were identified using conventional biochemical tests. Minimal inhibitory concentrations were determined with the Etest. RESULTS: No statistical differences were found in the presence of S. sanguinis comparing baseline and day 7 (p = 0.62). However, the existing number of positive cultures of S. oralis on day 7 after Benzathine penicillin G presented a significant increase compared to baseline (p = 0.04). No statistical difference was found between baseline and day 7 concerning the number of S. sanguinis or S. oralis CFU/mL and median minimal inhibitory concentrations. CONCLUSION: This study showed that Benzathine penicillin G every 3 weeks did not change the colonization by S. sanguinis, but increased colonization of S. oralis on day 7 of administration. Therefore, susceptibility of Streptococcus sanguinis and Streptococcus oralis to penicillin G was not modified during the penicillin G routine secondary rheumatic fever prophylaxis. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Pulmonary hypertension represents an important cause of morbidity and mortality in patients with mitral stenosis who undergo cardiac surgery, especially in the postoperative period. The aim of this study was to test the hypothesis that inhaled nitric oxide (iNO) would improve the hemodynamic effects and short-term clinical outcomes of patients with mitral stenosis and severe pulmonary hypertension who undergo cardiac surgery in a randomized, controlled study. Twenty-nine patients (4 men, 25 women; mean age 46 ± 2 years) were randomly allocated to receive iNO (n = 14) or oxygen (n = 15) for 48 hours immediately after surgery. Hemodynamic data, the use of vasoactive drugs, duration of stay, and short-term complications were assessed. No differences in baseline characteristics were observed between the groups. After 24 and 48 hours, patients receiving iNO had a significantly greater increase in cardiac index compared to patients receiving oxygen (p

FUNDAMENTO: A análise dos resultados imediatos e a longo prazo da valvoplastia mitral por catéter-balão (VMCB) ainda são escassos na literatura, principalmente no contexto nacional. OBJETIVO: Avaliar os resultados imediatos e tardios dos pacientes submetidos à VMCB. MÉTODO: 330 pacientes consecutivos foram seguidos por 47 ± 36 meses (até 126 meses). Análises univariadas e multivariadas avaliaram os fatores relacionados ao sucesso do procedimento, à reestenose e aos eventos tardios (morte ou necessidade de nova intervenção na valva mitral). O método de Kaplan-Meier estimou a sobrevida livre de eventos. RESULTADOS: Houve sucesso do procedimento em 305 (92,4%). A anatomia valvar mitral foi o principal preditor de sucesso imediato do procedimento. Durante o seguimento, a reestenose ocorreu em 77 (23,3%) pacientes e esteve associada a menor área valvar mitral e maior calcificação antes do procedimento. Ocorreram 67 eventos em um tempo médio de seguimento de 38 ± 26 meses. A probabilidade de sobrevida livre de eventos foi de 95 % em 1 ano, 75% aos 5 anos e 61% aos 10 anos. Os preditores de sobrevida livre de eventos foram: idade, escore ecocardiográfico e resultado imediato do procedimento. CONCLUSÃO: A VMCB é um procedimento efetivo, sendo que mais de 60% dos pacientes estiveram livres de eventos ao final do seguimento. A condição anatômica da valva mitral e a idade do paciente foram os melhores preditores da sobrevida livre de eventos e devem ser levados em consideração na seleção dos pacientes para VMCB. BACKGROUND: The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE: To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD: A total of 330 consecutive patients were followed-up by 47 ± 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS: The procedure was successful in 305 cases (92.4%). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3%) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 ± 26-month follow-up, 67 events occurred. The probability of survival without events was of 95% in one year, 75% in five years and 61% in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION: Mitral valve repair by balloon catheter is an effective procedure, as 60% patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patient's age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure. (Arq Bras Cardiol 2010; 94(3):383-390)

La diseccion de aorta puede ocurrir tardiamente tras cirugia de reemplazo de valvula aortica y raramente en el primer mes postoperatorio. La diseccion de arteria coronaria es rara y normalmente ocurre despues de angiografia coronaria. Se relata un caso raro de diseccion de arteria coronaria, seguido de infarto de miocardio, en el postoperatorio inmediato de reemplazo de valvula aortica con correccion y evolucion exitosas.

OBJETIVO: A plástica da valva mitral em pacientes reumáticos permanece um desafio. O objetivo deste estudo é analisar a técnica e os resultados da plástica da valva mitral em pacientes com insuficiência mitral reumática. MÉTODOS: Foram analisados, retrospectivamente, 330 pacientes portadores de insuficiência mitral reumática submetidos à plástica da valva mitral no Instituto do Coração do HC-FMUSP, entre 1985 e 2005. A idade média foi de 26,9 ± 15,4 anos e 57,6% dos pacientes eram do sexo feminino. No pré-operatório, 39,5% dos pacientes estavam em classe funcional IV. As técnicas de plástica mais comumente utilizadas foram a anuloplastia posterior com tira de pericárdio bovino em 48,4% dos pacientes e a anuloplastia com anel de Carpentier em 22,6%. As técnicas associadas foram empregadas em 55,2% dos pacientes, sendo as mais comuns: encurtamento de cordas (20%) e papilarotomias múltiplas (17,8%). Plástica da valva tricúspide (26,7%) e substituição da valva aórtica (27,2%) foram os procedimentos associados mais frequentes. RESULTADOS: A mortalidade hospitalar foi 0,9% (três pacientes), sendo dois deles crianças em atividade reumática. As taxas linearizadas de tromboembolismo, endocardite, reoperação e óbito tardio foram de 0,2%, 0,2%, 3,5% e 0,5% pacientes-ano, respectivamente. A sobrevida actuarial foi de 86,4 ± 6,6% em 20 anos. A curva livre de reoperação foi de 30,3 ± 11,1% em 20 anos. CONCLUSÕES: A plástica da valva mitral em pacientes reumáticos é uma técnica factível na correção da insuficiência mitral, com baixa mortalidade operatória.

Descrevemos um caso raro de implante de marcapasso definitivo em gestante, portadora de valvopatia mitral reumática, previamente submetida à valvoplastia percutânea por cateter-balão. A paciente apresentava bloqueio atrioventricular de grau avançado, de causa não-reversível, sintomático e manifesto no 3º trimestre da gestação.

Q fever is a zoonosis of worldwide distribution that is caused by Coxiella burnetii. However, reports of this disease in Brazil are rare. Seroepidemiological studies have shown relatively high frequencies of antibodies against Coxiella burnetii in populations with occupational exposure. In humans, it can be manifested clinically as acute or chronic disease. Endocarditis is the most frequent chronic form of Q fever and the form with the greatest morbidity and mortality. We report a severe case of endocarditis due to Coxiella burnetii acquired in Brazil that had a fatal outcome, despite specific antibiotic therapy and valve surgery treatment.

FUNDAMENTO: A literatura é controversa no que se refere ao uso de vasoconstritores para anestesia local em cardiopatas, havendo preocupação com a indução de descompensação cardíaca. OBJETIVO: Avaliar parâmetros eletrocardiográficos e de pressão arterial durante procedimento odontológico restaurador sob anestesia local com e sem vasoconstritor em portadores de doença arterial coronária. MÉTODOS: Neste estudo foram avaliados 62 pacientes. As idades variaram de 39 a 80 anos (média de 58,7 + 8,8) anos, sendo 51 pacientes (82,3%) do sexo masculino. Do total de pacientes, 30 foram randomizados para receber anestesia com lidocaína 2% com adrenalina (grupo LCA) e os demais para lidocaína 2% sem vasoconstritor (grupo LSA). Todos foram submetidos a monitorização ambulatorial da pressão arterial e eletrocardiografia dinâmica por 24 horas. Foram considerados três períodos: 1) basal (registros obtidos durante os 60 minutos que antecederam o procedimento); 2) procedimento (registros obtidos desde o início da anestesia até o final do procedimento) e 3) das 24 horas. RESULTADOS: Houve elevação da pressão arterial do período basal para o procedimento nos dois grupos quando analisados separadamente; quando confrontados, não apresentaram diferença entre si. A freqüência cardíaca não se alterou nos dois grupos. Depressão do segmento ST > 1 mm não ocorreu durante os períodos basal e procedimento. Arritmias em número superior a 10 por hora estiveram presentes durante o procedimento em sete pacientes (12,5%), sendo quatro (13,8%) do grupo que recebeu anestesia sem adrenalina e três (11,1%) do grupo com adrenalina. CONCLUSÃO: Não houve diferença em relação a comportamento da pressão arterial, freqüência cardíaca, evidência de isquemia e arritmias entre os grupos. O uso de vasoconstritor mostrou-se seguro dentro dos limites do estudo.

We evaluated culture-negative, community-acquired endocarditis by using indirect immunofluorescent assays and molecular analyses for Bartonella spp. and Coxiella burnetii and found a prevalence of 19.6% and 7.8%, respectively. Our findings reinforce the need to study these organisms in patients with culture-negative, community-acquired endocarditis, especially B. henselae in cat owners.

Objective:a) to propose and implement an evaluation system; b) to classify the pulmonary involvement and determine levels of physical therapy; c) to check the progress postoperatively.Methods:Patients underwent physiotherapy assessment preoperatively, postoperatively and after 5 days of intervention. They were classified into three levels of care: level 1 - low risk of complication; Level 2 - medium risk; Level 3 - high risk. We used analysis of variance and Kruskal-Wallis and analysis of variance for repeated measures or Friedman. Chi-square test or Fisher for proportions. We considered statistical significance level P

International audience; Background - The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods - Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results - EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions - In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

This is a typical case! Collecting them is not enough. The bedside library has to offer different readings in the official language of the book. Knowledge of bedside dialects is necessary. They are the means of communication of random meetings of shreds of the book chapters with the patient’s values. The combinations shape the bedside hazards. This is a “bedside hazard!” Collecting its infinite biopsychosocial compositions requires the inveterate of variants, a minuteness that goes far beyond ordering mere plagiarisms of the book. Making the components of hazard intelligible gives rise to the sensation of clinical hyperesthesia, that thrust that stems from texts, grows in the alliance with the patient and matures in the ethical commitment.Bedside hazards are multipotent. They turn into academic boomerangs, ideas of clinical research perceived from them that are sent forward, applications based on evidences that come back. They are converted into a humanistic thrust that brings afloat the biopsychosocial portion submerged in the pedagogical iceberg, hidden in the learning of the disease dissociated from the patient. They mobilize clinical bioethics for the stabilization of the tripod supporting the society’s desires regarding the physician’s performance: honesty, confidentiality and efficiency. They send a warning that schematizations may be as didactic as illusory, for it is simplifications – see hazard 1 – that support the jocosity of “we are not new graduates, so we do not know everything”.

OBJETIVO: Estudar a reatividade vascular mediante a análise do fluxo sangüíneo e da resistência vascular periférica em repouso e estresse mental na gravidez de mulheres com estenose mitral. MÉTODOS: Foram estudadas 22 mulheres portadoras de estenose mitral, 13 grávidas (GE) e 9 não-grávidas (EM), e 9 gestantes saudáveis voluntárias (GN). Na gestação, 9 (GEB) das 13 do GE necessitaram de betabloqueador e 4 restantes (GESB) evoluíram sem medicação. A plestimografia em repouso e sob estresse mental analisou o fluxo sangüíneo muscular, resistência vascular periférica (RVP), pressão arterial média (PAM) e freqüência cardíaca (FC) na gestação e no puerpério. RESULTADOS: Na gestação do GESB, os valores do fluxo sangüíneo muscular e da FC foram maiores em 1,6% e 20,5% (p = 0,05), e os da RVP e da PAM foram menores em 19,3% e 4,4%, respectivamente, em comparação ao puerpério; no estresse mental, o fluxo sangüíneo muscular aumentou em 55,9%, a FC reduziu em 30,2% e houve semelhança da RVP e PAM. No GEB, os valores do fluxo e da FC foram maiores em 5,9% e 14,9% (p = 0,001) e os da PAM e da RVP menores em 10,3% e 9,1%, respectivamente, quando comparados ao puerpério; no estresse mental o fluxo e a PAM aumentaram em 69,8% e 174,1%, respectivamente, a FC foi semelhante e a RVP reduziu em 53,7%. O estudo comparativo mostrou que no grupo GN o fluxo sangüíneo muscular foi maior, a RVP menor e houve semelhança na PAM e FC em relação ao grupo GE e que os grupos GE, GN, EM apresentaram semelhança na resposta ao estresse mental. CONCLUSÕES: A reatividade vascular na gestação de mulheres com estenose mitral foi preservada e a análise das medidas mostrou valores menores de fluxo sangüíneo muscular e maiores da RVP quando comparados às gestantes saudáveis. OBJECTIVE: To study vascular reactivity according to the analysis of blood flow and peripheral vascular resistance at rest and during mental stress in pregnant women with mitral stenosis. METHODS: Twenty two women with mitral stenosis, 13 of whom were pregnant (PS) and 9 were non-pregnant (MIS), and 9 healthy pregnant women (NP) were studied. During gestation, 9 out of the 13 patients of the PS group required a beta-blocker (PSB) and the remaining 4 progressed without medication (PSWB). Plethysmography at rest and during mental stress analyzed muscle blood flow, peripheral vascular resistance (PVR), mean arterial pressure (MAP) and heart rate (HR) during gestation and puerperium. RESULTS: During gestation of PSWB, muscle blood flow and HR were higher in 1.6% and 20.5% (p = 0.05), and PVR and MAP were lower in 19.3% and 4.4%, respectively, in comparison to the puerperium; during mental stress, the muscle blood flow increased by 55.9%, HR decreased by 30.2% and PVR and MAP were similar. In PSB, muscle blood muscle blood flow and HR were greater in 5.9% and 14.9% (p= 0.001) and MAP and PVR were lower in 10.3% and 9.1%, respectively, when compared to the puerperium. During mental stress, muscle blood flow and MAP increased by 69.8% and 174.1%, respectively. HR was similar and PVR decreased by 53.7%. The comparative study showed that in the NP group the muscle blood flow was higher, PVR was lower, and MAP and HR were similar in relation to the PS group, and that the PS, NP, MIS groups had a similar response to mental stress. CONCLUSIONS: Vascular reactivity in pregnant women with mitral stenosis was preserved and the analysis of measurements showed lower values of muscle blood flow and higher values of PVR when compared to those of healthy pregnant women.

OBJETIVO: O objetivo deste estudo é apresentar resultados imediatos e tardios da plástica da valva mitral pela técnica de Duplo Teflon, em pacientes com insuficiência mitral importante que apresentam anel valvar gravemente calcificado e degeneração mixomatosa. MÉTODO: Entre 1985 e 2002, 162 pacientes com insuficiência mitral devido à degeneração mixomatosa foram submetidos a plástica da valva mitral no Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo. Deste total, 13 pacientes que apresentavam anel valvar gravemente calcificado foram submetidos à plástica da valva com ressecção quadrangular e anuloplastia pela técnica de Duplo Teflon. A idade média dos pacientes foi 65,4 +/- 12,9 anos, e 69,2% dos pacientes eram do sexo masculino. Um (7,7%) paciente tinha doença coronariana associada e foi submetido à cirurgia de revascularização do miocárdio. No período pré-operatório, 15,4% dos pacientes estavam em classe funcional IV, 69,2% em classe III e 15,4% em classe II. RESULTADOS: Não houve óbito no período pós-operatório imediato. No período pós-operatório tardio, 90,9% dos pacientes vivos estavam em classe funcional I. Não houve complicações como hemólise ou endocardite. Um paciente foi reoperado no segundo mês do período pós-operatório sendo realizada troca da valva mitral. A sobrevida atuarial em 14 anos foi 71,4 +/- 17,1%. CONCLUSÃO: A plástica da valva mitral com a técnica de Duplo Teflon, em pacientes com insuficiência mitral importante devido à degeneração mixomatosa e anel valvar gravemente calcificado, apresentou taxa de sobrevida satisfatória e boa evolução clínica, sugerindo ser melhor alternativa em relação à troca valvar. OBJECTIVE: The purpose of this study is to present the immediate and long-term results of mitral valve repair using the double Teflon technique in patients with mitral insufficiency due to myxomatous disease and severely calcified annuli. METHOD: Between 1985 and 2002, 162 patients with mitral insufficiency due to myxomatous degeneration were submitted to mitral valve repair in the Heart Institute of University of São Paulo Medical School. From these, 13 presented severely calcified annuli and underwent mitral valve repair with quadrangular resection and annuloplasty using the double Teflon technique. The mean patient age was 65.4 +/- 12.9 year with 69.2% of the patients being male. One (7.7%) patient had associated coronary artery disease and was submitted to coronary artery bypass grafting. In the preoperative period, 15.4% of the patients were in functional class IV of the New York Heart Association, 69.2% in class III and 15.4% in class II. RESULTS: There was no operative death.In late postoperative period, 90.9% of the surviving patients were in functional class I. There were no episodes of hemolysis or endocarditis. One patient was reoperated on the second postoperative month and was submitted to mitral valve replacement. The actuarial survival at 14 years was 71.4% +/- 17.1%. CONCLUSIONS: Mitral valve repair using the double Teflon technique in patients with myxomatous disease and severely calcified annuli presented satisfactory survival rates and good clinical evolution and proved to be a better alternative than mitral valve replacement.

esta relacionada em 80% dos casos ao parto e a doencas obste-tricas nem sempre evitaveis, como abortamento espontâneo, pla-centa previa, descolamento prematuro de placenta e parto pre-maturo. A fibrilacao atrial, por ser evento habitual na historianatural das valvopatias reumaticas, e situacao clinica observadacom frequencia na gestante cardiopata

OBJECTIVE: To compare, from the clinical and laboratory points of view, 3 groups of patients undergoing surgical treatment for isolated chronic mitral insufficiency. One group underwent valvuloplasty, and the other 2 groups underwent mitral valve replacement with different techniques for chordal preservation. METHODS: Twenty-eight patients with a mean age of 54.1 years, no coronary or multivalvular disease, and no reoperation, underwent surgery as follows: 9 underwent valvuloplasty; 10 underwent mitral valve replacement with chordal preservation in both leaflets; and 9 underwent mitral valve replacement with chordal preservation only in the posterior leaflet. Clinical, Doppler echocardiographic, and radionuclide ventriculographic assessments were performed until the 6th month of follow-up. RESULTS: At the end, 88.8% of the patients were in functional class I. One died due to intracranial hemorrhage during anticoagulant treatment. The left ventricular diastolic diameter (P

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 ≥70 mm and 76% for a patient with left ventricular end-systolic (LVESD) ≥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.

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

Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.

10.5935/abc.20140115Crisis is a point of progression of an illness at which either a tendency to improvement or to worsening is evident. Crises that happen later have a better prognosis.Hippocrates (460‑370 BC) The physician, in good faith, assumes a civil and criminal liability when making ethical judgments for which he is sometimes ill equipped to makeKaren Williams TeelPediatrician who suggested boards to share responsibilities in the 70s

"An idealist is a person who helps other people to be prosperous." Henry Ford (1863 - 1947) The morality of medical practice is based on beneficence. The benefit is applicable to an organ, however, it is not enough. The safety of the procedure to the patient's life is a concern1. The sense of the usefulness of a therapeutic method is well validated by effect extent class I/IIa in a guideline, but he/she can be harmed when the unexpected wins predictability. The high complexity collects unquestionable medical indications that exhibit poor individual prognosis due to severe comorbidities2. In this comparison between illness and patient, the contraindication illustrates that the major limitations of physician are the limits of medical science. Fortunately, we live in a moment of endless technological innovations. Readily globalized, they expand the skill bounderies and, at the same time, they give vitality to the classic, for the ongoing development is imperative in medical science. A new horizon requires interdisciplinarity, which, in turn, demands interpersonal communication. In the interests of the best clinical practice for the patient, the propaedeutics communicates with clinical and scientific evidence that is understood as the clinical reasoning under the tension of the imminence of conduct, listening to the values and preferences of the patient. The efficient communication - to talk, to hear oneself (am I being objective?), to listen and to hear oneself hearing (am I connected?) - energizes the trespassing through the essential ethical tolls: benefit of method, patient safety and human character of medical science3. In recent millennium transition, the routine of "discussion of the case" included the gap between the availability of medical science and medical care to the elderly with aortic valve stenosis ineligible for conventional surgical treatment. However, already in the early years of the 21st century, the discomfort of "if we can't do-good, at least let us not do harm" was reduced by the prospects of support to this subgroup of patients by means of transcateter implant of a bioprosthesis. Due to the initial results, the sentence has changed, following the change of the paradigm, to "we can do-good, but we have to take care of its potential harm". The systematized research4 proved the positive impact on the "hard" outcome pro-life and raised the likelihood of the certainty of benefit to B level. However, the best survival curve does not invalidate the uncertainties of complications related to innovation, a base of the modern concept of iatrogenesis5. Bedside conflicts arise between using an alternative method to conventional surgery to correct aortic valve hemodynamics and, at the same time, envision strong objections to satisfy the purpose both of survival and quality of life. They direct the physician to establish the applicable proportions of science and humanism, strongly advised by soliloquy, with the ontological component of ethics. The "I do-good to the patient because it crops out from being who I am and not just because I read the code of ethics" makes prudence and zeal flow in indicating/non-indicating/contraindicating depending on the symbolism of the Hippocratic oath. The resulting ordering of adjustments to the benefit ensures value for deliberation. It is worth remembering that, about 20 years ago, this moral plumbing occurred in establishing balloon catheter of mitral valvuloplasty and encouraged a close and progressive knowledge feedback and skill on the patient with mitral stenosis. Physician, surgeon, interventional cardiologist and echocardiographist got together and converted the field of the then innovation into an efficient relationship benefit/security that made it a rare AI recommendation in guideline of valvular heart disease. Currently, the transcateter implant of bioprosthetic in aortic position causes similar mobilization6. The search for answers to the questions brought about by the new therapeutic heritage recommends to appreciate it further than just a procedure. It is preferable to see it as a program comparable to a transplant7. The commitment of a collective of experts as far as the learning curve of this change of therapeutic standard in patients with valvular heart disease is concerned neither plastic nor native tissue replacement - is better structured in the formation of an interdisciplinary team to valvular heart disease. The team set-up replaces the one of disciplinary workgroup enough for sustainable routines by the coldness of reports and the monologue opinions juxtaposed. The interdisciplinary team for valvular heart disease links space and time. These dimensions make the refinement of movements and countermovements easier and to support excellence. Indication/non indication/contraindication may, therefore, be appropriately customized to the symptomatic elderly with aortic valve stenosis, respecting the enormous heterogeneity of the real world twinned by right to dignity. Transparency in interdisciplinary coordination of complementary expertises in patients with valvular heart disease is the raw material for the construction of a platform of clarity of tasks to be fulfilled, limits to be respected and performance levels to be achieved. Interdisciplinary meanings for the professional proficiency make the team an opinion maker. The interdisciplinary team for valvular heart disease confers nationality. The hierarchy between methods with flexibility in its borders, the tone for subjectivities (body weakness) and inaccurate objectivities (surgical risk scores), critical analysis on personal and literature results and the modulation to the sociocultural and economic develop the necessary fine tuning with Brazilian realities. The interdisciplinary team for valvular heart disease is greater than the sum of their participants, which does not happen with the working group. The expansion lies in the attitude of each member - sometimes as a disclosure, other as a receiver. I teach, you learn, he improves, we progress, is the conjugation intended from a system connected to attain the highest level of mutual understanding on cost-risk-effectiveness about the trinomial aortic valve stenosis -non valvular cardiac abnormalities-extra cardiac comorbidities. The interdisciplinary team to valvular heart disease thrusts the clippings out of interest the vertical provisions verticalized by the hyperspecialization turns to a horizontal solidarity position between one another, useful for the needs, preferences ad values of the Brazilian elderly The interdisciplinary team for valvular heart disease highlights the value of current cardiology as it extracts information from the three imaging giants - ultrasonography, CT scan and MRI - and introduces it into the hammer of decision making present in the calloused hands of sovereign clinic, powerful surgical clinic and the skillful interventionist cardiology. In short, the interdisciplinary team for valvular heart disease builds a strong interdisciplinarity. When exchanging not only methods but also concepts, the transdisciplinarity8 becomes closer by using rigor together with fundamental concepts, the opening to the unknown and the tolerance toward the gaps of medical science based on evidence about practices that cannot be disproved by personal experience. The hybrid room is the emblem. It is known that languages are neither static nor closed. Loan words occur as the result of dominance over a particular segment of society. In this context, the niche of present medical science is influenced by the supremacy of English language literature. TAVI is an anglicism that was quietly incorporated. Just as we should not insist on a Brazilian acronym by repositioning letters - ITVA or IVAT -, It seems reasonable to us to adopt the globalized (and synthetic) name Heart Team to express an interdisciplinary team specialized in cardiology. The concept of Heart Team was revived less than a decade ago as a methodological imperative deriving from the SYNTAX study9. The name gained notoriety for its contribution to the discipline communication and has migrated from research to assistance fields. The Heart Team acquired high organizational value in valvular heart disease, being understood that its absence is an absolute contraindication to the bioprosthetic transcateter implant in aortic position10. I propose that the Heart Team expression that (in)vests the shirt on in reliable relationship in a interdisciplinary network and acquires scientific capital facilitator of complex deliberations before the symptomatic elderly suffering from aortic valve stenosis to be termed as Heart Valve Team (VHT). VHT specificity includes: a) bioprosthesis management techniques and improvement ; b) contributions from imaging methods; c) safety by reducing adversity; d) early and late results, including participation in records; e) propensity to the use transcateter implant under minor surgical risk. It is appropriate to emphasize that the VHT should not be viewed with an expiration date to be set by taking innovation for granted. The VHT means aggregation in favour for excellence in the attention given to grey areas experienced by patients with valvular heart disease with dubious issues according to valvular and/or non valvular cardiac and /or extra-cardiac complexities. Finally, the VHT does not reinvent the wheel. VHT rediscovers the union and the gathering of people that give vitality to the analysis of uncertainties, the overcoming of adversity and the extent of the benefit.

Author contributions Conception and design of the research, Acquisition of data, Writing of the manuscript and Critical revision of the manuscript for intellectual content: Grinberg M. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work.

Dear Editor, In Brazil, a country where digital inclusion at home is growing1, there is a lack of data on the patients' use of the Internet for health information. A survey conducted among 118 patient in the Heart Valve Diseases Outpatient Clinic of InCor, resulted in the findings shown in Table 1. Table 1 Profile of the patients interviewed The figure of 11% of active participation, albeit modest, signals the value of initiatives in communication training in the doctor-patient relationship.

Background: The sensitivity and specificity of non-invasive methods – specifically single-photon emission computed tomography (SPECT) dipyridamole–thallium myocardial perfusion – for detecting coronary artery disease (CAD) in patients with severe aortic stenosis remains unclear. Occasionally, these patients present with atypical angina. Therefore, a CAD diagnosis must be excluded to prevent unnecessary cardiac catheterization. Methods: To determine the diagnostic value of SPECT dipyridamole–thallium imaging in this population, we compared the effectiveness of the imaging procedure with that of coronary angiography by prospectively analyzing patients who underwent both procedures. Group 1 included 59 patients who were asymptomatic or had atypical angina; group 2; 51 preoperative aged-matched patients with typical angina. SPECT acquisition was performed 15 min after 0.142 mg/kg/min of dipyridamole infusion completion, and redistribution images were performed 4 h after thallium injection. Two cut-off values of luminal diameter narrowing, >50 and >70%, defined significant CAD. Results: Coronary angiography with significant CAD (>50%) was present in 15 (25%) group 1 patients and in 16 (32%) group 2 patients ( P =NS). The sensitivity was greater in group 2 than in group 1 (56 versus 26%; P =0.001). The specificity, positive and negative predictive value, and accuracy in the groups were similar. CAD of >70% luminal stenosis was present in 11 (19%) group 1 patients and in 12 (23%) group 2 patients ( P =NS). The positive predictive value was greater in group 2 than in group 1 (75 versus 43%; P =0.001) but similar sensitivity, specificity, negative predictive value, and accuracy. The likelihood ratio for abnormal test increased in patients with CAD of >70%. Conclusions: symptoms of typical angina had significant impact on test sensitivity, positive predictive value and likelihood ratio for abnormal test. Furthermore, SPECT dipyridamole–thallium imaging was a useful non-invasive method to exclude the diagnosis of significant CAD (high specificity) in asymptomatic and symptomatic patients with isolated severe aortic stenosis.

Hypercholesterolemia has been related to aortic valve stenosis (AS). Polymorphisms of apolipoproteins (apo) AI, B, and E are associated with variable levels of plasma lipids, but the association between these polymorphisms and AS is unknown. In a case- control study of groups matched by age, sex, comparable body mass index, hypertension, triglycerides, high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol, we analyzed the distribution of apo AI A/G mutation, apo B signal peptide insertion/deletion, apo B Xbal restriction fragment length, and apo E polymorphisms in 62 non-diabetic patients with severe aortic valve stenosis and 62 control subjects. All patients underwent echocardiographic analysis. Univariate analysis showed a higher prevalence of the XbaI X + /X + genotype (p = 0.007) of apo B and the apo E2 allele (p = 0.034) in patients with severe AS. Apo polymorphisms were not associated with lipid levels, left ventricular mass, or the aortic gradient.

OBJETIVO: O objetivo deste estudo é analisar a experiência do Instituto do Coração com a utilização de próteses mecânicas de duplo folheto. CASUÍSTICA E MÉTODOS: No período compreendido entre junho de 1989 e agosto de 1998, foram implantadas 323 próteses mecânicas de duplo folheto em 300 pacientes. A idade média foi de 38,7 ± 18,4 anos. Cento e noventa e um (63,7%) pacientes eram do sexo masculino. A etiologia foi reumática em 161 (53,7%) pacientes. Foram realizadas 186 substituições da valva aórtica, 89 da valva mitral, 2 da valva tricúspide, 22 substituições mitro-aórticas e 1 mitro-tricuspídea. Quanto à classe funcional (CF), 73 (24,3%) pacientes se encontravam em CF IV, 165 (55,4%) em CF III e 61 (20,3%) em CF II. RESULTADOS: A mortalidade hospitalar foi de 9% (27 pacientes), sendo de 13,5% no grupo mitral, 7,5% no grupo aórtico e 4,5% no mitro-aórtico. As taxas linearizadas dos eventos no pós-operatório tardio são: 0,2% pacientes/ano (pac./ano) para endocardite, 0,3% pac./ano para escape paravalvar, 0,2% pac./ano para hemorragia relacionada à anticoagulação e 1,0% pac./ano para tromboembolismo. No pós-operatório tardio 213 (91%) pacientes encontram-se em classe funcional I ,16 (6,8%) em CF II e 4 (1,7%) em CF III e 1 (0,5%) em CF IV. A sobrevida actuarial em 9 anos foi de 68,1 ± 15,5% para a posição mitral e 67,5 ± 10,8% para a aórtica. CONCLUSÃO: Concluímos que os resultados com a utilização das próteses mecânicas de duplo folheto são satisfatórios.

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

Background: Endocarditis associated with ring abscess is a pathology with high morbidity and mortality. Aim of the study: The purpose of this study was to analyze hospital mortality risk factors in patients with ring abscess due to endocarditis. Methods: From January 1982 to December 2000, 104 patients underwent surgical intervention at the Heart Institute of the University of Sao Paulo Medical School for valve endocarditis with ring abscess. The age ranged from 6 years to 73 years, with an average of 40.3 years and 72.1% were male. According to NYHA functional class (FC), 12 (11.5%) were in FC II, 62 (59.6%) in FC III, and 30 (28.9%) in FC IV. Seventy-seven (74.0%) patients had endocarditis on a bioprosthesis, 58 (55.8%) in the aortic position and 19 (18.3%) in the mitral position. Twenty-nine (26.9%) patients had atrioventricular blockage prior to the operation. Univariate analysis was performed comparing variables and hospital mortality with a level of significance of 5%. Multivariate analysis was performed by logistic regression. Results: The hospital mortality was 19.2% (20 patients). Univariate analysis showed that atrioventricular blockage, age, and prosthetic valve endocarditis significantly influenced hospital mortality. Multivariate analysis identified atrioventricular blockage as an independent predictor of hospital mortality. Conclusions: Preoperative atrioventricular blockage is an independent risk factor for hospital mortality in the surgical treatment of endocarditis with ring abscess.