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Mitral valve prolapse (MVP) is thought to be one of the causes of unexplained cardiac arrest (UCA). However, previous studies are limited by the lack of a standardized evaluation of UCA and the absence of a control group to identify predictors of cardiac arrest. We performed a systematic review of studies that examined the yield UCA evaluation. We then reported the prevalence and characteristics of MVP patients from a multi-centre registry of patients with UCA. Lastly, we completed a protocol of a matched case-control study aiming at comparing echocardiographic features of MVP patients with and without cardiac arrest. As a result of these studies, we proposed a standardized algorithm for UCA evaluation and a definition for idiopathic ventricular fibrillation. Also, we reported the prevalence of MVP in patients with UCA and described few features that could potentially help distinguish patients with MVP at risk for cardiac arrest.

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Conventional echocardiographic parameters are currently used in determining the timing for surgery in patients with mitral regurgitation. Since brain natriuretic peptide (BNP) rises in response to ventricular muscle stretch, and is to detect early heart failure, we hypothesized that BNP would be activated in patients with regurgitant valvular heart disease and concomitant left ventricular dilatation. Aim/Objectives: We therefore studied the pattern of changes in NT-pro BNP in patients with chronic severe rheumatic mitral regurgitation who were undergoing mitral valve replacement and compared this with the newer modality of tissue Doppler imaging (TDI). Setting: Patients submitted to surgery were prospectively evaluated over 8 months at Inkosi Albert Luthuli Central Hospital, Department of Cardiology. Controls were obtained from the outpatients' follow-up clinic. Methods: Simultaneous quantification of the severity of mitral regurgitation (MR), left ventricular (LV) end systolic volume (ESV), left atrial (LA) volume and Doppler filling ratios (mitral (E)/annulus (Ea)) were performed at baseline in all patients and was repeated at 1-week and at the six-week follow-up visit in surgical patients. Results: Both groups were similar for age and gender and echo-Doppler parameters in all patients preoperatively except LA size (p< 0.01) and volume (p<0.004) which were more elevated in the surgical group. Mean NT-pro BNP levels were markedly elevated preoperatively (262 pmolll) in all surgical cases compared to controls (57 pmol/l; p=0.0001). NT-pro BNP levels increased further at one week post surgery (395 pmol/l) and subsided at the six week follow-up visit (94 pmol/I). These changes were accompanied by significant reduction in LA (p= 0.003) and LV chamber dimensions (EDD = 0.004) with an increase in the ejection fraction from 42% at one week to 52 % at six weeks. Four patients had abnormally elevated NT-pro BNP levels (>53pmol/l) at the 6-week follow-up visit. A ROC curve was constructed for all variables to separate surgical cases from controls. The area under the curve was highest for NT-pro BNP (sensitivity= 96%, specificity 45 %). Conclusion: 1. There was a significant difference in the left atrial chamber size and volume, as well as Em/Ea (TDI) and NT-proBNP levels preoperatively between the two groups. The lack of a significant difference in the LV parameters between surgical and control groups suggest an almost total reliance on symptoms in deciding the timing of surgery which was reflected by markedly elevated NT-pro BNP in all surgical patients. 2. Postoperatively, there was a significant reduction in LA and LV dimensions. 3. The high false positivity rate for NT-pro BNP suggests that the test is most likely reflecting early LV decompensation in the less symptomatic control patients who rightly need surgery. 4. Tissue Doppler indices had similar sensitivity but low specificity compared to NT-proBNP. 5. Serial estimations of NT-pro BNP may prove useful in selecting patients for surgery. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, 2007.

Varón de 15 años, con 2 meses de enfermedad caracterizada por sudoración profusa y dolor en miembros inferiores que le dificultaba caminar. El dolor aumento de intensidad asociándose después a taquipnea y disnea al caminar 50 m más náuseas y vómitos, disnea en reposo y edema de miembros inferiores. Ingreso por Emergencia al Hospital Nacional Dos de Mayo (HNDM) el 27/04/2016, presentando a su ingreso palpitaciones y disnea a pequeños esfuerzos. El Servicio de Cardiología del HNDM, diagnostico : Insuficiencia aórtica y mitral severa, insuficiencia tricúspidea leve e hipertensión pulmonar. Pulso arterial: 104 lat/min, FR: 32 resp/min, PA: 110/50 mm Hg, T°: 36,5°C, choque de la punta en 7mo espacio intercostal izquierdo, Soplo diastólico III/IV en foco aórtico, S sistólico III/IV en foco mitral, pulso radial en martillo de agua. Glucosa 74 mg/dl., creatinina 0.47 mg/dl, antiesptreptolisina (ASO) : 355 IU/ml, AAN: negativo, Hb : 11.6 g/dl, Proteínas Totales: 6.09gr/dl, albumina: 3.19gr/dl, globulina : 2.90gr/dl, Ecocardiograma: dilatación severa de aurícula y ventrículo izquierdo, hipertrofia de VI, dilatación de aurícula derecha, dilatación de arteria pulmonar y ramas. Insuficiencia severa aórtica y mitral, insuficiencia tricuspídea leve. Sometido a reemplazo valvular, hubo notable mejoria. / 15 years old, male, with 2 months clinical record characterized by profuse sweating and lower limbs pain that produced trouble on walking. Increased pain intensity was associated to tachypnea nausea,vomiting and dyspnea after walking 50 m.Beside it he had dyspnea at rest and lower limb edema. He entered to Dos de Mayo National Hospital (HNDM) on 04.27.2016, presenting palpitations and dyspnea at small efforts. HNDM, Department of Cardiology, diagnosed : severe mitral and aortic insufficiency, mild tricuspid regurgitation and pulmonary hypertension. Arterial pulse: 104 beats/min, FR: 32 breaths/min, PA: 110/50 mm Hg, T °: 36.5 ° C, tip heart beat at 7th left intercostal space, diastolic murmur III/IV at aortic focus, systolic murmur III/IV at mitral focus, water hammer radial pulse, glucose 74 mg/dl, creatinine 0.47 mg/dL, antiesptreptolisina (ASO) : 355 IU/ml, AAN: negative, Hb: 11.6 g / dl, total proteins: 6.09gr/dl, albumin: 3.19gr/dL globulin : 2.90gr/dl, Echocardiogram : severe dilated atrium and left ventricle hypertrophy, dilated right atrium, pulmonary artery and branches dilatation. Severe aortic and mitral insufficiency, mild tricuspid regurgitation. After valve replacement, the patient showed remarkable improvement.

Introdução: A Insuficiência Mitral (IM) crônica orgânica tem fisiopatologia complexa. Os sintomas de insuficiência cardíaca e piora da capacidade funcional, podem aparecer apenas tardiamente, quando já existe disfunção contrátil do ventrículo esquerdo (VE). O teste cardiopulmonar de exercício (TCPE) pode avaliar objetivamente a capacidade funcional e auxiliar a conduta médica nos pacientes com IM, mas, pouco se conhece sobre o efeito da cirurgia em suas variáveis. Objetivos: Avaliar os efeitos da correção cirúrgica da IM nas variáveis do TCPE realizados em bicicleta e em esteira rolante. Métodos: Foram selecionados 72 pacientes com IM grave e submetidos à cirurgia corretiva da valvopatia, sendo nestes realizados ecocardiograma (ECO) e TCPE ± 30 dias antes da cirurgia, e de seis a 12 meses após a cirurgia. Resultados: A média das idades foi de 49,9 ± 16,9 anos. Houve predominância do sexo masculino, da etiologia degenerativa e da classe funcional I ou II pela NYHA em 41 pacientes (56,9%), 50 pacientes (69,4%) e 51 pacientes (70,8%), respectivamente. O reparo mitral foi realizado em 47 pacientes (65,3%) e a troca valvar em 25 pacientes. Após a cirurgia houve redução do volume atrial esquerdo (VAE), de 124,4 ± 58,9 ml para 76,4 ± 34,0 ml (p<0,001), do volume diastólico final do VE (VDFVE), de 151,7 ± 35,7ml para 109,6 ± 42,8 ml (p<0,001), do volume sistólico final do VE (VSFVE), de 47,6 ± 18,0 para 43,9 ± 27,1ml (p<0,001), da fração de ejeção (FE), de 69,1 ± 6,3 para 61,30 ± 8,2% (p<0,001) e da pressão sistólica em artéria pulmonar (PSAP), de 46,7 ± 15,9 para 35,4 ± 12,5 mm Hg (p<0,001). Também foi observado uma diminuição do consumo de oxigênio (VO2) pico em ambas as modalidades de exercício após a cirurgia (bicicleta: de 1356 ± 506 para 1269 ± 408 mL.min-1, p=0,015; esteira: de 1618 ± 579 para 1536 ± 447 mL.min-1, p=0,06), assim como a variável OUES (bicicleta: de 1530 ± 516 para 1414 ± 415, p=0,001; esteira: de 1761 ± 585 para 1691 ± 508, p=0,050). O pulso de oxigênio (O2) aumentou após a cirurgia apenas no TCPE realizado em esteira, de 10,7 ± 4,0 para 11,5 ± 3,2 mL.bat-1 (p=0,023). No TCPE realizado em esteira, a diferença percentual do OUES apresentou significativa correlação negativa com a diferença percentual do VDFVE (r=-0,277; p=0,034), do VAE (r=-0,275; p=0,035) e da PSAP (r=-0,282; p=0,041), respectivamente. No TCPE realizado na bicicleta, a diferença percentual do OUES revelou correlação negativa apenas com a diferença percentual da PSAP (r=-0,359; p=0,010). Conclusão: A cirurgia valvar mitral, não determinou aumento do VO2 pico e do OUES apesar da melhora sintomática avaliada pela classe funcional (NYHA). Entretanto, a variável OUES apresentou correlação negativa com parâmetros ecocardiográficos de remodelação cardíaca. O TCPE é uma ferramenta útil e promissora, podendo auxiliar na conduta médica em pacientes com IM. / Introduction: Chronic organic Mitral Regurgitation (MR) has a complex physiopathology. The symptoms of heart failure and functional capacity worsening may appear too late, when a left ventricle (LV) contractile dysfunction already exists. The cardiopulmonary exercise testing (CPET) may objectively assess the functional capacity and helps in the medical conduct concerning patients with MR, but little is known about the surgery effect on its variables. Objectives: To evaluate the effects of the MR surgical correction on the variables related to the CPET performed on stationary bicycle and treadmill. Methods: A total of 72 patients with severe MR were selected and underwent a surgery for valvulopathy correction and an echocardiogram (ECHO) and CPET were performed around 30 days before the surgery and then from six to 12 months after the surgery. Results: The patients were aged an average 49.9 ± 16.9 years. There was a predominance of male patients [41 patients (56.9%)], degenerative etiology [50 patients (69.4%)] and NYHA I or II functional class [51 patients (70.8%)]. Forty-seven (47) patients (65.3%) had their mitral valves repaired and 25 patients had them replaced. After the surgery, there was a reduction in the left atrial volume (LAV) from 124.4 ± 58.9 ml to 76.4 ± 34.0 ml (p<0.001), in the LV end-diastolic volume (LVEDV) from 151.7 ± 35.7ml to 109.6 ± 42.8 ml (p<0.001), in the LV end-systolic volume (LVESV) from 47.6 ± 18.0 to 43.9 ± 27.1ml (p<0.001), in the ejection fraction (EF) from 69.1 ± 6.3 to 61.30 ± 8.2% (p<0.001) and in the pulmonary artery systolic pressure (PASP) from 46.7 ± 15.9 to 35.4 ± 12.5 mm Hg (p<0.001). A reduction in the peak consumption of oxygen (VO2) was also observed in both types of exercise testing after the surgery (stationary bicycle: from 1356 ± 506 to 1269 ± 408 mL.min-1, p=0.015; treadmill: from 1618 ± 579 to 1536 ± 447 mL.min-1, p=0.06), as well as in the variable Oxygen Uptake Efficiency Slope (OUES) (stationary bicycle: from 1530 ± 516 to 1414 ± 415, p=0.001; treadmill: from 1761 ± 585 to 1691 ± 508, p=0.050). Pulse oxymetry readings (O2) increased after the surgery only for the CPET performed on the treadmill from 10.7 ± 4.0 to 11.5 ± 3.2 mL. heartbeat -1 (p=0.023). For the CPET performed on the treadmill, the OUES percent difference showed significant negative correlation with the percent difference of LVEDV (r=-0.277; p=0.034), LAV (r=-0.275; p=0.035) and PASP (r=-0.282; p=0.041), respectively. For the CPET performed on the stationary bicycle, the percent difference of the OUES showed a negative correlation only with the percent difference of PSAP (r=-0.359; p=0.010). Conclusion: The mitral valve surgery caused no increase in the peak VO2 or OUES despite the symptomatic improvement as assessed through the functional class (NYHA). However, the variable OUES showed negative correlation with the echocardiographic parameters of cardiac remodeling. The CPET is a useful and promising tool, and may help in the medical conduct concerning patients with MR.

A fração solúvel de ST2 (sST2) é a isoforma circulante do ST2, um receptor membro da família das interleucinas-1. O sST2 é considerado um biomarcador cardíaco, pois é induzido mecanicamente pelo estiramento de cardiomiócitos e fibroblastos em situações de estresse miocárdico secundário à sobrecargas de volume ou de pressão, podendo ser detectado no soro. Este biomarcador tem demonstrado valor prognóstico em humanos, sendo considerado um importante preditor de mortalidade independente. Embora possua capacidade limitada como teste diagnóstico quando utilizado isoladamente, as concentrações séricas de sST2 apresentam-se aumentadas em pacientes humanos com ICC aguda, motivo pelo qual sua utilidade tem sido estudada em associação a outros biomarcadores como o NT-proBNP e a troponina I (cTnI). Entretanto, ainda não há estudos clínicos avaliando o sST2 em cães com degeneração valvar crônica de mitral (DVCM). Portanto, a proposta deste estudo foi determinar a utilidade do sST2, comparado ao NT-proBNP e a cTnI, para a avaliação de cães predispostos ou em diferentes estágios da DVCM. Para tanto, foram selecionados 151 cães em diferentes estágios de DVCM. Os animais foram submetidos à exame clínico, testes laboratoriais, radiografias torácicas, eletrocardiografia, ecodopplercardiografia, mensuração de pressão arterial sistólica e dosagens dos biomarcadores sST2, NT-proBNP e cTnI. Os resultados deste estudo demonstraram que as concentrações de sST2 foram maiores nos cães com ICC secundária a DVCM, em relação aos cães sem ICC. Entretanto, quando os cães foram agrupados de acordo com os estágios da DVCM, não houve diferença nas mensurações de sST2 entre os grupos. As mensurações de NT-proBNP e a cTnI foram maiores tanto nos cães com ICC, em relação aos cães sem ICC, quanto nos estágios mais avançados da DVCM. Observou-se correlação entre o sST2 e os biomarcadores NT-proBNP e cTnI, assim como entre sST2 e variáveis ecodopplercardiográficas de avaliação da função diastólica. Na análise de curva ROC para o diagnóstico de ICC, as áreas sob a curva (AUC) foram de 0,66 para o sST2, 0,86 para NT-proBNP e 0,76 para cTnI. Na avaliação de prognóstico, observou-se que o grupo de cães com mensurações de sST2 maiores que 40 pg/mL apresentou maior ocorrência de óbito, comparado ao grupo com menores valores de sST2. Concluiu-se que o desempenho do sST2, como teste diagnóstico para ICC, isoladamente, foi limitado e inferior aos outros biomarcadores estudados. Entretanto, a correlação observada entre sST2, NT-proBNP, cTnI e variáveis ecodopplercardiográficas, sugere que o sST2 pode acrescentar valor diagnóstico em uma análise de regressão multivariada. O sST2 parece possuir utilidade como marcador prognóstico independente, sendo preditor de mortalidade em cães com DVCM. / The soluble fraction of ST2 (sST2) is the circulating isoform of ST2, a member of the interleukin-1 (IL-1) receptor family. Soluble ST2 is considered a cardiac biomarker, which is induced mechanically by the stretch of cardiomyocytes and fiblobasts in situations of myocardial stress, due to volume or pressure overload, and may be measured in serum. This biomarker has shown prognostic value in human cardiology, and is considered an important independent mortality predictor. Although it holds limited diagnostic capacity by itself, serum concentration of sST2 is increased in acute heart failure human patients, reason why its utility has been studied in association to other biomarkers as NT-proBNP and cardiac troponin I (cTnI). However, studies assessing sST2 in dogs with chronic mitral valve disease (CMVD) are still lacking. Therefore, this study aimed to determine the utility of sST2, compared to NT-proBNP and cTnI, for assessment of dogs predisposed to or in different stages of CMVD. With this purpose, 151 dogs in different stages of CMVD were recruited and submitted to clinical exam, laboratory tests, thoracic radiography, electrocardiography, echocardiography, systolic arterial blood pressure assessment and measurement of the biomarkers sST2, NT-proBNP and cTnI. The results demonstrate that sST2 concentration was higher in dogs in congestive heart failure (CHF) secondary to CMVD compared to dogs without CHF. However, when dogs were stratified according to CMVD stages, it was not possible to differentiate the groups based on sST2 concentrations. NT-proBNP and cTnI concentrations were higher in CHF dogs compared to non-CHF dogs, as well as in more advanced stages of CMVD. There was correlation between sST2 and NT-proBNP and cTnI, and also between sST2 and diastolic function echocardiographic variables. Analysis of ROC curve for HF diagnosis showed areas under the curve (AUC) of 0,66 for sST2; 0,86 for NT-proBNP and 0,76 for cTnI. As for prognosis assessment, sST2 concentrations higher than 40 pg/mL indicated higher mortality compared to groups with lower sST2 values. We conclude that sST2 performance as a stand alone diagnostic test is limited and inferior to the other studied biomarkers. However, the correlation observed between sST2, NT-proBNP, cTnI and echocardiographic variables, suggests that sST2 may add diagnostic value in a multivariate regression analysis. sST2 seems to be a useful independent prognostic marker, and mortality predictor in dogs with CMVD.