Caso 6/2007: criança de dez anos com estenose pulmonar valvar discreta

Abstract

A ten-year-old white male child who had been diagnosed with a heart murmur at six months of age in a routine examination and remained asymptomatic, active and with no physical limitations. On physical examination he was eupneic and with normal pulses. He weighed 47 kg and was 147 cm tall. His blood pressure was 110/70 mm Hg and heart rate was 76 bpm. No cyanosis was observed. The aorta was not palpable in the suprasternal notch. Chest examination showed neither deformities nor cardiac impulses, and a valve and muscular apical impulse + was located at the 4th left intercostal space limited by the breadth of one finger. Cardiac auscultation revealed regular rate and rhythm, and a split second sound with both components of equal intensity. A +/++ systolic ejection murmur was heard in the 2nd, 1st, and 3rd left intercostal spaces, accompanied by a soft systolic thrill. The liver was not palpable.The electrocardiogram showed sinus rhythm with mild right ventricular overload, R-wave amplitude of 8 mm in V1 and mild ventricular conduction delay. P-axis: +45°, QRSaxis:+100°, T-axis:+40°. Radiographic examinationRadiographic images showing a straight mid-arch and normal pulmonary vasculature (Figure 1). Diagnostic impressionThis image may correspond to that of a normal heart or even an acyanotic congenital heart disease with little repercussion. Differential diagnosisBoth the obstructive heart diseases and those with left-to-right shunting , with little repercussion, share similar features. It is difficult to differentiate between pulmonary valve stenosis and atrial septal defect when both conditions are mild. Therefore, other clinical data should be considered. Diagnostic confirmationThe systolic murmur in the pulmonary area accompanied by systolic thrill suggests the diagnosis of pulmonary valve stenosis. The normal splitting of the second sound demonstrates the little repercussion of the defect, as well as the electrocardiographic (Figure 2) and radiographic findings. The echocardiogram corroborated this hypothesis, with pressure gradient of 34 mm Hg between the right ventricle and pulmonary trunk. The pulmonary annulus was18 mm in diameter, the pulmonary valve was thick and trileaflet, and the pulmonary trunk was slightly dilated. Other measurements were as follows: left ventricular diastolic diameter, 40 mm; aorta, 25 mm; left atrium, 26 mm; right ventricle, 19 mm; septum, 7 mm; and myocardial fiber shortening, 30%. The interatrial septum was intact. ManagementThe boy should be treated expectantly, given the mild degree of the defect, with pressure gradient less than 40 mm Hg, since he was six months old.

Methodological adequacy of articles published in two open-access Brazilian cardiology periodicals

“…For example, Arquivos Brasileiros de Cardiologia presented the following sections: Anatomopathological Session (sic), Clinical Radiological Session (sic), Brief Comments, In Memoriam, Point of View, Image, Clinical Update and Guideline. [8][9][10][11] In Revista Brasileira de Cirurgia Cardiovascular, different sections were found, for example: Special Article, Brief Communication, Clinical Surgical Correlation and Experience of the Service. [12][13][14] Among the articles appearing in sections with different names in Arquivos Brasileiros de Cardiologia, there were two in the Clinical-Radiographic Correlation section that in reality were case reports.…”

“…[12][13][14] Among the articles appearing in sections with different names in Arquivos Brasileiros de Cardiologia, there were two in the Clinical-Radiographic Correlation section that in reality were case reports. 8,9 In the Brief Comments, one cohort study was found. 11 One of the strong points of the present study was that it made comparisons between recent, simultaneously published journals within the same field, in the same country, without apparent conflicts of interest.…”

“…For example, Arquivos Brasileiros de Cardiologia presented the following sections: Anatomopathological Session ( sic ), Clinical Radiological Session ( sic ), Brief Comments, In Memoriam, Point of View, Image, Clinical Update and Guideline. 8 - 11 In Revista Brasileira de Cirurgia Cardiovascular, different sections were found, for example: Special Article, Brief Communication, Clinical Surgical Correlation and Experience of the Service. 12 - 14 …”