Caso 04/12: homem, 44 anos, portador de valvopatia reumática com múltiplas cirurgias de trocas valvares aórticas, internado para tratamento de insuficiência cardíaca congestiva

Abstract

KeywordsRheumatic fever / complications; heart valve diseases / surgery; aortic valve / abnormalities; aortic valve / surgery.Male, 44 years old, with a history of rheumatic attacks in childhood and adolescence and multiple aortic valve replacement surgeries, was admitted with decompensated heart failure.The present illness began with rheumatic attacks characterized by fever, arthritis of the right knee, when he was 7-11 old. At age 15, paroxysmal palpitations appeared. At age 16, the patient initiated follow-up at the outpatient services at InCor. Double aortic lesion and rheumatic disease activity were diagnosed.At the time, the electrocardiogram (ECG) revealed severe left ventricular hypertrophy; a chest radiograph revealed cardiomegaly +++/ 4+.At age 17, the palpitations became more frequent, dyspnea on moderate exertion appeared.Physical examination in primary care (May 1977) revealed pulse rate of 80 bpm, blood pressure 100/0 mmHg; auscultation was normal, cardiac auscultation revealed systolic murmur +++/ 4+ in the aortic area and diastolic murmur in the left sternal border. There was also the presence of a third heart sound; the abdomen showed no changes, no edema, and the pulse was of rapid ascent and descent. The patient was under use of digoxin (0.25 mg daily) and prophylaxis of rheumatic fever with benzathine penicillin 1.2 million units intramuscularly (IM) every two weeks. Surgical treatment of the aortic valve was prescribed.After the indication for surgical treatment, there were several attempts of hospitalization. However, these were frustrated by frequent episodes of fever and arthralgia of the knees treated as rheumatic disease activity and, due to the persistence of this condition, an investigation was conducted for infective endocarditis. Finally, the patient underwent aortic valve replacement with dura mater bioprostheses in 1979 (at age 19) and remained asymptomatic for five years, until 1984, when complaints similar to those prior to the surgery reappeared. Rough systolic murmur +++/4+ appeared and irradiated to the wishbone and tip.ECG revealed left chamber overload. Radiography revealed cardiomegaly ++/4+.An echocardiogram showed normal left ventricular dimensions (diastole 53 mm and systole 36 mm). The left atrium was 36 mm and there was dilatation of the aortic root (42 mm). There was concentric hypertrophy of the left ventricle and the prosthesis was considered to be normofunctioning.Medication in this period was 0.25 mg digoxin, 40 mg furosemide daily and benzathine penicillin every 15 days.In two years, the patient complained of chest pain and dyspnea initially on major exertion, then on moderate exertion. There were complaints of generalized arthralgias on several occasions.A new evaluation revealed the following echocardiographic changes (July 1986): concentric hypertrophy of the left ventricle with septal and posterior wall thickness of 14 mm, left ventricular dilatation (66 mm) with preserved systolic function (left ventricular ejection fraction of -LVEF = 64%), aortic dilata...