IJCS | Volume 31, Nº6, November / December 2018

581 Lemos et al. Evolutive study of rheumatic carditis cases Int J Cardiovasc Sci. 2018;31(6)578-584 Original Article times. In 12 cases (12.90%), surgery was required for two or three valves damaged by carditis. The median follow-up time in our service was 5 years. During outpatient follow-up, we observed that secondary prophylaxis with Penicillin G Benzathine was administered on a regular basis to 55 patients (59.14%) and irregularly to 38 (40.86%) others. As a result of one episode of carditis, 44 patients (47.31%) had only one hospitalization and five (5.38%) were maintained in outpatient control only. All of these were free of surgery. There were indications of two to three subsequent hospital admissions for 31 patients (33.33%) and four to five or more returns to hospital for another 11 (11.83%). In 12 cases (12.90%), the diagnosis was rheumatic carditis with bacterial endocarditis, using the modified Duke criteria. 20 Among them, three patients (3.23%) required surgery, of which one (1.08%) died after a double valve replacement using mitral and aortic biological prostheses. Evidence of vegetation at the two- dimensional Doppler echocardiogramwas foundmainly in the mitral valve (MV) of 10 patients (10.75%). In two others (2.15%), one showed damage to the aortic valve (AoV) only, while the other had mitral-aortic injury. Microorganisms were identified through blood cultures in six patients (6.47%), as follows: two (2.15%) with coagulase-negative Staphylococcus ; one (1.08%) had community-acquiredmethicillin-resistant Staphylococcus aureus (CA–MRSA); one (1.08%) had Streptococcus pneumoniae ; one (1.08%) had Streptococcus thermophilus ; and another (1.08%) had Klebsiella pneumoniae . The initial clinical status of carditis related to arthritis or arthralgia was found in 63 cases (67.74%). Other 12 patients (12.90%) also showed an association with Sydenham’s chorea (SC). In terms of clinical evolution: improvement was observed in 66 patients (70.96%); one (1.08%) showed worsening; 19 (20.43%) showed no change in the clinical picture; two (2.15%) were lost to follow-up and did not return for control visits; and five (5.38%) died. Consequently, we currently have 86 patients (92.47%) still undergoing outpatient follow-up. We observed good outcomes in the 49 patients (52.65%) who received clinical treatment only (valve regurgitation improvement) and the 17 (18.31%) submitted to successful surgical procedures (decreased pressure gradient and intracavitary volume, with an improvement in left ventricular systolic function). After corticotherapy, echocardiography showed that of the 52 cases (55.91%) with an initial lesion in three heart valves, 36 (38.69%) had a favorable evolution, with regression to univalvular disease and only 16 (17.20%) remainedwith the trivalvular involvement (mitral, aortic and tricuspid). Therefore, at the end of the treatment, we demonstrated that most patients showed a decrease in the carditis intensity. Comparison of the frequencies of the initial and final lesions (triple, double and single) showed a reduction in the number of patients with trivalvular involvement, with a significant difference (p value < 0.001 and chi-square 34.7473). LVEF determination by conventional transthoracic echocardiography (TTE) was performed before and after treatment was instituted. Subsequently, we verified the median ejection fraction (EF) values (Table 4). It was observed that in both the echocardiographic study at the acute phase and in the final evolution assessment, the EF was preserved, although a statistical significance was found in the comparison between these LVEFmedians (p value = 0.048). Only two patients (2.15%) showed ventricular systolic dysfunction (LVEF < 50%) and died. These were male patients with an initial estimated mean LVEF of 33.50% and final LVEF of 27.00%. Table 4 - Median initial and final left ventricular ejection fraction (LVEF) in patients with rheumatic carditis (n = 93) EF n Median p value* Interquartile range Lower Upper Initial 93 69.0 0.0484 40 81 Final 93 71.0 66 76 Female gender Initial 47 69.0 0.0408 60 73 Final 47 71.0 66 77 Male gender Initial 46 69.0 0.4475 61 74 Final 46 71.5 67 75 *Wilcoxon's test.