IJCS | Volume 31, Nº6, November / December 2018

582 Lemos et al. Evolutive study of rheumatic carditis cases Int J Cardiovasc Sci. 2018;31(6)578-584 Original Article Discussion Most of the cases already had severe carditis, as previously shown. Of the 93 patients assessed by this study, more than half developed triple valvular injury, indicating the severity of the disease during the initial examination. However, there was a predominance of preserved LVEF. In the study by Rocha and Silva et al., 21 most patients underwent repairs at an advanced stage of valve damage, being in functional class IV of congestive heart failure (CHF), according to the criteria established by the New York Heart Association (NYHA). The MV surgical approach was performed in a large number of patients, due mainly to mitral insufficiency (MI). Most of the monitored children showed satisfactory responses to MV reconstruction. In the study by Travancas et al., 22 more than half of the replacement surgeries were focused on this valve. In our sample, surgical valve repair occurred mainly in the MV, as mentioned above. Patients undergoing surgery at the ideal time evolved well and death occurred in those treated at the later stages, who already showed compromised myocardial function. In our group, valve replacement was performed due to device deformity, being in agreement with the literature. According to Rocha and Silva et al., 21 one of the causes of mitral repair failure was the advanced inflammatory process of the valve. In the study carried out by Travancas et al., 22 patients with severe valve damage required surgical prosthesis implantation. It was also stressed that biological prostheses were appropriate, for children and adolescents, in case of difficulty resulting from the prescription or maintenance of laboratory control over anticoagulant use. Inadequate control of the international normalized ratio (INR) might lead to hemorrhagic or thrombo-embolic complications. This study showed that, of the total number of cases with vegetation image, preferably in theMV, 50%had the bacteriological isolation of the triggering microorganism of infective endocarditis (IE), with the coagulase-negative Staphylococcus being the main pathogen identified. Similarly, the results of Torbey et al., 23 showed that the mitral valve was predominantly affected, accompanied by significant regurgitation, and that Staphylococcus had been isolated, especially in newborns and patients with prosthetic valves. In some of our patients, treatment with oral corticoids was not effective initially, requiring the introduction of intravenous Methylprednisolone. The protocol followed for intravenous immunosuppression continued to be used in severe cases, of which importance has been underscored in certain publications. 15,24 However, pulse therapywas not widely used in our sample, probably due to prior treatment optimization with oral medications. Our clinical control and monitorization through the echocardiography series showed lesion improvement in most of the severe carditis cases treated with oral and/or intravenous immunosuppression and in those who remained in outpatient control with regular administration of secondary prophylaxis. This outcome was similar to that found in the follow-up study byHerdy et al., 25 which showed that even critically-ill patients had achieved a satisfactory evolution. Secondary prophylaxis failed in some of our adolescent patients. Adherence difficulty was observed regarding the systematic use of periodic injections of Penicillin G Benzathine, which has also been previously reported. 9,26 In the study by Herdy et al., 25 carditis reappeared in 49% of the cases, due to secondary prophylaxis disregard. Furthermore, recent failures in the free distribution of medication in some parts of the country and at certain times, resulted in higher RF recurrence rates, constituting a serious national public health problem. Our outpatient follow-up drop-out rate was lower than the initially expected one, comprising only two patients (2.15%). In the study carried out byMuller et al., 6 10.8% of the patients gave up on treatment. The drop- out rate and loss of follow-up in the group studied by Herdy et al., 25 reached a considerably high rate of 51%. This difference of results may be explained through the efforts of our multi-disciplinary team to get patients and their families to understand the disease severity and the need to prevent further RF flare-ups, stressing the importance of prevention. Limitations of the study Due to the retrospective nature of the study, we considered the possibility of limiting the sample size, because it is time-defined. Additionally, thedata collectionwas restricted to a single hospital, not representing the entire State of Rio de Janeiro. Conclusions We observeda favorable clinical evolution inmost cases of severe carditis treated through immunosuppression with corticoids and periodic outpatient follow-up. The