Implante transcateter valve‐in‐valve para disfunção de biopróteses cirúrgicas aórticas

RESUMOIntroduçãoEstudos recentes têm demonstrado a eficácia do implante transcateter valve‐in‐valve para o tratamento de disfunção de biopróteses em pacientes de alto risco cirúrgico. Apresentamos nossa experiência inicial com o implante valve‐in‐valve.MétodosCaracterizamos o perfil clínico, ecocardiográfico e do procedimento, e reportamos os resultados de médio prazo de pacientes com disfunção de bioprótese submetidos a implante valve‐in‐valve em posição aórtica.ResultadosIncluímos sete pacientes do sexo masculino, com idade de 72,6 ± 10,0 anos. O escore STS foi 9,6 ± 10,5%, e o EuroSCORE logístico foi 22,7 ± 14,7%. Três pacientes apresentavam dupla disfunção; dois tinham insuficiência; e dois exibiam estenose isolada. A via transfemoral foi utilizada em seis casos, e a transapical, em um caso. Os dispositivos implantados incluíram as próteses Sapien XT (n = 5) e CoreValve (n = 2). O sucesso do procedimento foi obtido em seis (85,7%) casos. Após o procedimento, o gradiente médio reduziu‐se de 38,2 ± 9,6mmHg para 20,9 ± 5,9mmHg, e a área valvar elevou‐se de 1,2 ± 0,4cm2 para 1,5 ± 0,5cm2. Ao final de 1 ano, não ocorreram óbitos e nem outros desfechos adversos significativos; 80% dos pacientes encontravam‐se em classe funcional NYHA I/II. Os gradientes transvalvares e a área valvar permaneceram inalterados nesse período.ConclusõesO procedimento valve‐in‐valve foi eficaz na maioria dos pacientes de alto risco cirúrgico com disfunção de bioprótese. Quando realizado em pacientes bem selecionados, resulta em desfechos clínicos e hemodinâmicos satisfatórios.ABSTRACTBackgroundRecent studies have demonstrated the efficacy of the transcatheter valve‐in‐valve implantation for the treatment of bioprosthesis dysfunction in high‐risk surgical patients. This study presents the initial experience with valve‐in‐valve implantation.MethodsClinical, echocardiographic, and procedural profiles were characterized, and the mid‐term results of patients with surgical bioprosthesis dysfunction submitted to valve‐in‐valve implantation in the aortic position were reported.ResultsSeven male patients were included, aged 72.6 ± 10.0 years. The STS score was 9,6 ± 10,5%, and the logistic EuroSCORE was 22.7 ± 14.7%. Three patients had combined aortic bioprosthesis failure; two had isolated regurgitation; and two had isolated stenosis. The transfemoral access was used in six cases, and the transapical access in one case. Implanted devices included Sapien XT (n = 5) and CoreValve (n = 2) prostheses. Procedural success was achieved in six (85.7%) cases. After the procedure, the mean gradient decreased from 38.2 ± 9.6mmHg to 20.9 ± 5.9mmHg, and the valve area increased from 1.2 ± 0.4cm2 to 1.5 ± 0.5cm2. After 1 year, there were no deaths and no other significant adverse outcomes; 80% of patients were in NYHA functional class I/II. The transvalvular gradients and valve area remained unchanged in this period.ConclusionsThe valve‐in‐valve procedure was effective in most high‐risk surgical patients with bioprosthesis dysfunction. When performed in well‐selected patients, it results in satisfactory clinical and hemodynamic outcomes

Preditores de anormalidades do sistema de conduçao cardíaco e necessidade de marcapasso definitivo após implante por cateter de bioprótese valvar aórtica (Transcatheter Aortic Valve Implantation - TAVI)

O implante por cateter de bioprótese valvar aórtica (do inglês Transcatheter Aortic Valve Implantation - TAVI) vem ganhando espaço e configura-se como opçao terapêutica para pacientes com estenose aórtica grave sintomática e risco cirúrgico elevado ou proibitivo. Apesar da menor manipulaçao e da menor agressividade comparativamente à abordagem cirúrgica tradicional, a incidência de bloqueio atrioventricular avançado é expressiva e resulta em aproximadamente 30% de implantes de marcapasso cardíaco definitivo. A identificaçao de fatores clínicos, eletrocardiográficos, anatômicos e relacionados ao tipo de prótese ou à técnica de liberaçao do dispositivo é fundamental para o desenvolvimento de novas técnicas e materiais, visando a reduzir a taxa de bloqueio atrioventricular avançado após o procedimento de TAVI. Os preditores mais relevantes analisados foram: bloqueio de ramo direito prévio, tipo de prótese (autoexpansível vs. balao expansível), profundidade do implante sobre a via de saída do ventrículo esquerdo, expansao excessiva da prótese, bloqueio atrioventricular total intraprocedimento, bloqueio atrioventricular de 1º grau ao eletrocardiograma de base e sexo masculino

Preditores de anormalidades do sistema de conduçao cardíaco e necessidade de marcapasso definitivo após implante por cateter de bioprótese valvar aórtica (Transcatheter Aortic Valve Implantation - TAVI)

O implante por cateter de bioprótese valvar aórtica (do inglês Transcatheter Aortic Valve Implantation - TAVI) vem ganhando espaço e configura-se como opçao terapêutica para pacientes com estenose aórtica grave sintomática e risco cirúrgico elevado ou proibitivo. Apesar da menor manipulaçao e da menor agressividade comparativamente à abordagem cirúrgica tradicional, a incidência de bloqueio atrioventricular avançado é expressiva e resulta em aproximadamente 30% de implantes de marcapasso cardíaco definitivo. A identificaçao de fatores clínicos, eletrocardiográficos, anatômicos e relacionados ao tipo de prótese ou à técnica de liberaçao do dispositivo é fundamental para o desenvolvimento de novas técnicas e materiais, visando a reduzir a taxa de bloqueio atrioventricular avançado após o procedimento de TAVI. Os preditores mais relevantes analisados foram: bloqueio de ramo direito prévio, tipo de prótese (autoexpansível vs. balao expansível), profundidade do implante sobre a via de saída do ventrículo esquerdo, expansao excessiva da prótese, bloqueio atrioventricular total intraprocedimento, bloqueio atrioventricular de 1º grau ao eletrocardiograma de base e sexo masculino

Aspergillus infection in the ascending aorta of a patient with aortic and mitral valve prostheses

We report the case of implantation of metallic mitral and aortic valve prostheses 6 months earlier, with subsequent multiple embolic episodes. The anatomicopathological examination of the thrombus of the third embolic episode was compatible with Aspergillus sp, which was treated with amphotericin B, followed by oral itraconazole. On the fourth embolism, vegetations were visualized in the ascending aorta on echocardiography and resonance imaging, and the patient underwent replacement of the aortic segment by a Haemashield tube and exploration of the aortic prosthesis, which was preserved, because no signs of endocarditis were found. Four months later, the patient died due to cardiogenic shock secondary to acute myocardial infarction caused by probable coronary embolism and partial dysfunction of the aortic prosthesis

Mortality Predictors in the Surgical Treatment of Active Infective Endocarditis

Abstract Introduction: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. Objective: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. Methods: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. Results: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). Conclusion: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period

Paravalvular Regurgitation: Clinical Outcomes in Surgical and Percutaneous Treatments

Abstract Background: Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair. Objectives: To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure. Methods: This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure. Results: The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08). Conclusion: Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk

Efeito da plástica mitral nas variáveis do teste cardiopulmonar em pacientes com insuficiência mitral crônica Effect of mitral valve repair on cardiopulmonary exercise testing variables in patients with chronic mitral regurgitation

FUNDAMENTO: A plástica valvar mitral é o procedimento cirúrgico de escolha para pacientes com Insuficiência Mitral (IM) crônica. Os bons resultados imediatos e tardios permitem a indicação cirúrgica antes do início dos sintomas. O teste cardiopulmonar de exercício (TCPE) pode avaliar objetivamente a capacidade funcional, mas pouco se conhece o efeito da cirurgia em suas variáveis. OBJETIVOS: Avaliar os efeitos da plástica mitral nas variáveis do TCPE em pacientes com IM crônica. MÉTODOS: Foram selecionados 47 pacientes com IM grave e submetidos plástica da valva mitral, sendo nestes, realizado TCPE ± 30 dias antes da cirurgia, e de seis a 12 meses após a cirurgia. RESULTADOS: Houve predominância da classe funcional I ou II pela NYHA em 30 pacientes (63,8%) e 34 pacientes (72,3%), respectivamente. Após a cirurgia foi observado uma diminuição significativa do consumo de oxigênio (VO2), de 1.719 ± 571 para 1.609 ± 428 mL.min-1, p = 0,036. Houve redução do Oxygen Uptake Efficiency Slope (OUES), de 1.857 ± 594 para 1.763 ± 514, p = 0,073 e o pulso de oxigênio (O2) aumentou após a cirurgia, de 11,1 ± 3,2 para 11,9 ± 3,2 mL.bat-1 (p = 0,003). CONCLUSÃO: A plástica da valva mitral, não determinou aumento do VO2 pico e do OUES apesar do remodelamento cardíaco positivo observado após sete meses de cirurgia. Entretanto, o pulso de O2 aumentou no pós-operatório, sugerindo melhora do desempenho sistólico do VE. O TCPE é uma ferramenta útil, podendo auxiliar na conduta médica em pacientes com IM.<br>BACKGROUND: Mitral valve repair is the surgical procedure of choice for patients with chronic Mitral Regurgitation (MR). The good early and late results allow surgical indication before symptom onset. The cardiopulmonary exercise test (CPET) can objectively assess functional capacity, but little is known about the effect of surgery on their variables. OBJECTIVE: Evaluate the effects of mitral repair on CPET variables in patients with chronic MR. METHODS: A total of 47 patients with severe MR were selected; these patients underwent mitral valve repair and were submitted to CPET ± 30 days before surgery, as well as six to 12 months after the surgery. RESULTS: There was predominance of functional class I or II NYHA in 30 (63.8%) and 34 patients (72.3%), respectively. A significant decrease in oxygen consumption (VO2) was observed after surgery, from 1,719 ± 571 to 1609 ± 428 mL min-1, p = 0.036. There was a decrease in Oxygen Uptake Efficiency Slope (OUES) from 1,857 ± 594 to 1763 ± 514, p = 0.073 and oxygen pulse (O2) increased after surgery, from 11.1 ± 3.2 to 11.9 ± 3, 2 mL.beat-1 (p = 0.003). CONCLUSION: The mitral valve repair did not increase peak VO2 and OUES despite positive cardiac remodeling observed seven months after surgery. However, O2 pulse increased postoperatively, suggesting improved LV systolic performance. The CPET is a useful tool to assist in the medical management of patients with MR. (Arq Bras Cardiol. 2013; [online].ahead print, PP.0-0