The structural heart disease (r)evolution. TAVI et al., where and how?

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Transcatheter aortic valve implantation (TAVI) a reference model in percutaneous cardiovascular intervention

Cardiovascular diseases (CVDs) are the leading causes of death and hospitalization and represent an enormous clinical and public health burden, which disproportionately affects older adults. According to the Instituto Nacional de Estatística (INE), life-expectancy at born and at 65 years has increased, respectively, 9,6% (73,93 to 81,06 years) and 5,1% (80,60 to 84,69 years), between 1990 and 2020. This evolution is observed worldwide and the World Health Organization (WHO) expects octogenarians to quadruple to 396 million by 2050. The 2060 INE estimates for life expectancy at born in Portugal are 84,21 years for men and 89,88 years for women1,2. This has increased the relative importance of heart valve diseases whose prevalence reached more than one in every ten octogenarians. This document summarizes a coherent professional path dedicated to the cardiovascular area, marked by the search for professional excellence, based on solid evidence-based clinical experience, phased research and the constant challenge of technical-scientific evolution. In the following pages, you will find the testimony of the drastic change caused by the structural cardiac intervention model in the aortic valve, with consequences in the organization and training of cath labs, as well as in the entire Cardiology department in terms of care and investigations. Before becoming a cardiologist, I intended already to be an interventional cardiologist and it was with the formulation of this question that I first addressed Prof. Dr. Ricardo Seabra-Gomes, in 1996. His provocative answer has since then placed the responsibility over my shoulders by the success, or not, of this ambition. The endeavor was, and still is, extremely demanding - no more than for everyone - and guided by the critical spirit of the tutored clinical activity in the light of emerging evidence-based medicine. Hospital de Santa Cruz is a pioneer unit in several techniques and percutaneous coronary intervention assumed dominance in 1990, when it surpassed, in number, surgical myocardial revascularization. In 2008 the Cardiology Director, Dr. Aniceto Silva, accepted my proposal for the organization, structuring and development of a program based on the individualized approach of each patient, using all types of percutaneous and other techniques - and all sorts of devices. Thus, it was born the Percutaneous Valves (VaP) program, transversal between Cardiology and Cardiac Surgery, encompassing referral, assessment, patient study, multidisciplinary meetings, discharge and follow-up during the consultation. Parallel and progressively, there was a strong pedagogical and training project to endow the team with a critical mass that allowed the senior operators to achieve autonomy and transversal competence, like that of coronary intervention, unique in the national reality. Finally, several international research consortia were conquered and integrated, in parallel with the international path followed that culminates in the prestigious Board of the European Association of Interventional Cardiology (EAPCI). Safety and efficacy have always been the first requirements for any cardiovascular technique, because mortality and complications are extremely important from a clinical point of view, resulting in prolonged admission and increased hospital costs. Coordinating the structural program is an enormous challenge that intersects all professional groups and colleagues, from resident to the cardiology head, highlighting the importance of building and caring for the referral network. It essentially went through four phases, each requiring an adaptation of the clinical, organizational, research, communication and management strategic plan: I. From 2008 to 2013, the technical and device launch phase, with a concentration of the volume on the three most experienced operators, intensive use of imaging and general anesthesia as default; II. From 2014 to 2016, the strategic innovation and sustained growth phase, with the expansion of the team to other senior operators, with the use of new techniques and devices - including mitral valves - with the cautious introduction of more simplified protocols for TAVI anesthesia and replication of image expertise to non-aortic space. The institution became a national leader and the period includes an official institutional survey that creates waiting lists in 2015 and provides a growth opportunity. The Presidency of Associação Portuguesa de Cardiologia de Intervenção (APIC) poses challenges and provides national and international collaborative opportunities that were distant, until then; III. From 2016 to 2017, the accelerated growth phase to respond to waiting lists and achieve maturation in the entire structural field. The visit of similar institutions is carried out with the adoption of an innovative model of sedation-analgesia with the support of anesthesiology, the teaching of the technique to all senior operators as well as the simplification of intra-hospital processes. The space of transseptal techniques enlarges and with it, all the imaging knowledge. Integration into EAPCI's European Valve For Live project projects APIC into EAPCI. The invitation to join its Board is challenging and allows you to competitively integrate prestigious European and North American research consortia. IV. From 2018 onwards, the consolidation phase, that is based on the daily routine of structural intervention techniques, with underlying administrative coordination and the implementation of a long-distance program that concentrates clinical examinations and evaluations in a single day. There is a growing and unique transversal experience that makes the center the Iberian leader in TAVI and that makes it a hands-on training center for other centers such as Centro Hospitalar do Funchal and Centro Hospitalar da Universidade de Coimbra, in addition to very important care partnerships with the Hospital Garcia de Orta, Hospital Fernando da Fonseca and Centro Hospitalar de Leiria. The biggest current challenge is to provide our network with a simple, expeditious and efficient articulation, expanding the center's narrative to the area of quality from the perspective of the patient and the referrer, based on scientific research within the scope of consortia. Other challenges, such as percutaneous mitral and tricuspid valve intervention, closure of the left atrial appendage and percutaneous closure of valve leaks, arise from this maturity and become a natural evolution in the field of percutaneous structural interventions

Manual or automatic?

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O leitor deve estar consciente do potencial iatrogénico desta publicação

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Acute left main coronary occlusion after transcatheter aortic valve implantation: life-saving intervention using the snare technique-a case report

Transcatheter aortic valve implantation (TAVI) has rapidly evolved and changed the field of structural cardiovascular intervention. Its advances lead to a marked reduction in the risk of complications and improved outcomes. However, TAVI is still associated with potential serious complications.publishersversionpublishe

Late results (>10 years) of intracoronary beta brachytherapy for diffuse in-stent restenosis

Introduction Until the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES. Objective To assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis. Methods This single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43-77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta-CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization. Results In all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients). Conclusions Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation.publishersversionpublishe

Iniciativa stent for life : fatores preditivos de atraso do sistema em doentes com enfarte do miocárdio com supradesnivelamento do segmento ST

© 2018 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.Introduction and Aims: System delay (time between first medical contact and reperfusion therapy) is an indicator of quality of primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) patients. This study aimed to assess changes in system delay between 2011 and 2015, and to identify its predictors. Methods: The study included 838 patients admitted to 18 Portuguese interventional cardiology centers suspected of having STEMI with less than 12 hours’ duration who were referred for primary percutaneous coronary intervention. Data were collected for a one-month period every year from 2011 to 2015. Univariate and multivariate logistic regression models were used to determine predictors of system delay. Results: No significant changes in system delay were observed during the study. Only 27% of patients had a system delay of ≤90 min. Multivariate analysis identified four predictors of system delay: age ≥75 years (OR 2.57; 95% CI 1.50-4.59; p=0.001), attending a center without pPCI (OR 4.08; 95% CI 2.75-6.10; p<0.001), not calling the national medical emergency number (112) (OR 0.47; 95% CI 0.32-0.68; p<0.001), and Central region (OR 3.43; 95% CI 1.60-8.31; p=0.003). Conclusions: The factors age ≥75 years, attending a center without pPCI, not calling 112, and Central region were identified as predicting longer system delay. This knowledge may help in planning interventions to reduce system delay and to improve the clinical outcomes of patients with STEMI.Introduction and Aims: System delay (time between first medical contact and reperfusion therapy) is an indicator of quality of primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) patients. This study aimed to assess changes in system delay between 2011 and 2015, and to identify its predictors. Methods: The study included 838 patients admitted to 18 Portuguese interventional cardiology centers suspected of having STEMI with less than 12 hours’ duration who were referred for primary percutaneous coronary intervention. Data were collected for a one-month period every year from 2011 to 2015. Univariate and multivariate logistic regression models were used to determine predictors of system delay. Results: No significant changes in system delay were observed during the study. Only 27% of patients had a system delay of ≤90 min. Multivariate analysis identified four predictors of system delay: age ≥75 years (OR 2.57; 95% CI 1.50-4.59; p=0.001), attending a center without pPCI (OR 4.08; 95% CI 2.75-6.10; p<0.001), not calling the national medical emergency number (112) (OR 0.47; 95% CI 0.32-0.68; p<0.001), and Central region (OR 3.43; 95% CI 1.60-8.31; p=0.003). Conclusions: The factors age ≥75 years, attending a center without pPCI, not calling 112, and Central region were identified as predicting longer system delay. This knowledge may help in planning interventions to reduce system delay and to improve the clinical outcomes of patients with STEMI.info:eu-repo/semantics/publishedVersio

Single photon emission computed tomography, invasive coronary angiography and cardiac computed tomography angiography

Introduction: Diagnostic tests that use ionizing radiation play a central role in cardiology and their use has grown in recent years, leading to increasing concerns about their potential stochas-tic effects. The aims of this study were to compare the radiation dose of three diagnostic tests: single photon emission computed tomography (SPECT), invasive coronary angiography (ICA) and cardiac computed tomography (cardiac CT) and their evolution over time, and to assess the influence of body mass index on radiation dose. Methods: We assessed consecutive patients included in three prospective registries (SPECT, ICA and cardiac CT) over a period of two years. Radiation dose was converted to mSv and compared between the three registries. Differences over time were evaluated by comparing the first with the fourth semester. Results: A total of 6196 exams were evaluated: 35% SPECT, 53% ICA and 22% cardiac CT. Mean radiation dose was 10.7±1.2 mSv for SPECT, 8.1±6.4 mSv for ICA, and 5.4±3.8 mSv for cardiac CT (p<0.001 for all). With regard to the radiation dose over time, there was a very small reduction in SPECT (10.7 to 10.5 mSv, p=0.004), a significant increase (25%) in ICA (7.0 to 8.8mSv; p<0.001), and a significant reduction (29%) in cardiac CT (6.5 to 4.6 mSv, p<0.001). Obesity was associated with a significantly higher radiation dose in all three exams. Conclusions: Cardiac CT had a lower mean effective radiation dose than invasive coronary angiography, which in turn had a lower mean effective dose than SPECT. There was a significant increase in radiation doses in the ICA registry and a significant decrease in the cardiac CT registry over time.publishersversionpublishe

A practical clinical score

Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.INTRODUCTION AND OBJECTIVES: Obstructive coronary artery disease (CAD) remains the most common etiology of heart failure with reduced ejection fraction (HFrEF). However, there is controversy whether invasive coronary angiography (ICA) should be used initially to exclude CAD in patients presenting with new-onset HFrEF of unknown etiology. Our study aimed to develop a clinical score to quantify the risk of obstructive CAD in these patients. METHODS: We performed a cross-sectional observational study of 452 consecutive patients presenting with new-onset HFrEF of unknown etiology undergoing elective ICA in one academic center, between January 2005 and December 2019. Independent predictors for obstructive CAD were identified. A risk score was developed using multivariate logistic regression of designated variables. The accuracy and discriminative power of the predictive model were assessed. RESULTS: A total of 109 patients (24.1%) presented obstructive CAD. Six independent predictors were identified and included in the score: male gender (2 points), diabetes (1 point), dyslipidemia (1 point), smoking (1 point), peripheral arterial disease (1 point), and regional wall motion abnormalities (3 points). Patients with a score ≤3 had less than 15% predicted probability of obstructive CAD. Our score showed good discriminative power (C-statistic 0.872; 95% CI 0.834-0.909: p<0.001) and calibration (p=0.333 from the goodness-of-fit test). CONCLUSIONS: A simple clinical score showed the ability to predict the risk of obstructive CAD in patients presenting with new-onset HFrEF of unknown etiology and may guide the clinician in selecting the most appropriate diagnostic modality for the assessment of obstructive CAD.proofepub_ahead_of_prin

Eight years of experience

Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.INTRODUCTION: Aortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. METHODS: The heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. RESULTS: TAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients' outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). CONCLUSIONS: The heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner.publishersversionpublishe