Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry. / Tendência Temporal no Implante Percutâneo de Bioprótese Aórtica: Análise de 10 Anos do Registro TAVIDOR.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown. OBJECTIVES: To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D'Or São Luiz. METHODS: Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05. RESULTS: This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008). CONCLUSIONS: The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients' clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

FUNDAMENTO: O implante percutâneo de bioprótese valvar aórtica (TAVI) consolidou-se como opção terapêutica da estenose aórtica de grau importante. Dados sobre as características evolutivas dos procedimentos e dos resultados obtidos com a técnica ao longo da última década, em escala nacional, são desconhecidos. OBJETIVOS: Analisar a tendência temporal referente ao perfil demográfico, características dos procedimentos e desfechos hospitalares de pacientes submetidos a TAVI na Rede D'Or São Luiz. MÉTODOS: Registro observacional envolvendo 29 instituições nacionais. Comparou-se características dos procedimentos realizados de 2012 a 2017 (Grupo 1) e de 2018 a 2023 (Grupo 2). Foram considerados significantes os resultados com valor de p < 0,05. RESULTADOS: Foram analisados 661 casos, 95 pertencentes ao Grupo 1 e 566 ao Grupo 2. A média de idade foi 81,1 anos. Observou-se no Grupo 1 maior prevalência de pacientes em classe funcional III ou IV e escore de risco > 8%. Foi mais frequente o emprego de anestesia geral, monitorização ecocardiográfica transesofágica e via de acesso por dissecção. Maior taxa de sucesso do procedimento (95,4% versus 89,5%; p = 0,018) foi aferida em implantes efetivados a partir de 2018, assim como menor mortalidade (3,9% versus 11,6%; p = 0,004) e necessidade de marcapasso definitivo (8,5% versus 17,9%; p = 0,008). CONCLUSÕES: A análise temporal de 10 anos do Registro TAVIDOR demonstra uma queda na complexidade clínica dos pacientes. Além disso, o avanço para técnicas de implante minimalistas, somadas à evolução tecnológica dos dispositivos, podem ter contribuído para desfechos favoráveis dentre aqueles cujo implante ocorreu no último quinquênio.

Effect of Discontinuing vs Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers on Days Alive and Out of the Hospital in Patients Admitted With COVID-19: A Randomized Clinical Trial.

Importance: It is unknown whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have a positive, neutral, or negative effect on clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Objective: To determine whether discontinuation compared with continuation of ACEIs or ARBs changed the number of days alive and out of the hospital through 30 days. Design, Setting, and Participants: A randomized clinical trial of 659 patients hospitalized in Brazil with mild to moderate COVID-19 who were taking ACEIs or ARBs prior to hospitalization (enrolled: April 9-June 26, 2020; final follow-up: July 26, 2020). Interventions: Discontinuation (n = 334) or continuation (n = 325) of ACEIs or ARBs. Main Outcomes and Measures: The primary outcome was the number of days alive and out of the hospital through 30 days. Secondary outcomes included death, cardiovascular death, and COVID-19 progression. Results: Among 659 patients, the median age was 55.1 years (interquartile range [IQR], 46.1-65.0 years), 14.7% were aged 70 years or older, 40.4% were women, and 100% completed the trial. The median time from symptom onset to hospital admission was 6 days (IQR, 4-9 days) and 27.2% of patients had an oxygen saturation of less than 94% of room air at baseline. In terms of clinical severity, 57.1% of patients were considered mild at hospital admission and 42.9% were considered moderate. There was no significant difference in the number of days alive and out of the hospital in patients in the discontinuation group (mean, 21.9 days [SD, 8 days]) vs patients in the continuation group (mean, 22.9 days [SD, 7.1 days]) and the mean ratio was 0.95 (95% CI, 0.90-1.01). There also was no statistically significant difference in death (2.7% for the discontinuation group vs 2.8% for the continuation group; odds ratio [OR], 0.97 [95% CI, 0.38-2.52]), cardiovascular death (0.6% vs 0.3%, respectively; OR, 1.95 [95% CI, 0.19-42.12]), or COVID-19 progression (38.3% vs 32.3%; OR, 1.30 [95% CI, 0.95-1.80]). The most common adverse events were respiratory failure requiring invasive mechanical ventilation (9.6% in the discontinuation group vs 7.7% in the continuation group), shock requiring vasopressors (8.4% vs 7.1%, respectively), acute myocardial infarction (7.5% vs 4.6%), new or worsening heart failure (4.2% vs 4.9%), and acute kidney failure requiring hemodialysis (3.3% vs 2.8%). Conclusions and Relevance: Among patients hospitalized with mild to moderate COVID-19 and who were taking ACEIs or ARBs before hospital admission, there was no significant difference in the mean number of days alive and out of the hospital for those assigned to discontinue vs continue these medications. These findings do not support routinely discontinuing ACEIs or ARBs among patients hospitalized with mild to moderate COVID-19 if there is an indication for treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT04364893.

Oclusão percutânea do apêndice atrial na fibrilação atrial com risco embólico / Percutaneous occlusion of the left appendage in atrial fibrillation

Fundamentos: A fibrilação atrial está associada a maior risco de eventos embólicos. O apêndice atrial esquerdoé a principal fonte de trombos.Objetivos: Avaliar a segurança e descrever a técnica de oclusão por cateter do apêndice atrial esquerdo.Métodos: Dois pacientes (um masculino com 79 anos e outro feminino com 91 anos) com fibrilação atrial, alto risco tromboembólico e contraindicação à anticoagulação foram submetidos à oclusão do apêndice atrial por viapercutânea. Resultados: Em ambos os casos, a prótese foi liberada sem fluxo residual, com completa exclusão da circulação e sem complicações. Os pacientes foram mantidos com dupla antiagregação plaquetária por três meses. Conclusões: A oclusão percutânea do apêndice atrialesquerdo é um novo e efetivo método para prevenção de eventos embólicos em pacientes com fibrilação atrial.

Segurança da ablação de fibrilação atrial com RNI terapêutico: comparação com a transição com heparina de baixo peso / Safety of ablation for atrial fibrillation with therapeutic INR: comparison with transition to low-molecular-weight heparin

FUNDAMENTO: O manejo ideal da anticoagulação oral (ACO) no período pré- e pós-ablação de fibrilação atrial (FA) ainda é motivo de controvérsia. OBJETIVO: Comparar duas estratégias de anticoagulação: suspensão da warfarina com a utilização de heparina de baixo peso molecular (HBPM) e a realização da ablação sem a suspensão da warfarina, mantendo o RNI terapêutico (entre 2,0 e 3,0). MÉTODOS: 140 pacientes (pt) portadores de FA persistente/ permanente submetidos à ablação por cateter de FA foram divididos em dois grupos: no grupo I (70 pt), a warfarina foi suspensa cinco dias antes do procedimento e utilizada terapia de transição com HBPM (enoxaparina 1 mg/kg 2x/dia pré-ablação e 0,5 mg/kg 2x/dia após o procedimento); no grupo II (70 pt), a warfarina não foi suspensa e o procedimento foi realizado com RNI terapêutico. Ambos os grupos receberam heparina intravenosa (TCA > 350 seg) durante o procedimento. RESULTADOS: No Grupo I, observou-se complicação hemorrágica maior (1,4 por cento) e 4 pt (5,7 por cento) com complicações hemorrágicas menores. No Grupo II, 2 pt (2,8 por cento) apresentaram complicações hemorrágicas menores e 1 pt apresentou sangramento maior; porém, este ocorreu após uso de HBPM por RNI < 2,0. Não houve complicação tromboembólica ou morte cardiovascular nos dois grupos após 16 ± 8 meses. CONCLUSÃO: A realização de ablação por cateter de FA sem a suspensão de ACO e RNI terapêutico é uma estratégia semelhante em segurança e eficácia quando comparada à tradicional transição com HBPM, evitando um período inicial pós-ablação de anticoagulação potencialmente inadequada.

BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4 percent) had a major hemorrhagic complication and four pts (5.7 percent) had minor hemorrhagic complications. In Group II, two pts (2.8 percent) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.

Very low risk of thromboembolic events in patients undergoing successful catheter ablation of atrial fibrillation with a CHADS2 score ≤3: a long-term outcome study.

BACKGROUND: Long-term cessation of oral anticoagulation (OAC) after catheter ablation of atrial fibrillation (AF) has been deemed controversial. The safety of this management strategy in patients without recurrent AF and with historically elevated risks for thromboembolism remains largely unknown. In this study, we sought to evaluate the long-term results of OAC cessation after successful catheter ablation of AF. METHODS AND RESULTS: OAC and antiarrhythmic drugs (AADs) were discontinued irrespective of AF type or baseline CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) risk score in 327 patients (mean age, 63±13 years; 79% men) with drug-refractory AF after catheter ablation (mean CHADS(2) score, 1.89±0.95; median, 2.0). Patients with a CHADS(2) score of 2 (45.4%) and 3 (23.2%) accounted for 68.8% of this cohort. In patients with a high risk of recurrence or prior thromboembolic complications, OAC was continued for up to 6 to 12 months postablation and antiplatelet therapy was administered to all patients who maintained sinus rhythm upon OAC interruption. After a follow-up of 46±17 months (range, 13-82 months), 82% remained AF free (off AADs). Significant predictors of late AF recurrence (P<0.05) were nonparoxysmal AF (hazard ration [HR], 1.83), female sex (HR, 2.19), age ≥60 years (HR, 1.81), left atrial size >40 mm (HR, 3.52), CHADS(2) score ≥2 (HR, 1.81), and early recurrences (HR, 5.52). No symptomatic ischemic cerebrovascular events were detected during follow-up despite interruption of OAC in 298 (91%) patients and AADs in 293 (89%) patients. CONCLUSIONS: No significant thromboembolic-related morbidity is observed when AADs and OAC are discontinued after successful catheter ablation of AF in patients with a CHADS(2) score ≤3 who are maintained on antiplatelet therapy during long-term follow-up.

Safety of ablation for atrial fibrillation with therapeutic INR: comparison with transition to low-molecular-weight heparin.

BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4%) had a major hemorrhagic complication and four pts (5.7%) had minor hemorrhagic complications. In Group II, two pts (2.8%) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.

Curso de Atualização em Cardiologia: aula 8: Arritmias para conduta clínica / Course Updating in Cardiologyclass 8: Arrhythmias for clinical conduct

As arritmias cardíacas apresentam grande prevalência na prática clínica diária e, desta forma, o diagnóstico correto é fundamental para a instituição da terapia adequada. O reconhecimento dos principais sinais e sintomas clínicos associados à interpretação criteriosa do eletrocardiograma são peças determinantes do sucesso terapêutico. Neste artigo serão abordadas as principais arritmias supraventriculares e ventriculares, no que diz respeito à sua apresentação clínica, critérios eletrocardiográficos, conduta imediata e em longo prazo. Vale enfatizar que a arritmologia atual oferece inúmeras opções terapêuticas efetivas e curativas para a grande maioria dos pacientes.

Fatores clínicos e eletrocardiográficos relacionados ao circuito do flutter atrial / Clinical and electrocardiographic factors related to the atrial flutter circuit

Objetivos: definir fatores e/ou eletrocardiográficos relacionados à localização do circuito do flutter atrial (FLA). Verificar a taxa de sucesso imediato e de recorrência a curto e médio prazos. Métodos: 95 pacientes não-consecutivos, portadores de FLA, submeteram-se a estudo eletrocardiológico e ablação por cateter. Foram estratificados em dois grupos: Grupo I:80 pacientes (84,2 por cento ) com FLA istmo-dependente, idade média de 66 maior ou menor 17 anos, sendo 68 (85 por cento) do sexo masculino. Grupo II: 15 pacientes (15,8 por cento) com FLA não-istmo-dependente, idade média 73 maior ou menor 14 anos, sendo 3 (33 por cento) do sexo masculino. As seguintes variáveis foram analisadas: presença de cardiopatia, documentação de FLA típico, taxa de sucesso imediato, taxa de recorrência. Para a análise estatística foi utilizado o teste exato de Fischer. Resultados: No Grupo I havia cardiopatia estrutural em 25 pacientes (35 por cento) e em 71 (88,7 por cento) havia FLA típico ao ECG. Todos os pacientes obtiveram sucesso e a taxa de recorrência foi de 3,75 por cento (3 pacientes)....

Objective: To define clinical and/or electrocardiography factors related to the location of the atrial flutter circuit(AF), ascertaining immediate success and recurrence rates over the short and medium terms. Methods: 95 non-consecutive patients with AF underwentan electrophysiological study and catheter ablation, stratified into two groups: Group I: eighty patients(84.2%) with isthmus dependent AF; average age 66±17 years; 68 (85%) men. Group II: fifteen patients (15.8%)com non-isthmus dependent AF; average age 73±14 years; five (33%) men. The following variables were analyzed: presence of cardiopathy; documented typical AF; immediate success rate; recurrence rate. Fischer’s exact test was used for the statistical analysis.Results: Group I − structural cardiopathy in 25 patients (35%) and 71 (88.7%) with typical AF in the ECG. All patients attained success and the recurrence rate was 3.75% (three patients). Group II − structural cardiopathy in ten patients (66.6%) and three patients (20%) had typical AF in the ECG. Critical points of the arrhythmiacircuit: AE (n=5 – 33.2%); AD (n=9 - 60%) (side wall and interatrial septum) and coronary sinus (n=1 – 6.7%). Nosuccess − one patient (6.7%); recurrence rate − 14.2% (two patients). The presence of cardiopathy presented significant correlation with Group II (non-isthmus AF), and records of typical AF / ECG were related to Group I – isthmus AF (p<0.05).Conclusions: For patients with AF, the presence of structural cardiopathy suggests the mechanism wouldbe non-isthmus, and records of typical AF / ECG suggest an isthmus macroreentry mechanism.