The learning curve effect on outcomes with frozen elephant trunk technique for extensive thoracic aorta disease.

OBJECTIVE: The purpose of this study was to analyze the learning curve effect on hospital mortality, postoperative outcomes, freedom from reintervention in the aorta and long-term survival after frozen elephant trunk (FET) operation. METHODS: From July 2009 to June 2018, 79 patients underwent surgery with the FET technique. They had type A aortic dissection (acute 7.6%, chronic 33%), type B aortic dissection (acute 1.26%, chronic 34.2%), and complex thoracic aortic aneurysm (24%). 27.8% were reoperations and 43% received concomitant cardiac procedures. To compare the results, the sample was divided into group 1 (G1) (first half of the sample - operations from 2009 to 2014) and group 2 (G2) (first half of the sample - operations from 2015 to 2018). RESULTS: The in-hospital mortality was 20.25%, 30.7% for G1 and 10% for G2 (P = .02). The mean cardiopulmonary bypass time, myocardial ischemia time, and selective cerebral perfusion at 25°C time were 154 ± 31, 118 ± 32, and 59 ± 12 minutes, respectively, similar for both groups. Stroke and spinal cord injury occurred in four and two patients, with no difference between groups (P = .61 and P = .24). The necessity for secondary intervention on the downstream aorta for both groups was also similar (P = .136). Five of sixty-three surviving patients died during the follow-up period and the estimated survival rate was different between groups 49% vs 88% (P = .007). CONCLUSION: The learning curve with the FET procedure had a significant impact on hospital mortality and midterm survival over the follow-up period, albeit did not influence the freedom from reintervention on the downstream aorta.

Was the Enalapril Dose Too Low in the PARADIGM-HF Trial?

Heart failure (HF) is a common clinical syndrome associated with significant morbidity and mortality, and there remains a clear need for innovative therapies that can modify disease progression. Sacubitril/valsartan (LCZ696) is a novel complex that combines simultaneous neprilysin inhibition and angiotensin II receptor blockade, that has demonstrated significant cardiovascular death or HF hospitalization reduction in the Prospective Comparison of Angiotensin Receptor/Neprilysin Inhibitor (ARNI) With Angiotensin-Converting Enzyme (ACE) Inhibitors to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial when compared with evidence-based doses of the gold standard ACE inhibitor enalapril. In this comprehensive review, the authors discuss historical trials that have investigated clinical outcomes utilizing variable dosing levels of ACE inhibitors or angiotensin receptor blockers in patients with HF with reduced ejection fraction. A critical analysis of the highlighted studies is proposed in the context of current HF management guidelines and HF clinical practice. In conclusion, based on current evidence, it is unclear whether a maximum recommended enalapril dose would promote improved patient outcomes compared with an intermediate dose. However, no prospective study to date comparing ACE inhibitor doses has documented that higher doses result in significant mortality reduction, although the data suggest that there may be a decrease in HF hospitalizations when compared with lower doses.

Estimativa da capacidade de exercício na miocardiopatia hipertrófica não-obstrutiva com base em dados demográficos e ecocardiográficos / Prediction of exercise capacity based on echocardiographic and demographic data in no-obstructive hypertrophic cardiomyopathy

Introdução: Além dos mecanismos centrais e periféricos, a determinação da capacidade de exercício depende de fatores, como sexo e idade. Os sintomas e a capacidade de exercício em pacientes com miocardiopatia hipertrófica (MCH) são variáveis, mesmo naqueles com a forma não-obstrutiva da doença. Portanto, determinar a capacidade de exercício a partir de exames complementares de execução simples é desejável. Métodos: Foram estudados 27 pacientes com MCH não-obstrutiva (grupo MCH) e 20 indivíduos normais (grupo NL). Todos foram submetidos a um estudo ecocardiográfico e teste cardiopulmonar (TCP). Foram medidas: ondas E e A, E/A, tempo de desaceleração de E (TDE) e tempo de relaxamento isovolumétrico (TRIV) do fluxo mitral, ondas S, D, Avp, S/D e fração de enchimento atrial (S/[S+D}) do fluxo da veia pulmonar superior direita, ondas Ea, Aa, Ea/Aa e E/Ea pelo Dopper tecidual, e V02 de pico e limiar anaeróbio (LA) pelo TCP. Foi realizada análise de regressão multivariada escalonada relacionando as variáveis ecocardiográficas, demográficas. VO2 de pico e LA. Resultados: Os seguimentos modelos de regressão foram obtidos: VO2 de pico=11,28 + 0,876)Ea lat)+ 9,080(se do sexo masculino) - 0,295 (idade); R2 = 0,67. LA = 7,61 + 0,117(D) + 5,539 (se do sexo masculino) - 0,130(idade); R2 = 0,61. Conclusão: Na MCH não-obstrutiva, a capacidade de exercício pode ser estimada a partir de dados demográficos e ecocardiográficos. Esta informação pode ser utilizada para uma melhor categorização do estado clínico de pacientes portadores da doença.