A deep dive into the percutaneous mitral valve data.

PURPOSE OF REVIEW: This review offers insights into percutaneous mitral valve management, emphasizing pivotal trials that contributed to its evolution. RECENT FINDINGS: Mitral regurgitation (MR) is a highly prevalent heart valve disease, with surgical intervention being the gold standard for managing primary MR. However, a notable proportion of patients face ineligibility criteria or are at high surgical risk, particularly in the setting of secondary MR. To fill this gap, transcatheter therapies have emerged as less invasive alternatives. Initially guided by the EVEREST trial criteria, transcatheter leaflet repair techniques have shown impressive technological improvements, addressing nowadays a wide range of anatomical scenarios. Evidence supporting the safety and efficacy of transcatheter leaflet repair is derived from pivotal trials, including EVEREST II, COAPT, MITRA-FR, and CLASP IID, and large multicenter registries including EXPAND, EXPAND G4, and EuroSMR. However, not all patients meet the anatomical and clinical criteria for leaflet repair. For those patients, transcatheter mitral valve replacement may be a minimally invasive option and multiple clinical trials are current underway. SUMMARY: From MitraClip to newer and more innovative technologies, the landscape of percutaneous mitral valve interventions continues to evolve, offering new hopes to patients who may not be ideal candidates for conventional surgery.

Balloon Fracturing Valve-in-Valve: How to Do It and a Case Report of TAVR in a Rapid Deployment Prosthesis.

Transcatheter aortic valve replacement (TAVR) to treat degeneration of bioprosthetic heart valves (BHVs), called as valve-in-valve (ViV), is becoming a key feature since the number of BHVs requiring intervention is increasing and many patients are at high risk for a redo cardiac surgery. However, a TAVR inside a small previous cardiac valve may lead to prosthesis-patient mismatch (PPM) and not be as effective as we hoped for. An effective option to decrease the chance of PPM is to fracture the previous heart valve implanted using a high-pressure balloon. By performing a valve fracture, the inner valve ring of small BHVs can be opened up by a single fracture line, allowing subsequent implantation of a properly sized transcatheter heart valve, without increasing substantially the procedure risk. In this article, we provide a step-by-step procedure on how to safely and properly fracture a BHV and report a case of a TAVR in a degenerated rapid deployment valve.

Totally Percutaneous Repair of an Aortic Arch Dissection: A Case Report.

Although the endovascular repair of descending thoracic aorta diseases is an already consolidated procedure, this approach is not well-established for ascending aorta and arch pathologies. A 71-year-old male patient who had undergone an open ascending aorta replacement ten years ago presented with a huge dissected aortic arch aneurysm. Vascular accesses were obtained with ultrasound-guided punctures, followed by aortic arch exclusion using aortic endoprostheses and the chimney-graft technique for preserving supra-aortic branches flow. This case demonstrates the feasibility of a totally percutaneous aortic arch repair provided that careful preprocedural planning and a dedicated team are available for such a challenging intervention.

Preoperative TAVR Planning: How to Do It.

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for patients with severe symptomatic aortic stenosis (AS) whose procedural efficacy and safety have been continuously improving. Appropriate preprocedural planning, including aortic valve annulus measurements, transcatheter heart valve choice, and possible procedural complication anticipation is mandatory to a successful procedure. The gold standard for preoperative planning is still to perform a multi-detector computed angiotomography (MDCT), which provides all the information required. Nonetheless, 3D echocardiography and magnet resonance imaging (MRI) are great alternatives for some patients. In this article, we provide an updated comprehensive review, focusing on preoperative TAVR planning and the standard steps required to do it properly.

Endovascular Treatment of Coarctation of the Aorta with a Self-Expanding Endoprosthesis: How I Do It Using the Braile Dominus® Coarctation Aorta Device.

The coarctation of the aorta is a relatively highly prevalent congenital heart disease and may be diagnosed as an underline cause of hypertension in adolescents and adults. The gold standard treatment for coarctation of the aorta in these patients is being replaced - from open surgery to endovascular therapy. Some prostheses have been developed to treat the coarctation with less acute and chronic complications. The Dominus® Coarctation Aorta (Braile Biomédica) is the first self-expandable prosthesis created specifically to treat coarctation of the aorta, reducing possible acute complications, like aortic rupture or aortic dissection. Here, we discuss the step-by-step method for using this prosthesis.

The Role of the Axillary Artery as a Second Access Choice in TAVI Procedures.

With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.

Insights from the axillary vein puncture guided by ultrasound versus cephalic vein dissection trial.

Axillary vein puncture guided by ultrasound (US-Ax) versus cephalic vein dissection in pacemaker and defibrillator implant: a multicenter randomized clinical trial is a recently published study in which 88 patients were randomized in a 1:1 fashion to one of the two methods. Even being performed by operators with not previous ultrasound-guided axillary vein puncture experience, this group presented a higher success rate, lower procedural time and comparable complication incidence.

Lay abstract Recently a study evaluating two different approaches to cardiac devices implant was published. In the study, 88 patients were assigned to one of two methods for this procedure. The operators had no previous experience in one of the methods, but it demonstrated a higher success rate, took less time and had the same number of complications as the method the doctors had experience in. This paper evaluated the study and discusses what changes might take place in clinics as a result of these findings.

Axillary vein puncture guided by ultrasound vs cephalic vein dissection in pacemaker and defibrillator implant: A multicenter randomized clinical trial.

BACKGROUND: Axillary vein puncture guided by ultrasound (US-Ax) has emerged as a valid alternative access route to pacemaker and defibrillator lead insertion. OBJECTIVE: The purpose of this study was to evaluate whether US-Ax compared to cephalic vein dissection (CV) improves success and early complications in pacemaker or defibrillator implant. METHODS: This prospective, multicenter clinical trial included 88 adult patients randomized 1:1 to US-Ax (n = 44) or CV (n = 44). All procedures were performed by operators with no previous experience in axillary approach. Primary endpoint was defined as success rate. Secondary endpoints were venous access site change, time to obtain venous access, total procedural time, and early complication rate. Analyses were performed using the intention-to-treat principle. RESULTS: Median age was 70.5 years (58.2-79.7), and 60.2% were male. For the primary outcome, a higher success rate was observed in the axillary group (97.7% vs 54.5%; P <.001), as well as a lower rate of venous access site change (2.3% vs 40.9%; P <.001) and shorter time to obtain venous access (5 vs 15 minutes; P <.001) and procedural time (40 vs 51 minutes; P = .010), with no difference in complication rate (2.3% vs 11.4%; P =.20). In multivariate analysis, US-Ax (P <.001), single-chamber device (P = .015), and body mass index (P = .015) were independent predictors of overall success. CONCLUSION: This is the first randomized trial comparing self-learned US-Ax to CV in cardiac lead implantation. Our results indicate that the axillary approach was superior in terms of success rate, time to obtain venous access and procedural time, with similar complication rate.

Ultrasound-guided Axillary Vein Puncture in Cardiac Lead Implantation: Time to Move to a New Standard Access?

Cardiac stimulation therapy has evolved significantly over the past 30 years. Currently, cardiac implantable electronic devices (CIED) are the mainstream therapy for many potentially lethal heart conditions, such as advanced atrioventricular block or sustained ventricular tachycardia or fibrillation. Despite sometimes being lifesaving, the implant is surgical and therefore carries all the inevitable intrinsic risks. In the process of technology evolution, one of the most important factors is to make it safer for the patient. In the context of CIED implants, complications include accidental puncture of intrathoracic structures. Alternative strategies to intrathoracic subclavian vein puncture include cephalic vein dissection or axillary vein puncture, which can be guided by fluoroscopy, venography or, more recently, ultrasound. In this article, the authors analyse the state of the art of ultrasound-guided axillary vein puncture using evidence from landmark studies in this field.

Urinary Incontinence and Surgery for Obesity and Weight-Related Diseases: Are There Predictors of Improvement?

PURPOSE: The aim of this study was to evaluate changes in urinary incontinence (UI) before and after surgery for obesity in female patients and to identify factors related to the remission of symptoms. MATERIALS AND METHODS: This was a prospective cohort study with female patients over 18 years old who underwent surgery for obesity and weight-related diseases between June 2016 and September 2017. Urinary symptoms and quality of life related to UI were assessed based on a structured interview and the results of the validated questionnaires. RESULTS: Two hundred twenty-one patients were assessed pre-operatively, and 118 (53.3%) reported UI. Eighty-eight patients (74.6%) completed the pre- and postoperative questionnaires. After 6 to 12 months, patients were revaluated, and 50 (56.8%) were considered to be in remission of urinary symptoms. Women who had only a cesarean birth had a 117% increase in the probability of achieving remission of UI compared with women who had both vaginal and cesarean deliveries, and patients with an additional point in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score at the beginning had a 4% lower probability of having remission of symptoms. CONCLUSIONS: Improvement in UI may be an important outcome of surgery for obesity and weight-related diseases. In this study, previous cesarean section was only associated with the highest rate of remission of symptoms, and patients with higher scores in the ICIQ-UI-SF had a lower probability of remission.

Totally Percutaneous Repair of an Aortic Arch Dissection: A Case Report

ABSTRACT Although the endovascular repair of descending thoracic aorta diseases is an already consolidated procedure, this approach is not well-established for ascending aorta and arch pathologies. A 71-year-old male patient who had undergone an open ascending aorta replacement ten years ago presented with a huge dissected aortic arch aneurysm. Vascular accesses were obtained with ultrasound-guided punctures, followed by aortic arch exclusion using aortic endoprostheses and the chimney-graft technique for preserving supra-aortic branches flow. This case demonstrates the feasibility of a totally percutaneous aortic arch repair provided that careful preprocedural planning and a dedicated team are available for such a challenging intervention.

Urinary Incontinence and Quality of Life in Female Patients with Obesity.

OBJECTIVE: To analyze the prevalence of urinary incontinence (UI) in female patients with an indication for bariatric surgery, to investigate the potential risk factors and the impact on quality of life. METHODS: A cross-sectional study with female patients with obesity. The evaluation consisted of a structured interview, a specific study form and quality of life questionnaires. The Poisson regression was performed to identify independent risk factors related to UI. RESULTS: A total of 221 patients were enrolled; 118 of the study participants (53.4%) reported UI episodes. Mixed UI (MUI), stress UI (SUI) only, and urgency UI (UUI) only were reported by 52.5% (62), 33.9% (40) , and 13.5% (16) of these patients respectively. The prevalence of UI was increased by 47% among the women who had given birth vaginally and by 34% of the women who had entered menopause. Vaginal delivery and menopause were identified as independent risk factors related to UI. The mean International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) score was 9.36 ± 4.9. The severity of symptoms was considered moderate in 53.3% (63) of the patients with UI. CONCLUSION: Urinary incontinence impacts quality of life negatively, and the prevalence of UI is high among obese patients. In the present study, vaginal delivery and menopause were independently associated with UI.

OBJETIVO: Analisar a prevalência de incontinência urinária (IU), os fatores de risco e o impacto na qualidade de vida em pacientes femininas com indicação para realização de cirurgia bariátrica. MéTODOS: Estudo transversal com pacientes femininas obesas. A avaliação consistiu em entrevista estruturada, com questionários de estudo específico e de qualidade de vida. A regressão de Poisson foi utilizada para identificar os fatores de risco independentes para IU. RESULTADOS: Um total de 221 pacientes foram incluídos; 118 participantes (53.4%) relataram episódios de IU. Incontinência urinária mista, IU de esforço e IU de urgência foram relatadas por 52.5% (62), 33.9% (40) e 13.5%(16) das pacientes, respectivamente. A prevalência de IU foi 47% maior em mulheres que tiveram parto vaginal, e 34% maior em mulheres que já entraram no período da menopausa. Parto vaginal e menopausa foram identificados como fatores de risco independentes para IU. A média da pontuação do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) foi de 9.36 ± 4.9. A severidade dos sintomas foi considerada moderada em 53.3% (63) das pacientes com IU. CONCLUSãO: A IU impacta negativamente a qualidade de vida, e a prevalência de IU é maior em pacientes obesas. Neste estudo, parto vaginal e menopausa foram fatores de risco independentes para a ocorrência de IU.

Endovascular recanalization of occluded superior mesenteric artery using retrograde access through the inferior mesenteric artery.

Symptomatic occlusion of the superior mesenteric artery can be treated by open repair, hybrid procedure, or endovascular revascularization. In most cases, endovascular procedures are done by the antegrade approach. We report a case of a 67-year-old woman who presented with acute-on-chronic mesenteric ischemia successfully treated by retrograde endovascular recanalization of an occluded common hepatomesenteric trunk through the inferior mesenteric artery and arc of Riolan.

Ecocardiografia Tridimensional na avaliação de endocardite de válvula nativa: um relato de caso e semelhança entre achados ecocardiográficos e cirúrgicos / Three-Dimensional transesophageal echocardiography in native valve endocarditis: a case report and similarities between echocardiography and surgical findings

A endocardite de valva nativa é uma doença incomum, complexa, e de alta morbimortalidade. Requer tratamento clínico prolongado, com várias complicações possíveis, e o seu tratamento cirúrgico é complexo e tecnicamente difícil. O ecocardiograma transtorácico e transesofágico são fundamentais na avaliação da doença, inclusive seus achados são parte dos critérios diagnósticos de endocardite. Adicionalmente, o ecocardiograma tridimensional (3D) contribui com detalhamento anatômico na avaliação das estruturas cardíacas acometidas pela doença. Mostramos um caso em que é ilustrado o papel da ecocardiografia no diagnóstico e avaliação de complicações da endocardite, comparando as imagens do ecocardiograma 3D pré-operatórias, com os achados durante o ato cirúrgico. (AU)

Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings. (AU)

Endovascular treatment of coarctation of the aorta with a self-expanding endoprosthesis: how i do it using the braile dominus ® coarctation aorta device

Abstract The coarctation of the aorta is a relatively highly prevalent congenital heart disease and may be diagnosed as an underline cause of hypertension in adolescents and adults. The gold standard treatment for coarctation of the aorta in these patients is being replaced - from open surgery to endovascular therapy. Some prostheses have been developed to treat the coarctation with less acute and chronic complications. The Dominus® Coarctation Aorta (Braile Biomédica) is the first self-expandable prosthesis created specifically to treat coarctation of the aorta, reducing possible acute complications, like aortic rupture or aortic dissection. Here, we discuss the step-by-step method for using this prosthesis.

The role of the axillary artery as a second access choice in TAVI procedures

Abstract With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.

Urinary incontinence and quality of life in female patients with obesity / Incontinência urinária e qualidade de vida em pacientes femininas com obesidade

Abstract Objective To analyze the prevalence of urinary incontinence (UI) in female patients with an indication for bariatric surgery, to investigate the potential risk factors and the impact on quality of life. Methods A cross-sectional study with female patients with obesity. The evaluation consisted of a structured interview, a specific study form and quality of life questionnaires. The Poisson regression was performed to identify independent risk factors related to UI. Results A total of 221 patients were enrolled; 118 of the study participants (53.4%) reported UI episodes. Mixed UI (MUI), stress UI (SUI) only, and urgency UI (UUI) only were reported by 52.5% (62), 33.9% (40) , and 13.5% (16) of these patients respectively. The prevalence of UI was increased by 47% among the women who had given birth vaginally and by 34% of the women who had entered menopause. Vaginal delivery and menopause were identified as independent risk factors related to UI. The mean International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) score was 9.36 ± 4.9. The severity of symptoms was considered moderate in 53.3% (63) of the patients with UI. Conclusion Urinary incontinence impacts quality of life negatively, and the prevalence of UI is high among obese patients. In the present study, vaginal delivery and menopause were independently associated with UI.

Resumo Objetivo Analisar a prevalência de incontinência urinária (IU), os fatores de risco e o impacto na qualidade de vida em pacientes femininas comindicação para realização de cirurgia bariátrica. Métodos Estudo transversal com pacientes femininas obesas. A avaliação consistiu em entrevista estruturada, com questionários de estudo específico e de qualidade de vida. A regressão de Poisson foi utilizada para identificar os fatores de risco independentes para IU. Resultados Um total de 221 pacientes foram incluídos; 118 participantes (53.4%) relataram episódios de IU. Incontinência urinária mista, IU de esforço e IU de urgência foram relatadas por 52.5% (62), 33.9% (40) e 13.5%(16) das pacientes, respectivamente. A prevalência de IU foi 47%maior emmulheres que tiveramparto vaginal, e 34% maior em mulheres que já entraram no período da menopausa. Parto vaginal e menopausa foram identificados como fatores de risco independentes para IU. A média da pontuação do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) foi de 9.36 ± 4.9. A severidade dos sintomas foi considerada moderada em 53.3% (63) das pacientes com IU. Conclusão A IU impacta negativamente a qualidade de vida, e a prevalência de IU é maior empacientes obesas. Neste estudo, parto vaginal e menopausa foram fatores de risco independentes para a ocorrência de IU.

Síndrome da veia cava superior / Superior vena cava syndrome

Introdução: A síndrome da veia cava superior (SVCS) é uma condição potencialmente grave, principalmente em pacientes acometidas por neoplasias malignas (2 a 4% dos pacientes com neoplasias pulmonares malignas desenvolverão SVCS em algum momento da doença). A obstrução normalmente é gradual, permitindo formação de circulação venosa colateral como fluxo alternativo do sangue ao encontro do átrio direito. Métodos: Revisão narrativa da literatura, a fim de elucidar os aspectos mais importantes sobre a síndrome da veia cava superior. Resultados: O diagnóstico é feito basicamente por sinais e sintomas da obstrução venosa central, tanto clínicos quanto radiológicos, sendo a dispneia o sintoma mais comum. A tomografia computadorizada é o exame de imagem geralmente utilizado para o diagnóstico. O tratamento é voltado para a causa base e alívio dos sintomas. O alívio sintomático pode ser conseguido tanto por terapia clínica quanto intervencionista. O tratamento definitivo é realizado pela terapia oncológica. Conclusão: Em paciente com SVCS por compressão extrínseca por câncer de pulmão não pequenas células, que é a causa mais comum, a SVCS é um forte preditor de mal prognóstico, com sobrevida mediana de cinco meses. Esse artigo visa fazer uma revisão sobre os aspectos clínicos e de diagnóstico e tratamento da SVCS.

Introduction: Superior vena cava syndrome (SVCS) is a potentially serious condition, especially in patients with malignancy, (2 to 4% of patients with malignant lung tumors will develop SVCS at some point in the disease). The obstruction is usually gradual, allowing formation of collateral venous circulation as an alternative blood flow to the right atrium. Methods: Narrative review of the literature in order to elucidate the most important aspects about superior vena cava syndrome. Results: The diagnosis is basically made by signs and symptoms of central venous obstruction, both clinical and radiological, with dyspnea being the most common symptom. Computed tomography is the imaging test usually used for diagnosis. The treatment is geared towards the underlying cause and symptoms relief. Symptomatic relief can be achieved by both clinical and interventional therapy. Definitive treatment is provided by oncologic therapy. Conclusion: In a patient with SVCS by extrinsic compression from non-small cell lung cancer, which is the most common cause, SVCS is a strong predictor of poor prognosis, with a median survival of five months. This article aims to review the clinical presentation, diagnosis and treatment of SVCS.

Imunização nos pacientes em tratamento oncológico / Immunization in patients under oncological treatment

Introdução: A vacinação representa importante impacto na saúde populacional. No paciente oncológico, a importância de um calendário vacinal completo faz-se ainda maior, visto que muitos pacientes tornam-se mais suscetíveis a infecções devido ao estado de imunossupressão facilitado pela neoplasia e pelos tratamentos impostos. Métodos: Revisão de literatura visando elucidar questionamentos relacionados à vacinação em pacientes oncológicos. Resultados: Em geral, as vacinas inativadas são seguras e incapazes de causar infecção, mesmo nos pacientes em vigência de tratamento oncológico. Já as vacinas de vírus vivos atenuados, em imunodeprimidos, são capazes de desencadear um processo infeccioso exacerbado e devem ser aplicadas seguindo algumas regras. Conclusão: Devido às peculiaridades relacionadas à vacinação de pacientes em tratamento oncológico, as orientações para sua implantação devem ser seguidas com atenção visando o benefício do paciente e a prevenção de danos.

Introduction: Vaccination represents an important impact on social health. In oncologic patients, the importance of a complete immunization schedule is even greater, since many patients become more susceptible to infections due to the immunosuppressed state facilitated by neoplasia and by the imposed treatments. Methods: Literature review in order to elucidate questions related to vaccination in cancer patients. Results: In general, inactivated vaccines are safe and unable to cause infection even in patients under oncological treatment. In contrast, live attenuated vaccines in immunosuppressed patient are likely to trigger an exacerbated infectious process and must be applied following a few rules. Conclusion: Due to the peculiarities related to vaccination in patients under oncological treatment, the guidelines for its application must be carefully followed aiming benefit and prevention of harm.