RESUMO
BACKGROUND: Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis. OBJECTIVES: The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR). METHODS: Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed. RESULTS: A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions. CONCLUSIONS: Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185).
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Estenose da Valva Aórtica/terapia , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Disfunção Ventricular Esquerda/prevenção & controle , Função Ventricular Esquerda/fisiologia , Remodelação Ventricular , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/efeitos dos fármacos , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/etiologiaAssuntos
Estenose da Valva Aórtica/cirurgia , Endocardite Bacteriana/cirurgia , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/prevenção & controle , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Valva Aórtica/microbiologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estudos de Coortes , Intervalos de Confiança , Bases de Dados Factuais , Endocardite Bacteriana/etiologia , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Segurança do Paciente , Seleção de Pacientes , Valor Preditivo dos Testes , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Esterilização/métodos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
A stochastic deformable model is proposed for the segmentation of the myocardium in Magnetic Resonance Imaging. The segmentation is posed as a probabilistic optimization problem in which the optimal time-dependent surface is obtained for the myocardium of the heart in a discrete space of locations built upon simple geometric assumptions. For this purpose, first, the left ventricle is detected by a set of image analysis tools gathered from the literature. Then, the segmentation solution is obtained by the Maximization of the Posterior Marginals for the myocardium location in a Markov Random Field framework which optimally integrates temporal-spatial smoothness with intensity and gradient related features in an unsupervised way by the Maximum Likelihood estimation of the parameters of the field. This scheme provides a flexible and robust segmentation method which has been able to generate results comparable to manually segmented images for some derived cardiac function parameters in a set of 43 patients affected in different degrees by an Acute Myocardial Infarction.