Evaluation of myocardial work in patients with resistant arterial hypertension

AIMS: Individuals with resistant arterial hypertension are particularly at risk of developing target organ damage and cardiovascular events. The advanced echocardiography technique called myocardial work (MW), through the analysis of the left ventricular pressure-strain loop, is among the possibilities for evaluating these individuals. Our study was designed to describe the behavior of MW indices in individuals with resistant arterial hypertension (RH), controlled hypertension (CH), and normal arterial pressure (N). METHODS AND RESULTS: Seventy-one patients underwent Ambulatory Blood Pressure Monitoring (ABPM) and were characterized into three groups after a medical consult: RH (subjects with hypertension on four or more antihypertensive medications despite having controlled blood pressure); CH (subjects with hypertension on up to two antihypertensive medications); and N (individuals with normal ABPM; not using any medications). Echocardiographic analysis was performed using the Vivid E95 ultrasound system and blood pressure was measured at the time of the examination and subsequently used to determine myocardial work indices. RH demonstrated lower global work efficiency (GWE, mean = .95%; p = .005) and higher global wasted work (GWW, mean = 114 mm Hg%; p = .011) compared to other groups. Left ventricular mass measured by three-dimensional echocardiography, systolic wall stress, relative wall thickness and peak systolic dispersion were inversely correlated to GWE. No difference was observed between CH and N groups regarding MW indices. On multivariate analysis, only systolic wall stress remained as an independent predictor of GWE, when controlled by 3D mass index, relative wall thickness, peak systolic dispersion, and the hypertension group. CONCLUSION: Individuals with resistant hypertension have lower global work efficiency and higher global wasted work, compared to individuals with controlled hypertension and without arterial hypertension.

2016 Left ventricular diastolic function guideline have better prognostic value than 2009 guideline in patients with acute coronary syndrome

BACKGROUND: Cardiovascular disease is the leading cause of death in Brazil and worldwide. In the context of diastolic dysfunction, echocardiography is the best non-invasive diagnostic method. However, the comparison of the two main guidelines for evaluate left ventricular diastolic function in acute coronary syndrome (ACS) is scarce. OBJECTIVE: To compare the prognostic value of both guidelines of American Society of Echocardiography, from 2009 and 2016, in patients with ACS. METHODS: This is a sub-analysis of a prospective cohort observational study with 109 patients admitted to the emergency with ACS. The follow up was performed within 1 year and combined outcome was cardiovascular death or new heart failure. We used the non-parametric Spearman method to assess the correlation between the categories of diastolic function according to the guideline used. The Cox model and the Log rank test with Kaplan-Meier curves were used to compare the prognostic value of categorizing patients according to the guideline used. The results were expressed as hazard ratio with a confidence interval of 95%. RESULTS: The mean age was 63 years ± 11, most male patients (73.4%) and the predominant color of patients was white (60.4%). Among the main risk factors, the most frequent for coronary artery disease was dyslipidemia (78%), followed by systemic arterial hypertension (77.1%) and sedentary lifestyle (65.9%). The study identified a mean borderline ejection fraction, a high E/E' ratio, and LV diastolic and systolic volumes presented means above normal. The most common electrocardiographic change on admission was T-wave inversion (45%), and NSTEMI was the main clinical diagnosis (74%). The categories in which there was a greater disagreement between the guidelines were grade II diastolic dysfunction and normal function. The correlation between the diagnosis of diastolic dysfunction when compared to the use of the 2009 and 2016 guidelines was weak (R = 0.56 by Spearman's method; p<0.001). By the Kaplan-Meier curves, dividing the groups into with or without LA pressure elevation, the distinction between the evolution of the two groups is significant when performed by the 2016 guideline (Log Rank = 8.17; p = 0.04). CONCLUSION: The current guideline (2016) for the assessment of left ventricular diastolic dysfunction showed a higher prognostic value of combined outcome of cardiovascular death or new heart failure within one year, when compared to the guideline of 2009 in patients.

Left atrial minimum volume is better correlate of left atrial dysfunction by two-dimensional strain

BACKGROUND: The analysis of left atrial (LA) function can add important information to the understanding of cardiovascular diseases. Therefore, to assess its functioning the use of volumetric measurements is adopted. The maximum LA volume is the most echocardiography parameter used, however, some studies demonstrated that minimum LA volume is better to correlate with atrial dysfunction. Purpose: The purpose of this study was compare the accuracy of the phasic volumes of the left atrium in determining LA dysfunction identified by the two-dimensional strain. METHODS: This observational, cross-sectional study admitted 109 participants with diagnosis of acute coronary syndrome non-ST-segment elevation. The exams were performed within 72 hours of admission. LA volume was defined by the mean of measurements performed in the four and two-chamber apical windows using Simpson's method. The phasic volumes of the left atrium were measured using an electrocardiogram synchronized with the device. Reservoir LA strain less than 21% was the cut off to LA dysfunction. RESULTS: The phasic LA volume variables analyzed were maximal (LAVMAX), minimal (LAVMIN) and before atrial contraction (LAVBAC) volume, and each variable indexed for body surface (LAVIMAX, LAVIMIN and LAVIBAC). Therefore, a Roc curve was generated for each volume variable to assess which would be more accurate in predicting left atrial dysfunction. The Youden index was used to determine the cutoff point for each one of them. The areas under the Roc curves were: 0.83 (LAVIMIN), 0.81 (LAVMIN), 0.78 (LAVBAC), 0.76 (LAVIMAX), 0.74 (LAVIBAC) and 0.71 (LAVMAX). CONCLUSION: This study concluded that phasic volumes were good determinants of left atrial dysfunction identified by 2D strain. The minimum left atrial volume was the better correlated with left atrial dysfunction.

Echocardiographic assessment of atrial function in patients with hypertrophic cardiomyopathy with and without paroxysmal atrial fibrillation

INTRODUCTION AND OBJECTIVES: Hypertrophic cardiomyopathy (HCM) is accompanied by pathophysiological changes that predispose to the development of atrial fibrillation (AF). This arrhythmia impacts negatively on the morbidity, mortality and quality of life of these patients. Our objective was to evaluate the behavior of left atrial function, by means of atrial strain (derived from speckle tracking) and volumetric analysis by three-dimensional echocardiography, in patients with HCM with paroxysmal AF. METHOD: We analysed left atrial function in 53 patients with HCM, 25 of whom were paroxysmal AF carriers (mean age 61.7±9.9 years; 56% female) compared with 28 members of the control group (mean age 60.5±10 years; 53.6% female) who were matched especially for sex, age and other demographic data. RESULTS: It was observed that patients with HCM and a history of paroxysmal AF had lower left atrial emptying fractions than individuals in the control group; and the active atrial emptying fraction was a factor independently associated with the presence of this arrhythmia (p=0.018; odds ratio=0.93). Moreover, we found a significant reduction of the left atrial strain in all its components in the total sample of patients, with no difference between the groups. CONCLUSIONS: Measurements of atrial emptying fractions by three-dimensional echocardiography allowed differentiating patients with HCM with and without paroxysmal AF.

Left atrial minimum volume is better correlate of left atrial dysfunction by two-dimensional strain

BACKGROUND: The analysis of left atrial (LA) function can add important information to the understanding of cardiovascular diseases. Therefore, to assess its functioning the use of volumetric measurements is adopted. The maximum LA volume is the most echocardiography parameter used, however some studies demonstrated that minimum LA volume is better to correlate with atrial dysfunction. PURPOSE: The purpose of this study was compare the accuracy of the phasic volumes of the left atrium in determining LA dysfunction identified by the two-dimensional strain. METHODS: This observational, cross-sectional study admitted 109 participants with diagnosis of acute coronary syndrome non-ST-segment elevation. The exams were performed within 72 hours of admission. LA volume was defined by the mean of measurements performed in the four and two-chamber apical windows using Simpson's method. The phasic volumes of the left atrium were measured using an electrocardiogram synchronized with the device. Reservoir LA strain less than 21% was the cut off to LA dysfunction. RESULTS: The phasic LA volume variables analyzed were maximal (LAVMAX), minimal (LAVMIN) and before atrial contraction (LAVBAC) volume, and each variable indexed for body surface (LAVIMAX, LAVIMIN and LAVIBAC). Therefore, a Roc curve was generated for each volume variable to assess which would be more accurate in predicting left atrial dysfunction. The Youden index was used to determine the cutoff point for each one of them. The areas under the Roc curves were: 0.83 (LAVIMIN), 0.81 (LAVMIN), 0.78 (LAVBAC), 0.76 (LAVIMAX), 0.74 (LAVIBAC) and 0.71 (LAVMAX). CONCLUSION: This study concluded that phasic volumes were good determinants of left atrial dysfunction identified by 2D strain. The minimum left atrial volume was the better correlate with left atrial dysfunction.

Ablação septal com cateteres e radiofrequência guiada pela ecocardiografia para tratamento de pacientes com cardiomiopatia hipertrófica obstrutiva: experiência inicial / Septal ablation with radiofrequency catheters guided by echocardiography for treatment of patients with obstructive hypertrophic cardiomyopathy: initial experience

BACKGROUND: Hypertrophic cardiomyopathy (HCM) can cause obstruction in the left ventricular outflow tract (LVOT), and be responsible for the onset of limiting symptoms, such as tiredness. When such symptoms are refractory to pharmacological treatment, interventionist alternative therapies can be useful, such as septal ablation through the infusion of alcohol in the coronary artery or through myectomy. Recently, the use of a radiofrequency (RF) catheter for endocardial septal ablation guided by electroanatomic mapping has proven to be efficient, despite the high incidence of complete atrioventricular block. An alternative would be the application of RF at the beginning point of the septal gradient guided by the transesophageal echocardiography (TEE). The echocardiography is an imaging method with high accuracy to determine septal anatomy. OBJECTIVE: To assess the long term effect of septal ablation for the relief of ventricular-arterial gradient, using TEE to help place the catheter in the area of larger septal obstruction. Besides, to assess the effects of ablation on the functional class and echocardiographic parameters. METHODS: Twelve asymptomatic patients, with LVOT obstruction, refractory to pharmacological therapy, underwent endocardial septal ablation with 8mm-tip catheters, whose placement was oriented in the region of larger obstruction, assisted by the TEE. Temperature-controlled and staggered RF applications were performed. After each application, the gradient was reassessed and a new application was performed according to the clinical criterion. The effects of RF applications were assessed both for the gradient at rest and for that provoked by the Valsalva maneuver, and considering the gradient. The differences were significant when p-value was lower than or equal to 0.05. RESULTS: It was possible to observe that the mean reduction of the maximum gradients was from 96.8±34.7 mmHg to 62.7±25.4 mmHg three months after the procedure (p=0.0036). After one year, the mean of maximum gradient was 36.1±23.8 mmHg (p=0.0001). The procedure was well tolerated, without records of complete atrioventricular block nor severe complications. CONCLUSION: The TEE-guided septal ablation was efficient and safe, and the results were maintained during the clinical follow-up period. It is a reasonable option for the interventionist treatment of LVOT obstruction in HCM.

FUNDAMENTOS: A cardiomiopatia hipertrófica (CMH) pode causar obstrução da via de saída do ventrículo esquerdo (VSVE) e ser responsável pelo surgimento de sintomas limitantes, como cansaço físico. Quando tais sintomas são refratários ao tratamento farmacológico, os tratamentos alternativos intervencionistas podem ser úteis, como a ablação septal por meio da infusão de álcool na artéria coronária ou por meio da miectomia cirúrgica. Recentemente, o uso de cateter de radiofrequência (RF) para ablação do septo endocárdico guiado por mapeamento eletroanatômico mostrou-se eficaz apesar da elevada incidência de bloqueio atrioventricular total. Uma alternativa seria a aplicação de radiofrequência no ponto de início do gradiente septal guiada pelo ecocardiograma transesofágico (ETE). O ecocardiograma é um método de imagem com elevada acurácia para determinação da anatomia septal. OBJETIVO: Avaliar o efeito em longo prazo da ablação septal para alívio do gradiente ventrículo-arterial, utilizando o ETE para auxiliar no posicionamento do cateter na área de maior obstrução septal. Avaliar também os efeitos da ablação na classe funcional e parâmetros ecocardiográficos. MÉTODOS: Doze pacientes sintomáticos com obstrução da VSVE, refratários à terapia farmacológica, foram submetidos à ablação endocárdica septal com cateteres com ponta de 8 mm, cujo posicionamento foi orientado na região de maior obstrução com auxílio do ETE. Foram realizadas aplicações de radiofrequência (RF) termocontrolada e escalonadas sobre a área alvo. Após cada aplicação, o gradiente era reavaliado e nova aplicação era realizada de acordo com critério clínico. Foram avaliados os efeitos das aplicações de RF tanto para o gradiente em repouso como para o provocado por meio da manobra de Valsalva, e considerado o gradiente. As diferenças foram significativas quando o valor de p foi menor ou igual a 0,05. RESULTADOS: Observou-se que a redução da média dos gradientes máximos obtidos foi de 96,8±34,7 mmHg para 62,7±25,4 mmHg ao final de três meses do procedimento (p=0,0036). Após um ano, a média dos gradientes máximos obtidos foi de 36,1±23,8 mmHg (p=0,0001). O procedimento foi bem tolerado e não houve registro de bloqueio atrioventricular total e nem complicações graves. CONCLUSÃO: A ablação septal guiada pelo ETE foi eficaz e segura, com resultados mantidos durante o período de seguimento clínico. É uma opção razoável para o tratamento intervencionista da obstrução da VSVE em CMH.

Left atrial function analysis in patients with functional mitral regurgitation associated with dilated cardiomyopathy / Análise da função atrial esquerda em pacientes com insuficiência mitral funcional associada à miocardiopatia dilatada

BACKGROUND: Functional mitral regurgitation (FMR) is associated with dilated cardiomyopathy (DC), heart failure (HF), and worsening left atrial function (LAF). Patients with DC and FMR may present left atrial dysfunction resulting from both ventricular dysfunction and valve disease, but it is unknown whether the presence of valve disease will lead to greater LAF impairment. OBJECTIVE: This study aimed to evaluate the relationship between LAF parameters and FMR degree in patients with DC. METHODS: This cross-sectional observational study included 214 patients with DC, 46 without FMR (control group) and 168 with mild, moderate or severe FMR. An LAF analysis was performed by speckle tracking echocardiography (STE) and atrial volumetric variation. RESULTS: LAF analyzed by STE by means of reservoir strain, conduit strain and active contraction strain was reduced in the sample, with values of 14.3%, 8.49% and 5.92%, respectively. FMR degree was significantly associated with reservoir strain (0.27 ± 0.16 versus 0.15 ± 0.09; p < 0.001) and contraction strain (19.2 ± 7.3 versus 11.2 ± 2.7; p < 0.001). FMR was also associated with a reduced LAF assessed by volumetric analysis: total atrial emptying fraction of 0.51 ± 0.13 versus 0.34 ± 0.11 and active atrial emptying fraction of 0 .27 ± 0.16 versus 0.15 ± 0.09 (p < 0.001). CONCLUSION: In a population with DC, FMR was associated with reduced LAF assessed by STE and atrial volume variation.

FUNDAMENTO: A insuficiência mitral funcional (IMF) está associada à miocardiopatia dilatada (MD), à insuficiência cardíaca (IC) e à piora da função atrial esquerda (FAE). A FAE pode decair tanto pela disfunção ventricular quanto pela valvopatia, mas não se sabe se esta leva a um prejuízo maior da FAE. OBJETIVO: Avaliar a relação entre a piora de parâmetros de FAE com o grau de IMF, em pacientes com MD. MÉTODOS: Trata-se de estudo observacional transversal, que incluiu 214 pacientes com MD, sendo 46 sem IMF (controle) e 168 com IMF discreta, moderada ou grave. A análise da FAE foi realizada por ecocardiografia por speckle tracking (STE) e por variação volumétrica atrial. RESULTADOS: A FAE, analisada por STE­ por meio do strain de reservatório, conduto e contração ativa ­ encontrou-se reduzida na amostra, com valores respectivos de 14,3%, 8,49% e 5,92%. O grau de IMF associou-se significativamente com os valores do strain de reservatório (0,27±0,16 versus 0,15±0,09; p <0,001. CONCLUSÃO: Em uma população com MD, a presença de IMF associa-se à redução da FAE de reservatório e de contração, avaliada por STE e pela variação volumétrica atrial.

Focused Endocardial Septal Ablation: A New Technique to Treat Postmyectomy Recurrent Gradient

This report describes the case of a 64-year-old woman with a previous diagnosis of obstructive hypertrophic cardiomyopathy who underwent surgical myectomy but who had a persistent midventricular residual gradient. The patient was symptomatic despite medical treatment and chose to undergo percutaneous radiofrequency (RF) ablation focused on the gradient. RF delivery was performed, and the gradient was reduced from the initial 105/68 mm Hg (during Valsalva maneuver/at rest before ablation) to 24/10 mm Hg. This reduction was sustained for the next 12 months. Percutaneous RF ablation may be a reasonable option for second surgical myectomy, and the protocol can be easily reproduced.

Myocardial strain pattern progress in patients with Coarctation of the Aorta undergoing aortic stenting

ABSTRACT Background and Aim: Ventricular function evaluation in coarctation of the aorta (CoA) has become more sophisticated and precise with speckle tracking, revealing subclinical changes. However, CoA stenting treatment effects in on myocardial strain are still controversial. This study aimed to estimate the extent to which changes in left ventricular global longitudinal strain (LV GLS) occur in patients with CoA who undergo stenting. METHODS: The study included 21 patients with CoA (median age: 15 years [8­39]) and 21 healthy individuals matched by age and gender. Clinical and echocardiographic evaluations were performed 1 day before, 6 months, and 1 year after stenting. Correlations between LV GLS and arm-leg gradient, isthmus gradient on echocardiogram, age at intervention, left ventricular mass, and ejection fraction were tested. RESULTS: Before treatment, patients with CoA had lower LV GLS than the control group (−18.4% ± 1.96 vs −21.5% ± 1.37; P < .01), showing significant increase to −19.4% ± 2.1 at 6 months and −20.7% ± 2.19 at 1 year, P < .001. Only 28.5% (6 patients) had preserved GLS before treatment, improving to 80.9% (17 patients) in 1 year. The only variable correlated with low LV GLS values before treatment was age at intervention (Spearman's index = −0.571; P = .007). CONCLUSION: Percutaneous therapy showed significant LV GLS improvement 12 months after aortic stenting. Older patients have lower GLS, suggesting that early intervention may have positive effects on preservation of LV systolic function.

Análise elétrica, estrutural e funcional do remodelamento atrial em pacientes com apneia obstrutiva do sono / Electrical, structural and functional analysis of atrial remodeling in patients with obstructive sleep apnea

INTRODUÇÃO: A apneia obstrutiva do sono (AOS) constitui importante fator de risco para fibrilação atrial. O remodelamento atrial é um pilar neste processo. O objetivo deste estudo foi avaliar o impacto da AOS em variáveis representativas do remodelamento atrial (elétrico, estrutural e funcional). Método: Trezentos e quatro pacientes consecutivos submetidos à polissonografia foram rastreados e 80 incluídos para realização de eletrocardiograma de 12 derivações e de alta resolução (ECGAR) e ecocardiograma bi e tridimensional. Foram divididos em grupos de acordo com: 1. Índice de Apneia-Hipopneia [AOS- (90%, 80-90% e 60minutos]. RESULTADOS: A idade média foi de 60,8±11,1 anos (60% do sexo feminino) e o IMC médio 31,95±6,5 kg/m². O grupo AOS+ apresentou menor fração de esvaziamento passivo do átrio esquerdo (FEPAE) comparado com AOS-. SatMin90%. T90 >60minutos à maior duração de onda P-ECGAR, P-máxima, P-média e P na derivação DII, menor intervalo Tinício-Tpico e menor FEPAE quando comparado ao grupo

Mid- to long-term clinical and echocardiographic outcomes after transcatheter aortic valve replacement with a newgeneration, self-expandable system / Desfechos clínicos e ecocardiográficos de médio a longo prazo após a substituição da válvula aórtica transcateter com uma nova geração, sistema auto-expansível

Abstract Objectives: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with A curate neo™ (Boston Scientific, Boston, MA). Background: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. Methods: All consecutive patients (n = 104) who underwent A curate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. Results: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5­4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. Conclusions: A curate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Predictive role of Selvester QRS score in patients undergoing transcatheter aortic valve replacement

INTRODUCTION: Few data exist regarding the late clinical impact of the Selvester score prediction of myocardial fibrosis after transcatheter aortic valve replacement (TAVR). This study evaluated the predictive power of the Selvester score on survival in patients with aortic stenosis (AS) undergoing TAVR. METHODS And Results: Patients with severe AS who had preoperative electrocardiograms were included. Clinical follow-up was obtained retrospectively. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular death and major adverse cardiac events (MACEs). Two-hundred twenty-eight patients were included (mean age, 81.5 ± 7.4 years; women, 58.3%). Deceased patients had a higher mean score (4.6 ± 3.2 vs. 1.4 ± 1.3; p < .001). At a mean follow-up of 36.2 ± 21.2 months, the Selvester score was independently associated with all-cause mortality (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.48-1.84; p < .001), cardiovascular death (HR, 1.59; 95% CI, 1.38-1.74; p < .001), and MACE (HR, 1.55; 95% CI, 1.30-1.68; p < .001). After 5 years, the mortality risk was incrementally related to the Selvester score. The involvement of the inferior wall of the left ventricle was a lower mortality risk factor (HR, 0.42; 95% CI, 0.18-0.98; p = .046). For a Selvester score of 3, the area under the curve showed 0.92, 0.94, and 0.86 (p < .001), respectively, for 1, 2, and 3 years. CONCLUSIONS: Elevated Selvester scores increase the risk of poor outcomes in patients with AS undergoing TAVR. The involvement of the anterior or lateral wall presents worse prognosis.

New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series / Nova cânula orofaríongea de duplo lúmen para sedação em ecocardiografia transesofágica: série de casos

Abstract Introduction: Currently, transesophageal echodopplercardiography is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient transesophageal echo exam, under sedation and using the oropharyngeal cannula. Method: 30 patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion and, comfort of examiner were analyzed. Results: The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and transesophageal echo probe handling was appropriate in 93.33% of exams performed. Conclusions: Transesophageal echo exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO2 during the exams.

Resumo Introdução: Nos dias atuais, exames de ecocardiografia transesofágica (ETE) são realizados de forma frequente sob sedação em regime ambulatorial. A sedação está relacionada com aumento de intercorrências nas vias aéreas. Dentro desse contexto, desenvolvemos uma cânula orofaríngea de duplo-lúmen com finalidade de manutenção da via aérea pérvia, reduzindo riscos aos pacientes durante procedimentos endoscópicos sob sedação. O principal objetivo do nosso estudo foi avaliar a incidência de dessaturação em uma série de casos de pacientes adultos submetidos a ETE ambulatorial sob sedação com o uso da cânula orofaríngea. Métodos: Foram avaliados 30 pacientes sedados com midazolam e propofol intravenoso. A cânula foi inserida após perda da consciência e os pacientes foram mantidos com ventilação espontânea. Analisados saturação de oxigênio, capnometria, frequência cardíaca e pressão arterial não invasiva, além de dados subjetivos: patência das vias aéreas, manuseio e inserção da cânula e conforto ao examinador. Resultados: A incidência de dessaturação leve foi de 23.3% e não houve dessaturação grave em nenhum caso. A inserção da cânula orotraqueal foi considerada fácil em 29 pacientes (96,6%) e o manuseio da sonda de ETE foi adequada em 93,33% dos exames realizados. Conclusões: A realização dos exames de ETE sob sedação com auxílio da cânula orofaríngea de duplo lúmen apresentou baixa incidência de dessaturação nos pacientes avaliados, além de permitir análise do CO2 expirado durante a realização dos exames.

Ablação septal por radiofrequencia em pacientes com miocardiopatia hipertrofica obstrutiva: primeira serie nacional / Radiofrequency septal ablation in patients with obstructive hypertrophic cardiomyopathy: first national series

INTRODUÇÃO: A Cardiomiopatia Hipertrófica (CMH) está associada a obstrução da via de saída (VSVE) em 40% dos casos e a obstrução medioventricular (MV) em 8-10 % dos casos. Quando há obstrução significativa (gradiente maior que 50mmHg em repouso ou após manobra provocativa) e sintomas graves refratários ao tratamento medicamentoso, considera-se o alívio da obstrução, seja através da cirurgia (miectomia septal) procedimento considerado "padrão ouro", seja através de intervenção percutânea (alcoolização). Este último associado à evolução satisfatória, com resultados semelhantes à cirurgia a longo prazo, porém também à criação de área de fibrose e maior prevalência de arritmias. Recentemente, têm sido publicados artigos sobre os resultados de um novo procedimento intervencionista, a ablação septal por radiofrequência, guiado por mapeamento eletroanatômico, com resultados favoráveis, com alivio da obstrução e pouca fibrose secundária. Descrevemos nossa experiência pioneira com ablação septal com radiofrequência utilizando ecocardiograma transesofágico como método guia, substituindo o mapeamento eletroanatômico. Utilizamos o procedimento para alívio do gradiente de VSVE e MV CASUÍSTICA: total de 12 pacientes (p) 75% do sexo feminino, idade média de 56 + 15 anos, frequência cardíaca inferior a 60bpm. Os sintomas foram principalmente dispneia aos esforços e síncopes de repetição. 10 p (83%) tinham obstrução de VSVE) e 2p (17%) tinham obstrução MV. A via de acesso foi retroaórtico- Foram utilizados cateteres de 8 mm não irrigados. A redução do gradiente provocado 35,2% em três meses e 62,3% em um ano (de inicial 96,83 mmHg ± 28,30 para 62,72 ± 20mmHg em três meses para 36,41 mmHg ± 16,81 em um ano). A redução do gradiente de repouso foi de 52,9% em três meses e 69,7% em um ano (de inicial de 73,58 mmHg ± 29,51 para 34,63 ± 13,78mmHg em três meses para 22,25 mmHg ± 13,83 ao final de um ano). Não ocorreu bloqueio atrioventricular, não foi necessário implantes de marcapassos ou outros dispositivos, nem outras complicações graves. COMENTÁRIOS E CONCLUSÕES: A ablação septal guiada por ecocardiograma transesofágico foi segura e eficaz para redução do gradiente tanto de VSVE como MV. Deve ser considerada uma alternativa terapêutica para tratamento da CMH obstrutiva. Destacamos o papel deste método intervindo no gradiente MV, condição extremamente desafiadora pelo fato da cirurgia e a alcoolização terem limitações significativas neste quadro.

Avaliação dos pacientes com estenose aórtica grave e alto risco cirúrgico não submetidos à TAVI / Evaluation of patients with severe aortic stenosis and high surgical risk who did not undergo TAVI

INTRODUÇÃO: A Estenose Aórtica (EAO) é a doença valvar adquirida mais prevalente na população acima de 75 anos. A correção da valvopatia cirúrgica (TVA) ou transcateter (TAVR) é o tratamento mais efetivo. OBJETIVOS: Identificar quantos pacientes (pts) com EAO encaminhados o Heart team são encaminhados para TAVR, TVA ou fica em tratamento conservador e qual a evolução a médio prazo dos pacientes que são excluídos do protocolo TAVR. MÉTODOS: Estudo prospectivo, em que foram avaliados pts com EAO grave, sintomáticos, de alto risco cirúrgico (2000- 2017), não candidatos à TAVR, encaminhados para TVA ou tratamento conservador. RESULTADOS: Avaliados 475 pts. Durante o screening 25 pts (5. 26%) morreram, 326 (68,63%) encaminhados para TAVR e 124 pts em acompanhamento clínico ou submetidos à TVA. Características dos 124 pts: idade 80,66 ± 6,37 anos; 44,5% NYHA III; STS score 6,8 ± 5,27 %; 31 pts (25,6%) com insuficiência mitral grave, FEVE 55,84 ± 15,35%, ClCr 48,37 ± 17,67. Razões clínicas que levaram os pacientes a não serem encaminhados para TAVR: baixo risco cirúrgico, idade inferior a 75 anos, trombo no VE e contra indicação ao uso de antiplaquetários. Razões anatômicas que contra indicaram: acesso vascular inadequado e válvula aórtica bicúspide. Destes 124 pacientes, 31 (25%) foram submetido à troca valvar convencional e 93 (75%) pacientes ficaram em tratamento clínico. Os pts foram mantidos em tratamento clínico pelos seguintes motivos: expectativa de vida menor que um ano, recusa ao procedimento, ausência de sintomas, EAO moderada. Quando comparados os pts clínicos com os de TVA: os pts clínicos eram mais idosos (81,91 ± 6,1 versus 76,87 ± 5,71, p < 0,01), tinham menor peso (64,2 ± 16,2 versus 70,5 ± 11,6, p = 0,011) e menor ClCr (45,17 ± 17,5 versus 56,6 ± 15,4, p = 0,002). Houve diferença em relação ao STS score (7,2 ± 5,23 no subgrupo clínico versus 5,7 ± 5,31 no subgrupo cirúrgico, p < 0,004). Os pts encaminhados para cirurgia eram mais sintomáticos (p = 0,023). Já a FEVE, o gradiente médio, a área valvar, o diâmetro diastólico e sistólico final do VE foram semelhantes em ambos os grupos. Em relação aos 93 pacientes que permaneceram em tratamento clínico, 43 (46,2%) evoluíram para óbito em um intervalo de 56 meses. Já os 31 pacientes encaminhados para o procedimento cirúrgico, sete (22,6%) evoluíram para óbito, em um intervalo de 47,4 meses.

Evolução tardia das próteses biológicas e mecânicas em posição aórtica / Late evolution of biological and mechanical prostheses in aortic position

INTRODUÇÃO: Apesar da constante renovação e aprimoramento das próteses valvares cardíacas a decisão sobre substituição por prótese biológica ou mecânica permanece controversa. OBJETIVO: Esse estudo avalia pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico. MÉTODOS: Estudo observacional, do tipo coorte histórica por análise de prontuário. Foram selecionados 202 pacientes operados entre 2004 e 2008, com seguimento médio de 10 anos. RESULTADOS: A probabilidade de sobrevida livre de óbito por qualquer causa e reoperação foi significativamente maior em pacientes tratados com prótese biológica em comparação com a prótese mecânica (HR = 0,33; 95% intervalo de confiança [IC] 0,13-0,79; p =0,013). Foram observados oito óbitos num período de 10 anos no grupo de pacientes portadores de prótese biológica e cinco no grupo de prótese mecânica. Esses dados correspondem a um percentual ajustado de 6,11% de mortalidade para o grupo de prótese biológica e 7,9% para prótese mecânica (p = 0,68). A análise de reoperação isolada evidenciou uma diferença significativa a favor da prótese mecânica (HR = 0,062; IC = 0,008-0,457; p = 0,006), principalmente para menores de 30 anos, quando analisados por subgrupo. Num período de 10 anos, dezenove pacientes portadores de prótese biológica foram reoperados, correspondendo a um percentual de 21,24% e nenhum paciente do grupo de prótese mecânica. O risco de eventos adversos composto de acidente vascular cerebral, sangramento, endocardite, trombose e regurgitação paraprotética não foi diferente entre os grupos (HR = 1,20; IC 95% = 0,74-1,93; p = 0,44). O risco de sangramento foi significativamente maior em pacientes tratados com prótese mecânica em comparação com a prótese biológica (HR = 3,65; IC 95% = 1,43-9,29; p = 0,0064), porém não houve sangramento fatal. CONCLUSÕES: Não há diferença de mortalidade em 10 anos entre os dois grupos. Há um aumento significativo no risco de reoperação ao se optar por próteses biológicas, principalmente para os menores de 30 anos. Já os pacientes portadores de prótese mecânica têm maior risco de sangramento não fatal. Figura 1 - Curva de Kaplan-Meier para avaliar probabilidade de sobrevida livre de eventos (óbito ou reoperação). Figura 2 - Gráfico de forest plot do efeito dos eventos adversos em relação ao tipo de prótese (mecânica ou biológica).