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New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.
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BACKGROUND: Chronic pressure overload predisposes to heart failure, but the pathogenic role of microvascular endothelial cells (MiVEC) remains unknown. We characterized transcriptional, metabolic, and functional adaptation of cardiac MiVEC to pressure overload in mice and patients with aortic stenosis (AS). METHODS: In Tie2-Gfp mice subjected to transverse aortic constriction or sham surgery, we performed RNA sequencing of isolated cardiac Gfp+-MiVEC and validated the signature in freshly isolated MiVEC from left ventricle outflow tract and right atrium of patients with AS. We next compared their angiogenic and metabolic profiles and finally correlated molecular and pathological signatures with clinical phenotypes of 42 patients with AS (50% women). RESULTS: In mice, transverse aortic constriction induced progressive systolic dysfunction, fibrosis, and reduced microvascular density. After 10 weeks, 25 genes predominantly involved in matrix-regulation were >2-fold upregulated in isolated MiVEC. Increased transcript levels of Cartilage Intermediate Layer Protein (Cilp), Thrombospondin-4, Adamtsl-2, and Collagen1a1 were confirmed by quantitative reverse transcription polymerase chain reaction and recapitulated in left ventricle outflow tract-derived MiVEC of AS (P<0.05 versus right atrium-MiVEC). Fatty acid oxidation increased >2-fold in left ventricle outflow tract-MiVEC, proline content by 130% (median, IQR, 58%-474%; P=0.008) and procollagen secretion by 85% (mean [95% CI, 16%-154%]; P<0.05 versus right atrium-MiVEC for all). The altered transcriptome in left ventricle outflow tract-MiVEC was associated with impaired 2-dimensional-vascular network formation and 3-dimensional-spheroid sprouting (P<0.05 versus right atrium-MiVEC), profibrotic ultrastructural changes, and impaired diastolic left ventricle function, capillary density and functional status, especially in female AS. CONCLUSIONS: Pressure overload induces major transcriptional and metabolic adaptations in cardiac MiVEC resulting in excess interstitial fibrosis and impaired angiogenesis. Molecular rewiring of MiVEC is worse in women, compromises functional status, and identifies novel targets for intervention.
Assuntos
Estenose da Valva Aórtica/genética , Vasos Coronários/metabolismo , Células Endoteliais/metabolismo , Átrios do Coração/metabolismo , Ventrículos do Coração/metabolismo , Microvasos/metabolismo , Proteínas ADAMTS/genética , Idoso , Animais , Aorta , Estenose da Valva Aórtica/metabolismo , Estenose da Valva Aórtica/patologia , Estenose da Valva Aórtica/cirurgia , Colágeno Tipo I/genética , Cadeia alfa 1 do Colágeno Tipo I , Constrição Patológica , Vasos Coronários/patologia , Modelos Animais de Doenças , Células Endoteliais/patologia , Proteínas da Matriz Extracelular/genética , Ácidos Graxos/metabolismo , Feminino , Perfilação da Expressão Gênica , Átrios do Coração/patologia , Implante de Prótese de Valva Cardíaca , Ventrículos do Coração/patologia , Humanos , Masculino , Camundongos , Camundongos Transgênicos , Densidade Microvascular , Microvasos/patologia , Pró-Colágeno/metabolismo , Prolina/metabolismo , Pirofosfatases/genética , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Análise de Sequência de RNA , Trombospondinas/genéticaRESUMO
Background: Embolisation and metastatic infection occur frequently in infective endocarditis (IE). We aimed to evaluate the impact of nuclear imaging on diagnosis, therapy and mortality.Methods: All patients hospitalised for definite IE at the University Hospitals of Leuven in 2001 and in 2015 were retrospectively included. Demographic, clinical, diagnostic and outcome data were analysed by univariate statistical analysis.Results: Data of 122 patients were analysed. Demographic parameters of 61 patients hospitalised in 2015 compared with 61 patients hospitalised in 2001 showed no significant differences. More fundoscopic examinations (p = .002) and more nuclear imaging (p < .001) were performed in 2015. This did not result in a higher detection of retinal embolisms (p = .543). However, more episodes of symptomatic embolisation and metastatic infection (p = .002) and more occult systemic complications (p = .014) were found. In particular, spondylodiscitis was more frequently diagnosed in 2015 (p = .013). The amount of cardiac surgery and the in-hospital mortality did not differ between the two years (p = .131 and p = .810). After exclusion of patients presenting in heart failure who needed emergent surgery, the overall time to surgery was significantly shorter in 2015 (p = .043).Conclusion: The use of nuclear imaging was increased in 2015 compared to 2001. This led to more diagnoses of embolisation and metastatic infections that were not clinically evident. In patients not presenting in a critical clinical state, cardiac surgery was performed earlier in 2015. However, the in-hospital mortality was not affected.
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Discite , Embolia/diagnóstico por imagem , Endocardite , Disco Intervertebral/diagnóstico por imagem , Cintilografia , Oclusão da Artéria Retiniana , Idoso , Bélgica/epidemiologia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Discite/diagnóstico por imagem , Discite/etiologia , Embolia/etiologia , Embolia/microbiologia , Endocardite/complicações , Endocardite/diagnóstico por imagem , Endocardite/mortalidade , Endocardite/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Oftalmoscopia/métodos , Utilização de Procedimentos e Técnicas/tendências , Cintilografia/métodos , Cintilografia/estatística & dados numéricos , Oclusão da Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/etiologiaRESUMO
Background: Development of carcinoid heart disease (CHD) is the major negative prognostic factor in patients with the carcinoid syndrome. The only effective treatment is valve replacement. However, the selection of candidates and determination of optimal timing remain unclear. Considerable variability in local screening and treatment strategies exist. Methods: In this single-centre study, we retrospectively analysed the diagnostic process and outcome of all CHD patients who underwent valve surgery between 2000 and 2016. We propose a new CHD screening and management algorithm. Results: All patients (n = 15), mean age 64 ± 7, underwent tricuspid valve surgery. In 14 of them (93%) an additional valve was replaced. In only a minority of patients (27%) CHD diagnosis was established by screening. Survival after 1, 3, 12 and 24 months was 93%, 80%, 53% and 33%, respectively. Causes of death included infections and critical illness immediately postoperatively, and tumour progression and right heart failure in the longer term. There was a trend (p = .099) towards better preoperative right ventricular function in the patients who survived more than 12 months postoperatively (TAPSE 20 mm ± 4) compared to those who died between 3 to 12 months after surgery (TAPSE 16 mm ± 1). The former group had a shorter mean interval from diagnosis of the carcinoid syndrome to cardiac diagnosis than the latter (13 vs. 105 months, p = .014). Conclusion: Mortality after valve replacement for CHD remains high. A probably underestimated cause is late referral for cardiac surgery. We propose a systematic, multidisciplinary approach to all carcinoid syndrome patients.
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Algoritmos , Doença Cardíaca Carcinoide/cirurgia , Procedimentos Clínicos , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Equipe de Assistência ao Paciente , Tempo para o Tratamento , Valva Tricúspide/cirurgia , Adulto , Idoso , Bélgica , Doença Cardíaca Carcinoide/diagnóstico , Doença Cardíaca Carcinoide/mortalidade , Doença Cardíaca Carcinoide/fisiopatologia , Causas de Morte , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Valva Tricúspide/fisiopatologiaRESUMO
BACKGROUND: The optimal aortic substitute in extensive aortic valve active infective endocarditis (AIE) continues to be debated. To determine the surgical approach in aortic valve AIE with infection extension beyond the leaflets, we evaluated the outcome of reconstructive surgery with various valve substitutes in those patients. METHODS: During 2000-2013, 168 patients had surgery for extensive aortic valve AIE. Patients were categorised based on aortic valve substitute: Group A: Stented aortic valve replacement (AVR), Group B: Stented AVR with patch support, Group C: Stentless valve, Group D: Aortic allograft, and Group E: Composite valve graft. Outcome parameters were mortality, postoperative cardiogenic or septic shock, stroke, or reinfection. RESULTS: Stented valves with patch support were more frequently utilised in cases of native valve endocarditis (p<0.001). Postoperative complications were comparable among groups. Concomitant preoperative extension of infection in the mitral valve predicted reinfection (OR 3.6; confidence interval 1.46-8.66; p=0.005). Survival was not affected by operative group (log rank=0.6). Univariable preoperative predictors of mortality were: septic shock (hazard ratio 8.3; 95% confidence interval 3.6-19.2; p<0.001), ejection fraction (hazard ratio 0.96; 95% confidence interval 0.93-0.99; p=0.006), preoperative cardiogenic shock (hazard ratio 1.9; 95%CI 1.1-3.6, p=0.02) and concomitant mitral valve surgery (hazard ratio 1.8; 95% confidence interval 1.2-2.5; p=0.002). CONCLUSIONS: Surgical treatment of extensive aortic valve infective endocarditis remains a challenge. Outcomes were not affected by the surgical complexity of aortic reconstruction procedure or valve substitute. Surgical approach should be tailored to individual patient's characteristics.
Assuntos
Valva Aórtica/cirurgia , Endocardite/mortalidade , Endocardite/cirurgia , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/microbiologia , Endocardite/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/microbiologia , Valva Mitral/cirurgia , Complicações Pós-Operatórias/microbiologia , Estudos RetrospectivosRESUMO
Neuroendocrine tumours are a rare malignancy, which can be complicated by a carcinoid syndrome and, in more rare cases, also valve destruction. The correct timing for surgical repair remains unknown. We report the first-in-men exercise cardiac magnetic resonance imaging with pulmonary artery catheter measurements in order to better understand the haemodynamic impact of isolated tricuspid valve insufficiency in a low symptomatic patient. Not pressure but volume overload is the key factor in the development of symptoms, as long as the right ventricular function is intact. Based on our findings, we referred the patient for tricuspid valve replacement. This case, together with the review of all carcinoid heart disease cases in our hospital (a large tertiary cardiology and oncology centre) since 2000, indicates a potential benefit for early intervention in carcinoid heart disease.
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Doença Cardíaca Carcinoide/complicações , Cateterismo de Swan-Ganz/métodos , Imagem Cinética por Ressonância Magnética/métodos , Monitorização Fisiológica/métodos , Pressão Propulsora Pulmonar/fisiologia , Insuficiência da Valva Tricúspide/fisiopatologia , Doença Cardíaca Carcinoide/diagnóstico , Doença Cardíaca Carcinoide/fisiopatologia , Feminino , Humanos , Pessoa de Meia-Idade , Artéria Pulmonar , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/diagnósticoRESUMO
BACKGROUND: The aim of this study was to determine the incidence and recovery of hospitalisation-associated disability (HAD), the associated risk factors, and the link with care processes in patients aged 70 years or older hospitalised with valvular heart disease (VHD). METHODS: Prospective cohort study performed on the cardiology and cardiac surgery units of University Hospitals Leuven, Belgium. HAD was defined as the loss of independence to complete one of the Activities of Daily Living (ADLs) between hospital admission and discharge. Recovery of HAD at 30 days post hospital discharge was achieved when patients recovered their baseline ADL status (2 weeks before hospital admission) (ClinicalTrials.gov: NCT02572999). RESULTS: Eighty patients were enrolled in the study, 77 completed the assessment at discharge and 62 responded at 30 days follow-up. Forty patients (51.9%) developed HAD; 18 of them (45.0%) recovered their baseline ADL status. The risk of HAD increased when patients were physically restrained (relative risk (RR) 1.73, 95% confidence interval (CI) 1.20-2.49), had indwelling catheters (RR 1.80, 95% CI 0.85-3.80) and received preventive pressure ulcer measures (RR 1.71, 95% CI 1.07-2.74). Patients with HAD had longer hospital stays (+3 days, p = .011) and longer use of indwelling catheters (+2 days, p = .024). CONCLUSION: Half of the older adults with VHD developed HAD. The results indicate a potential association between HAD and care processes, which could be used as quality measures and intervention targets. Validation in larger cohort studies is recommended.
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OBJECTIVES: Although the effects of pulmonary regurgitation after tetralogy of Fallot repair are detrimental, timing of pulmonary valve replacement (PVR) is unclear. Our goal was to evaluate the midterm efficacy and safety of early PVR. METHODS: Patients with tetralogy of Fallot who underwent repair from 1962 to 2015 were included from the local database. Statistical analyses compared patients who underwent early PVR (age ≤16 years), late PVR and no PVR. The timing of the intervention was compared for efficacy-all-cause mortality and the combined end-point of all-cause mortality, ventricular tachycardia and defibrillator implantation-and for safety-the combined end-point of 1-year postoperative mortality after PVR, endocarditis and reintervention. Echocardiographic and electrocardiographic data at the last follow-up examination were compared across the 3 groups. RESULTS: Two hundred seventy-three patients (age 21 ± 5 years; 52% female) were included. The mean follow-up was 24 (95% confidence interval 22.7-26.2) years; the observed median was 21 years (interquartile range 11-31). No significant difference in survival was found between the early PVR (n = 106; 39%), the late PVR (n = 47; 17%) and the no PVR groups (n = 120; 44%) (P = 0.990). No significant difference in the combined efficacy end-point was noted between patients who underwent early PVR compared with patients who underwent late PVR (P = 0.247). Worse event-free survival for the 3-point safety end-point was observed after early PVR (P < 0.001). Right ventricular morphology (P < 0.001) and function (P < 0.001) were better preserved in the patient group that underwent PVR before the age of 16 years. CONCLUSIONS: As expected, PVR-related morbidity was higher in patients who underwent early PVR but the midterm outcome was similar. Nevertheless, better preservation of right ventricular morphology and function in the early PVR group might result in better long-term survival.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Complicações Pós-Operatórias/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Intervalo Livre de Doença , Ecocardiografia , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Insuficiência da Valva Pulmonar/diagnóstico , Tetralogia de Fallot/diagnóstico , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The clinical benefit of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery (MVS) is still debated. We evaluated the immediate surgical success, postoperative outcome and the medium-term effect of TA in MVS. METHODS: Patients were included between September 2003 and December 2009 and followed until September 2013 to achieve a median follow-up time of 5â years (IQR 3.7-6.9). The end point of mortality due to cardiac causes and combined end point of cardiac mortality or hospitalisation for heart failure were evaluated. Propensity score adjusted Cox regression was used to evaluate the clinical benefit of TA at the time of MVS. RESULTS: Of 150 patients (84 female; 67±12â years), 82 presented with tricuspid regurgitation (TR) <2/4 and underwent isolated MVS. Of 68 patients presenting with TR≥2/4, 31 underwent isolated MVS whereas 37 underwent additional TA. In patients with preoperative TR≥2/4, TR was significantly reduced until 5â years postoperatively (mean reduction 0.81±1.31; p=0.04) when additional TA was done. The combined end point occurred in 29% vs 6% at 1â year and in 57% vs 39% at 5â years follow-up for patients with isolated MVS and patients undergoing concomitant TA, respectively. Patients with preoperative TR≥2/4 had worse unadjusted survival than those with TR<2/4 (logrank p=0.009). In the patients with TR≥2/4, propensity score-adjusted risk for the combined end point was higher in those with isolated MVS versus MVS with additional TA (Cox HR 2.855 (1.082-7.532), p=0.035). CONCLUSIONS: Additional TA is an effective surgical measure to reduce functional TR severity. This approach results in a decreased risk of cardiac mortality and hospitalisation in patients with preoperative TR≥2/4.
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Anuloplastia da Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Insuficiência da Valva Tricúspide/cirurgia , Idoso , Anuloplastia da Valva Cardíaca/mortalidade , Terapia Combinada , Intervalo Livre de Doença , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Anuloplastia da Valva Mitral/métodos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/mortalidade , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Insuficiência da Valva Tricúspide/mortalidadeRESUMO
OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has been proposed as a treatment alternative for patients with aortic valve stenosis (AS) at high or prohibitive risk for surgical aortic valve replacement (AVR). We aimed to assess real-world outcomes after treatment according to the decisions of the multidisciplinary heart team. METHODS: At a tertiary centre, all high-risk patients referred between 1 March 2008 and 31 October 2011 for symptomatic AS were screened and planned to undergo AVR, TAVI or medical treatment. We report clinical outcomes as defined by the Valve Academic Research Consortium. RESULTS: Of 163 high-risk patients, those selected for AVR had lower logistic EuroSCORE and STS scores when compared with TAVI or medical treatment (median [interquartile range] 18 [12-26]; 26 [17-36]; 21 [14-32]% (P = 0.015) and 6.5 [5.1-10.7]; 7.6 [5.8-10.5]; 7.6 [6.1-15.7]% (P = 0.056)). All-cause mortalities at 1 year in 35, 73 and 55 patients effectively undergoing AVR, TAVI and medical treatment were 20, 21 and 38%, respectively (P = 0.051). Cardiovascular death and major stroke occurred in 9, 8 and 33% (P < 0.001) and 6, 4 and 2% (P = 0.62), respectively. For patients undergoing valve implantation, device success was 91 and 92% for AVR and TAVI, respectively. The combined safety endpoint at 30 days was in favour of TAVI (29%) vs AVR (63%) (P = 0.001). In contrast, the combined efficacy endpoint at 1 year tended to be more favourable for AVR (10 vs 24% for TAVI, P = 0.12). CONCLUSIONS: Patients who are less suitable for AVR can be treated safely and effectively with TAVI with similar outcomes when compared with patients with a lower-risk profile undergoing AVR. Patients with TAVI or AVR have better survival than those undergoing medical treatment only.
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Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/terapia , Cateterismo Cardíaco/métodos , Fármacos Cardiovasculares/uso terapêutico , Implante de Prótese de Valva Cardíaca/métodos , Equipe de Assistência ao Paciente , Seleção de Pacientes , Encaminhamento e Consulta , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/tratamento farmacológico , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Bélgica , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Serviço Hospitalar de Cardiologia , Fármacos Cardiovasculares/efeitos adversos , Distribuição de Qui-Quadrado , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoAssuntos
Embolia/prevenção & controle , Endocardite Bacteriana/cirurgia , Feminino , Humanos , MasculinoRESUMO
We discuss the case of a 55-year-old woman with a history of gastric ulcer, mechanical tricuspid and mitral valve replacement and a pacemaker for post-operative total heart block. The patient underwent elective pacemaker replacement. She developed a large infra-umbilical rectal sheath haematoma during bridging therapy with low-molecular-weight heparins (LMWH), for which she was treated with angiographic embolisation of the epigastric artery. Subsequently, an intravenous unfractionated heparin (UFH) drip was started. Shortly thereafter, the patient developed severe upper gastrointestinal bleeding, caused by a gastric ulcer with a visible vessel. Anticoagulant therapy was interrupted. On the third day after cessation of the UFH drip, the patient developed thrombosis of the prosthetic tricuspid valve, confirmed by transthoracic echocardiography and cinefluoroscopy. Due to the risk of bleeding (from gastric ulcer and rectus sheath), both thrombolytic therapy and redo surgery were deemed to pose an unacceptable risk. We decided to treat the patient with intravenous heparin and postpone thrombolytic therapy until after healing of the gastric ulcer. At 5 weeks after the bleeding event, alteplase was administered, with dissolution of the thrombus and restoration of valve disc motion. No embolic or bleeding complications occurred thereafter and six months after the event, the patient is in excellent general condition.
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Próteses Valvulares Cardíacas/efeitos adversos , Úlcera Gástrica/complicações , Terapia Trombolítica , Trombose/etiologia , Valva Tricúspide , Cinerradiografia , Ecocardiografia , Feminino , Fibrinolíticos/administração & dosagem , Fluoroscopia , Seguimentos , Hemorragia Gastrointestinal/etiologia , Bloqueio Cardíaco/terapia , Humanos , Pessoa de Meia-Idade , Terapia Trombolítica/métodos , Trombose/diagnóstico , Trombose/tratamento farmacológico , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do TratamentoAssuntos
Endocardite Bacteriana/complicações , Endocardite Bacteriana/diagnóstico por imagem , Fluordesoxiglucose F18 , Staphylococcus aureus Resistente à Meticilina/patogenicidade , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Embolia Pulmonar/complicações , Sepse/complicações , Tomografia Computadorizada por Raios X , Endocardite Bacteriana/patologia , Endocardite Bacteriana/fisiopatologia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To compare the decrease in left ventricular mass index (LVMI) by magnetic resonance imaging (MRI) versus transthoracic echocardiography (TTE) after aortic valve replacement (AVR) for severe aortic stenosis with Epic and Epic Supra stented porcine bioprostheses (St Jude Medical, Inc, St Paul, Minn). METHODS: This prospective multicenter study enrolled 149 patients who underwent AVR between January 2006 and February 2008. TTE and cardiac MRI measurements of LVMI were made at baseline and at 6 months of follow-up and were compared. Changes in mean pressure gradients were examined using TTE. RESULTS: TTE measurements of LVMI were 48% to 63% higher than the MRI measurements. A decrease in LVMI from 137 ± 32 to 95 ± 16 g/m(2) with the Epic and from 139 ± 29 to 104 ± 28 g/m(2) with the Epic Supra valves (P < .0001 for both comparisons) was measured by TTE. Cardiac MRI revealed decreases in LVMI from 84 ± 20 to 64 ± 12 g/m(2) and from 86 ± 27 to 64 ± 17 g/m(2) with the Epic and Epic Supra valves, respectively (P < .0001 for both comparisons). TTE revealed a significant regression of mean pressure gradients from 51.6 ± 15.3 to 15.5 ± 5.2 mm Hg with the Epic and from 46.7 ± 19.4 to 17.9 ± 12.8 mm Hg with the Epic supra (P < .0001 for both comparisons). CONCLUSIONS: A significant decrease in LVMI was measured after AVR with all sizes of both bioprosthetic models. Because of the overestimation of the decrease in LVMI by the Devereux formula, as well as the higher accuracy and reproducibility of cardiac MRI measurements, the latter should be preferred to TTE. An ultimate validation of this thesis could only be done comparing each of these modalities with pathologic examination.
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Estenose da Valva Aórtica/cirurgia , Bioprótese , Ecocardiografia Doppler , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Hipertrofia Ventricular Esquerda/diagnóstico , Imageamento por Ressonância Magnética , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Europa (Continente) , Feminino , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/patologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Desenho de Prótese , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , Pressão VentricularRESUMO
OBJECTIVES: This study reports survival, functional status, the change in post-operative left ventricular dimensions and function after'undersized mitral annuloplasty' in patients with non-ischaemic non-valvular dilated cardiomyopathy and secondary mitral regurgitation. PATIENTS AND METHODS: Between 2003 and 2009 10 patients (mean age 61.5 +/- 14 years) with non-ischaemic, non-valvular dilated cardiomyopathy with left ventricular ejection fraction (LV EF) <40% (mean +/- SD, 30.7 +/- 5.27) underwent isolated mitral repair and annuloplasty. All patients were receiving maximal drug therapy. Preoperatively 1 patient (10%) was functioning in New York Heart Association (NYHA) class II, 8 patients (80%) in class III and 1 patient (10%) in class IV. Transthoracic echocardiography was performed immediately before surgery and one year after surgery to assess valvular and ventricular function. For statistical analysis we have used paired t-tests and Wilcoxon's rank test. RESULTS: There were no hospital deaths. Duration of intubation and ICU stay was 1.8 +/- 1.3 and 3.8 +/- 1.8 days, respectively. Functional class after one year was significantly better than the preoperative value (from 3.00 +/- 0.47 to 1.40 +/- 0.52, P<0.001). One year post-operative data showed significant improvement of LV EF (from 30.70 +/- 5.27 to 46.60 +/- 14.47%) and a decrease of the left ventricular diastolic dimension (LVDd) (from 59.30 +/- 5.62 to 50.70 +/- 6.04 mm). CONCLUSION: Isolated undersized mitral annuloplasty in patients with non-ischaemic non-valvular dilated cardiomyopathy with associated mitral regurgitation, is a safe method with the potential of improving functional class, LV EF, and LVDd after one year.
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Anuloplastia da Valva Cardíaca , Cardiomiopatia Dilatada/cirurgia , Valva Mitral/cirurgia , Adulto , Idoso , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/epidemiologia , Cardiomiopatia Dilatada/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/epidemiologia , Estudos Retrospectivos , Volume Sistólico , UltrassonografiaRESUMO
OBJECTIVE: Prolonged aortic crossclamping can increase mortality and morbidity after aortic valve replacement in elderly and high-risk patients. Sutureless implantation of the prosthesis has the potential to shorten aortic crossclamp time. METHODS: The Perceval S valve (Sorin Biomedica Cardio Srl, Sallugia, Italy), a sutureless implantable aortic bioprosthesis, was used in 32 patients (median age, 78 years; median logistic euroSCORE, 9.99) requiring aortic valve replacement with or without concomitant coronary artery bypass grafting. Hemodynamic parameters and clinical outcome were obtained at discharge, at 6 months, and up to 1 year postoperatively. RESULTS: Aortic crossclamp time needed for aortic valve replacement was 18 ± 6 minutes. Hemodynamics at discharge showed good function of all Perceval S valves with low transvalvular pressure gradients (mean, 12 ± 5 mm Hg and peak, 23 ± 9 mm Hg) and low incidence of paravalvular or valvular leakage. Operative mortality was 0%. Follow-up at 1 year showed 3 non-valve-related deaths. Survivors showed good clinical outcome and stable hemodynamic function of the valve prosthesis, except for 1 patient in whom endocarditis developed. Despite a moderate decrease in platelet counts persisting up to 12 months, freedom of bleeding and thromboembolic events was 100%. CONCLUSIONS: It is possible to implant a well-functioning sutureless stent-mounted valve in the aortic position in less than 20 minutes of aortic crossclamping. This is associated with excellent early clinical and hemodynamic outcome in high-risk patients. Moderate changes in hematologic parameters persisted but were not related to clinical events.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Ecocardiografia , Feminino , Humanos , Masculino , Desenho de Prótese , Resultado do TratamentoRESUMO
Prosthetic valve thrombosis (PVT) is one of the most serious long-term complications after heart valve replacement, and optimal treatment remains unclear. The investigators report clinical characteristics and outcome of all consecutive patients with PVT treated with urgent surgery or thrombolysis with recombinant tissue plasminogen activator at a single center from January 1988 to December 2008. Thirty-one patients (mean age 59 years, range 20 to 75, 19% men) were diagnosed with PVT a median of 11 years after valve replacement (range 4 months to 32 years). Affected valve positions were mitral in 17 (55%), aortic in 8 (26%), and tricuspid in 6 (19%), and all but 1 were mechanical valves. Eighteen patients underwent urgent surgery, with 2 deaths in the immediate perioperative phase and 2 recurrences (11%) of PVT over a median follow-up period of 76 months. Of 13 patients treated with thrombolysis, there was immediate clinical improvement after a single administration of recombinant tissue plasminogen activator in 12 (92%), of whom 8 (61%) showed complete response with normalization of echocardiographic findings. The only nonresponder was subsequently referred for urgent surgery. Over a median follow-up period of 18 months, recurrence of PVT was seen in 4 patients (31%), with 1 fatal event in a patient refusing further anticoagulation treatment 1 week after successful thrombolysis. Other complications in the recombinant tissue plasminogen activator group included 1 stroke, 1 transient ischemic attack, 1 hemorrhagic complication requiring surgery, and 2 peripheral embolic events with spontaneous resolution. In conclusion, thrombolysis is an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably with the standard surgical approach.
Assuntos
Fibrinolíticos/uso terapêutico , Doenças das Valvas Cardíacas/terapia , Próteses Valvulares Cardíacas , Falha de Prótese , Reoperação/métodos , Terapia Trombolítica/métodos , Trombose/terapia , Adulto , Idoso , Ecocardiografia , Feminino , Seguimentos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/diagnóstico por imagem , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND AIM OF THE STUDY: Triple valve surgery remains a challenge, although with an improved survival rate compared to historical data. Aws assessment was made as to whether the type of valve surgery, underlying valve lesion and pathology were independent predictors of outcome. The patient characteristics were also described according to the type of surgery performed. METHODS: A total of 166 consecutive patients underwent triple valve surgery and were followed up between October 1972 and June 2006. The clinical and operative variables were obtained retrospectively by physicians. The median follow up was 6.11 years (interquartile range 2.13-10.43). RESULTS: The overall 30-day mortality was 10%, five-year survival 70%, and 10-year survival 60%. In patients with three mechanical valves, survival at five years was 90%, and 85% at 10 years, compared to 40% at five years and 30% at 10 years in patients with three bioprostheses. Among all patients with a mechanical valve in the aortic and mitral positions, those with a tricuspid bioprosthesis were compared to patients with tricuspid repair. The survival rate at 10 years was 60%, and similar between groups. The survival rate of patients with aortic and mitral bioprostheses and tricuspid repair was comparable to that in patients with three bioprostheses. Multivariable analyses showed that the type of tricuspid surgery, age, and NYHA functional class were each significant and independent predictors of survival, with a tricuspid mechanical prosthesis favoring survival. According to the type of surgery, the patient groups differed in their cardiovascular and non-cardiovascular risk profiles. CONCLUSION: Triple-valve surgery is a difficult procedure, with greatly improved survival rates compared to historically reported data. The decision of prosthetic valve type and repair should be tailored to the individual patient, as both patient characteristics and chosen surgery appear to determine survival and morbidity. In young patients, a mechanical prosthesis should also be considered in the tricuspid position.
Assuntos
Bioprótese , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Adulto , Fatores Etários , Idoso , Valva Aórtica/cirurgia , Estudos de Coortes , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Taxa de Sobrevida , Valva Tricúspide/cirurgiaRESUMO
BACKGROUND: Prosthesis-patient mismatch (P-PtM) after aortic valve replacement results in disturbed valve performance associated with increased pressure gradients. However, it is unknown whether this can be related to future structural valve deterioration (SVD) of the bioprosthesis. METHODS AND RESULTS: In 564 patients (mean age, 74+/-5 years) receiving an aortic valve bioprosthesis, clinical follow-up (median, 6.1 years; maximum, 16.4 years) was analyzed including echocardiography. SVD was diagnosed in 40 patients (7%) as substantially increased stenosis (n=24) or regurgitation (n=16) of the operated valve over time. When patients with P-PtM (effective orifice area index <0.85 cm(2)/m(2); n=285) developed SVD, it was preferentially of the stenosis type, whereas when patients without P-PtM (n=279) developed SVD, the majority was of the incompetence type (P<0.05). Multivariable analysis including patient- and valve-related variables revealed that P-PtM and label size =21 were independent predictors of SVD (P=0.04 and P=0.02, respectively). A nonparametric Turnbull estimate analysis showed that SVD is virtually nonexistent for up to 9 years in patients without P-PtM. Thereafter, SVD starts to occur and is mainly of the incompetence-type SVD (79% of cases). In patients with P-PtM, SVD starts to occur after 2 to 3 years after implantation and is mainly of the stenosis-type SVD (81% of cases). CONCLUSIONS: These data suggest that stenosis-type SVD is an early, P-PtM-related, and thus preventable phenomenon. Incompetence-type SVD is a time-dependent, nonspecific wear damage to bioprosthetic valves, which is not related to P-PtM.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Próteses Valvulares Cardíacas/estatística & dados numéricos , Hemodinâmica , Falha de Prótese , Idoso , Insuficiência da Valva Aórtica/mortalidade , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Tamanho Corporal , Calcinose/mortalidade , Calcinose/fisiopatologia , Ecocardiografia , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Análise Multivariada , Tamanho do Órgão , Valor Preditivo dos Testes , Modelos de Riscos ProporcionaisRESUMO
Calcific aortic stenosis is the most frequent heart valve disease and the main indication for valve replacement in western countries. For centuries attributed to a passive wear and tear process, it is now recognized that aortic stenosis is an active inflammatory and potentially modifiable pathology, with similarities to atherosclerosis. Statins were first-line candidates for slowing down progression of the disease, as established drugs in primary and secondary cardiovascular prevention. Despite promising animal experiments and nonrandomized human trials, the prospective randomized trials SEAS and SALTIRE did not confirm the expected benefit. We review SEAS and SALTIRE starting with the preceding studies and discuss basic science experiments covering the major known contributors to the pathophysiology of calcific aortic valve disease, to conclude with a hypothesis on the absent effect of statins, and suggestions for further research paths.