Changing trends in clinical characteristics and in-hospital mortality of patients with infective endocarditis over four decades.

BACKGROUND: Infective endocarditis continues to be a significant concern and may be undergoing an epidemiological transition. METHODS: Were studied 1804 consecutive episodes of infective endocarditis between 1978 and 2022. The mean age was 48 ( ± 19), and 1162 (64%) patients were male. Temporal trends in demographic data, comorbidities, predisposing conditions, microorganisms, complications and in-hospital death have been studied over the decades (1978-1988, 1989-1999, 2000-2010 and 2011-2022). The outcomes and clinical characteristics were modeled using nonlinear cubic spline functions. FINDINGS: Valve surgery was performed in 50% of the patients and overall in-hospital mortality was 30%. From the first to the fourth decade studied, the average age of patients increased from 29 to 57 years (p < 0.001), with significant declines in the occurrence of rheumatic valvular heart disease (15% to 6%; p < 0.001) and streptococcal infections (46% to 33%; p < 0.001). Healthcare-associated infections have increased (9% to 21%; p < 0.001), as have prosthetic valve endocarditis (26% to 53%; p < 0.001), coagulase-negative staphylococcal infections (4% to 11%; p < 0.001), and related-complications (heart failure, embolic events, and perivalvular abscess; p < 0.001). These changes were associated with a decline in adjusted in-hospital mortality from 34% to 25% (p = 0.019). INTERPRETATION: In the 44 years studied, there was an increase in the mean age of patients, healthcare-related, prosthetic valve, coagulase-negative staphylococci/MRSA infections, and related complications. Notably, these epidemiological changes were associated with a decline in the adjusted in-hospital mortality.

Myocardial Injury After Transcatheter Mitral Valve Replacement Versus Surgical Reoperation.

This study aimed to evaluate the incidence and clinical implications of myocardial injury, as determined by cardiac biomarker increase, in patients who underwent mitral bioprosthesis dysfunction treatment with transcatheter mitral valve replacement (TMVR) versus surgical mitral valve replacement reoperation (SMVR-REDO). Between 2014 and 2023, 310 patients with mitral bioprosthesis failure were included (90 and 220 patients for TMVR and SMVR-REDO, respectively). Multivariable analysis and propensity score matching were performed to adjust for the intergroup differences in baseline characteristics. Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTn) were collected at baseline and 6 to 12, 24, 48, and 72 hours after intervention. The cardiac biomarkers values were evaluated in relation to their reference values. The outcomes were determined according to the Mitral Valve Academic Research Consortium criteria. CK-MB and cTn increased above the reference level in almost all patients after SMVR-REDO and TMVR (100% vs 94%, respectively), with the peak occurring within 6 to 12 hours. SMVR-REDO was associated with a two- to threefold higher increase in cardiac biomarkers. After 30 days, the mortality rates were 13.3% in the TMVR and 16.8% in the SMVR-REDO groups. At a median follow-up of 19 months, the mortality rates were 21.1% in the TMVR and 17.7% in the SMVR-REDO groups. Left ventricular ejection fraction, estimated glomerular filtration rate, CK-MB, and cTn were predictors of mortality. In conclusion, some degree of myocardial injury occurred systematically after the treatment of mitral bioprosthetic degeneration, especially after SMVR, and higher CK-MB and cTn levels were associated with increased cumulative late mortality, regardless of the approach.

Mitral re-valve-in-valve as a new perspective for high-risk patients with prosthetic valve dysfunction: case reports.

Background: Mitral valve diseases are a common medical condition, and surgery is the most used therapeutic approach. The need for less invasive interventions led to the development of transcatheter valve implantation in high-risk patients. However, the treatment to the dysfunctions of these prosthetic valves is still uncertain, and the yield and safety of repeated transcatheter valve implantations remain unclear. Cases summary: A 69-year-old Caucasian woman with three previous mitral valve procedures performed due to rheumatic valve disease (currently with a biological prosthetic mitral valve) and a 76-year-old Latin woman with previous liver transplantation (due to metabolic-associated fatty liver disease) and biological mitral prosthesis due to mitral valve prolapse with severe regurgitation underwent mitral valve-in-valve (ViV) transcatheter implantation at the time of dysfunction of their surgical prostheses. Later, these patients developed prosthetic valve dysfunction and clinical worsening, requiring another invasive procedure. Due to maintained high-risk status and unfavourable clinical conditions for surgery, re-valve-in-valve (re-ViV) was performed. Discussion: Valve-in-valve transcatheter mitral valve implantation was approved in 2017, and, since then, it has been used in several countries, mainly in high-risk patients. Nevertheless, these prosthetic valves may complicate with stenosis or regurgitation, demanding reinterventions. Although there are favourable data for mitral ViV, re-ViV still lacks robust data to support its performance, with only case reports in the literature so far. It is possible that in high-risk patients, there is a greater benefit from re-ViV when compared with the surgical strategy. However, this hypothesis must be studied in future controlled trials.

Incidental Diagnosis of Rheumatic Myocarditis during Cardiac Surgery-Impact on Late Prognosis.

Rheumatic fever (RF) and rheumatic heart disease (RHD) are still highly prevalent, particularly in low- and middle-income countries. RHD is a neglected and underdiagnosed disease for which no specific laboratory diagnostic test is completely reliable. This is a retrospective observational study, which included 118 patients with RHD who underwent cardiac surgery from 1985 to 2018. The aim of this investigation was to evaluate the clinical, epidemiological, echocardiographic and pathological characteristics in two cohorts of RHD patients: one cohort with Aschoff bodies present in their pathological results and the other without such histopathological characteristics. No conventional clinical and laboratory tests for RHD myocarditis were able to identify active carditis during the preoperative phase of valve repair or replacement. Patients who had Aschoff bodies in their pathological results were younger (median age of 13 years (11-24 years) vs. 27 years (17-37 years), p = 0.001) and had higher rate of late mortality (22.9% vs. 5.4%, p = 0.043). In conclusion, the presence of Aschoff bodies in pathological findings may predict increased long-term mortality, emphasizing the importance of comprehensive pathology analysis for suspected myocarditis during heart surgery.

Risk prediction in patients with classical low-flow, low-gradient aortic stenosis undergoing surgical intervention.

Introduction: Classical low-flow, low-gradient aortic stenosis (LFLG-AS) is an advanced stage of aortic stenosis, which has a poor prognosis with medical treatment and a high operative mortality after surgical aortic valve replacement (SAVR). There is currently a paucity of information regarding the current prognosis of classical LFLG-AS patients undergoing SAVR and the lack of a reliable risk assessment tool for this particular subset of AS patients. The present study aims to assess mortality predictors in a population of classical LFLG-AS patients undergoing SAVR. Methods: This is a prospective study including 41 consecutive classical LFLG-AS patients (aortic valve area ≤1.0 cm2, mean transaortic gradient <40 mmHg, left ventricular ejection fraction <50%). All patients underwent dobutamine stress echocardiography (DSE), 3D echocardiography, and T1 mapping cardiac magnetic resonance (CMR). Patients with pseudo-severe aortic stenosis were excluded. Patients were divided into groups according to the median value of the mean transaortic gradient (≤25 and >25 mmHg). All-cause, intraprocedural, 30-day, and 1-year mortality rates were evaluated. Results: All of the patients had degenerative aortic stenosis, with a median age of 66 (60-73) years; most of the patients were men (83%). The median EuroSCORE II was 2.19% (1.5%-4.78%), and the median STS was 2.19% (1.6%-3.99%). On DSE, 73.2% had flow reserve (FR), i.e., an increase in stroke volume ≥20% during DSE, with no significant differences between groups. On CMR, late gadolinium enhancement mass was lower in the group with mean transaortic gradient >25 mmHg [2.0 (0.0-8.9) g vs. 8.5 (2.3-15.0) g; p = 0.034), and myocardium extracellular volume (ECV) and indexed ECV were similar between groups. The 30-day and 1-year mortality rates were 14.6% and 43.8%, respectively. The median follow-up was 4.1 (0.3-5.1) years. By multivariate analysis adjusted for FR, only the mean transaortic gradient was an independent predictor of mortality (hazard ratio: 0.923, 95% confidence interval: 0.864-0.986, p = 0.019). A mean transaortic gradient ≤25 mmHg was associated with higher all-cause mortality rates (log-rank p = 0.038), while there was no difference in mortality regarding FR status (log-rank p = 0.114). Conclusions: In patients with classical LFLG-AS undergoing SAVR, the mean transaortic gradient was the only independent mortality predictor in patients with LFLG-AS, especially if ≤25 mmHg. The absence of left ventricular FR had no prognostic impact on long-term outcomes.

Postoperative myocardial fibrosis assessment in aortic valvular heart diseases-a cardiovascular magnetic resonance study.

AIMS: Left ventricular remodelling occurs during the chronic course of aortic regurgitation (AR) and aortic stenosis (AS), leading to myocardial hypertrophy and fibrosis. Several studies have shown that extracellular volume fraction (ECV) and indexed extracellular volume (iECV) are important surrogate markers of diffuse myocardial fibrosis (MF). Postoperative data on these cardiovascular magnetic resonance (CMR) extracellular expansion parameters for either AS or AR are scarce. This study aimed to demonstrate the postoperative changes that occur in diffuse MF, and the influence of preoperative MF on the reversal of LV remodelling, in patients with AR or AS. METHODS AND RESULTS: Patients with severe AR or AS and indications for surgery were prospectively enrolled. Patients underwent pre- and postoperative CMR, and ECV and iECV were quantified. Data from 99 patients were analysed (32 with AR and 67 with AS). After surgery, the left ventricle mass index decreased in both groups (AR: 110 vs. 91 g/m2; AS: 86 vs. 68 g/m2, both P < 0.001). The late gadolinium enhancement fraction (AR: preoperative 1.9% vs. postoperative 1.7%, P = 0.575; AS: preoperative 2.4% vs. postoperative 2.4%, P = 0.615) and late gadolinium enhancement mass (AR: preoperative 3.8 g vs. postoperative 2.5 g, P = 0.635; AS: preoperative 3.4 g vs. postoperative 3.5 g, P = 0.575) remained stable in both groups. Preoperative iECV and ECV were greater in the AR group (iECV: 30 mL/m2 vs. 22 mL/m2, P = 0.001; ECV: 28.4% vs. 27.2%, P = 0.048). Indexed extracellular volume decreased after surgery in both groups (AR: 30-26.5 mL/m2, AS: 22-18.2 mL/m2, both P < 0.001); it was still greater in the AR group (AR: 26.5 mL/m2 vs. AS: 18.2 mL/m2, P < 0.001). Postoperative ECV remained stable in the AR group (preoperative 28.4% vs. postoperative 29.9%; P = 0.617) and increased in the AS group (preoperative 27.2% vs. postoperative 28.6%; P = 0.033). CONCLUSION: Patients with both AR or AS presented reduction in iECV after surgery, unfolding the reversible nature of diffuse MF. In contrast to patients with AS, those with AR developed postoperative iECV regression with stable ECV, suggesting a balanced reduction in both intracellular and extracellular myocardial components.

Emergências Relacionadas à Doença Valvar Cardíaca: Uma Revisão Abrangente da Abordagem Inicial no Departamento de Emergência / Valvular Heart Disease Emergencies: A Comprehensive Review Focusing on the Initial Approach in the Emergency Department

Resumo A doença valvar cardíaca é um problema de saúde crescente no mundo. Os pacientes com valvopatia podem apresentar diversas emergências cardiovasculares. O manejo desses pacientes é um desafio no departamento de emergência, principalmente quando a condição cardíaca prévia é desconhecida. Atualmente, recomendações específicas para o manejo inicial são limitadas. A presente revisão integrativa propõe uma abordagem baseada em evidência, de três etapas, desde a suspeita de valvopatia à beira do leito até o tratamento inicial das emergências. A primeira etapa é a suspeita de uma condição valvar subjacente com base nos sinais e sintomas. A segunda etapa consiste na tentativa de confirmação diagnóstica e avaliação da gravidade da valvopatia com exames complementares. Finalmente, a terceira etapa aborda as opções diagnósticas e terapêuticas para insuficiência cardíaca, fibrilação atrial, trombose valvar, febre reumática aguda, e endocardite infecciosa. Além disso, apresentamos imagens de exames complementares e tabelas para apoio aos médicos.

Abstract Valvular heart disease (VHD) is an increasing health problem worldwide. Patients with VHD may experience several cardiovascular-related emergencies. The management of these patients is a challenge in the emergency department, especially when the previous heart condition is unknown. Specific recommendations for the initial management are currently poor. This integrative review proposes an evidence-based three-step approach from bedside VHD suspicion to the initial treatment of the emergencies. The first step is the suspicion of underlying valvular condition based on signs and symptoms. The second step comprises the attempt to confirm the diagnosis and assessment of VHD severity with complementary tests. Finally, the third step addresses the diagnosis and treatment options for heart failure, atrial fibrillation, valvular thrombosis, acute rheumatic fever, and infective endocarditis. In addition, several images of complementary tests and summary tables are provided for physician support.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil.

INTRODUCTION: Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition. METHODS: Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed. RESULTS: Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%. CONCLUSION: Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

Clinical Profile and 30-Day Outcomes of Patients with Bicuspid Aortic Valve Undergoing Aortic Valve and/or Aorta Surgery. / Perfil Clínico e Desfechos em 30 Dias de Pacientes Portadores de Valva Aórtica Bicúspide Submetidos à Cirurgia em Valva Aórtica e/ou Aorta.

BACKGROUND: The bicuspid aortic valve (BAV) affects 0.5 to 2% of the population and is associated with valve and aortic alterations. There is a lack of studies on the profile of these patients in the Brazilian population. OBJECTIVE: To describe the profile of patients with BAV undergoing valve and/or aortic surgery in a tertiary cardiology center, in addition to the outcomes related to the intervention. METHODS: Retrospective cohort including 195 patients (mean age 54±14 years, 73.8% male) diagnosed with BAV who underwent surgical approach (valvular and/or aorta) from 2014 to 2019. Clinical data, echocardiographic and tomographic studies were evaluated, as well as characteristics of the intervention and events in 30 days. A value of p<0.05 was considered statistically significant. RESULTS: We found a high prevalence of aortic aneurysm (56.5%), with a mean diameter of 46.9±10.2 mm. Major aortic regurgitation was found in 25.1% and major aortic stenosis in 54.9%. Isolated aortic valve surgery was performed in 48.2%, isolated aortic surgery in 6.7% and combined surgery in 45.1%. The 30-day mortality was 8.2%. In the multivariate analysis, the predictors of the combined outcome at 30 days (death, atrial fibrillation and reoperation) were age (OR 1.044, 95% CI 1.009-1.081, p=0.014) and left ventricular mass index (OR 1.009, 95% CI 1.000-1.018, p=0.044). CONCLUSION: Patients with BAV approached in our service have a higher incidence of aortopathy, with the additional need to evaluate the aorta with computed tomography or magnetic resonance imaging.

FUNDAMENTO: A válvula aórtica bicúspide (VAB) atinge de 0,5 a 2% da população e está associada a alterações valvares e de aorta. Há carência de estudos sobre o perfil desses pacientes na população brasileira. OBJETIVO: Descrever o perfil de pacientes com VAB submetidos à cirurgia valvar e/ou de aorta em um centro cardiológico terciário, assim como os desfechos relacionados à intervenção. MÉTODOS: Coorte retrospectiva incluindo 195 pacientes (idade média 54±14 anos, 73,8% do sexo masculino) com diagnóstico de VAB submetidos à abordagem cirúrgica (valvar e/ou de aorta) no período de 2014 a 2019. Foram avaliados dados clínicos, ecocardiográficos e tomográficos, além das características da intervenção e eventos em 30 dias. O valor de p<0,05 foi considerado estatisticamente significante. RESULTADOS: Encontramos alta prevalência de aneurisma de aorta (56,5%), com diâmetro médio de 46,9±10,2 mm. Insuficiência aórtica importante foi encontrada em 25,1% e estenose aórtica importante em 54,9%. Cirurgia isolada em valva aórtica foi realizada em 48,2%, cirurgia isolada de aorta em 6,7% e cirurgia combinada em 45,1%. A mortalidade em 30 dias foi de 8,2%. Na análise multivariada, os fatores preditores de desfecho combinado em 30 dias (morte, fibrilação atrial e reoperação) foram idade (OR 1,044, IC 95% 1,009-1,081, p=0,014) e o índice de massa do ventrículo esquerdo (OR 1,009, IC 95% 1,000-1,018, p=0,044). CONCLUSÃO: Pacientes com VAB abordados no nosso serviço apresentam uma maior incidência de aortopatia, com a necessidade adicional de avaliação da aorta com tomografia computadorizada ou ressonância magnética.

Deslocamento linear longitudinal do ventrículo esquerdo comparado ao strain longitudinal global por ressonância magnética cardiovascular / Left ventricular longitudinal linear displacement versus global longitudinal strain on cardiovascular magnetic resonance

Introdução: A função sistodiastólica do ventrículo esquerdo é prognóstica nas doenças cardiovasculares e pode ser avaliada por strain longitudinal global por meio de ecocardiografia e de ressonância magnética cardíaca. O strain longitudinal global pela ressonância magnética cardíaca exige a utilização de software de alto custo. O deslocamento linear longitudinal do ventrículo esquerdo pode ser uma alternativa simples e barata ao strain longitudinal global, porém eles não foram ainda comparados sistematicamente. Objetivo: Comparar o deslocamento linear longitudinal com o strain longitudinal global e fração de ejeção do ventrículo esquerdo em valvopatas aórticos e controles. Métodos: Incluímos 44 participantes (26 valvopatas aórticos/19 controles). O strain longitudinal global utilizou software específico (Circle Cardiovascular Imaging 42) e o deslocamento linear longitudinal apenas medidas lineares de distância entre a base e o ápex do ventrículo esquerdo, gerando deslocamento máximo, velocidade máxima no início da diástole, velocidade na diástase e a relação entre velocidade na diástase e velocidade máxima no início da diástole. Resultados: Deslocamento máximo e velocidade máxima no início da diástole correlacionaram-se com strain longitudinal global (r=0,69 e r=0,65 respectivamente) e com a fração de ejeção do ventrículo esquerdo (r=0,47 e r=0,57, p<0,001 para ambos). Deslocamento máximo e velocidade máxima no início da diástole apresentaram área sob a curva Característica de Operação do Receptor de 0,88 e 0,91 e, no melhor ponto de corte (-0,13 e 0,66), sensibilidade de 72,43% e 57,14% e especificidade 80,65% e 87,10%, respectivamente, quando comparados ao strain longitudinal global. Utilizando a fração de ejeção do ventrículo esquerdo como referência, foram obtidos 0,70 e 0,82, e, no melhor ponto de corte (-0,11 e 0,61), sensibilidade de 75,00% e 50,00% e especificidade 72,97% e 78,38%, respectivamente. Conclusão: O deslocamento linear longitudinal foi semelhante ao strain longitudinal global. O deslocamento máximo derivado do deslocamento linear longitudinal foi o melhor parâmetro na sístole, enquanto a velocidade máxima no início da diástole foi o melhor na diástole, o que possibilita a avaliação da função diastólica pela ressonância magnética cardíaca na rotina clínica de forma rápida e sem custo adicional.(AU)

Background: Left ventricular (LV) systolic diastolic function is prognostic in cardiovascular diseases and can be assessed via global longitudinal strain (GLS) on echocardiography and cardiac magnetic resonance (CMR). However, GLS by CMR requires the use of expensive software. Longitudinal linear displacement (LLD) may be a simple and inexpensive alternative to GLS, but the two have not been systematically compared. Objective: To compare LLD with GLS and LV ejection fraction (LVEF) in aortic valve disease patients and controls. Methods: We included 44 participants (26 with aortic valve disease, 19 controls). GLS was determined using CVI42 software (Circle Cardiovascular Imaging), while the LLD linear measurements of the distance between the base/apex of the LV included maximum displacement (MD), maximum velocity in early diastole (MVED), atrioventricular junction velocity in diastasis (VDS), and VDS/MVED ratio. Results: DM and MVED were correlated with GLS (r=0.69 and r=0.65, respectively) and LVEF (r=0.47 and r=0.57, p<0.001 for both). DM and MVED showed areas under the receiver operating characteristic curve (AUC) of 0.88 and 0.91, and at the best cut-off point (-0.13 and 0.66), sensitivities of 72.43% and 57.14% and specificities of 80.65% and 87.10%, respectively, compared to GLS. Using LVEF as a reference, we obtained AUC of 0.70 and 0.82, and at the best cut-off point (-0.11 and 0.61), sensitivities of 75.00% and 50.00% and specificities of 72.97% and 78.38%, respectively. Conclusion: LLD demonstrated similar performance to that of GLS. MD derived from LLD was the best parameter during systole, while MVED was the best during diastole. Our findings demonstrate the routine, quick, and inexpensive assessment of diastolic function on CMR.(AU)

Prevalence of Frailty in Patients Undergoing Cardiac Valve Surgery: Comparison of Frailty Tools

Abstract Background There is no consensus among tools for assessing frailty. Objective To evaluate the prevalence of frailty according to different tools in patients referred for elective valve cardiac surgery. Methods This is a cross-sectional study. All patients were ≥ 18 years of age, clinically stable. The following patients were excluded: those unable to perform the tests because of physical, cognitive, or neurological limitations; those requiring non elective/emergency procedures or hemodynamic instability. During the preoperative cardiology visit, frailty was assessed by the Short Physical Performance Battery (SPPB), the Frailty Deficit Index (FDI), handgrip strength, and gait speed 3m. For the entire analysis, the statistical significance was set at 5%. Results Our cohort consisted of 258 subjects. From the total cohort, 201 were ≤ 70 years of age (77.9%), the predominant etiology according to rheumatic disease (50.7% vs 8.8%; p=0.000) with double mitral lesion (24.9% vs 0%; p=0.000). Frailty was present in 32.9% according SPPB, 29.1% with reduced muscular strength. and 8.9% with FDI. Handgrip strength was weaker in elderly patients (26.7 vs 23.6; p=0.051) and gait speed was lower in the younger group, in which 36% were considered frail (36% vs 14%; p=0.002). Variables associated with frailty were age ≥ 70 years, female gender, aortic stenosis, and regurgitation. Conclusion Frailty in adult patients who will have elective heart valve surgery is present even in the younger groups, although the older group with comorbidities are more frail. Frailty was more clearly shown by the SPPB than by the FDI and handgrip tests.

Síndrome de Heyde: Estratégias Terapêuticas e Seguimento de Longo Prazo / Heyde's Syndrome: Therapeutic Strategies and Long-Term Follow-Up

Resumo Fundamentos A síndrome de Heyde é a associação de estenose aórtica importante com episódio de sangramento gastrointestinal por lesões angiodisplásicas. Pouco é conhecido sobre os fatores associados a novos sangramentos e desfechos em longo prazo. Além disso, a maioria dos dados é restrita a relatos de casos e pequenas séries. Objetivo Avaliar o perfil clínico, laboratorial e ecocardiográfico de pacientes com síndrome de Heyde submetidos a intervenção valvar ou tratamento medicamentoso. Métodos Coorte prospectiva de 24 pacientes consecutivos entre 2005 e 2018. Foram avaliados dados clínicos, laboratoriais, ecocardiográficos e relacionados à intervenção valvar e a desfechos após o diagnóstico. Valor de p<0,05 foi considerado estatisticamente significante. Resultados Metade dos 24 pacientes apresentou sangramento com necessidade de transfusão sanguínea na admissão. Angiodisplasias foram encontradas mais frequentemente no cólon ascendente (62%). Intervenção valvar (cirúrgica ou transcateter) foi realizada em 70,8% dos pacientes, e 29,2% foram mantidos em tratamento clínico. Novos episódios de sangramento ocorreram em 25% dos casos, e não houve diferença entre os grupos clínico e intervenção (28,6 vs. 23,5%, p=1,00; respectivamente). A mortalidade no seguimento de 2 e 5 anos foi de 16% e 25%, sem diferença entre os grupos (log-rank p = 0,185 e 0,737, respectivamente). Conclusões Pacientes com síndrome de Heyde tiveram alta taxa de sangramento com necessidade de transfusão sanguínea na admissão, sugerindo ser uma doença grave e com risco elevado de mortalidade. Não encontramos diferenças entre os grupos submetidos ao tratamento clínico e à intervenção valvar em relação a taxas de ressangramento e mortalidade tardia.

Abstract Background Heyde's syndrome is the association of severe aortic stenosis with episodes of gastrointestinal bleeding due to angiodysplastic lesion. Little is known about the factors associated with new episodes of bleeding and long-term outcomes. Furthermore, most data are restricted to case reports and small case series. Objective To assess the clinical, laboratory and echocardiography profile of patients with Heyde's syndrome who underwent valve intervention or drug therapy. Methods Prospective cohort of 24 consecutive patients from 2005 to 2018. Clinical, laboratory and echocardiography data were assessed, as well as those related to valve intervention and outcomes after diagnosis. A P <0.05 was used to indicate statistical significance. Results Half of the 24 patients presented with bleeding requiring blood transfusion on admission. Angiodysplasias were more frequently found in the ascending colon (62%). Valve intervention (surgical or transcatheter) was performed in 70.8% of the patients, and 29.2% remained on drug therapy. News episodes of bleeding occurred in 25% of the cases, and there was no difference between clinical and intervention groups (28.6 vs 23.5%, p = 1.00; respectively). Mortality at 2-year and 5-year was 16% and 25%, with no difference between the groups (log-rank p = 0.185 and 0.737, respectively). Conclusions Patients with Heyde's syndrome had a high rate of bleeding requiring blood transfusion on admission, suggesting that it is a severe disease with high mortality risk. No difference was found between clinical and intervention group regarding the rate of rebleeding and late mortality.

Demographic, cardiological, microbiologic, and dental profiles of Brazilian patients who developed oral bacteria-related endocarditis.

OBJECTIVE: Infective endocarditis (IE) may cause devastating complications with high morbidity and mortality rates. The aim of the present study was to study the demographic, cardiological, microbiologic, and dental profiles of patients with oral bacteria-related IE. STUDY DESIGN: We present a retrospective study of patients with oral bacteria-related IE treated at Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil, between January 2009 and December 2019. RESULTS: Of the 100 patients included, 70% were male with a mean age of 45.4 years at diagnosis. The most affected sites were aortic and mitral valves, 60% in prosthetic heart valves, 34% in native valves, and 3% in pacemakers. The most common cause of valvular disease was rheumatic cardiopathy (51.9%), and the most frequent complications were valvular and perivalvular damage (26%). Streptococcus viridans was the most common species (96%), dental caries were present in 57% of the patients, 78% had tooth loss, 45% had apical periodontitis, and 77% were at high/moderate risk for periodontal disease. CONCLUSION: Oral bacteria-related IE among Brazilians was predominant in the prosthetic heart valves of young male adults previously affected by rheumatic cardiopathy. Streptococcus viridans was the main cause of IE, which was linked to patients with a poor oral health status.

A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial.

The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain. DESIGN: RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20 mg once daily (15 mg in those with creatinine clearance <50 mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12 months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism. SUMMARY: RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.

Cardiac Magnetic Resonance Analysis of Mitral Annular Dynamics after Mitral Valve Repair.

OBJECTIVES: The aim of this study was to analyze mitral annulus (MA) dynamics using cardiac magnetic resonance (CMR) in patients with degenerative mitral insufficiency who underwent mitral valve repair (MVR). METHODS: Mitral valve imaging was performed by CMR in twenty-nine patients with degenerative mitral insufficiency who underwent MVR between July 2014 and August 2016, with quadrangular resection of the posterior leaflet without ring annuloplasty. They were prospectively followed up from the preoperative period up to 2 years postoperatively. RESULTS: We observed a significant reduction in all measurements of the MA after surgery. The mean systolic circumference of the MA was reduced from 13.28±1.95 cm to 11.50±1.59 cm, and the diastolic circumference was reduced from 12.51±2.01 cm to 10.66±2.09 cm in the immediate postoperative period, measures that remained stable 2 years after MVR (p<0.001). The mean maximum area of the MA was significantly reduced from 14.34±4.03 to 10.45±3.17 cm2 when comparing the immediate postoperative period and the 2 year follow-up (p<0.001). The same occurred with the mean minimum area of the MA, which was reduced from 12.53±3.68 cm2 to 9.23±2.84 cm2 in the same period, and this reduction was greater in the antero-posterior diameter than in the mid-lateral diameter. The mobility of the MA was preserved after surgery, ranging between 19.6% and 25.7% at 2-year follow-up. CONCLUSION: We observed a significant reduction in the MA size after MVR, with preservation of the MA mobility at the 2-year follow-up.