ABSTRACT
BACKGROUND: Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a dismal prognosis. However, scarce data exist on IE perivalvular extension (PEE) in such patients. METHODS: This multicenter study included 579 patients who had the diagnosis of definite IE at a median of 171 (53-421) days following TAVR. PEE was defined as the presence of an intracardiac abscess, pseudoaneurysm, or fistula. RESULTS: A total of 105 patients (18.1%) were diagnosed with PEE (perivalvular abscess, pseudoaneurysm, fistula, or a combination in 87, 7, 7, and 4 patients, respectively). A history of chronic kidney disease (adjusted odds ratio [ORadj], 2.08; 95% confidence interval [CI]: 1.27-3.41; Pâ =â .003) and IE secondary to coagulase-negative staphylococci (ORadj, 2.71; 95% CI: 1.57-4.69; Pâ <â .001) were associated with an increased risk of PEE. Surgery was performed at index IE episode in 34 patients (32.4%) with PEE (vs 15.2% in patients without PEE, Pâ <â .001). In-hospital and 2-year mortality rates among PEE-IE patients were 36.5% and 69.4%, respectively. Factors independently associated with an increased mortality were the occurrence of other complications (stroke post-TAVR, acute renal failure, septic shock) and the lack of surgery at index IE hospitalization (padjâ <â 0.05 for all). CONCLUSIONS: PEE occurred in about one-fifth of IE post-TAVR patients, with the presence of coagulase-negative staphylococci and chronic kidney disease determining an increased risk. Patients with PEE-IE exhibited high early and late mortality rates, and surgery during IE hospitalization seemed to be associated with better outcomes.
Subject(s)
Aneurysm, False , Endocarditis, Bacterial , Endocarditis , Renal Insufficiency, Chronic , Transcatheter Aortic Valve Replacement , Abscess , Aneurysm, False/complications , Aneurysm, False/surgery , Coagulase , Endocarditis/epidemiology , Endocarditis/etiology , Endocarditis/surgery , Endocarditis, Bacterial/epidemiology , Endocarditis, Bacterial/etiology , Endocarditis, Bacterial/surgery , Humans , Renal Insufficiency, Chronic/complications , Risk Factors , Transcatheter Aortic Valve Replacement/adverse effectsABSTRACT
BACKGROUND: Procedural improvements combined with the contemporary clinical profile of patients undergoing transcatheter aortic valve replacement (TAVR) may have influenced the incidence and outcomes of infective endocarditis (IE) following TAVR. We aimed to determine the temporal trends, characteristics, and outcomes of IE post-TAVR. METHODS: Observational study including 552 patients presenting definite IE post-TAVR. Patients were divided in 2 groups according to the timing of TAVR (historical cohort [HC]: before 2014; contemporary cohort [CC]: after 2014). RESULTS: Overall incidence rates of IE were similar in both cohorts (CC vs HC: 5.45 vs 6.52 per 1000 person-years; Pâ =â .12), but the rate of early IE was lower in the CC (2.29 vs 4.89, Pâ <â .001). Enterococci were the most frequent microorganism. Most patients presented complicated IE ( CC: 67.7%; HC: 69.6%; Pâ =â .66), but the rate of surgical treatment remained low (CC: 20.7%; HC: 17.3%; Pâ =â .32). The CC exhibited lower rates of in-hospital acute kidney injury (35.1% vs 44.6%; Pâ =â .036) and in-hospital (26.6% vs 36.4%; Pâ =â .016) and 1-year (37.8% vs 53.5%; Pâ <â .001) mortality. Higher logistic EuroScore, Staphylococcus aureus etiology, and complications (stroke, heart failure, and acute renal failure) were associated with in-hospital mortality in multivariable analyses (Pâ <â .05 for all). CONCLUSIONS: Although overall IE incidence has remained stable, the incidence of early IE has declined in recent years. The microorganism, high rate of complications, and very low rate of surgical treatment remained similar. In-hospital and 1-year mortality rates were high but progressively decreased over time.
Subject(s)
Endocarditis, Bacterial , Endocarditis , Transcatheter Aortic Valve Replacement , Endocarditis/epidemiology , Endocarditis/etiology , Endocarditis/surgery , Endocarditis, Bacterial/epidemiology , Endocarditis, Bacterial/etiology , Endocarditis, Bacterial/surgery , Humans , Incidence , Postoperative Complications/epidemiology , Risk Factors , Transcatheter Aortic Valve Replacement/adverse effects , Treatment OutcomeABSTRACT
Importance: The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. Objective: To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Design, Setting, and Participants: Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Interventions: Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. Main Outcomes and Measures: The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Results: Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Conclusions and Relevance: Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. Trial Registration: clinicaltrials.gov Identifier: NCT01448642.
Subject(s)
Acute Coronary Syndrome/drug therapy , Atorvastatin/administration & dosage , Cardiovascular Diseases/prevention & control , Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage , Percutaneous Coronary Intervention , Acute Coronary Syndrome/therapy , Aged , Atorvastatin/adverse effects , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/mortality , Double-Blind Method , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/adverse effects , Male , Middle Aged , Preoperative Care , ST Elevation Myocardial Infarction/drug therapy , ST Elevation Myocardial Infarction/therapyABSTRACT
BACKGROUND: We aimed to determine the incidence, predictors, clinical characteristics, management, and outcomes of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: This multicenter registry included 53 patients (mean age, 79±8 years; men, 57%) who suffered IE after TAVI of 7944 patients after a mean follow-up of 1.1±1.2 years (incidence, 0.67%, 0.50% within the first year after TAVI). Mean time from TAVI was 6 months (interquartile range, 1-14 months). Orotracheal intubation (hazard ratio, 3.87; 95% confidence interval, 1.55-9.64; P=0.004) and the self-expandable CoreValve system (hazard ratio, 3.12; 95% confidence interval, 1.37-7.14; P=0.007) were associated with IE (multivariate analysis including 3067 patients with individual data). The most frequent causal microorganisms were coagulase-negative staphylococci (24%), followed by Staphylococcus aureus (21%) and enterococci (21%). Vegetations were present in 77% of patients (transcatheter valve leaflets, 39%; stent frame, 17%; mitral valve, 21%). At least 1 complication of IE occurred in 87% of patients (heart failure in 68%). However, only 11% of patients underwent valve intervention (valve explantation and valve-in-valve procedure in 4 and 2 patients, respectively). The mortality rate in hospital was 47.2% and increased to 66% at the 1-year follow-up. IE complications such as heart failure (P=0.037) and septic shock (P=0.002) were associated with increased in-hospital mortality. CONCLUSIONS: The incidence of IE at 1 year after TAVI was 0.50%, and the risk increased with the use of orotracheal intubation and a self-expandable valve system. Staphylococci and enterococci were the most common agents. Although most patients presented at least 1 complication of IE, valve intervention was performed in a minority of patients, and nearly half of the patients died during the hospitalization period.
Subject(s)
Endocarditis, Bacterial/etiology , Heart Valve Prosthesis/adverse effects , Postoperative Complications/etiology , Prosthesis-Related Infections/etiology , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Aortic Valve Stenosis/surgery , Endocarditis, Bacterial/mortality , Endocarditis, Bacterial/surgery , Enterococcus , Equipment Contamination , Female , Gram-Positive Bacterial Infections/etiology , Gram-Positive Bacterial Infections/surgery , Heart Failure/etiology , Hospital Mortality , Humans , Incidence , Intubation, Intratracheal/adverse effects , Kaplan-Meier Estimate , Male , Postoperative Complications/mortality , Postoperative Complications/surgery , Proportional Hazards Models , Prosthesis-Related Infections/mortality , Prosthesis-Related Infections/surgery , Registries , Retrospective Studies , Risk , Staphylococcal Infections/etiology , Staphylococcal Infections/surgery , Treatment OutcomeABSTRACT
An 89-year-old woman with severe aortic regurgitation and an aneurysmal interventricular membranous septum extending into the aortic annulus underwent successful transcatheter aortic valve replacement. A challenging case because of the risk of valve mispositioning complications attributed to the co-occurrence of pure aortic regurgitation (very low calcium burden) with an aneurysmal interventricular membranous septum. (Level of Difficulty: Intermediate.).
ABSTRACT
BACKGROUND: Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries. OBJECTIVES: To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil. METHODS: Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months. RESULTS: Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%. CONCLUSIONS: CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.
FUNDAMENTO: Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento. OBJETIVOS: Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil. MÉTODOS: Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução. RESULTADOS: Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. CONCLUSÕES: As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica.
Subject(s)
Coronary Occlusion , Percutaneous Coronary Intervention , Humans , Adolescent , Brazil , Coronary Occlusion/surgery , Prospective Studies , Treatment Outcome , Percutaneous Coronary Intervention/methods , Chronic Disease , RegistriesABSTRACT
Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.
Subject(s)
Aortic Valve Insufficiency , Aortic Valve Stenosis , Endocarditis , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Aortic Valve/surgery , Aortic Valve Insufficiency/complications , Aortic Valve Insufficiency/epidemiology , Aortic Valve Insufficiency/surgery , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/surgery , Catheters/adverse effects , Endocarditis/epidemiology , Endocarditis/etiology , Heart Valve Prosthesis/adverse effects , Humans , Mitral Valve/surgery , Risk Factors , Transcatheter Aortic Valve Replacement/adverse effects , Treatment OutcomeABSTRACT
BACKGROUND: Staphylococcus aureus (SA) has been extensively studied as causative microorganism of surgical prosthetic-valve infective endocarditis (IE). However, scarce evidence exists on SA IE after transcatheter aortic valve replacement (TAVR). METHODS: Data were obtained from the Infectious Endocarditis After TAVR International Registry, including patients with definite IE after TAVR from 59 centres in 11 countries. Patients were divided into 2 groups according to microbiologic etiology: non-SA IE vs SA IE. RESULTS: SA IE was identified in 141 patients out of 573 (24.6%), methicillin-sensitive SA in most cases (115/141, 81.6%). Self-expanding valves were more common than balloon-expandable valves in patients presenting with early SA IE. Major bleeding and sepsis complicating TAVR, neurologic symptoms or systemic embolism at admission, and IE with cardiac device involvement (other than the TAVR prosthesis) were associated with SA IE (P < 0.05 for all). Among patients with IE after TAVR, the likelihood of SA IE increased from 19% in the absence of those risk factors to 84.6% if ≥ 3 risk factors were present. In-hospital (47.8% vs 26.9%; P < 0.001) and 2-year (71.5% vs 49.6%; P < 0.001) mortality rates were higher among patients with SA IE vs non-SA IE. Surgery at the time of index SA IE episode was associated with lower mortality at follow-up compared with medical therapy alone (adjusted hazard ratio 0.46, 95% CI 0.22-0.96; P = 0.038). CONCLUSIONS: SA IE represented approximately 25% of IE cases after TAVR and was associated with very high in-hospital and late mortality. The presence of some features determined a higher likelihood of SA IE and could help to orientate early antibiotic regimen selection. Surgery at index SA IE was associated with improved outcomes, and its role should be evaluated in future studies.
Subject(s)
Endocarditis, Bacterial/epidemiology , Heart Valve Prosthesis/adverse effects , Prosthesis-Related Infections/epidemiology , Registries , Staphylococcal Infections/epidemiology , Staphylococcus aureus/isolation & purification , Aged , Aged, 80 and over , Aortic Valve/surgery , Aortic Valve Stenosis/surgery , Endocarditis, Bacterial/microbiology , Female , Follow-Up Studies , Global Health , Heart Valve Prosthesis/microbiology , Hospital Mortality/trends , Humans , Incidence , Male , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Retrospective Studies , Risk Factors , Staphylococcal Infections/diagnosis , Staphylococcal Infections/microbiology , Survival Rate/trends , Transcatheter Aortic Valve Replacement/adverse effectsABSTRACT
BACKGROUND: The optimal treatment of patients developing infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is uncertain. OBJECTIVES: The goal of this study was to investigate the clinical characteristics and outcomes of patients with TAVI-IE treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB). METHODS: Crude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery vs medical therapy on 1-year all-cause mortality in patients with definite TAVI-IE. The study used data from the Infectious Endocarditis after TAVI International Registry. RESULTS: Among 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (HRunadj: 0.85; 95% CI: 0.58-1.25) and 1-year all-cause mortality (HRunadj: 0.88; 95% CI: 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB was also not associated with lower mortality rates for in-hospital mortality (HRadj: 0.92; 95% CI: 0.80-1.05) and 1-year all-cause mortality (HRadj: 0.95; 95% CI: 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock. CONCLUSIONS: In this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patients' characteristics, pathogen, and IE-related complications.
Subject(s)
Endocarditis, Bacterial/drug therapy , Endocarditis, Bacterial/surgery , Prosthesis-Related Infections/drug therapy , Prosthesis-Related Infections/surgery , Staphylococcal Infections/drug therapy , Staphylococcal Infections/surgery , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Cardiac Surgical Procedures , Combined Modality Therapy , Endocarditis, Bacterial/etiology , Female , Humans , Male , Prosthesis-Related Infections/etiology , Staphylococcal Infections/etiology , Transcatheter Aortic Valve Replacement/adverse effectsABSTRACT
BACKGROUND: Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR). OBJECTIVES: The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization. METHODS: Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]). RESULTS: A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47). CONCLUSIONS: Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.
Subject(s)
Endocarditis, Bacterial/complications , Postoperative Complications , Stroke/etiology , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Female , Humans , Incidence , Male , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , Postoperative Complications/therapy , Retrospective Studies , Risk Factors , Stroke/diagnosis , Stroke/epidemiology , Stroke/therapyABSTRACT
BACKGROUND: Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment. OBJECTIVES: To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV). METHODS: Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05. RESULTS: From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm2; post-intervention, 2.18±0.36 cm2; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up. CONCLUSION: The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients' selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).
FUNDAMENTO: A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional. OBJETIVO: Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal). MÉTODOS: Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05. RESULTADOS: Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias, 50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão: A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Mitral Valve Insufficiency , Aged , Aged, 80 and over , Brazil , Cardiac Catheterization , Humans , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Insufficiency/surgery , Prosthesis Design , Treatment OutcomeABSTRACT
INTRODUÇÃO: Implante transcateter de válvula aórtica (TAVI) é o tratamento de escolha para pacientes com estenose aórtica acima de 70 anos de idade com anatomia favorável. No entanto, o impacto das diferenças de entre os sexos e local de realização do procedimento (público versus privado) nos desfechos de TAVI no Brasil permanecem ainda indefinidos. MÉTODOS: O banco de dados RIBAC-NT (Registro de Implante de Bioprotese Aórtica por Cateter) incluiu 3,194 pacientes submetidos a TAVI de 2009 a 2021. Esta análise retrospectiva explorou as características basais, de procedimento e dos desfechosintra-hospitalares, estratificando os pacientes porsexo e local da realização do procedimento. Tendênciastemporaistambém foram avaliadas. RESULTADOS: Foram incluídos 1551 (49%) mulheres e 1.643 (51%) homens. As mulheres eram mais velhas(83 [78-87] vs. 81 [75-85] anos; p<0,01), porém apresentavam menor prevalência de diabetes mellitus (30,2% vs. 36,3%, p<0,01) e doença arterial coronariana (39,0% vs. 52,2%, p<0,01). Com respeito às complicações periprocedimento, as mulheres apresentaram risco 3 vezes maior de sangramento com risco de vida (6,1% vs. 2,4%, p<0,01), bem como maiores taxas de mortalidade de procedimento e intra-hospitalar (4,4% vs. 2,5% e 7,7% vs. 4,5%, respectivamente; p<0,01). A maioria dos procedimentos foi realizada em hospitais privados (66,2%), sendo que pacientes de hospitais públicos apresentaram maistaxas de complicações vasculares maiores(7,2% vs. 3,3%), implante de marcapasso (12,3% vs. 8,9%), mortalidade do procedimento (5,0% vs. 2,7%) e intra-hospitalar (7,5% vs. 5,3%; todos com p<0,01) em relação aos hospitais privados. Ao longo do tempo, as taxas de mortalidade intra-hospitalar diminuíram tanto em hospitais públicos quanto privados, principalmente no grupo de mulheres(p<0,01). CONCLUSÕES: Mulheres apresentaram maiores taxas de mortalidade de procedimento e intra- -hospitalares após TAVI em comparação aos homens, assim como taxas mais altas de sangramento com risco de vida e eventos adversos. Hospitais públicos foram associados a maiores taxas de mortalidade do que centros privados. Nos últimos anos, as mulheres experimentaram reduções mais significativas nas taxas de mortalidade, tanto em hospitais públicos quanto privados.
Subject(s)
Humans , Male , Female , Aged , Transcatheter Aortic Valve ReplacementABSTRACT
INTRODUÇÃO: Não existem estudos comparando os desfechos clínicos do implante de válvula aórtica transcateter (TAVI) com próteses balão-expansíveis (BE) versus auto-expansíveis (AE) de nova geração na realidade brasileira. OBJETIVO: Comparar os resultados clínicos intra-hospitalares de TAVI realizados com próteses BE de nova geração contra próteses AE de nova geração em centros brasileiros participantes do RIBAC-NT. MÉTODOS: Foram utilizados dados de centros ativamente participantes do registro brasileiro de TAVI. Critério de inclusão: todos os procedimentos de TAVI em válvula nativa tricúspide com utilização de próteses de nova geração. Critério de exclusão principal: procedimentos pela via transapical. Os casos foram separados conforme a prótese utilizada em grupo BE (Sapien S3, S3 Ultra e Myval) e AE (Evolut R, Evolut PRO, Acurate Neo, Acurate Neo2 e Portico). Desfecho primário analisado foi morte intra-hospitalar. Desfechos secundários: complicação vascular maior, sangramento maior, sangramento com risco de vida, qualquer acidente vascular encefálico (AVE) e novo implante de marcapasso. RESULTADOS: Ao todo 1703 pacientes de 25 centros foram incluídos na análise, sendo 887 no grupo BE e 819 no grupo AE. A idade média da população foi 80,7±7,2 anos e 48,9% eram mulheres. O grupo AE teve uma maior proporção de pacientes do sexo feminino (53,5% vs. 44,6%, P=<0,001), maior prevalência de doença arterial periférica (16,2% vs. 11%, P=0,002) e de doença pulmonar obstrutiva crônica (16,8% vs. 11,5%, P=0,002), além de Euroscore 2 maior (6,2 vs. 5,5, P=0,03). Tabela 1 estão demonstradas a comparação das características do procedimento entre os grupos. Pacientes do grupo BE realizaram mais procedimentos com anestesia geral, mais por via transfemoral e também com maior proporção de acessos totalmente percutâneos. No grupo AE houve maior necessidade de pré e pós-dilatação e discreta maior incidência de embolização e necessidade de uma segunda prótese, assim como maior incidência de oclusão coronariana. Tabela 2 sumariza o comparativo dos desfechos clínicos. Não houve diferença significativa para a mortalidade intra-hospitalar entre os grupos. Também não se observou diferença entre complicações vasculares, sangramentos, AVE e necessidade de novo marcapasso. Regressão logístico multivariada ajustando para diferenças entre os grupos não indicou diferença de mortalidade entre utilização de prótese BE vs. AE (OR 0,95, P=0,8). Preditores independentes de mortalidade foram sexo feminino (OR 0,49, P=0,009) e Euroscore 2 (OR 1,04, P=0,006). CONCLUSÃO: Em estudo de vida real de pacientes submetidos a TAVI no Brasil, não houve diferença da mortalidade intra-hospitalar entra a utilização de próteses BE de nova geração em comparação a utilização de próteses AE de nova geração.
Subject(s)
Angioplasty, Balloon , Transcatheter Aortic Valve ReplacementABSTRACT
Resumo Fundamento Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento. Objetivos Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil. Métodos Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução. Resultados Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. Conclusões As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica.
Abstract Background Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries. Objectives To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil. Methods Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months. Results Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%. Conclusions CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.
ABSTRACT
OBJECTIVE: The excellent results obtained with sirolimus (rapamicin)-eluting stents for preventing restenosis have motivated the evaluation of other substances with that property. Batimastat is a highly effective metalloproteinase enzyme blocker, with the potential to reduce the degradation of extracellular matrix and to inhibit the migration of smooth muscle cells, with the consequent capacity to control coronary restenosis. METHODS: From October 2001 to April 2002, 34 patients were prospectively selected with de novo lesions in a native coronary artery > 50% and < 100%, which could be treated with stents of 3 to 4 mm in diameter and 18 mm in length. The primary outcome of the study was to assess the occurrence of major cardiovascular events (death of cardiac origin, acute myocardial infarction, and the need for revascularizing the target vessel) by the 30th day and fourth month; the secondary outcome of the study was to assess the rate of coronary restenosis 4 months after implantation and subacute thrombosis by the 30th day. RESULTS: The success rate of the procedure was 97.1%. The primary outcome occurred in 2.9% and 27.2% of the patients by the 30th day and fourth month, respectively. The binary restenosis rate on angiography was 39.3%. No episode of subacute thrombosis occurred. The comparative analysis between groups with and without restenosis showed no significant difference between both, except for late luminal loss, which was greater in G-I. CONCLUSION: Batimastat-eluting stents had a good safety profile; however, they were not effective in controlling coronary restenosis.
Subject(s)
Coronary Artery Disease/therapy , Coronary Restenosis/prevention & control , Phenylalanine/analogs & derivatives , Protease Inhibitors/administration & dosage , Stents , Thiophenes/administration & dosage , Adult , Brazil , Catheterization , Female , Humans , Male , Middle Aged , Phenylalanine/administration & dosage , Pilot Projects , Prospective StudiesABSTRACT
BACKGROUND: High sensitivity C-reactive protein (hs-CRP) is commonly used in clinical practice to assess cardiovascular risk. However, a correlation has not yet been established between the absolute levels of peripheral and central hs-CRP. OBJECTIVE: To assess the correlation between serum hs-CRP levels (mg/L) in a peripheral vein in the left forearm (LFPV) with those in the coronary sinus (CS) of patients with coronary artery disease (CAD) and a diagnosis of stable angina (SA) or unstable angina (UA). METHODS: This observational, descriptive, and cross-sectional study was conducted at the Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, and at the Hospital Beneficência Portuguesa de Sao Paulo, where CAD patients referred to the hospital for coronary angiography were evaluated. RESULTS: Forty patients with CAD (20 with SA and 20 with UA) were included in the study. Blood samples from LFPV and CS were collected before coronary angiography. Furthermore, analysis of the correlation between serum levels of hs-CRP in LFPV versus CS showed a strong linear correlation for both SA (r = 0.993, p < 0.001) and UA (r = 0.976, p < 0.001) and for the entire sample (r = 0.985, p < 0.001). CONCLUSION: Our data suggest a strong linear correlation between hs-CRP levels in LFPV versus CS in patients with SA and UA.
Subject(s)
Angina, Stable/blood , Angina, Unstable/blood , C-Reactive Protein/analysis , Coronary Artery Disease/blood , Coronary Sinus/metabolism , Veins/metabolism , Adult , Aged , Analysis of Variance , Biomarkers/blood , Coronary Angiography , Coronary Sinus/diagnostic imaging , Cross-Sectional Studies , Female , Forearm/blood supply , Humans , Male , Middle Aged , Predictive Value of Tests , Reference Values , Risk FactorsABSTRACT
Resumo Fundamento A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional. Objetivo Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal). Métodos Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05. Resultados Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias, 50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão: A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
Abstract Background Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment. Objectives To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV). Methods Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05. Results From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm2; post-intervention, 2.18±0.36 cm2; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up. Conclusion The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients' selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
Subject(s)
Humans , Aged , Aged, 80 and over , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency/surgery , Prosthesis Design , Brazil , Cardiac Catheterization , Treatment Outcome , Mitral Valve/surgery , Mitral Valve/diagnostic imagingABSTRACT
OBJECTIVE: To assess coronary stent placement in patients with multivessel coronary disease and involvement of the proximal portion of the anterior descending coronary artery. METHODS: We retrospectively analyzed the in-hospital and late evolution of 189 patients with multivessel coronary disease, who underwent percutaneous coronary stent placement. These patients were divided into 2 groups as follows: group I (GI) - 59 patients with involvement of the proximal segment of the anterior descending coronary artery; and group II (GII) - 130 patients without involvement of the proximal segment of the anterior descending coronary artery. RESULTS: No significant difference was observed in the success rate of the procedure (91.5% versus 97.6%, p=0.86), nor in the occurrence of major adverse cardiac events (5.1% versus 1.5%, p=0.38), nor in the occurrence of major vascular complications (1.7% versus 0%, p=0.69) in the in-hospital phase. In the late follow-up, the incidence of major adverse cardiac events (15.4% versus 13.7%, p=0.73) and the need for new revascularization (13.5% versus 10.3%, p=0.71) were similar for both groups. CONCLUSION: The in-hospital and late evolution of patients with multivessel coronary disease with and without involvement of the proximal segment of the anterior descending coronary artery treated with coronary stent placement did not differ. This suggests that this revascularization method is an effective procedure and a valuable option for treating these types of patients.