Comparison of self-expanding and balloon-expandable transcatheter aortic valves morphology and association with paravalvular regurgitation: Evaluation using multidetector computed tomography.

OBJECTIVES: Compare final morphology of self-expanding and balloon-expandable prosthesis and association with paravalvular regurgitation (PVR). BACKGROUND: PVR after transcatheter aortic valve replacement (TAVR) remains a frequent complication. A better understanding of the prosthesis geometry may be important to improve selection of the best device for each case and possibly reduce the rates of PVR. METHODS: Retrospective study including patients consecutively submitted to transcatheter aortic valve replacement: August/2007-October/2016. Three months after the procedure a multidetector computed tomography (MDCT) was performed to assess prosthesis geometry: dimensions, eccentricity, and expansion. RESULTS: A total of 147 individuals were included (mean age of 78.8 ± 6.7 and 50.3% males), 57% treated with a self-expanding prosthesis. On the postprocedure MDCT, the self-expanding group had higher eccentricity index (15.0 vs. 7.1%, p < .001) and lower expansion (68.3 vs. 82.8%, p < .001). In that group, the volume of calcium of landing zone had a significant correlation with eccentricity index and under-expansion. Patients with ≥mild PVR presented higher eccentricity (12.6 vs. 7.9%, p < .001) and lower expansion (68 vs. 75%, p = .012). Eccentricity index and landing zone calcium volume were independent predictors of PVR. CONCLUSIONS: Self-expanding prosthesis have greater eccentricity and under-expansion. Calcium burden exerts more influence in the final morphology of that type of valve. Calcification and eccentricity are associated with the development of PVR. These factors should be considered in the selection of the most appropriate type of prosthesis for each scenario.

BNP and NT-proBNP elevation after running--a systematic review.

OBJECTIVE: A systematic review was carried out to study the pattern of BNP and NT-proBNP release after running. METHODS: Data were collected by searching the PubMed, ISI Web of Knowledge and Scopus databases. RESULTS: Fifty-three reports were identified as meeting the pre-specified criteria. Twenty-seven reports, representing 1,034 participants, presented data comparing post-running BNP or NT-proBNP levels with a pre-specified cut-off. Values exceeding the upper reference limit were seen in 22.9% and 35.9% of runners, respectively. CONCLUSION: Studies have shown post-running values exceeding the upper reference limit in up to a third of runners.

Acute coronary syndrome and depression.

INTRODUCTION: Clinical depression is associated with poor compliance in risk reduction recommendations and has been suggested as an independent risk factor for increased postmyocardial infarction morbidity and mortality. AIM: To determine the prevalence of depressive symptoms, their main determinants and their influence on clinical evolution in acute coronary syndromes (ACS) patients. METHODS: We studied depressive symptoms, sociodemographic variables, cardiovascular status and therapeutic procedures in 240 consecutive patients admitted for ACS. Depressive symptoms were assessed using the Beck Depression Inventory (BDI) after clinical stabilization, in patients with more than 4 years' education. RESULTS: The majority of the patients were male (203); their average age was 59.4 +/- 13 yrs; 31.8% were admitted for unstable angina, 33.1% for acute myocardial infarction with ST elevation and 31.8% without ST elevation. Depressive symptoms (BDI > or =10) were present in 100 patients (41.6%). Depressed patients were older (61.1 vs. 58.2 years, p = 0.06) and had a history of previous cardiovascular events /47.5 vs. (34.8% p = 0.05). The proportion of female was higher in the group of patients with BDI > or =10 (24% vs. 9.3%, p = 0.02). Traditional cardiovascular risk factors were not associated with depressive symptoms. There were no statistically significant differences between the depressed and non-depressed patients in admission diagnosis, in-hospital clinical evolution and treatment. There were 35 patients (14.6%) with moderate/severe depression (BDI > or =19), 12 of whom were women (OR = 3.8, p = 0.001); no relation was established between age and previous cardiac events. These scores were less frequent in patients with a higher level of education (OR = 0.28, p = 0.09) and married (OR = 0.31 vs. not married, p = 0.03). Clinical follow-up of 158 patients was achieved (16 +/- 4 months), in patients with BDI > or =19, the presence of cardiovascular symptoms (angina, congestive heart failure) was higher (46% vs. 23%, OR = 2.8, p = 0.03), even after adjustment for age (OR = 2.5; p = 0.06). However, there was no association between the presence of depressive symptoms and readmission and/or fatal events. CONCLUSION: Depression is a common finding after hospital admission for ACS, particularly in women, and is mainly associated with prehospital factors. In our group of patients, the presence of depressive symptoms was closely related to clinical status during follow-up.

Acute coronary syndrome and predictors of quality of life.

INTRODUCTION: Coronary disease in its various forms of presentation is associated with a reduction in the patients' own perception of their quality of life (QoL). QoL is an important measure of effectiveness of treatment; however, the predictors of QoL after admission for acute coronary syndrome (ACS) are not completely clear. AIM: To identify the clinical, demographic and psychosocial characteristics of patients admitted for ACS that were predictive of QoL in clinical follow-up. METHODS: Physical and mental QoL were prospectively evaluated in 278 patients admitted for ACS, using Short Form-36 v2 physical (PCS) and mental (MCS) component summary scales. Based on the median PCS (55) and MCS (56) scores, the population was divided into two groups. Depressive symptoms were assessed using the Beck Depression Inventory. RESULTS: The patients with a better QoL perception were male, young, smokers and had more than 12 years' education. A greater proportion of patients with PCS and MCS below the median score presented prior cardiovascular events and depressive symptoms. A worse physical QoL perception was more common in unmarried, hypertensive and diabetic patients. There was no association between clinical evolution or in-hospital complications and baseline QoL scores. Baseline PCS and MCS were 55 +/- 24 and 55 +/- 27 and at 16 months, 63 +/- 25 and 66 +/- 29. Clinical follow-up was achieved in 181 patients. A worse mental QoL perception at follow-up was related to female gender, baseline MCS < 56 and depressive symptoms. A PCS below median score at follow-up was more frequent in women and in patients with prior cardiovascular events, hypertension, diabetes, dyslipidemia and a lower level of education. Patients with better physical QoL at follow-up were smokers, presented higher baseline PCS and MCS, and had fewer depressive symptoms. Percutaneous myocardial revascularization was associated with a better physical QoL. In a logistic regression model the independent predictors of PCS were: gender, baseline PCS, level of education and prior cardiovascular events. Gender and depressive symptoms were independent predictors of MCS. CONCLUSIONS: In the study population, baseline clinical and psychosocial characteristics were the most important predictors of QoL after ACS. Depression was associated with worse mental QoL. In-hospital evolution and treatment did not appear to strongly affect patients' follow-up perceptions of QoL.

Value of fractional flow reserve in the management of patients with moderate coronary stenosis.

INTRODUCTION: A considerable number of patients present a single intermediate lesion (>40% and <70%) in one coronary artery on coronary angiography, with no clear evidence that the lesion is responsible for the patient's symptoms. Fractional flow reserve is a method of evaluating the functional importance of stenosis, a value of <0.75 indicating hemodynamically significant lesions. The aim of this study is to determine the safety of non-revascularization of an angiographically moderate and hemodynamically non-significant lesion. METHODS: Fractional flow reserve (FFR) was evaluated in 87 patients over a period of 34 months. Retrospective analysis and follow-up were conducted of patients referred for coronary angiography, without acute coronary syndrome, who presented an angiographically moderate lesion of a single epicardial coronary artery with an FFR of 0.75, and in whom intervention was deferred. RESULTS: We found 21 patients with a mean age of 66 years, 66.7% male. All patients presented vascular risk factors, 14 with prior cardiovascular events. Before coronary angiography 7 patients were asymptomatic, 7 had atypical symptoms and 7 presented CCS class 2 angina. Among these patients, 16 performed a non-invasive stress test, which was positive in 11 patients and inconclusive or doubtful in the others. Angiographically most of the lesions were located in the left anterior descending artery (12 patients). In the 19 +/- 12-month follow-up, 16 patients were asymptomatic and the others maintained the same symptoms. There was no change in the amount of antianginal drugs prescribed. No cardiac events occurred. CONCLUSION: FFR is a useful tool when clinical symptoms and non-invasive tests are inconclusive in the presence of moderate stenosis in a coronary artery. In our group of patients, the decision to defer intervention based on an FFR of 0.75 was found to be safe and associated with absence of clinical events.

Transcatheter device occlusion of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance.

BACKGROUND: Transcatheter device occlusion of atrial septal defects is becoming an effective alternative to surgery. In order to avoid the discomfort of transesophageal echocardiography and the need for general anesthesia we started using intracardiac ultrasound (ICUS) to guide device implantation in adult patients. OBJECTIVE: To assess the efficacy and safety of transcatheter closure of atrial septal defect (ASD) and patent foramen ovale (PFO) assisted by ICUS. METHODS: Between April 2001 and November 2002, 27 patients with ASD and four patients with PFO were selected for transcatheter device occlusion. Patient selection was based on previous transesophageal echocardiogram and clinical data. All patients were treated without anesthesia or sedation. The percutaneous occlusion technique was assisted by ICUS and fluoroscopy. Morphological aspects of the defect and measurement of its largest diameter were used to select device diameter. RESULTS: Thirty-one patients were treated (27 with ASD, four with PFO); 21 (68%) were female, mean age was 40.1+/-13.5 years, and mean ASD diameter was 20.1+/-6.4 mm. We implanted ASD Amplatzer occluding devices in all ASD patients, the size being selected by adding 4 to 6 mm to the maximum ASD diameter. The patients with PFO had an Amplatzer PFO occluder. Mean total procedure time was 50.1+/-18.9 minutes and mean fluoroscopy time was 11.7+/-5.9 minutes. All devices were successfully deployed. We had neither complications nor mortality. Follow-up evaluation was performed by transthoracic echocardiography at 24 hours, one, six and 12 months after occlusion. During a mean follow-up period of 8.5+/-7.1 months, all patients were free of symptoms and on transthoracic echocardiographic evaluation at 24 hours all but three patients had complete occlusion (three ASD patients had insignificant residual shunt), with 100% occlusion rate at six months. CONCLUSIONS: Transcatheter occlusion of atrial septal defects can be effectively and safely performed using ICUS to guide device implantation in selected adult patients.

[Myocardial revascularization surgery, depressive symptoms and labeling effect]. / Cirurgia de revascularização miocárdica, sintomas depressivos e efeito rotulação.

INTRODUCTION: The individual awareness of one's own disease, the so called labeling effect, may result in a reduction of one's sense of perceived health. In patients submitted to coronary artery bypass surgery it has been reported that the diagnosis of depression is associated with a higher rate of hospitalization and it's an independent risk factor for cardiac events. The aim of this study was to evaluate the modification of depressive symptoms induced by the information of medical indication for myocardial revascularization surgery. METHODS: We studied the presence of depressive symptoms, socio-demographic variables, cardiovascular status and therapeutic procedures in two groups of consecutive patients admitted for acute coronary syndrome. In the labeled group the BDI-1 was performed after clinical stabilization and the BDI-2 after the information of myocardial revascularization surgery need. In the control group the BDI-1 was answered after clinical stabilization and the BDI-2 48-72 hours later. The Mann-Whitney test was used to compare the difference of depressive symptoms between the groups. RESULTS: Distribution by age, marital status and education level was similar between the two groups. The cardiovascular risk profile was alike. The difference between BDI-1 and BDI-2 was significantly higher in the labeled group (4.6-/+4.2 vs 0.8-/+3.2; p=0.005). There were no significant differences between the final diagnosis (unstable angina in the labeled group 50% vs control group 45.5%; AMI without Q wave 30% vs 27.3%; AMI with Q wave 20% vs 27.3%) and in hospital clinical evolution. CONCLUSION: The individual awareness of the need to coronary bypass surgery was associated with a clinical and statistical significant increase of depressive symptoms. Hence, routine evaluation of depressive symptoms as a part of a preoperative protocol, may allow identification of the patients, who may benefit from therapeutic intervention.