Perspectivas futuras e novos dispositivos transcateter no tratamento da estenose aórtica / Future perspectives and new transcatheter devices in the treatment of aortic tenosis

O implante de prótese valvar aórtica por cateter (TAVI, do inglês transcatheter aortic valve implantation) constitui o tratamento de escolha para pacientes com estenose aórtica considerada inoperável e surge como opção terapêutica à cirurgia em indivíduos com alto e moderado risco operatório. Embora excelentes resultados clínicos sejam obtidos com as próteses primeiramente disponibilizadas para uso clínico, a ocorrência de complicações ­ como acidente vascular cerebral (AVC), regurgitação (leak) paraprotética, distúrbios de condução com implante de marca-passo (MP) e complicações vasculares ­ deve ser prevenida. As novas próteses têm como características primordiais: menor calibre dos instrumentais, implante valvar mais seguro e previsível e a incorporação de características no arcabouço das próteses que reduzam a ocorrência de refluxo paravalva

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for patients with aortic stenosis that is considered inoperable, and has emerged as a treatment option to surgery in individuals with high to moderate surgical risk. Although excellent clinical results have been obtained with the prostheses primarily provided for clinical use, the occurrence of complications ­ such as cerebral stroke, paraprosthetic regurgitation (leak), pacemaker (MP) implant conduction disorders, and vascular complications ­ should be prevented. The main characteristics of the new prostheses are: narrower instruments, a safer, more predictable valve implant, and the incorporation of characteristics in the framework of the prostheses that reduce the occurrence of paravalvular leaks

A single degree of oversize does not fit all valve types.

Moderate valve oversize increases the risk of aortic regurgitation with self-expandable valves, and larger oversizing may be preferable with this valve type. Large oversizing increases the risk of aortic annular rupture in patients treated with balloon-expandable valves and less oversizing appears safer. Anatomical factors may also may influence procedural success and should not be overlooked.

Aortic valvular heart disease in adults

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the second of a series of two that deals with valvular problems in the adults in concise and practical form (11). Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this second and final article we will discuss aortic valve disorders.

Aortic valvular heart disease in adults.

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the second of a series of two that deals with valvular problems in the adults in concise and practical form (11). Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this second and final article we will discuss aortic valve disorders.

Aspectos práticos da abordagem terapêutica de pacientes com disfunção ventricular secundária a valvopatia / Practical aspects of the management of the ventricular dysfuntion related to valvar heart disease

O tratamento das valvopatias deve sempre considerar o dano secundário ao miocárdio. Na indicação cirúrgica, deve-se sempre avaliar judiciosamente a evolução da disfunção ventricular, ocasionada pela remodelação e pela fibrose intersticial. Se não for corrigida em tempo adequado, a valvopatia irá se comportar, no futuro, como verdadeira "miocardiopatia". Após a correção da valvopatia existe o remodelamento reverso, com melhora da função global do coração. O grau desse remodelamento reverso relaciona-se com o prognóstico pós-operatório. O atual arsenal terapêutico dos inibidores da enzima de conversão, betabloqueadores, inibidores da angiotensina II e aldactone desempenha um papel na melhora da remodelação reversa no pós-operatório.

Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology.

OBJECTIVES: This study was designed to assess the feasibility and the long-term results of a symptom-based strategy of aortic valve replacement in a Brazilian population with predominant rheumatic etiology. BACKGROUND: Optimal criteria for valve replacement in aortic regurgitation (AR) are still not entirely clear. The appearance of symptoms is an indication for surgery, but may be associated with myocardial damage. Although cardiac imaging data have provided a safer guide for such decisions, the use of symptom-based surgical indication has not been validated and might conceivably be better in populations with predominant rheumatic etiology and younger age. METHODS: Echocardiography and rest-exercise radionuclide ventriculography were performed in 75 patients with severe AR, age 28 +/- 9 years, over a period of 10 +/- 0.69 years. Thirty-seven patients developed symptoms and underwent aortic valve replacement surgery within six months. Thirty-eight patients remained asymptomatic and were managed medically. RESULTS: Survival was 100% in asymptomatic patients and 82% in symptomatic. Surgical treatment caused marked ventricular remodeling, with ventricular diameter involution and an improvement of rest-exercise ejection fraction percent variation. Multivariate analysis showed that the probability of developing symptoms within 10 years was 58% for a patient with a left ventricular end-diastolic diameter > or =70 mm and 76% for a patient with left ventricular end-systolic (LVESD) > or =50 mm. Logistic regression identified LVESD and age as the most predictive and specific, but not sensitive, indicators of symptom development. CONCLUSIONS: Application of a standardized therapeutic strategy to patients with severe AR and predominant rheumatic etiology resulted in 90.6% survival after 10 years of follow-up.

Manejo de la insuficiencia aórtica

La insuficiencia aórtica es una valvulopatía producida por múltiples entidades que van a desencadenar un proceso fisiopatológico común, el cual finalmente producirá daño miocárdico, aparición de síntomas y desarrollo de mortalidad. El manejo de esta patología va dirigido inicialmente a retardar el desarrollo de daño miocárdico con el uso de vasodilatadores, pero una vez este se ha desarrollado o, el paciente presenta síntomas, se debe realizar el tratamiento definitivo que corresponde al cambio valvular aórtico. El médico debe estar en capacidad de realizar un adecudo seguimiento para detectar precozmente los indicios del desarrollo de disfunción ventricular izquierda con el fin de indicar el reemplazo valvular pero, si dicha disfunción ya se ha desarrollado no se debe contraindicar por este solo motivo el tratamiento quirúrgico

Función ventricular izquierda y reemplazo valvular aortico / Leff ventricular function and aortic valvular surgery

El reemplazo valvular aótico en patología aórtica pura determinada una mejoría inmediata y muy significativa del FE, asi como también del la función. La mortalidad operatoria es muy aceptable y guarda un relación directa con el EF avanzado y con el grado de depresión de la FE del IV. Esta mortalidad puede ser reducida mucho mas si los pacientes son referidos para su intervención mas preocozmente antes que se necuntren en el FE IV y antes de que la función sistólitica del IV medida por la FE este severamente comprometiada como courría en los dos casos que fallecieron.

Tratamiento de la enfermedad valvular mitral y aórtica / Treatment of the valvular mitral and aortic disease

El presente trabajo constituye una revisión y actualización del tratamiento médico e intervención de la estenosis valvular mitral, insuficiencia valvular mitral, estenosis valvular aórtica e insuficiencia valvular aórtica. Se describen las indicaciones y limitaciones de esas modalidades de tratamiento para cada una de las lesiones valvulares referidas. Del mismo modo se precisan las contraindicaciones de las distintas alternativas y se elaboraron tablas con el esquema del tratamiento intervencionista y quirúrgico para cada valvulopatía

Terapeutica medicamentosa nas valvopatias / Medical treatment of valvopathies

Neste artigo, os autores abordam os varios farmacos, tanto de acao cardiovascular quanto sistemica, que sao rotineiramente prescritos ao paciente com valvopatias, inclusive no que se refere a profilaxia da febre reumatica recorrente e da endocardite infecciosa