Experiência inicial com o implante percutâneo da Valva Venus-P Valve® no trato de saída nativo pulmonar / Initial experience with Valve Venus-P Valve® percutaneous implantation in the native pulmonary outflow tract

INTRODUÇÃO: O restabelecimento da função valvar pulmonar com implante percutâneo de próteses atualmente é realizado somente nos pacientes portadores de biopróteses, condutos ou homoenxertos posicionados na via de saída do VD. Próteses dedicadas para tratos de saída nativo estão sendo estudadas e implantadas com sucesso em diversos centros mundiais. OBJETIVOS: Apresentar a experiência inicial do implante percutâneo da VENUS-P Valve® em trato de saída nativo pulmonar. Materiais e métodos: A prótese VENUS-P Valve® (Venus Medtech, Shanghai) é um stent autoexpansível com uma valva de pericárdio porcino. Os pacientes são avaliados com ecocardiografia transtorácica, angiotomografia, ressonância magnética e cateterismo cardíaco. São critérios de inclusão a presença de regurgitação pulmonar importante, com volumes diastólicos do VD>130 ml/m2, sem estenoses na VSVD ou ramos pulmonares e trato de saída com no máximo 35 mm de diâmetro após insuflação de cateter-balão medidor. O ecotranstorácico é o método padrão de escolha da prótese. Os pacientes realizaram ecocardiografia transtorácica e avaliação clínica 24 horas e 30 dias após os procedimentos. RESULTADOS: Quatro pacientes (3 homens) foram submetidos ao implante percutâneo das valvas pulmonares. O peso e idade médio foi de 62,2 kg e 25,8 anos. A via de saída teve 30 mm em média e a prótese utilizada apresentou diâmetro médio de 32 mm. Três próteses tinham 25 mm de comprimento e a última 30 mm. Houve sucesso no implante de todos os dispositivos com restabelecimento imediato da função valvar pulmonar. Uma prótese foi considerada em posição mais baixa no trato de saída porém sem interferência em estruturas cardíacas. Ao ecocardiograma de controle todos os dispositivos encontravam-se sem refluxo significativo, com fluxo preservado para as artérias pulmonares bilaterais e sem complicações relacionadas. Não houve complicações ou óbitos relacionados aos procedimentos. CONCLUSÕES: O restabelecimento da função valvar pulmonar em pacientes com trato de saída nativo com o implante percutâneo da VENUS-P Valve® mostrou-se uma excelente alternativa nesta experiência inicial. Os procedimentos são factíveis e seguros. Por tratar-se de experiência inicial, acreditamos que um maior número de implantes e análise dos resultados tardios devem ser realizadas para incorporação definitiva destes dispositivos neste grupo selecionado de pacientes. (AU)

Addressing Hospital Readmissions: Impact of Weekly Review.

BACKGROUND AND OBJECTIVES: The prevention of hospital readmissions has become an area for improvement for most health care organizations. Systematic reviews have been unable to identify a single intervention or bundle of interventions that reliably reduced risk of readmission in a generalizable manner. The aim of this quality improvement project was to examine the readmission rate to a family medicine residency program inpatient service following the implementation of a once per week session that reviewed patients who were readmitted during the prior week. METHODS: The inpatient admissions and readmission to the family medicine inpatient service associated with a large academic health center were used for analysis. The impact of a regularly scheduled multidisciplinary team meeting that reviewed a list of patients was examined. Readmitted patients who were at high risk for readmission were specifically identified. Descriptive statistics were used to characterize and summarize the integral data obtained. The weekly readmission rate was presented using a control chart. RESULTS: The readmission rate for the patients hospitalized after the intervention was 18.4%, compared to the readmission rate prior to the intervention (23.0%). While not a statistically different rate, a significant signal was noted. Demographic differences were noted in the group of patients considered to be high risk for readmission. CONCLUSIONS: Regular rounds of an inpatient team that focuses on readmissions during the previous week reduced hospital readmissions. The impact of these sessions appears to be multifactorial.

Quantification of respiration-induced abdominal tumor motion and its impact on IMRT dose distributions.

PURPOSE: The treatment of moving targets with intensity-modulated radiotherapy may introduce errors in dose delivery. The motion of tumors in the abdomen was studied using quantitative fluoroscopic analysis, and the effect on dose delivery to the target was studied. METHODS AND MATERIALS: Fluoroscopy sessions for 7 patients with pancreas or liver tumors and fiducial clips were recorded, converted to digital format, and analyzed to quantify the characteristics of tumor motion. Intensity-modulated radiotherapy plans were generated for 3 patients (a total of five plans), and the dose-volume histograms for the target volume were compared between plans with and without tumor motion. RESULTS: The average magnitude of the peak-to-peak motion for the 7 patients in the craniocaudal and AP directions was 7.4 mm and 3.8 mm, respectively. The clip motion varied widely, because the maximal clip excursions were about 47% greater than the average clip excursions for each patient. The inclusion of tumor motion did not lead to a significant degradation in the target dose-volume histogram for four of five treatment plans studied. CONCLUSION: The amount of tumor motion for most patients in this study was not large but could, in some instances, significantly degrade the planned target dose-volume histogram. For some patients, therefore, motion mitigation or intervention during treatment may be necessary.