Reduced-fat Frescal sheep milk cheese with inulin: a first report about technological aspects and sensory evaluation.

This research paper aimed to evaluate the role of inulin as a fat replacer on the quality of Frescal sheep milk cheese. Sheep milk and its derivatives are a promising niche in the dairy industry, mainly due to increasing interest of consumers in diversified products. Three Frescal sheep milk cheese formulations, namely whole milk cheese (WMC), semi-skimmed cheese (SSC) and semi-skimmed cheese with 5 g/100 g inulin (SSCI) were prepared. Their composition was evaluated and the feasibility of using inulin as a fat substitute was investigated. SSC and SSCI were considered 'reduced fat' or 'reduced calorie' products. The addition of inulin to SSCI cheeses yielded textural parameters (firmness, adhesiveness, cohesiveness, and gumminess) with intermediate characteristics between SSC and WMC. All the formulations presented scores higher than 7.6 in sensory analysis. In conclusion, the use of inulin in semi-skimmed sheep cheese allowed the production of cheese with texturizing properties similar to whole milk sheep cheese, enabling the development of a foodstuff with lower caloric content and beneficial characteristics valued by consumers.

Mitral implant of the Inovare transcatheter heart valve in failed surgical bioprostheses: a novel alternative for valve-in-valve procedures.

Objectives: Reoperative procedure for the treatment of a failed mitral bioprosthesis is associated with considerable risk. In some cases, mortality is high and might contraindicate the benefit of the procedure. The minimally invasive valve-in-valve (ViV) transcatheter mitral valve implant offers an alternative less-invasive approach, reducing morbidity and mortality. The objective of this paper was to evaluate the mitral ViV approach using the Braile Inovare prosthesis. Methods: The transcatheter balloon-expandable Braile Inovare prosthesis was used in 12 cases. Procedures were performed in a hybrid operating room, under fluoroscopic and echocardiographic control. Through left minithoracotomy, the prostheses were implanted through the cardiac apex. Serial echocardiographic and clinical examinations were performed. Follow-up varied from 1 to 30 months. Results: A total of 12 transapical mitral ViV procedures were performed. Patients had a mean age of 61.6 ± 9.9 years and 92% were women. Mean logistic EuroSCORE was 20.1%. Successful valve implantation was possible in all cases. In one case, a right lateral thoracotomy was performed for the removal of an embolized prosthesis. There was no operative mortality. Thirty-day mortality was 8.3%. Ejection fraction was preserved after the implant (66.7%; 64.8%; P = 0.3). The mitral gradient showed a significant reduction (11 mmHg; 6 mmHg; P < 0.001). Residual mitral regurgitation was not present. There was no left ventricular outflow tract obstruction. Conclusions: The mitral ViV implant in a failed bioprosthesis is an effective procedure. This possibility might alter prosthesis selection in the future initial surgical prosthesis selection, favouring bioprostheses. Further large trials should explore its safety.

New Braile Inovare transcatheter aortic prosthesis: clinical results and follow-up.

AIMS: Transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients. Diverse prostheses are currently under investigation. The aim of this study was the clinical, safety and efficacy assessment of Braile Inovare Transcatheter Aortic Prosthesis usage. METHODS AND RESULTS: Ninety high-risk or inoperable patients underwent transcatheter aortic valve implantation. The mean logistic EuroSCORE was 39.3%. All patients presented calcified aortic stenosis. The procedures were performed under fluoroscopic and echocardiographic guidance. Prostheses were implanted through the transapical approach under rapid ventricular pacing. Echocardiographic and angiographic controls were included. Implantation was feasible in 87 cases. There was only one case of operative mortality, and 30-day mortality was 13.3%. The median transvalvular aortic gradient was reduced from 44.8±15.3 to 14.1±8.0 mmHg. Left ventricular function improved in the first seven postoperative days. Paravalvular aortic regurgitation was present in 29.7% of cases, mostly trace. One case presented a major vascular complication, and there were two cases of permanent pacemaker implantation. Two cases of major stroke occurred. CONCLUSIONS: Transcatheter aortic valve replacement using the Braile Inovare prosthesis is able to provide encouraging results with significant functional and structural cardiac improvement. It is mandatory to continue follow-up to measure the benefits of this device as well as to improve selection criteria of patients.

Influence of gender on the risk of death and adverse events in patients with acute myocardial infarction undergoing pharmacoinvasive strategy.

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in São Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (<24 h) coronary angiography. A total of 469 patients were evaluated [329 men (70.1%)]. Compared to men, women had more advanced age (60.2 ± 12.3 vs. 56.5 ± 11 years; p = 0.002); lower body mass index (BMI; 25.85 ± 5.07 vs. 27.04 ± 4.26 kg/m2; p = 0.009); higher rates of hypertension (70.7 vs. 59.3%, p = 0.02); higher incidence of hypothyroidism (20.0 vs. 5.5%; p < 0.001), chronic renal failure (10.0 vs. 8.8%; p = 0.68), peripheral vascular disease (PVD; 19.3 vs. 4.3%; p = 0.03), and previous history of stroke (6.4 vs. 1.3%; p = 0.13); and higher thrombolysis in myocardial infarction risk scores (40.0 vs. 23.7%; p < 0.001). The overall in-hospital mortality and MACE rates for women versus men were 9.3 versus 4.9% (p = 0.07) and 12.9 versus 7.9% (p = 0.09), respectively. By multivariate analysis, diabetes (OR 4.15; 95% CI 1.86-9.25; p = 0.001), previous stroke (OR 4.81; 95% CI 1.49-15.52; p = 0.009), and hypothyroidism (OR 3.75; 95% CI 1.44-9.81; p = 0.007), were independent predictors of mortality, whereas diabetes (OR 2.05; 95% CI 1.03-4.06; p = 0.04), PVD (OR 2.38; 95% CI 0.88-6.43; p = 0.08), were predictors of MACE. In STEMI patients undergoing pharmacoinvasive strategy, mortality and MACE rates were twice as high in women; however, this was due to a higher prevalence of risk factors and not gender itself.

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients. .

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment.

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.

Estudo iWONDER (Imaging WhOle vessel coroNary tree with intravascular ultrasounD and iMap in patiEnts with acute miocaRdial infarction): racional e desenho do estudo / iWONDER (imaging whOle vessel coroNary tree with intravascular ultrasounD and iMap in patiEnts with acute miocaRdial infarction)study: rationale and study design

Introdução: O ultrassom intracoronário (USIC) é um método capaz de fornecer medida sensível e reprodutível das dimensões da artéria coronária, da placa aterosclerótica e do lúmen arterial. Avanços em sua tecnologia permitem agora a caracterização da composição e da morfologia das placasateroscleróticas. Embora estudos prévios tenham reportado dados utilizando USIC com análise de radiofrequência, o uso de uma nova modalidade (iMap®, Boston Scientific, Santa Clara, Estados Unidos) de caracterização da placa ateroscleróticaé muito pouco conhecida. Nosso objetivo será analisar as características morfológicas, teciduais e fenotípicas das placas ateroscleróticas consideradas angiograficamente “culpadas” e“não-culpadas” em pacientes submetidos a angiografia coronáriadecorrente de infarto agudo do miocárdio (IAM). Métodos: Estudo prospectivo, transversal, em único centro (Hospital São Paulo – Escola Paulista de Medicina – UniversidadeFederal de São Paulo/UNIFESP, São Paulo, SP, Brasil). Serão selecionados50 pacientes para análise ultrassonográfica, de acordo com os seguintes critérios de inclusão: idade < 75 anos, IAM sem supradesnivelamento do segmento ST ou IAM com supradesnivelamento do segmento ST recente, com ou sem uso de fibrinolítico prévio. Conclusões: O presente estudoobjetivará a caracterização morfológica, tecidual e fenotípica da placa aterosclerótica utilizando uma nova modalidade de imagem ainda pouco estudada em pacientes com IAM.

Tricuspid transcatheter valve-in-valve: an alternative for high-risk patients.

Tricuspid valve disease is not uncommon. Some patients with tricuspid valve disease require tricuspid replacement with bioprosthesis and, over time, may require re-interventions. Transcatheter tricuspid valve-in-valve approach has emerged as an alternative to treat dysfunctional bioprosthesis. In this article, we report a case of a patient with four previous cardiac interventions presenting with tricuspid bioprosthesis dysfunction. The patient was treated with the transcatheter transatrial tricuspid valve-in-valve procedure. The procedure was successful with no residual leakage and a non-significant mean gradient. The patient recovered well and was discharged in 1 week. The procedure is a feasible alternative for high-risk patients. Selection and postoperative care are crucial for the outcome.

Transcatheter aortic valve implantation: results of the current development and implantation of a new Brazilian prosthesis.

OBJECTIVE: Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS: Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS: Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION: The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival.

Implante transcateter de valva aórtica: resultados atuais do desenvolvimento e implante de um nova prótese brasileira / Transcatheter aortic valve implantation: results of the current development and implantation of a new Brazilian prosthesis

OBJETIVO: A troca valvar aórtica é procedimento rotineiro com risco aceitável. Em alguns casos, a mortalidade é elevada, contraindicando o procedimento. O implante minimamente invasivo transcateter de valva aórtica parece ser alternativa, reduzindo a morbimortalidade. A avaliação dos resultados clínicos, segurança e eficácia do procedimento são o objetivo desse estudo. MÉTODOS: Uma prótese transcateter, balão expansível foi utilizada em 33 casos de alto risco. EuroScore médio foi de 39,30% e STS score de 30,28%. Oito pacientes apresentavam disfunção de bioprótese e o restante, estenose aórtica calcificada. Os procedimentos foram realizados em ambiente cirúrgico híbrido, sob controle ecocardiográfico e fluoroscópico. Através de minitoracotomia esquerda, as próteses foram implantadas pelo ápice ventricular, sob estimulação de alta frequência ou choque hemorrágico. Foram realizados controles clínicos e ecocardiográficos. RESULTADOS: A correta liberação da prótese foi possível em 30 casos. Três conversões ocorreram. A mortalidade operatória foi de um caso e a mortalidade em 30 dias, 18,18%. O gradiente médio reduziu de 43,58 para 10,54 mmHg. A fração de ejeção apresentou aumento significativo após o 7º pós-operatório. Insuficiência aórtica residual esteve presente em 30,30% dos pacientes. Ocorreu uma complicação vascular periférica e um caso de bloqueio atrioventricular total. Um paciente apresentou acidente vascular cerebral. A mortalidade em 30 dias foi de 18,18%. CONCLUSÃO: O implante transapical de valva aórtica transcateter é procedimento seguro e com resultados de médio prazo satisfatórios. São necessários estudos de longo prazo com maior poder amostral no intuito de determinar resultado hemodinâmico, qualidade de vida e sobrevida em longo prazo.

OBJECTIVE: Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS: Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS: Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION: The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival.

Transapical aortic valve implantation: results of a Brazilian prosthesis.

OBJECTIVE: The aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such a risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation has been viable, with lower morbidity and mortality. The aim of this study was to develop a national catheter-mounted aortic bioprosthesis for the aortic position implant. METHODS: After animal studies, 14 patients with high EuroSCORE underwent transcatheter aortic valve implantation. Median Logistic EuroSCORE was 43.7%. Four patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. All patients presented symptoms. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis was implanted through the ventricular apex under ventricular pacing or hemorrhagic shock, after aortic valvoplasty. Echocardiograph and angiograph controls were performed, and the patients were referred to ICU. RESULTS: Implant was feasible in 13 cases. There were no intra-operative deaths. Median peak transvalvular aortic gradient reduced to 25.0 mmHg, and left ventricular function improved in the first seven post-operative days. Paravalvular aortic regurgitation was mild and present in 71%. No definitive pacemaker was needed. There was no peripheral vascular complication. Overall mortality was 42%. CONCLUSION: The transapical implantation of cathetermounted bioprosthesis was a feasible procedure. Long term follow-up is mandatory in order to access efficacy and indications.

Implante transapical de valva aórtica: resultados de uma nova prótese brasileira / Transapical aortic valve implantation: results of a brazilian prosthesis

OBJETIVO: A troca valvar aórtica é procedimento rotineiro com risco aceitável. Em alguns casos, a mortalidade é elevada, levando à contraindicação do procedimento, apesar dos sintomas. O implante minimamente invasivo transcateter de valva aórtica parece ser uma alternativa, reduzindo a morbi-mortalidade. O objetivo deste estudo foi o desenvolvimento e implante de nova prótese para implante transcateter. MÉTODOS: Após desenvolvimento em animais, uma prótese transcateter, balão-expansível foi utilizada em 14 casos de alto risco. O EuroSCORE médio foi de 43,7 por cento. Quatro pacientes apresentavam disfunção de biopróteses e o restante, estenose aórtica calcificada. Todos os pacientes eram sintomáticos. Os procedimentos foram realizados em ambiente cirúrgico híbrido, sob controle ecocardiográfico e fluoroscópico. Com o uso de minitoracotomia esquerda, as próteses foram implantadas através do ápice ventricular, sob estimulação ventricular de alta frequência ou choque hemorrágico controlado, após valvoplastia aórtica. Foram realizados controles clínicos e ecocardiográficos seriados. RESULTADOS: A correta liberação da prótese foi possível em 13 casos. Uma conversão ocorreu. Não houve mortalidade operatória. O gradiente de pico médio pós-implante foi de 25 mmHg. A fração de ejeção apresentou aumento significativo após o 7º pós-operatório. Insuficiência aórtica residual não significativa esteve presente em 71 por cento dos casos, nenhuma significativa. Não ocorreu complicação vascular periférica. Não houve necessidade de marcapasso definitivo. Um caso de acidente vascular cerebral ocorreu. A mortalidade geral foi de 42 por cento. CONCLUSÃO: O implante transapical de valva aórtica transcateter é um procedimento possível com esta nova prótese. O comportamento hemodinâmico foi satisfatório. São necessários estudos de longo prazo e com maior poder amostral, no intuito de determinar a real eficácia e indicação do procedimento alternativo.

OBJECTIVE: The aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such a risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation has been viable, with lower morbidity and mortality. The aim of this study was to develop a national catheter-mounted aortic bioprosthesis for the aortic position implant. METHODS: After animal studies, 14 patients with high EuroSCORE underwent transcatheter aortic valve implantation. Median Logistic EuroSCORE was 43.7 percent. Four patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. All patients presented symptoms. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis was implanted through the ventricular apex under ventricular pacing or hemorrhagic shock, after aortic valvoplasty. Echocardiograph and angiograph controls were performed, and the patients were referred to ICU. RESULTS: Implant was feasible in 13 cases. There were no intra-operative deaths. Median peak transvalvular aortic gradient reduced to 25.0 mmHg, and left ventricular function improved in the first seven post-operative days. Paravalvular aortic regurgitation was mild and present in 71 percent. No definitive pacemaker was needed. There was no peripheral vascular complication. Overall mortality was 42 percent. CONCLUSION: The transapical implantation of cathetermounted bioprosthesis was a feasible procedure. Long term follow-up is mandatory in order to access efficacy and indications.

Off-pump transapical balloon-expandable aortic valve endoprosthesis implantation.

OBJECTIVE: The aortic valve replacement is a routine procedure, and involves replacement of the native valve/prosthesis. In most of the patients who undergo such procedure the risk is acceptable, but in some cases, such risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation without cardiopulmonary bypass (CPB) has been shown to be viable, with lower morbidity and mortality. The aim of this study was to develop a catheter-mounted aortic bioprosthesis for implantation without CPB. METHODS: After developing in animals, three patients with high EuroSCORE underwent implantation. Case 1: patients with bioprosthesis dysfunction; Case 2: severe aortic stenosis; Case 3: dysfunction of aortic bioprosthesis. After minithoracotomy and under echocardiographic and fluoroscopic control, a balloon catheter was placed on aortic position and inflated. After, a second balloon with valved endoprosthesis was positioned and released under high ventricular rate. Echocardiographic and angiographic controls were performed and the patients were referred to ICU. RESULTS: In the first case, implantation without CPB was possible with appropriate results. The patient evolved with improvement of ventricular function. After, this patient developed bronchopneumonia, tracheoesophageal fistula and died due to mediastinitis. Autopsy confirmed proper valve positioning and leaflets preservation. The second case showed the device migration after inflation of the balloon, with the need for urgent median sternotomy, CPB and conventional valve replacement. This patient evolved well and was discharged from the ICU on the 14th postoperative day without complications. This patient developed respiratory infection, septic shock and died on the 60th postoperative day. The patient from the third case underwent successful implantation. CONCLUSION: The off-pump transapical implantation of catheter-mounted bioprosthesis was shown to be a feasible procedure. Technical details and learning curve require further discussion.

Implante transapical de endoprótese valvada balão-expansível em posição aórtica sem circulação extracorpórea / Off-pump transapical balloon-expandable aortic valve endoprosthesis implantation

OBJETIVO: A troca valvar aórtica é procedimento rotineiro, envolve substituição da valva nativa/prótese. Na maioria destes pacientes o risco é aceitável, porém, em alguns casos, o risco predito pode justificar contra-indicação. O implante de valva aórtica minimamente invasivo transcateter e sem circulação extracorpórea (CEC) tem se mostrado viável, com menor morbi-mortalidade. O objetivo deste trabalho foi desenvolver bioprótese aórtica, montada em cateter, para implante sem CEC. MÉTODOS: Após desenvolvimento em animais, três pacientes com EuroSCORE elevado foram submetidos ao implante. Caso 1: portador de bioprótese com disfunção; Caso 2: estenose aórtica grave; Caso 3: disfunção de bioprótese aórtica. Após minitoracotomia e sob controle ecocardiográfico e fluoroscópico, cateter-balão foi posicionado sobre posição aórtica e insuflado. Após, segundo cateter-balão, com endoprótese valvada, foi posicionado e liberado sob alta frequência ventricular. Controles angiográficos e ecocardiográficos foram realizados e pacientes encaminhados para UTI. RESULTADOS: No primeiro caso foi possível implante sem CEC com resultados adequados. Evoluiu com melhora da função ventricular. Cursou com broncopneumonia, fístula traqueo-esofágica e óbito por mediastinite. Necropsia confirmou bom posicionamento valvar e preservação dos folhetos. O segundo caso apresentou migração do dispositivo após insuflação do balão, necessidade de esternotomia mediana de urgência, CEC e troca valvar convencional. O paciente evoluiu bem, recebendo alta da UTI 14 dias após procedimento e sem complicações. Cursou com infecção respiratória, choque séptico e óbito no 60º pós-operatório. O terceiro caso foi submetido a implante com sucesso. CONCLUSÃO: O implante de bioprótese transapical montada em cateter sem CEC mostrou ser procedimento factível. Detalhes técnicos e a curva de aprendizado demandam discussão.

OBJECTIVE: The aortic valve replacement is a routine procedure, and involves replacement of the native valve/prosthesis. In most of the patients who undergo such procedure the risk is acceptable, but in some cases, such risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation without cardiopulmonary bypass (CPB) has been shown to be viable, with lower morbidity and mortality. The aim of this study was to develop a catheter-mounted aortic bioprosthesis for implantation without CPB. METHODS: After developing in animals, three patients with high EuroSCORE underwent implantation. Case 1: patients with bioprosthesis dysfunction; Case 2: severe aortic stenosis; Case 3: dysfunction of aortic bioprosthesis. After minithoracotomy and under echocardiographic and fluoroscopic control, a balloon catheter was placed on aortic position and inflated. After, a second balloon with valved endoprosthesis was positioned and released under high ventricular rate. Echocardiographic and angiographic controls were performed and the patients were referred to ICU. RESULTS: In the first case, implantation without CPB was possible with appropriate results. The patient evolved with improvement of ventricular function. After, this patient developed bronchopneumonia, tracheoesophageal fistula and died due to mediastinitis. Autopsy confirmed proper valve positioning and leaflets preservation. The second case showed the device migration after inflation of the balloon, with the need for urgent median sternotomy, CPB and conventional valve replacement. This patient evolved well and was discharged from the ICU on the 14th postoperative day without complications. This patient developed respiratory infection, septic shock and died on the 60th postoperative day. The patient from the third case underwent successful implantation. CONCLUSION: The off-pump transapical implantation of catheter-mounted bioprosthesis was shown to be a feasible ...

Endovascular treatment of type B aortic dissection: the challenge of late success.

BACKGROUND: Thoracic endovascular aortic repair of type B aortic dissection is a therapeutic option for selected patients. However, late outcomes of this intervention are virtually unknown, and the series already published are heterogenous regarding demographics, indications, and type of devices. METHODS: From 1997 to 2004, 106 patients exclusively with classic complicated or symptomatic type B aortic dissection were treated with thoracic endovascular aortic repair, using the same device. We present in-hospital outcomes and late follow-up for 73 patients. RESULTS: Technical success was achieved for 99% of patients, and the clinical success rate was 83% (exclusion of the false lumen, no early death or surgical conversion). In-hospital death occurred in 5 patients, 2 of them after surgical conversion. Three patients required urgent surgical conversion. Neurologic complications occurred in 5 patients (1 case of paraplegia). The average time of follow-up was 35.9 +/- 28.5 months. During follow-up, 37% of patients initially successfully treated reached a failure criterion (new endovascular or surgical intervention in the same aortic segment or death due to aortic or unknown cause). Kaplan-Meier curve showed late survival rates higher than 80% in 2 years. CONCLUSIONS: Patients with both acute and chronic type B aortic dissection had excellent initial results with thoracic endovascular aortic repair. Although event-free survival rates decreased gradually with time owing to the frequent need for new interventions, survival curves were comparable to those for less complex patients undergoing clinical or surgical treatment. Randomized studies are required to establish the actual benefit of this new approach.

Tratamento endovascular nos aneurismas verdadeiros e na dissecção aórtica do tipo B: fase intra-hospitalar, seguimento de médio prazo e uma reflexão sobre seleção de pacientes / Endovascular treatment of aortic aneurysms and type B dissections: in-hospital results, mid-term follow-up and a consideration of patient selection

Introdução: O tratamento endovascular das doenças da aorta é procedimento estabelecido, mas com resultados tardios e diferenças nos resultados entre diferentes grupos demográficos ainda desconhecidos. Método: No período de dezembro de 1996 a dezembro de 2004, 92 pacientes com aneurismas verdadeiros ou úlcera penetrante de aorta em posição torácica (G1) e 130 pacientes com dissecção aórtica do tipo B ou hematoma intramural (G2) foram submetidos a tratamento endovascular primário ou secundário. Na fase hospitalar, sucesso clínico foi considerado como exclusão da lesão, sem morte ou conversão cirúrgica. Falência tardia foi definida pela ocorrência de morte por qualquer causa, conversão cirúrgica ou reintervenção. Resultados: A média de idade do G1 foi de 65 ± 11 anos e de 56 ± 11 anos no G2 (P < 0,0001). Quanto aos dados demográficos, destacou-se a alta frequência de acidente vascular cerebral prévio no G1 (8,7% vs. 0; P = 0,0007). Sucesso clínico do procedimento foi obtido em 71% do G1 e em 84% dos pacientes do G2 (P = 0,02), com maior mortalidade intra-hospitalar no G1 (14% vs. 4,6%; P = 0,01). Complicações neurológicas foram semelhantes (6,5% vs. 3%; P = 0,32), com discreto predomínio de paraplegia no G1 (3,2% vs. 0,8%; P = 0,3). Em seguimento de 33 ± 27 meses, falência tardia foi atingida em 60% (28/47) dos pacientes do G1 e em 43% (31/74) do G2 (P = 0,09). Conclusão: Resultados em pacientes com aneurismas verdadeiros submetidos a tratamento endovascular são discretamente inferiores aos de pacientes com dissecção aórtica do tipo B. Isso pode ser explicado pelas diferenças demográficas entre os grupos e pelas dificuldades técnicas inerentes à anatomia. O conhecimento dessas peculiaridades permite a melhor seleção de pacientes nos quais o procedimento será eficaz em reduzir a mortalidade.

Background: Endovascular treatment of thoracic aortic diseases is a well established procedure although late results and differences among demographic groups are unknown. Method: From December/1996 to December/ 2004, 92 patients with true aneurysms or penetrating ulcers (G1) and 130 patients with type B dissection or intramural hematoma (G2) were submitted to primary or complementary endovascular treatment. Clinical success was defined as sustained technical success without death or surgical conversion. Late failure was defined as death of any cause, surgical conversion or re-intervention. Results: G1 mean age was 65 ± 11 years and 56 ± 11 years in G2 (P < 0.0001). A high frequency of previous stroke was observed in G1 (8.7% vs. 0; P = 0.0007). Clinical success was observed in 71% in G1 and 84% in G2 (P = 0.02) with higher in-hospital death rates in G1 (14% vs. 4.6%; P = 0.01). Neurologic complications were similar (6.5% vs. 3%, respectively; P = 0.32), with a mild prevalence of paraplegia in G1 (3.2% vs. 0.8%; P = 0.3). Late failure rates of 60% were observed in G1 and 43% in G2 (P = 0.09) at 33 ± 27 months of follow-up. Conclusions: Endovascular treatment in patients with true aneurysms may be slightly inferior to those achieved in patients with type B dissection. This might be due to demographic differences between groups and technical difficulties related to aortic anatomy. The knowledge and understanding of these peculiarities enables better patient selection for theprocedure resulting in decreased mortality rates.

Patent ductus arteriosus: endovascular treatment in adult patient.

The patent ductus arteriosus (PDA) is a common type of congenital heart defect and its correction is simple when performed early in life. Surgery is performed using stitches or clips. In adults, the anomaly can lead to pulmonary hypertension and ventricular dysfunction. Surgery in adults is controversial and high-risk. This report describes an alternative endovascular approach in an adult patient.

Tratamento endovascular da persistência do canal arterial em adulto / Patent ductus arteriosus: endovascular treatment in adult patient

A persistência do canal arterial (PCA) é uma anomalia relativamente freqüente e de simples correção. A correção envolve a ligadura do ducto com ou sem a sua secção. A anomalia em adultos pode provocar hipertensão pulmonar persistente e disfunção ventricular. A correção em adultos é controversa e de maior risco. Um caso de correção endovascular com acesso intra-abdominal da PCA em adulto é descrito.

The patent ductus arteriosus (PDA) is a common type of congenital heart defect and its correction is simple when performed early in life. Surgery is performed using stitches or clips. In adults, the anomaly can lead to pulmonary hypertension and ventricular dysfunction. Surgery in adults is controversial and high-risk. This report describes an alternative endovascular approach in an adult patient.