Septal Ablation with Radiofrequency Catheters Guided by Echocardiography for Treatment of Patients with Obstructive Hypertrophic Cardiomyopathy: Initial Experience. / Ablação Septal com Cateteres e Radiofrequência Guiada pela Ecocardiografia para Tratamento de Pacientes com Cardiomiopatia Hipertrófica Obstrutiva: Experiência Inicial.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) can cause obstruction in the left ventricular outflow tract (LVOT), and be responsible for the onset of limiting symptoms, such as tiredness. When such symptoms are refractory to pharmacological treatment, interventionist alternative therapies can be useful, such as septal ablation through the infusion of alcohol in the coronary artery or through myectomy. Recently, the use of a radiofrequency (RF) catheter for endocardial septal ablation guided by electroanatomic mapping has proven to be efficient, despite the high incidence of complete atrioventricular block. An alternative would be the application of RF at the beginning point of the septal gradient guided by the transesophageal echocardiography (TEE). The echocardiography is an imaging method with high accuracy to determine septal anatomy. OBJECTIVE: To assess the long term effect of septal ablation for the relief of ventricular-arterial gradient, using TEE to help place the catheter in the area of larger septal obstruction. Besides, to assess the effects of ablation on the functional class and echocardiographic parameters. METHODS: Twelve asymptomatic patients, with LVOT obstruction, refractory to pharmacological therapy, underwent endocardial septal ablation with 8mm-tip catheters, whose placement was oriented in the region of larger obstruction, assisted by the TEE. Temperature-controlled and staggered RF applications were performed. After each application, the gradient was reassessed and a new application was performed according to the clinical criterion. The effects of RF applications were assessed both for the gradient at rest and for that provoked by the Valsalva maneuver, and considering the gradient. The differences were significant when p-value was lower than or equal to 0.05. RESULTS: It was possible to observe that the mean reduction of the maximum gradients was from 96.8±34.7 mmHg to 62.7±25.4 mmHg three months after the procedure (p=0.0036). After one year, the mean of maximum gradient was 36.1±23.8 mmHg (p=0.0001). The procedure was well tolerated, without records of complete atrioventricular block nor severe complications. CONCLUSION: The TEE-guided septal ablation was efficient and safe, and the results were maintained during the clinical follow-up period. It is a reasonable option for the interventionist treatment of LVOT obstruction in HCM.

FUNDAMENTOS: A cardiomiopatia hipertrófica (CMH) pode causar obstrução da via de saída do ventrículo esquerdo (VSVE) e ser responsável pelo surgimento de sintomas limitantes, como cansaço físico. Quando tais sintomas são refratários ao tratamento farmacológico, os tratamentos alternativos intervencionistas podem ser úteis, como a ablação septal por meio da infusão de álcool na artéria coronária ou por meio da miectomia cirúrgica. Recentemente, o uso de cateter de radiofrequência (RF) para ablação do septo endocárdico guiado por mapeamento eletroanatômico mostrou-se eficaz apesar da elevada incidência de bloqueio atrioventricular total. Uma alternativa seria a aplicação de radiofrequência no ponto de início do gradiente septal guiada pelo ecocardiograma transesofágico (ETE). O ecocardiograma é um método de imagem com elevada acurácia para determinação da anatomia septal. OBJETIVO: Avaliar o efeito em longo prazo da ablação septal para alívio do gradiente ventrículo-arterial, utilizando o ETE para auxiliar no posicionamento do cateter na área de maior obstrução septal. Avaliar também os efeitos da ablação na classe funcional e parâmetros ecocardiográficos. MÉTODOS: Doze pacientes sintomáticos com obstrução da VSVE, refratários à terapia farmacológica, foram submetidos à ablação endocárdica septal com cateteres com ponta de 8 mm, cujo posicionamento foi orientado na região de maior obstrução com auxílio do ETE. Foram realizadas aplicações de radiofrequência (RF) termocontrolada e escalonadas sobre a área alvo. Após cada aplicação, o gradiente era reavaliado e nova aplicação era realizada de acordo com critério clínico. Foram avaliados os efeitos das aplicações de RF tanto para o gradiente em repouso como para o provocado por meio da manobra de Valsalva, e considerado o gradiente. As diferenças foram significativas quando o valor de p foi menor ou igual a 0,05. RESULTADOS: Observou-se que a redução da média dos gradientes máximos obtidos foi de 96,8±34,7 mmHg para 62,7±25,4 mmHg ao final de três meses do procedimento (p=0,0036). Após um ano, a média dos gradientes máximos obtidos foi de 36,1±23,8 mmHg (p=0,0001). O procedimento foi bem tolerado e não houve registro de bloqueio atrioventricular total e nem complicações graves. CONCLUSÃO: A ablação septal guiada pelo ETE foi eficaz e segura, com resultados mantidos durante o período de seguimento clínico. É uma opção razoável para o tratamento intervencionista da obstrução da VSVE em CMH.

Applicability of Longitudinal Strain of Left Ventricle in Unstable Angina.

BACKGROUND: Unstable angina (UA) is a common cause of hospital admission; risk stratification helps determine strategies for treatment. OBJECTIVE: To determine the applicability of two-dimensional longitudinal strain (SL2D) for the identification of myocardial ischemia in patients with UA. METHODS: Cross-sectional, descriptive, observational study lasting 60 days. The sample consisted of 78 patients, of which fifteen (19.2%) were eligible for longitudinal strain analysis. The value of p < 0.05 was considered significant. RESULTS: The group of ineligible patients presented: a lower proportion of women, a higher prevalence of diabetes mellitus (DM), use of ASA, statins and beta-blockers and larger cavity diameters. The main causes of non-applicability were: presence of previous infarction (56.4%), previous CTA (22.1%), previous MRI (11.5%) or both (16.7%) and the presence of specific electrocardiographic abnormalities (12.8%). SL2D assessment revealed a lower global strain value in those with stenosis greater than 70% in some epicardial coronary arteries (17.1 [3.1] versus 20.2 [6.7], with p = 0.014). Segmental strain assessment showed an association between severe CX and RD lesions with longitudinal strain reduction of lateral and inferior walls basal segments; (14 [5] versus 21 [10], with p = 0.04) and (12.5 [6] versus 19 [8], respectively). CONCLUSION: There was very low SL2D applicability to assess ischemia in the studied population. However, the global strain showed a correlation with the presence of significant coronary lesion, which could be included in the UA diagnostic arsenal in the future.

Applicability of Longitudinal Strain of Left Ventricle in Unstable Angina / Aplicabilidade do Strain Longitudinal do Ventrículo Esquerdo na Angina Instável

Abstract Background: Unstable angina (UA) is a common cause of hospital admission; risk stratification helps determine strategies for treatment. Objective: To determine the applicability of two-dimensional longitudinal strain (SL2D) for the identification of myocardial ischemia in patients with UA. Methods: Cross-sectional, descriptive, observational study lasting 60 days. The sample consisted of 78 patients, of which fifteen (19.2%) were eligible for longitudinal strain analysis. The value of p < 0.05 was considered significant. Results: The group of ineligible patients presented: a lower proportion of women, a higher prevalence of diabetes mellitus (DM), use of ASA, statins and beta-blockers and larger cavity diameters. The main causes of non-applicability were: presence of previous infarction (56.4%), previous CTA (22.1%), previous MRI (11.5%) or both (16.7%) and the presence of specific electrocardiographic abnormalities (12.8%). SL2D assessment revealed a lower global strain value in those with stenosis greater than 70% in some epicardial coronary arteries (17.1 [3.1] versus 20.2 [6.7], with p = 0.014). Segmental strain assessment showed an association between severe CX and RD lesions with longitudinal strain reduction of lateral and inferior walls basal segments; (14 [5] versus 21 [10], with p = 0.04) and (12.5 [6] versus 19 [8], respectively). Conclusion: There was very low SL2D applicability to assess ischemia in the studied population. However, the global strain showed a correlation with the presence of significant coronary lesion, which could be included in the UA diagnostic arsenal in the future.

Resumo Fundamento: A angina instável (AI) é uma causa comum de internação hospitalar, a estratificação de risco ajuda a determinar estratégias para o tratamento. Objetivo: Determinar a aplicabilidade do strain longitudinal bidimensional (SL2D) para identificação de isquemia miocárdica, em pacientes com AI. Métodos: Estudo observacional transversal, descritivo, com duração de 60 dias. A amostra foi composta por 78 pacientes, sendo quinze (19,2%) elegíveis para análise do strain longitudinal. O valor de p < 0.05 foi considerado significativo. Resultados: O grupo dos não elegíveis apresentou: menor proporção de mulheres, maior prevalência de diabetes mellitus (DM), do uso de AAS, estatinas e betabloqueadores e maiores diâmetros cavitários. As principais causas da não aplicabilidade foram: presença de infarto prévio (56,4%), ATC prévia (22,1%), RM prévia (11,5%) ou ambos (16,7%) e presença de alterações eletrocardiográficas específicas (12,8%). A avaliação do SL2D revelou um valor de strain global inferior naqueles com estenose maior que 70% em alguma coronária epicárdica (17,1 [3,1] versus 20,2 [6,7], com p = 0,014). A avaliação do strain segmentar demonstrou associação entre lesão grave nas coronárias CX e CD com redução do strain longitudinal dos segmentos basais das paredes lateral e inferior; (14 [5] versus 21 [10], com p = 0,04) e (12,5 [6] versus 19 [8], com p = 0,026), respectivamente. Conclusão: Houve aplicabilidade muito baixa do SL2D para avaliar isquemia na população estudada. Entretanto, o strain global apresentou correlação com presença de lesão coronária significativa, podendo, futuramente, ser incluído no arsenal diagnóstico da AI.

[Consensus on Perioperative Transesophageal Echocardiography of the Brazilian Society of Anesthesiology and the Department of Cardiovascular Image of the Brazilian Society of Cardiology]. / Consenso sobre Ecocardiografia Transesofágica Perioperatória da Sociedade Brasileira de Anestesiologia e do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia.

Through the Life Cycle of Intraoperative Transesophageal Echocardiography (ETTI/SBA) the Brazilian Society of Anesthesiology, together with the Department of Cardiovascular Image of the Brazilian Society of Cardiology (DIC/SBC), createded a task force to standardize the use of intraoperative transesophageal echocardiography by Brazilian anesthesiologists and echocardiographers based on scientific evidence from the Society of Cardiovascular Anesthesiologists/American Society of Echocardiography (SCA/ASE) and the Brazilian Society of Cardiology.

Progression and Prognosis of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation / Evolução e Prognóstico da Regurgitação Paravalvar Após Implante de Valva Aórtica Transcateter

Abstract Background: The impact of paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) remains uncertain. Objective: To evaluate the impact of PVR on mortality and hospital readmission one year after TAVI. Methods: Between January 2009 and June 2015, a total of 251 patients underwent TAVI with three different prostheses at two cardiology centers. Patients were assessed according to PVR severity after the procedure. Results: PVR was classified as absent/trace or mild in 92.0% (n = 242) and moderate/severe in 7.1% (n = 18). The moderate/severe PVR group showed higher levels of aortic calcification (22% vs. 6%, p = 0.03), higher serum creatinine (1.5 ± 0.7 vs. 1.2 ± 0.4 mg/dL, p = 0.014), lower aortic valve area (0.6 ± 0.1 vs. 0.7 ± 0.2 cm2, p = 0.05), and lower left ventricular ejection fraction (49.2 ± 14.8% vs. 58.8 ± 12.1%, p = 0.009). Patients with moderate/severe PVR had more need for post-dilatation (p = 0.025) and use of larger-diameter balloons (p = 0.043). At one year, all-cause mortality was similar in both groups (16.7% vs. 12%, p = 0.08), as well as rehospitalization (11.1% vs. 7.3%, p = 0.915). PVR grade significantly reduced throughout the first year after the procedure (p < 0.01). The presence of moderate/severe PVR was not associated with higher one-year mortality rates (HR: 0.76, 95% CI: 0.27-2.13, p = 0.864), rehospitalization (HR: 1.08, 95% CI: 0.25-4.69, p=0.915), or composite outcome (HR: 0.77, 95% CI: 0.28-2.13, p = 0.613). Conclusion: In this sample, moderate/severe PVR was not a predictor of long-term mortality or rehospitalization. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Resumo Fundamento: O impacto da regurgitação paravalvular (RPV) após implante de valva aórtica transcateter (TAVI) permanece incerto. Objetivo: Analisar o impacto da RPV na mortalidade e re-hospitalização 1 ano após o TAVI. Métodos: Entre janeiro de 2009 e junho de 2015, 251 pacientes foram submetidos ao TAVI em dois centros cardiológicos com 3 diferentes próteses. Os pacientes foram analisados de acordo com a gravidade da RPV pós-procedimento. Resultados: RPV foi classificada como ausente/mínima ou discreta em 92,0% (n=242) dos pacientes e moderada/grave em 7,1% (n = 18). Os pacientes com RPV moderada/importante apresentaram maior grau de calcificação aórtica (22,0% vs. 6,0%; p = 0,03), creatinina sérica (1,53 ± 0,71 vs. 1,18 ± 0,43 mg/dL; p = 0,01), menor área valvar aórtica (0,61 ± 0,12 vs. 0.69 ± 0,17 cm2; p = 0,05) e menor fração de ejeção do ventrículo esquerdo (49,17±14,79% vs. 58,82±12,14%; p = 0,009). Nos pacientes com RPV moderada/importante a necessidade de pós-dilatação foi maior (p = 0,025) e eventualmente com balão de diâmetro maior (p = 0,04). Ao final de 1 ano, a mortalidade por todas as causas foi similar em ambos os grupos (16,7% vs. 12,0%; p = 0,08), assim como re-hospitalização (11,1% vs. 7,3%; p = 0,91). O grau de RPV ao longo do primeiro ano reduziu progressivamente (p < 0,01). A presença de RPV moderada/importante não foi associada a maiores taxas de mortalidade em 1 ano [RR (risco relativo): 0,76; IC (intervalo de confiança) 95%: 0,27-2,13; p = 0,864)], re-hospitalização (RR: 1,08; IC 95%: 0,25-4,69; p = 0,915) ou desfecho combinado (RR: 0,77; IC 95%: 0,28-2,13; p = 0,61). Conclusões: Nesta amostra, a presença de regurgitação paravalvular moderada/importante não foi um preditor de mortalidade ou reinternação a longo prazo. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Progression and Prognosis of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation.

BACKGROUND: The impact of paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) remains uncertain. OBJECTIVE: To evaluate the impact of PVR on mortality and hospital readmission one year after TAVI. METHODS: Between January 2009 and June 2015, a total of 251 patients underwent TAVI with three different prostheses at two cardiology centers. Patients were assessed according to PVR severity after the procedure. RESULTS: PVR was classified as absent/trace or mild in 92.0% (n = 242) and moderate/severe in 7.1% (n = 18). The moderate/severe PVR group showed higher levels of aortic calcification (22% vs. 6%, p = 0.03), higher serum creatinine (1.5 ± 0.7 vs. 1.2 ± 0.4 mg/dL, p = 0.014), lower aortic valve area (0.6 ± 0.1 vs. 0.7 ± 0.2 cm2, p = 0.05), and lower left ventricular ejection fraction (49.2 ± 14.8% vs. 58.8 ± 12.1%, p = 0.009). Patients with moderate/severe PVR had more need for post-dilatation (p = 0.025) and use of larger-diameter balloons (p = 0.043). At one year, all-cause mortality was similar in both groups (16.7% vs. 12%, p = 0.08), as well as rehospitalization (11.1% vs. 7.3%, p = 0.915). PVR grade significantly reduced throughout the first year after the procedure (p < 0.01). The presence of moderate/severe PVR was not associated with higher one-year mortality rates (HR: 0.76, 95% CI: 0.27-2.13, p = 0.864), rehospitalization (HR: 1.08, 95% CI: 0.25-4.69, p=0.915), or composite outcome (HR: 0.77, 95% CI: 0.28-2.13, p = 0.613). CONCLUSION: In this sample, moderate/severe PVR was not a predictor of long-term mortality or rehospitalization. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0).

Primary Mitral Valve Regurgitation Outcome in Patients With Severe Aortic Stenosis 1 Year After Transcatheter Aortic Valve Implantation: Echocardiographic Evaluation / Evolução da Insuficiência Mitral Primária em Pacientes com Estenose Aórtica Grave 1 Ano Após Implante Transcateter de Valva Aórtica: Avaliação Ecocardiográfica Evolutiva

Abstract Background: Mitral valve regurgitation (MR), present in up to 74% of the patients with severe aortic stenosis (AS), can be a negative prognostic factor when moderate or severe. The outcome of MR after percutaneous transcatheter aortic valve implantation (TAVI) and predictors associated with that outcome have not been well established in the literature. Objective: To assess the outcome of primary MR in patients submitted to TAVI and to identify associated factors. Methods: Observational study of patients with symptomatic severe AS submitted to TAVI from January 2009 to April 2015 at two specialized centers. Echocardiographic outcome was assessed with data collected before and 1 year after TAVI. Results: Of the 91 patients with MR submitted to TAVI and followed up for at least 12 months, 67 (73.6%) had minimum/mild MR before the procedure and 24 (26.4%) had moderate/severe MR. Of those with minimum/mild MR, 62 (92.5%) had no change in the MR grade (p < 0.001), while 5 (7.5%) showed worsening. Of those with moderate/severe MR, 8 (33.3%) maintained the same grade and 16 (66.7%) improved it (p = 0.076). Patients with moderate/severe MR who improved MR grade had lower EuroSCORE II (p = 0.023) and STS morbidity (p = 0.027) scores, as compared to those who maintained the MR grade. Conclusion: MR grades change after TAVI. This study suggests a trend towards improvement in moderate/severe MR after TAVI, which was associated with lower preoperative risk scores.

Resumo Fundamentos: A insuficiência valvar mitral (IM), presente em até 74% dos pacientes com estenose aórtica (EA) grave, pode representar um fator prognóstico negativo quando moderada ou importante. A evolução da IM após implante percutâneo de valva aórtica transcateter (TAVI) e preditores associados a essa evolução não estão bem estabelecidos na literatura. Objetivos: Avaliar a evolução da IM primária em pacientes submetidos ao TAVI e identificar fatores associados a essa evolução. Métodos: Realizou-se um estudo observacional em pacientes com EA grave sintomática, submetidos ao TAVI no período de janeiro de 2009 a abril de 2015 em dois centros especializados. Foram avaliados desfechos ecocardiográficos com dados antes e 1 ano após a intervenção. Resultados: Dos 91 pacientes com IM que realizaram TAVI e tinham acompanhamento de pelo menos 12 meses, 67 (73,6%) apresentavam IM mínima ou discreta antes da realização do procedimento e 24 (26,4%), IM moderada ou grave. Entre os com IM mínima ou discreta, 62 (92,5%) não apresentaram mudança no grau de refluxo (p < 0,001) e 5 (7,5%) tiveram piora. Entre os com IM moderada ou grave, 8 (33,3%) permaneceram na mesma classe e 16 (66,7%) tiveram melhora (p = 0,076). Pacientes com IM moderada ou grave que melhoraram o grau de insuficiência apresentavam menores valores de EuroSCORE II (p = 0,023) e STS morbidade (p = 0,027), quando comparados aos que continuaram na mesma classe. Conclusão: Observou-se mudança significativa no grau de IM após realização de TAVI. Este estudo sugere uma tendência de melhora da IM moderada ou grave após TAVI, o que se associou a escores de risco pré-operatórios menos elevados.

Primary Mitral Valve Regurgitation Outcome in Patients With Severe Aortic Stenosis 1 Year After Transcatheter Aortic Valve Implantation: Echocardiographic Evaluation.

BACKGROUND:: Mitral valve regurgitation (MR), present in up to 74% of the patients with severe aortic stenosis (AS), can be a negative prognostic factor when moderate or severe. The outcome of MR after percutaneous transcatheter aortic valve implantation (TAVI) and predictors associated with that outcome have not been well established in the literature. OBJECTIVE:: To assess the outcome of primary MR in patients submitted to TAVI and to identify associated factors. METHODS:: Observational study of patients with symptomatic severe AS submitted to TAVI from January 2009 to April 2015 at two specialized centers. Echocardiographic outcome was assessed with data collected before and 1 year after TAVI. RESULTS:: Of the 91 patients with MR submitted to TAVI and followed up for at least 12 months, 67 (73.6%) had minimum/mild MR before the procedure and 24 (26.4%) had moderate/severe MR. Of those with minimum/mild MR, 62 (92.5%) had no change in the MR grade (p < 0.001), while 5 (7.5%) showed worsening. Of those with moderate/severe MR, 8 (33.3%) maintained the same grade and 16 (66.7%) improved it (p = 0.076). Patients with moderate/severe MR who improved MR grade had lower EuroSCORE II (p = 0.023) and STS morbidity (p = 0.027) scores, as compared to those who maintained the MR grade. CONCLUSION:: MR grades change after TAVI. This study suggests a trend towards improvement in moderate/severe MR after TAVI, which was associated with lower preoperative risk scores. FUNDAMENTOS:: A insuficiência valvar mitral (IM), presente em até 74% dos pacientes com estenose aórtica (EA) grave, pode representar um fator prognóstico negativo quando moderada ou importante. A evolução da IM após implante percutâneo de valva aórtica transcateter (TAVI) e preditores associados a essa evolução não estão bem estabelecidos na literatura. OBJETIVOS:: Avaliar a evolução da IM primária em pacientes submetidos ao TAVI e identificar fatores associados a essa evolução. MÉTODOS:: Realizou-se um estudo observacional em pacientes com EA grave sintomática, submetidos ao TAVI no período de janeiro de 2009 a abril de 2015 em dois centros especializados. Foram avaliados desfechos ecocardiográficos com dados antes e 1 ano após a intervenção. RESULTADOS:: Dos 91 pacientes com IM que realizaram TAVI e tinham acompanhamento de pelo menos 12 meses, 67 (73,6%) apresentavam IM mínima ou discreta antes da realização do procedimento e 24 (26,4%), IM moderada ou grave. Entre os com IM mínima ou discreta, 62 (92,5%) não apresentaram mudança no grau de refluxo (p < 0,001) e 5 (7,5%) tiveram piora. Entre os com IM moderada ou grave, 8 (33,3%) permaneceram na mesma classe e 16 (66,7%) tiveram melhora (p = 0,076). Pacientes com IM moderada ou grave que melhoraram o grau de insuficiência apresentavam menores valores de EuroSCORE II (p = 0,023) e STS morbidade (p = 0,027), quando comparados aos que continuaram na mesma classe. CONCLUSÃO:: Observou-se mudança significativa no grau de IM após realização de TAVI. Este estudo sugere uma tendência de melhora da IM moderada ou grave após TAVI, o que se associou a escores de risco pré-operatórios menos elevados.

Initial experience of two national centers in transcatheter aortic prosthesis implantation.

BACKGROUND: Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk. OBJECTIVES: To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation. METHODS: From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation. RESULTS: Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly. CONCLUSIONS: Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up.

Experiência Inicial de Dois Centros Nacionais no Implante de Prótese Aórtica Transcateter / Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Fundamento: O implante de prótese aórtica transcateter é uma alternativa efetiva para o tratamento cirúrgico para a correção de estenose aórtica grave em pacientes inoperáveis ou de alto risco cirúrgico. Objetivos: Apresentar os resultados clínicos e ecocardiográficos imediatos e no médio prazo da experiência inicial do implante de prótese aórtica transcateter. Métodos: Entre junho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de prótese aórtica transcateter. Resultados: A idade média foi 82,5 ± 6,5 anos e o Euro SCORE logístico foi 23,6 ± 13,5. O sucesso do procedimento foi de 84%. Após o implante, houve queda do gradiente sistólico médio (pré = 54,7 ± 15,3 mmHg vs. pós = 11,7 ± 4,0 mmHg; p < 0,01). Acidente vascular cerebral ocorreu em 3,6% dos pacientes, complicações vasculares em 19%, e foi necessário o implante de marca-passo definitivo em 13% dos pacientes nos primeiros 30 dias pós-implante. A mortalidade aos 30 dias e no seguimento médio de 16 ± 11 meses foi, respectivamente, de 14 e de 8,9%. A presença de doença pulmonar obstrutiva crônica foi o único preditor de mortalidade em 30 dias e no seguimento. A área valvar aórtica e o gradiente sistólico médio não apresentaram variações significativas durante o seguimento. Conclusões: O implante de prótese aórtica transcateter é um procedimento eficaz e seguro para o tratamento da estenose aórtica em pacientes de alto risco cirúrgico ou inoperáveis. A presença de doença pulmonar obstrutiva crônica foi o único preditor independente de mortalidade identificado, tanto no primeiro mês pós-intervenção quanto no seguimento mais tardio. .

Background: Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk. Objectives: To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation. Methods: From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation. Results: Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly. Conclusions: Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up. .