EuroSCORE II and STS as mortality predictors in patients undergoing TAVI.

INTRODUCTION: the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. OBJECTIVE: to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. METHODS: we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. RESULTS: mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). CONCLUSION: in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

EuroSCORE II and STS as mortality predictors in patients undergoing TAVI / EuroSCORE II e STS como preditores de mortalidade em pacientes submetidos ao TAVI

SUMMARY Introduction: the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. Objective: to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. Methods: we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. Results: mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). Conclusion: in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

RESUMO Introdução: STS e EuroSCORE II são os escores mais utilizados para a estratificação de risco cirúrgico e indicação do implante de válvula aórtica transcateter (TAVI). Entretanto, seu papel como ferramenta para predição de mortalidade em pacientes submetidos ao TAVI ainda é incerto. Objetivo: avaliar o desempenho do EuroSCORE II e STS como preditores de mortalidade intra-hospitalar em 30 dias em pacientes submetidos ao TAVI. Métodos: 59 pacientes com estenose aórtica importante submetidos ao TAVI entre 2010 e 2014. Variáveis foram analisadas por meio do teste t-Student e teste exato de Fisher, e o poder discriminativo foi avaliado pela curva ROC e área sob a curva, acompanhada de intervalo de confiança de 95%. Resultados: a idade média foi de 81±7,3 anos, 42,3% homens. Média do EuroSCORE II foi de 6,07±7,3%, e do STS, 20,7±10,3%. Procedimento transfemoral foi realizado em 88,13%, transapical, em 3,38% e transaórtico, em 8,47%. A mortalidade intra-hospitalar foi 10,1%, e em 30 dias, 13,5%. Os pacientes que evoluíram para óbito apresentavam STS e EuroSCORE II mais elevados que os sobreviventes (33,7±16,7% vs. 18,6±7,3%; p=0,0001 para STS e 13,9±16,1% vs. 4,8±3,8%; p=0,0007 para EuroSCORE II). O STS apresentou AUC de 0,81, e o EuroSCORE II, 0,77. Não houve diferença na capacidade de discriminação pelas curvas ROC (p=0,72). Conclusão: STS e EuroSCORE II foram preditores de mortalidade intra-hospitalar em 30 dias.

Patient Management with Metallic Valve Prosthesis during Pregnancy and Postpartum Period.

Prosthetic thrombosis is a rare complication, but it has high mortality and morbidity. Young women of childbearing age that have prosthetic heart valves are at increased risk of thrombosis during pregnancy due to changes in coagulation factors. Anticoagulation with adequate control and frequent follow-up if pregnancy occurs must be performed in order to prevent complications related to anticoagulant use. Surgery remains the treatment of choice for prosthetic heart valve thrombosis in most clinical conditions. Patients with metallic prosthetic valves have an estimated 5% risk of thrombosis during pregnancy and maternal mortality of 1.5% related to the event. Anticoagulation with vitamin K antagonists during pregnancy is related to varying degrees of complications at each stage of the pregnancy and postpartum periods. Warfarin sodium crosses the placental barrier and when used in the first trimester of pregnancy is a teratogenic agent, causing 1-3% of malformations characterized by fetal warfarin syndrome and also constitutes a major cause of miscarriage in 10-30% of cases. In the third trimester and at delivery, the use of warfarin is associated with maternal and neonatal bleeding in approximately 5 to 15% of cases, respectively. On the other hand, inadequate anticoagulation, including the suspension of the oral anticoagulants aiming at fetal protection, carries a maternal risk of about 25% of metallic prosthesis thrombosis, particularly in the mitral valve. This fact is also due to the state of maternal hypercoagulability with activation of coagulation factors V, VI, VII, IX, X, platelet activity and fibrinogen synthesis, and decrease in protein S levels. The Registry of Pregnancy and Cardiac Disease (ROPAC), assessing 212 pregnant women with metal prosthesis, showed that prosthesis thrombosis occurred in 10 (4.7%) patients and maternal hemorrhage in 23.1%, concluding that only 58% of patients with metallic prosthesis had a complication-free pregnancy.

Abordagem e tratamento da estenose aórtica assintomática / Evaluation and treatment of asymptomatic aortic stenosis

A estenose aórtica degenerativa representa atualmente a valvopatia mais frequente nos países desenvolvidos, com prevalência de 3% a 5% na população acima dos 75 anos de idade. Do ponto de vista epidemiológico, o Brasil apresenta distribuição bimodal da prevalência de estenose aórtica, aco- metendo idosos (etiologia calcifica/degenerativa) e faixas etárias mais jovens, devido, sobretudo, à febre reumática e alterações congênitas (valvas bicúspides). Clinicamente, a estenose aórtica caracteriza-se por sintomas de insufici- ência cardíaca esquerda associados à dor torácica anginosa e síncope. Atualmente, observamos um crescente interesse no manejo da estenose aórtica degenerativa sem sintomas. A análise do perfil dos portadores de estenose aórtica assin- tomáticos revela grande heterogeneidade clínica. Diversos estudos descrevem preditores de mau prognóstico para estes pacientes, os quais devem ser levados em conta na estratificação de risco e definição do momento ideal para a intervenção cirúrgica.

Degenerative aortic stenosis is currently the most common valvular heart disease in developed countries, with prevalence ranging from 3 to 5% in the population above 75 years of age. From an epiderniological perspective, Brazil has a classical bi- modal distribution of the prevalence of aortic stenosis, affecting both elderly (calcification/degenerative etiology) and younger age groups, especially due to rheumatic fever and congenital abnormalities (bicuspid valves). Clinically, aortic stenosis is characterized by symptoms of left heart failure associated with anginal chest pain and syncope. Currently, we could observe an increasing interest in the management of degenerative aor- tic stenosis without symptoms. The analysis of the profile of asymptomatic aortic stenosis shows great clinical heterogeneity. Several studies describe predictors of poor prognosis for these patients, which should be taken into account in risk stratification and definition of the optimal time for surgical intervention.

A expertise clássica da ausculta cardíaca para o diagnóstico do prolapso da valva mitral / The expertise of the classic cardiac auscultation for the diagnosis of mitral valve prolapses

JUSTIFICATIVA E OBJETIVOS: O prolapso da valva mitral possui inúmeras etiologias, é a valvopatia mais frequentee é a causa isolada de insuficiência mitral mais comum. Possui uma clínica muito diversificada e ultimamente tem-se buscado critérios diagnósticos mais rígidos para padronizar a sua identificação.Este estudo teve como objetivo oferecer as bases da ausculta cardíaca, determinar sua importância e aprofundar nos critérios diagnósticos, na clínica e prognóstico do prolapso da valva mitral. CONTEÚDO: A invenção do estetoscópio por René Hyacinthe Laënec em 1816 mudou o cenário da medicina. Para uma boa prática médica é necessário se ter um bom conhecimento das bases da ausculta cardíaca, que se baseia na utilização correta do estetoscópio, sistematização do exame físico cardíaco e na correta caracterização dos sons auscultados. São frequentes as novas tecnologias que auxiliam no diagnóstico das valvopatias, porém os exames complementares possuem suas limitações. A ausculta cardíaca está perdendo espaço diante dos novos equipamentos,encarecendo a prática médica. CONCLUSÃO: Mesmo com as novas tecnologias, além da correta utilização dos exames complementares, é de extrema importância a realização da anamnese e exame físico para o diagnóstico do prolapso da valva mitral, se fazendo necessário o uso dos critérios diagnósticos vigentes.

BACKGROUND AND OBJECTIVES: The mitral valve prolapsed have numerous etiologies and it is the most common valvular disease and the most common isolated cause of mitral insufficiency. Besides having a very diverse clinical, more stringent diagnostic criteria have been sought in order to reduce overdiagnosis that they had prior to these criteria. This aims to give the basics of cardiac auscultation, and deepen their importance in diagnostic criteria, the clinical course and prognosis of mitral valve prolapse. CONTENTS: The invention of the stethoscope by René Laënec Hyacinthe in 1816 changed completely the medicine scenario. For a good medical practice it is necessary to have a good knowledge of the bases of cardiac auscultation, which is focused on the correct use of the stethoscope, systematic physical examination and on the correct characterization of auscultation of heart sounds. Increasingly there are technologies that help the physicianin the diagnosis of valvular heart disease, and even studies showing that all these tests have their limitations, the cardiac auscultation has been put aside in exchange for these new technologies, making the medical practice more and more expensive. CONCLUSION: Even with new technologies, besides the correct use of supplementary tests, it is extremely important the anamnesis and physical examination for the diagnosis of mitral valve prolapse, if necessary making use of current diagnostic criteria.