Relationship between Mitral Regurgitation and Transcatheter Aortic Valve Implantation: a Multi-Institutional Follow-up Study. / A Relação entre Regurgitação Mitral e Implante Transcateter de Válvula Aórtica: um Estudo de Acompanhamento Multi-Institucional.

BACKGROUND: Mitral regurgitation (MR) is prevalent in patients undergoing transcatheter aortic valve implantation (TAVI). There are some controversies about the prognostic impact of MR in survival of TAVI patients. OBJECTIVE: To examine the relationship between TAVI and MR in a patient population from the Brazilian TAVI Registry. METHODS: Seven hundred and ninety-five patients from the Brazilian TAVI Registry were divided at baseline, discharge, and follow-up according to their MR grade as follows: absent/mild (AMMR) or moderate/severe (MSMR). They were subsequently regrouped according to their immediate and late changes in MR severity after TAVI as follows: no change, improved, or worsened MR. Predictors and prognostic impact on baseline as well as changes in MR severity were analyzed. Statistical significance was set at p < 0.05. RESULTS: Baseline MSMR was present in 19.3% of patients and was a predictor of increased late mortality. Immediately after TAVI, 47.4 % of cases improved to AMMR, predicted by a higher Society of Thoracic Surgeons score and a higher grade of baseline aortic regurgitation. Upon follow-up, 9.2% of cases of AMMR worsened to MSMR, whereas 36.8% of cases of MSMR improved to AMMR. Lower baseline left ventricular ejection fraction (LVEF) and improvement in LVEF at follow-up were predictors of MR improvement. Progressive worsening of MR upon follow-up was an independent predictor of higher late mortality after TAVI (p = 0.005). CONCLUSIONS: Baseline MSMR predicts late mortality after TAVI. Lower LVEF and improved LVEF at follow-up predict MR improvement after TAVI. Progressive worsening of MR severity at follow-up is an independent predictor of late mortality, which is a rare finding in the literature.

FUNDAMENTO: A regurgitação mitral (RM) é prevalente em pacientes submetidos a implante transcateter de válvula aórtica (TAVI). Há algumas controvérsias sobre o impacto prognóstico da RM na sobrevida de pacientes submetidos a TAVI. OBJETIVO: Examinar a relação entre TAVI e RM em uma população de pacientes do Registro Brasileiro de TAVI. MÉTODOS: Setecentos e noventa e cinco pacientes do Registro Brasileiro de TAVI foram divididos na linha de base, alta e acompanhamento de acordo com o grau da RM da maneira seguinte: ausente/leve (RMAL) ou moderado/grave (RMMG). Eles foram subsequentemente reagrupados de acordo com as mudanças imediatas e tardias na gravidade da RM após TAVI da maneira seguinte: RM sem mudança, melhora ou piora. Foram analisados os preditores e o impacto prognóstico na linha de base, bem como as mudanças na gravidade da RM. A significância estatística foi estabelecida em p < 0,05. RESULTADOS: RMMG basal estava presente em 19,3% dos pacientes e foi um preditor de aumento da mortalidade tardia. Imediatamente após o TAVI, 47,4% dos casos melhoraram para RMAL, previsto por uma pontuação mais alta da Society of Thoracic Surgeons e um grau mais alto de regurgitação aórtica basal. No acompanhamento, 9,2% dos casos de RMAL pioraram para RMMG, enquanto 36,8% dos casos de RMMG melhoraram para RMAL. Fração de ejeção do ventrículo esquerdo (FEVE) mais baixa na linha de base e melhora na FEVE durante o acompanhamento foram preditores de melhora da RM. Piora progressiva da RM no acompanhamento foi um preditor independente de maior mortalidade tardia após TAVI (p = 0,005). CONCLUSÕES: A RMMG na linha de base é um preditor de mortalidade tardia após TAVI. FEVE mais baixa e melhora na FEVE durante o acompanhamento são preditores de melhora da RM após TAVI. A pior progressiva da gravidade da RM durante o acompanhamento é um preditor independente de mortalidade tardia; isto é um achado raro na literatura.

A Relação entre Regurgitação Mitral e Implante Transcateter de Válvula Aórtica: um Estudo de Acompanhamento Multi-Institucional / Relationship between Mitral Regurgitation and Transcatheter Aortic Valve Implantation: a Multi-Institutional Follow-up Study

Resumo Fundamento A regurgitação mitral (RM) é prevalente em pacientes submetidos a implante transcateter de válvula aórtica (TAVI). Há algumas controvérsias sobre o impacto prognóstico da RM na sobrevida de pacientes submetidos a TAVI. Objetivo Examinar a relação entre TAVI e RM em uma população de pacientes do Registro Brasileiro de TAVI. Métodos Setecentos e noventa e cinco pacientes do Registro Brasileiro de TAVI foram divididos na linha de base, alta e acompanhamento de acordo com o grau da RM da maneira seguinte: ausente/leve (RMAL) ou moderado/grave (RMMG). Eles foram subsequentemente reagrupados de acordo com as mudanças imediatas e tardias na gravidade da RM após TAVI da maneira seguinte: RM sem mudança, melhora ou piora. Foram analisados os preditores e o impacto prognóstico na linha de base, bem como as mudanças na gravidade da RM. A significância estatística foi estabelecida em p < 0,05. Resultados RMMG basal estava presente em 19,3% dos pacientes e foi um preditor de aumento da mortalidade tardia. Imediatamente após o TAVI, 47,4% dos casos melhoraram para RMAL, previsto por uma pontuação mais alta da Society of Thoracic Surgeons e um grau mais alto de regurgitação aórtica basal. No acompanhamento, 9,2% dos casos de RMAL pioraram para RMMG, enquanto 36,8% dos casos de RMMG melhoraram para RMAL. Fração de ejeção do ventrículo esquerdo (FEVE) mais baixa na linha de base e melhora na FEVE durante o acompanhamento foram preditores de melhora da RM. Piora progressiva da RM no acompanhamento foi um preditor independente de maior mortalidade tardia após TAVI (p = 0,005). Conclusões A RMMG na linha de base é um preditor de mortalidade tardia após TAVI. FEVE mais baixa e melhora na FEVE durante o acompanhamento são preditores de melhora da RM após TAVI. A pior progressiva da gravidade da RM durante o acompanhamento é um preditor independente de mortalidade tardia; isto é um achado raro na literatura.

Abstract Background Mitral regurgitation (MR) is prevalent in patients undergoing transcatheter aortic valve implantation (TAVI). There are some controversies about the prognostic impact of MR in survival of TAVI patients. Objective To examine the relationship between TAVI and MR in a patient population from the Brazilian TAVI Registry. Methods Seven hundred and ninety-five patients from the Brazilian TAVI Registry were divided at baseline, discharge, and follow-up according to their MR grade as follows: absent/mild (AMMR) or moderate/severe (MSMR). They were subsequently regrouped according to their immediate and late changes in MR severity after TAVI as follows: no change, improved, or worsened MR. Predictors and prognostic impact on baseline as well as changes in MR severity were analyzed. Statistical significance was set at p < 0.05. Results Baseline MSMR was present in 19.3% of patients and was a predictor of increased late mortality. Immediately after TAVI, 47.4 % of cases improved to AMMR, predicted by a higher Society of Thoracic Surgeons score and a higher grade of baseline aortic regurgitation. Upon follow-up, 9.2% of cases of AMMR worsened to MSMR, whereas 36.8% of cases of MSMR improved to AMMR. Lower baseline left ventricular ejection fraction (LVEF) and improvement in LVEF at follow-up were predictors of MR improvement. Progressive worsening of MR upon follow-up was an independent predictor of higher late mortality after TAVI (p = 0.005). Conclusions Baseline MSMR predicts late mortality after TAVI. Lower LVEF and improved LVEF at follow-up predict MR improvement after TAVI. Progressive worsening of MR severity at follow-up is an independent predictor of late mortality, which is a rare finding in the literature.

Tratamento percutâneo da insuficiência mitral por MitraClip®: relato dos dois primeiros procedimentos no Brasil / Percutaneous treatment of mitral regurgitation by MitraClipTM: report on the first two procedures in Brazil

O sistema MitraClip® foi recentemente aprovado para uso clínico no Brasil para o tratamento percutâneo da insuficiência valvar mitral. Esse dispositivo se baseia na cirurgia de Alfieri, criando um orifício duplo pela união central das duas cúspides da valva mitral. Descrevemos aqui os dois primeiros procedimentos realizados em nosso meio utilizando esse dispositivo. Tratam-se de duas pacientes do sexo feminino, consideradas de alto risco cirúrgico pela idade avançada e pela presença de comorbidades, portadoras de insuficiência mitral degenerativa por prolapso/flail associado à rotura de cordoalhas. Nos dois casos, obteve-se redução expressiva da intensidade da regurgitação mitral com a utilização do MitraClip®, demonstrando o grande potencial dessa tecnologia inovadora para o tratamento percutâneo da insuficiência valvar mitral.

The MitraClipTM system has been recently approved for clinical use in Brazil for percutaneous treatment of mitral valve regurgitation. This device is based on the Alfieri surgical procedure, creating a double orifice by bringing together the central segments of the two mitral valve cusps. This report describes the first two procedures performed in Brazil using this device. Two female patients considered to be at high surgical risk due to advanced age and presence of comorbidities were treated, with degenerative mitral regurgitation due to prolapse/flail, associated with chordae tendineae rupture. In both cases, significant mitral regurgitation intensity reduction was obtained using the MitraClipTM, demonstrating the great potential of this innovative technology for the percutaneous treatment of mitral valve regurgitation.

Outcomes and predictors of mortality after transcatheter aortic valve implantation: results of the Brazilian registry.

OBJECTIVE: The study sought to evaluate outcomes and predictors of mortality after transcatheter aortic valve implantation (TAVI). BACKGROUND: TAVI registries can reliably address outcomes and issues that adversely affect results in real-life. METHODS: All endpoints and complications were analyzed according to Valve Academic Research Consortium-2 criteria. RESULTS: Between January 2008 and January 2013, 418 patients underwent TAVI in 18 centers and were included in the Brazilian registry. The transfemoral approach was used in 96.2% of the procedures. The CoreValve and Sapien XT prosthesis were used in 360 (86.1%) and 58 (13.9%) cases, respectively. All-cause mortality at 30 days and 1 year were 9.1 and 21.5%. Chronic obstructive pulmonary disease (COPD) (HR: 3.50), acute kidney injury (AKI) (HR: 3.07), stroke (HR: 2.71) and moderate/severe paravalvular regurgitation (PVR) (HR: 2.76) emerged as independent predictors of overall mortality. COPD (OR: 3.00), major vascular complications (OR: 7.99) and device malpositioning (OR: 6.97) were predictors of early (≤30 days) mortality, while COPD (HR: 2.68), NYHA class III/IV (HR: 3.04), stroke (HR: 4.15), AKI (HR: 2.44) and moderate/severe PVR (HR: 3.20) impacted late (>30 days) mortality. The use of transesophageal echocardiogram (TEE) to monitor the procedure was found to be a protective factor against overall (HR: 0.57) and late (HR: 0.47) mortality. CONCLUSION: This multicenter registry reflected a real-life national TAVI experience. Comorbidities, periprocedural complications and moderate/severe PVR were associated with increased mortality and the use of TEE to monitor the procedure acted as a protective factor.

Outcomes and Predictors of Mortality AfterTranscatheter Aortic Valve Implantation: results of theBrazilian Registry

The study sought to evaluate outcomes and predictors of mortality after transcatheteraortic valve implantation (TAVI). Background: TAVI registries can reliablyaddress outcomes and issues that adversely affect results in real-life. Methods: Allendpoints and complications were analyzed according to Valve Academic ResearchConsortium-2 criteria. Results: Between January 2008 and January 2013, 418 patientsunderwent TAVI in 18 centers and were included in the Brazilian registry. The transfemoralapproach was used in 96.2% of the procedures. The CoreValve and Sapien XTprosthesis were used in 360 (86.1%) and 58 (13.9%) cases, respectively. All-cause mortalityat 30 days and 1 year were 9.1 and 21.5%. Chronic obstructive pulmonary disease(COPD) (HR: 3.50), acute kidney injury (AKI) (HR: 3.07), stroke (HR: 2.71) and moderate/severe paravalvular regurgitation (PVR) (HR: 2.76) emerged as independent predictors ofoverall mortality. COPD (OR: 3.00), major vascular complications (OR: 7.99) and devicemalpositioning (OR: 6.97) were predictors of early ( 30 days) mortality, while COPD (HR:2.68), NYHA class III/IV (HR: 3.04), stroke (HR: 4.15), AKI (HR: 2.44) and moderate/severePVR (HR: 3.20) impacted late (>30 days) mortality. The use of transesophageal echocardiogram(TEE) to monitor the procedure was found to be a protective factor againstoverall (HR: 0.57) and late (HR: 0.47) mortality. Conclusion: This multicenter registryreflected a real-life national TAVI experience. Comorbidities, periprocedural complicationsand moderate/severe PVR were associated with increased mortality and the useof TEE to monitor the procedure acted as a protective factor.

A importância do ecocardiograma transesofágico na captação do coração para transplante cardíaco / The importance of transesophageal echocardiography in heart harvesting for cardiac transplantation / La importancia del ecocardiograma transesofágico en la captación del corazón para el transplante cardíaco

JUSTIFICATIVA E OBJETIVOS: A utilização do ecocardiograma transesofágico na captação para o transplante cardíaco pode orientar a avaliação do coração, pois, se for captado um coração marginal, pode-se colocar em risco o sucesso do transplante cardíaco. RELATO DO CASO: Homem, 30 anos, sofreu um acidente automobilístico que lhe causou um TCE grave, evoluindo para morte cerebral. O paciente encontrava-se entubado, ventilando com auxílio de um respirador, 0,6 de fração inspirada de oxigênio, VC 500 mL, FR 14 irpm, PEEP de 3 mmHg, 99 por cento de saturação periférica de O2 e gasometria normal. Estava também hipovolêmico, com débito urinário de 9.300 mL.dia-1, sódio de 157 meq.L-1, hematócrito de 27 por cento e PAI 90x60 mmHg mantida por infusão de noradrenalina a 0,5 mcg.kg.min-1. Foi otimizado clinicamente e avaliado pelo ecocardiograma transesofágico (ETE), que mostrava cavidades cardíacas de tamanho normal, fração de ejeção de 66 por cento, válvulas cardíacas anatômicas e sem alterações funcionais e forâmen oval íntegro. Imediatamente após a confirmação da viabilidade cardíaca e estabilização clínica, o paciente foi encaminhado ao centro cirúrgico e iniciou-se a captação. O período de isquemia teve a duração de duas horas e o coração foi transplantado com sucesso. CONCLUSÕES: Na maioria dos serviços de transplante cardíaco, a avaliação do coração é realizada de forma subjetiva pelo cirurgião, que muitas vezes não tem o suporte do anestesiologista para otimizar clinicamente o doador. No Instituto Nacional de Cardiologia (INC/MS), o anestesiologista faz parte da equipe de captação para poder realizar o ETE intraoperatório, avaliando de forma objetiva o coração captado. Desta forma, proporcionam-se maiores chances de sucesso do transplante cardíaco com um menor custo para o sistema público de saúde brasileiro.

BACKGROUND AND OBJECTIVES: The use of transesophageal echocardiography (TEE) during heart harvesting for transplantation can guide the heart assessment, as harvesting a marginal heart can jeopardize the cardiac transplantation. CASE REPORT: Male, 30 years old, suffered a car crash that resulted in a severe traumatic brain injury (TBI) that evolved to brain death. The patient was intubated and ventilated with a fraction of inspired oxygen of 0.6, presetting Vt 500 mL, RR 14 bpm, PEEP of 3 mmHg, 99 percent O2 saturation, and normal blood gases. He was also hypovolemic, with urine output of 9,300 mL.day-1, sodium level of 157 mEq.L-1, hematocrit of 27 percent, and BP 90/60 mmHg maintained by infusion of norepinephrine 0.5 mcg.kg.min-1. The patient was clinically optimized and evaluated by TEE, which showed normal size cardiac chambers, ejection fraction 66 percent, anatomical and functional heart valves with no changes, and foramen ovale integrity. Immediately after the confirmation of cardiac viability and clinical stabilization, the patient was taken to the operating room and the harvest began. The ischemic period lasted two hours and the heart was successfully transplanted. CONCLUSIONS: In most heart transplant services, the cardiac assessment is made subjectively by the surgeon who often does not have the anesthesiologist support to clinically optimize the donor. At the Instituto Nacional de Cardiologia (INC/MS), the anesthesiologist is part of the harvesting team in order to perform intraoperative TEE, evaluating objectively the harvested heart. In doing so, it provides greater chances of heart transplantation success with lower costs for the Brazilian public health system.

JUSTIFICATIVA Y OBJETIVOS: La utilización del ecocardiograma transesofágico en la captación para el transplante cardíaco, puede orientar la evaluación del corazón, porque si captamos un corazón marginal podremos poner en riesgo el éxito del transplante cardíaco. RELATO DEL CASO: Hombre de 30 años, que sufrió un accidente automovilístico que le causó un TCE grave, y que falleció por muerte cerebral. El paciente estaba entubado, ventilando con la ayuda de un respirador 0,6 de fracción inspirada de oxígeno, VC 500 ml, FR 14 irpm, PEEP de 3 mmHg, con 99 por ciento de saturación periférica de O2 y gasometría normal. También estaba hipovolémico, con débito urinario de 9.300 mL.día-1, sodio de 157 meq.L-1, hematocrito de 27 por ciento y PAI 90x60 mmHg mantenida por infusión de noradrenalina al 0,5 mcg. kg.min-1. Fue optimizado clínicamente y evaluado por el ETE, que arrojó cavidades cardíacas de tamaño normal, fracción de eyección de un 66 por ciento, válvulas cardíacas anatómicas y sin alteraciones funcionales y foramen oval íntegro. Justo después de la confirmación de la viabilidad cardíaca y de la estabilización clínica, el paciente fue derivado al quirófano y se inició la captación. El período de isquemia tuvo una duración de dos horas y el corazón fue transplantado con éxito. CONCLUSIONES: En la mayoría de los servicios de transplante cardíaco, la evaluación del corazón se hace de forma subjetiva por parte del cirujano, que muchas veces no cuenta con la ayuda del anestesista para optimizar clínicamente el donante. En el Instituto Nacional de Cardiología (INC/MS), el anestesista forma parte del equipo de captación para poder realizar el ETE intraoperatorio, evaluando, de forma objetiva, el corazón captado. Así, tenemos más chances de éxito del transplante cardíaco con un menor coste para el sistema público de sanidad en Brasil.

The importance of transesophageal echocardiography in heart harvesting for cardiac transplantation.

BACKGROUND AND OBJECTIVES: The use of transesophageal echocardiography (TEE) during heart harvesting for transplantation can guide the heart assessment, as harvesting a marginal heart can jeopardize the cardiac transplantation. CASE REPORT: Male, 30 years old, suffered a car crash that resulted in a severe traumatic brain injury (TBI) that evolved to brain death. The patient was intubated and ventilated with a fraction of inspired oxygen of 0.6, presetting Vt 500 mL, RR 14 bpm, PEEP of 3 mm Hg, 99% O(2) saturation, and normal blood gases. He was also hypovolemic, with urine output of 9,300 mL.day(-1), sodium level of 157 mEq.L(-1), hematocrit of 27%, and BP 90/60 mm Hg maintained by infusion of norepinephrine 0.5 mcg.kg.min(-1). The patient was clinically optimized and evaluated by TEE, which showed normal size cardiac chambers, ejection fraction 66%, anatomical and functional heart valves with no changes, and foramen ovale integrity. Immediately after the confirmation of cardiac viability and clinical stabilization, the patient was taken to the operating room and the harvest began. The ischemic period lasted two hours and the heart was successfully transplanted. CONCLUSIONS: In most heart transplant services, the cardiac assessment is made subjectively by the surgeon who often does not have the anesthesiologist support to clinically optimize the donor. At the Instituto Nacional de Cardiologia (INC/MS), the anesthesiologist is part of the harvesting team in order to perform intraoperative TEE, evaluating objectively the harvested heart. In doing so, it provides greater chances of heart transplantation success with lower costs for the Brazilian public health system.