Transcatheter Aortic Valve Implantation and Morbidity and Mortality-Related Factors: a 5-Year Experience in Brazil / Implante de Válvula Aórtica por Cateter e Seus Fatores de Morbimortalidade em Experiência de 5 Anos no Brasil

Abstract Background: Transcatheter aortic valve implantation has become an option for high-surgical-risk patients with aortic valve disease. Objective: To evaluate the in-hospital and one-year follow-up outcomes of transcatheter aortic valve implantation. Methods: Prospective cohort study of transcatheter aortic valve implantation cases from July 2009 to February 2015. Analysis of clinical and procedural variables, correlating them with in-hospital and one-year mortality. Results: A total of 136 patients with a mean age of 83 years (80-87) underwent heart valve implantation; of these, 49% were women, 131 (96.3%) had aortic stenosis, one (0.7%) had aortic regurgitation and four (2.9%) had prosthetic valve dysfunction. NYHA functional class was III or IV in 129 cases (94.8%). The baseline orifice area was 0.67 ± 0.17 cm2 and the mean left ventricular-aortic pressure gradient was 47.3±18.2 mmHg, with an STS score of 9.3% (4.8%-22.3%). The prostheses implanted were self-expanding in 97% of cases. Perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and one-year mortality, 15.5%. Blood transfusion (relative risk of 54; p = 0.0003) and pulmonary arterial hypertension (relative risk of 5.3; p = 0.036) were predictive of in-hospital mortality. Peak C-reactive protein (relative risk of 1.8; p = 0.013) and blood transfusion (relative risk of 8.3; p = 0.0009) were predictive of 1-year mortality. At 30 days, 97% of patients were in NYHA functional class I/II; at one year, this figure reached 96%. Conclusion: Transcatheter aortic valve implantation was performed with a high success rate and low mortality. Blood transfusion was associated with higher in-hospital and one-year mortality. Peak C-reactive protein was associated with one-year mortality.

Resumo Fundamento: O implante de válvula aórtica por cateter tornou-se uma opção para pacientes com doença valvar aórtica de elevado risco cirúrgico. Objetivo: Avaliar os resultados dos seguimentos intra-hospitalar e de até 1 ano do implante de válvula aórtica por cateter. Métodos: Estudo de coorte prospectiva de casos de implante de válvula aórtica por cateter entre julho de 2009 e fevereiro de 2015. Análise de variáveis clínicas e do procedimento, correlacionando com mortalidade intra-hospitalar e de 1 ano. Resultados: Foram submetidos ao implante 136 pacientes, com média de idade de 83 (80-87) anos, sendo 49% mulheres, 131 (96,3%) deles com estenose aórtica, um (0,7%) com insuficiência aórtica e quatro (2,9%) com disfunção de prótese. A classe funcional da NYHA foi III ou IV em 129 (94,8%) casos. A área valvar inicial foi 0,67 ± 0,17 cm2 e o gradiente ventrículo esquerdo-aorta médio de 47,3 ± 18,2 mmHg, com STS de 9,3% (4,8%-22,3%). As próteses implantadas eram autoexpansíveis em 97% dos casos. A mortalidade peroperatória em 1,5% dos casos; em 30 dias em 5,9%; intra-hospitalar em 8,1%; e após 1 ano em 15,5% dos casos. A hemotransfusão (risco relativo de 54; p = 0,0003) e a hipertensão arterial pulmonar (risco relativo de 5,3; p = 0,036) foram preditoras de mortalidade hospitalar; e a proteína C-reativa pico (risco relativo de 1,8; p = 0,013) e a hemotransfusão (risco relativo de 8,3; p = 0,0009) de mortalidade em 1 ano. Aos 30 dias, 97% dos pacientes estavam em classe NYHA I/II e, em 1 ano, o número chegou a 96%. Conclusão: O implante de válvula aórtica por cateter foi realizado com alto índice de sucesso e baixa mortalidade. A hemotransfusão associou-se com maior mortalidade hospitalar e de 1 ano. Proteína C-reativa pico se associou com a mortalidade de 1 ano.

Transcatheter Aortic Valve Implantation and Morbidity and Mortality-Related Factors: a 5-Year Experience in Brazil.

BACKGROUND: Transcatheter aortic valve implantation has become an option for high-surgical-risk patients with aortic valve disease. OBJECTIVE: To evaluate the in-hospital and one-year follow-up outcomes of transcatheter aortic valve implantation. METHODS: Prospective cohort study of transcatheter aortic valve implantation cases from July 2009 to February 2015. Analysis of clinical and procedural variables, correlating them with in-hospital and one-year mortality. RESULTS: A total of 136 patients with a mean age of 83 years (80-87) underwent heart valve implantation; of these, 49% were women, 131 (96.3%) had aortic stenosis, one (0.7%) had aortic regurgitation and four (2.9%) had prosthetic valve dysfunction. NYHA functional class was III or IV in 129 cases (94.8%). The baseline orifice area was 0.67 ± 0.17 cm2 and the mean left ventricular-aortic pressure gradient was 47.3±18.2 mmHg, with an STS score of 9.3% (4.8%-22.3%). The prostheses implanted were self-expanding in 97% of cases. Perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and one-year mortality, 15.5%. Blood transfusion (relative risk of 54; p = 0.0003) and pulmonary arterial hypertension (relative risk of 5.3; p = 0.036) were predictive of in-hospital mortality. Peak C-reactive protein (relative risk of 1.8; p = 0.013) and blood transfusion (relative risk of 8.3; p = 0.0009) were predictive of 1-year mortality. At 30 days, 97% of patients were in NYHA functional class I/II; at one year, this figure reached 96%. CONCLUSION: Transcatheter aortic valve implantation was performed with a high success rate and low mortality. Blood transfusion was associated with higher in-hospital and one-year mortality. Peak C-reactive protein was associated with one-year mortality.

Dissecção coronariana espontânea / Spontaneous coronary artery dissection

Relata-se o caso de paciente feminina, 54 anos,admitida no serviço de emergência com dor torácica isquêmica iniciada em repouso, durante o períodode forte estresse emocional. Apresentou eletrocardiograma (ECG) com alterações de repolarização ventricular, marcadores de necrose miocárdica elevados e coronariografia com aspecto angiográfico de dissecção da artéria coronária descendente anterior (ACDA). Foi tratada conservadoramente com boa evolução clínica hospitalar e no seguimento ambulatorial.

Report on a female (54 years old) admitted to the Emergency Department with ischemic chest pain that began while at rest, during a period of severe emotional stress. An electrocardiogram (ECG) showed changes in ventricular repolarization, high myocardial necrosis markers and coronary angiography indicating anterior descending coronary artery dissection. The patient was treated conservatively, with satisfactory clinical progression in hospital and during out patient follow-up.

Intracoronary stem-cell injection after myocardial infarction: microcirculation sub-study.

BACKGROUND: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route. OBJECTIVE: To compare the cell distribution and retention pattern in the anterograde and retrograde routes. To investigate the role of microvascular obstruction by magnetic resonance imaging in cell retention by cardiac tissue after the injection of bone marrow mononuclear cells (BMMC) in AMI. METHODS: This was a prospective, open label, randomized study. Patients with AMI who presented: (1) successful chemical or mechanical reperfusion within 24 hours of symptom onset and (2) infarction involving more than 10% of the left ventricle (LV) at the myocardial scintigraphy were included in the study. One hundred million BMMC were injected into the infarction-related artery through IAC route, or vein through the IVC route. One percent of the injected cells were labeled with 99mTc-hexamethyl-propylene-amine-oxime (99mTc-HMPAO). Cell distribution was evaluated at 4 and 24 hours after the myocardial scintigraphy injection. Cardiac magnetic resonance imaging was performed before cell injection. RESULTS: Thirty patients were randomized into three groups. There were no serious adverse events related to the procedure. The early and late retention of labeled cells was higher in the IAC group than in IVC group, regardless of the presence of microcirculation obstruction. CONCLUSION: The injection using the retrograde approach was feasible and safe. Cell retention by cardiac tissue was higher using the anterograde approach. More studies are needed to confirm these findings.

Injeção intracoronariana de células tronco após infarto do miocárdio: subestudo da microcirculação / Intracoronary stem-cell injection after myocardial infarction: microcirculation sub-study

FUNDAMENTO: A injeção de células-tronco no contexto do infarto agudo do miocárdio (IAM) tem sido testada quase exclusivamente pela via anterógrada intra-arterial coronariana (IAC). A via retrógrada intravenosa coronariana (IVC) pode ser uma via adicional. OBJETIVO: Comparar o padrão de distribuição e retenção celular nas vias anterógrada e retrógrada. Investigar o papel da obstrução microvascular pela ressonância magnética na retenção de células pelo tecido cardíaco após a injeção de células mononucleares da medula óssea (CMMO) no IAM. MÉTODOS: Estudo prospectivo, aberto, randomizado. Foram incluídos pacientes com IAM que apresentassem: (1) reperfusão mecânica ou química com sucesso em até 24 horas do início dos sintomas e (2) infarto acometendo mais de 10 por cento da área do ventrículo esquerdo (VE) pela cintilografia miocárdica. Cem milhões de CMMO foram injetadas na artéria relacionada ao infarto pela via IAC ou veia, pela via IVC. Um por cento das células injetadas foi marcado com Tc99m-hexametil-propileno-amina-oxima(99mTc-HMPAO). A distribuição das células foi avaliada 4 e 24 horas após a injeção da cintilografia miocárdica. Ressonância magnética cardíaca foi realizada antes da injeção de células. RESULTADOS: Trinta pacientes foram distribuídos aleatoriamente em três grupos. Não houve eventos adversos graves relacionados ao procedimento. A retenção precoce e tardia das células marcadas foi maior no grupo IAC do que no grupo IVC, independentemente da presença de obstrução da microcirculação. CONCLUSÃO: A injeção pela abordagem retrógrada mostrou-se viável e segura. A retenção de células pelo tecido cardíaco foi maior pela via anterógrada. Mais estudos são necessários para confirmar esses achados.

BACKGROUND: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route. OBJECTIVE: To compare the cell distribution and retention pattern in the anterograde and retrograde routes. To investigate the role of microvascular obstruction by magnetic resonance imaging in cell retention by cardiac tissue after the injection of bone marrow mononuclear cells (BMMC) in AMI. METHODS: This was a prospective, open label, randomized study. Patients with AMI who presented: (1) successful chemical or mechanical reperfusion within 24 hours of symptom onset and (2) infarction involving more than 10 percent of the left ventricle (LV) at the myocardial scintigraphy were included in the study. One hundred million BMMC were injected into the infarction-related artery through IAC route, or vein through the IVC route. One percent of the injected cells were labeled with 99mTc-hexamethyl-propylene-amine-oxime (99mTc-HMPAO). Cell distribution was evaluated at 4 and 24 hours after the myocardial scintigraphy injection. Cardiac magnetic resonance imaging was performed before cell injection. RESULTS: Thirty patients were randomized into three groups. There were no serious adverse events related to the procedure. The early and late retention of labeled cells was higher in the IAC group than in IVC group, regardless of the presence of microcirculation obstruction. CONCLUSION: The injection using the retrograde approach was feasible and safe. Cell retention by cardiac tissue was higher using the anterograde approach. More studies are needed to confirm these findings.

Avaliação da função diastólica após o transplante autólogo, intracoronário, de células mononucleares da medula óssea em pacientes submetidos à angioplastia primária / Left ventricle diastolic function after intracoronary autologous bone marrow mononuclear cells transplantation in patients treated primary angioplasty

Objetivo:Avaliar o impacto do transplante autólogo de células mononucleares da medula óssea(TACMMO) sobre a função diastólica(FD) do ventrículo esquerdo, através do ecocardiograma(ECO) COM Doppler Tecidual(DT). Métodos: Estudo randomizado e aberto. Foram incluídos 9 pacientes(7 homens), admitidos no Hospital Pró-Cardíaco com IAM com supradesnivelamento do segmento ST e submetidos a angioplastia primária coronariana com sucesso. Estavam entre o 3° e 5° dias pós-infarto, com disfunção segmentar no ECO e defeito fixo de perfusão maior que 10 por cento na área relacionada ao infarto na cintigrafia de repouso. Foram acompanhados por 3 meses e distribuídos aleatoriamente em 2 grupos: grupo tratado com TACMMO (GT; n igual 6) e grupo controle(GC, n igual 3). O ECO foi arquivado digitalmente e analisado de forma "cega". Foi estudado o fluxo diastólico mitral(FDM), incluindo-se os picosE, A e relação E/A. Ao DT avaliaram-se os picos E' e A' do anel mitral(AM) lateral(E'lat e A'lat) e septal(E's e A's), além das relações E'lat/A'lat, E's/A's entre os picos E e E'lat(E/E'). Resultados: No GT, normalizou-se o FDM em 2 pacientes. No GC piorou o FDM em 1 paciente, sem melhora nos outros 2. Ao DT, ocorreu normalização da FD em 3 pacientes no AM septal, sem melhora no GC. O E'lat diminuiu no GC e aumentou no GT. A E'lat não mudou no GC e aumentou no GT. A E/E' aumentou no GC e diminuiu no GT. Conclusões: Nos pacientes estudados, a FD analisada pelo FDM e pelo DT apresentou melhor evolução no grupo com TACMMO