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.

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.

[Functional assessment of the left atrial appendage with transesophageal echocardiography before and after percutaneous valvotomy in the mitral stenosis]. / Avaliação funcional do apêndice atrial esquerdo ao ecocardiograma transesofágico antes e após valvotomia percutânea na estenose mitral.

OBJECTIVE: To assess the effects of the relief of the mitral stenosis by percutaneous ballon valvotomy in the function of the left atrial appendage. METHODS: Twelve patients with symptomatic mitral stenosis, in sinus rhythm, were studied. They were submitted to the transesophageal echocardiogram before and after effective percutaneous ballon valvotomy. Concerning the left atrial appendage, the peak flow velocities and the respective integral of the anterograde and retrograde flow, in addition to the ejection fraction calculated through the planimetry of the area of that structure, were analyzed at the pulsatile Doppler. RESULTS: There was a significant increase of the anterograde flow velocity of the left atrial appendage after percutaneous ballon valvotomy (pre: mean of 0.30 m/s; post: mean of 0.47 m/s; p<0.05) and their respective integrals. The same happened with the retrograde flow velocity (pre: mean of 0.35 m/s, post: mean of 0.53 m/s; p<0.05). There was a tendency of increase of the ejection fraction of the left atrial appendage after the procedure (pre: mean of 20%, post: mean of 31%; p=0.08). CONCLUSION: The effective opening of the stenosed mitral orifice resulting from the percutaneous ballon valvotomy determined an improvement of the flow pattern of the left atrial appendage, which can potentially contribute for the reduction of the embolic risk.

Revolutionary treatment of aneurysms and dissections of descending aorta: the endovascular approach.

BACKGROUND: Acute aortic dissection is a life-threatening medical condition. It is associated with high morbidity and mortality. Type B dissections are usually managed clinically during the acute phase. Conventional surgery carries high mortality rates due to the presence of serious complications. We herein present treatment of this condition with a less invasive endovascular approach. Other clinical situations such as penetrating ulcers, intramural hematomas, and true aneurysms of descending aorta were similarly treated. METHODS: From December 1996 to March 2002, 191 patients with type B dissections were treated with self-expandable, polyester-covered stents. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematomas, and 4 patients (2.1%) with trauma. Patients with abdominal aneurysms (44) and stents introduced under direct vision through the aortic arch (70) were excluded. The stent graft was delivered in the catheterization laboratory under general anesthesia, with induced hypotension and heparinization. All stents used were made in Brazil (Braile Biomedics, Sao Jose do Rio Preto, SP). RESULTS: The procedure was performed in 191 consecutive cases. The success rate was 91.1% (174/191). Success was defined as occlusion of the thoracic intimal tear, or exclusion of the aneurysm without leaks. Hospital mortality was 10.4% (20/191 patients), due to preoperative comorbidities. Six patients required conversion to surgery. No case of paraplegia was observed. An actuarial survival curve showed 87.4% +/- 29% survival in the late follow-up period. CONCLUSIONS: Stent grafts are an important development in the treatment of descending aortic aneurysms or dissections. This novel approach may replace conventional surgical treatment of these conditions, with earlier intervention and less morbidity.

Self-expandable aortic stent-grafts for treatment of descending aortic dissections.

BACKGROUND: Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality. METHODS: Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension. RESULTS: The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive. CONCLUSIONS: Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.

Endovascular treatment of thoracic disease: patient selection and a proposal of a risk score.

BACKGROUND: Although selection criteria and subgroup analysis are still in the early developmental stages, endovascular treatment of aortic disease has become an alternative to surgery for many patients. METHODS: From November 1996 to November 1999, 49 patients were treated with a self-expandable endoprosthesis at our institution. Most patients had acute aortic dissections. Thirteen of these patients did not follow the anatomic selection protocol. We retrospectively analyzed these patients to compare our numerical risk score (which includes clinical and anatomic criteria) between groups with or without success and between groups that followed the anatomic protocol (P) or did not follow the anatomic protocol (E [exception]). RESULTS: Success rates were similar in groups P and E, although mortality rates were higher in group E. Patients from group E had longer procedures and required multiple stents more frequently. The proposed risk score was able to differentiate between groups with or without success, as well as between groups P and E. CONCLUSIONS: In order to reduce mortality and morbidity rates, careful selection criteria must be followed when treating patients endovascularly. Although it is time-consuming, using objective criteria can help select patients for endovascular treatment. We propose that patients with a risk score higher than 11 should only undergo percutaneous treatment when they have an unacceptably high surgical risk, and even so only after a detailed discussion of the risks.

Treatment of thoracoabdominal aneurysm with self-expandable aortic stent grafts.

A 67-year-old man with a large thoracoabdominal aneurysm was treated utilizing the endovascular approach with multiple stent graft implantation. The proximal thoracic and distal abdominal necks of the aneurysm had favorable anatomy for insertion of multiple endovascular stents. The proximal end was located just distal to the left subclavian artery, and stents were placed to the region of the celiac axis. The infrarenal aneurysm was treated with a bifurcated stent graft to the iliac arteries. The patient has had a smooth post-stent insertion course and remains well after 3 months of follow-up.

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.

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.

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.

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.

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.

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.

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. .

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.

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.