Encuesta multinacional y transversal sobre las controversias del reemplazo de la raíz aórtica con conservación valvular / Multinational and Cross-Sectional Survey on Valve-Sparing Aortic Replacement Controversies

RESUMEN Introducción : El reemplazo de la raíz aórtica con conservación valvular (valve-sparing aortic root replacement, VSAR) se ha consolidado como un procedimiento eficaz para el tratamiento del aneurisma de la raíz aórtica, el síndrome de Marfan, la válvula bicúspide y la disección aórtica. Sin embargo, es necesario llegar a una opinión unánime sobre los aspectos clave del VSAR. Material y métodos : Se realizó una revisión bibliográfica de los debates y controversias más frecuentes del VSAR. A partir de esta información se elaboró una encuesta en línea que se envió a cirujanos con experiencia comprobada en VSAR para conocer su opinión sobre los factores relacionados con los pacientes, los aspectos técnicos, la ecocardiografía, la investigación, la formación y el futuro del VSAR. Resultados : Veinte cirujanos completaron la encuesta. Según 14 de cada 20 encuestados, la fracción de eyección grave se consideró una contraindicación para el llevar a cabo este procedimiento. El límite del diámetro del anillo aórtico para la remodelación fue heterogéneo entre los participantes. Todos ellos consideraron que el VSAR es un procedimiento seguro para los pacientes con síndrome de Marfan y válvula bicúspide. En el caso de disección de tipo A, 11 de cada 20 prefirieron este procedimiento solo para los pacientes jóvenes. En lo que respecta al tamaño del injerto, la altura del triángulo intervalvar (8/20) y el diámetro sinotubular (7/20) fueron los más frecuentes. Los cirujanos informaron una tasa de fracaso del 7% en la conversión al procedimiento de Bentall, y un cambio de estrategia intraoperatoria del 26%. No se consideró que un abordaje mínimamente invasivo mejorara los resultados. La mayoría de los cirujanos coincidieron en que el VSAR lo deben realizar cirujanos con mucha experiencia. Conclusiones : El VSAR ha sido aceptado como una opción terapéutica para el aneurisma de la raíz aórtica, y, aunque todavía no es posible llegar a un consenso definitivo, se presenta la valiosa experiencia de los cirujanos más destacados en este campo.

ABSTRACT Background : The valve-sparing aortic root replacement (VSAR) has been established as a successful procedure for aortic root aneurysms, Marfan's syndrome, bicuspid valves, and aortic dissections. However, there is a need for a consensus opinion regarding key aspects of VSAR. Methods : A literature review was performed regarding the most frequent debates and controversies in VSAR. An online survey was developed based on this information, and sent to surgeons with known expertise in VSAR regarding their opinion on patient-related factors, technical aspects, echocardiography, research, training, and the future of VSAR. Results : Twenty surgeons completed the survey. The reduction of left ventricular ejection fraction was considered a contra indication to VSAR when severe by 14/20 surveyed. The aortic annulus diameter cutoff point for the remodeling was heterogenous among participants. All of them felt that VSAR is safe for the Marfan´s syndrome population and bicuspid valves. For type A dissections, 11/20 preferred this procedure only in young patients. Regarding to graft sizing, the height of the interleaflet triangle (8/20) and the sino-tubular diameter (7/20) were the more frequent considered parameters. Surgeons reported a 7% of failure rate, leading to conversion to Bentall surgery, and a 26% change of strategy intraoperatively. A minimally invasive approach was not considered to improve results. Most of the surgeons agreed that VSAR should be performed by high-experienced surgeons. Conclusions : The VSAR has been accepted as a treatment option for the aortic root´s aneurysms, and even though there is still not possible to reach a final consensus, a valuable experience from the most relevant surgeons in the field is presented.

Health-related quality of life of patients submitted to correction of heart valve diseases / Qualidade de vida relacionada à saúde de pacientes submetidos à correção de valvopatias

INTRODUCTION: The measurement of the health-related quality of life construct can reveal the positive repercussions on the lives of patients undergoing corrective valve procedures, as well as revealing points that prevent new surgical approaches. OBJECTIVE: To identify the health-related quality of life of valvular heart disease in the perioperative period of conventional valve surgery. METHODS: This is an integrative literature review. Searches were performed independently in four databases using controlled and uncontrolled descriptors. Eligibility criteria were: original articles that addressed the assessment of the health-related quality of life of valvular patients undergoing valve repair and/or valve prosthesis implantation; in Portuguese, English, and Spanish; with a time frame for convenience between 2015 and 2019. RESULTS: 14 studies comprised the final review sample, despite being studies conducted in different countries and with different designs, it was possible to verify the improvement in health-related quality of life when evaluated through generic instruments in valvular patients after valve surgery. However, in studies in which the assessment of the construct occurred through specific instruments, the existence of factors that can interfere with the quality of life of patients undergoing valve implantation was revealed. CONCLUSION: It was noticed that there was generally an improvement in health-related quality of life after the surgical intervention.

INTRODUÇÃO: A mensuração do constructo qualidade de vida relacionada à saúde pode revelar as repercussões positivas na vida dos pacientes submetidos a procedimentos valvares corretivos, bem como revelar pontos que para prevenção de novas abordagens cirúrgica. OBJETIVO: Identificar a qualidade de vida relacionada à saúde de valvopatas no perioperatório de intervenção cirúrgica valvar convencional. MÉTODO: Trata-se de uma revisão integrativa da literatura. As buscas foram realizadas de forma independente, em quatro bases de dados por meio de descritores controlados e não controlados. Os critérios de elegibilidade foram: artigos originais que abordassem a avaliação da qualidade de vida relacionada à saúde de valvopatas submetidos à plastia valvar e/ou implante de prótese valvar; nos idiomas português, inglês e espanhol; com recorte temporal por conveniência entre 2015 e 2019. RESULTADOS: 14 estudos compuseram a amostra final da revisão, apesar de serem estudos realizados em distintos países e com diferentes delineamentos foi possível verificar a melhora da qualidade de vida relacionada à saúde quando avaliada por meio de instrumentos genéricos em valvopatas após a intervenção cirúrgica valvar. Todavia, nos estudos em que a avaliação do constructo ocorreu por meio de instrumentos específicos, foi revelada a existência de fatores que podem interferir na qualidade de vida dos pacientes submetidos aos implantes valvares. CONCLUSÃO: Percebeu-se que geralmente houve melhora da qualidade de vida relacionada à saúde após a intervenção cirúrgica.

Outra falha de bioprótese valvar cirúrgica: uma segunda solução transcateter valve-in-valve / Another failed surgical bioprosthetic valve: a second transcatheter valve-in-valve solution

A substituição transcateter valve-in-valve da valva mitral surgiu recentemente como uma alternativa cada vez mais utilizada nos pacientes de alto risco cirúrgico. O presente caso relata uma substituição de valva mitral transcateter valve-in-valve, por via transeptal, como tratamento da degeneração de uma bioprótese mitral cirúrgica e regurgitação grave, em paciente de 86 anos já submetido a uma substituição transcateter valve-in-valve aórtica, há 6 anos. Este caso enfatiza o papel crucial de uma avaliação pré-operatória cuidadosa, com uso de diferentes modalidades de exames de imagem, para planejamento do procedimento, em paciente com maior risco de obstrução da via de saída do ventrículo esquerdo, devido a um procedimento valve-in-valve aórtico prévio.

Transcatheter mitral valve-in-valve replacement has recently emerged as an increasingly common alternative for high surgical risk patients. We report a case of a successful transseptal transcatheter mitral valve-in-valve replacement for the treatment of a bioprosthetic mitral valve degeneration and severe regurgitation, in an 86-year-old patient who had undergone transcatheter aortic valve-in-valve procedure 6 years ago. This case emphasizes the crucial role of a careful preoperative assessment using multimodality imaging to plan the procedure, in a patient with higher risk of left ventricular outflow obstruction due to the previous transcatheter aortic valve-in- valve procedure.

Reparo valvar percutâneo borda a borda da insuficiência mitral após implante transcateter de válvula aórtica / Percutaneous edge-to-edge mitral regurgitation valve repair after transcatheter aortic valve implantation

A insuficiência mitral moderada a grave é observada em 17 a 35% dos pacientes submetidos a implante transcateter de válvula aórtica. Estudo que reporta a insuficiência mitral pós- realização de implante transcateter de válvula aórtica por estenose aórtica demonstra que 50% dos pacientes com refluxo moderado a grave apresentaram melhora da regurgitação, e 8,7% evidenciam piora do quadro. Nesses pacientes com piora, houve aumento da mortalidade. Essa progressão sugere que condutas convencionais, baseadas em otimização medicamentosa, podem não ser capazes de prevenir quadros negativos. Relatamos um caso sobre a evolução da insuficiência mitral após implante transcateter de válvula aórtica e o uso do MitraClip® como alternativa de tratamento e benefícios.

Moderate to severe mitral regurgitation is observed in 17 to 35% of patients undergoing transcatheter aortic valve implantation. A study reporting mitral regurgitation after transcatheter aortic valve implantation due to aortic stenosis demontrated 50% of patients with moderate to severe reflux showed improvement in regurgitation, and 8.7% showed worsening of the condition, which led to increased mortality. This progression suggested conventional management, based on medication optimization, may not be able to prevent poor outcomes. We report a case on the clinical course of a patient with mitral regurgitation after transcatheter aortic valve implantation, and the use of MitraClip® as an alternative treatment and its benefits.

Emergências Relacionadas à Doença Valvar Cardíaca: Uma Revisão Abrangente da Abordagem Inicial no Departamento de Emergência / Valvular Heart Disease Emergencies: A Comprehensive Review Focusing on the Initial Approach in the Emergency Department

Resumo A doença valvar cardíaca é um problema de saúde crescente no mundo. Os pacientes com valvopatia podem apresentar diversas emergências cardiovasculares. O manejo desses pacientes é um desafio no departamento de emergência, principalmente quando a condição cardíaca prévia é desconhecida. Atualmente, recomendações específicas para o manejo inicial são limitadas. A presente revisão integrativa propõe uma abordagem baseada em evidência, de três etapas, desde a suspeita de valvopatia à beira do leito até o tratamento inicial das emergências. A primeira etapa é a suspeita de uma condição valvar subjacente com base nos sinais e sintomas. A segunda etapa consiste na tentativa de confirmação diagnóstica e avaliação da gravidade da valvopatia com exames complementares. Finalmente, a terceira etapa aborda as opções diagnósticas e terapêuticas para insuficiência cardíaca, fibrilação atrial, trombose valvar, febre reumática aguda, e endocardite infecciosa. Além disso, apresentamos imagens de exames complementares e tabelas para apoio aos médicos.

Abstract Valvular heart disease (VHD) is an increasing health problem worldwide. Patients with VHD may experience several cardiovascular-related emergencies. The management of these patients is a challenge in the emergency department, especially when the previous heart condition is unknown. Specific recommendations for the initial management are currently poor. This integrative review proposes an evidence-based three-step approach from bedside VHD suspicion to the initial treatment of the emergencies. The first step is the suspicion of underlying valvular condition based on signs and symptoms. The second step comprises the attempt to confirm the diagnosis and assessment of VHD severity with complementary tests. Finally, the third step addresses the diagnosis and treatment options for heart failure, atrial fibrillation, valvular thrombosis, acute rheumatic fever, and infective endocarditis. In addition, several images of complementary tests and summary tables are provided for physician support.

Safety, Effectiveness, and Hemodynamic Performance of the Bovine Pericardium Organic Valvular Bioprosthesis

ABSTRACT Objective: To assess actual data on the safety, effectiveness, and hemodynamic performance of Bovine Pericardium Organic Valvular Bioprosthesis (BVP). Methods: The BIOPRO Trial is an observational, retrospective, non-comparative, non-randomized, and multicenter study. We collected data from 903 patients with symptomatic, moderate, or severe valve disease who underwent BVP implants in the timeframe from 2013 to 2020 at three Brazilian institutions. Death, valve-related adverse events (AEs), functional recovery, and hemodynamic performance were evaluated at the hospital, at discharge, and six months and one year later. Primary analysis compared late (> 30 days after implant) linearized rates of valve-related AEs, such as thromboembolism, valve thrombosis, major hemorrhage, major paravalvular leak, and endocarditis, following objective performance criteria (OPC). Analysis was performed to include at least 400 valve-years for each valve position (aortic and mitral) for complete comparisons to OPC. Kaplan-Meier survival and major adverse cardiovascular and cerebrovascular event analyses were also performed. Results: This retrospective study analyzed follow-up data collected from 903 patients (834.2 late patient-years) who have undergone surgery for 455 isolated aortic valve replacement (50.4%), 382 isolated mitral valve replacement (42.3%), and 66 combined valve replacement or other intervention (7.3%). The linearized rates of valve-related AEs were < 2 × OPC. One-year survival rates were 95.1% and 92.7% for aortic and mitral valve replacement, respectively. This study demonstrated an improvement in the New York Heart Association classification from baseline and hemodynamic performance within an expected range. Conclusion: According to this analysis, BVP meets world standards for safety and clinical efficacy.

Características de las intervenciones en cirugía cardiaca en un hospital general de Lima, Perú

Objetivos: Describir las características epidemiológicas, clínicas y quirúrgicas de las intervenciones en cirugía cardiaca en un hospital general de Lima - Perú. Material y métodos: Estudio observacional, descriptivo y retrospectivo. La población estudiada fue de pacientes operados de cirugía cardiaca electivamente entre 2009 y 2019 en el Hospital María Auxiliadora. Se incluyeron 41 pacientes. Resultados: La mediana de edad fue 44 (rango intercuartílico: 26,5 - 58,5) años y el sexo femenino fue 75,6%. Los principales antecedentes patológicos fueron: arritmia cardiaca (56,1%), hipertensión arterial (36,6%), accidente cerebrovascular (24,4%) y diabetes mellitus tipo 2 (14,6%). La cirugía realizada con más frecuencia fue el reemplazo valvular con válvula protésica (39%), principalmente de la válvula mitral; en segundo lugar, cirugías correctivas de defecto de tabique (26,8%), principalmente comunicación interauricular. Las complicaciones postoperatorias más frecuentes fueron: neumonía intrahospitalaria (14%), arritmia cardiaca nueva (14%) y síndrome de bajo gasto cardiaco (12%). Las medias de los tiempos de circulación extracorpórea y tiempo de pinzamiento aórtico fueron de 97,5 ± 39,0 min y 68,1 ± 35,5 min, respectivamente. La media de la estancia en unidad de cuidados intensivos fue 4,1 ± 2,9 días y la media de la estancia hospitalaria fue 22,3 ± 10,9 días. No hubo mortalidad hasta 30 días del postoperatorio. Conclusiones: Los pacientes intervenidos fueron principalmente adultos jóvenes y a predominio del sexo femenino, con comorbilidades cardiovasculares importantes. La principal cirugía realizada fue el reemplazo de válvula cardiaca y las demás características clínico-quirúrgicas fueron similares a lo reportado en Latinoamérica.

SUMMARY Objective: To describe the clinical, epidemiological, and surgical characteristics of cardiac interventions in a general hospital in Lima, Peru. Methods : a retrospective and descriptive study was carried-out at Hospital Maria Auxiliadora from 2009-2019, 41 patients were included. Results: Median age was 44 years (IQR: 26.5-58.5); 75.6% were females. Underlying conditions were arrhythmias (56.1%); blood hypertension (36.6%); strokes (24.4%) and diabetes (14.6%). Valve replacement using prosthetic valves was the most frequent procedure (39%), mainly mitral valve replacement; followed by surgical repairs of septum abnormalities, mainly atrial defects (26.8%). The most common post-operative complications were nosocomial pneumonia (14%), new arrhythmia (14%) and low output syndrome (12%). Mean times of extracorporeal circulation and aortic clamping were 97.5 ± 39.0 min and 68.1 ± 35.5 min, respectively. Mean ICU and hospital stays were 4.1 ± 2.9 and 22.3 ± 10.9 days, respectively. No fatalities were recorded 30-days after the procedures. Conclusions: Young, predominantly female adults with significant comorbidities were surgically intervened in this setting. The main surgical procedure was valve replacement, no differences with reports from Latin America were found.

Prótesis Starr-Edwards vigente y funcional por más de 40 años / Starr-Edwards prosthesis current and functional for more than 40 years

INTRODUCCIÓN. Las enfermedades valvulares cardíacas han sido un foco de estudio y de evolución continua, pues existen grupos de pacientes seleccionados en quienes el cambio valvular es parte de su terapéutica. En 1960 surgió el modelo de prótesis de válvula en forma de esfera enjaulada de Albert Starr y Lowell Edwards. El diseño fue perfeccionándose y es usado hasta la actualidad ya que muestra resultados clínicos aceptables. OBJETIVO. Describir el caso de un paciente portador, de uno de los primeros prototipos de prótesis valvular cardiaca metálica Starr-Edwards vigente y funcional por más de 40 años. CASO CLÍNICO. Paciente masculino con prótesis Starr-Edwards en posición aórtica, quien hasta la fecha lleva más de 40 años de uso, mantiene la clase funcional II de la New York Heart Association, realizando anticoagulación con Warfarina así como controles estrictos del índice internacional normalizado. DISCUSIÓN. Es primordial la evaluación y seguimiento de portadores de prótesis valvular para analizar anifestaciones clínicas (disnea) y hallazgos en los exámenes de laboratorio o de imagen (ecografía) para el control clínico y hemodinámica del paciente, con la intención de contemplar circunstancias que podrían determinar la nueva intervención valvular. CONCLUSIONES. Las válvulas metálicas, en particular las del tipo de prótesis de Starr-Edwards presentan alto riesgo trombótico por lo que es recomendable mantener anticoagulación plena evitando valores de índice internacional normalizado muy elevados que podrían crear escenarios de eventos hemorrágicos. Varios pacientes portadores de una de las prótesis más antiguas como es el modelo la prótesis Starr-Edwards, pueden llegar a tener una mejor supervivencia y resultados clínicos aceptables.

INTRODUCTION. Cardiac valve diseases have been a focus of study and continuous evolution, since there are selected groups of patients in whom valve replacement is part of their therapy. In 1960, the caged sphere valve prosthesis model of Albert Starr and Lowell Edwards was developed. The design was refined and is still used today because it shows acceptable clinical results. OBJECTIVE. To describe the case of a patient with one of the first prototypes of Starr- Edwards metallic heart valve prosthesis, which has been in use and functional for more than 40 years. CLINICAL CASE. Male patient with Starr-Edwards prosthesis in aortic position, who to date has been used for more than 40 years, maintains functional class II of the New York Heart Association, performing anticoagulation with Warfarin as well as strict controls of the international normalized index. DISCUSSION. The evaluation and follow-up of valve prosthesis carriers is essential to analyze clinical manifestations (dyspnea) and findings in laboratory or imaging tests (ultrasound) for the clinical and hemodynamic control of the patient, with the intention of contemplating circumstances that could determine the new valve intervention. CONCLUSIONS. Metallic valves, particularly those of the Starr-Edwards prosthesis type, present a high thrombotic risk and it is therefore advisable to maintain full anticoagulation, avoiding very high values of the international normalized index that could create scenarios of hemorrhagic events. Several patients carrying one of the older prostheses, such as the Starr-Edwards prosthesis model, may have better survival and acceptable clinical results.

Resultados del implante percutáneo de válvula aórtica (TAVI). Experiencia después de la primera década desde la introducción de la técnica / Transcatheter aortic-valve implantation. A ten years clinical experience

BACKGROUND: Transcatheter aortic-valve implantation (TAVI) was introduced in 2002 and the first implants in our country were performed in 2010. AIM: To review the TAVI experience in our hospital, considering the technology improvements and gained experience throughout this period. MATERIAL AND METHODS: All patients undergoing TAVI in our center were included. Results and complications were adjudicated according to the Valve Academic Research Consortium-2 (VARC-2) criteria. Patients were divided in 3 groups, according to procedural year: Period 1: 2010-2015 (n = 35); Period 2: 2016-2018 (n = 35); Period 3: 2019-2021 (n = 41). Mortality up to one year after the procedure was recorded. RESULTS: Between 2010 and 2021, 111 TAVI procedures were performed. The mean age of patients was 82 years and 47% were women. Risk scores for in-hospital mortality were STS 6.7%, EUROSCORE II 8.0% and ACC/STS TAVR Score 4.9%. The trans-femoral route was used in 88% and a balloon-expandable valve was chosen in 82% of patients. A successful implant was achieved in 96%, with an in-hospital mortality of 1.8%. Mortality at 30 days and 1-year were 2.7 and 9.0%, respectively. During period 3, 100% of implants were successful, with no in-hospital mortality, less vascular complications (p < 0.01), less stroke (p = 0.04), less severe paravalvular leak (p = 0.01) and significantly lower rate of acute complications (p < 0.01). CONCLUSIONS: TAVI achieves excellent results. With greater experience and better available technologies, these results are even more favorable.

Aspectos Clínicos e de Sobrevida de Pacientes pós Implante de Valva Mecânica, com Ênfase em Trombose de Prótese Valvar / Clinical Features and Survival Analysis of Patients after Mechanical Heart Valve Replacement, with an Emphasis on Prosthetic Valve Thrombosis

Resumo Fundamento As doenças oro-valvares têm prevalência mundial expressiva, e a cirurgia de troca valvar melhorou a sobrevida dos pacientes. Objetivos Descrever aspectos clínico-laboratoriais dos pacientes submetidos a implante valvar mecânico e determinar a incidência de trombose de próteses valvares (TPV). Métodos Estudo de coorte retrospectivo com seguimento até nove anos; as variáveis de estudo foram buscadas em prontuários físicos e eletrônicos. Os cálculos foram realizados pelo programa Jamovi 1.2.2.; p<0,05 foi considerado estatisticamente significante. Foram construídas curvas de Kaplan Meier, e realizada análise de regressão de Cox para fatores relacionados à mortalidade. Resultados Foram incluídos 473 pacientes com média de idade de 46,9 ±11,3 anos. A doença reumática foi a principal etiologia. Em média de acompanhamento de 4,43 anos, a mortalidade foi de 16,1%. Pacientes com implantes de próteses na posição aórtica tiveram sobrevida melhor que os portadores em posição mitro-aórtica (p=0,026). Entre os fatores ajustados para mortalidade, apenas classe funcional e insuficiência renal crônica apresentaram significância estatística. A incidência de TPV foi de 0,24/100 pacientes/ano, com primeiro evento após 1000 dias da cirurgia. Tabagismo e pannus foram estatisticamente associados a TPV. Não houve diferenças na variabilidade de INR entre pacientes com e sem trombose por posição protética, mas houve diferença estatística no INR pré-evento trombótico comparado aos que não apresentaram trombose (INR= 2,20[1,80-2,20] vs 2,80[2,20-3,40]; p= 0,040). Identificamos 4,4% de acidentes vasculares cerebrais e 5,2% de sangramentos. Conclusões A população mostrou-se jovem e valvopatia reumática foi frequente. A frequência de TPV foi semelhante à descrita na literatura, apesar da baixa renda e escolaridade da amostra.

Abstract Background Valvular heart diseases are highly prevalent in the world, and surgical valve replacement has improved patients' survival. Objectives To describe clinical and laboratory data of patients undergoing mechanical valve replacement, and to determine the incidence of prosthetic valve thrombosis (PVT). Methods Retrospective cohort study with a follow-up of up to nine years. The study variables were collected from conventional and electronic medical charts. Statistical calculations were performed using the Jamovi software version 1.2.2.; a p<0.05 was considered statistically significant. Kaplan Meier curves were constructed, and Cox regression analysis was performed for analysis of factors related to mortality. Results A total of 473 patients were included, mean age of 46.9 ±11.3 years. Rheumatic disease was the most common etiology. In a mean follow-up period of 4.43 years, mortality rate was 16.1%. Patients with aortic prosthesis showed higher survival than patients with double implant (mitral and aortic) (p=0.026). Of the factors adjusted for mortality, only functional class and chronic renal failure showed statistically significant association. The incidence of PVT was 0.24/100 patients/year, and the first event occurred more than 1000 days after the implant. Smoking and pannus formation were significantly associated with PVT. No differences were found in INR variability between patients with and without thrombosis by prosthetic position, but significant differences were found in INR before thrombosis as compared with patients without thrombosis (INR= 2.20 [1.80-2.20] vs. 2.80 [2.20-3.40]; p= 0.040). The incidence of stroke and bleeding was 4.4% and 5.2% respectively. Conclusions The study population was young, and rheumatic valve disease was common in this group. The prevalence of PVT was similar to that described in the literature, despite the low income and low educational level of our sample.

Comparison of anesthesia management in transcatheter aortic valve implantation: a retrospective cohort study

Abstract Background and objectives We aimed to investigate the effects of two different anesthetic techniques in our patients who underwent transcatheter aortic valve implantation (TAVI). Methods In this study, 303 patients who underwent TAVI procedure with a diagnosis of severe aortic stenosis between January 1, 2012 and December 31, 2018 were retrospectively evaluated. The patients were divided according to the type of anesthesia given during each procedure as; general anesthesia (GA), local anesthesia (LA). Results LA was preferred in 245 (80.8%) of 303 patients who underwent TAVI, while GA was preferred in 58 patients (19.1%). Median ages ​​of our patients who received LA and GA were 83 and 84, respectively. The procedure and anesthesia durations of the patients in the GA group were longer than the LA group (p< 0.00001, p< 0.00001, respectively). Demographic and pre-operative clinical data were similar in comparison between two groups (p> 0.05) except for peripheral artery disease. Hypertension was the most common comorbidity in both groups. While the number of inotrope use was significantly higher in patients who received GA (p< 0.00001), no significant differences were found between LA and GA patients in terms of major complications and mortality (p> 0.05). Intensive care and hospital stays were significantly shorter in the LA group (p= 0.001, p= 0.023, respectively). Conclusion The anesthetic technique of TAVI procedure did not have a significant effect on outcomes including; complications, mortality and success of the procedure. LA provides shorter duration of procedure and hospital stay.

Dependência de Pacing a Longo-Prazo e Preditores de Implante de Pacemaker após Implante Percutâneo de Prótese Valvular Aórtica - 1 Ano de Seguimento / Long-Term Ventricular Pacing Dependency and Pacemaker Implantation Predictors after Transcatheter Aortic Valve Replacement - A 1-Year Follow-Up

Resumo Fundamento Os distúrbios de condução (DC) são a complicação mais frequente após a substituição da válvula aórtica transcateter (TAVR) e ainda não há consenso sobre seu tratamento. Objetivo Avaliar novos DC e implante de marca-passo definitivo (MPD) após a TAVR e avaliar a porcentagem de estimulação ventricular (EV) até 1 ano de acompanhamento. Métodos Pacientes submetidos a TAVR de outubro de 2014 a novembro de 2019 foram cadastrados; pacientes com MPD anterior foram excluídos. Dados clínicos, do procedimento, do ECG e do MPD foram coletados até 1 ano após o implante. O nível de significância adotado para a análise estatística foi 0,05%. Resultados Um total de 340 indivíduos foram submetidos a TAVR. O DC mais comum foi bloqueio de ramo esquerdo novo (BRE; 32,2%), sendo que 56% destes foram resolvidos após 6 meses. O bloqueio do ramo direito (BRD) foi o maior fator de risco para bloqueio atrioventricular avançado (BAV) [RC=8,46; p<0,001] e implante de MPD [RC=5,18; p<0,001], seguido de BAV de baixo grau prévio [RC=2,25; p=0,016 para implante de MPD]. Em relação às características do procedimento, válvulas de gerações mais recentes e procedimentos de válvula-em-válvula foram associados a menos DC. No total, 18,5% dos pacientes tiveram MPD implantado após a TAVR. Na primeira avaliação do MPD, pacientes com BAV avançado tinham uma porcentagem mediana de EV de 80%, e, após um ano, de 83%. Em relação aos pacientes com BRE e BAV de baixo grau, a EV mediana foi mais baixa (6% na primeira avaliação, p=0,036; 2% após um ano, p = 0,065). Conclusão O BRE foi o DC mais frequente após a TAVR, com mais da metade dos casos se resolvendo nos primeiros 6 meses. O BRD foi o principal fator de risco para BAV avançado e implante de MPD. O BAV avançado foi associado a uma porcentagem mais alta de EV no acompanhamento de 1 ano.

Abstract Background Conduction disturbances (CD) are the most frequent complication after transcatheter aortic valve replacement (TAVR), and there continues to be a lack of consensus on their management. Objective To assess new CD and permanent pacemaker (PPM) implantation after TAVR and to evaluate the ventricular pacing percentage (VP) up to 1 year of follow-up. Methods Patients who underwent TAVR from October 2014 to November 2019 were enrolled; patients with previous PPM were excluded. Clinical, procedure, ECG, and PPM data were collected up to 1 year after implantation. The significance level adopted in the statistical analysis was 0.05. Results A total of 340 patients underwent TAVR. The most frequent CD was the new left bundle branch block (LBBB; 32.2%), which 56% resolved after 6 months. Right bundle branch block (RBBB) was the biggest risk factor for advanced atrioventricular block (AVB) [OR=8.46; p<0.001] and PPM implantation [OR=5.18, p<0.001], followed by previous low-grade AVB [OR=2.25; p=0.016 for PPM implantation]. Regarding procedure characteristics, newer generation valves and valve-in-valve procedures were associated with fewer CDs. Overall, 18.5% of patients had a PPM implanted post-TAVR. At first PPM evaluation, patients with advanced AVB had a median percentage of VP of 80% and 83% at one year. Regarding patients with LBBB plus low-grade AVB, median VP was lower (6% at first assessment, p=0.036; 2% at one year, p = 0.065). Conclusion LBBB was the most frequent CD after TAVR, with more than half being resolved in the first six months. RBBB was the major risk factor for advanced AVB and PPM implantation. Advanced AVB was associated with a higher percentage of VP at 1 year of follow-up.

Multiple Anterior Mitral Valve Perforation After Deep Transfemoral Aortic Valve Implantation

Abstract Transcatheter aortic valve implantation (TAVI) is an alternative for high-risk aortic valve replacement. There are limited data related to the late complications of TAVI. Deep aortic prosthetic valve implantation can cause direct erosive perforation of anterior mitral leaflet or erosive endothelial lesion which predisposes the tissue to infective endocarditis. Our report emphasizes anterior mitral leaflet perforation after TAVI, which may be seen especially in patients exposed to sepsis.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement

Abstract Objective: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. Methods: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. Results: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). Conclusions: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection

Abstract Introduction: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. Methods: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. Results: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. Conclusion: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Endocarditis infecciosa luego del implante de válvula aórtica por cateterismo / Infective Endocarditis after Transcatheter Aortic Valve Implantation

RESUMEN Introducción: La endocarditis infecciosa (EI) post implante percutáneo de válvula aórtica (TAVI) es poco frecuente, con una alta tasa de morbimortalidad. Métodos: Se analizaron 630 pacientes consecutivos con TAVI, de los cuales 6 (0,95%) presentaron EI. Resultados: Cuatro eran hombres, edad 81,3 ± 2,2 años, y todos sintomáticos. La fracción de eyección ventricular izquierda (FEVI) fue 56,8 ± 5,3%. Todos recibieron un implante exitoso y uno presentó regurgitación moderada. Dos requirieron marcapaso definitivo, a uno de ellos se le debió recolocar el cable a las 24 hs. La EI se presentó a los 63,5 ± 73,3 días (mediana de 35 días). El germen aislado fue un coco (+) en cuatro casos. En uno se observó una vegetación en el ecocardiograma transesofágico. Un paciente falleció dentro de los 30 días. El seguimiento fue a 23 ± 22 meses, ningún paciente presentó nuevos eventos o internaciones. En el eco Doppler la FEVI fue de 55,9 ± 4,6%, el gradiente medio 8,2 ± 1,8 mmHg y la velocidad pico de 1,8 ± 0,2 m/seg. Un paciente terminó una regurgitación moderada. Conclusiones: En esta serie de pacientes, la EI post TAVI fue poco frecuente y presentó una evolución favorable con el tratamiento antibiótico.

ABSTRACT Background: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a rare complication with high morbidity and mortality. Methods: Of 630 consecutive patients undergoing TAVI, 6 (0.95%) presented IE. Results: Four patients were men, mean age was 81.3 ± 2.2 years and all the patients were symptomatic. Left ventricular ejection fraction (LVEF) was 56.8 ± 5.3%. The procedure was successful in all the patients and one presented moderate regurgitation. Two patients required definitive pacemaker and the lead had to be reimplanted 24 hours later in 1 patient. Time to IE was 63.5 ± 73.3 days (median 35 days). A Gram-positive coccus was isolated in four cases. One patient presented a vegetation on transesophagic echocardiography. One patient died within 30 days. During follow-up of 23 ± 22 months none of the patients presented new events or hospitalizations. On Doppler echocardiography, LVEF was 55.9 ± 4.6%, mean trans-aortic gradient was 8.2 ± 1.8 mm Hg and peak systolic velocity was 1.8 ± 0.2 m/s. One patient had moderate regurgitation. Conclusions: In this series of patients, IE after TAVI was uncommon and had a favorable course with antibiotic treatment.

Aortic Valve Reconstruction with Ozaki Technique

Abstract Modern bioprostheses offer a complete and definitive solution to elderly patients who need aortic valve surgery. Nonetheless, the scenario is more demanding when dealing with younger and less fragile patients. In this setting, any prosthetic aortic valve replacement can provide only a suboptimal solution and its related issues have not been fixed yet. The answer to the needs of this special population is the enhancement and refinement of the surgical technique. The Ozaki technique relies on custom-tailored autologous aortic cusps individually sutured in the aortic position. This approach has been showing optimal results if performed after a dedicated training period.