Treatment For Infected Frozen Elephant Trunk Prosthesis Caused by Propionibacterium acnes: A Surgical Challenge

ABSTRACT In this article, we present the case of a 47-year-old man who underwent Bentall-Bono procedure and frozen elephant trunk prosthesis implantation due to severe aortic regurgitation and aortic dilatation with a second-time endovascular stent-graft repair in descending aorta. Over eight years, a subacute graft infection by Propionibacterium acnes was developed, culminating in cardiogenic shock secondary to severe aortic regurgitation due to a complete aortic root dehiscence because of multiple aortic pseudoaneurysms. The patient underwent emergency surgery in which the replacement of the graft by a biological valve tube was performed accompanied by a complete debranching of the three supra-aortic vessels.

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.

Management of glaucoma with Boston type 1 keratoprosthesis / Manejo do glaucoma em olhos com ceratoprótese Boston tipo 1

ABSTRACT Purpose: To describe the frequency, clinical characteristics, complications, and management of glaucoma in eyes that underwent keratoprosthesis implantation. Methods: Patients who underwent keratoprosthesis surgery between June 2010 and January 2020 were retrospectively evaluated for glaucoma association and prognoses. Results: Among 17 patients who underwent keratoprosthesis surgery, 9 (52.9%) were associated with underlying or keratoprosthesis-induced glaucoma. Five eyes (29.4%) had underlying glaucoma and underwent a glaucoma drainage device implantation at least 6 months before keratoprosthesis surgery. One eye (5.9%) with normal intraocular pressure had glaucoma drainage device implantation at the same session with keratoprosthesis surgery due to high-risk characteristics of anterior segment structures. Four eyes with preexisting glaucoma showed progression after keratoprosthesis surgery. Additional antiglaucomatous treatment was commenced in two eyes whereas implantation of 2nd glaucoma drainage device was performed in two eyes. Postoperative complications in three eyes (100%) with glaucoma drainage device implanted 6 months before or at the same session with aphakic type keratoprosthesis surgery with partial vitrectomy included rhegmatogenous retinal detachment in two eyes and bacterial endophthalmitis in one eye. Migration of silicone oil through the tube to the subconjunctival area was seen after pars plana vitrectomy in one eye. None of the three eyes (0%) that underwent glaucoma drainage device implantation years before keratoprosthesis surgery experienced a posterior segment complication other than glaucomatous progression. Out of 11 eyes with no previous history of glaucoma, 3 (27.3%) showed high intraocular pressure and glaucomatous disc changes after keratoprosthesis surgery, which could be pharmacologically controlled. Conclusions: In this cohort, eyes with preexisting glaucoma were more difficult to manage compared to eyes with de novo glaucoma after keratoprosthesis surgery. Retinal complications appeared more often when glaucoma drainage device implantation was performed no more than 6 months before aphakic type keratoprosthesis surgery with partial vitrectomy.

RESUMO Objetivo: Descrever a frequência, as características clínicas, as complicações e o manejo do glaucoma em olhos submetidos a implantes de ceratoprótese. Métodos: Pacientes submetidos à cirurgia de ceratoprótese entre junho de 2010 e janeiro de 2020 foram avaliados retrospectivamente em termos de glaucoma associado e prognóstico. Resultados: Dos 17 pacientes submetidos à cirurgia de ceratoprótese, em 9 (52,9%) foi constatado glaucoma subjacente ou induzido por ceratoprótese. Cinco olhos (29,4%) tinham glaucoma subjacente e receberam a implantação de um dispositivo de drenagem de glaucoma pelo menos 6 meses antes da cirurgia de ceratoprótese. Um olho (5,9%) com pressão intraocular normal teve implantado um dispositivo de drenagem de glaucoma na mesma sessão da cirurgia de ceratoprótese, devido às características de "alto risco" das estruturas do segmento anterior. Quatro dos olhos com glaucoma preexistente apresentaram progressão após a cirurgia de ceratoprótese. Foi iniciado um tratamento antiglaucomatoso adicional em 2 olhos, enquanto outros 2 olhos receberam o implante de um segundo dispositivo de drenagem de glaucoma. Foram observadas complicações pós-operatórias em 3 olhos (100%) com dispositivo de drenagem de glaucoma implantado 6 meses antes ou na mesma sessão da cirurgia de ceratoprótese tipo afácica com vitrectomia parcial, incluindo descolamento de retina regmatogênico em 2 olhos e endoftalmite bacteriana em 1 olho. Em 1 olho observou-se migração do óleo de silicone para a área subconjuntival através do tubo após vitrectomia via pars plana. Nenhum dos 3 olhos (0%) implantados com dispositivo de drenagem de glaucoma anos antes da cirurgia de ceratoprótese apresentou complicações do segmento posterior, exceto progressão glaucomatosa. Dos 11 olhos sem história prévia de glaucoma, 3 (27,3%) apresentaram alta pressão intraocular e alterações do disco glaucomatoso após cirurgia de ceratoprótese, condições que podem ser controladas clinicamente. Conclusões: Nesta coorte, os olhos com glaucoma pré-existente foram mais difíceis de manejar, comparados àqueles que desenvolveram glaucoma após a cirurgia de ceratoprótese. Apareceram mais complicações retinianas quando o implante do dispositivo de drenagem de glaucoma foi realizado no máximo 6 meses antes da cirurgia de ceratoprótese do tipo afácico com vitrectomia parcial.

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.

Application and prospect of endoscopic prepectoral prosthetic breast reconstruction / 国际外科学杂志

Endoscopic breast surgery has become more and more popular, and prepectoral prosthetic breast reconstruction is also becoming more and more widely used. The combination of endoscopic surgery and prepectoral prosthetic breast reconstruction has produced a good complementary effect and promoted their respective development. This paper describes the characteristics of endoscopic breast surgery and prepectoral prosthetic breast reconstruction, analyzing the current status of the combination of these two technologies, and looks forward to the application of endoscopic prepectoral prosthetic breast reconstruction

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.

Caracterización clínico epidemiológica de los pacientes con alteraciones bucomaxilofaciales en la provincia Camagüey

Introducción: Las personas con una deformación facial comúnmente están expuestas a las críticas o presión, colocando al individuo en situaciones embarazosas. El uso de prótesis es una solución eficiente a las deformidades faciales ya que evita complicaciones quirúrgicas y produce un buen resultado estético cuando no es posible la reconstrucción quirúrgica o se prefiere por el paciente. Objetivo: Caracterizar clínica y epidemiológicamente los pacientes con alteraciones bucomaxilofaciales en la provincia Camagüey. Métodos: Se realizó un estudio descriptivo de serie de casos en el periodo comprendido entre marzo y diciembre de 2022. Se tomó la información existente en las bases de datos y en los trabajos de terminación de la especialidad de Prótesis Estomatológica, realizados entre los años 2001 al 2019. Se utilizó para el análisis de la información, estadística descriptiva para distribución de frecuencias y los resultados finales se incluyeron en tablas. Resultados: La mayoría de los casos fueron pacientes masculinos, de edades entre 46 y 60; los defectos más frecuentes encontrados fueron los oculares. En cuanto al sexo fue evidente una mayor necesidad de prótesis bucomaxilofacial en los hombres y dentro de estas las prótesis oculares. Entre las principales causas de pérdida de estructuras se encontraron los traumatismos y las lesiones oncológicas. Conclusiones: Los defectos bucomaxilofaciales repercuten de forma negativa en la calidad de vida de quienes los padecen; las causas que generan los mismos, las regiones donde más se presentan, el sexo y la edad en que aparecen son elementos a tener en cuenta para un correcta prevención de dichas lesiones pero también permiten establecer pautas de trabajo encaminadas a brindar una atención multidisciplinaria para su rehabilitación protésica e integral.

Introduction: People with a facial deformity are commonly exposed to criticism or pressure, placing the individual in embarrassing situations. The use of prostheses is an efficient solution to facial deformities since it avoids surgical complications and produces a good aesthetic result when surgical reconstruction is not possible or is preferred by the patient. Objective: To characterize clinically and epidemiologically patients with oral and maxillofacial alterations in Camagüey province. Methods: A case report type study was carried out taking the results of the databases, completion works of the Dentistry Prosthesis specialty between the years 2001 and 2019. The study was carried out in the period between March and December 2022. The results were reflected in tables using descriptive statistics for them. Results: Most of the cases were male patients, aged between 46 and 60; the most frequent defects found were the ocular ones. Regarding gender, a greater need for oral and maxillofacial prostheses was evident in men, and within these, ocular prostheses. Among the main causes of loss of structures were traumatisms and oncological lesions. Conclusions: Oral and maxillofacial defects have a negative impact on the quality of life of those who suffer from them; the causes that generate them, the regions where they occur most, the sex and the age in which they appear are elements to take into account for a correct prevention of said injuries but also allow the establishment of work guidelines aimed at providing multidisciplinary care for their prosthetic and integral rehabilitation.

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.

Acute Paraplegia Result from Spinal Ischemia Nine Years After Hybrid Total Arch Repair with Frozen Elephant Trunk: A Case Report

ABSTRACT Spinal cord ischemia due to decreased cord perfusion is a devastating complication in patients with thoracoabdominal dissection following frozen elephant trunk (FET) repair surgery. However, rare occurrence of spinal cord ischemia leading to paraplegia after long-term follow-up of FET repair has been reported. Here, we describe a case of spinal cord ischemia resulting in paraplegia nine years after hybrid total arch repair with FET. Cerebrospinal fluid drainage and serial treatment were utilized to decrease intraspinal pressure and increase blood flow to the spinal cord. Three months after the onset of paraplegia and with treatment and rehabilitation, the patient recovered to walk.

Periprosthetic fractures: the increasing challenges / 中华创伤骨科杂志

Surgery for periprosthetic fractures (PPF) is one of the most complex procedures in orthopedics. It is difficult, highly risky and extremely challenging, because the patients are usually advanced in age and suffering from essential organ dysfunction, numerous comorbidities, poor overall body condition, poor bone quality combined with osteolysis and even bone loss, and because the surgeons have to apply the concepts and techniques of Modern Orthopedic Trauma and artificial joint revision techniques in fracture fixation and prosthesis revision. This paper expounds on the clinical challenges due to the characteristics of PPF in order to call on clinical surgeons to update their concepts, deal with seriously and standardize their PPF treatment, and effectively improve their efficacy.

Clinical application of LARS artificial ligament in anterior cruciate ligament reconstruction: an update / 中华创伤杂志

The anterior cruciate ligament (ACL) is one of the most crucial components to maintain knee joint stability and also the most vulnerable structure during knee-related sports activities. ACL injuries often cause knee instability, difficulty in returning to sports, and secondary degenerative knee disease. Although using autograft to reconstruct the ACL is currently a popular choice in clinical settings, it has drawbacks such as limited autograft source, donor site morbidity and delayed return to sports. Ligament advanced reinforcement system (LARS) artificial ligament possesses unique advantages such as wide availability, no donor-site morbidity, and early recovery, avoiding the problems associated with autograft reconstruction of ACL, and it has drawn increasing attention in recent years. In this paper, the authors reviewed the characteristics of LARS artificial ligament and its application in ACL reconstruction, so as to provide reference for clinical treatment of ACL injuries.

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.

Combination of surgical techniques and reconstructive devices as an alternative treatment after fibula free flap mandibular reconstruction failure: a case report

Loss of mandibular continuity and functionality in cancer patients undergoing extensive mandible resections is challenging. In these situations, the gold standard treatment is fibula free flap reconstruction. The major challenge occurs when there is a failure of the transplanted fibula. Here we report the case of a patient who underwent right hemimandibulectomy with disarticulation and immediate mandibular reconstruction with a fibula free flap. Subsequently, the flap viability was lost, and there was necrosis of the transplanted bone segment in the short-term follow-up. Considering the best form of rehabilitation for the patient, minimizing the risks of loss and optimizing the reconstructive quality, we opted to install a customized prosthesis including a condylecavity joint component associated with a new free flap and subsequent rehabilitation of the dental occlusion with an implant-supported fixed prosthesis.

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.

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.

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.

Conhecimento sobre anticoagulação oral de pacientes após correção cirúrgica de valvopatias: revisão integrativa / Conocimiento sobre la anticoagulación oral de los pacientes después de la corrección quirúrgica de valvulopatías: revisión integradora / Knowledge about oral anticoagulation of patients after surgical correction of valve diseases: integrative review

Objetivo: Verificar a existência de evidências científicas na literatura sobre o conhecimento dos pacientes em relação ao uso do anticoagulante oral após o implante de valva cardíaca metálica. Método: Revisão integrativa realizada nas bases de dados Embase, Scopus, Web of Science e Sistema Online de Busca e Análise de Literatura Médica (MEDLINE)/PubMed, utilizando descritores controlados e não controlados, sem delimitação temporal quanto à publicação, nos idiomas português, inglês e espanhol. A busca ocorreu em junho de 2022, por duas pesquisadoras de forma independente. Resultado: Verificou-se a existência de lacunas no conhecimento dos pacientes sobre os efeitos adversos relacionados ao uso dos anticoagulantes orais, às interações medicamentosas, às interações alimentares, aos fatores que interferem nos níveis do international normalized ratio e ao que deve ser feito em aso de esquecimento das doses diárias. Conclusão: A síntese elaborada enfatiza a necessidade de maior enfoque nas orientações aos pacientes sobre os anticoagulantes e suas implicações relacionadas aos hábitos de vida diária (AU)

Objective: To verify the existence of scientific evidence in the literature on patients regarding the use of oral anticoagulants after implantation of a metallic heart valve. Method: Integrative review carried out in the Embase, Scopus, Web of Science, and Online Medical Literature Search and Analysis System (MEDLINE)/PubMed databases, using controlled and uncontrolled descriptors, without temporal delimitation regarding publication, in Portuguese, English, and Spanish. The search took place in June 2022, by two researchers independently. Result: There were gaps in patients' knowledge about adverse effects related to the use of oral anticoagulants, drug interactions, food interactions, factors that interfere with international normalized ratio levels and what should be done in case of forgetting the daily doses. Conclusion: The synthesis elaborated emphasizes the need for greater focus on patient guidance on anticoagulants and their implications related to daily life habits (AU)

Objetivo: Verificar la existencia de evidencia científica en la literatura sobre el conocimiento de los pacientes sobre el uso de anticoagulantes orales después del implante de una válvula cardíaca metálica. Método: Revisión integradora realizada en las bases de datos Embase, Scopus, Web of Science y MEDLINE/PubMed, utilizando descriptores controlados y no controlados, sin delimitación temporal con respecto a la publicación, en portugués, inglés y español. La búsqueda tuvo lugar en junio de 2022, por dos investigadores de forma independiente. Resultado: Hubo lagunas en el conocimiento de los pacientes sobre los efectos adversos relacionados con el uso de anticoagulantes orales, interacciones medicamentosas, interacciones alimentarias, factores que interfieren con los niveles de la razón internacional normalizada y qué se debe hacer en caso de olvido de las dosis diarias. Conclusión: La síntesis elaborada enfatiza la necesidad de un mayor enfoque en la orientación del paciente sobre los anticoagulantes y sus implicaciones relacionadas con los hábitos de la vida diaria (AU)

Troca valvar transcateter valve-in-valve mitral por via transeptal em paciente com prótese mitral biológica degenerada / Transeptal valve-in-valve transcatheter mitral valve replacement in patient with deteriorated mitral bioprosthesis

A troca valvar mitral transcateter apresenta-se como uma nova opção terapêutica para o tratamento de próteses cirúrgicas degeneradas em pacientes com alto risco cirúrgico. É crescente o número de procedimentos valve-in-valve mitral ao longo dos últimos anos. O presente caso relata uma experiência inicial com esse tipo de procedimento, sendo efetivado de forma segura e eficaz em uma paciente idosa de alto risco cirúrgico para retroca valvar.

Transcatheter mitral valve replacement is a new option to treat deteriorated surgical prosthesis in high surgical risk patients. The number of valve-in-valve mitral procedures has been growing in the last few years. This case reports an initial experience with this type of procedure, safely and effectively performed in an elderly female patient with high-risk for valve replacement.