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3.
Brasília; CONITEC; maio 2021.
Non-conventional in Portuguese | LILACS, BRISA | ID: biblio-1353432

ABSTRACT

INTRODUÇÃO: A estenose aórtica é relacionada a fatores de risco para aterosclerose, principalmente ao envelhecimento. A prevalência na faixa etária entre 65 e 74 anos é de 1,3%, e acima de 75 anos, 2,8%. Pacientes com estenose aórtica têm risco aumentado de morte cardiovascular (HR 2,14; IC 95% 1,21-3,76). As manifestações clínicas são relacionadas à insuficiência cardíaca, podendo também estarem presentes dor no peito (angina) e síncope. O prognóstico, após início dos sintomas, é de 50% de mortalidade em dois anos, sendo recomendada a cirurgia de troca valvar aórtica, mas cerca de 30% dos idosos têm a cirurgia contraindicada pelo alto risco cirúrgico. O TAVI é uma opção de tratamento percutâneo (transapical ou transfemoral), com troca valvar sem necessidade de toracotomia e circulação extracorpórea. Apresenta benefícios em relação ao tratamento clínico tais como maior sobrevida e qualidade de vida, reduzindo sintomas relacionados à insuficiência cardíaca e o número de internações hospitalares, porém, associa-se com riscos imediatos como necessidade de implante de marcapasso, hemotransfusões, insuficiência renal, diálise, acidente vascular cerebral, lesões vasculares, tamponamento cardíaco e morte. Como os resultados de eficácia são distintos de acordo com a via de acesso à valva aórtica, este relatório contempla apenas TAVI por via transfemoral. TECNOLOGIA: Implante percutâneo transfemoral de válvula aórtica (TAVI). PERGUNTA DE PESQUISA: Em pacientes com estenose aórtica grave considerados inoperáveis, o TAVI, em comparação com o tratamento clínico, é seguro e custo-efetivo? EVIDÊNCIAS CLÍNICAS: Um ensaio randomizado (PARTNER B), além de registros e estudos observacionais, apresentaram ganhos em sobrevida e na qualidade de vida com o TAVI. Resultados de 5 anos do PARTNER B, com 179 pacientes em cada braço de intervenção, revelam menor mortalidade (71,8% versus 93,6%), HR 0,50 (IC95% 0,39-0,65), menor chance de hospitalização (47,6% versus 87,3%; p < 0,0001) e maior chance de estar em classe funcional NYHA I e II (New York Heart Association) (86% versus 60%) nos pacientes do grupo TAVI. Acidente vascular cerebral foi mais frequente até o seguimento de três anos do TAVI (14,4% TAVI versus 4,12% braço clínico; p = 0,0007). AVALIAÇÃO ECONÔMICA: Avaliação do tipo custo-utilidade em modelo de Markov, com ciclos mensais, horizonte temporal de 5 anos, perspectiva do SUS, revela razão de custo-utilidade incremental (RCUI) de R$189.920,69/QALY. Na análise de sensibilidade determinística, observou-se que o custo do TAVI é o parâmetro com maior impacto na RCUI. Considerando um limiar de 3 PIB per capita por ano de vida ajustado por qualidade (QALY) e analisando separadamente os componentes do custo TAVI como o custo do procedimento (considerado fixo e equivalente a R$ 28.244,41) e o custo da prótese (variável), estimou-se que, para o TAVI ser considerado custo-efetivo, o custo máximo do procedimento TAVI deve ser de R$ 57.292,1 e consequentemente, o custo máximo isolado da prótese equivalente a R$ 29.047,69. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: O impacto orçamentário é proporcional à quantidade de procedimentos de TAVI realizados. Baseado no pressuposto de realização de um máximo de 80 procedimentos por mês no Brasil, foi estimado um impacto em torno de 78 milhões de reais no primeiro ano e um impacto total, em 5 anos, de aproximadamente 467 milhões de reais. MONITORAMENTO DO HORIZONTE TECNOLÓGICO: Foram realizadas pesquisas nos bancos de dados de ensaios clínicos e patentes Clinical Trials , Cortellis , ECRI, Espacenet e Patentscope e no site do FDA. Para isto, foram utilizados os descritores "severe aortic stenosis" e "aortic stenosis". Dentre os resultados obtidos foram desconsiderados os implantes que já são comercializados no mercado do brasileiro, de modo a proporcionar uma melhor prospecção de mercado. Foi identificado um TAVI registrado no FDA e quatro pedidos patentários internacionais que possuem depósito brasileiro, contudo devido a sua recente inclusão internacional ainda não possui pedido em fase nacional. CONSIDERAÇÕES FINAIS: A principal vantagem do TAVI é permitir a troca valvar aórtica sem a necessidade de toracotomia ou circulação extracorpórea, o que o coloca como opção terapêutica para pacientes com estenose aórtica inoperáveis. Demanda expertise médica e estrutura hospitalar com suporte de sala de hemodinâmica e cirurgia cardíaca. O controle na qualidade do atendimento e no impacto orçamentário estão diretamente relacionados a quantidade de centros e de procedimentos por centro que poderão ser autorizados para realização do TAVI. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Pelo exposto, os membros da Conitec, em sua 95ª reunião ordinária, no dia 04 de março de 2021, recomendaram por unanimidade, a não incorporação no SUS do TAVI para tratamento de pacientes com estenose aórtica grave inoperáveis. Considerou-se que, apesar das evidências que suportam o benefício clínico da intervenção, os dados econômicos de relação de custo-utilidade incremental e impacto orçamentário são desfavoráveis. A matéria foi disponibilizada em consulta pública. CONSULTA PÚBLICA: A Consulta Pública nº 15/2021 foi realizada entre os dias 18/03/2021 e 06/04/2021. Foram recebidas 17 contribuições, sendo 12 pelo formulário para contribuições técnico-científicas e cinco pelo formulário para contribuições sobre experiência ou opinião de pacientes, familiares, amigos ou cuidadores de pacientes, profissionais de saúde ou pessoas interessadas no tema. RECOMENDAÇÃO FINAL: Pelo exposto, o Plenário da Conitec, em sua 96ª Reunião Ordinária, no dia 05 de maio de 2021, deliberou por unanimidade recomendar a incorporação do implante percutâneo da válvula aórtica (TAVI) para tratamento da estenose aórtica grave em pacientes com estenose aórtica grave sintomática inoperáveis. Os membros da Conitec consideraram o benefício clínico com ganhos em sobrevida e qualidade de vida dos pacientes para recomendar a incorporação desta tecnologia que está condicionada, no máximo, ao valor considerado custo-efetivo na análise para o Sistema Único de Saúde (SUS). Assim, foi assinado o Registro de Deliberação nº 606/2021. DECISÃO: Incorporar o implante percutâneo de válvula aórtica (TAVI) para tratamento da estenose aórtica grave em pacientes inoperáveisno âmbito do Sistema Único de Saúde ­ SUS, conforme Portaria nº 32, republicada no Diário Oficial da União nº 123, Seção 1, página 195, em 02 de julho de 2021.


Subject(s)
Humans , Aortic Valve Stenosis/rehabilitation , Heart Valve Prosthesis Implantation/instrumentation , Unified Health System , Brazil , Cost-Benefit Analysis
5.
Rev. bras. cir. cardiovasc ; 36(1): 120-124, Jan.-Feb. 2021. graf
Article in English | LILACS | ID: biblio-1155801

ABSTRACT

Abstract Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.


Subject(s)
Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Aortic Valve/surgery , Thoracotomy , Treatment Outcome , Sternotomy
6.
Rev. urug. cardiol ; 36(3): e405, 2021. ilus, graf, tab
Article in Spanish | LILACS, BNUY, UY-BNMED | ID: biblio-1367044

ABSTRACT

Desde que Edward Heyde vislumbró en 1958 una misteriosa asociación entre estenosis aórtica y hemorragia digestiva han transcurrido seis décadas y se ha suscitado no poca controversia. En la época en que fue propuesta, el estatus técnico y metodológico de la ciencia médica y una interpretación sesgada de su idea original impidieron obtener un sustento estadístico y fisiopatológico que le otorgara un amplio reconocimiento como entidad clínica individual. Los avances en varias disciplinas permitieron demostrar que su frecuencia de presentación excede el efecto del azar, además de esclarecer con precisión y elegancia sus mecanismos fisiopatológicos. Su consolidación como síndrome nos revela una verdadera encrucijada entre la cardiología, la gastroenterología, la hematología y el laboratorio, especialidades involucradas tanto en su proceso de comprensión como en su manejo práctico en la actualidad. Sin embargo, a pesar de tener una incidencia no desdeñable y adquirir un papel central en la conducción clínica de la estenosis aórtica, esta entidad parece haber pasado de ser resistida a relativamente ignorada. Con el objetivo de contribuir a su visibilidad, la presente revisión ofrece un panorama integral sobre el tema, incluyendo una perspectiva histórica de los principales aportes en pos de su conocimiento y un abordaje en profundidad de sus mecanismos, las claves de su detección clínica y su impacto en el manejo de la estenosis aórtica y otras entidades con fisiopatología afín.


Since Edward Heyde perceived in 1958 a mysterious association between aortic stenosis and gastrointestinal bleeding, six decades have passed and no little controversy has arisen. At the time it was proposed, the technical and methodological status of medical science and a biased interpretation of his original idea prevented obtaining a statistical and pathophysiological support that would grant it wide recognition as and individual clinical entity. Advances in several disciplines allowed to demonstrate that its frequency of presentation exceeds the effect of chance, besides clarifying with precision and elegance its pathophysiological mechanisms. Its consolidation as a syndrome reveals a true crossroads between Cardiology, Gastroenterology, Hematology and Laboratory, specialties involved both in its understanding process and in its practical management today. However, despite having a not negligible incidence and acquiring a central role in the clinical conduction of aortic stenosis, this entity seems to have gone from being resisted to relatively ignored. With the objective of contributing to its visibility, this review offers a comprehensive overview of the subject, covering the main historical contributions to its knowledge and approaching in depth its mechanisms, the keys to its clinical detection and its impact on the management of aortic stenosis and other entities with related pathophysiology.


Desde que Edward Heyde imaginou em 1958 uma misteriosa associação entre estenose aórtica e hemorragia gastrointestinal, seis décadas se passaram e não houve pouca controvérsia. Na época em que foi levantada, o estado técnico e metodológico da ciência médica e uma interpretação tendenciosa de sua ideia original impediram a construção de um apoio estatístico e fisiopatológico que lhe concederia amplo reconhecimento como entidade clínica individual. Avanços em diversas disciplinas permitiram demonstrar que sua frequência de apresentação excede o efeito do acaso, além de esclarecer com precisão e elegância seus mecanismos fisiopatológicos. Sua consolidação como síndrome revela uma verdadeira encruzilhada entre Cardiologia, Gastroenterologia, Hematologia e Laboratório, especialidades envolvidas tanto em seu processo de compreensão quanto em sua gestão prática hoje. No entanto, apesar de ter uma incidência não desprezível e adquirir um papel central no manejo clínico da estenose aórtica, esta entidade parece ter passado de resistida para relativamente ignorada. Com o intuto de contribuir para sua visibilidade, esta revisão oferece um panorama abrangente do tema, revendo as principais contribuições históricas ao seu conhecimento e abordando em profundidade seus mecanismos, as chaves para sua detecção clínica e seu impacto na gestão da estenose aórtica e outras entidades com fisiopatologia relacionada.


Subject(s)
Humans , Aortic Valve Stenosis/complications , Angiodysplasia/complications , Gastrointestinal Hemorrhage/etiology , Aortic Valve Stenosis/surgery , von Willebrand Diseases/complications , Angiodysplasia/etiology , Angiodysplasia/therapy , Heart Valve Prosthesis Implantation , Gastrointestinal Hemorrhage/therapy
7.
Rev. urug. cardiol ; 36(3): e704, 2021. ilus
Article in Spanish | LILACS, BNUY, UY-BNMED | ID: biblio-1367089

ABSTRACT

La disfunción valvular protésica es cada vez más frecuente debido al envejecimiento de la población portadora de bioprótesis y se presenta como un desafío en el momento de su diagnóstico, valoración y tratamiento. Aplicar un enfoque imagenológico multimodal es fundamental para su manejo. Respecto al tratamiento, surge como nueva alternativa un procedimiento mínimamente invasivo de sustitución valvular percutánea, denominado valve in valve, principalmente en pacientes con riesgo quirúrgico elevado. Presentamos uno de los primeros casos locales de implante percutáneo de prótesis mitral transeptal dentro de una bioprótesis mitral quirúrgica disfuncionante.


Prosthetic valve dysfunction is increasingly common due to the aging of the bioprosthesis-bearing population, and it presents a challenge at the time of diagnosis, evaluation, and treatment. A multimodal imaging approach is essential for its management. In relation to treatment, a minimally invasive percutaneous valve replacement procedure called valve in valve arises as a new alternative, mainly in patients with high surgical risk. We present one of first local cases of percutaneous implantation of a transseptal mitral prosthesis within a dysfunctional surgical mitral bioprosthesis.


A disfunção valvular protética é cada vez mais comum devido ao envelhecimento da população portadora de biopróteses e representa um desafio no momento do diagnóstico, avaliação e tratamento. A multimodalidade da imagem cardiovascular é essencial para sua avaliação. Em relação ao tratamento, um procedimento de troca valvular percutânea minimamente invasivo, denominado valve in valve, surge como uma nova alternativa, principalmente em pacientes com alto risco cirúrgico. Apresentamos um dos primeiros casos realizados no Uruguai de implantação percutânea de prótese mitral transeptal dentro de bioprótese mitral cirúrgica disfuncional.


Subject(s)
Humans , Female , Aged , Bioprosthesis , Prosthesis Failure , Tomography , Echocardiography, Doppler , Echocardiography, Transesophageal , Multimodal Imaging , Mitral Valve Stenosis/diagnostic imaging , Heart Valve Prosthesis Implantation , Percutaneous Coronary Intervention
9.
Arq. bras. cardiol ; 115(6): 1201-1204, dez. 2020. tab, graf
Article in Portuguese | LILACS | ID: biblio-1152930

ABSTRACT

Resumo Apresentamos o relato de caso de uma paciente com mixoma valvar mitral infectado e uma revisão da literatura sobre o assunto. Uma mulher de 33 anos apresentou histórico de febre e dispneia com evolução de alguns dias. Na hospitalização, ela apresentava uma síndrome semelhante ao lúpus, com hemoculturas positivas para Haemophilus spp . O ecocardiograma revelou uma massa gigante envolvendo ambos os folhetos mitrais associada à regurgitação grave, necessitando de troca valvar mitral biológica. A microscopia revelou mixoma infectado e a paciente recebeu alta assintomática após o término da antibioticoterapia. Ela apresentou bons resultados no seguimento. Este é o sexto caso de mixoma valvar mitral infectado relatado na literatura e o terceiro caso de mixoma cardíaco infectado pelo grupo HACEK. Devido à alta incidência de eventos embólicos, a antibioticoterapia precoce aliada à pronta intervenção cirúrgica são decisivos para a redução da morbimortalidade. O tempo para o diagnóstico foi muito mais breve do que o geralmente relatado em casos de endocardite por HACEK. A troca valvar foi a intervenção mais comum e todos os pacientes em relatos de caso anteriores apresentaram bons resultados no seguimento.


Abstract We present a case report of a patient with an infected mitral valve myxoma and a literature review on the subject. A 33-year-old female presented with a history of fever and dyspnea evolving over a few days. On admission, she had a lupus-like syndrome with positive blood cultures for Haemophilus species . Echocardiogram revealed a giant mass involving both mitral leaflets causing severe regurgitation, requiring biological mitral valve replacement. Microscopy showed an infected myxoma and the patient was discharged asymptomatic upon completion of antibiotics. She did well on follow-up. This is the sixth case of an infected mitral valve myxoma reported in the literature and the third case of a cardiac myxoma infected by the HACEK group. Exceedingly high incidence of embolic events makes prompt imaging, antibiotic therapy and surgery crucial for better outcomes. Time to diagnosis was much briefer than usually reported in other cases of HACEK endocarditis. Valve replacement was the most common surgical procedure and all patients from previous reports did well on follow-up.


Subject(s)
Humans , Female , Adult , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Endocarditis/surgery , Endocarditis/diagnostic imaging , Mitral Valve Insufficiency/surgery , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve/surgery , Mitral Valve/diagnostic imaging
10.
Arch. cardiol. Méx ; 90(4): 490-497, Oct.-Dec. 2020. tab, graf
Article in English | LILACS | ID: biblio-1152824

ABSTRACT

Abstract Background: Overweight and obesity (O/O) generate lipotoxicity of the cardiac fiber and increase the incidence and progression of aortic valve stenosis. The low cardiac output syndrome (LCOS) is a timing complication after to aortic valve replacement (AVR) surgery. Objective: The objective of the study was to investigate if body mass index (BMI) kg/m2 is a risk factor associated with LCOS and mortality in the post-operative period of AVR. Methods: A historic cohort study was designed, including patients with severe aortic stenosis (SAS), who were subjected to AVR. Results: 152 patients were included, 45 (29.6%), with normal weight (NW), 60 were overweight (39.5%), and 47 obese (30.9%). The prevalence of systemic hypertension (HT) was higher in O/O (p < 0.0001). Incidence of LCOS was 44.7%, being more frequent in the O/O groups compared to the NW group, 43.3%, 68.1%, and 22.2%, respectively, (p < 0.05 in overweight and p < 0.0001 in the obese). Assessing the presence or absence of LCOS associated with BMI as a numerical variable, we found that women, HT, BMI, left ventricular mass, and valve size, were associated with LCOS (p < 0.02, p < 0.02, p < 0.001, p < 0.032, and p < 0.045, respectively). Mortality was higher in patients who had LCOS (p < 0.02). Multivariate model showed that BMI was an independent risk factor for LCOS (odds ratio [OR] 1.21 [95% CI 1.08-1.35], p < 0.001). Conclusion: BMI is a risk factor associated to LCOS in the post-operative period of AVR in patients with SAS.


Resumen Antecedentes: El sobrepeso y la obesidad (O/O) generan lipotoxicidad de la fibra cardíaca y aumentan la incidencia y progresión de la estenosis de la válvula aórtica. El síndrome de bajo gasto cardíaco (SBGC) es una complicación postquirúrgica de la cirugía de reemplazo de válvula aórtica (RVA). Objetivo: Investigar si el índice de masa corporal kg/m2 (IMC) es un factor de riesgo asociado con SBGC y mortalidad en el postoperatorio de RVA. Métodos: Se diseñó un estudio de cohorte histórico, que incluyó pacientes con estenosis aórtica importante (EAI), que fueron sometidos a RVA. Resultados: Se incluyeron 152 pacientes, 45 (29.6%), con peso normal (N), 60 tenían sobrepeso (39.5%) y 47 obesos (30.9%). La prevalencia de hipertensión sistémica (HT) fue mayor en O/O (p < 0.0001). La incidencia de SBGC fue del 44.7%, siendo más frecuente en los grupos O/O en comparación con el grupo N, 43.3%, 68.1%, 22.2% respectivamente, (p < 0.05 en sobrepeso y p < 0.0001 en obesos). Al evaluar la presencia o ausencia de SBGC asociado con el IMC como una variable numérica, encontramos que las mujeres, HT, IMC, masa ventricular izquierda y tamaño de la válvula, se asociaron con SBGC (p < 0.02, p < 0.02, p < 0.001, p < 0.032, p < 0.045, respectivamente). La mortalidad fue mayor en pacientes con SBGC (p < 0.02). El modelo multivariado mostró que el IMC fue un factor de riesgo independiente asociado a SBGC [OR 1.21 (IC 95% 1.08-1.35), p < 0.001]. Conclusión: El IMC es un factor de riesgo asociado a SBGC en el postoperatorio de RVA en pacientes con EAI.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Aortic Valve Stenosis/surgery , Postoperative Complications/epidemiology , Cardiac Output, Low/epidemiology , Heart Valve Prosthesis Implantation/adverse effects , Postoperative Complications/mortality , Cardiac Output, Low/etiology , Cardiac Output, Low/mortality , Body Mass Index , Incidence , Retrospective Studies , Risk Factors , Cohort Studies , Heart Valve Prosthesis Implantation/methods , Overweight/complications , Ideal Body Weight , Obesity/complications
11.
Rev. bras. cir. cardiovasc ; 35(6): 958-963, Nov.-Dec. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1144013

ABSTRACT

Abstract Rheumatic heart disease (RHD) remains the most common cardiovascular disease in young adults and adolescents in need of heart surgery in low- and middle-income countries (LMICs). The mean age of patients is 20-25 years, often much younger. By contrast, the few patients with chronic RHD in developed countries present a mean age of around 55 years. It is absolutely fundamental to differentiate these two types of population. Pathology, lesions and surgical methods are different, and the results should not be compared. It is not all the same! A certain enthusiasm for mitral repair has recently surged, with several reports showing excellent results in children and young adults, resulting from the renewed interest of cardiac surgeons, also based on new and modified techniques developed in the meantime. While surgery is easily accessible to patients in developed countries, the situation in LMICs is often dramatic, with countries where there is a complete absence of or few surgical facilities absolutely unable to meet gigantic demands. Many foreign surgical teams conduct humanitarian missions in several of these countries. They are just a "drop of water in the ocean" of needs. In some cases, however, these missions led to the establishment of local teams that now work independently and, in some cases, outperform the foreign teams still visiting.


Subject(s)
Humans , Child , Adolescent , Adult , Middle Aged , Young Adult , Rheumatic Heart Disease/surgery , Rheumatic Heart Disease/epidemiology , Heart Valve Prosthesis Implantation , Cardiac Surgical Procedures
12.
Rev. bras. cir. cardiovasc ; 35(6): 869-877, Nov.-Dec. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1143995

ABSTRACT

Abstract Introduction: The objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique. Methods: Between January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression. Results: The hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperation-free survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P<0.001), hemorrhagic-free survival (P<0.001), and endocarditis-free survival (P=0.048). Multivariate analysis showed that the following aspects had an impact on mortality: age > 70 years (P<0.001; hazard ratio [HR] 1.05), preoperative acute kidney injury (P<0.0042; HR 2.9), diagnosis of dissection (P<0.01; HR 2.0), previous cardiac surgery (P<0.027; HR 2.3), associated coronary artery bypass grafting (P<0.038; HR 1.8), reoperation for postoperative tamponade (P<0.004; HR 2.2) and postoperative acute kidney injury (P<0.02; HR 3.35). Conclusion: Valve-sparing technique seems to be the operation of choice, whenever possible, for aortic root reconstruction.


Subject(s)
Humans , Male , Aortic Valve/surgery , Heart Valve Prosthesis Implantation , Aorta/surgery , Postoperative Complications , Reoperation , Brazil , Retrospective Studies , Treatment Outcome
13.
Rev. bras. cir. cardiovasc ; 35(6): 1007-1009, Nov.-Dec. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1143993

ABSTRACT

Abstract We present a case of a 36-year-old male patient with known arthrogryposis multiplex congenita and an associated unicuspid aortic valve. The patient later developed a significant aneurysm of the ascending aorta, however refused surgical intervention and missed follow-up appointments for 5 years. During an urgent, general practitioner-initiated transthoracic echocardiography follow-up, a chronic type A aortic dissection was diagnosed as a result of progressive aortic dilatation. Due to the stationary pressure gradients and non-progressive leaflet fibrosis, a conservative approach for to the unicuspid aortic valve was chosen, combined with replacement of the ascending aorta and partial replacement of the aortic arch.


Subject(s)
Humans , Male , Adult , Heart Valve Prosthesis Implantation , Aneurysm, Dissecting/surgery , Aneurysm, Dissecting/diagnostic imaging , Aortic Valve/surgery , Aortic Valve/diagnostic imaging , Conservative Treatment , Heart Valve Diseases
14.
Rev. bras. cir. cardiovasc ; 35(5): 644-653, Sept.-Oct. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137339

ABSTRACT

Abstract Objective: To evaluate the mid-term survival rate after tricuspid valve replacement (TVR). Methods: We retrospectively studied 110 consecutive patients who underwent TVR from January 2007 to November 2017. A survival analysis was performed with the Kaplan-Meier method and the log-rank test. Results: The median survival was 65.81 months. Mean age was 50 (range 39 to 59) years. Forty-eight patients (43.6%) were male, and 62 patients (56.4%) were female. Most of the patients (78.5%) were categorized into the New York Heart Association (NYHA) functional classes III/IV. Seventy-two patients (65.5%) had isolated TVR. Six-three patients (57.3%) had previously undergone heart surgery. The Kaplan-Meier survival rates at one year, three years, and five years were 59.0%±5%, 52.0%±6%, and 48.0%±6%, respectively. A Cox regression analysis demonstrated that the risk factors for mid-term mortality were advanced NYHA class (hazard ratio [HR] 2.430, 95% confidence interval [CI] 1.099-5.375, P=0.028), need for continuous renal replacement therapy (CRRT) treatment (HR 3.121, 95% CI 1.610-6.050, P=0.001), and need for intra-aortic balloon pump (IABP) treatment (HR 3.356, 95% CI 1.072-10.504, P=0.038). Conclusion: In TVR, impaired cardiac function before the operation and a need for CRRT or IABP treatment after the operation is independently associated with increased mid-term mortality.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Tricuspid Valve/surgery , Heart Valve Prosthesis Implantation , Stroke Volume , Retrospective Studies , Ventricular Function, Left , Treatment Outcome , Cardiac Surgical Procedures
15.
Arq. bras. cardiol ; 115(4): 680-687, out. 2020. graf
Article in Portuguese | SES-SP, LILACS, SES-SP | ID: biblio-1131356

ABSTRACT

Resumo Fundamento O implante valvar aórtico percutâneo (TAVR, do inglês Transcatheter Aortic Valve Replacement) reduz a mortalidade de pacientes portadores de estenose aórtica grave. O conhecimento da distribuição da pressão e tensão de cisalhamento na parede aórtica pode ajudar na identificação de regiões críticas, onde o processo de remodelamento aórtico pode ocorrer. Neste trabalho é apresentado um estudo de simulação computacional da influência do posicionamento do orifício valvar protético na hemodinâmica na raiz de aorta e segmento ascendente. Objetivos A presente análise apresenta um estudo da variação do padrão de fluxo devido a alterações no ângulo do orifício valvar. Métodos Um modelo tridimensional foi gerado a partir do exame de angiotomografia computadorizada da aorta de um paciente que foi submetido ao procedimento de TAVR. Diferentes vazões de fluxo foram impostas através do orifício valvar. Resultados Pequenas variações no ângulo de inclinação causaram mudanças no padrão de fluxo, com deslocamento na posição dos vórtices, na distribuição de pressão e no local de alta tensão cisalhante na parede aórtica. Conclusão Essas características hemodinâmicas podem ser importantes no processo de remodelamento aórtico e distribuição de tensão, além de auxiliar, em um futuro próximo, a otimização do posicionamento da prótese valvar percutânea. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)


Abstract Backgroud Transcatheter aortic valve replacement (TAVR) can reduce mortality among patients with aortic stenosis. Knowledge of pressure distribution and shear stress at the aortic wall may help identify critical regions, where aortic remodeling process may occur. Here a numerical simulation study of the influence of positioning of the prosthetic valve orifice on the flow field is presented. Objective The present analysis provides a perspective of great variance on flow behavior due only to angle changes. Methods A 3D model was generated from computed tomography angiography of a patient who had undergone a TAVR. Different mass flow rates were imposed at the inlet valve. Results Small variations of the tilt angle could modify the nature of the flow, displacing the position of the vortices, and altering the prerssure distribution and the location of high wall shear stress. Conclusion These hemodynamic features may be relevant in the aortic remodeling process and distribution of the stress mapping and could help, in the near future, the optimization of the percutaneous prosthesis implantation. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)


Subject(s)
Humans , Aortic Valve Stenosis/diagnostic imaging , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Transcatheter Aortic Valve Replacement/adverse effects , Aorta , Aortic Valve/surgery , Aortic Valve/diagnostic imaging , Aortic Valve Stenosis/surgery , Prosthesis Design , Treatment Outcome , Computed Tomography Angiography , Hemodynamics
16.
Arq. bras. cardiol ; 115(3): 515-524, out. 2020. tab, graf
Article in English, Portuguese | SES-SP, LILACS, SES-SP | ID: biblio-1131307

ABSTRACT

Resumo Fundamento A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional. Objetivo Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal). Métodos Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05. Resultados Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias, 50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão: A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)


Abstract Background Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment. Objectives To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV). Methods Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05. Results From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm2; post-intervention, 2.18±0.36 cm2; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up. Conclusion The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients' selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)


Subject(s)
Humans , Aged , Aged, 80 and over , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency/surgery , Prosthesis Design , Brazil , Cardiac Catheterization , Treatment Outcome , Mitral Valve/surgery , Mitral Valve/diagnostic imaging
18.
Arch. cardiol. Méx ; 90(3): 313-320, Jul.-Sep. 2020. tab, graf
Article in Spanish | LILACS | ID: biblio-1131049

ABSTRACT

Resumen Los pacientes con cardiopatías congénitas que afectan la continuidad del ventrículo derecho con la arteria pulmonar deben someterse con frecuencia a intervenciones debido a la limitada vida útil de los conductos quirúrgicos, lo que lleva al desarrollo de disfunción ventricular derecha por cambios en la geometría ventricular y predisposición a arritmias letales, con el consiguiente riesgo de reintervenciones. El implante valvular percutáneo pulmonar es una nueva alternativa terapéutica, menos invasiva en comparación con la quirúrgica, para pacientes seleccionados. Se realiza una revisión de las publicaciones médicas actuales disponibles y se describe la experiencia inicial del implante valvular pulmonar percutáneo en un centro colombiano de alta complejidad para el tratamiento de enfermedades cardiovasculares, en dos pacientes con disfunción del homoinjerto aórtico en posición pulmonar con doble lesión valvular, en los cuales el implante valvular pulmonar percutáneo fue una conducta exitosa. Se eligió a pacientes con cardiopatías congénitas, conductos quirúrgicos disfuncionales con estenosis o insuficiencia pulmonar significativa, y disfunción y dilatación ventricular derechas. Se empleó la técnica regular para el implante de la válvula pulmonar Melody, sin documentarse complicaciones durante el procedimiento ni al año de seguimiento. El implante percutáneo de la válvula pulmonar es un gran avance en el tratamiento de pacientes con cardiopatías congénitas, con resultados favorables a corto y mediano plazos, lo cual hace posible la restauración de la función ventricular con riesgo mínimo, frente al reemplazo quirúrgico en pacientes seleccionados.


Abstract Patients with congenital heart disease that involves reconstruction of the right ventricular outflow tract must frequently undergo interventions derived from the limited useful life of the surgical canals, which leads to the development of right ventricular dysfunction due to changes in the ventricular geometry and predisposition to lethal arrhythmias, with the consequent risk of reinterventions. The percutaneous pulmonary valvular implant is a new therapeutic alternative, less invasive, compared to surgery, for selected patients. A review of the available literature is made and the initial experience of percutaneous pulmonary valve implantation in a Colombian center of high complexity for the treatment of cardiovascular diseases is described, in two patients with aortic homograft dysfunction in a pulmonary position with double valvular lesion, in which the percutaneous pulmonary valve implant was a successful strategy. Patients with congenital heart disease were chosen, with dysfunctional surgical conduits with stenosis or significant pulmonary insufficiency, with dysfunction and right ventricular dilatation. The standard technique for the implantation of the Melody pulmonary valve was used, without complications during the procedure or one year of follow-up. Percutaneous implantation of the pulmonary valve is a great advance in the management of patients with congenital heart diseases, with favorable results in the short and medium term, allowing the restoration of ventricular function with minimal risk, compared to surgical replacement in selected patients.


Subject(s)
Humans , Male , Adolescent , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Stenosis/surgery , Heart Valve Prosthesis Implantation/methods , Prosthesis Design , Pulmonary Valve/surgery , Pulmonary Valve/pathology , Pulmonary Valve Insufficiency/congenital , Pulmonary Valve Stenosis/congenital , Colombia
19.
Rev. chil. cardiol ; 39(2): 159-164, ago. 2020. graf
Article in Spanish | LILACS | ID: biblio-1138529

ABSTRACT

Abstract A 68-year-old man previously subjected to radiotherapy had a prior aortic valve replacement due de radiation induced calcification of the aortic valve. Presently the patient developed severe calcification of the mitral valve ring leading to critical mitral valve stenosis. A supra annular implantation of an On X Conform valve was successfully achieved. The clinical course was uneventful, and the echocardiographic evaluation demonstrated a normal function of the valve. Different alternatives for the surgical management of this complication are discussed.


Subject(s)
Humans , Male , Aged , Calcinosis/complications , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Mitral Valve Stenosis/surgery , Mitral Valve Stenosis/complications , Calcinosis/surgery , Calcinosis/diagnostic imaging , Echocardiography , Fluoroscopy , Mitral Valve Annuloplasty , Mitral Valve Stenosis/diagnostic imaging
20.
Rev. bras. cir. cardiovasc ; 35(4): 411-419, July-Aug. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137311

ABSTRACT

Abstract Introduction: People with aortic/prosthetic valve endocarditis are a high-risk cohort of patients who present a challenge for all medically involved disciplines and who can be treated by various surgical techniques. Methods: We analyzed the results of treatment of root endocarditis with Medtronic Freestyle® in full-root technique over 19 years (1999-2018) and compared them against treatment with other tissue valves. Comparison was made with propensity score matching, using the nearest neighbor method. Various tests were performed as suited for adequate analyses. Results: Fifty-four patients in the Medtronic Freestyle group (FS group) were matched against 54 complex root endocarditis patients treated with other tissue valves (Tissue group). Hospital mortality was 9/54 (16.7%) in the FS group vs. 14/54 (25.6%) in the Tissue group (P=0.24). Cox regression performed for early results demonstrated coronary heart disease (P=0.004, odds ratio 2.3), among others, influencing early mortality. Recurrent infection was low (1.8% for FS and Tissue patients) and freedom from reoperation was 97.2% at a total of 367 patient-years of follow-up (median of 2.7 years). Conclusion: The stentless xenograft is a viable alternative for treatment of valve/root/prosthetic endocarditis, demonstrating a low rate of reinfection. The design of the bioroot allows for complex reconstructive procedures at the outflow tract and the annular level with at an acceptable operative risk. Endocarditis patients can be treated excluding infective tissue from the bloodstream, possibly with benefits, concerning bacteremia and recurrent infection. Furthermore, the use of the stentless bioroot offers varying treatment options in case of future valve degeneration.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Bioprosthesis/adverse effects , Heart Valve Prosthesis/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Endocarditis, Bacterial/surgery , Aortic Valve/surgery , Prosthesis Design , Reoperation , Treatment Outcome , Propensity Score
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