Immediate outcomes of aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium: a multicenter study

Abstract Objective: To determine the feasibility of aortic valve neocuspidization (AVNeo) with glutaraldehyde-treated autologous pericardium. Methods: One hundred and seventy (170) AVNeo (84 males/86 females) were performed from January 2017 through March 2019 in three centers. All the records were prospectively collected and retrospectively reviewed. Results: Most of the patients were older than 60 years and over 95% were operated for aortic stenosis. Preoperatively, pressure gradients were 69.9±21.3 mmHg for patients with aortic stenosis, and the surgical annular diameter was 21.0±2.0 mm for all patients. Effective orifice area (EOA) and indexed EOA (iEOA) averaged 0.7±0.3 cm2 and 0.4±0.2 cm2/m2 for patients with aortic stenosis before surgery, respectively. There was no conversion to prosthetic aortic valve replacement. Eight patients needed reoperation for bleeding, but no patient needed reoperation due to early infective endocarditis. There were five in-hospital deaths due to noncardiac cause. Compared to preoperative echocardiographic measurements, postoperative peak pressure gradient decreased significantly (-58.7±1.7 mmHg; P<0.001) and reached 11.2±5.6 mmHg, and mean pressure gradient also decreased significantly (-36.8±1.1 mmHg; P<0.001) and reached 6.0±3.5 mmHg. Accordingly, EOA and iEOA increased significantly 2.0 cm2 and 1.0 cm2/m2 (both P<0.001) to reach 2.7±0.6 cm2 and 1.4±0.3 cm2/m2 after surgery, respectively, with minimal significant aortic regurgitation (0.6% > mild). Conclusion: AVNeo is feasible and reproducible with good clinical results. Hemodynamically, AVNeo produces immediate postoperative low-pressure gradients, large EOA, and minimal regurgitation of the aortic valve. Further studies are necessary to evaluate mid- and long-term evolution.

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis? / Determinantes da Desproporção de Prótese Aórtica em Hospital de Atendimento de Saúde Pública Brasileiro: Pacientes Grandes ou Próteses Pequenas?

Abstract Background: Prosthesis-patient mismatch (PPM) is associated with worse outcomes. Objective: Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care. Methods: A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm2/m2), mild to moderate PPM (iEOA, 0.65 cm2/m2 - 0.85 cm2/m2) and without PPM (iEOA > 0.85 cm2/m2) for a BMI < 30 kg/m2 and severe PPM (iEOA) < 0.55 cm2/m2), mild to moderate (iEOA, 0.55 cm2/m2- 0.70 cm2/m2) and without PPM (iEOA > 0.7 cm2/m2) for a BMI > 30 kg/m2. Statistical significance was considered when p < 0.05. Results: iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m2, age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82. Conclusion: The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

Resumo Fundamento: A desproporção entre o tamanho da prótese aórtica-paciente (DPP) está associada a maior mortalidade. Objetivo: Determinar a frequência e avaliar variáveis ​​pré-operatórias associadas à DPP acentuada no cenário da saúde pública em hospital terciário. Métodos: 316 pacientes submetidos à troca valvar aórtica (TVA), com ecocardiograma realizado nos primeiros 30 dias após cirurgia, foram analisados retrospectivamente. A área de orifício efetivo indexado (AOEi) da prótese foi utilizada para classificar os pacientes em três grupos de acordo com a DPP, considerando o índice de massa corporal (IMC): DPP acentuada (AOEi) < 0,65 cm2/m2, DPP discreta a moderada (AOEi, 0,65 cm2/m2 - 0,85 cm2/m2) e sem DPP (iEOA > 0,85 cm2/m2) para IMC < 30 kg/m2 e DPP acentuada (AOEi) < 0,55 cm2/m2), discreta a moderada (AOEi, 0,55 cm2/m2 - 0,70 cm2/m2) e sem DPP (AOEi > 0,7 cm2/m2) para IMC > 30 kg/m2. Significância estatística foi considerada com p < 0,05. Resultados: A AOEi foi obtida em 176 pacientes. A frequência de DPP acentuada foi de 33,4% e moderada de 36,2%. Pacientes com DPP acentuada foram mais jovens e com maior IMC, mas menor diâmetro da via de saída do ventrículo esquerdo (DVSVE). As variáveis independentes que podem predizer DPP acentuada são: gênero masculino, IMC > 25 kg/m2, idade < 60 anos, DVSVE < 21 mm e etiologia reumática com área sob a curva ROC de 0,82. Conclusão: A frequência de DPP acentuada é alta em uma população brasileira submetida à TVA no Sistema Público de Saúde. Os principais determinantes de DPP acentuada são: valvopatia reumática, gênero masculino, IMC alto, idade < 60 anos e menor DVSVE.

Prosthesis-patient mismatch negatively affects outcomes after mitral valve replacement: meta-analysis of 10, 239 patients

Abstract Objective: This study sought to evaluate the impact of prosthesis-patient mismatch on the risk of perioperative and long-term mortality after mitral valve replacement. Methods: Databases were researched for studies published until December 2018. Main outcomes of interest were perioperative and 10-year mortality and echocardiographic parameters. Results: The research yielded 2,985 studies for inclusion. Of these, 16 articles were analyzed, and their data extracted. The total number of patients included was 10,239, who underwent mitral valve replacement. The incidence of prosthesis-patient mismatch after mitral valve replacement was 53.7% (5,499 with prosthesis-patient mismatch and 4,740 without prosthesis-patient mismatch). Perioperative (OR 1.519; 95%CI 1.194-1.931, P<0.001) and 10-year (OR 1.515; 95%CI 1.280-1.795, P<0.001) mortality was increased in patients with prosthesis-patient mismatch. Patients with prosthesis-patient mismatch after mitral valve replacement had higher systolic pulmonary artery pressure and transprosthethic gradient and lower indexed effective orifice area and left ventricle ejection fraction. Conclusion: Prosthesis-patient mismatch increases perioperative and long-term mortality. Prosthesis-patient mismatch is also associated with pulmonary hypertension and depressed left ventricle systolic function. The findings of this study support the implementation of surgical strategies to prevent prosthesis-patient mismatch in order to decrease mortality rates.

Recomendações para Avaliação por Imagens das Próteses Valvares Cardíacas / Recommendations for the Imaging Assessment of Prosthetic Heart Valves

Disfunção de prótese valvar cardíaca (PVC) é rara, porém é uma potencial ameaça à vida. Estabelecer o exato mecanismo da disfunção da PVC é desafiador, no entanto é essencial para determinar a estratégia terapêutica apropriada. Na prática clinica, uma abordagem abrangente que integra vários parâmetros de morfologia e função avaliados pelo eco transtorácico 2D/3D e transesofágico são fundamentais para detectar e quantificar a disfunção da PVC. A cinefluoroscopia, a tomografia computadorizada com multidectetores, a ressonância magnética cardíaca, e em menor escala, a imagem nuclear, são ferramentas complementares para o diagnóstico e abordagem das complicações das PVC. Este documento apresenta recomendações para o uso de imagem em multimodalidade para avaliação das PVCs