Implante de válvulas transcatéter en prótesis valvulares quirúrgicas disfuncionantes: un cambio de paradigma / Transcatheter valve implantation in dysfunctioning surgical valvular prostheses: a paradigm shift

La disfunción de las bioprótesis quirúrgicas frecuentemente ocurre en pacientes añosos, con severas comorbilidades, lo que implica un riesgo elevado frente a una nueva cirugía valvular. El implante de válvulas transcatéter dentro de bioprótesis disfuncionantes o procedimiento valve in valve (VIV), ha sido desarrollado como una nueva alternativa terapéutica para este tipo de situación. Los procedimientos VIV deben ser considerados para pacientes con disfunción protésica severa sintomática con alto riesgo quirúrgico, luego de un exhaustivo análisis individualizado por un grupo de expertos o heart team. La selección y evaluación previa de los pacientes son fundamentales para el éxito del procedimiento. La evidencia respalda más fuertemente este tipo de intervención en posición aórtica que en posición mitral. En esta revisión analizamos brevemente las indicaciones, la evaluación previa de los pacientes, los aspectos relevantes del procedimiento y sus complicaciones eventuales, con especial énfasis en el procedimiento VIV mitral, que ha sido motivo de dos recientes reportes de casos en esta revista.

Bioprosthetic surgical valve dysfunction occurs frequently in elderly patients with severe comorbidities, which implies a high surgical risk in case of redo valve surgery. Transcatheter valve implantation within a surgical bioprosthesis, so-called valve in valve procedure (VIV), has been developed as new treatment option for this situation. VIV procedures should be considered in patients with severely symptomatic prosthetic valve dysfunction with high surgical risk, after careful heart team evaluation. Patient selection and pre-procedural evaluation are mainstay for procedural success. Current evidence has stronger support for VIV procedure in aortic than in mitral position. In this review, we briefly analyze VIV procedure indications, patient evaluation, as well as relevant aspects of the procedure itself and its most frequent complications. Special emphasis will be given for VIV in mitral position which has been the focus of two recent case reports in this journal.

The short term outcome after mitral valve replacement with the perimount bovine pericardial valve / 天津医药

Objective To evaluate the short term outcome after mitral valve replacement with the Perimount bovine pericardial valve. Methods Eighty-eight patients underwent mitral valve replacement with the bovine pericardial valve in hospital were included in this study. Postoperative general condition including mortality and cerebral hemorrhage was observed. The hemodynamic and New York heart disease association (NYHA) heart function classification were recorded by Doppler echocardiograms before operation, postoperative 1 week, 3 months and 1 year after mitral valve replacement. Values of the different time points of NYHA, left atrial diameter (LA), left ventricular end diastolic diameter (LVDD), left ventricular end systolic diameter (LVSD), left ventricular ejection fraction (LVEF) and pulmonary artery pressure (PAP) were compared. The hemodynamic parameters were also compared including the peak cross valve pressure (PG), mean cross valve pressure (MG), peak cross valve velocity (PV) and effective orifice area (EOA) 1 week, 3 months and 1 year after surgery. Results There were two cases (2.3%) dead in one year (one died of cerebral hemorrhage and another one died of thromboembolism). There was 1 perivalvular leakage (1.2%). There was no endocarditis or structural valve deterioration. NYHA cardiac function was improved at postoperative 3 months and 1 year (P < 0.05). The values of LA, LVDD and PAP were significantly decreased at postoperative 1 week, 3 months and 1 year compared with those before operation (P<0.05). Values of LVSD and LVEF were significantly decreased at postoperative 1 week compared with those before operation (P<0.05). The value of LVEF was significantly increased at postoperative 3 months and 1 year (P<0.05). Compared with postoperative 1 week, the values of LA and LVEF were significantly increased at postoperative 3 months and 1 year (P < 0.05). There were no significant differences in PG, MG, PV and EOA between postoperative 1 week, 3 months and 1 year. Conclusion With the excellent performance of cardiac function recovery, left ventricular restoration and hemodynamic, the Perimount bovine pericardial valve remains a reliable choice as a mitral tissue valve.

Transcatheter, valve-in-valve transapical aortic and mitral valve implantation, in a high risk patient with aortic and mitral prosthetic valve stenoses.

Transcatheter valve implantation continues to grow worldwide and has been used principally for the nonsurgical management of native aortic valvular disease‑as a potentially less invasive method of valve replacement in high‑risk and inoperable patients with severe aortic valve stenosis. Given the burden of valvular heart disease in the general population and the increasing numbers of patients who have had previous valve operations, we are now seeing a growing number of high‑risk patients presenting with prosthetic valve stenosis, who are not potential surgical candidates. For this high‑risk subset transcatheter valve delivery may be the only option. Here, we present an inoperable patient with severe, prosthetic valve aortic and mitral stenosis who was successfully treated with a trans catheter based approach, with a valve‑in‑valve implantation procedure of both aortic and mitral valves.

Expressão da quinase de adesão focal e correlação com fibrose no miocardio humano exposto a sobrecarga volumetrica por insuficiencia da valvula mitral / Expression of focal adhesion kinase is increased and correlates with fibrosis in failing human myocardium

A insuficiência cardíaca é um dos maiores problemas de saúde pública da atualidade. Esforços têm sido feitos para a obtenção do entendimento dos mecanismos que resultam no comprometimento funcional e estrutural do miocárdio, responsáveis, em última instância, pela síndrome clínica. Doenças das válvulas constituem importante contingente dentre as causas de disfunção miocárdica que resulta insuficiência cardíaca. Tipicamente, as doenças das válvulas resultam em sobrecargas mecânicas das câmaras ventriculares que têm papel central no estabelecimento e evolução das alterações estruturais que acompanham a deterioração funcional do miocárdio e, por conseguinte, a da função global das câmaras cardíacas. É fato bem estabelecido na prática clínica a estreita relação entre a presença e a intensidade de comprometimento da função das câmaras ventriculares e o prognóstico clínico ou cirúrgico dos pacientes. Portanto, o esclarecimento dos mecanismos moleculares e celulares que resultam em alterações estruturais irreversíveis, bem como o estabelecimento de indicadores clínico-laboratoriais de alterações precoces é área de grande interesse prático. No presente estudo foram avaliados pacientes portadores de insuficiência mitral com indicação clínica de tratamento cirúrgico, com o objetivo de avaliar alterações estruturais do miocárdio e sua relação com a função ventricular e a expressão e atividade da quinase de adesão focal, uma tirosino-quinase envolvida em mecanismos de sinalização de estímulos mecânicos. Pacientes com insuficiência mitral (21) foram avaliados clinica e ecocardiograficamente no período pré-operatório e em seguimento de um ano após a cirurgia. Foram realizadas biópsias intra-operatórias do ventrículo esquerdo para análise histo-morfométrica e bioquímica da expressão e atividade da quinase de adesão focal e quantificação da área...

Heart failure is one of the biggest problems faced by public health. Efforts have been made in order to achieve full understanding of the mechanisms that result in the myocardium structural and functional deterioration, which is responsible for advanced symptoms. Valvular diseases are important causes of myocardium dysfunction, which result in heart failure. Typically, valvular diseases result in mechanic overload of the ventricular chambers, which play a central role in the setting up and evolution of the structural alterations that follow myocardium functional deterioration and, consequently, the global dysfunction of the cardiac chambers. The close relation between the ventricular dysfunction and the clinical or surgical prognosis of the patient is well documented in clinical practice. Therefore, the understanding of the cellular and molecular mechanisms that result in the irreversible structural alterations, as well as the setting up of clinical-laboratorial indicators of early alterations is an area of great practical interest. In the present study patients presenting mitral valve disease with clinic indication for surgical treatment, aiming at evaluating structural alterations of the myocardium and their relations to the ventricular function, and the expression and activity of focal adhesion kinase, a tyrosine-kinase involved in mechanisms of mechanic stimulus signalization. Patients suffering from mitral regurgitation (21) were evaluated by clinical exams and echocardiography in the pre-operative period and underwent clinical and echocardiograph exams for a period of one year after surgery. Intra-operative biopsies of the left ventricle were performed in order to carry out histomorphometric and biochemical analyses of the expression and activity of focal adhesion kinase and quantification of the area occupied by the myocardium interstice. The majority of the patients presented advanced symptoms of heart failure (CF III-IV) in the...