Morbimortalidad cardiovascular y variación del grado funcional en pacientes ancianos portadores de marcapasos / Medium-long term mortality and change in functional status in elderly patients with pacemaker

Resumen Antecedentes: Aproximadamente un 49% de los implantes se efectúan a individuos mayores de 80 años; sin embargo, la evidencia científica sobre mortalidad y cambio en la situación funcional de estos pacientes es muy pobre. Objetivo: Diseñamos un estudio prospectivo para analizar la morbimortalidad cardiovascular y la variación de su grado funcional a medio plazo en pacientes ancianos con electroestimulación permanente. Método: Estudio observacional prospectivo, que incluye 308 pacientes ancianos sometidos a implante de marcapasos en un hospital terciario entre 2012 y 2014. Como variables principales se evaluaron eventos cardiovasculares, mortalidad y grado funcional, con una media de seguimiento de 3.5 años. Resultados: El 60% de los pacientes incluidos en nuestro estudio tenían una edad superior a 80 años, y la indicación más frecuente fue el bloqueo auriculoventricular completo (44.3%), seguido de la fibrilación auricular lenta o bloqueada (16.7%). El modo de estimulación más frecuente en la muestra general fue el DDD (38.6%) (VVI en pacientes octogenarios, 38.7%). En el seguimiento, la mortalidad a largo plazo fue mayor en dispositivos ventriculares, especialmente en octogenarios (p = 0.001). El modo de estimulación ventricular (VVI) fue predictor independiente de mortalidad. A largo plazo, no se observó mejoría del índice de Barthel ni del grado funcional tras el implante del marcapasos. Conclusiones: La morbimortalidad cardiovascular en pacientes octogenarios portadores de marcapasos resulta superior a la de la población general, especialmente en dispositivos monocamerales. La electroestimulación permanente no se asocia con mejoría del grado funcional a medio-largo plazo en estos pacientes.

Abstract Background: Nowadays, 49% of patients with pacemakers are older than 80 years old. Nevertheless, mortality and change in functional status after pacemaker implantation are not well documented in elderly patients. Objective: We designed a prospective study to analyze cardiovascular mortality and change in functional status of elderly patients, medium-long term after pacemaker implantation. Methods: Observational study including pacemaker implants in individual older than 70 years old in a single center university hospital between 2012 and 2014. Analysis testing for an association between pacemaker system, medium-long term mortality and functional status after implantation were undertaken. Results: 60% of patients were older than 80 years old. Third-degree atrio-ventricular block (44.3%) and slow ventricular response atrial fibrillation (16.7%) were the most frequent electrocardiogram abnormalities, while bicameral DDD was the sort of pacing our department used the most (38.6%) (VVI in octogenarian patients, 38.7%). Long-term mortality was significantly higher in ventricular devices, especially in octogenarian patients (p = 0.001 respectively). Single-chamber VVI pacing acted as independent predictors of all-cause mortality in these individuals (p = 0.001). We found no significant improvement in Barthel index and functional status in this subgroup of patients, 3 years after pacing. Conclusion: Long-term mortality in individuals older than 80 years old with pacemaker implantation, was significantly higher comparing with general population, especially in ventricular devices. No significant improvement in functional status was detected in this subgroup of patients.

A comparative study of perventricular and percutaneous device closure treatments for isolated ventricular septal defect: a chinese single-institution experience

Abstract Objectives: To compare the advantages and disadvantages of perventricular and percutaneous procedures for treating isolated ventricular septal defect (VSD). Methods: A total of 572 patients with isolated VSD were selected in our hospital between January 2015 and December 2016. The patients' median age and weight were five years (1-26 years) and 29 kg (9-55 kg), respectively. The median diameter of VSD was 6.0 mm (5-10 mm). Patients were divided into two groups. In group A, perventricular device closure was performed in 427 patients; in group B, 145 patients underwent percutaneous device closure. Results: Four hundred twelve patients in group A and 135 patients in group B underwent successful closure. The total occlusion rate was 98.5% (immediately) and 99.5% (3-month follow-up) in group A, which were not significantly different from those in group B (97.7% and 100%, respectively). Patients in group A had longer intensive care unit (ICU) stay than those in group B, but patients in group B experienced significantly longer operative times than those in group A. The follow-up period ranged from 8 months to 1.5 year (median, 1 year). During the follow-up period, late-onset complete atrioventricular block occurred in two patients. No other serious complications were noted in the remaining patients. Conclusion: Both procedures are safe and effective treatments for isolated VSD. The percutaneous procedure has obvious advantages of shorter ICU stay and less trauma than the perventricular procedure. However, the perventricular procedure is simpler to execute, results in a shorter operative time, and avoids X-ray exposure.

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function / Marca-passo Definitivo após Implante Valvar Aórtico Transcateter: Incidência, Preditores e Evolução da Função Ventricular Esquerda

Abstract Background: Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication. Objectives: To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI. Methods: The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted. Results: Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01). Conclusion: BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Resumo Fundamento: O implante valvar aórtico transcateter (TAVI) está bem estabelecido, porém, o bloqueio atrioventricular, com necessidade de marca-passo definitivo (MPD), é complicação frequente. Objetivo: Determinar a incidência, preditores e desfechos clínicos de implante de MPD após TAVI, focando em como a evolução da fração de ejeção do ventrículo esquerdo (FEVE), após o TAVI, é afetada pelo MPD. Métodos: No registro brasileiro foram incluídos 819 pacientes submetidos a TAVI por estenose aórtica severa em 22 centros entre janeiro/2008 e janeiro/2015. Após exclusões, os preditores de implante de MPD foram avaliados em 670 pacientes por regressão multivariada. Análise da curva ROC foi utilizada para medir a habilidade dos preditores; p < 0,05 foi considerado significativo. Resultados: Aos 30 dias, 135 pacientes (20,1%) necessitaram de MPD. Tais pacientes eram mais velhos (82,5 vs. 81,1 anos; p = 0,047) e predominantemente homens (59,3% vs 45%; p = 0,003). A permanência hospitalar foi maior no Grupo MPD (média= 15,7 ± 25,7 vs. 11,8 ± 22,9 dias; p < 0,001), mas o implante não afetou morte por qualquer causa (26,7% vs. 25,6%; p = 0,80) nem morte cardiovascular (14,1% vs. 14,8%; p = 0,84). Por análise multivariada, a presença prévia de bloqueio de ramo direito (BRD) (OR, 6,19; 3,56-10,75; p ≤ 0,001), o uso da prótese CoreValve® (OR, 3,16; 1,74-5,72; p ≤ 0,001) e gradiente transaórtico basal > 50 mmHg (OR, 1,86; 1,08-3,2; p= 0,025) foram preditores de implante de MPD. O risco estimado de implante de MPD foi 4%, quando nenhum dos fatores de risco estava presente, e 63% na presença de todos. O modelo mostrou boa habilidade de prever a necessidade de MPD: 0,69 (IC95%: 0,64 - 0,74) na curva ROC. Subestudo de 287 ecocardiogramas durante o seguimento de 1 ano mostrou pior evolução da FEVE no Grupo MPD (p = 0,01). Conclusão: Em crianças de 6 a 11 anos, circunferência da cintura aumentada está associada à PA elevada, mesmo quando o IMC é normal. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Disincronía ventricular izquierda en la estimulación septal prolongada / Left ventricular dyssynchrony in prolonged septal stimulation

La estimulación por marcapasos se asocia con eventos adversos graves. En la siguiente serie de casos se evaluó la disincronía mecánica intraventricular izquierda (DMVI) en la estimulación endocárdica prolongada del ventrículo derecho a nivel septal. Se estudiaron 6 personas con marcapasos implantados no antes de un año utilizando SPECT gatillado con 99mTc-MIBI y análisis de fase en reposo. Se registraron variables clínicas, duración del QRS, tasa y modo de estimulación ventricular, presencia y extensión de isquemia y/o infarto, volúmenes cavitarios y FEVI en reposo. Utilizando V-Sync de Emory Cardiac Toolbox se obtuvieron el ancho de banda (AB) y el desvío estándar de fase (DEF) en reposo (grados), comparándolos con una población control. La estimulación endocárdica prolongada en el septum ventricular derecho se asoció con marcada DMVI, aun cuando la función sistólica estaba conservada. Aquellos con FEVI moderada/gravemente disminuida (caracterizados por diámetros cavitarios mayores, infarto o isquemia grave) exhibieron mayor disincronía que aquellos con FEVI conservada/levemente disminuida (AB: 177.3o vs. 88.3o; DEF: 53.1o vs. 33.8o). En los casos con cardiopatía isquémica portadores de marcapasos, el AF es una herramienta válida de potencial utilidad para evaluar la disincronía asociada al infarto y, eventualmente, aportar a la decisión oportuna del pasaje al modo de estimulación biventricular.

Pacemaker stimulation is associated with unpredictable severe cardiac events. We evaluated left ventricular mechanical dyssynchrony (LVMD) during prolonged septal right ventricular pacing. We performed 99mTc-MIBI gated-SPECT and phase analysis in 6 patients with pacemakers implanted at least one year before scintigraphy due to advanced atrioventricular block. Using V-Sync of Emory Cardiac Toolbox we obtained phase bandwidth (PBW) and standard deviation (PSD) from rest phase histogram. Clinical variables, QRS duration, rate and mode of pacing in septal right ventricle wall, chamber diameters, presence and extension of myocardial scar and ischemia and rest LVEF were recorded. Prolonged septal endocardial pacing is associated with marked LVMD, even when systolic function was preserved. More severe dyssynchrony was found in patients with impaired LVEF, higher left ventricle diameters, extensive infarct or severe ischemia than in patients with preserved LVEF (PBW: 177.3o vs. 88.3o; PSD: 53.1o vs. 33.8o). In the patients with ischemic heart disease and pacemaker, gated-SPECT phase analysis is a valid and potentially useful technique to evaluate LMVD associated with myocardial scar and to decide the upgrading to biventricular pacing mode.

A estimulação cardíaca convencional é prejudicial em pacientes com função ventricular normal? / Is conventional cardiac pacing harmful in patients with normal ventricular function?

FUNDAMENTO: A estimulação de ventrículo direito pode ser deletéria em pacientes com disfunção ventricular, porém, em pacientes com função normal, o impacto desta estimulação desencadeando disfunção ventricular clinicamente relevante não é completamente estabelecido. OBJETIVOS: Avaliar a evolução clínica, ecocardiográfica e laboratorial de pacientes, com função ventricular esquerdapreviamente normal, submetidos a implante de marca-passo. MÉTODO: Estudo observacional transversal em que foram acompanhados de forma prospectiva 20 pacientes submetidos a implante de marca-passo com os seguintes critérios de inclusão: função ventricular esquerda normal definida pelo ecocardiograma e estimulação ventricular superior a 90%. Foram avaliados: classe funcional (CF) (New York Heart Association), teste de caminhada de 6 minutos (TC6), dosagem do hormônio natriurético tipo B (BNP), avaliação ecocardiográfica (convencional e parâmetros de dessincronismo) e questionário de qualidade de vida (QV) (SF-36). A avaliação foi feita com dez dias (t1), quatro meses (t2), oito meses (t3), 12 meses (t4) e 24 meses (t5). RESULTADOS: Os parâmetros ecocardiográficos convencionais e de dessincronismo não apresentaram variação estatística significante ao longo do tempo. O TC6, a CF e a dosagem de BNP apresentaram piora ao final dos dois anos. A QV teve melhora inicial e piora ao final dos dois anos. CONCLUSÃO: O implante de marca-passo convencional foi associado à piora da classe funcional, piora do teste de caminhada, aumento da dosagem de BNP, aumento da duração do QRS e piora em alguns domínios da QV ao final de dois anos. Não houve alterações nas medidas ecocardiográficas (convencionais e medidas de assincronia).

BACKGROUND: Right ventricular pacing may be deleterious in patients with left ventricular dysfunction, but in patients with normal function the impact of this stimulation triggering clinically relevant ventricular dysfunction is not fully established. OBJECTIVES: To evaluate the clinical, echocardiographic findings of patients with previously normal left ventricular function underwent implantation of a pacemaker. METHODS: Observational, cross-sectional study with 20 patients, who underwent implantation of pacemaker, prospectively followed-up, with the following inclusion criteria: normal left ventricular function defined by echocardiography and ventricular pacing higher than 90%. Were evaluated functional class (FC) (New York Heart Association), 6-minute walk test (6MWT), B-type natriuretic peptide (BNP), echocardiographic assessment (conventional and dyssynchrony parameters), and quality of life questionnaire (QLQ) (SF-36). The assessment was performed at ten days (t1), four months (t2), eight months (t3), 12 months (t4) and 24 months (t5). RESULTS: Conventional echocardiographic parameters and dyssynchrony parameters showed statistically significant variation over time. The 6MWT, FC, and BNP showed worsening at the end of two years. QLQ showed initial improvement and worsening at the end of two years. CONCLUSION: The implantation of conventional pacemaker was associated with worsening in functional class, worsening in walk test, increased BNP levels, increased duration of QRS, and worsening in some domains of the QLQ at the end of two years. There were no changes in echocardiography measurements (conventional and asynchrony measures).

Criss-cross con concordancia aurícular-ventricular y discordancia ventrículo-arterial: presentación clínica / Criss-cross with atrioventricular concordance and ventriculoarterial discordance: clinical presentation

El corazón con entrecruzamiento de la circulación venosa pulmonar y sistémica a nivel auriculoventricular, denominada criss-cross, puede coexistir en presencia de situs solitus o situs inversus con concordancia o discordancia aurículo-ventricular dependiendo de la rotación cardíaca sobre el eje longitudinal ventricular, a favor o en contra de las manecillas del reloj. Presentamos el caso clínico de un lactante menor masculino con diagnóstico de corazón en criss-cross con concordancia aurículo-ventricular y discordancia ventrículo-arterial que ingresó a nuestro centro con disnea y cianosis. En un primer abordaje se le practica atrioseptostomía quirúrgica, sin embargo, en su evolución intrahospitalaria presenta falla cardíaca global refractaria a tratamiento convencional, por lo cual es llevado a nuevamente a cirugía donde se le realiza intervención de Damus-Kaye-Stansel. En el presente artículo se analizan los detalles de la evaluación ecocardiográfica, el cateterismo cardíaco, la resonancia magnética cardíaca y se plantean las opciones quirúrgicas de esta fascinante entidad patológica.

A heart with cross circulation (criss – cross) can coexist in the presence of situs solitus or situs inversus, with atrioventricular concordance or discordance, depending on the cardiac rotation over the ventricular longitudinal axis, clockwise or clock counterwise. This is the presentation of the clinical case of a male lactant, with diagnosis of criss–cross heart with atrioventricular concordance and ventriculoarterial discordance, who was admitted to these facilities with dyspnoea and cyanosis. In a first approach, a surgical atrioseptectomy was performed on the patient. However, in his intrahospitalary evolution, the patient had a global heart failure refractory to conventional treatment, causing his admission into the operating room for surgery, where the Damus–Kaye–Stensel procedure was performed on him. This article presents an analysis of the details of the echocardiographic evaluation, the cardiac catheterization, and the cardiac magnetic resonance of the clinical case, raising the surgical options for this fascinating pathological entity.

Bloqueio atrioventricular total pós- correção cirúrgica de defeito do septo atrioventricular parcial em paciente com associação charge / Total atrioventricular block after septum defect correction surgery partial atrioventricular in patients with charge association / Bloqueo aurículoventricular total post-corrección quirúrgica de defecto del septo aurículoventricular parcial en paciente con asociación charge

Descreveremos o caso de uma paciente com uma síndrome rara (Associação Charge), que evoluiu para uma complicação bastante temida, o bloqueio atrioventricular total, no pós-operatório de correção do defeito do septo atrioventricular parcial.

We will describe a woman’s case with a rare syndrome (Charge Association) with a quite feared complication evolution, the total atrioventricular block, in the postoperative of partialatrioventricular defect correction.

Describiremos el caso de una paciente con un síndrome raro (Asociación Charge), que evolucionó hacia una complicación bastante temida, el bloqueo aurículoventricular total, en el postoperatorio de corrección del defecto del septo aurículoventricular parcial.