Clinical characteristics and mid-term follow-up of elderly patients with severe aortic stenosis not eligible for TAVI

BACKGROUND: The treatment for symptomatic severe aortic stenosis (AS) is the correction of valve stenosis by surgical valve replacement and more recently by transcatheter aortic valve implant (TAVI). However, in some high risk surgical patients, TAVI is not possible for technical or clinical reasons or due to the unavailability of the endoprosthesis. OBJECTIVE: The aim of this study was to evaluate a mid-term follow-up of symptomatic severe AS patients who are not eligible for TAVI trials, as well as to identify the clinical features of these patients. METHODS: This was an observational, retrospective study conducted with 475 symptomatic severe AS patients, evaluated by the Heart Team between 2000 and 2017. Inclusion criterias were: patients considered not to be eligible for TAVI. The Shapiro-Wilk test was applied to evaluate normality. Non-paired t and Mann-Whitney tests were applied for continuous variables, while the chi-squared and Fischer exact tests were applied for categorical variables, with a level of significance of p<0,05. RESULTS: The heart team evaluated 475 patients: 25 (5.26%) died before any intervention could be proposed; 326 (68.3%) were submitted to TAVI, so the study population consisted of 124 patients not eligible for TAVI. Of these, 31 (25%) underwent surgery and 93 (75%) remained in clinical treatment. In a mean 56 months- follow-up the mortality in clinical group was 46.2%. In the surgical group the mortality was 23.9% (in-hospital 12.9% and late mortality 11% in a mean 47.4 months follow-up). The patients that died presented a significantly lower left ventricle ejection fraction (LVEF), a smaller valve area, and a larger end-systolic diameter of the LV. CONCLUSION: The mortality of the clinical group's patients was significantly higher than the surgical mortality (46.2% vs. 12.9%; p=0.021). The patients of the clinical group were older, weighed less, and had a higher incidence of renal failure and a higher STS score.

Initial experience of cardiac catheterization through distal radial access in a femoralist center / Experiencia inicial de cateterización cardiaca mediante acceso radial distal en un centro femoralista

Objective: to share our experience in the radial distal approach to perform coronary angiography and / or dilation of coronary stenosis. The initial results are exposed in the access of the distal radial artery or in the so-called anatomical "snuff box". Methods: The left or right radial distal artery was used as an access site in 6 patients admitted to the Institute of Cardiology and Cardiovascular Surgery for coronary angiography and dilatation of coronary stenosis between May 6 and June 6 of 2019. All with pulse present in their distal radial artery. In the laboratory, they had the access arm flexed with respect to the homolateral shoulder so that the hand was placed on their contralateral groin. In all cases, the operator was placed on the right side of the patient, to perform coronary angiography and / or dilation of coronary stenosis. During the hospital stay, the main demographic characteristics and complications were recorded. Results: the average age of the patients was 72 +/- 10 years and 83.3 percent were men. We use the Judkins and Amplatz 6 and 5 French catheters for the procedures. Five admitted with the diagnosis of angina and one with severe aortic valve stenosis. In 5 patients, distal transradial coronary angiography was successfully performed. Only one patient experienced distal radial spasm, using in this case the ipsilateral proximal radial access, without making it necessary to approach the femoral artery. In total, 4 patients had coronary intervention, performing successfully in the 4 patients. The right coronary artery was the artery that required most of the intervention (3 patients). There were no cases of occlusion of the radial arteries, no hematoma of the hand, of the B.A.R.C scale greater than 1 was observed in any patient. Numbness of the hand was documented in none. The radial introducer was removed at the end of the procedure. Hemostasis was achieved with manual compression. Conclusion: the distal radial approach is feasible in a selected group of patients as a procedure for coronary angiography and dilatation of coronary stenosis(AU)

Objetivo: compartir nuestra experiencia en el abordaje radial distal para realizar la angiografía coronaria y/o la dilatación de la estenosis coronaria. Se exponen los resultados iniciales en el acceso de la arteria radial distal o en la llamada "tabaquera" anatómica. Métodos: se utilizó la arteria radial distal izquierda o derecha como sitio de acceso en 6 pacientes ingresados en el Instituto de Cardiología y Cirugía Cardiovascular para angiografía coronaria y dilatación de estenosis coronaria del 6 de mayo al 6 de junio de 2019. Todos los pacientes tenían pulso en la arteria radial distal. En el laboratorio, se les flexionó el brazo de acceso con respecto al hombro homolateral de modo que la mano descansara sobre la ingle contralateral. En todos los casos, el técnico se situó a la derecha del paciente para realizar la angiografía coronaria y/o dilatación de la estenosis coronaria. Durante la estancia de los pacientes en el hospital, se registraron sus principales características demográficas y complicaciones. Resultados: la edad promedio de los pacientes fue de 72 +/- 10 años y 83,3 por ciento eran hombres. Usamos catéteres franceses Judkins y Amplatz 6 y 5 para los procedimientos. Cinco pacientes habían sido ingresados con un diagnóstico de angina y uno con estenosis valvular aórtica severa. La angiografía coronaria transradial distal fue exitosa en 5 pacientes. Solo un paciente experimentó un espasmo distal radial, usándose en ese caso el acceso radial proximal ipsilateral sin que fuera necesario abordar la arteria femoral. Un total de 4 pacientes se sometieron a intervención coronaria, la que fue exitosa en los 4. La arteria coronaria derecha fue la que requirió la mayor parte de la intervención (3 pacientes). No hubo ningún caso de oclusión de las arterias radiales ni de hematoma de la mano. Tampoco se observó un valor de la escala BARC mayor de 1 en ningún paciente. No se documentó entumecimiento de la mano en ningún paciente. El introductor radial se retiró al final del procedimiento. La hemostasia se alcanzó mediante compresión manual. Conclusión: el abordaje radial distal es factible en un grupo seleccionado de pacientes como procedimiento para la angiografía coronaria y la dilatación de la estenosis coronaria(AU)

Incidence of Conduction Disorders and Requirements for Permanent Pacemaker After Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has become a therapeutic option for high-risk or non-operable patients with severe symptomatic aortic stenosis. Atrioventricular conduction disturbances requiring permanent pacemaker (PPM) are a common and clinically important complication. Objectives: To evaluate the incidence of conduction disorders (CDs) after TAVI and the need for subsequent PPM implantation. To identify the predictors of postoperative PPM implantation. Methods: Retrospective study. All patients who underwent TAVI in a public hospital from December/2011 to June/2016 were included. Multivariate analysis was conducted to establish the predictor of permanent pacemaker implantation. Survival curves were constructed by the Kaplan-Meyer method. Statistically significant variables were those with p value < 0.05. Results: 64 patients with AS underwent TAVI. Eleven patients were excluded. TAVI induced a new CD in 40 (77%) of the remaining 53 patients. The most common new CDs were 3rd degree AV block (32%) and left bundle branch block (30%). Sixteen patients (30,2%) underwent PPM implantation during the index hospitalization. On univariate analysis the risk factors for PPM implantation were CoreValve® use (OR: 1,76; P = 0,005), larger prosthesis implantation (P = 0,015), presence of a QRS ≥ 120 ms (OR: 5,62; P = 0,012), and 1st degree AV block (OR: 13; P = 0.008). On multivariate analysis the presence of 1st degree AV block predicted the need for PPM. Conclusion: TAVI induced CDs requiring PPM in 30% of the patients. The presence of 1st degree AV block predicted the need for PPM

Estenosis aórtica y lesión severa de tronco coronario: tratamiento percutáneo exitoso / Severe aortic valve stenosis with co-existing critical obstruction of the main left coronary artery

Abstracts: Successful treatment following percutaneous angioplasty (PTCA) and percutaneous trans aortic valve aortic valve stenosis and critical obstruction of the main left coronary artery is presented. Due to a very high estimated surgical risk the patient underwent PTCA of the main left trunk followed, a week later, by trans catheter implantation of an aortic valve (TAVI). The procedure was uneventful, and the clinical condition of the patient was excellent at one year (Functional class I).

Guía de práctica clínica para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú / Clinical practice guideline for the evaluation and management of patients with severe aortic stenosis for the Peruvian Social Security

Resumen Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud basadas en evidencia científica. Métodos: Se conformó un grupo elaborador local (GEG-Local) que incluyó médicos especialistas y metodólogos. El GEG-Local formuló siete preguntas clínicas que ser respondidas en la presente GPC. Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando fue considerado pertinente, estudios primarios en PubMed durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La calidad de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG-Local usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y tratamiento. Finalmente, la GPC fue aprobada con Resolución N.° 47 — IETSI — ESSALUD — 2018. Resultados: La presente GPC abordó siete preguntas clínicas, respecto a dos temas: la evaluación inicial y el tratamiento de la estenosis aórtica severa. Con base en dichas preguntas se formularon nueve recomendaciones (una recomendación fuerte y ocho recomendaciones débiles), 16 puntos de buena práctica clínica y un flujograma. Conclusión: El presente artículo resume la metodología y las conclusiones de la GPC para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud.

Abstract Introduction: This article summarizes the clinical practice guide (CPG) for the evaluation and management of patients with severe aortic stenosis in the Social Security of Peru (EsSalud). Objective: To provide clinical evidence-based recommendations for the evaluation and management of patients with severe aortic stenosis in the EsSalud. Methods: A local guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 7 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and, when it was considered pertinent, primary studies, were conducted in PubMed during 2018. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, points of good clinical practice, and the flowchart of evaluation and management. Finally, the CPG was approved with Resolution N.° 47 — IETSI — ESSALUD — 2018. Results: This CPG addressed 7 clinical questions regarding two issues: the initial evaluation and the management of severe aortic stenosis. Based on these questions, 9 recommendations (1 strong recommendation and 8 weak recommendations), 16 points of good clinical practice, and 1 flowchart were formulated. Conclusion: This article summarizes the methodology and evidence-based conclusions from the CPG for the evaluation and management of patients with severe aortic stenosis in the EsSalud.

Principais estudos clínicos sobre implante de válvula aórtica transcateter / Main clinical studies on transcatheter aortic valve implantation

A estenose aórtica (EA) é uma doença frequente na população idosa e, quando sintomática, tem prognóstico desfavorável, sendo recomendada nesta situação a substituição valvar cirúrgica. Embora o tratamento cirúrgico seja o padrão para a correção da EA muitos pacientes não são candidatos adequados, devido ao risco perioperatório muito elevado. O implante da valva aórtica transcateter (TAVI) surgiu como interessante alternativa, principalmente nos casos de pacientes inoperáveis, demonstrando melhora significativa na sobrevida com relação ao tratamento clínico. Nos pacientes com risco cirúrgico elevado apresentou resultados equivalentes à troca valvar aórtica cirúrgica, com taxas de sobrevivência equivalentes ou até superiores. Os resultados clínicos encorajadores somados aos rápidos avanços da tecnologia geraram interesse no uso desses dispositivos em pacientes de risco intermediário. Atualmente já existem evidências demonstrando a não inferioridade da TAVI com relação à cirurgia para a correção da EA em pacientes de médio risco e esses dispositivos já estão aprovados nos Estados Unidos e Europa para o tratamento desse grupo de pacientes. No presente artigo são sumarizados os principais estudos que foram fundamentais para a implementação da TAVI na prática clínica atual e para aprovação pelos principais órgãos reguladores mundiais

Aortic stenosis (AS) is a common disease in the elderly population; when symptomatic, it has an unfavorable prognosis and aortic valve replacement is recommended. Although surgical replacement is the standard treatment for AS, many patients are not suitable candidates because of high perioperative risk. Transcatheter aortic valve implantation (TAVI) has emerged as an interesting alternative, especially in inoperable cases, showing significant improvements in survival over clinical treatment. In patients with high surgical risk TAVI has demonstrated results equivalent to surgical aortic valve replacement with similar or even higher survival rates. These encouraging clinical results coupled with advances in technology have generated interest in using TAVI in lower-risk populations. There is currently evidence showing that TAVI is not inferior to surgical treatment of AS in intermediate-risk patients, and these devices have already been approved in the United States and Europe for treating this group of patients. This article summarizes the main studies that were fundamental in implementing TAVI into current clinical practice and approval by the main global regulatory agencies

Seleção de pacientes para implante de valva aórtica transcateter / Patient selection for transcatheter aortic valve implantation

Com o envelhecimento populacional, o implante percutâneo de bioprótese valvular aórtica (TAVI, sigla em inglês) vem ganhando espaço no tratamento da estenose aórtica em indivíduos de maior risco operatório. A seleção do paciente para intervenção, no atual momento, leva em consideração risco cirúrgico, comorbidades, fragilidade e patologias que contraindicam o procedimento operatório, além de exames de imagem, tais como a tomografia de tórax, que tem papel importante na avaliação anatômica da válvula aórtica, aorta e seus ramos, e auxilia a escolha da via de acesso, da prótese adequada e a predição de complicações. A avaliação do Heart Team é imprescindível e desaconselha-se a realização do TAVI em locais desprovidos desse grupo. Desta forma, apesar de complexa, a avaliação e seleção do paciente adequado pode reduzir de maneira signficativa a morbidade e a mortalidade do procedimento e se faz estritamente necessária

With the aging of the population, transcatheter aortic valve implantation (TAVI) has gained popularity in the treatment of aortic stenosis in individuals with higher operative risk. The patient selection for intervention, at the present time, takes into account surgical risk, comorbidities, frailty and pathologies that contraindicate the surgical procedure, as well as imaging tests, such as computed tomography of the chest, which plays an important role in the anatomical evaluation of the aortic valve, the aorta and its branches, assisting in the choice of access route and appropriate prosthesis, and the prediction of complications. Evaluation by the Heart Team is imperative, and it is not advisable to perform TAVI in services that do not have this group. Thus, although complex, evaluation and selection of the appropriate patient can significantly reduce the morbidity and mortality of the procedure, and is essential

Perspectivas futuras e novos dispositivos transcateter no tratamento da estenose aórtica / Future perspectives and new transcatheter devices in the treatment of aortic tenosis

O implante de prótese valvar aórtica por cateter (TAVI, do inglês transcatheter aortic valve implantation) constitui o tratamento de escolha para pacientes com estenose aórtica considerada inoperável e surge como opção terapêutica à cirurgia em indivíduos com alto e moderado risco operatório. Embora excelentes resultados clínicos sejam obtidos com as próteses primeiramente disponibilizadas para uso clínico, a ocorrência de complicações ­ como acidente vascular cerebral (AVC), regurgitação (leak) paraprotética, distúrbios de condução com implante de marca-passo (MP) e complicações vasculares ­ deve ser prevenida. As novas próteses têm como características primordiais: menor calibre dos instrumentais, implante valvar mais seguro e previsível e a incorporação de características no arcabouço das próteses que reduzam a ocorrência de refluxo paravalva

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for patients with aortic stenosis that is considered inoperable, and has emerged as a treatment option to surgery in individuals with high to moderate surgical risk. Although excellent clinical results have been obtained with the prostheses primarily provided for clinical use, the occurrence of complications ­ such as cerebral stroke, paraprosthetic regurgitation (leak), pacemaker (MP) implant conduction disorders, and vascular complications ­ should be prevented. The main characteristics of the new prostheses are: narrower instruments, a safer, more predictable valve implant, and the incorporation of characteristics in the framework of the prostheses that reduce the occurrence of paravalvular leaks

Estratégia minimamente invasiva para o implante percutâneo de bioprótese aórtica de segunda geração Lotus™ / Minimally-invasive strategy for transcatheter implantation of second-generation Lotus™ aortic valve system

O implante percutâneo de bioprótese aórtica é a terapia estabelecida em pacientes com estenose aórtica grave. Houve um progressivo aperfeiçoamento na tecnologia dos dispositivos que, associada a maior experiência dos operadores, resultou em procedimentos mais seguros e com melhores resultados. O primeiro dispositivo de segunda geração aprovado no Brasil, o sistema de válvula Lotus™ (Boston Scientific Corporation, Natick, EUA), incorpora várias dessas novas características. Descrevemos aqui os dois primeiros casos realizados no país, conduzidos sob anestesia local e sedação consciente, ambos com sucesso

Transcatheter aortic valve implantation is a well-established therapy in patients with severe aortic stenosis. There has been a progressive improvement in device technology associated with increased experience of the interventionists, resulting in safer procedures with better outcomes. The first secondgeneration device approved in Brazil, Lotus™ Valve System (Boston Scientific Corporation, Natick, USA), incorporates several of these new characteristics. This report describes the first two cases, both successfully performed in the country, carried out under local anesthesia and conscious sedation

Implante percutâneo de prótese valvar aórtica ­ experiência com o dispositivo reposicionável LotusTM / Percutaneous aortic valve implantation ­ an experience with the LotusTM repositionable device

Introdução: A válvula aórtica transcateter de segunda geração LotusTM foi desenhada para proporcionar ao intervencionista o controle completo de sua liberação durante o procedimento. O presente estudo apresenta a experiência inicial e os desfechos hospitalares de pacientes tratados com essa prótese no Brasil. Métodos: Registro observacional, retrospectivo, que incluiu pacientes com estenose aórtica grave sintomáticos, considerados de alto risco cirúrgico, tratados em sete centros.Resultados: Receberam o dispositivo 31 pacientes, sendo 61,3% do sexo feminino, com idade de 82,9 ± 6,9 anos e escore STS de 6,5 ± 4,1%. A área valvar aórtica foi de 0,73 ± 0,18 cm2 e o gradiente médio de 51,7 ± 13,9 mmHg. Todos os procedimentos foram realizados pela via transfemoral, e a pré-dilatação foi necessária em 65% dos casos. A taxa de sucesso do procedimento foi de 96,7%. Não houve complicação vascular com necessidade de intervenção cirúrgica e nem casos de acidente vascular cerebral. O gradiente médio após o procedimento foi de 10,5 ± 5,8 mmHg e não foram observadas regurgitações aórticas de graus moderado/importante. A taxa de implante de marca-passo definitivo foi de 38,7%, e a permanência hospitalar de 8,5 ± 4,8 dias. Conclusões: Na experiência inicial com o implante da válvula aórtica LotusTM, os resultados hospitalares demostraram a segurança e a eficácia do dispositivo, além de ausência de regurgitação aórtica relevante

Background: The second-generation LotusTM transcatheter aortic valve was designed to provide the interventional cardiologist with complete control of its release during the procedure. This study presents the initial experience and in-hospital outcomes of patients treated with this prosthesis in Brazil. Methods: This observational and retrospective study included patients with symptomatic severe aortic stenosis considered at high surgical risk, treated in seven centers. Results: The device was used in 31 patients, 61.3% female, aged 82.9 ± 6.9 years, and with STS score of 6.5 ± 4.1%. The aortic valve area was 0.73 ± 0.18 cm2 and the mean gradient was 51.7 ± 13.9 mmHg. All procedures were performed by the transfemoral access route, and pre-dilation was necessary in 65% of cases. The success rate of the procedure was 96.7%. There were no vascular complications requiring surgical intervention nor cases of stroke. The mean gradient after the procedure was 10.5 ± 5.8 mmHg; no cases of moderate to severe aortic regurgitation were observed. The rate of permanent pacemaker implantation was 38.7%, and mean in-hospital length of stay was 8.5 ± 4.8 days. Conclusions: In the initial experience with the use of the LotusTM aortic valve, in-hospital results demonstrated the safety and efficacy of the device; no cases of significant aortic regurgitation were observed

Transcatheter aortic valve implantation with balloonexpandable valve: early experience from China / Implantação da válvula aórtica transcateter com válvula balão-expansível: experiência inicial da China

AbstractObjective:The aim of the current study was to evaluate the early experience of the application of transcatheter aortic valve implantation with the balloon-expandable system in China. The transcatheter aortic valve implantation technology has been widely used for patients with inoperable severe aortic stenosis in the developed world. The application of transcatheter aortic valve implantation is still in the early stages of testing in China, particularly for the balloon-expandable valve procedure.Methods:This was a retrospective study. All patients undergoing transcatheter aortic valve implantation with balloon-expandable system in our hospital between 2011 and 2014 were included. Edwards SAPIEN XT Transcatheter Heart Valve was used. The improvement of valve and heart function was evaluated as well as 30-day mortality and major complications according to the VARC-2 definition.Results:A total of 10 transcatheter aortic valve implantation procedures with the balloon-expandable system were performed in our hospital, of which 9 were transfemoral and 1 was transapical. The median age was 76 years, and the median STS score and Logistic EuroSCORE (%) were 8.9 and 16.2. The implantation was successfully conducted in all patients, only 2 patients had mild paravalvular leak. There was no second valve implantation. Moreover, no 30-day mortality or complications was reported. Following the transcatheter aortic valve implantation procedure, the heart and valve functions had improved significantly. During the follow-up period of 3-34 months, one patient died of lung cancer 13 months after the operation.Conclusion:This early experience has provided preliminary evidence for the safety and efficacy of transcatheter aortic valve implantation procedure with the balloon-expandable system in the developing world with an increasing aging population.

ResumoObjetivo:O objetivo do presente estudo foi avaliar a experiência inicial da aplicação do implante percutâneo da válvula aórtica com o sistema balão-expansível na China. A tecnologia TAVI tem sido amplamente utilizada para pacientes com estenose aórtica grave inoperável no mundo desenvolvido. A aplicação de implante percutâneo da válvula aórtica está ainda nas etapas iniciais de teste na China, em particular o procedimento de válvula balão-expansível.Métodos:O estudo foi retrospectivo e todos os pacientes submetidos a implante percutâneo da válvula aórtica com sistema balão-expansível em nosso hospital entre 2011 e 2014 foram incluídos. Edwards SAPIEN XT Válvula Cardíaca Transcatheter foi usado. A melhoria do funcionamento da válvula e do coração foi avaliada, bem como mortalidade em 30 dias e as principais complicações de acordo com a definição VARC-2.Resultados:Um total de 10 procedimentos Tavi com o sistema balão-expansível foram realizados em nosso hospital, dos quais 9 foram transfemorais e 1 foi transapical. A idade média foi de 76 anos, e os STS mediana marcar e Logistic EuroSCORE (%) foram de 8,9 e 16,2. A implantação foi realizada com sucesso em todos os pacientes, apenas 2 pacientes tiveram vazamento paravalvar leve. Não houve um futuro implante valvar. Além disso, mortalidade em 30 dias ou complicações não foram relatadas. Seguindo o procedimento de implante percutâneo da válvula aórtica, as válvulas cardíacas e funções melhoraram significativamente. Durante o período de acompanhamento de 3-34 meses, um paciente morreu de câncer de pulmão 13 meses após a operação.Conclusão:Esta experiência inicial apresentou elementos de prova preliminar para a segurança e eficácia do procedimento implante percutâneo da válvula aórtica com o sistema balão-expansível no mundo em desenvolvimento com crescente envelhecimento da população.

Preditores de anormalidades do sistema de condução cardíaco e necessidade de marcapasso definitivo após implante porcateter de bioprótese valvar aórtica (Transcatheter Aortic ValveImplantation – TAVI) / Predictors of cardiac conduction system abnormalities and permanent pacemaker indications after Transcatheter Aortic Valve Implantation (TAVI)

O implante por cateter de bioprótese valvar aórtica (do inglês Transcatheter Aortic Valve Implantation –TAVI) vem ganhando espaço e configura-se como opção terapêutica para pacientes com estenose aórtica grave sintomática e risco cirúrgico elevado ou proibitivo. Apesar da menor manipulação e da menor agressividade comparativamente à abordagem cirúrgica tradicional, a incidência de bloqueio atrioventricular avançado é expressiva e resulta em aproximadamente 30% de implantes de marcapasso cardíaco definitivo. A identificação de fatores clínicos, eletrocardiográficos, anatômicos e relacionados ao tipo de prótese ou à técnica de liberação do dispositivo é fundamental para o desenvolvimento de novas técnicas e materiais, visando a reduzir a taxa de bloqueio atrioventricular avançado após o procedimento de TAVI. Os preditores mais relevantes analisados foram: bloqueio de ramo direito prévio, tipo de prótese (autoexpansível vs. balão expansível), profundidade do implante sobre a via de saída do ventrículo esquerdo, expansão excessiva da prótese, bloqueio atrioventricular total intra procedimento, bloqueio atrioventricular de 1o grau ao eletrocardiograma de base e sexo masculino...

Transcatheter Aortic Valve Implantation (TAVI) has emerged as a therapeutic option for patients with symptomatic severe aortic stenosis who have a high surgical risk. Despite of less aggressive manipulation when compared to conventional surgery, the incidence of atrioventricular block is significant and 30% of patients require permanent pacemaker. The identification of clinical, electrocardiographic, anatomic and technical factors related to the type of implant or device release technique is essential for the development of new techniques and materials aiming at reducing the advanced atrioventricular block rate after TAVI. The most relevant predictors analyzed were: previous right bundle branch block, type of device (self-expanding vs. balloon-expandable), depth of frame in left ventricular outflow tract, valve over expansion, intraprocedural total atrioventricular block, first degree atrioventricular block in baseline electrocardiogram and male gender...

Implante transcateter valve-in-valve para disfunção de biopróteses cirúrgicas aórticas / Transcatheter valve-in-valve implantation for surgical aortic bioprosthesis dysfunction

Introdução: Estudos recentes têm demonstrado a eficácia do implante transcateter valve-in-valve para otratamento de disfunção de biopróteses em pacientes de alto risco cirúrgico. Apresentamos nossa experiênciainicial com o implante valve-in-valve.Métodos: Caracterizamos o perfil clínico, ecocardiográfico e do procedimento, e reportamos os resultados de médio prazo de pacientes com disfunção de bioprótese submetidos a implante valve-in-valve em posição aórtica. Resultados: Incluímos sete pacientes do sexo masculino, com idade de 72,6 ± 10,0 anos. O escore STS foi 9,6± 10,5%, e o EuroSCORE logístico foi 22,7 ± 14,7%. Três pacientes apresentavam dupla disfunção; dois tinham insuficiência; e dois exibiam estenose isolada. A via transfemoral foi utilizada em seis casos, e a transapical, em um caso. Os dispositivos implantados incluíram as próteses Sapien XT (n = 5) e CoreValve (n = 2). O sucesso do procedimento foi obtido em seis (85,7%) casos. Após o procedimento, o gradiente médio reduziu-se de 38,2 ± 9,6mmHg para 20,9 ± 5,9 mmHg, e a área valvar elevou-se de 1,2 ± 0,4 cm2 para 1,5 ± 0,5 cm2. Ao final de 1 ano, nãoocorreram óbitos e nem outros desfechos adversos significativos; 80% dos pacientes encontravam-se em classefuncional NYHA I/II. Os gradientes transvalvares e a área valvar permaneceram inalterados nesse período. Conclusões: O procedimento valve-in-valve foi eficaz na maioria dos pacientes de alto risco cirúrgico comdisfunção de bioprótese. Quando realizado em pacientes bem selecionados, resulta em desfechos clínicos e hemodinâmicos satisfatórios.

Background: Recent studies have demonstrated the efficacy of the transcatheter valve-in-valveimplantation for the treatment of bioprosthesis dysfunction in high-risk surgical patients. This study presents the initial experience with valve-in-valve implantation. Methods: Clinical, echocardiographic, and procedural profiles were characterized, and the mid-term results of patients with surgical bioprosthesis dysfunction submitted to valve-in-valve implantation in theaortic position were reported.Results: Seven male patients were included, aged 72.6 ± 10.0 years. The STS score was 9,6 ± 10,5%, andthe logistic EuroSCORE was 22.7 ± 14.7%. Three patients had combined aortic bioprosthesis failure; two had isolated regurgitation; and two had isolated stenosis. The transfemoral access was used in six cases, and the transapical access in one case. Implanted devices included Sapien XT (n = 5) and CoreValve (n = 2) prostheses. Procedural success was achieved in six (85.7%) cases. After the procedure, the mean gradient decreased from 38.2 ± 9.6 mmHg to 20.9 ± 5.9 mmHg, and the valve area increased from 1.2 ±0.4 cm2 to 1.5 ± 0.5 cm2. After 1 year, there were no deaths and no other significant adverse outcomes; 80% of patients were in NYHA functional class I/II. The transvalvular gradients and valve area remained unchanged in this period.

Oclusão coronariana após TAVI: relato de estratégia de segurança / Coronary occlusion after TAVI: safety strategy report

O implante de valva aórtica transcateter (TAVI) é uma alternativa para pacientes com estenose aórtica de alto risco cirúrgico e para muitos daqueles considerados inoperáveis. Apesar de sua característica minimamente invasiva, podem ocorrer complicações relacionadas ao procedimento. Obstrução coronária durante o TAVI é uma complicação rara, com incidência inferior a 1%, mas potencialmente letal. Em nosso país, essa complicação foi encontrada em 0,72% dos procedimentos − 3 de 418 casos do Registro Brasileiro de Implante de Bioprótese Aórtica por Cateter − com mortalidade hospitalar de 100%. Apresentamos, neste relato de caso, medidas de prevenção e tratamento de oclusão coronária após o TAVI.

Transcatheter aortic valve implantation (TAVI) is an alternative for patients with aortic stenosis at high surgical risk and for many of those considered inoperable. Despite its minimally invasive features,complications related to the procedure may occur. Coronary obstruction during TAVI is a rare (incidence rate of less than 1%) but potentially lethal complication. In Brazil, this complication was found in 0.72% of procedures – three of 418 cases from the Brazilian Transcatheter Aortic Valve Implantation Registry – with an in-hospital mortality rate of 100%. This case report presents prevention and treatment measures forcoronary occlusion after TAVI.