Bioprosthetic aortic valve replacement in <50 years old patients - where is the evidence?

Abstract Aortic valve disease is one of the most common valvular heart diseases in the cardiovascular category. Surgical replacement of the diseased aortic valve remains the definitive intervention for most diseases. There is a clear consensus that in young patients who require aortic valve replacement, a mechanical prosthesis is the preferred choice due to its durable prosthesis without fear of wear and tear over time. However, this comes at the expense of increased risk of bleeding and thromboembolic events; in addition, there is a lack of strict evidence in using bioprosthesis in patients younger than 50 years. The objective of this review article is to assess the current evidence behind using bioprosthetic aortic valve in this young cohort.

Previous cardiac surgery: a predictor of mortality in aortic valve replacement?

Abstract Introduction: Previous cardiac surgery (PCS) is a risk factor for operative mortality in pa-tients undergoing reoperative aortic valve replacement (AVR) and may be influenced by the volume of patients in each center. The aim of this study was to evaluate the results of AVR in patients with previous cardiac surgery in a low volume cardiac center (400 cases per year). Methods: Between January 2006 and December 2016, 854 patients underwent isolated AVR surgery at our institution. Of these, 70 had PCS. Propensity match (PM) was per-formed to balance basal covariates. Operative mortality and survival were the primary outcomes. Results: The PCS and first-time surgery (FTS) groups had significant differences in base-line characteristics (PCS group were older, higher incidence of hypertension, endocarditis, NYHA III/IV, lower LVEF, higher creatinine and higher EuroSCORE). In the unmatched population, patients with PCS had higher operative mortality (17.1% vs. 4.6%, P=0.001). In the PM groups, this difference was not significant (12.5% and 3.6%, P=0.08). The only independent predictors for operative mortality found in the PCS group were age and fe-male gender. Age and diabetes were identified as the only independent predictors of sur-vival. Conclusion: PCS was not a predictor for operative mortality nor long-term survival in pa-tients undergoing isolated aortic valve replacement.

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.

Should sinus of valsalva be replaced in patients with dilated ascending aorta and aortic valve diseases?

Abstract Introduction: The aim of this study is to investigate the change in the dimension of sinus of Valsalva in patients who underwent supracoronary ascending aorta replacement with aortic valve replacement. Methods: A total of 81 patients who underwent supracoronary ascending aorta replacement with aortic valve replacement were included. Ten of 81 patients died during the follow-up. The patients were divided into three groups according to the aortic valve diseases. Group I (n=17) included patients with bicuspid valves, group II (n=30) included patients with stenotic degenerative valves, and patients with aortic regurgitation constituted group III (n=24). In preoperative and follow-up periods, the sinus of Valsalva diameter of the patients was evaluated by echocardiographic examination. The mean age was 54.1±15.1 years. Twenty-eight (34.6%) patients were female and 12 (14.8%) patients were in New York Heart Association functional class III. Results: There was no early mortality. Late mortality was developed in 10 (12.4%) patients, 8 (9.9%) due to non-cardiac reasons. Late follow-up was obtained in 71 patients with a mean of 60±30.1 months postoperatively. During follow-up, the increase in the diameter of the sinus of Valsalva was significant in Group I (P<0.01), while in Group II and III it was insignificant (P>0.05). Conclusion: To avoid the risks associated with sinus of Valsalva dilatation, it is reasonable to replace the sinus of Valsalva in the setting of aortic valve replacement and ascending aorta replacement for bicuspid aortic valve with a dilated ascending aorta and relatively normal sinuses of Valsalva in young patients.

Validation of german aortic valve score in a multi-surgeon single center

Abstract OBJECTIVE: Risk assessment for operative mortality is mandatory for all cardiac operations. For some operation types such as aortic valve repair, EuroSCORE II overestimates the mortality rate and a new scoring system (German AV score) has been developed for a more accurate assessment of operative risk. In this study, we aimed to validate German Aortic Valve Score in our clinic in patients undergoing isolated aortic valve replacement. METHODS: A total of 35 patients who underwent isolated open aortic valve replacement between 2010 and 2013 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores EuroSCORE II were calculated online according to criteria described by EuroSCORE taskforce, Aortic Valve Scores were also calculated. RESULTS: The mean age of patients was 61.14±13.25 years (range 29-80 years). The number of female patients was 14 (40%) and body mass index of 25 (71.43%) patients was in range of 22-35. Mean German Aortic Valve Score was 1.05±0.96 (min: 0 max: 4.98) and mean EuroSCORE was 2.30±2.60 (min: 0.62, max: 2.30). The Aortic Valve Score scale showed better discriminative capacity (AUC 0.647, 95% CI 0.439-0.854). The goodness of fit was x2HL=16.63; P=0.436). EuroSCORE II scale had shown less discriminative capacity (AUC 0.397, 95% CI 0.200-0.597). The goodness of fit was good for both scales. The goodness of fit was x2HL=30.10; P=0.610. CONCLUSION: In conclusion, German AV score applies to our population with high predictive accuracy and goodness of fit.

Long-term mortality predictors in patients with small aortic annulus undergoing aortic valve replacement with a 19- or 21-mm bioprosthesis

Abstract Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm2/m2. Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm2/m2, without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm2/m2 did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Paravalvular Regurgitation: Clinical Outcomes in Surgical and Percutaneous Treatments / Regurgitação Paravalvar: Análise de Desfechos Clínicos no Tratamento Cirúrgico e Percutâneo

Abstract Background: Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair. Objectives: To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure. Methods: This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure. Results: The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08). Conclusion: Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk.

Resumo Fundamento: Regurgitação ou escape paravalvar é uma complicação grave e incomum associada ao implante de prótese valvar. Estudos mostram incidência de 3% a 6% com repercussão hemodinâmica. Existem poucos estudos na literatura que comparam as abordagens cirúrgica e percutânea para sua correção. Objetivos: Comparar as abordagens cirúrgica e percutânea de correção da regurgitação paravalvar quanto a desfechos clínicos durante a internação e após 1 ano do procedimento. Métodos: Este é um estudo retrospectivo, descritivo e observacional, que incluiu 35 pacientes com escape paravalvar acompanhados no Instituto Dante Pazzanese de Cardiologia entre janeiro de 2011 e dezembro de 2013 e que necessitaram de correção. Os pacientes foram divididos de acordo com o tratamento estabelecido e acompanhados por um período 1 ano após o procedimento. Resultados: O grupo submetido ao tratamento percutâneo foi considerado como de maior risco para complicações por apresentar pacientes mais idosos, com maior prevalência de diabetes, maior quantidade de cirurgias valvares prévias e menor valor médio de clearance de creatinina. Durante a evolução intra-hospitalar, observou-se grande número de complicações nos dois grupos (74,3% dos casos), sem diferença estatística nos desfechos analisados. Após 1 ano, o grupo percutâneo teve maior número de reintervenções (8,7% vs. 20%, p = 0,57) e mortalidade maior (0% vs. 20%, p = 0,08). Uma alta incidência de escape residual mitral foi verificada após procedimento percutâneo (8,7% vs. 50%, p = 0,08). Conclusão: A cirurgia é o tratamento de escolha da regurgitação paravalvar. A abordagem percutânea pode ser uma alternativa para os pacientes com risco cirúrgico elevado.

Age, Creatinine and Ejection Fraction Score in Brazil: Comparison with InsCor and the EuroSCORE / Age, Creatinine and Ejection Fraction Score no Brasil: Comparação com o InsCor e o EuroSCORE

AbstractBackground:Risk scores for cardiac surgery cannot continue to be neglected.Objective:To assess the performance of “Age, Creatinine and Ejection Fraction Score” (ACEF Score) to predict mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery, and to compare it to other scores.Methods:A prospective cohort study was carried out with the database of a Brazilian tertiary care center. A total of 2,565 patients submitted to elective surgeries between May 2007 and July 2009 were assessed. For a more detailed analysis, the ACEF Score performance was compared to the InsCor’s and EuroSCORE’s performance through correlation, calibration and discrimination tests.Results:Patients were stratified into mild, moderate and severe for all models. Calibration was inadequate for ACEF Score (p = 0.046) and adequate for InsCor (p = 0.460) and EuroSCORE (p = 0.750). As for discrimination, the area under the ROC curve was questionable for the ACEF Score (0.625) and adequate for InsCor (0.744) and EuroSCORE (0.763).Conclusion:Although simple to use and practical, the ACEF Score, unlike InsCor and EuroSCORE, was not accurate for predicting mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery in a Brazilian tertiary care center. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0).

ResumoFundamento:Escores de risco para cirurgia cardíaca não podem continuar sendo neglicenciados.Objetivo:Avaliar o desempenho do Age, Creatinine and Ejection Fraction Score (ACEF Score) na predição de mortalidade dos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva, e compará-lo a outros escores.Métodos:Estudo de coorte prospectivo no banco de um centro terciário brasileiro. Foram avaliados 2.565 pacientes operados de maneira eletiva entre maio de 2007 e julho de 2009. Para uma análise mais detalhada, o desempenho do ACEF Score foi comparado ao do InsCor e ao do EuroSCORE por meio de testes de correlação, calibração e discriminação.Resultados:Os pacientes foram estratificados em leve, moderado e grave para todos os modelos. A calibração foi inadequada para o ACEF Score (p = 0,046) e adequada para o InsCor (p = 0,460) e o EuroSCORE (p = 0,750). Na discriminação, a área abaixo da curva ROC apresentou-se questionável para o ACEF Score (0,625) e apropriada para o InsCor (0,744) e o EuroSCORE (0,763).Conclusão:Embora simples e prático, o ACEF Score, ao contrário do InsCor e do EuroSCORE, não se mostrou acurado para predizer mortalidade nos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva em centro terciário brasileiro. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0).

Impact of body mass index on outcome in patients undergoing coronary artery bypass grafting and/or valve replacement surgery / Impacto do índice de massa corporal no desfecho de pacientes submetidos às cirurgias de revascularização do miocárdio e/ou troca valvar

AbstractObjective:This study aimed to analyze the impact of body mass index on outcomes of 101 patients undergoing coronary artery bypass grafting, valve replacement, or combined valve/ coronary artery bypass grafting surgery in a private hospital in Belo Horizonte, Brazil.Methods:This was a prospective cross-sectional study of patients undergoing cardiac surgery from May 2009 to December 2012. All patients were followed up from the first day of admission until discharge or death. Patients were divided into three groups according to BMI: normal weight, overweight, and obese. The main outcome measure was the association between BMI and postoperative morbidities and mortality.Results:Multivariate analysis identified obesity as an independent predictor of increased risk of surgical reintervention (odds ratio [OR] 13.6; 95%CI 1.1 - 162.9; P=0.046) and reduced risk of bleeding (OR 0.05; 95% CI 0.09 - 0.69; P=0.025). Univariate analysis showed that obesity was associated with increased frequency of wound dehiscence (P=0.021). There was no association between BMI and other complications or mortality in univariate analysis. There was also no association between body mass index and duration of cardiopulmonary bypass, aortic clamping, mechanical ventilation, and intensive care unit or hospital stay.Conclusion:Obese individuals undergoing coronary artery bypass grafting, valve replacement, or combined surgery have a higher postoperative risk of surgical reintervention and lower chances of bleeding.

ResumoObjetivo:Analisar o impacto do índice de massa corporal no desfecho de 101 pacientes submetidos à cirurgia revascularização do miocárdio, troca valvar ou cirurgia cardíaca combinada em um hospital privado de Belo Horizonte, Minas Gerais.Métodos:Trata-se de um estudo transversal com inclusão prospectiva de pacientes submetidos à cirurgia cardíaca no período de maio de 2009 a dezembro de 2012. Todos os pacientes foram acompanhados do primeiro dia de internação até a alta hospitalar ou óbito. Os pacientes foram divididos em três grupos definidos pelo índice de massa corporal aferido no pré-operatório: eutrófico, sobrepeso e obeso. O principal desfecho avaliado neste estudo foi a associação entre índice de massa corporal e morbimortalidade pós-operatória.Resultados:análise multivariada revelou obesidade como preditor independente de aumento nas chances de reintervenção cirúrgica por deiscência de sutura de esterno (OR 13,6; IC95% 1,1-162,9; P=0,046) e redução no risco de sangramento (OR 0,05; IC95% 0,09-0,69; P=0,025). Na análise univariada, obesidade também foi associada a maior frequência de deiscência de sutura (P=0,021). Estado nutricional não foi associado à presença de outras complicações no pós-operatório e nem de mortalidade, ainda na análise univariada. No intraoperatório não houve diferença nos tempos de circulação extracorpórea e de pinçamento aórtico. No pós-operatório, os tempos de ventilação mecânica e de internação na unidade de terapia intensiva ou hospital foram semelhantes entre os pacientes eutróficos, com sobrepeso e obesos.Conclusão:Pacientes obesos apresentam risco aumentado de reintervenção cirúrgica por deiscência de sutura e menor risco sangramento no pós-operatório de cirurgia de revascularização do miocárdio, troca valvar ou cirurgia cardíaca combinada.

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients? / Cirurgia da raiz da aorta: deve-se preservar a valva aórtica ou a operação com o tubo valvulado ainda é a primeira opção de tratamento para esses pacientes?

AbstractObjective:To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.Methods:From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.Results:In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.Conclusion:The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.

ResumoObjetivo:Analisar comparativamente os resultados da operação de preservação da valva aórtica e do tubo valvulado nas reconstruções da raiz da aorta.Métodos:No período de janeiro de 2002 a outubro de 2013, 324 pacientes foram submetidos à reconstrução da raiz da aorta. Foram 263 tubos valvulados e 61 preservações da valva aórtica (43 reimplantes e 18 remodelamentos). 26% dos pacientes estavam em classe funcional III e IV; 9,6% com síndrome de Marfan e 12% apresentavam valva aórtica bivalvulada. Houve predomínio dos aneurismas sobre as dissecções (81% contra 19%), sendo 7% de dissecções agudas. O seguimento completo de 100% dos pacientes foi realizado com tempo mediano de seguimento de 902 dias para pacientes submetidos à tubo valvulado e de 1492 para aqueles submetidos à preservação da valva aórtica.Resultados:A mortalidade hospitalar foi de 6,7% contra 4,9% respectivamente para tubo valvulado e preservação da valva aórtica (ns). No seguimento tardio, a insuficiência aórtica importante foi de 0% e 5,8%, e a insuficiência cardíaca crônica, classe funcional I e II de 89,4% e 94%, respectivamente, para tubo valvulado e preservação da valva aórtica (ns). A reconstrução da raiz da aorta com a preservação da valva aórtica apresentou menor mortalidade tardia (P=0,001) e menos complicações hemorrágicas (P=0,006). Não houve diferença para tromboembolismo, endocardite ou necessidade de reoperação.Conclusão:A reconstrução da raiz da aorta com a preservação valvar deve ser a operação a ser realizada por apresentar menor mortalidade e sobrevida livre de eventos hemorrágicos.

Evaluation of variables responsible for hospital mortality in patients with rheumatic heart disease undergoing double valve replacement / Avaliação de variáveis responsáveis pela mortalidade hospitalar em pacientes portadores de doença reumática submetidos à dupla troca valvar

Objective: To describe the hospital mortality and associated clinical and echocardiographic variables in patients with rheumatic disease who underwent double valve replacement surgery. Methods: This is a cross sectional descriptive study of mortality, performed in a referral hospital in Salvador, Bahia. Records from patients with rheumatic disease who underwent double valve replacement surgery during the years 2007-2011 were analyzed. Results: The studied sample comprises 104 patients and 60 (57.7%) were male. The mean age was 38.04±14.45. Sixty five bioprostheses and 38 mechanical prostheses were used in these patients at the time of surgery. There were statistically significant differences between the two groups, when we analyzed the following variables: the mean age (36.30±13.03 vs. 45.35±17.8 years-old, P=0.011), mean hemoglobin (11.10±2.19 vs. 9.22±2.26 g/dL, P=0.002), mean hematocrit (34.22±5.86 vs. 28.44±6.62%, P<0.001). New York Heart Association functional class III and IV (NYHA) (P=0.022) was statistically associated with mortality. Conclusion: We concluded that the mean hemoglobin/hematocrit level and the NYHA functional class was the major variables associated to the mortality among these patients. Based on these data one may concern about the patient best moment for surgery and the patient hemoglobin level. .

Objetivo: Descrever a mortalidade hospitalar em pacientes reumáticos submetidos à cirurgia de dupla troca valvar e sua relação com variáveis clínicas e ecocardiográficas. Métodos: Trata-se de um estudo de corte transversal. Foram estudados pacientes maiores que 18 anos, com valvopatia reumática que foram submetidos à cirurgia de DTV do período de janeiro de 2007 a dezembro de 2011 no Hospital Ana Nery - Salvador - Bahia. A coleta de dados se deu por meio de consulta aos prontuários dos pacientes. Resultados: Foram estudados 104 pacientes, 60 (57,7%) eram do sexo masculino. A média de idade da população estudada foi de 38,04±14,45 anos. Foram utilizadas 65 próteses biológicas e 38 próteses metálicas. Houve diferença estatisticamente significante entre os grupos comparados, pacientes que obtiveram alta versus pacientes que foram a óbito, em relação às seguintes variáveis: média de idade dos pacientes que receberam alta para casa e foram a óbito, respectivamente (36,30±13,03 vs. 45,35±17,8, P=0,011); média de hemoglobina, (11,10±2,19 vs. 9,22±2,26 g/dL, P=0,002); média do hematócrito, (34,22±5,86 vs. 28,44±6,62%, P<0,001). As classes funcionais III e IV (New York Heart Association) estiveram associadas estatisticamente com a mortalidade (P=0.022). Conclusão: Os dados encontrados no estudo apresentam uma população pouco estudada na qual os principais achados foram a média do nível de hemoglobina/hematócrito e classe funcional NYHA. Deve se levar em conta esses dados para a escolha do melhor momento de cirurgia para essa população. .

A influência da escolha da prótese valvar sobre a mortalidade intra-hospitalar no pós-operatório em pacientes submetidos à cirurgia valvar / Influence of valve prosthesis type on early mortality in patients undergoing valve surgery

Objetivo: Avaliar a influência do tipo de prótese na mortalidade intra-hospitalar no período de pós-operatório imediato nos pacientes que fizeram substituição de válvula. Métodos: Estudo transversal, em que dados, como sexo, origem, idade, etiologia, dados ecocardiográficos, o tipo de cirurgia realizada e da prótese utilizada em casos de substituição de válvula foram analisadas r etrospectivamente. Resultados: Foram revisados 353 prontuários de pacientes que realizaram cirurgia de troca valvar. A idade média foi de 41,87±17,9 anos. Em relação ao gênero, 52,8% eram do sexo feminino. Quanto à origem, 61,1% vieram de cidades do interior do estado. Do total de pacientes, 58,5% eram portadores da doença reumática. Avaliando o tipo de prótese implantada, 70% realizou troca por bioprótese e 30% metálica. A mortalidade hospitalar desse estudo foi de 11%, não havendo diferença significativa entre o tipo de prótese utilizada. Conclusão: O tipo de prótese utilizada não influenciou na mortalidade intra-hospitalar. .

Objective: To evaluate the influence of the type of prosthesis in-hospital mortality in the post-operative period in patients who had valve replacement. Methods: A cross-sectional data, such as gender, origin, age, etiology, echocardiograph data, the type of surgery performed and the prosthesis used in cases of valve replacement were analyzed retrospectively. Results: We reviewed 353 charts of patients who underwent valve replacement surgery. The mean age was 41.87±17.9 years. Regarding gender, 52.8% were female. As for the origin, 61.1% came from small cities within the state. Of all patients, 58.5% suffered from rheumatic disease. Assessing the type of prosthesis implanted, 70% held replace by bioprosthesis and 30% metallic. The hospital mortality in this study was 11%, with no significant difference between the types of prosthesis utilized. Conclusion: The type of implant used had no effect on in-hospital mortality. .

Late outcome analysis of the Braile Biomédica® pericardial valve in the aortic position / Avaliação dos resultados tardios da bioprótese de pericárdio bovino Braile Biomédica® em posição aórtica

Objective: Aortic valve replacement with Braile bovine pericardial prosthesis has been routinely done at the Heart Institute of the Universidade de São Paulo Medical School since 2006. The objective of this study is to analyze the results of Braile Biomédica® aortic bioprosthesis in patients with aortic valve disease. Methods: We retrospectively evaluated 196 patients with aortic valve disease submitted to aortic valve replacement with Braile Biomédica® bovine pericardial prosthesis, between 2006 and 2010. Mean age was 59.41±16.34 years and 67.3% were male. Before surgery, 73.4% of patients were in NYHA functional class III or IV. Results: Hospital mortality was 8.16% (16 patients). Linearized rates of mortality, endocarditis, reintervention, and structural dysfunction were 1.065%, 0.91%, 0.68% and 0.075% patients/year, respectively. Actuarial survival was 90.59±2.56% in 88 months. Freedom from reintervention, endocarditis and structural dysfunction was respectively 91.38±2.79%, 89.84±2.92% and 98.57±0.72% in 88 months. Conclusion: The Braile Biomédica® pericardial aortic valve prosthesis demonstrated actuarial survival and durability similar to that described in the literature, but further follow up is required to assess the incidence of prosthetic valve endocarditis and structural dysfunction in the future. .

Objetivo: A troca valvar aórtica por substitutos biológicos de pericárdio bovino Braile é realizada rotineiramente no Instituto do Coração da Faculdade de Medicina da USP desde 2006. O objetivo deste estudo é analisar os resultados da utilização da prótese aórtica Braile Biomédica® em pacientes com doença valvar aórtica. Métodos: Foram analisados, retrospectivamente, 196 pacientes portadores de valvopatia aórtica submetidos à troca valvar aórtica por prótese biológica de pericárdio bovino Braile Biomédica® entre 2006 e 2010. A idade média foi de 59,41±16,34 anos e 67,3% eram do sexo masculino. No pré-operatório, 73,4% dos pacientes estavam em classe funcional III ou IV. Resultados: A mortalidade hospitalar foi 8,16% (16 pacientes). As taxas linearizadas de óbito, endocardite, reoperação e disfunção estrutural foram de 1,065%, 0,91%, 0,68% e 0,075% pacientes/ano, respectivamente. A sobrevida actuarial foi de 90,59±2,56% em 88 meses. A curva livre de reoperação, endocardite e disfunção estrutural foi respectivamente de 91,38±2,79%, 89,84±2,92% e 98,57±0,72% em 88 meses. Conclusão: O implante da prótese aórtica de pericárdio bovino Braile Biomédica® demonstrou sobrevida e durabilidade compatível com a literatura, porém maior seguimento é necessário para avaliar a incidência de endocardite e disfunção estrutural no futuro. .

Experiência Inicial de Dois Centros Nacionais no Implante de Prótese Aórtica Transcateter / Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Fundamento: O implante de prótese aórtica transcateter é uma alternativa efetiva para o tratamento cirúrgico para a correção de estenose aórtica grave em pacientes inoperáveis ou de alto risco cirúrgico. Objetivos: Apresentar os resultados clínicos e ecocardiográficos imediatos e no médio prazo da experiência inicial do implante de prótese aórtica transcateter. Métodos: Entre junho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de prótese aórtica transcateter. Resultados: A idade média foi 82,5 ± 6,5 anos e o Euro SCORE logístico foi 23,6 ± 13,5. O sucesso do procedimento foi de 84%. Após o implante, houve queda do gradiente sistólico médio (pré = 54,7 ± 15,3 mmHg vs. pós = 11,7 ± 4,0 mmHg; p < 0,01). Acidente vascular cerebral ocorreu em 3,6% dos pacientes, complicações vasculares em 19%, e foi necessário o implante de marca-passo definitivo em 13% dos pacientes nos primeiros 30 dias pós-implante. A mortalidade aos 30 dias e no seguimento médio de 16 ± 11 meses foi, respectivamente, de 14 e de 8,9%. A presença de doença pulmonar obstrutiva crônica foi o único preditor de mortalidade em 30 dias e no seguimento. A área valvar aórtica e o gradiente sistólico médio não apresentaram variações significativas durante o seguimento. Conclusões: O implante de prótese aórtica transcateter é um procedimento eficaz e seguro para o tratamento da estenose aórtica em pacientes de alto risco cirúrgico ou inoperáveis. A presença de doença pulmonar obstrutiva crônica foi o único preditor independente de mortalidade identificado, tanto no primeiro mês pós-intervenção quanto no seguimento mais tardio. .

Background: Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk. Objectives: To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation. Methods: From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation. Results: Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly. Conclusions: Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up. .

Idade avançada e incidência de fibrilação atrial em pós-operatório de troca valvar aórtica / Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

Objetivo: Descrever, em idosos, a correlação entre faixa etária e ocorrência de fibrilação atrial após cirurgia por estenose aórtica, além de avaliar a influência da ocorrência de fibrilação atrial na incidência de acidente vascular cerebral, tempo de internação e mortalidade hospitalar. Métodos: Estudo transversal retrospectivo incluindo pacientes com idade > 70 anos submetidos à cirurgia de troca valvar aórtica isolada. Resultados: Foram estudados 348 pacientes com idade média de 76,8±4,6 anos. A incidência de fibrilação atrial no pós-operatório foi 32,8% (n=114), sendo superior nos pacientes > 80 anos (42,9 vs. 28,8% 70-79 anos, P=0,017) e havendo significância estatística limítrofe (P=0,055) para tendência linear na correlação idade e incidência de fibrilação atrial. Verificou-se significativo maior tempo de internação na Unidade de Terapia Intensiva e hospitalar total, porém, não se observou maior taxa de acidente vascular cerebral ou de mortalidade hospitalar decorrente da fibrilação atrial. Conclusão: A incidência de fibrilação atrial no pós-operatório de cirurgia para estenose valvar aórtica em pacientes idosos com > 70 anos foi elevada e linearmente correlacionada ao avanço da idade, especialmente após 80 anos, causando aumento dos tempos de internação total e em Unidade de Terapia Intensiva, sem aumento significativo da morbimortalidade. O conhecimento desses dados é importante para evidenciar a necessidade de medidas profiláticas e de tratamento precoce dessa arritmia nesse subgrupo. .

Objective: This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. Methods: Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. Results: 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. Conclusion: Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup. .

EuroSCORE II e a importância de um modelo local, InsCor e o futuro SP-SCORE / EuroSCORE II and the importance of a local model, InsCor and the future SP-SCORE

Introdução: O modelo mais utilizado para predição de mortalidade em cirurgia cardíaca foi recentemente remodelado, mas dúvidas referentes à sua metodologia e desenvolvimento têm sido relatadas. Objetivo: O objetivo deste estudo foi avaliar o desempenho do EuroSCORE II na predição de mortalidade em pacientes submetidos a cirurgia de coronária e/ou valva na instituição. Métodos: Mil pacientes, operados consecutivamente de coronária e/ou valva, entre outubro de 2008 e julho de 2009, foram analisados. O desfecho de interesse foi mortalidade intra-hospitalar. A calibração foi realizada pela correlação entre mortalidade esperada e observada por meio do teste de Hosmer Lemeshow. A discriminação foi calculada pela área abaixo da curva ROC. O desempenho do EuroSCORE II foi comparado com os modelos EuroSCORE e InsCor (modelo local). Resultados: Na calibração, o teste de Hosmer Lemeshow foi inadequado para o EuroSCORE II (P=0,0003) e bom para os modelos EuroSCORE (P=0,593) e InsCor (P=0,184). No entanto, na discriminação, a área abaixo da curva ROC para o EuroSCORE II foi de 0,81 [IC 95% (0,76-0,85), P<0,001]; para o EuroSCORE foi de 0,81 [IC 95% (0,77-0,86), P<0,001] e para o InsCor foi de 0,79 [IC 95% (0,74-0,83), P<0,001], revelando-se adequada para todos. Conclusão: O EuroSCORE II se tornou mais complexo e, à semelhança com a literatura internacional, mal calibrado para predizer mortalidade nos pacientes operados de coronária e/ou valva em nosso meio. Esses dados reforçam a importância do modelo local. .

Introduction: The most widely used model for predicting mortality in cardiac surgery was recently remodeled, but the doubts regarding its methodology and development have been reported. Objective: The aim of this study was to assess the performance of the EuroSCORE II to predict mortality in patients undergoing coronary artery bypass grafts or valve surgery at our institution. Methods: One thousand consecutive patients operated on coronary artery bypass grafts or valve surgery, between October 2008 and July 2009, were analyzed. The outcome of interest was in-hospital mortality. Calibration was performed by correlation between observed and expected mortality by Hosmer Lemeshow. Discrimination was calculated by the area under the ROC curve. The performance of the EuroSCORE II was compared with the EuroSCORE and InsCor (local model). Results: In calibration, the Hosmer Lemeshow test was inappropriate for the EuroSCORE II (P=0.0003) and good for the EuroSCORE (P=0.593) and InsCor (P=0.184). However, the discrimination, the area under the ROC curve for EuroSCORE II was 0.81 [95% CI (0.76 to 0.85), P<0.001], for the EuroSCORE was 0.81 [95% CI (0.77 to 0.86), P<0.001] and for InsCor was 0.79 [95% CI (0.74-0.83), P<0.001] showing up properly for all. Conclusion: The EuroSCORE II became more complex and resemblance to the international literature poorly calibrated to predict mortality in patients undergoing coronary artery bypass grafts or valve surgery at our institution. These data emphasize the importance of the local model. .

Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valve-sparing root replacement with those from the Bentall procedure / Reparação de raiz aórtica em pacientes com aneurisma ou dissecção: comparando os resultados da técnica de substituição valve-sparing com os da operação de Bentall

INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.

INTRODUÇÃO: Manejo de aneurisma da aorta ou dissecção da raiz tem sido objeto de muita discussão que levou a algumas modificações. A tendência atual é o uso da técnica de substituição valve-sparing (VSR). Nós comparamos o resultado da reparação da raiz utilizando a técnica de substituição valve-sparing com o procedimento de Bentall. MÉTODOS: Foram avaliados, retrospectivamente, 70 pacientes submetidos à substituição da raiz de aneurisma ou dissecção, comparando os resultados da técnica de substituição valve-sparing com os do procedimento Bentall de janeiro de 2007 a dezembro de 2011 em nossa instituição. RESULTADOS: Vinte e cinco pacientes foram submetidos à substituição da valva aórtica com o uso da técnica valve-sparing (VSR, incluindo o reimplante ou remodelação) (23 homens e duas mulheres), e 45 pacientes pelo procedimento de Bentall (34 homens e 11 mulheres). Pacientes que se submeteram à VSR eram mais jovens, com idade média de 55,4 ± 14,8 anos em comparação àqueles que foram submetidos ao procedimento Bentall, idade média de 60,6 ± 12,7 anos (P = ns). A insuficiência aórtica pré-operatória no grupo VSR foi moderada em oito (32%) pacientes e grave em seis (24%). Creatinina pré-operatória foi 1 ± 0,35 mg/dl, no grupo do VSR, e 1,1 ± 0,87 mg/dl, no grupo de Bentall. No grupo VSR, três (12%) pacientes foram operados em caráter de emergência e, no grupo de Bentall, oito (17%). Revascularização do miocárdio concomitante (excluindo reimplante coronariano) foi realizada em oito (32%) pacientes no grupo VSR e, em 12 (26,6%), no grupo de Bentall (P=0,78); procedimentos valvares adicionais foram realizados em 2 (8%) pacientes no grupo do VSR e em 11 (24,4%) no grupo de Bentall. A mortalidade perioperatória foi de 8% (n = 2) e 13,3% (n = 6), para os procedimentos de VSR e Bentall, respectivamente (P=0,7, ns). O tempo de internação na unidade de terapia intensiva foi de 116,6 ± 106,0 horas para pacientes VSR e 152,5 ± 218,2 horas para pacientes Bentall (P=0,5). O tempo de permanência no hospital foi de 10 ± 8,1 dias para VSR e 11 ± 9,52 dias para Bentall (P=0,89). A sobrevida em um ano foi de 92,0 % para o grupo VSR e 79,0% para o grupo de Bentall. A sobrevivência de sete anos para o grupo VSR foi de 92% e 79% para o grupo de Bentall (IC95% [1,215 a 0,1275], P=0,1). CONCLUSÃO: A técnica valve-sparing substituição da raiz aórtica pode ser realizada com a morbidade e mortalidade aceitáveis, e sobrevivência aceitável a longo prazo comparável com o procedimento de Bentall.

Análise da incidência e preditores clínicos e ecocardiográficos do refluxo paraprotético aórtico após o implante de prótese aórtica transcateter / Analysis of the incidence and clinical and echocardiographic predictors of paravalvular aortic regurgitation after transcatheter aortic valve implantation

INTRODUÇÃO: A incidência de refluxo paraprotético (RPP) parece maior entre os pacientes submetidos a implante de prótese aórtica transcateter e sua potencial associação com aumento da mortalidade tardia tem suscitado preocupação na comunidade científica. Nosso objetivo foi avaliar a incidência e o impacto clínico e estabelecer preditores do RPP em nossa casuística. MÉTODOS: Entre julho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de prótese aórtica transcateter. O grau do RPP pós-procedimento foi avaliado segundo os critérios do VARC 2. Dividiu-se a população em grupo RPP ausente/RPP discreto e grupo RPP moderado/RPP grave. RESULTADOS: A média da idade foi de 82,5 ± 3,9 anos, 58,9% eram do sexo feminino e o EuroSCORE logístico foi de 23,6 ± 13,4. Houve queda do gradiente sistólico médio (54,7 ± 15,3 mmHg vs. 11,7 ± 4 mmHg; P < 0,01) e ganho da área valvar aórtica (0,66 ± 0,15 cm² vs. 1,8 ± 0,3 cm²; P < 0,01). Ao final do procedimento, 46,4% não apresentaram RPP, e RRP discreto ou moderado foi observado em 42% e 11,6% dos pacientes. Nenhum paciente apresentou RPP grave. A análise multivariada identificou sexo masculino [odds ratio (OR) 5,85, intervalo de confiança (IC] 1,29-26,7; P = 0,022), valvoplastia aórtica percutânea prévia (OR 18,44, IC 2,30-147,85; P = 0,006), fração de ejeção < 35% (OR 4,160, IC 1,014-17,064; P = 0,048) e presença de hipertensão pulmonar grave (OR 7,649, IC 1,86-31,51; P = 0,005) como preditores independentes de RPP moderado/grave. CONCLUSÕES: A incidência de RPP moderado/grave foi baixa e comparável à de outras casuísticas. Sexo masculino, antecedente de valvoplastia aórtica percutânea prévia, presença de hipertensão pulmonar grave e disfunção ventricular esquerda grave foram preditores independentes dessa complicação.

BACKGROUND: The incidence of paravalvular aortic regurgitation (PAR) seems higher among patients submitted to transcatheter aortic valve implantation and its potential association with an increased late mortality has raised concerns in the scientific community. Our objective was to evaluate the incidence and clinical impact of PAR and establish PAR predictors in our patient population. METHODS: Between July/2009 and February/2013, 112 patients were submitted to transcatheter aortic valve implantation. The degree of PAR after the procedure was assessed according to the VARC 2 criteria. The population was divided into no/mild PAR group and moderate/severe PAR group. RESULTS: Mean age was 82.5 ± 3.9 years, 58.9% were female and the logistic EuroSCORE was 23.6 ± 13.4. There was a decrease in the mean systolic gradient (54.7 ± 15.3 mmHg vs 11.7 ± 4 mmHg; P < 0.01) and a gain in the aortic valve area (0.66 ± 0.15 cm² vs 1.8 ± 0.3 cm²; P < 0.01). At the end of the procedure 46.4% did not have PAR, and mild or moderate PAR was observed in 42% and 11.6% of the patients. No patient presented severe PAR. Multivariate analysis identified male gender [odds ratio (OR) 5.85, confidence interval (CI] 1.29-26.7; P = 0.022), previous percutaneous aortic val­vuloplasty (OR 18.44, CI 2.30-147.85; P = 0.006), ejection fraction < 35% (OR 4.160, CI 1.014-17.064; P = 0.048) and the presence of severe pulmonary hypertension (OR 7.649, CI 1.86-31.51; P = 0.005) as independent predictors of moderate/severe PAR. CONCLUSIONS: The incidence of moderate/severe PAR was low and comparable to other studies. Male gender, history of prior percutaneous aortic valvuloplasty, presence of severe pulmonary hypertension and severe left ventricular dysfunction were independent predictors of this complication.

Implante valvular aórtico transarterial: experiencia en Chile / Transcatheter aortic valve implantation: Experience in 17 patients

Background: Transcatheter aortic valve implantation (TAVI) is taking a leading role in the management of patients with severe aortic stenosis. Valve replacement surgery prolongs survival and is the technique of choice considering its historical background and long experience worldwide. Recently however, TAVI has positioned itself as the only standard therapy for symptomatic patients who are not candidates for surgery. Aim: To report the experience with this new technique comparing our results with those reported in the literature. Material and Methods: Between May 2010 and December 2011,17patients aged 81 ± 7.3 years (58.8% men with an Euro SCORE 29 ± 22.4%) underwent a TAVI. Results: The median transvalvular gradient was 54 ± 15.7 mmHg. All patients received a CoreValveTM. Technical success was 100%, with a post implant gradient of 6.29 ± 3.3 mmHg. Residual aortic regurgita-tion was observed in 94%, none greater than grade II. There were no complications at the vascular access site. One patient developed cardiac tamponade during the procedure. Permanent pacemaker implantation was required in 35.2%. Hospital mortality rate was 5.8%, a figure that remained unchanged at 30 days offollow-up. Conclusions: In high-risk patients with aortic stenosis, TAVI has a high success rate and a low rate of complications. Besides an appropriate patient selection, a trained multidisciplinary team and technical conditions to solve possible complications of the procedure are required.