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.

Papel da ressonância magnética nuclear cardíaca na terapia de ressincronização cardíaca / Role of cardiac magnetic resonance imaging in cardiac resynchronization therapy

A insuficiência cardíaca é um importante problema de saúde pública. As modificações cardíacas estruturais que surgem com o processo de cronificação da insuficiência cardíaca levam a anormalidades na contração miocárdica e à dessincronização ventricular. A terapia de ressincronização cardíaca busca o tratamento dessa dessincronia. Neste trabalho é feita revisão bibliográfica que busca evidenciar o papel da ressonância magnética nuclear cardíaca na terapia de ressincronização cardíaca. Apesar de ainda não existir um grande estudo randomizado comparando os métodos complementares disponíveis, a análise da literatura médica sugere que a ressonância magnética nuclear cardíaca venha a ter papel crucial na obtenção de melhores resultados da terapia de ressincronização cardíaca, principalmente após o surgimento dos novos ressincronizadores compatíveis. A qualidade da imagem capturada, com melhor caracterização da estrutura tecidual miocárdica, localização das áreas de fibrose, e mensuração mais acurada dos volumes ventriculares e índices funcionais, associado ao fato de ser um método menos dependente de operador, sem emissão de radiação ionizante, e que utiliza contrastes menos nefrotóxicos, a coloca como um dos melhores métodos complementares para avaliar selecionar candidatos, guiar o implante dos cabos-eletrodos e avaliar a resposta individual ao tratamento. No contexto da insuficiência cardíaca e da terapia de ressincronização cardíaca, a classe médica pode ter certeza e segurança em optar pela ressonância magnética nuclear cardíaca como método adequado e confiável para avaliação e acompanhamento de seus pacientes

Heart failure is an important public healthcare problem. Structural heart changes resulting from chronic heart failure lead to abnormalities in myocardial contraction and ventricular dyssynchrony. Cardiac resynchronization therapy attempts to treat this dyssynchrony. This is a literature review that seeks to determine the role of cardiac magnetic resonance imaging in cardiac resynchronization therapy. Although there are no large randomized trials comparing the complementary methods available, a medical literature review suggests that cardiac magnetic resonance imaging plays a crucial role in obtaining the best results of cardiac resynchronization therapy, especially after the appearance of the new resynchronizers. The quality of the image captured with the best characterization of myocardial tissue structure, location of areas of fibrosis, and a more accurate measurement of ventricular volumes and functional indices, in addition to the fact that it is less operator dependent without ionizing radiation emition, which uses less nephrotoxic contrasts, turns it as one of the best complementary methods to evaluate, select candidates, guide electrode implantation and evaluate the individual response to treatment. In the context of heart failure and cardiac resynchronization therapy, doctors can be sure and confident in choosing cardiac magnetic resonance imaging as an adequate and reliable method for the evaluation and follow-up of their patients