Impacto de un Heart Team en pacientes con estenosis aórtica candidatos a reemplazo percutáneo / Impact of a Heart Team in patients with aortic stenosis who are candidates for transcatheter aortic valve replacement

RESUMEN La difusión del reemplazo valvular aórtico percutáneo (TAVI) en la estenosis aórtica (EAo) generó la creación de un Heart Team (HT), para elegir el mejor tratamiento. Existen pocos reportes sobre su utilidad. Objetivos: analizar los resultados del tratamiento de los pacientes con EAo evaluados por un HT durante 10 años Material y métodos: Inclusión consecutiva de todos los pacientes con EAo candidatos a TAVI entre enero del 2012 y julio del 2021 para seleccionar el mejor tratamiento, incluyendo además Cirugía de reemplazo valvular aórtico (CRVA) y Tratamiento médico conservador (TMC). Resultados: De 841 pacientes, se asignaron a TAVI 455 (53%), CRVA 213 (24%) y TMC 183 (23%). El porcentaje asignado a TAVI aumentó con el tiempo de 48 a 62% (p < 0,05). Los pacientes que fueron a TAVI, con respecto a los enviados a CRVA, eran mayores (86 ± 7 vs 83 ± 7 años), con mayor EUROSCORE II (6,2, IC95% 5,7-6,6 vs 5,6, IC95% 4,4-6,5) y más frágiles (1,62 ± 1 vs 0,91 ± 1), en todos los casos p <0,01. La sobrevida actuarial (IC 95%) a 1 y a 2 años fue, para TAVI 88% (84-91%) y 82% (77-86%), para CRVA 83% (76-88%) y 78% (70-84%) y para TMC 70% (60-87%) y 59% (48-68%) respectivamente (p <0,001). Conclusiones: Durante los primeros 10 años de establecido un Heart Team para la toma de decisiones en EAo, se asignaron a TAVI aproximadamente la mitad y el resto se asignó por mitades a cirugía u observación. La sobrevida de los pacientes intervenidos fue similar a 2 años y mayor que la de los no intervenidos.

ABSTRACT As transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) became widespread, the need for a Heart Team (HT) arose to choose the best treatment. There are few reports regarding its usefulness. Objectives: To analyze treatment outcomes in patients with AS evaluated by a HT for 10 years. Methods: Consecutive enrollment of all patients with AS who were candidates for TAVI between January 2012 and July 2021 to choose the best treatment, including surgical aortic valve replacement (SAVR) and conservative medical management (CMM). Results: Out of 841 patients, 455 were assigned to TAVI (53%), 213 to SAVR (24%), and 183 to CMM (23%). The percentage assigned to TAVI has increased from 48% to 62% over time (p <0.05). Patients who underwent TAVI versus those who underwent SAVR were older (86 ± 7 vs. 83 ± 7 years), had a higher EUROSCORE II (6.2, 95% CI 5.7-6.6 vs. 5.6; 95% CI 4.4-6.5) and were frailer (1.62 ± 1 vs. 0.91 ± 1), in all cases p <0.01. Actuarial survival (95% CI) at 1 and 2 years was 88% (84-91%) and 82% (77-86%) for TAVI, 83% (76-88%) and 78% (70-84%) for SAVR, and 70% (60-87%) and 59% (48-68%) for CMM, respectively (p <0.001). Conclusions: For the first 10 years after a Heart Team was established for AS decision-making, approximately half of the patients were assigned to TAVI, and the rest were equally assigned in halves to either surgery or observation. Survival for patients who received interventions was similar at 2 years and higher than in those who did not.

Endocarditis infecciosa en válvulas protésicas / Prosthetic valve endocarditis

RESUMEN Introducción: La endocarditis infecciosa sobre prótesis valvulares cardíacas es una de las formas más graves de esta enfermedad, de difícil diagnóstico y asociada con elevada mortalidad. Objetivo: Describir las características de la endocarditis infecciosa en válvulas cardíacas protésicas. Método: Se realizó un estudio observacional, descriptivo y transversal desde 2006 hasta 2019 en el Hospital Hermanos Ameijeiras. La muestra fue de 40 pacientes. Se utilizaron estadígrafos descriptivos como la media aritmética y la desviación estándar para las variables cuantitativas continuas y el porcentaje para las cualitativas. Resultados: La edad media de los pacientes fue de 54,29±16,07 años, predominaron aquellos con edades entre 40-49 y 60-69 años (27,5%), así como del sexo masculino (67,5%), y el tipo de endocarditis más frecuente fue la tardía 65%. La sepsis oral (27,5%) y la cirugía previa (25%) fueron la puerta de entrada más frecuente. Prevalecieron los cultivos negativos (40%) y los agentes causales estafilococos coagulasa negativos (25%) y estafilococos áureos (10%). En las complicaciones predominaron las insuficiencias cardíacas (32%) y renal (22,5%), y un 20% de los casos tuvo dehiscencia de sutura. El 52,5% de los pacientes recibió tratamiento quirúrgico y la mortalidad fue del 30%. Conclusiones: Predominó la endocarditis tardía, con hemocultivo negativo y de prótesis aórtica. La dehiscencia de prótesis fue el hallazgo ecocardiográfico más encontrado y la insuficiencia cardíaca, la complicación más frecuente. El tratamiento quirúrgico fue el más utilizado y la mortalidad, ajustada para esta enfermedad, fue baja.

ABSTRACT Introduction: Infective endocarditis in prosthetic heart valves is one of the most severe forms of this disease of difficult diagnosis and associated with high mortality. Objective: To describe the characteristics of prosthetic valve endocarditis. Method: An observational, descriptive and cross-sectional study was conducted from 2006 to 2019 at Hospital Hermanos Ameijeiras. The sample consisted of 40 patients. Descriptive statistics such as arithmetic mean and standard deviation were used for continuous quantitative variables, and percentage for qualitative ones. Results: The average age of the patients was 54.29+16.07 years old, predominating those between 40-49 and 60-69 years old, as well as males (67.5%); the most frequent type of endocarditis was the late one (65%). Oral sepsis (27.5%) and previous surgery (25%) %) were the most frequent entry points. Negative cultures (40%) and coagulase-negative staphylococcus causative agents (25%) and staphylococcus aureus (10%) prevailed. Heart failure (32%) and kidney failure (22.5%) were the most frequent complications, and 20% of cases had suture dehiscence. The 52.5% of patients received surgical treatment and the mortality was of the 30%. Conclusions: Late endocarditis predominated, with negative blood cultures and of aortic valve prosthesis. Prosthesis dehiscence was the most frequent echocardiographic finding and the heart failure, the most frequent complication. The surgical treatment was the most used, and the mortality, adjusted for this disease, was low.

Strategy of anticoagulation therapy during pregnancy in patients with mechanical heart valve / 中国胸心血管外科临床杂志

@#The management of women with mechanical heart valves during pregnancy remains difficult and controversial. The selection of prosthetic heart valve, management during pregnancy and delivery period, guidelines and anticoagulation strategy used in patients with a mechanical heart valve in China are summarized in this review.

EuroSCORE II and STS as mortality predictors in patients undergoing TAVI / EuroSCORE II e STS como preditores de mortalidade em pacientes submetidos ao TAVI

SUMMARY Introduction: the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. Objective: to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. Methods: we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. Results: mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). Conclusion: in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

RESUMO Introdução: STS e EuroSCORE II são os escores mais utilizados para a estratificação de risco cirúrgico e indicação do implante de válvula aórtica transcateter (TAVI). Entretanto, seu papel como ferramenta para predição de mortalidade em pacientes submetidos ao TAVI ainda é incerto. Objetivo: avaliar o desempenho do EuroSCORE II e STS como preditores de mortalidade intra-hospitalar em 30 dias em pacientes submetidos ao TAVI. Métodos: 59 pacientes com estenose aórtica importante submetidos ao TAVI entre 2010 e 2014. Variáveis foram analisadas por meio do teste t-Student e teste exato de Fisher, e o poder discriminativo foi avaliado pela curva ROC e área sob a curva, acompanhada de intervalo de confiança de 95%. Resultados: a idade média foi de 81±7,3 anos, 42,3% homens. Média do EuroSCORE II foi de 6,07±7,3%, e do STS, 20,7±10,3%. Procedimento transfemoral foi realizado em 88,13%, transapical, em 3,38% e transaórtico, em 8,47%. A mortalidade intra-hospitalar foi 10,1%, e em 30 dias, 13,5%. Os pacientes que evoluíram para óbito apresentavam STS e EuroSCORE II mais elevados que os sobreviventes (33,7±16,7% vs. 18,6±7,3%; p=0,0001 para STS e 13,9±16,1% vs. 4,8±3,8%; p=0,0007 para EuroSCORE II). O STS apresentou AUC de 0,81, e o EuroSCORE II, 0,77. Não houve diferença na capacidade de discriminação pelas curvas ROC (p=0,72). Conclusão: STS e EuroSCORE II foram preditores de mortalidade intra-hospitalar em 30 dias.

Trombosis de válvulas cardiacas biológicas: presentación de dos casos evaluados con ecocardiografía 3D en tiempo real / Thrombosis of biological valves: report of two cases evaluated by 3D echocardiography in real time

La trombosis de las válvulas protésicas biológicas es una complicación infrecuente, que se asocia con mortalidad elevada. En este artículo se reporta el caso de un paciente de género masculino, de 72 años de edad, con prótesis valvular biológica en posición aórtica y trombosis asociada a degeneración valvular, así como el de una paciente de género femenino de 64 años de edad, con prótesis biológica en posición mitral y trombosis de la misma en el contexto de una infección sistémica. Ambos casos se evaluaron mediante ecocardiografía transesofágica tridimensional en tiempo real.

Thrombosis of biological prosthetic valves is a rare complication, associated with high mortality. We report the case of a 72 years old male patient with biological valve prosthesis in the aortic position and thrombosis associated with valvular degeneration, as well as that of a 64 years old female patient with bioprosthesis in the mitral position and thrombosis of it in the context of a systemic infection. Both cases were evaluated by three-dimensional transesophageal echocardiography in real time.

Análisis in vitro de la influencia sobre el campo de flujo de dos modelos de válvulas cardiacas mecánicas bivalvas mediante un túnel de viento / Analysis in vitro of the influence of two mechanical bivalve models of heart valves by a wind tunnel model

INTRODUCCIÓN: las prótesis valvulares cardiacas se evalúan mediante diferentes técnicas que involucran ensayos in vitro y métodos computacionales, además de los estudios clínicos convencionales. Los datos funcionales a evaluar reflejan la necesidad de contar con métodos de gran sensibilidad para determinar su operación en condiciones que emulen situaciones hemodinámicas específicas. Con este objetivo se proyectó un método alternativo que ayuda a un mejor entendimiento de la funcionalidad de estos dispositivos, analizando el comportamiento fluidodinámico in vitro de dos modelos de válvulas mecánicas cardiacas mediante un túnel de viento. MÉTODOS: se diseñó y desarrolló un túnel de viento disponiendo condiciones instrumentales que permitieran evaluar las válvulas mecánicas en distintas situaciones fluidodinámicas: túnel subsónico de sección circular (norma ANSI/AMCA_210-99 y ANSI/ASHRAE_51-99). Empleando el método de similitud dinámica se caracterizó la experimentación utilizando valores típicos de caudales y propiedades de la sangre en un adulto sano. RESULTADOS Y DISCUSIÓN: se evaluaron dos modelos valvulares tipo SJM®, uno de valvas planas y una variante de valvas convexas, con flujos de aire equivalentes a caudales sanguíneos de 1,5, 6,0 y 9,3 L/min. La prótesis de valvas convexas presenta un flujo dividido en tres campos equivalentes, a diferencia de la de valvas planas que tiene un flujo más pequeño en la parte central y dos laterales predominantes. El fenómeno de arrastre producido por las dos corrientes externas con respecto a la central, genera un RNS mayor para la válvula tipo SJM® que para la variante con valvas convexas. El campo de velocidad adyacente al lado convexo, se halla menos afectado por la turbulencia que en el caso de la valva plana; pero al contrario, el campo adyacente al lado cóncavo está más afectado por fenómenos fluidodinámicos locales: cambios de dirección, reducción de área y aumento de velocidad...

INTRODUCTION: prosthetic heart valves are evaluated using different techniques that involve in vitro studies and computational methods in addition to conventional clinical studies. Functional data to evaluate reflect the need for highly sensitive methods to determine its operating conditions that may emulate specific hemodynamic situations. With this objective, we designed an alternative method for better understanding the functionality of these models, analyzing in vitro fluid dynamic behavior of two models of mechanical heart valves using a wind tunnel. METHODS: we designed and developed a wind tunnel providing instrumental conditions that permit the evaluation of mechanical valves in different fluid dynamic conditions: subsonic tunnel of circular section (standard ANSI/AMCA_210-99 and ANSI/ASHRAE_51-99). Using the method of dynamic similarity, the experiment was characterized using typical values of flow rates and blood properties in a healthy adult. RESULTS AND DISCUSSION: we evaluated two SJM® valve models, one with flat leaflet, and a variant of convex valves with air flows equivalent to blood flow rates of 1.5, 6.0 and 9.3 L/min. The convex valve prosthesis has a flow divided in three equivalent fields, in contrast to the flat valves that have a smaller central flow and two predominant laterals. The drag phenomenon produced by the two external currents wit regard to the central generates a higher RNS for the SJM® valve than the generated for the variant of convex valves. The velocity field adjacent to the convex side is less affected by turbulence than in the case of the flat leaflet, but on the contrary, the adjacent field to the concave side is more affected by local fluid dynamic effects: changes in direction, area reduction and increased velocity...

Univariate Risk Factors for Prolonged Mechanical Ventilation in Patients Undergoing Prosthetic Heart Valves Replacement Surgery / 华中科技大学学报（医学）（英德文版）

Data from 736 patients undergoing prosthetic heart valve replacement surgery and concomitant surgery (combined surgery) from January 1998 to January 2004 at Union Hospital were retrospectively reviewed. Univariate logistic regression analyses were conducted to identify risk factors for prolonged mechanical ventilation. The results showed that prolonged cardiopulmonary bypass duration, prolonged aortic cross clamp time and low ejection fraction less than 50 percent (50 %)were found to be independent predictors for prolonged mechanical ventilation. Meanwhile age,weight, and preoperative hospital stay (days) were not found to be associated with prolonged mechanical ventilation. It was concluded that, for age and weight, this might be due to the lower number of old age patients (70 years and above) included in our study and genetic body structure of majority Chinese population that favor them to be in normal weight, respectively.