Papel preditivo do escore de selvester em pacientes submetidos a troca transcateter de valva aórtica / Predictive role of selvester score in patients undergoing transcatheter aortic valve replacement

INTRODUÇÃO: O escore de Selvester é um escore eletrocardiográfico que estima e localiza a carga de fibrose miocárdica. Existem poucos dados sobre o impacto clínico da predição de fibrose em pacientes submetidos a troca transcateter de valva aórtica (TAVR). Este estudo avaliou o poder preditivo do escore de Selvester na sobrevida em pacientes com estenose aórtica (EA) submetidos a TAVR. MÉTODOS: Foram incluídos pacientes com estenose aórtica importante que realizaram eletrocardiograma pré-procedimento. Follow-up clínico foi obtido retrospectivamente. O desfecho primário foi morte por todas as causas e os secundários foram morte cardiovascular e MACE. RESULTADOS: 228 pacientes foram incluídos (idade média 81,5 ± 7,4 anos; 58,3% mulheres). Pacientes que morreram apresentaram escore de Selvester mais elevado (4,6 ± 3,2 vs. 1,4 ± 1,3; p < 0,001). Em um follow-up médio de 36,2 ± 21,2 meses, o escore de Selvester foi associado independentemente com mortalidade por todas as causas (HR, 1,65; 95% CI, 1,48-1,84; p < 0,001), mortalidade cardiovascular (HR, 1,59; 95% CI, 1,38-1,74; p < 0,001) e MACE (HR, 1,55; 95% CI, 1,30-1,68; p < 0,001). Após 5 anos, o risco de mortalidade foi diretamente correlacionado ao escore e o envolvimento da parede inferior do ventrículo esquerdo apresentou menor risco de mortalidade (HR, 0,42; 95% CI, 0,18-0,98; p = 0,046). Para o valor do escore de Selvester de 3, a área sobre a curva ROC foi de 0,92, 0,94 e 0,86 (p < 0,001) para 1, 2 e 3 anos, respectivamente. CONCLUSÃO: Valores elevados do escore de Selvester aumentam o risco de desfechos negativos em pacientes com EA submetidos a TAVR. O envolvimento das paredes anterior e lateral apresentam pior prognóstico.

Role of the supplementary motor area in motor deficit following medial frontal lobe surgery.

OBJECTIVE: Patients undergoing surgical resection of medial frontal lesions may present a transient postoperative deficit that remains largely unpredictable. The authors studied the role of the supplementary motor area (SMA) in the occurrence of this deficit using fMRI. METHODS: Twenty-three patients underwent a preoperative fMRI before resection of medial frontal lesions. Tasks included self-paced flexion/extension of the left and right hand, successively. Preoperative fMRI data were compared with postoperative MRI data and with neurologic outcome. RESULTS: Following surgery, 11 patients had a motor deficit from which all patients recovered within a few weeks or months. The deficit was similar across patients, consisting of a global reduction in spontaneous movements contralateral to the operated side with variable severity. SMA activation was observed in all patients. The deficit was observed when the area activated in the posterior part of the SMA (SMA proper) was resected. CONCLUSIONS: fMRI is able to identify the area at risk in the SMA proper whose resection is highly related to the occurrence of the motor deficit. The clinical characteristics of this deficit support the role of the SMA proper in the initiation and execution of the movement.

Cerebral mechanisms of word masking and unconscious repetition priming.

We used functional magnetic resonance imaging (fMRI) and event-related potentials (ERPs) to visualize the cerebral processing of unseen masked words. Within the areas associated with conscious reading, masked words activated left extrastriate, fusiform and precentral areas. Furthermore, masked words reduced the amount of activation evoked by a subsequent conscious presentation of the same word. In the left fusiform gyrus, this repetition suppression phenomenon was independent of whether the prime and target shared the same case, indicating that case-independent information about letter strings was extracted unconsciously. In comparison to an unmasked situation, however, the activation evoked by masked words was drastically reduced and was undetectable in prefrontal and parietal areas, correlating with participants' inability to report the masked words.

Functional MRI of galvanic vestibular stimulation.

The cortical processing of vestibular information is not hierarchically organized as the processing of signals in the visual and auditory modalities. Anatomic and electrophysiological studies in the monkey revealed the existence of multiple interconnected areas in which vestibular signals converge with visual and/or somatosensory inputs. Although recent functional imaging studies using caloric vestibular stimulation (CVS) suggest that vestibular signals in the human cerebral cortex may be similarly distributed, some areas that apparently form essential constituents of the monkey cortical vestibular system have not yet been identified in humans. Galvanic vestibular stimulation (GVS) has been used for almost 200 years for the exploration of the vestibular system. By contrast with CVS, which mediates its effects mainly via the semicircular canals (SCC), GVS has been shown to act equally on SCC and otolith afferents. Because galvanic stimuli can be controlled precisely, GVS is suited ideally for the investigation of the vestibular cortex by means of functional imaging techniques. We studied the brain areas activated by sinusoidal GVS using functional magnetic resonance imaging (fMRI). An adapted set-up including LC filters tuned for resonance at the Larmor frequency protected the volunteers against burns through radio-frequency pickup by the stimulation electrodes. Control experiments ensured that potentially harmful effects or degradation of the functional images did not occur. Six male, right-handed volunteers participated in the study. In all of them, GVS induced clear perceptions of body movement and moderate cutaneous sensations at the electrode sites. Comparison with anatomic data on the primate cortical vestibular system and with imaging studies using somatosensory stimulation indicated that most activation foci could be related to the vestibular component of the stimulus. Activation appeared in the region of the temporo-parietal junction, the central sulcus, and the intraparietal sulcus. These areas may be analogous to areas PIVC, 3aV, and 2v, respectively, which form in the monkey brain, the "inner vestibular circle". Activation also occurred in premotor regions of the frontal lobe. Although undetected in previous imaging-studies using CVS, involvement of these areas could be predicted from anatomic data showing projections from the anterior ventral part of area 6 to the inner vestibular circle and the vestibular nuclei. Using a simple paradigm, we showed that GVS can be implemented safely in the fMRI environment. Manipulating stimulus waveforms and thus the GVS-induced subjective vestibular sensations in future imaging studies may yield further insights into the cortical processing of vestibular signals.