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.

Valvotomia percutânea com balão em pacientes com menos de 18 anos / Percutaneous balloon valvotomy in patients under 18 years

INTRODUÇÃO: Valvotomia mitral percutânea (VMP) é o tratamento de escolha em pacientes com estenose mitral reumática. Em pacientes jovens, o implante de uma prótese pode trazer diversas complicações no curto e longo prazo como durabilidade bastante reduzida. O OBJETIVO desse trabalho é descrever os resultados imediatos e acompanhar o follow-up desse grupo de pacientes. MÉTODOS: Foram selecionados, em uma coorte retrospectiva, pacientes que se submeteram a VMP com idade menor do que 18 anos devido a estenose mitral reumática. Os procedimentos e a ecocardiografia foram realizados em centro único. RESULTADOS: 58 pacientes (15,41±2,42 anos, 69% mulheres) foram submetidos a 66 procedimentos. A área valvar prévia foi de 0,87±1,94 cm2 e após o procedimento passou a ser 2,00±0,46cm2, com 74% de insuficiência mitral graduada como menor do que discreta, 98,5% tinham ritmo sinusal e o procedimento foi considerado sucesso em 89,4%, sucesso parcial em 6,1% e insucesso 4,5%. No acompanhamento de curto prazo, 19,7% evoluíram para necessidade de cirurgia, sendo 3% emergencial. 22 casos evoluíram para necessidade de redilatação, sendo 12 casos ainda com menos de 18 anos e os demais acima dessa idade. CONCLUSÃO: A VMP é o método de escolha para o tratamento da estenose mitral reumática em pacientes abaixo de 18 anos, de mostrando segurança e bons resultados. Nessa faixa etária a prevalência em homens foram significativamente superior.

Long-term analysis of pulmonary hypertension and tricuspid regurgitation after transcatheter aortic valve replacement

INTRODUCTION: transcatheter aortic valve replacement (TAVR) is increasingly utilized in treatment of aortic stenosis (AS). AS is commonly associated to pulmonary hypertension (PH) and tricuspid regurgitation (TR). We aimed to evaluate the long-term post-TAVR course of PH and TR. METHODS: Patients undergoing TAVR were screened for 24-month echocardiographic data on PH and TR. All echocardiograms were performed by a sing le team. Patients were divided in groups according to TR and PH (pulmonary systolic pressure ≥ or < 45 mmHg) grading at 24 months with follow-up of up to 96 months. Standardized clinical outcomes and survival were compared. RESULTS: 156 and 151 patients were se le cted for PH and TR follow-up, respectively. Mean follow-up was 42.23±17.53 months and 42.60±17.67 months for PH and TR groups. Maximum follow-up was 96 months. PH was reduced post-TAVR (32.7% pre-TAVR vs. 20.5% post-TAVR, p<0.001), but no significant difference in TR was found (11.9% pre-TAVR vs. 10.6% post-TAVR). Increased le ft atrial (LA) diameter (p = 0.002) was associated to maintenance PH. Moreover, increased LA diameter (p=0.015) and increased EuroSCORE II (p=0.041) were correlated to new onset PH. On a multivariab le Cox regression model, new onset PH (HR 6.17, 95% CI 1.71­22.29, p=0.005), diastolic dysfunction type II or III (HR 1.06, 95% CI 1.06-1.11, p=0.036) and LA diameter (HR 1.11, 95% CI 1.02­1.21, p=0.02) were independent predictors of long-term mortality. CONCLUSIONS: TAVR was ab le to reduce the severity of PH, but not TR, in this cohort. Additionally, long-term survival was affected by PH, diastolic dysfunction and LA sizing.

Use of rapamycin-impregnated stents in coronary arteries.

FIM STUDY: We investigated the 2-year safety and efficacy of sirolimus-eluting stents. Thirty patients had a single 18-mm sirolimus-eluting coronary stent implanted. Twenty-eight patients underwent angiographic and intravascular ultrasound follow-up at 2 years. No death occurred during the study period. No patient developed in-stent restenosis. One patient had a 52% in-lesion stenosis that required repeated revascularization and another patient underwent target vessel revascularization. Neointimal hyperplasia volume was minimal at 2 years in both groups. This study demonstrates the 2-year safety and efficacy of sirolimus-eluting stenting. The slow release formulation showed slight superiority over the fast-release formulation in preventing late lumen loss, which was minimal in both groups. RAVEL TRIAL: This-study was a randomized, double-blind study that included 238 patients at 19 medical centers (15 in Europe, 3 in Brazil, and 1 in Mexico). Patients were eligible for the study if they were between 18 and 85 years of age, and had been given a diagnosis of stable or unstable angina or silent ischemia. Additional eligibility criteria were presence of a single primary target lesion in a native coronary artery that was 2.5 to 3.5 mm in diameter and that could be covered by an 18-mm stent stenosis of 51% to 99% of the luminal diameter and a flow rate of grade 1 or higher according to the Thrombolysis in Myocardial Infarction. RESULTS: One hundred twenty patients were randomly assigned to receive the sirolimus-eluting stent, and 118 were assigned to receive the standard stent. At 6 months, the degree of neointimal proliferation, manifested as the mean (+/-SD) late luminal loss, was significantly lower in the sirolimus-stent group (-0.01 +/- 0.33 mm) than in the standard-stent group (0.80 +/- 0.53 mm, P <.001). None of the patients in the sirolimus-stent group, as compared with 26.6% of those in the standard-stent group, had restenosis of >/=50% of the luminal diameter (P <.001). There were no episodes of stent thrombosis. During a follow-up period of up to 1 year, the overall rate of major cardiac events was 5.8% in the sirolimus-stent group and 28.8% in the standard-stent group (P <.001). The difference was due entirely to the higher rate of revascularization of the target vessel in the standard-stent group. CONCLUSION: Patients with angina who received sirolimus-eluting stents for the treatment of single, primary lesions in native coronary arteries had no angiographic evidence of late luminal loss or in-stent restenosis at 6 months, no episodes of thrombosis, and a very low rate of cardiac events at 1 year.