Independent clinical and echocardiographic predictors of restenosis after percutaneous mitral balloon commissurotomy in a large, consecutive cohort followed for 24 years

OBJECTIVES: to enlighten preprocedural risk factors of mitral valve restenosis in a large, single-center cohort of patients submitted to percutaneous mitral balloon commissurotomy (PMBC) for the treatment of mitral stenosis (MS) secondary to rheumatic heart disease. METHODS: this is a database analysis of a single-center, high-volume tertiary institution involving all consecutive PMBC procedures performed in the mitral valve (MV). Restenosis was diagnosed when MV area was <1.5 cm2 and/or loss of 50% or more of the immediate procedural result aligned with the return/worsened symptoms of heart failure. The primary endpoint was to determine the preprocedural independent predictors of restenosis after PMBC. Results: among a total of 1921 PMBC procedures, 1794 consecutive patients without previous intervention were treated between 1987 and 2010. Throughout 24 years of follow-up, MV restenosis was observed in 483 cases (26%). Mean age was 36 years and most (87%) were female. Median follow-up duration was 9.03 years (interquartile range, 0.33-23.38). Restenosis population, however, presented a significantly lower age at the procedure time as well as a higher Wilkins-Block score. At multivariate analysis, independent preprocedure predictors of restenosis were left atrium diameter (hazard risk [HR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.04), preprocedure maximum gradient (HR, 1.02; 95% CI, 1.00-1.03; P=.04), and higher Wilkins-Block score (>8) (HR, 1.38; 95% CI, 1.14-1.67; P<.01). CONCLUSIONS: at long-term follow-up, MV restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum MV gradient, and Wilkins-Block score were found to be the only independent predictors.

Independent clinical and echocardiographic predictors of restenosis after percutaneous mitral balloon commissurotomy followed for 24 years

BACKGROUND: Mitral valve stenosis (MVS) is one of the most common structural heart diseases in developing countries, primarily due to rheumatic disease. Percutaneous mitral balloon valvuloplasty (PMBV) has been, since its introduction in 1984, the preferred option of treatment for such disease. However, restenosis is presented with an approximate incidence of 20%. Echocardiographic scoring of the mitral apparatus has been the main tool used to indicate and foresee the possible result of the procedure. The objective of this study was to enlight risk factors of mitral valvular restenosis in a significant number of patients submitted to percutaneous mitral balloon commissurotomy for the treatment of mitral stenosis (MS), particularly when secondary to rheumatic heart disease. METHODS: This study reports the vast experience of a single center high volume tertiary institution where 1.794 consecutive patients were treated with PMBC between 1987 and 2011. The primary endpoint was to determine the independent predictors of this untoward event, defined as loss of over 50% of the original increase in maximum valve area (MVA) or MVA< 1.5 cm2. RESULTS: Mitral valve restenosis was observed in 26% of the cases (n=483). Mean population age was 36 years old, with most patients being female (87%). Mean follow up duration was 4.8 years. At multivariate analysis independent pre-procedural predictors of restenosis were: left atrial diameter (HR: 1.03, 95% ci: 1.01-1.04, p<0.01), pre procedure maximum gradient (HR: 1.01, 95% ci: 1.00-1.03, p=0.02) and higher wilkins scores (HR: 1.37, 95% ci: 1.13-1.66, p<0.01). CONCLUSION: In the very long term follow-up, mitral valve restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum valve gradient and high Wilkins scores were found to be the only independent predictors of this deleterious event.

Long-term follow-up in patients with rheumatic mitral stenosis and severe pulmonary artery hypertension submitted to percutaneous mitral balloon commissurotomy

BACKGROUND: Percutaneous balloon mitral commissurotomy (PMBC) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMBC in patients with severe pulmonary hypertension (PH). METHODS: Among all procedures (in more than two decades of experience), PMBC was performed from 1987 until 2011 at a single-center in 147 patients who had significant PH defined as baseline pulmonary artery mean pressure (PAMP) (systolic pulmonary pressure > 75 mmHg). All-cause mortality, need for mitral valve replacement (MVR) or new PMBC, and valve restenosis were evaluated during follow-up yearly. RESULTS: Mean age was 33.8 ± 12.8 years and 83.6% (123 patients) were women. Primary success was achieved in 89.8% of the patients (132 patients). Mitral valve area (MVA) increased from 0.83 ± 0.17 cm2 to 2.03± 0.35 cm2 (p<0.001), and at 20-years, mitral valve area was 1.46± 0.34 cm2 (p=0.235). Systolic pulmonary artery pressure decreased from 87.0 ± 6.0 mmHg to 60.0 ± 0.9 mmHg (p<0.001) The rates of all-cause mortality, need for MVR, new PMV, and valve restenosis were 0.67%, 20.0%, 8.78% and 30.4%, respectively, in long-term follow- up (mean 15.6 ± 4.9 years). CONCLUSIONS: PMBC is a safe and effective technique for the treatment of patients with mitral stenosis and PH. A significant decrease in pulmonary pressure was observed after commissurotomy. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and without major adverse events.

Preditores independentes de reestenose da valva mitral após valvoplastia mitral percutânea por balão em uma grande coorte consecutiva com seguimento clínico por mais de duas décadas / Independent predictors of mitral valve restenosis after percutaneous balloon mitral valvuloplasty in a large consecutive cohort with clinical follow-up for more than two decades

INTRODUÇÃO: A valvoplastia mitral percutânea com balão (VMPB), sempre que tecnicamente viável, é a opção de tratamento preferencial para a estenose mitral, particularmente aquelas secundárias à doença cardíaca reumática. No entanto, a reestenose valvar mitral pode se desenvolver em um número significativo de pacientes submetidos a esse procedimento, com fatores de risco ainda pouco claros para tal ocorrência. OBJETIVOS: O objetivo deste estudo foi elucidar os fatores de risco da reestenose valvar mitral em um número significativo de pacientes submetidos à comissurotomia mitral percutânea por balão para tratamento da estenose mitral (EM), principalmente quando secundária à cardiopatia reumática. MÉTODOS: Trata-se de uma análise de centro único de uma coorte grande e consecutiva de pacientes tratados com VMP entre 1987 e 2010, que desenvolveram reestenose. O desfecho primário foi determinar os preditores independentes desse evento, definido como perda de mais de 50% do aumento original na área valvar mitral máxima (AVM) ou AVM menor que 1,5cm2. RESULTADOS: Um total de 1.794 pacientes consecutivos submetidos a VMP em um único centro, instituição terciária de alto volume, foram incluídos neste registro. Reestenose da valva mitral foi observada em 26% dos casos (n=483). A média de idade da população foi de 36 anos, com a maioria dos pacientes sendo do sexo feminino (87%). A duração média do acompanhamento foi de 4,8 anos. Na análise multivariada, os preditores independentes de reestenose foram: diâmetro atrial esquerdo [RR (risco relativo): 1,03; IC (intervalo de confiança) 95%: 1,01-1,04; p <0,01]; gradiente máximo pré-procedimento (RR: 1,01; IC 95%: 1,00-1,03; p=0,02) e Wilkinsscore > 8 (RR: 1,37; IC 95%: 1,13-1,66; p<0,01). CONCLUSÕES: No seguimento em longo prazo, a reestenose da valva mitral foi observada em até 25% da população submetida à VMP. Os achados ecocardiográficos pré-procedimento, incluindo o diâmetro do átrio esquerdo, o gradiente valvar máximo e o escore de Wilkins, foram os únicos preditores independentes desse desfecho desfavorável.

Independent clinical and echocardiographic predictors of restenosis after percutaneous mitral balloon commissurotomy followed for 24 years

INTRODUCTION: Mitral valve stenosis (MVS) is one of the most common structural heart diseases in developing countries, primarily due to rheumatic disease. Percutaneous mitral balloon valvuloplasty (PMBV) has been, since its introduction in 1984, the preferred option of treatment for such disease. However, restenosis is presented with an approximate incidence of 20%. Echocardiographic scoring of the mitral apparatus has been the main tool used to indicate and foresee the possible result of the procedure. OBJECTIVE: The objective of this study was to enlight risk factors of mitral valvular restenosis in a significant number of patients submitted to percutaneous mitral balloon commissurotomy for the treatment of mitral stenosis (MS), particularly when secondary to rheumatic heart disease. METHODS: This study reports the vast experience of a single center high volume tertiary institution where 1.794 consecutive patients were treated with PMBC between 1987 and 2011. The primary endpoint was to determine the independent predictors of this untoward event, defined as loss of over 50% of the original increase in maximum valve area (MVA) or MVA < 1.5 cm2. RESULTS: Mitral valve restenosis was observed in 26% of the cases (n = 483). Mean population age was 36 years old, with most patients being female (87%). Mean follow up duration was 4.8 years. At multivariate analysis independent pre-procedural predictors of restenosis were: left atrial diameter (HR: 1.03, 95% ci: 1.01-1.04, p < 0.01), pre procedure maximum gradient (HR: 1.01, 95% ci: 1.00-1.03, p = 0.02) and higher wilkins scores (HR: 1.37, 95% ci: 1.13-1.66, p < 0.01). CONCLUSION: In the very long term follow-up, mitral valve restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum valve gradient and high Wilkins scores were found to be the only independent predictors of this deleterious event.

Independent mitral valve predictors of restenosis after percutaneous mitral balloon commissurotomy in a large, consecutive cohort followed for more than two decades

AIMS: the objective of this study was to enlight risk factors of mitral valvular restenosis in a significant number of patients submitted to percutaneous mitral balloon commissurotomy for the treatment of mitral stenosis (ms), particularly when secondary to rheumatic heart disease. METHODS AND RESULTS: this study reports the vast experience of a single center high volume tertiary institution where 1,794 consecutive patients were treated with PMBC between 1987 and 2011. the primary endpoint was to determine the independent predictors of this untoward event, defined as loss of over 50% of the original increase in maximum valve area (mva) or mva < 1.5 cm2. mitral valve restenosis was observed in 26% of the cases (n=483). average population age was 36 years old, with most patients being female (87%). mean follow up duration was 4.8 years. at multivariate analysis independent pre-procedural predictors of restenosis were: left atrial diameter (hr: 1.03, 95% ci: 1.01-1.04, p<0.01). pre procedure maximum gradient (hr: 1.01, 95% ci: 1.00-1.03, p=0.02) and higher wilkins scores (hr: 1.37, 95% ci: 1.13-1.66, p<0.01). CONCLUSIONS: In the very long term follow-up, mitral valve restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum valve gradient and high wilkins scores were found to be the only indepen dent predictors of this deleterious event.

Long-term follow-up in patients with rheumatic mitral stenosis and severe pulmonary artery hypertension submitted to percutaneous mitral balloon commissurotomy

AIMS: Percutaneous balloon mitral commissurotomy (PMBC) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMBC in patients with severe pulmonary hypertension (PH). METHODS AND RESULTS: Among all procedures (in more than two decades of experience), PMBC was performed from 1987 until 2011 at a single-center in 147 patients who had significant PH defined as baseline pulmonary artery mean pressure (PAMP) (systolic pulmonary pressure > 75 mmHg). All-cause mortality, need for mitral valve replacement (MVR) or new PMBC, and valve restenosis were evaluated during follow-up yearly. Mean age was 33.8 ± 12.8 years and 83.6% (123 patients) were women. Primary success was achieved in 89.8% of the patients (132 patients). Mitral valve area (MVA) increased from 0.83 ± 0.17 cm2 to 2.03± 0.35 cm2 (p<0.001), and at 20-years, mitral valve area was 1.46 ± 0.34 cm2 (p=0.235). Systolic pulmonary artery pressure decreased from 87.0 ± 6.0 mmHg to 60.0 ± 0.9 mmHg (p<0.0001). The rates of all-cause mortality, need for MVR, new PMV, and valve restenosis were 0.67%, 20.0%, 8.78% and 30.4%, respectively, in long-term follow- up (mean 15.6 ± 4.9 years). CONCLUSIONS: PMBC is a safe and effective technique for the treatment of patients with mitral stenosis and PH. A significant decrease in pulmonary pressure was observed after commissurotomy. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and without major adverse events.

Preditores independentes de reestenose da valva mitral após valvoplastia mitral percutânea por balão em uma grande coorte consecutiva com seguimento clínico por mais de duas décadas / Independent predictors of mitral valve restenosis after percutaneous balloon mitral valvuloplasty in a large consecutive cohort with clinical follow-up for more than two decades

INTRODUÇÃO: A valvoplastia mitral percutânea com balão (VMP), sempre que tecnicamente viável, é a opção de tratamento preferencial para a estenose mitral, particularmente aquelas secundárias à doença cardíaca reumática. No entanto, a reestenose valvar mitral pode se desenvolver em um número significativo de pacientes submetidos a esse procedimento, com fatores de risco ainda pouco claros para tal ocorrência. MÉTODOS: Trata-se de uma análise de centro único de uma coorte grande e consecutiva de pacientes tratados com VMP entre 1987 e 2010, que desenvolveram reestenose. O desfecho primário foi determinar os preditores independentes desse evento, definido como perda de mais de 50% do aumento original na área valvar mitral máxima (AVM) ou AVM menor que 1,5 cm2. RESULTADOS: Um total de 1.794 pacientes consecutivos submetidos a VMP em um único centro, instituição terciária de alto volume, foram incluídos neste registro. Reestenose da valva mitral foi observada em 26% dos casos (n = 483). A média de idade da população foi de 36 anos, com a maioria dos pacientes sendo do sexo feminino (87%). A duração média do acompanhamento foi de 4,8 anos. Na análise multivariada, os preditores independentes de reestenose foram: diâmetro atrial esquerdo [RR (risco relativo): 1,03; IC (intervalo de confiança) 95%: 1,01-1,04; p <0,01]; gradiente máximo pré-procedimento (RR: 1,01; IC 95%: 1,00-1,03; p = 0,02 ) e Wilkins score maior que 8 (RR: 1,37; IC 95%: 1,13-1,66; p <0,01). CONCLUSÕES: No seguimento em longo prazo, a reestenose da valva mitral foi observada em até 25% da população submetida à VMP. Os achados ecocardiográficos pré-procedimento, incluindo o diâmetro do átrio esquerdo, o gradiente valvar máximo e o escore de Wilkins, foram os únicos preditores independentes desse desfecho desfavorável. (AU)

Very Long Term Follow-Up After Percutaneous Balloon Mitral Valvuloplasty

OBJECTIVES: The aim of this study was to assess very long term outcomes after successful percutaneous balloon mitral valvuloplasty (PBMV).BACKGROUND: PBMV remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and suitable anatomy.METHODS: All consecutive patients who underwent successful PBMV between 1987 and 2010 were included. The primary endpoint was the composite of all-cause mortality, need for mitral surgery, or repeat PBMV up to 23 years.RESULTS: Among all 1,582 consecutive patients undergoing PBMV, acute success was achieved in 90.9% (n»1,438).Independent predictors of acute success included left atrial size (odds ratio: 0.96; 95% confidence interval [CI]: 0.93 to0.99; p»0.045), Wilkins score#8 (odds ratio: 1.66; 95% CI: 0.48 to 0.93; p»0.02) and age (odds ratio: 0.97; 95% CI:0.96 to 0.99; p»0.006). Very long-term follow-up (median 8.3 years, mean 15.6 years) was obtained in 79.1% of successful cases. The incidence of the primary endpoint was 19.1% (95% CI: 17.0% to 21.1%). The rates of overall lmortality, need for mitral valve surgery, or repeat PBMV were 0.6% (95% CI: 0.3% to 1.2%), 8.3% (95% CI: 7.0% to9.9%), and 10.0% (95% CI: 8.5% to 11.7%), respectively. On multivariate analysis, New York Heart Association functional class III or IV (hazard ratio: 1.62; 95% CI: 1.26 to 2.09; p<0.001), higher age (hazard ratio: 0.97; 95% CI: 0.96 to0.98; p»0.028), and mitral valve area#1.75 cm2after the procedure (hazard ratio: 1.67; 95% CI: 1.28 to 2.11;p»0.028) were independent predictors of the primary endpoint. CONCLUSIONS: In very long term follow-up, more than 75% of patients exhibited sustained results. Prediction of late favorable results is multifactorial and strongly determined by age, previous symptoms and post-procedural mitral valve area.(J Am Coll Cardiol Intv 2018;11:1945­52) © 2018 by the American College of Cardiology Foundation.

Eficacia de la estrategia de control del ritmo en pacientes con miocardiopatía hipertrófica y fibrilación o flutter auricular, sometidos a cardioversión eléctrica / Efficacy of rhythm control strategy in patients with hypertrophic cardiomyopathy and atrial fibrillation or flutter, undergoing electrical cardioversion

Contexto: la fibrilación y el flutter auricular son arritmias frecuentes en pacientes con miocardiopatía hipertrófica e incrementan su morbilidad. La cardioversión de la arritmia mejora la calidad de vida del paciente, sin embargo, no existe información sobre la eficacia o predictores de esta terapia en la literatura. Objetivo: identificar en pacientes que presentan miocardiopatía hipertrófica asociada a fibrilación o flutter auricular que fueron sometidos a cardioversión eléctrica, las variables relacionadas con la evolución de la arritmia después de esta terapia. Métodos: se analizaron los datos de 37 pacientes con diagnóstico de miocardiopatía hipertrófica asociada a fibrilación auricular (n=21) y flutter auricular (n=16), sometidos a cardioversión eléctrica, en lo relativo a éxito inmediato (reversión después del choque), recurrencia (reaparición del problema después de la cardioversión eléctrica) y éxito tardío (ritmo sinusal observado en la última consulta registrada). Resultados: el éxito inmediato se produjo en el 96% de procedimientos de cardioversión eléctrica en pacientes con fibrilación auricular y en el 100% de pacientes con flutter auricular. La recurrencia se produjo en el 76,9% de los pacientes con fibrilación auricular sometidos a cardioversión eléctrica después de un tiempo medio de 630 días y en el 57,1% de los pacientes con flutter auricular luego de un seguimiento de 1.138 días. Conclusión: se evaluó la eficacia de la cardioversión eléctrica mediante los resultados clínicos observados en pacientes con miocardiopatía hipertrófica asociada a fibrilación o flutter auricular; además se identificaron las variables relacionadas con la recurrencia y el éxito tardío después de la cardioversión eléctrica. (AU)

Background: fibrillation and atrial flutter are frequent arrhythmias in patients with hypertrophic cardiomyopathy and increase their morbidity. Cardioversion of arrhythmia improves the quality of life of the patient; however, there is no information on the efficacy or predictors of this therapy in the literature. Aim: to identify the variables related to the evolution of the arrhythmia after therapy in patients with hypertrophic cardiomyopathy associated with atrial fibrillation or flutter were underwent electrical cardioversion. Methods: data from 37 patients with atrophic cardiomyopathy associated with atrial fibrillation (n = 21) and atrial flutter (n = 16), submitted to electrical cardioversion, were analyzed for immediate success (reversion after shock), Recurrence (recurrence of the problem after electrical cardioversion) and late success (sinus rhythm observed at the last recorded visit). Results: immediate success occurred in 96% of electrical cardioversion procedures in patients with atrial fibrillation and in 100% of patients with atrial flutter. Recurrence occurred in 76.9% of patients with atrial

Novas perspectivas no diagnóstico e tratamento das complicações mecânicas do infarto agudo do miocárdio / New perspectives in the diagnosis and treatment of mechanical complications of acute myocardial infarction

As complicações mecânicas do infarto agudo do miocárdio são um desfecho catastrófico que alteram o prognóstico do paciente, com elevadas taxas de morbidade e mortalidade. Todas as complicações são secundárias ao evento isquêmico agudo, com necrose de uma área gerando disfunção mecânica cardíaca, que, geralmente, culmina em choque cardiogênico. A ruptura da parede livre do ventrículo esquerdo, a ruptura do septo interventricular, a regurgitação mitral isquêmica e o pseudoaneurisma do ventrículo esquerdo são as complicações mais comuns. São muito pouco diagnosticadas, devendo ser cuidadosamente investigadas na presença de choque cardiogênico e súbita ou progressiva deterioração hemodinâmica. O diagnóstico e a intervenção precisam ser prococes a fim de alterar a evolução desfavorável do paciente e aumentar sua chance de sobrevivência...

Novas perspectivas no diagnóstico e tratamento das complicações mecânicas do infarto agudo do miocárdio / New perspectives in the diagnosis and treatment of mechanical complications of acute myocardial infarct

As complicações mecânicas do infarto agudo do miocárdio são um desfecho catastrófico que altera o prognóstico do paciente, com alta morbidade e mortalidade. Todas as complicações são secundárias ao evento isquêmico agudo, com necrose de uma área gerando disfunção mecânica cardíaca e, que geralmente, culmina em choque cardiogênico. A ruptura de parede livre do ventrículo esquerdo, a ruptura de septo interventricular, a regurgitação mitral isquêmica e o pseudoaneurisma de ventrículo esquerdo são as complicações mais comuns..

Obesidade e fatores de risco em alunos de Medicina de uma faculdade privada de Vitória - ES / Obesity and related risk factors in students of a private university in Vitória - ES

Objetivo: Avaliar obesidade e hábitos de vida em estudantes de Medicina de uma faculdade particular. Métodos: Estudo de corte transversal para avaliar 219 alunos, ambos os sexos, de 18 a 27 anos. Foi aplicado um questionário padronizado e realizados exames clínicos e laboratoriais. Dados foram submetidos à análise estatística descritiva e ao teste quiquadrado. Resultados: Observou bom consumo diário de alimentos protetores para doenças cardiovasculares e baixo consumo de alimentos de risco para essas doenças. Foram encontrados: obesidade, 1,4%; sobrepeso, 16,4%; peso saudável, 74,4%; baixo peso, 7,8%; 53,4% praticam atividade física; 46,6 % sedentários e uma baixa frequência de dislipidemias. Conclusões: A importância do envolvimento das faculdades em orientar futuros médicos e enfatizar a necessidade de uma alimentação saudável e incentivar os bons hábitos de vida.