Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry. / Tendência Temporal no Implante Percutâneo de Bioprótese Aórtica: Análise de 10 Anos do Registro TAVIDOR.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown. OBJECTIVES: To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D'Or São Luiz. METHODS: Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05. RESULTS: This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008). CONCLUSIONS: The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients' clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

FUNDAMENTO: O implante percutâneo de bioprótese valvar aórtica (TAVI) consolidou-se como opção terapêutica da estenose aórtica de grau importante. Dados sobre as características evolutivas dos procedimentos e dos resultados obtidos com a técnica ao longo da última década, em escala nacional, são desconhecidos. OBJETIVOS: Analisar a tendência temporal referente ao perfil demográfico, características dos procedimentos e desfechos hospitalares de pacientes submetidos a TAVI na Rede D'Or São Luiz. MÉTODOS: Registro observacional envolvendo 29 instituições nacionais. Comparou-se características dos procedimentos realizados de 2012 a 2017 (Grupo 1) e de 2018 a 2023 (Grupo 2). Foram considerados significantes os resultados com valor de p < 0,05. RESULTADOS: Foram analisados 661 casos, 95 pertencentes ao Grupo 1 e 566 ao Grupo 2. A média de idade foi 81,1 anos. Observou-se no Grupo 1 maior prevalência de pacientes em classe funcional III ou IV e escore de risco > 8%. Foi mais frequente o emprego de anestesia geral, monitorização ecocardiográfica transesofágica e via de acesso por dissecção. Maior taxa de sucesso do procedimento (95,4% versus 89,5%; p = 0,018) foi aferida em implantes efetivados a partir de 2018, assim como menor mortalidade (3,9% versus 11,6%; p = 0,004) e necessidade de marcapasso definitivo (8,5% versus 17,9%; p = 0,008). CONCLUSÕES: A análise temporal de 10 anos do Registro TAVIDOR demonstra uma queda na complexidade clínica dos pacientes. Além disso, o avanço para técnicas de implante minimalistas, somadas à evolução tecnológica dos dispositivos, podem ter contribuído para desfechos favoráveis dentre aqueles cujo implante ocorreu no último quinquênio.

Hematoma intracoronário como manifestação de dissecção espontânea de artéria coronária / Intracoronary hematoma as a manifestation of spontaneous coronary artery dissection

A dissecção espontânea de artéria coronária é um quadro de etiologia ainda não bem esclarecida. Diferentes estudos associam essa entidade a período gestacional, estresse físico, doenças do colágeno e vasculites. Em geral, os pacientes não apresentam os fatores de risco clássicos para doença arterial coronária, o que torna obrigatória a suspeita dessa afecção, especialmente em adultos jovens com síndrome coronária aguda. Neste artigo relatamos o caso de paciente do sexo feminino, de 38 anos de idade, com síndrome coronária aguda sem supradesnivelamento do segmento ST e hematoma intracoronário sem dissecção aparente, diagnosticado pelo ultrassom intracoronário, em artéria coronária direita. Não existe, até o presente momento, consenso quanto à melhor forma de tratamento nesses casos.

The etiology of spontaneous coronary artery dissection has not been well clarified. Different studies associate it to pregnancy, physical stress, collagen diseases and vasculitis. In general, patients do not have the classic risk factors for coronary artery disease, which makes mandatory the suspicion of this condition, especially in young adults with acute coronary syndromes. We report the case of a 38-year-old female with non-ST segment elevation acute coronary syndrome and intracoronary hematoma with no apparent dissection, diagnosed by intravascular ultrasound, in the right coronary artery. There is no consensus so far on the best way to treat these cases.

Prognostic value of CT angiography in patients with inconclusive functional stress tests.

OBJECTIVES: We attempted to determine the prognostic value of coronary computed tomographic angiography (CTA) in patients with inconclusive functional stress tests. BACKGROUND: Patients with suspected coronary artery disease (CAD) and inconclusive noninvasive cardiac stress tests represent a frequent management challenge. METHODS: We examined 529 consecutive patients with suspected CAD and prior inconclusive functional stress tests. All patients underwent a coronary CTA scan using a 64-slice multidetector row scanner. CAD severity by coronary CTA was categorized as: 1) no evidence of CAD; 2) nonobstructive coronary plaques (< 30%); 3) mild stenosis (30% to 49%); 4) moderate stenosis (50% to 69%); and 5) severe stenosis (≥ 70%). Patients were also categorized according to a modified Duke prognostic CAD index. Survival analyses were performed using Cox proportional hazards models adjusted for baseline risk factors and coronary artery calcium score. The primary outcome of the study was the combined endpoint of all-cause mortality and nonfatal myocardial infarction. RESULTS: Among patients with inconclusive stress tests, the large majority (69%) did not demonstrate significant CAD by coronary CTA. During a mean follow-up of 30.1 ± 11.1 months, there were 20 (3.8%) deaths and 17 (3.2%) nonfatal myocardial infarctions. Multivariable Cox regression analysis revealed that the presence of increasing degrees of obstructive CAD by CTA was an independent predictor of adverse events (hazard ratio [HR]: 1.66 [95% confidence interval (CI): 1.23 to 2.23], p = 0.001). Indeed, the presence of ≥ 50% coronary stenosis was associated with an increased risk of events (HR: 3.15 [95% CI: 1.26 to 7.89], p = 0.01). Likewise, the Duke prognostic CAD index was also found to be an independent predictor of events (HR: 1.54 [95% CI: 1.20 to 1.97], p = 0.001). CONCLUSIONS: Among patients with inconclusive functional stress tests, the noninvasive assessment of CAD severity by coronary CTA has been shown to provide incremental prognostic information beyond the evaluation of traditional risk factors and coronary artery calcium score.

Assessing intermediate coronary lesions: angiographic prediction of lesion severity on intravascular ultrasound.

BACKGROUND: Intravascular ultrasound (IVUS) can detect atherosclerotic compromise in coronary segments where conventional angiography cannot. However, IVUS is more invasive, expensive and laborious than angiography. We compared the detection of stenosis by IVUS and angiography and identified angiographic predictors of severe luminal stenosis on IVUS in patients with angiographically-intermediate coronary lesions. METHODS: Fifty-six patients with myocardial ischemia and intermediate stenosis by quantitative coronary angiography (QCA) underwent IVUS assessment of the culprit artery. The results from IVUS and QCA were compared using the two-tailed unpaired t-test. Multiple regression analysis was performed to identify QCA parameters that could predict the presence of severe stenosis on IVUS, defined as a minimum luminal area (MLA) < or = 4 mm2. RESULTS: A total of 63 stenotic coronary lesions were classified as intermediate by QCA; 68% of these were found to be severe on IVUS. There was a weak correlation between IVUS and QCA with respect to percentage of stenosis, minimum luminal diameter, reference segment diameter and length of atherosclerotic compromise. In contrast, there was a significant difference in the assessment of reference segment luminal diameter, which was 2.83 +/- 0.56 mm by angiography versus 3.45 +/- 0.69 mm by IVUS (p < 0.0001). The only angiographic predictor of the presence of severe coronary stenosis on IVUS was a distal reference segment diameter < or = 2.42 mm. CONCLUSIONS: In patients with angiographically-intermediate lesions, the frequency of severe stenosis detected by IVUS was high, indicating that angiography underestimated the severity of stenosis. Distal reference segment diameter was the only predictor of a small MLA and could be used to stratify these lesions into groups with higher and lower risk of severe stenosis.

Comparison of open commissurotomy and balloon valvuloplasty in mitral stenosis. A five-year follow-up.

OBJECTIVE: To compare clinical and laboratory data in patients with mitral stenosis undergoing open commissurotomy or balloon valvuloplasty, who were followed up for 5 years. METHODS: Eighty-one patients were prospectively assessed prior to the procedure (PRE) and immediately after the procedure, in the immediate postoperative period (IPO), and followed up yearly for 5 years (PO12M, PO24M, PO36M, PO48M, and PO60M). They were randomized into the following 2 groups: GC (group undergoing open commissurotomy): 37 patients (32.4 +/- 7.2 years; 89.2% females); and GV (group undergoing balloon valvuloplasty): 44 patients (32.9 +/- 9.5 years; 90.9% females). The patients' assessment comprised the following items: functional class, occurrence of events, electrocardiography, and Doppler echocardiography. RESULTS: A significant improvement in functional class occurred in most patients. Three patients in GC and in GV were in functional class III in PO60M. No difference in the mitral gradient was observed between the groups. A difference in the mean mitral valve areas was observed between the groups during the entire evaluation. No patients died. In regard to the IPO of GC, 3 patients had moderate mitral insufficiency (MI), and 3 had bleeding (1 was reoperated upon). In the IPO of GV, 4 patients had moderate MI, 1 had severe MI, 2 had cardiac tamponade, and 1 patient required surgery due to severe MI. Over 60 months, 9 GV patients evolved to moderate or severe MI, while 6 GC patients evolved to moderate or severe MI, and 2 other GC patients required surgery due to double mitral dysfunction. CONCLUSION: The rate of success in open mitral commissurotomy and balloon mitral valvuloplasty was 100%, and the rate of complications was low. During follow-up, a mild elevation in mitral gradient and a drop in mitral valve area were observed in both groups.

Comparação entre comissurotomia e valvoplastia por cateter-balão na estenose mitral: cinco anos de acompanhamento / Comparison of open commissurotomy and balloon valvuloplasty in mitral stenosis: a five-year follow-up

OBJETIVO: Comparar dados clínicos-laboratoriais em portadores de estenose mitral submetidos à comissurotomia ou valvoplastia por cateter-balão, obtidos ao longo de 5 anos de acompanhamento. MÉTODOS: Foram acompanhados, prospectivamente, 81 pacientes no pré (PRÉ), imediatamente após o procedimento (POI), e ao longo de cinco anos (PO12M, PO24M,..., PO60M) e randomizados em dois grupos: GC: 37 pacientes (32,4 ± 7,2 anos e 89,2 por cento mulheres) e GV: 44 pacientes (32,9 ± 9,5 anos e 90,9 por cento mulheres). A avaliação compreendeu: classe funcional, ocorrência de eventos, eletrocardiograma e ecodopplercardiograma. RESULTADOS: Houve melhora expressiva da classe funcional na maioria dos pacientes, três casos do GC e do GV estavam em classe funcional III no PO60M. Não houve diferença em relação ao gradiente mitral entre os grupos. Houve diferença das médias de área valvar mitral entre os grupos durante toda avaliação. Não ocorreram óbitos. No POI do GC observamos 3 casos com insuficiência mitral (IM) moderada, 3 com sangramento (1 reoperado) e, no GV, 4 casos com IM moderada, 1 com IM importante, 2 com tamponamento cardíaco, 1 caso necessitou cirurgia por IM importante. Ao longo de 60 meses, no GV, 9 casos evoluiram com IM moderada ou importante e no GC, 6 casos evoluiram com IM moderada ou importante e outros dois necessitaram cirurgia por dupla disfunção mitral. CONCLUSAO: Ambos os métodos obtiveram 100 por cento de sucesso com baixa taxa de complicações. No seguimento, houve elevação discreta do gradiente mitral e queda de área valvar mitral em ambos os grupos.

Comparison of direct stenting versus stenting with predilation for the treatment of selected coronary narrowings.

Direct stenting may reduce costs, procedure times, and injury to the vessel wall, positively influencing acute and late results. This study was designed to demonstrate 6-month clinical outcome equivalence between direct and standard stenting techniques. Four hundred eleven patients (425 lesions) were randomized in 7 sites to undergo direct (210 patients, 216 lesions) or conventional (201 patients, 209 lesions) stent implantation. Lesions with severe calcification were excluded. Angiographic success rate was 100% in the direct stent group (2.8% requiring balloon predilation) and 98.6% in the predilation group (p = 0.12). Direct stenting was associated with decreased use of balloons (0.15 vs 1.09 balloons/lesion treated) and with a trend toward a reduction of procedure time (22.7 +/- 15.0 vs 25.6 +/- 18.2 minutes; p = 0.073). Fluoroscopy time and contrast volume were not different between groups. At 6-month follow-up, the incidences of death (direct [1.4%] vs predilation [2.5%]), myocardial infarction (5.3% vs 5.0%), and target vessel revascularization (8.2% vs 10.5%) were similar in both groups. Major adverse cardiac event-free survival rate was 87.5% for those who underwent the direct stent technique and 85.5% for patients who underwent predilation (p = 0.0002 for equivalence). In conclusion, direct stenting is at least equivalent to the standard technique in terms of 6-month clinical outcomes when performed on selected coronary lesions without significant calcification. This strategy is associated with decreased use of balloons, but, in general, does not significantly reduce procedure times.

Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis. A prospective and randomized study.

Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.

Intracoronary brachytherapy in the treatment of in-stent restenosis. Initial experience in Brazil

Intracoronary brachytherapy using beta or gamma radiation is currently the most efficient type of therapy for preventing the recurrence of coronary in-stent restenosis. Its implementation depends on the interaction among interventionists, radiotherapists, and physicists to assure the safety and quality of the method. The authors report the pioneering experience in Brazil of the treatment of 2 patients with coronary in-stent restenosis, in whom beta radiation was used as part of the international multicenter randomized PREVENT study (Proliferation REduction with Vascular ENergy Trial). The procedures were performed rapidly and did not require significant modifications in the traditional techniques used for conventional angioplasty. Alteration in the radiological protection devices of the hemodynamic laboratory were also not required, showing that intracoronary brachytherapy using beta radiation can be incorporated into the interventional tools of cardiology in our environment

Angioplastia primária no infarto agudo do miocádio / Primary coronary angioplasty in acute myocardial infarction

Existem controvérsias quanto ao real benefício da angioplastia primária comparada ao tratamento trombolítico e, mais recentemente, ao implante do stent no infarto agudo do miocárdio. Neste artigo, os autores fazem uma revisão dos principais registros, das séries observacionais e dos estudos randomizados envolvendo a angioplastia primária como terapia de reperfusão no infarto agudo do miocárdio

Avaliação comparative entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral / Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis

PURPOSE: To compare immediate and late (12 months) follow-up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2 +/- 5.8 to 5.80 +/- 2.7 (p < 0.001) in commissurotomy group (CG) and from 11.7 +/- 6.1 to 5.0 +/- 2.4 (p < 0.001) in the balloon valvuloplasty group (VG). Mitral valve are (cm2) increased from 0.98 +/- 0.21 to 2.52 +/- 0.46 in CG and from 1.05 +/- 0.25 to 2.18 +/- 0.40 in VG (p < 0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however, there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

Estudo comparativo entre balão único de inoue e duplo balão na valvoplastia mitral percutânea. Resultados imediatos e após seguimento de um ano / Comparative study between inoue single balloon and double balloon in percutaneous mitral valvuloplasty. Immediate results and after 1 year follow-up

PURPOSE: To compare early and 12 months results of mitral stenosis (MS) correction by percutaneous balloon valvuloplasty (PMBV) using Inoue's single-balloon or double balloon techniques. METHODS: We submitted 139 consecutive patients to PMBV using Inoue single-balloon (n = 56, GI) or the double balloon technique (n = 83, GII). The two groups were similar, in: age, sex, functional class (FC), echocardiographic (ECHO) score, mitral valve area (MVA), and gradient (G) or presence of regurgitation. Clinical and ECHO data were compared before (PRE), immediately after (POI) and one year following the procedure (PO12M). RESULTS: PMBV was successfully performed in 53 (95) patients of GI and in 79 (96) of GII. Statistical analyses showed that the groups were similar at POI but different at PO12M (p < 0.002). ECHO immediately after PMBV showed that: MVA increased from 0.99 +/- 0.23 to 2.01 +/- 0.44cm2 (p < 0.001) in GI and from 0.94 +/- 0.23 to 2.09 +/- 0.35cm2 (p < 0.001) in GII and G decreased from 11.58 +/- 5.02 to 5.16 +/- 2.23mmHg (p < 0.001) in GI and from 12.48 +/- 4.89 to 5.96 +/- 3.21mmHg (p < 0.001) in GII. After one year 36 (64) patients in GI and 62 (74) in GII underwent an ECHO study. A comparison between immediate and one year follow-up results showed that MVA decreased from 2.01 +/- 0.4 to 2.00 +/- 0.3cm2 (NS) in GI and from 2.09 +/- 0.3 to 1.74 +/- 0.4cm2 (p < 0.001) in GII and G decreased from 5.16 +/- 2.2 to 5.50 +/- 2.9mmHg (NS) in GI and from 5.96 +/- 3.2 to 8.61 +/- 4.8mmHg (p < 0.001) in GII. There was therefore a sustained improvement of MVA and G after one year in GI and a significant decrease in MVA and G in GII. The FC after one year was similar and satisfactory in both groups. CONCLUSION: Both techniques are equally effective in relieving MS immediately after PMBV, but after one year, despite similar FC, Inoue-balloon technique seems to be superior to maintain MVA and G.

Objetivo - Comparar os resultados imediatos e de 12 meses das técnicas de duplo balão e do balão único de Inoue na correção da estenose mitral (EM) pela valvoplastia por cateter-balão (VMCB). Métodos - Submetemos 139 pacientes consecutivos, portadores de EM sintomática à VMCB. A técnica de Inoue foi utilizada em 56 pacientes (GI) e a do duplo balão em 83 (GII). Ambos os grupos eram semelhantes quanto a: idade, sexo, classe funcional (CF), escore ecocardiográfico, gradiente (G) e área valvar mitral (AVM), mitral (G) e pre sença de insuficiência mitral pela ecodopplercardiografia no pré-VMCB (PRE). Analisaram-se dados clínicoecocardiográficos, no PRE, logo após-VMCB (POI) e em 12 meses (PO12M). Resultados - A VMCB foi considerada com sucesso em 53 (95%) pacientes do GI e em 79 (96%) do GII. Análise estatística revelou que os grupos eram semelhantes no POI e diferentes no PO12M (p< 0,002). Os resultados no POI mostraram que a média da AVM (cm2) aumentou de 0,99 ± 0,23 para 2,01 ± 0,44 (p< 0,001) no GI e de 0,94 ± 0,23 para 2,09 ± 0,35 (p<0,001) no GII, o G (mmHg) diminuiu de 11,58 ± 5,02 para 5,16 ± 2,23 (p<0,001) no GI e de 12,48 ± 4,89 para 5,96 ± 3,21 (p<0,001) no GII. No PO12M, 36/53 (64%) pacientes no GI e 62/79 (74%) no GII realizaram acompanhamento clínico-ecocardiográfico. A comparação entre POI e PO12M mostrou: a) AVM de 2,01 ± 0,4 x 2,00 ± 0,3 (NS) no GI e de 2,09 ± 0,3 x 1,74 ± 0,4 no GII (p<0,001); b) G de 5,16 ± 2,2 x 5,50 ± 2,9 (NS) no GI e de 5,96 ± 3,2 x 8,61 ± 4,8 (p<0,001) no GII; c) no GI, dos 4 (11%) pacientes que estavam em CF II e 32 (89%) em CF III/IV no PRE, todos evoluíram para CF I/II no POI e permaneceram nesta CF no PO12M, de forma similar no GII, dos 12 (19%) pacientes que estavam em CF II e 50 (81%) em CF III/IV no PRE, todos menos um evoluíram para CF I/II no POI e permaneceram nesta CF no PO12M. Conclusão - As duas técnicas são igualmente efetivas no POI, todavia no PO12M, a técnica de Inoue mostrou-se superior na manutenção de AVM e G

Prevalência do shunt residual após fechamento de canal arterial persistente com umbrellas de Rashkind / Residual Shunt Prevalence after Closure of Patent Ductus Arteriosus with Rashkind Double Disc Occluding Device

PURPOSE--To determine the prevalence of residual left-to-right shunt in patients submitted to closure of patent ductus arteriosus with use of Rashkind double-disc ductal occluding device, analyzing predictive factors that determine short and long-term prevalence of residual shunt. METHODS--Thirteen patients were submitted to percutaneous closure of patent ductus arteriosus with use of Rashkind double-disc device. Ten patients were male with mean age of 5.7 years. A 12mm diameter device was used in 7 cases and a 17mm device in the remaining six patients. All patients had clinical, radiological and echocardiographic follow up, after 24h, 1 month, 6 months and one year after the procedure. Morphology and length of the ductus arteriosus and the presence of residual shunt after 15 min, 24h and one year after the procedure, were correlated. RESULTS--In one case, embolization of the device to the pulmonary artery determined the in success of the procedure. Residual shunt was present in 75 of the patients after 15 min of the procedure, in 33.3 after 24h, in 25 after 1 month and 6 months and in 16.6 after 1 year. The most important and isolated predictive factor leading to a high prevalence of residual shunt after 24h and after 1 year of the procedure was the presence of ductus arteriosus diameter > or = 4.5mm at the site of its insertion in the pulmonary artery. CONCLUSION--Prevalence of residual left-to-right shunt decreases over the time, with a low incidence after one year follow-up. A higher incidence of residual shunt at 24h and 1 year after the procedure occurred in the cases where the diameter of the ductus arteriosus was > or = 4.5mm, at the site of its insertion in the pulmonary artery.

Correçäo de estenose mitral através de valvoplastia por técnica de duplo cateter-baläo / Mitral stenosis correction by double catheter-ballon valvuloplasty technique

Objetivo - Avaliar a eficácia a longo prazo da valvoplastia mitral por cateter pela técnica do duplo baläo (VMC2B). Métodos - Sessenta e oito pacientes (76 por cento do sexo feminino), com média etária de 32 (15-69) anos, foram submetidos, consecutivamente, a VMC2B e realizaram avaliaçäo clínico-ecodopplercardiográfico no 12§ mês de acompanhamento (PO12M). Os critérios de seleçäo foram: sintomas de hipertensäo veno-capilar pulmonar, ausência de outra cardiopatia de indicaçäo cirúrgica, escore ecocardiográfico adequado, ausência de trombos intracavitários e insuficiência mitral (IM) no máximo discreta. Foram divididos em dois grupos: grupo A - composto por 7 (11 por cento) pacientes que apresentaram eventos cardíacos neste período e grupo B - composto por 61 pacientes que completaram o período de estudo sem eventos cardíacos. Näo havia diferença significativa entre os grupos em relaçäo aos dados demográficos, classe funcional (CF) e ao escore ecocardiográfico. Resultados - No grupo A, 3 pacientes apresentaram IM grave, em um caso houve insucesso e outro apresentou reestenose. Houve 2 óbitos näo relacionados ao procedimento. No grupo B, os resultados hemodinâmicos comparativos pré e imediatamente após (POI) VMC2B mostraram melhroa significativa, exceto em relaçäo ao índice cardíaco. Houve aumento do grau de IM em 17 (28 por cento) pacientes, tornando-se moderado em dois. A variaçäo da área valvar mitral (AVM) entre o PRÉ x POS x PO12M mostrou, comparando-se AVM no POI e PO12M, reduçäo significativa. Dois (3 por cento) pacientes com reduçäo >50 por cento do ganho inicial, 33 (54 por cento) entre 10 e 50 por cento e 26 (42 por cento) aquém de 10 por cento näo tiveram comprometimento da CF permanecendo em CF I/II. Conclusäo - A VMC2B é método atrativo para tratamento de estenose mitral em pacientes sintomáticos selecionados, com baixo índice de complicaçöes, melhora sintomática imediata que manteve-se a longo prazo apesar de reduçäo da AVM

Pontes miocárdicas múltiplas / Multiple myocardial coronary bridges

White woman, 31 years old, complaint pain in the left arm, at rest, and few months later she had pain in the precordial region with dyspnea, diaphoresis and dizziness without any inducing factor. One hour later, symptoms ceased spontaneously, remaining daily precordial pain. Subsidiary examinations as cineangiocoronariography revealed 100 per cent of arterial lumen constriction in the middle portion of the descending coronary artery, during systole, as well as in the diagnoalis and marginal branches. Multiple myocardial coronary bridges has been described in necropsy, but during cinecoronarioangiography, this case appeared to be the first one

Valvoplastia mitral por cateter-baläo em pacientes de alto risco operatório / Percutaneous Mitral Balloon Valvuloplasty in Surgical High Risk Patients

Objetivo - Analisar os reultados da valvoplastia mitral por cateter-baläo (VMCB) em pacientes de alto risco operatório. Métodos - Vinte (12// pacientes dentre 172 comsecutivos submetidos a VMCB foram considerados de alto risco operatório. Dezessete (85//) eram mulheres e a média etária de 43(18-69) anos. Treze (65//) encontravam-se em edema agudo dos pulmöes (3 gestantes, 2 com acidente vascular cerebral (AVC) prévio, 1 com tromboembolismo pulmonar e outro com insuficiência renal crônica) e 7 (35//) em classe funcional (CF) III (2 com insuficiência coronariana crônica, 2 com obesidade maligna, 1 com neoplasia de pulmäo, 1 com caquexia cardíaca e outro com AVC prévio). Realizaram VMCB pela técnica transeptal sendo utilizado duplo baläo em 10(45//), baläo Inoue em 5(25//), monofoíl em 3(15//) e bifoil em 2(10//) pacientes. Resultados - Dezessete (85//) pacientes com sucesso e 2 (10//) com melhora clínica expressiva. Os resultados hemodinâmicos pré x pós-VMCB foram: pressäo de átrio esquerdo (PAE) em mmHg 28,2 ñ 10,0 x 15,2 ñ 9,2 (n = 20) (p < 0,001); gradiente transvalvar mitral médio (G) em mmHg 21,2 ñ 10,7 x 10,7 ñ 6,7 (n = 18) ( , 0,001); área valvar mitral (AVM) em cm² 0,73 ñ 0,6 (n = 11) (p < 0,001); pressäo média de artéria pulmonar em mmHg 52,0 ñ 18,2 x 40,1 ñ 14,7 (n = 18) (p < 0,001); índice cardíaco em L/min/m² 2,1 ñ 0,4 x 2,5 ñ 0,6 (n = 14) (p < 0,001). No ecocardiograma os resultados comparativos pré, pós e após 6 meses da VMCB foram: área valvar mitral (cm²) 1,06 ñ 0,39 x 1,92 ñ 0,51 x 1,65 ñ 0,5 e gradientes transvalvar mitral (mmHg) 13,8 ñ 4,7 x 7,3 ñ 3,6 x 7,3 ñ 4,4. Houve 2 óbitos imediatos (tromboembolismo pulmonar e falência de multiplos órgäos) e 1 extra-hospitalar. As complicaçöes foram: 2(10//) pacientes com complicaçöes neurológicas, 1(5//) com comunicaçäo interatrial e outro com perfuraçäo da átrio direito (5//). Conclusäo - A VMCB oferece alternativa ao tratamento cirurgico em pacientes considerados de alto risco operatório e manutençäo do sucesso em seis meses de seguimento

Purpose - To evaluate percutaneous mitral balloon valvuloplasty (PMBV) in surgical high risk patients. Methods - Twenty (12%) patients out of 172 submitted to a PMBV were considered high surgical risk cases; 17 (85%) were women and mean age was 43 (18- 69). Thirteen (65%) were in acute pulmonary edema (3 were pregnant, 2 had previous cerebrovascular event, 1 had pulmonar thromboembolism and other had chronic renal failure), and 7 (35%) were in functional class (CF) III (2 had coronary artery disease, 2 severe obesity, 1 pulmonar neoplasy, 1 cardiac cachexia and one with previous cerebrovascular event). All patients underwent PMBV through transeptal technique. Double balloon was used in 10 (50%) patients; Inoue balloon in 5 (25%), monofoil in 3 (15%) and bifoil in 2 (10%). Results - Seventeen (85%) obtained success and 2 (10%) had clinical improvement. The hemodinamic results pre versus post-PMBV showed: left atrium pressure (LAP) mmHg 28.2±10,0 x 15.2±9.2 (n=20) (p<0.001), mitral mediam gradient (G) mmHg 21.2±10.7 x 10.7±.7 (n=18)(p<0.001), mitral valve area (MVA) cm2 0.73±0.3 x 1.73±0.6 (n=11) (p<0.001), pulmonary artery pressure mmHg 52.0±18.2 x 40.1±14.7 (n=18) (p<0.001) and cardiac index L/min/m2 2.1±0.4 x 2.5±0.6(n=14) (p<0.001). Comparative echocardiography results pre, post and 6 months after PMBV showed: MVA 1.06±0.39 x 1.92±0.51 x 1.65±0.5 and G 13.8±4.7 x 7.3±3.6 x 7.3±4.4. There were two immediate deaths (pulmonary thromboembolism and multiple organs failure) and other after hospital discharge. The complications were: 2 (10%) patients with neurological complications, 1 (5%) atrial septal deffect and other right atrium perforation (5%). Conclusion - PMBV offers an alternative to surgical treatment in high risk surgical patients and the results are maintained in the 6 month follow-up

Valvoplastia mitral percutanea utilizando o cateter balao Inoue: resultados imediatos e seguimento de 1 ano / Ballon mitral valvoplasty using Inoue ballon: immediate results and one year follow-up

Os autores objetivaram avaliar resultados imediatos e seguimento de um ano da valvoplastia mitral por cateter-balao (VMCB) utilizando o balao Inoue, em 40 pacientes portadores de estenose mitral (EM) sintomaticos e consecutivos, submetidos a VMCB; 37 mulheres, media etaria de 36 (22-67 anos), cinco portadores de ReEM. Trinta e sete estavam em classe funcional III/IV (NYHA) e a VMCBN foi realizada de urgencia em seis pacientes, devido a edema agudo dos pulmoes, incluindo duas gestantes. Foram analisados os dados hemodinamicos no pre e no pos-VMCB imediato e os dados ecodopplercardiograficos (ECO) no pre, pos imediato (POS) e apos 12 meses de seguimento (PO12M). Os resultados hemodinamicos pre X pos foram: gradiente mitral (G)17,6+/-7,6X6,3+/-5,5mmHg; area valvar mitral (AVM) 0,89+/-0,25X1,66+/-0,63cm2; pressao media do atrio esquerdo 25,5+/-9,0X14,3+/-6,4mmHg; pressao media de arteria pulmonar 34,8+/-13,0X23,8+/-10,8mmHg (todos p<0,0001) e indice cardiaco 2,8+/-0,5X2,9+/-0,8l/min/m2 (NS). Tres pacientes apresentaram insuficiencia mitral (IM) moderada, na ventriculografia esquerda pos-VMCB. As complicacoes relacionadas diretamente ao procedimento foram: 2 casos com tamponamento cardiaco necessitando drenagem cirurgica, 3 com comunicacao inter-atrial e 1 com perfuracao de aorta, sem tamponamento cardiaco. Um paciente apresentou acidente vascular cerebral, 72 horas apos a VMCB sem sequela motora. Houve 2 insucessos, sendo que 1 evoluiu para obito 2 meses apos VMCB. Os 29 pacientes que foram efetivamente acompanhados por um periodo de 12 meses nao apresentaram eventos cardiacos; os resultados do ECO PRE X POS X PO12M foram: AVM 1,00+/-0,24X2,12+/-0,33 e G 11,1+/-5,0+/-2,0X5,3+/-2,6. Todos os pacientes estavam em classe funcional I/II apos um ano de seguimento. Portanto, o balao Inoue mostra bons resultados imediatos e no seguimento por um periodo de 12 meses e serve como opcao terapeutica para EM em pacientes sintomaticos selecionados

Efeitos hemodinâmicos de baixas doses de clortalidona em pacientes com hipertensäo arterial sistêmica leve / Hemodynamic effects of low dosis of chlorthalidone in patients with light systemic arterial hypertension

Objetivo - Avaliar os efeitos hemodinâmicos de baixas doses de clortalidona em pacientes com hipertensäo arterial sistêmica leve. Métodos - Oito pacientes com hipertensäo arterial sistêmica (HAS) leve, com idade de 52 ñ 8.9 anos, sendo 7 do sexo masculino. Avaliaçäo clínica, medidas da pressäo arterial sistólica (PAS), diastólica (PAD) e da freqüência cardíaca, em posiçöes supina e ortostática, foram obtidas no início e, posteriormente, a cada 2 semanas, durante 12 semanas, sendo as 2 primeiras em uso de placebo. Os exames laboratoriais hemograma, sódio, potássio, uréia, creatinina, glicemia, transaminases hepáticas e urina I, foram realizados no início e no final do estudo. A monitorizaçäo hemodinâmica foi realizada com cateter de Swan-Ganz em artéria pulmonar obtendo-se as pressöes médias de átrio direito, artéria pulmonar e capilar pulmonar, em mmHg. O débito cardíaco (DC) foi obtido pela técnica da termodiluiçäo. Como parâmetro derivado obteve-se a resistência vascular sistêmica (RVS). As medidas foram realizadas nas 2ª (pré) e 12ª (pós) semanas de tratamento com 50mg de clortalidona em dias alternados. Resultados - Observou-se reduçäo significante, nas posiçöes supina e ortostática, da PAS (p = 0,005 e p = 0,003) e PAD (p < 0,001 em ambas as posiçöes). A FC manteve-se inalterada. A monitorizaçäo hemodinâmica observou-se reduçäo estatisticamente significativa da RVS (p < 0,02) e o DC manteve-se inalterado. Conclusäo - A clortalidona em baixas doses mostrou-se eficaz no tratamento da HAS e o mecanismo básico deve-se a reduçäo da RVS

Purpose - To evaluate the hemodynamic effects of low dosis of chlortalidone (CHT) in patients with systemic arterial hypertension (SAH). Methods - Eight patients with mild SAH, mean age of 52± 8.9 years, 7 men, were studied. Clinical evaluation, systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR), in supine and standing positions, were obtuined before and every two weeks, first two in placebo, during 12 weeks. Laboratory data, hemogram, sodium, potassium, urea, creatinine, glucose, hepatic aminotransferases and urinalysis, were done and at end of study. Hemodynamic monitorization was periormed by Swan-Gans catheter in pulmonary artery to obtain RAP and PAWP, in mmHg. Cardiac output (CO) was obtained by thermodilution method. Systemic vascular resistence (SVR) arised from variables above. Hemodynamic variables were measured at 2nd and 12th weeks during treatment with 50mg of chlorthalidone each 48 h. Results - A significant reduction of SBP (p = 0.005 and p = 0.003), DBP (p < 0.0001 and p < 0.0001), respectively in supine and standing positions. HR did not show statistical diference. At hemodynamic monitoring was observed a signifcative reduction of SVR (p < 0.02), but not with CO. Conclusion - Chlorthalidone in low dosis was effective to treat mild SAH, basically by lowering SVR