El cateterismo cardiaco derecho de esfuerzo predice eventos en los pacientes con estenosis aórtica degenerativa asintomática / Exercise right heart catheterization predicts outcome in asymptomatic degenerative aortic stenosis

INTRODUCCIÓN Y OBJETIVOS: La estenosis aórtica degenerativa es la valvulopatía más frecuente. Aún no está claro cómo identificar a los pacientes asintomáticos con fracción de eyección del ventrículo izquierdo normal y alta probabilidad de eventos que por ello pudieran beneficiarse de una intervención valvular precoz. En este estudio se describe un protocolo de hemodinámica de esfuerzo para los pacientes asintomáticos con estenosis aórtica moderada o grave para evaluar su valor pronóstico para esta población. MÉTODOS: Estudio prospectivo unicéntrico de una población de pacientes con estenosis aórtica moderada o grave asintomáticos. Los pacientes realizaron una ergoespirometría para confirmar la ausencia de síntomas en esfuerzo. Después los pacientes se sometieron a un cateterismo cardiaco derecho basal y de esfuerzo. Se definió evento como muerte o necesidad de reemplazo de válvula aórtica quirúrgico o percutáneo basado en las guías clínicas. RESULTADOS: Se sometió a 33 pacientes a cateterismo cardiaco derecho basal y de esfuerzo. El área valvular aórtica media fue de 1,08 cm2 y el gradiente aórtico medio, 39 mmHg. La presión arterial pulmonar media fue de 21 mmHg, con una presión de oclusión en la arteria pulmonar de 14 mmHg y un gasto cardiaco de 5,6 l/min. La presión pulmonar media en ejercicio máximo fue de 34 mmHg. Tras un seguimiento medio de 27 meses, 8 pacientes sufrieron un evento (24%). No hubo diferencias en las variables basales, el área valvular aórtica o los parámetros de ergoespirometría. Los pacientes con evento no tuvieron mayores presiones pulmonares o presiones de llenado en ejercicio máximo, pero el grupo con eventos mostró menor saturación de oxígeno en la arteria pulmonar en esfuerzo (mediana, el 48 frente al 57%; p = 0,03). CONCLUSIONES: El cateterismo cardiaco de esfuerzo es seguro y factible en esta población. La saturación de oxígeno en la arteria pulmonar en esfuerzo podría identificar a un grupo de pacientes con un aumento del riesgo de eventos adversos graves

INTRODUCTION AND OBJECTIVES: Degenerative aortic stenosis (DAS) is the most frequent valvular heart disease. It remains unclear how to identify asymptomatic DAS patients with normal left ventricular ejection fraction who have a high probability of event occurrence and would thus benefit from early intervention. Here, we describe a protocol for exercise hemodynamics in true asymptomatic patients with moderate or severe DAS and assess the prognostic value of the data obtained in this population. METHODS: This study involved a prospective single-centre registry of consecutive asymptomatic patients with moderate or severe DAS. Patients underwent cardiopulmonary exercise testing to confirm symptom absence during exercise and then right heart catheterization (RHC) at rest and during exercise. Events were defined as death, surgical aortic valve replacement, or transcatheter aortic valve implantation according to clinical guidelines. RESULTS: Thirty-three patients underwent baseline and exercise RHC. The mean aortic valve area was 1.08 cm2 and the aortic gradient was 39mmHg. The mean pulmonary artery pressure was 21mmHg with a pulmonary artery occlusion pressure of 14mmHg and cardiac output of 5.6 L/min. The mean pulmonary artery pressure at peak exercise was 34mmHg. After a mean follow-up of 27 months, 8 patients experienced an event (24%). There were no differences in baseline variables, aortic valve area, or cardiopulmonary exercise testing parameters between the event and event-free groups. Patients with an event did not have higher pulmonary or filling pressures after peak exercise but had lower pulmonary artery oxygen saturation on effort (median, 48% vs 57%, P=.03). Exercise RHC is feasible and safe in this population. Peak pulmonary artery oxygen saturation might identify patients with increased risk of serious adverse events

Exercise right heart catheterization predicts outcome in asymptomatic degenerative aortic stenosis.

INTRODUCTION AND OBJECTIVES: Degenerative aortic stenosis (DAS) is the most frequent valvular heart disease. It remains unclear how to identify asymptomatic DAS patients with normal left ventricular ejection fraction who have a high probability of event occurrence and would thus benefit from early intervention. Here, we describe a protocol for exercise hemodynamics in true asymptomatic patients with moderate or severe DAS and assess the prognostic value of the data obtained in this population. METHODS: This study involved a prospective single-centre registry of consecutive asymptomatic patients with moderate or severe DAS. Patients underwent cardiopulmonary exercise testing to confirm symptom absence during exercise and then right heart catheterization (RHC) at rest and during exercise. Events were defined as death, surgical aortic valve replacement, or transcatheter aortic valve implantation according to clinical guidelines. RESULTS: Thirty-three patients underwent baseline and exercise RHC. The mean aortic valve area was 1.08 cm2 and the aortic gradient was 39mmHg. The mean pulmonary artery pressure was 21mmHg with a pulmonary artery occlusion pressure of 14mmHg and cardiac output of 5.6 L/min. The mean pulmonary artery pressure at peak exercise was 34mmHg. After a mean follow-up of 27 months, 8 patients experienced an event (24%). There were no differences in baseline variables, aortic valve area, or cardiopulmonary exercise testing parameters between the event and event-free groups. Patients with an event did not have higher pulmonary or filling pressures after peak exercise but had lower pulmonary artery oxygen saturation on effort (median, 48% vs 57%, P=.03). CONCLUSIONS: Exercise RHC is feasible and safe in this population. Peak pulmonary artery oxygen saturation might identify patients with increased risk of serious adverse events.

Importancia clínica de la insuficiencia cardiaca congestiva en la endocarditis protésica. Estudio multicéntrico de 257 pacientes / Clinical significance of congestive heart failure in prosthetic valve endocarditis. A multicenter study with 257 patients

Introducción y objetivos. Hasta el momento no se han realizado estudios centrados en determinar la importancia de la insuficiencia cardiaca congestiva en los pacientes con endocarditis protésica. En este trabajo se ha estudiado la incidencia de la insuficiencia cardiaca congestiva en pacientes con endocarditis protésica y se ha analizado su perfil. Se aborda la importancia pronóstica de la insuficiencia cardiaca en los pacientes con endocarditis protésica y se analiza su evolución en función de las estrategias terapéuticas elegidas. Métodos. Se incluyeron prospectivamente en el estudio 639 episodios de endocarditis izquierda con diagnóstico definitivo. De ellos, 257 eran casos de endocarditis protésica. De los 257 episodios, en 145 (56%) se estableció diagnóstico de insuficiencia cardiaca. Se compararon los perfiles de los pacientes con endocarditis protésica según tuvieran o no insuficiencia cardiaca, se desarrolló un modelo de regresión logística multivariable para establecer la importancia pronóstica de la insuficiencia cardiaca en pacientes con endocarditis protésica y se identificaron los factores pronósticos de la mortalidad hospitalaria de esos pacientes. Resultados. La infección persistente (odds ratio=3,6; intervalo de confianza del 95%, 1,9-6,9) y la insuficiencia cardiaca (odds ratio=3; intervalo de confianza del 95%, 1,5-5,8) son los más potentes factores predictivos de la mortalidad hospitalaria de los pacientes con endocarditis protésica. Los factores determinantes del pronóstico a corto plazo en los pacientes con endocarditis protésica e insuficiencia cardiaca son la infección persistente (odds ratio=2,8; intervalo de confianza del 95%, 1,2-6,5), la afección aórtica (odds ratio=2,5; intervalo de confianza del 95%, 1,1-5,8), los abscesos (odds ratio=3,6; intervalo de confianza del 95%, 1,4-9,5), la diabetes mellitus (odds ratio=2,9; intervalo de confianza del 95%, 1,1-7,7) y la cirugía cardiaca (odds ratio=0,2; intervalo de confianza del 95%, 0,1-0,5). Conclusiones. La incidencia de insuficiencia cardiaca entre los pacientes con endocarditis protésica es muy alta. La insuficiencia cardiaca aumenta al triple el riesgo de mortalidad intrahospitalaria de los pacientes con endocarditis protésica. La infección persistente, la afección aórtica, el absceso y la diabetes mellitus son los factores de riesgo independientes asociados a la mortalidad de los pacientes con endocarditis protésica e insuficiencia cardiaca. Sin embargo, se demuestra que la cirugía cardiaca reduce la mortalidad de esos pacientes (AU)

Introduction and objectives. There have been no studies conducted in the past that focus on the significance of congestive heart failure in patients with prosthetic valve endocarditis. We studied the incidence of congestive heart failure in patients with prosthetic valve endocarditis and analyzed its profile. In this study, we addressed the prognostic significance of heart failure in patients with prosthetic valve endocarditis and analyzed its outcome based on chosen therapeutic strategies. Methods. A total of 639 episodes of definite left-sided endocarditis were prospectively enrolled. Of them, 257 were prosthetic. Of the 257 episodes, 145 (56%) were diagnosed with heart failure. We compared the profiles of patients with prosthetic valve endocarditis based on the presence of heart failure, and performed a multivariate logistic regression model to establish the prognostic significance of heart failure in patients with prosthetic valve endocarditis and identified the prognostic factors of in-hospital mortality in these patients. Results. Persistent infection (odds ratio=3.6; 95% confidence interval, 1.9-6.9) and heart failure (odds ratio=3; 95% confidence interval, 1.5-5.8) are the strongest predictive factors of in-hospital mortality in patients with prosthetic valve endocarditis. The short-term determinants of prognosis in patients with prosthetic valve endocarditis and heart failure are persistent infection (odds ratio=2.8; 95% confidence interval, 1.2-6.5), aortic involvement (odds ratio=2.5; 95% confidence interval, 1.1-5.8), abscess (odds ratio=3.6; 95% confidence interval, 1.4-9.5), diabetes mellitus (odds ratio=2.9; 95% confidence interval, 1.1-7.7), and cardiac surgery (odds ratio=0.2; 95% confidence interval, 0.1-0.5). Conclusions. The incidence of heart failure in patients with prosthetic valve endocarditis is very high. Heart failure increases the risk of in-hospital mortality by threefold in patients with prosthetic valve endocarditis. Persistent infection, aortic involvement, abscess, and diabetes mellitus are the independent risk factors associated with mortality in patients with prosthetic valve endocarditis and heart failure; however, cardiac surgery is shown to decrease mortality in these patients (AU)

Clinical significance of congestive heart failure in prosthetic valve endocarditis. A multicenter study with 257 patients.

INTRODUCTION AND OBJECTIVES: There have been no studies conducted in the past that focus on the significance of congestive heart failure in patients with prosthetic valve endocarditis. We studied the incidence of congestive heart failure in patients with prosthetic valve endocarditis and analyzed its profile. In this study, we addressed the prognostic significance of heart failure in patients with prosthetic valve endocarditis and analyzed its outcome based on chosen therapeutic strategies. METHODS: A total of 639 episodes of definite left-sided endocarditis were prospectively enrolled. Of them, 257 were prosthetic. Of the 257 episodes, 145 (56%) were diagnosed with heart failure. We compared the profiles of patients with prosthetic valve endocarditis based on the presence of heart failure, and performed a multivariate logistic regression model to establish the prognostic significance of heart failure in patients with prosthetic valve endocarditis and identified the prognostic factors of in-hospital mortality in these patients. RESULTS: Persistent infection (odds ratio=3.6; 95% confidence interval, 1.9-6.9) and heart failure (odds ratio=3; 95% confidence interval, 1.5-5.8) are the strongest predictive factors of in-hospital mortality in patients with prosthetic valve endocarditis. The short-term determinants of prognosis in patients with prosthetic valve endocarditis and heart failure are persistent infection (odds ratio=2.8; 95% confidence interval, 1.2-6.5), aortic involvement (odds ratio=2.5; 95% confidence interval, 1.1-5.8), abscess (odds ratio=3.6; 95% confidence interval, 1.4-9.5), diabetes mellitus (odds ratio=2.9; 95% confidence interval, 1.1-7.7), and cardiac surgery (odds ratio=0.2; 95% confidence interval, 0.1-0.5). CONCLUSIONS: The incidence of heart failure in patients with prosthetic valve endocarditis is very high. Heart failure increases the risk of in-hospital mortality by threefold in patients with prosthetic valve endocarditis. Persistent infection, aortic involvement, abscess, and diabetes mellitus are the independent risk factors associated with mortality in patients with prosthetic valve endocarditis and heart failure; however, cardiac surgery is shown to decrease mortality in these patients.