RESUMEN
BACKGROUND: Coronary artery obstruction after percutaneous aortic replacement is a complication with high short-term mortality secondary to the lack of timely treatment. There are various predictors of coronary obstruction prior to valve placement such as the distance from the ostia, the degree of calcification, the distance from the sinuses; In such a situation some measures must be taken to prevent and treat coronary obstruction. CASE PRESENTATION: An 84-year-old male, with severe aortic stenosis and high surgical risk, who was treated with TAVR. However, during the deployment of the valve he presented hemodynamic instability secondary to LMCA obstruction. The intravascular image showed obstruction of the ostium secondary to the displacement of calcium that he was successfully treated with a chimney stent technique. CONCLUSIONS: The high degree of calcification and the left ostium near the annulus are conditions for obstruction of the ostium at the time of valve release; In this context, provisional stenting prior to TAVR in patients at high risk of obstruction should be considered as a safe prevention strategy to achieve the success of the procedure.
Asunto(s)
Estenosis de la Válvula Aórtica , Calcinosis , Oclusión Coronaria , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Masculino , Humanos , Anciano de 80 o más Años , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Válvula Aórtica/cirugía , Vasos Coronarios/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Factores de Riesgo , Resultado del Tratamiento , Oclusión Coronaria/etiología , Calcinosis/complicaciones , Calcinosis/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Diseño de PrótesisRESUMEN
BACKGROUND: Aortic stenosis (AS) is currently the most common valvular disease, with an estimated prevalence of over 4% in octogenarians. OBJECTIVE: To describe the prevalence of moderate-severe aortic stenosis (AS) in patients with wild type transthyretin amyloidosis (ATTRwt). Also, describe the clinical features, echocardiographic characteristics and clinical evolution. METHOD: Retrospective cohort of patients with diagnosis of ATTRwt, belonging to Hospital Italiano de Buenos Aires Institutional Amyloidosis Registry, from 30/11/2007 to 31/05/2021. Patients follow up was carried out through the institution clinical history. The prevalence of moderate-severe AE was estimated and presented as a percentage with its 95% confidence interval (95% CI). The characteristics were compared by groups according to whether or not they had moderate-severe AS. RESULTS: 104 patients with ATTRwt were included. Median follow up was 476 days [interquartile range: 192-749]. Moderate-severe AS prevalence at the ATTRwt time of diagnosis was 10.5% (n = 11; 95% CI: 5-18%). The median age of patients with AS moderate-severe at the time of diagnosis of ATTRwt was 86 years [78-91] and the male sex predominated (82%). Most of the patients had a history of heart failure (n = 8) and atrial fibrillation (n = 8) prior to the diagnosis of ATTRwt. Most of the patients were subclassified as low flow low gradient severe AS group (n = 7). Four patients underwent some intervention on the aortic valve. During follow-up, 5 patients (46%) were hospitalized for decompensated heart failure and 4 (36%) died. CONCLUSIONS: In our cohort, the coexistence of both pathologies had a similar prevalence as reported in the international literature. It was an elderly population with a high percentage of atrial fibrillation and history of heart failure. Most of the patients presented with severe AS with low flow low gradient.
ANTECEDENTES: La estenosis aórtica (EA) es actualmente la enfermedad valvular más frecuente, con una prevalencia estimada de más del 4 % en octogenarios. OBJETIVO: Describir la prevalencia de estenosis aórtica (EA) moderada-grave en pacientes con amiloidosis por transtiretina wild type (ATTRwt). Además, describir las características clínicas, ecocardiográficas y la evolución en este grupo de pacientes. MÉTODO: Estudio de cohorte retrospectiva de pacientes con diagnóstico de ATTRwt, pertenecientes al Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, en el periodo del 30/11/2007 al 31/05/2021. El seguimiento de los pacientes se realizó a través de la historia clínica electrónica de la institución. Se estimó la prevalencia de EA moderada-grave, que se presenta como porcentaje con su intervalo de confianza del 95% (IC 95%). Se compararon las características por grupos según tuvieran o no EA moderada-grave. RESULTADOS: Se incluyeron 104 pacientes con diagnóstico de ATTRwt. La mediana de seguimiento fue de 476 días [rango intercuartílico: 192-749]. La prevalencia de EA moderada-grave al momento del diagnóstico de ATTRwt fue del 10.5% (n = 11; IC95%: 5-18%). La mediana de edad de los pacientes con EA fue de 86 años [78-91] y predominó el sexo masculino (81.8%). La mayoría de los pacientes tenían el antecedente de insuficiencia cardiaca (n = 8) y fibrilación auricular (n = 8). Predominaron los pacientes con EA grave de bajo flujo y bajo gradiente (n = 7). Cuatro pacientes fueron sometidos a alguna intervención en la válvula aórtica. Durante el seguimiento, 5 pacientes (46%) tuvieron internaciones por insuficiencia cardiaca descompensada y 4 (36%) fallecieron. CONCLUSIONES: En nuestra cohorte, la coexistencia de ambas patologías tuvo una prevalencia similar a la reportada en la literatura internacional. Se trató de una población añosa con alto porcentaje de fibrilación auricular y antecedente de insuficiencia cardiaca. La mayoría presentaron EA grave de bajo flujo y bajo gradiente.
Asunto(s)
Neuropatías Amiloides Familiares , Estenosis de la Válvula Aórtica , Fibrilación Atrial , Insuficiencia Cardíaca , Anciano de 80 o más Años , Humanos , Masculino , Anciano , Estudios Retrospectivos , Fibrilación Atrial/complicaciones , Prevalencia , Neuropatías Amiloides Familiares/complicaciones , Neuropatías Amiloides Familiares/epidemiología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/complicaciones , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/epidemiologíaRESUMEN
OBJECTIVES: A systematic review of the literature was conducted to analyze the current evidence on low-flow, low-gradient severe aortic stenosis. This analysis aimed to differentiate between subgroups of patients with reduced and preserved left ventricular ejection fraction (LVEF). METHODS: After conducting a systematic literature review, 35 observational studies were included. Out of these, 28 were prospective and 7 retrospective. The studies that included a mortality risk stratification of low-flow, low-gradient aortic stenosis (LF- LG AS) with both preserved and reduced LVEF were reviewed. RESULTS: The importance of considering multiple clinical and echocardiographic variables in diagnostic evaluation and therapeutic decision-making was highlighted. CONCLUSIONS: LF- LG AS, in any of its subgroups, is a common and challenging valve lesion. A careful assessment of severity and, in specific scenarios, a thorough reclassification is important. More high-quality studies are required to more precisely define the classification and prognosis of this entity.
Asunto(s)
Estenosis de la Válvula Aórtica , Volumen Sistólico , Función Ventricular Izquierda , Humanos , Válvula Aórtica/fisiopatología , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/complicaciones , Ecocardiografía/métodos , Pronóstico , Índice de Severidad de la Enfermedad , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiologíaRESUMEN
INTRODUCTION: There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease. METHODS: All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint. RESULTS: In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found. CONCLUSION: Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.
Asunto(s)
Estenosis de la Válvula Aórtica , Enfermedad de la Arteria Coronaria , Enfermedad Arterial Periférica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estudios de Seguimiento , Resultado del Tratamiento , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/cirugía , Enfermedad Arterial Periférica/complicaciones , Válvula Aórtica/cirugía , Factores de RiesgoRESUMEN
A 49-year-old male with a history of left ventricular systolic function dilated cardiomyopathy and severe symptomatic bicuspid aortic stenosis recently diagnosed (syncope, chest pain and dyspnea) was admitted to the coronary care unit. During hospitalization, he developed cardiogenic shock requiring double inotropic support. High surgical risk and an elevated chance of graft rejection contraindicated surgical replacement or heart transplant. We performed a transcatheter aortic valve replacement with a favorable evolution.
Un varón de 49 años ingresó en la unidad de cuidados coronarios, con antecedentes de miocardiopatía dilatada, con función sistólica del ventrículo izquierdo gravemente deteriorada y estenosis aórtica grave de origen bicúspide, sintomático para síncope, ángor y disnea de reciente diagnóstico. Durante la internación evolucionó con shock cardiogénico que requirió doble soporte inotrópico. Por presentar alto riesgo quirúrgico y elevada probabilidad de rechazo ante un eventual trasplante cardiaco, según sus estudios de histocompatibilidad, se procedió al reemplazo transcatéter de la válvula aortica, con evolución favorable.
Asunto(s)
Estenosis de la Válvula Aórtica , Enfermedad de la Válvula Aórtica Bicúspide , Enfermedades de las Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Masculino , Humanos , Persona de Mediana Edad , Enfermedad de la Válvula Aórtica Bicúspide/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Transthyretin amyloid cardiomyopathy was considered a rare pathology. However, recent studies show a significant prevalence in patients with degenerative aortic stenosis and heart failure with preserved ejection fraction. CASE PRESENTATION: An 85-year-old woman presented with a four-month history of pain in the rib cage with a history of diffuse large B-cell lymphoma of the oral cavity, essential thrombocytosis and dyslipidemia. She had no significant family history. A transthoracic echocardiogram showed degenerative aortic stenosis and normal systolic function with preserved left ventricular ejection fraction of 70%. Bone-avid tracer cardiac scintigraphy with technetium-99m-labeled hydroxymethylene diphosphonate with SPECT-CT documented grade two myocardial uptake according to the Perugini scale. MRI evidenced late patchy enhancement in the myocardium associated with diffuse subendocardial enhancement. Laboratory tests showed the absence of mutation in the transthyretin (TTR) gene, serum and urine immunofixation electrophoresis (IFE) negative for monoclonal protein and serum-free light chain (sFLC) assay with a normal kappa/lambda (K/L) ratio. All these findings were compatible with a non-invasive diagnosis of wild-type cardiac amyloidosis. CONCLUSION: The accepted criteria for the definitive non-invasive diagnosis of amyloid cardiomyopathy are based on myocardial uptake by scintigraphy (with SPECT), serum and urine immunofixation electrophoresis, serum-free light chain assay and suggestive findings on echocardiography and/or MRI. Genetic testing should differentiate between ATTRv (v for variant) and ATTRwt (wt for wild type) forms.
Asunto(s)
Neuropatías Amiloides Familiares , Estenosis de la Válvula Aórtica , Cardiomiopatías , Femenino , Humanos , Anciano de 80 o más Años , Volumen Sistólico , Prealbúmina , Función Ventricular Izquierda , Neuropatías Amiloides Familiares/diagnóstico por imagen , Neuropatías Amiloides Familiares/complicaciones , Cardiomiopatías/diagnóstico por imagen , Estenosis de la Válvula Aórtica/complicacionesAsunto(s)
Estenosis de la Válvula Aórtica , Dispositivos de Protección Embólica , Embolia Intracraneal , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/cirugía , Humanos , Embolia Intracraneal/etiología , Embolia Intracraneal/prevención & control , Diseño de Prótesis , Factores de Riesgo , Accidente Cerebrovascular/prevención & control , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. Material and Methods: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. Results: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.
Asunto(s)
Humanos , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Fibrilación Atrial/cirugía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Warfarina/efectos adversos , Resultado del Tratamiento , Hemorragia/inducido químicamente , Anticoagulantes/uso terapéuticoRESUMEN
INTRODUCCIÓN: La Estenosis Aórtica (EA) es la valvulopatía más frecuente en el mundo, cuya incidencia se va incrementando con el envejecimiento de la población; su etiología se asocia a la calcificación de la válvula con una prevalencia del 50%-70% en pacientes de la tercera edad; que por lo general son individuos que poseían una válvula aórtica anatómicamente normal que desarrolla calcificación entre la sexta y séptima década de la vida. La estenosis aórtica severa es una condición que afecta a las personas en edad avanzada, consiste en la obstrucción del flujo sanguíneo a través de la válvula aórtica debido a la fibrosis y calcificación de la misma, comprendida como un área de la válvula aórtica (AVA) < 1,0 cm2 y/o un gradiente medio de presión transaórtica (MPG) > 40 mm Hg y/o una velocidad máxima del chorro aórtico (Vmax) > 4 m/s. Un 30% del total de pacientes que padecen estenosis aórtica severa tienen riesgo quirúrgico muy elevado para cirugía convencional. Entre ellos figuran los pacientes de edad avanzada, a quienes se les debe evitar este tipo de cirugía, así como la circulación extracorpórea. Uno de los tratamientos más recientes para esta condición médica es el reemplazo percutáneo de la válvula aórtica o reemplazo transcatéter de la válvula aórtica. El Implante o reemplazo transcatéter de válvula aórtica, es una técnica en la que se puede implantar una válvula aórtica artificial guiada a través de un catéter introducido por punción de una arteria (femoral, axilar, aorta) o por la punta del corazón (vía apical). Todo ello sin parar el corazón ni necesitar seccionar de forma completa el esternón (como en la cirugía convencional) ni usar circulación extracorpórea. OBJETIVO: El objetivo de la presente Evaluación de tecnología sanitaria (ETS) es evaluar la eficacia y seguridad, así como documentos relacionados a la decisión de cobertura con el del dispositivo prótesis valvular aórtico percutáneo o transcatéter de válvula aórtica en el tratamiento de pacientes con estenosis aórtica severa y con elevado riesgo quirúrgico o inoperables por cirugía convencional. METODOLOGÍA: Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE, LILACS, COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Scholar. TRIPDATABASE, hasta el 11 de mayo de 2022. Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales agencias de tecnologías sanitarias y guías de práctica clínica. RESULTADOS: Se identificaron 9 Revisiones sistemáticas (RS), 4 Evaluación de Tecnologías Sanitarias (ETS) y una evaluación económica (EC) realizada para Chile. No se identificaron EC para Perú, ni Guías de Práctica Clínica (GPC) que puedan responder la pregunta PICO. La más reciente revisión sistemática del año 2021, incorpora la evidencia actualizada de los dos grandes ensayos clínicos que responden la pregunta, mientras que las demás RS incluyen parte de estos ensayos. La evaluación de la calidad de la RS más reciente ha sido valorada como baja debido a que solo presenta un criterio crítico. CONCLUSIONES La evidencia identificada en relación al implante valvular aórtico percutáneo para estenosis aórtica severa en pacientes con elevado riesgo quirúrgico, encontró que no se encuentran diferencias estadísticamente significativas entre ambos grupos en los desenlaces de: mortalidad por todas las causas, mortalidad por causa cardiovascular, stroke, stroke mayor discapacitante, infarto de miocardio, endocarditis, reintervención o reparación, hasta luego de 5 años de seguimiento. Se observó un menor riesgo para TAVI comparado con SAVR para los desenlaces: sangrado mayor, nuevo inicio o empeoramiento de fibrilación auricular. Por otro lado, se observó un mayor riesgo con TAVI comparado con SAVR para complicaciones vasculares mayores e implantación de marcapasos permanente.
Asunto(s)
Humanos , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Eficacia , Análisis Costo-Beneficio/economíaRESUMEN
PURPOSE OF REVIEW: Familial hypercholesterolemia is a high cardiovascular risk disorder. We will review the role of lipoprotein(a) in cardiovascular risk and in aortic valve stenosis in familial hypercholesterolemia, as well as its association with their phenotype, and strategies to identify this high-risk population. RECENT FINDINGS: Patients with familial hypercholesterolemia have higher lipoprotein(a) levels mainly due to an increased frequency of LPA variants, and the cardiovascular risk is increased twofolds when both conditions coexist. Also, an increased risk for aortic valve stenosis and valve replacement has been observed with high lipoprotein(a) levels. Assessment of lipoprotein(a) during the cascade screening for familial hypercholesterolemia is a good opportunity to identify this high-risk population. High cardiovascular risk in familial hypercholesterolemia is increased even more when lipoprotein(a) is also elevated. Measurement of lipoprotein(a) in these patients is crucial to identify those subjects who need to intensify LDL-cholesterol reduction pending availability of lipoprotein(a)-specific treatments.
Asunto(s)
Estenosis de la Válvula Aórtica , Hiperlipoproteinemia Tipo II , Lipoproteína(a)/sangre , Estenosis de la Válvula Aórtica/complicaciones , LDL-Colesterol , Crimen , Humanos , Hiperlipoproteinemia Tipo II/complicaciones , Hiperlipoproteinemia Tipo II/diagnóstico , Hiperlipoproteinemia Tipo II/genéticaRESUMEN
BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. MATERIAL AND METHODS: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. RESULTS: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.
Asunto(s)
Estenosis de la Válvula Aórtica , Fibrilación Atrial , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Anticoagulantes/uso terapéutico , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/cirugía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Hemorragia/inducido químicamente , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento , Warfarina/efectos adversosAsunto(s)
Estenosis de la Válvula Aórtica , Cardiopatías/complicaciones , Traumatismos del Nervio Laríngeo/etiología , Parálisis de los Pliegues Vocales/etiología , Alcoholismo , Estenosis de la Válvula Aórtica/complicaciones , Cardiopatías/diagnóstico , Insuficiencia Cardíaca , Ronquera/diagnóstico por imagen , Ronquera/etiología , Humanos , Masculino , Persona de Mediana Edad , Síndrome , Parálisis de los Pliegues Vocales/diagnóstico por imagenRESUMEN
Desde que Edward Heyde vislumbró en 1958 una misteriosa asociación entre estenosis aórtica y hemorragia digestiva han transcurrido seis décadas y se ha suscitado no poca controversia. En la época en que fue propuesta, el estatus técnico y metodológico de la ciencia médica y una interpretación sesgada de su idea original impidieron obtener un sustento estadístico y fisiopatológico que le otorgara un amplio reconocimiento como entidad clínica individual. Los avances en varias disciplinas permitieron demostrar que su frecuencia de presentación excede el efecto del azar, además de esclarecer con precisión y elegancia sus mecanismos fisiopatológicos. Su consolidación como síndrome nos revela una verdadera encrucijada entre la cardiología, la gastroenterología, la hematología y el laboratorio, especialidades involucradas tanto en su proceso de comprensión como en su manejo práctico en la actualidad. Sin embargo, a pesar de tener una incidencia no desdeñable y adquirir un papel central en la conducción clínica de la estenosis aórtica, esta entidad parece haber pasado de ser resistida a relativamente ignorada. Con el objetivo de contribuir a su visibilidad, la presente revisión ofrece un panorama integral sobre el tema, incluyendo una perspectiva histórica de los principales aportes en pos de su conocimiento y un abordaje en profundidad de sus mecanismos, las claves de su detección clínica y su impacto en el manejo de la estenosis aórtica y otras entidades con fisiopatología afín.
Since Edward Heyde perceived in 1958 a mysterious association between aortic stenosis and gastrointestinal bleeding, six decades have passed and no little controversy has arisen. At the time it was proposed, the technical and methodological status of medical science and a biased interpretation of his original idea prevented obtaining a statistical and pathophysiological support that would grant it wide recognition as and individual clinical entity. Advances in several disciplines allowed to demonstrate that its frequency of presentation exceeds the effect of chance, besides clarifying with precision and elegance its pathophysiological mechanisms. Its consolidation as a syndrome reveals a true crossroads between Cardiology, Gastroenterology, Hematology and Laboratory, specialties involved both in its understanding process and in its practical management today. However, despite having a not negligible incidence and acquiring a central role in the clinical conduction of aortic stenosis, this entity seems to have gone from being resisted to relatively ignored. With the objective of contributing to its visibility, this review offers a comprehensive overview of the subject, covering the main historical contributions to its knowledge and approaching in depth its mechanisms, the keys to its clinical detection and its impact on the management of aortic stenosis and other entities with related pathophysiology.
Desde que Edward Heyde imaginou em 1958 uma misteriosa associação entre estenose aórtica e hemorragia gastrointestinal, seis décadas se passaram e não houve pouca controvérsia. Na época em que foi levantada, o estado técnico e metodológico da ciência médica e uma interpretação tendenciosa de sua ideia original impediram a construção de um apoio estatístico e fisiopatológico que lhe concederia amplo reconhecimento como entidade clínica individual. Avanços em diversas disciplinas permitiram demonstrar que sua frequência de apresentação excede o efeito do acaso, além de esclarecer com precisão e elegância seus mecanismos fisiopatológicos. Sua consolidação como síndrome revela uma verdadeira encruzilhada entre Cardiologia, Gastroenterologia, Hematologia e Laboratório, especialidades envolvidas tanto em seu processo de compreensão quanto em sua gestão prática hoje. No entanto, apesar de ter uma incidência não desprezível e adquirir um papel central no manejo clínico da estenose aórtica, esta entidade parece ter passado de resistida para relativamente ignorada. Com o intuto de contribuir para sua visibilidade, esta revisão oferece um panorama abrangente do tema, revendo as principais contribuições históricas ao seu conhecimento e abordando em profundidade seus mecanismos, as chaves para sua detecção clínica e seu impacto na gestão da estenose aórtica e outras entidades com fisiopatologia relacionada.
Asunto(s)
Humanos , Estenosis de la Válvula Aórtica/complicaciones , Angiodisplasia/complicaciones , Hemorragia Gastrointestinal/etiología , Estenosis de la Válvula Aórtica/cirugía , Enfermedades de von Willebrand/complicaciones , Angiodisplasia/etiología , Angiodisplasia/terapia , Implantación de Prótesis de Válvulas Cardíacas , Hemorragia Gastrointestinal/terapiaRESUMEN
PURPOSE OF REVIEW: This review summarizes the pathophysiology of calcific aortic valve stenosis (CAVS) and surveys relevant clinical data and basic research that explain how CAVS arises. RECENT FINDINGS: Lipoprotein(a) [Lp(a)], lipoprotein-associated phospholipase A2 (Lp-PLA2), oxidized phospholipids (OxPL), autotaxin, and genetic driving forces such as mutations in LPA gene and NOTCH gene seem to play a major role in the development of CAVS. These factors might well become targets of medical therapy in the coming years. CVAS seems to be a multifactorial disease that has much in common with coronary artery disease, mainly regarding lipidic accumulation and calcium deposition. No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering and anti-calcific therapies confer a benefit in terms of reducing incidence or progression of CAVS, although additional outcome trials are ongoing.
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Estenosis de la Válvula Aórtica/sangre , Estenosis de la Válvula Aórtica/fisiopatología , Válvula Aórtica/patología , Calcinosis/sangre , Calcinosis/fisiopatología , Calcificación Vascular/sangre , Calcificación Vascular/fisiopatología , 1-Alquil-2-acetilglicerofosfocolina Esterasa/sangre , Animales , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/genética , Calcinosis/complicaciones , Calcinosis/genética , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/genética , Enfermedad de la Arteria Coronaria/fisiopatología , Progresión de la Enfermedad , Humanos , Lipoproteína(a)/sangre , Lipoproteína(a)/genética , Mutación , Fosfolípidos/sangre , Hidrolasas Diéster Fosfóricas/sangre , Receptor Notch1/genéticaRESUMEN
El implante valvular aórtico transcatéter, es un procedimiento cardiovascular de mínima invasión y una alternativa frente a la intervención convencional, en insuficiencia aórtica severa. En este trabajo se realiza una revisión de las complicaciones y la sobrevida, en pacientes sometidos a TAVI, frente a remplazo aórtico tradicional. Para ello se realizó una investigación documental con información entre los años 2010-2018. El implante valvular aórtico transcatéter debe efectuarse vía transfemoral o transapical, con una válvula Core o Sapien XT, según la necesidad del individuo, para evitar la regurgitación para valvular. Con este implante disminuyen las complicaciones y se remodela el ventrículo izquierdo; reduciendo la disnea y mejorando el pronóstico vida y la tasa de mortalidad en comparación con otros métodos(AU)
The transcatheter aortic valve implant is a minimally invasive cardiovascular procedure and, an alternative to conventional intervention in severe aortic insufficiency. In this work, a review of complications and survival is performed in patients undergoing TAVI, compared to traditional aortic replacement. For this, a documentary investigation was carried out with information between the years 2010-2018. The transcatheter aortic valve implant should be performed transfemorally or transapically, with a Core or Sapien XT valve, depending on the individual's need, to avoid regurgitation to valvulate. With this implant the complications decrease and the left ventricle is remodeled; reducing breathlessness and improving the life prognosis and mortality rate compared to other methods(AU)
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Humanos , Insuficiencia de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Radiografía Torácica/métodos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Evaluación Preoperatoria , Angiografía/métodos , Cateterismo Cardíaco , Tasa de Supervivencia , Estudios RetrospectivosRESUMEN
Abstract Background: Chronic kidney disease (CKD) is frequently present in patients with aortic valve disease. Decreased kidney perfusion as a consequence of reduced cardiac output may contribute to renal dysfunction in this setting. Objective: Given the potential reversibility of kidney hypoperfusion after valve repair, this study aimed to analyze the impact of percutaneous transcatheter aortic valve implantation (TAVI) on kidney function. Methods: We performed a retrospective analysis of 233 consecutive patients who underwent TAVI in a single center between November 2008 and May 2016. We assessed three groups according to their baseline estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2): Group 1 with eGFR ≥ 60; Group 2 with 30 ≤ eGFR < 60; and Group 3 with eGFR < 30. We analyzed the eGFR one month and one year after TAVI in these three groups, using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula to calculate it. Results: Patients from Group 1 had a progressive decline in eGFR one year after the TAVI procedure (p < 0.001 vs. pre-TAVI). In Group 2 patients, the mean eGFR increased one month after TAVI and continued to grow after one year (p = 0.001 vs. pre-TAVI). The same occurred in Group 3, with the mean eGFR increasing from 24.4 ± 5.1 mL/min/1.73 m2 before TAVI to 38.4 ± 18.8 mL/min/1.73 m2 one year after TAVI (p = 0.012). Conclusions: For patients with moderate-to-severe CKD, kidney function improved one year after the TAVI procedure. This outcome is probably due to better kidney perfusion post-procedure. We believe that when evaluating patients that might need TAVI, this 'reversibility of CKD effect' should be considered.
Resumo Fundamento: Pacientes com doença valvar aórtica frequentemente apresentam doença renal crônica (DRC). Diminuição da perfusão renal como consequência da redução do débito cardíaco pode contribuir para a disfunção renal neste cenário. Objetivo: Dado o potencial de reversibilidade da hipoperfusão renal após o reparo valvar, este estudo teve o objetivo de analisar o impacto do implante percutâneo de válvula aórtica (TAVI - transcatheter aortic valve implantation) na função renal. Métodos: Foi realizada uma análise retrospectiva de 233 pacientes consecutivos submetidos ao TAVI em um único centro, entre novembro de 2008 e maio de 2016. Três grupos foram avaliados de acordo com a taxa de filtração glomerular estimada (TFGe) basal (mL/min/1,73 m2): Grupo 1 com TFGe ≥ 60; Grupo 2 com 30 ≤ TFGe < 60; e Grupo 3 com TFGe < 30. O TFGe foi analisado nestes três grupos um mês e um ano após o TAVI e calculado usando a fórmula do Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Resultados: Os pacientes do Grupo 1 tiveram um declínio progressivo da TFGe um ano após o procedimento TAVI (p < 0,001 vs. pré-TAVI). Nos pacientes do Grupo 2, a média da TFGe aumentou um mês depois do TAVI e continuou crescendo depois de um ano (p = 0,001 vs. pré-TAVI). O mesmo ocorreu no Grupo 3, com a média da TFGe subindo de 24,4 ± 5,1 mL/min/1,73 m2 antes do TAVI para 38,4 ± 18,8 mL/min/1,73 m2 um ano após o TAVI (p = 0,012). Conclusões: Em pacientes com DRC moderada a grave, a função renal melhorou um ano após o procedimento TAVI. Este resultado é provavelmente devido à melhora da perfusão renal pós-procedimento. Acredita-se que, ao avaliar pacientes que possam precisar de TAVI, este 'efeito de reversibilidade da DRC' deva ser considerado.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Insuficiencia Renal Crónica/rehabilitación , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/complicaciones , Comorbilidad , Estudios Retrospectivos , Factores de Riesgo , Insuficiencia Renal Crónica/etiología , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Tasa de Filtración GlomerularRESUMEN
BACKGROUND: Chronic kidney disease (CKD) is frequently present in patients with aortic valve disease. Decreased kidney perfusion as a consequence of reduced cardiac output may contribute to renal dysfunction in this setting. OBJECTIVE: Given the potential reversibility of kidney hypoperfusion after valve repair, this study aimed to analyze the impact of percutaneous transcatheter aortic valve implantation (TAVI) on kidney function. METHODS: We performed a retrospective analysis of 233 consecutive patients who underwent TAVI in a single center between November 2008 and May 2016. We assessed three groups according to their baseline estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2): Group 1 with eGFR ≥ 60; Group 2 with 30 ≤ eGFR < 60; and Group 3 with eGFR < 30. We analyzed the eGFR one month and one year after TAVI in these three groups, using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula to calculate it. RESULTS: Patients from Group 1 had a progressive decline in eGFR one year after the TAVI procedure (p < 0.001 vs. pre-TAVI). In Group 2 patients, the mean eGFR increased one month after TAVI and continued to grow after one year (p = 0.001 vs. pre-TAVI). The same occurred in Group 3, with the mean eGFR increasing from 24.4 ± 5.1 mL/min/1.73 m2 before TAVI to 38.4 ± 18.8 mL/min/1.73 m2 one year after TAVI (p = 0.012). CONCLUSIONS: For patients with moderate-to-severe CKD, kidney function improved one year after the TAVI procedure. This outcome is probably due to better kidney perfusion post-procedure. We believe that when evaluating patients that might need TAVI, this 'reversibility of CKD effect' should be considered.
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Estenosis de la Válvula Aórtica/cirugía , Insuficiencia Renal Crónica/rehabilitación , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/complicaciones , Comorbilidad , Femenino , Tasa de Filtración Glomerular , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Renal Crónica/etiología , Estudios Retrospectivos , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricosRESUMEN
Transcatheter aortic valve implantation (TAVI) has become a therapeutic option for high-risk or non-operable patients with severe symptomatic aortic stenosis. Atrioventricular conduction disturbances requiring permanent pacemaker (PPM) are a common and clinically important complication. Objectives: To evaluate the incidence of conduction disorders (CDs) after TAVI and the need for subsequent PPM implantation. To identify the predictors of postoperative PPM implantation. Methods: Retrospective study. All patients who underwent TAVI in a public hospital from December/2011 to June/2016 were included. Multivariate analysis was conducted to establish the predictor of permanent pacemaker implantation. Survival curves were constructed by the Kaplan-Meyer method. Statistically significant variables were those with p value < 0.05. Results: 64 patients with AS underwent TAVI. Eleven patients were excluded. TAVI induced a new CD in 40 (77%) of the remaining 53 patients. The most common new CDs were 3rd degree AV block (32%) and left bundle branch block (30%). Sixteen patients (30,2%) underwent PPM implantation during the index hospitalization. On univariate analysis the risk factors for PPM implantation were CoreValve® use (OR: 1,76; P = 0,005), larger prosthesis implantation (P = 0,015), presence of a QRS ≥ 120 ms (OR: 5,62; P = 0,012), and 1st degree AV block (OR: 13; P = 0.008). On multivariate analysis the presence of 1st degree AV block predicted the need for PPM. Conclusion: TAVI induced CDs requiring PPM in 30% of the patients. The presence of 1st degree AV block predicted the need for PPM