RESUMEN

BACKGROUND: Predictors of permanent pacemaker implantation (PPMI) after self-expanding transcatheter aortic valve implant (TAVI) were described. Is unknown if PPMI predictors remain in the era of high implants using the cusp overlap (COP). METHODS: Single-center, prospective, consecutive case series of patients undergoing self-expanding TAVI with the COP approach. The status of PPMI and other clinical events were ascertained at 30 days. RESULTS: A total of 261 patients were included (84% with Evolut, n = 219). Implant depth >4 mm was infrequent (13.8%). TAVI depth (OR 1.259; p = 0.005), first or second-degree auriculo-ventricular block (OR 3.406; p = 0.033), right-bundle (OR 15.477; p < 0.0001), and incomplete left-bundle branch block (OR 7.964; p = 0.036) were found to be independent predictors of PPMI. The risk of PPMI with deep implant and no electrical disturbances was 3%, and 0% with high implant and no prior electrical disturbances. Those who received PPMI had no statistically significant increased risk of death, myocardial infarction, stroke, bleeding events, or vascular complications at 30 days, but longer hospital stay (mean difference 1.43 days more, p = 0.003). CONCLUSIONS: Implant depth and prior conduction abnormalities remain the main predictors of PPMI using self-expanding TAVI in the COP era. Patients with high implants and no prior conduction abnormalities may be candidates for early discharge after uneventful self-expanding TAVI, while the rest may need inpatient monitoring regardless of achieving a high implant. The need for PPMI was associated with longer hospital stays.

Asunto(s)

Estenosis de la Válvula Aórtica , Válvula Aórtica , Estimulación Cardíaca Artificial , Prótesis Valvulares Cardíacas , Marcapaso Artificial , Diseño de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Masculino , Femenino , Estudios Prospectivos , Anciano de 80 o más Años , Factores de Riesgo , Anciano , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Resultado del Tratamiento , Válvula Aórtica/cirugía , Válvula Aórtica/fisiopatología , Válvula Aórtica/diagnóstico por imagen , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Factores de Tiempo , Medición de Riesgo

RESUMEN

INTRODUCTION: Limited information exists on the prevalence and outcomes of patients undergoing surgical aortic valve replacement (SAVR) for aortic stenosis (AS) with reduced left ventricular ejection fraction (LVEF). This study aims to describe the number of AS patients undergoing SAVR with LVEF less than 55 % and quantify LVEF improvement at follow-up. MATERIAL AND METHODS: We analyzed patients undergoing SAVR with LVEF less than 55 % and the number of patients that improved the LVEF at 6 months. We defined 'improved LVEF' as a 10 % increase of LVEF compared to baseline. RESULTS: Out of 685 patients, 11.4 % (n = 78) had SAVR with LVEF <55 %. The median pre-surgery LVEF was 45 % [IQR 37-51]. In-hospital mortality was 5.1 % (n = 4). Follow-up data for 69 patients showed 50.7 % (n = 35) had improved LVEF. CONCLUSIONS: In our cohort, 10 % of severe AS patients underwent SAVR with LVEF <55 %, with half showing LVEF improvement at follow-up.

Asunto(s)

Estenosis de la Válvula Aórtica , Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Volumen Sistólico , Humanos , Masculino , Femenino , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/epidemiología , Volumen Sistólico/fisiología , Anciano , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prevalencia , Estudios de Seguimiento , Válvula Aórtica/cirugía , Válvula Aórtica/fisiopatología , Función Ventricular Izquierda/fisiología , Mortalidad Hospitalaria/tendencias , Resultado del Tratamiento , Estudios Retrospectivos , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/epidemiología , Persona de Mediana Edad , Anciano de 80 o más Años

RESUMEN

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/fisiología

Asunto(s)

Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Válvula Aórtica/fisiopatología , Trombosis Coronaria/complicaciones , Trombosis Coronaria/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Ecocardiografía Transesofágica/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos

RESUMEN

RESUMEN: ANTECEDENTES: La valvuloplastía aórtica es un procedimiento paliativo o como puente al reemplazo aórtico percutáneo o quirúrgico. Nuestro abordaje incluye una técnica minimalista y la utilización de balones de mayor tamaño que lo estándar. OBJETIVO: Evaluar los resultados clínicos inmediatos y alejados de pacientes tratados mediante esta técnica modificada. MÉTODOS: Se incluyó a todos los pacientes sometidos a balonplastía aórtica entre Julio del 2012 y Agosto del 2019 en nuestro centro. El procedimiento se realizó bajo sedación consciente mediante un único acceso femoral y sin instalación de un marcapasos transitorio. El éxito de la intervención se definió como caída de gradiente basal en 50% o más en ausencia de complicación mayor. RESULTADOS: Se realizaron un total de 52 procedimientos en 49 pacientes. La edad promedio fue 76 ± 9,9 años. Un tercio de los pacientes tenía una fracción de eyección del ventrículo izquierdo ≤35% y similar proporción tenía un perfil de riesgo STS score > 10 puntos. La duración total promedio fue de 31,1 + 10,0 min. Se utilizó un balón #28 en el 84.6% de los casos. El éxito del procedimiento se alcanzó en 94,2% de los casos. Ocurrieron 2 muertes intraoperatorias (3,9%), ambas en pacientes de muy alto riesgo y 2 (3,9%) complicaciones vasculares mayores. La sobreviva en el seguimiento alejado fue 32,7%. CONCLUSIÓN: La valvuloplastia aórtica percutánea con técnica modificada, utilizando balones de mayor tamaño que lo habitual, es una técnica segura que logra óptimos resultados hemodinámicos.

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ABSTRACT: Aortic balloon valvuloplasty (ABV) is a palliative procedure or a bridge to percutaneous or surgical aortic valve replacement. Our group proposes a minimalist approach that reduces the use of resources and also stands out for using larger balloons. AIM: To assess the safety and the immediate results of patients undergoing aortic balloon valvuloplasty using a minimally invasive procedure. METHODS: All patients who underwent ballon aortic valvuloplasty (BAV) between July 2012 and Au- gust 2019 were included. The procedure was performed under conscious sedation using a single femoral access and without the installation of a temporary pacemaker. Success was defined as a 50% drop in the mean aortic gradient plus the absence of major complications. RESULTS: 52 procedures in 49 patients were performed; the average age was 76 ± 9,9 years. A third of patients included had a left ventricular ejection fraction ≤35% and a similar proportion had a high risk profile with an STS score> 10 points. A 28 mm balloon was used in 84.6% of cases. The procedure was successful in 94,2% of cases. There were 2 (3,85%) intraoperative deaths in very high-risk patients and 2 (3,85%) major vascular complications. The survival rate at late follow up was 32,7%. CONCLUSION: Aortic balloon valvuloplasty with a minimally invasive technique using larger than usual balloons is a safe technique that achieves optimal hemodynamic results.

Asunto(s)

Humanos , Femenino , Anciano , Válvula Aórtica/fisiopatología , Válvula Aórtica/diagnóstico por imagen , Valvuloplastia con Balón/métodos , Estudios Retrospectivos , Sedación Consciente/métodos , Valvuloplastia con Balón/efectos adversos , Contraindicaciones de los Procedimientos

RESUMEN

OBJECTIVE: The durability of root repair for acute type A aortic dissection is not well studied in the context of aortic insufficiency and stability of the sinuses of Valsalva. We compared clinical and functional outcomes in patients undergoing root repair and replacement for acute type A aortic dissection. METHODS: Of 716 patients undergoing surgery for acute type A aortic dissection, 585 (81.7%) underwent root repair and 131 (18.3%) underwent root replacement. Survival, cumulative incidence of reoperation, aortic insufficiency, and sinuses of Valsalva dilation were compared between the 2 groups. RESULTS: Survival at 1, 5, and 10 years was 84.1% versus 77.3%, 70.8% versus 69.2%, 57.6% versus 58.0% in the root repair and replacement groups, respectively (P = .69). Cumulative incidence of reoperation at 1, 5, and 10 years was 0.0% versus 0.8%, 1.4% versus 3.8%, and 3.4% versus 8.6% in the root repair and root replacement groups, respectively (P = .011). Multivariable Cox regression identified sinuses of Valsalva diameter 45 mm or more as a risk factor for proximal aortic reoperation (hazard ratio, 9.06; 95% confidence interval, 1.26-65.24). In a repeated-measures, linear, mixed-effects model, root replacement was associated with smaller follow-up of sinuses of Valsalva dimensions (ß = -0.66, P < .001). In an ordinal longitudinal mixed model, root replacement was associated with lower severity of postoperative aortic insufficiency (ß = -3.10, P < .001). CONCLUSIONS: Survival is similar, but the incidence of aortic insufficiency and root dilation may be greater after root repair compared with root replacement for acute type A aortic dissection.

Asunto(s)

Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Quirúrgicos Cardíacos , Seno Aórtico/cirugía , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/cirugía , Recurrencia , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Seno Aórtico/diagnóstico por imagen , Seno Aórtico/fisiopatología , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

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.

Asunto(s)

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/genética

RESUMEN

Abstract Objective: The aim of this study was to evaluate the QT dispersion and echocardiographic parameters in patients before and after transcatheter aortic valve implantation (TAVI). Methods: One hundred and fifty-two patients with severe aortic valve stenosis (AS) were included in our study. Ninety five patients who underwent aortic valve replacement with TAVI were included in the TAVI group and 57 patients, who refused TAVI, were included in the medical treatment group. The QT interval and echocardiographic parameters of all patients were assessed before and after the procedure (first and sixth months and first year). The QT intervals were taken from the onset of the QRS to the end of the T wave. Results: All patients had severe AS. The average mean aortic valve gradient was 46.1±12. Left ventricular internal diastolic diameter (LVIDD) and interventricular septum diastolic thickness (IVSDT) did not change significantly after TAVI (P>0.05). QT dispersion, corrected QT dispersion, and mean aortic valve gradient changed significantly six months after TAVI (P<0.05). Compared to the medical treatment group, QT dispersion and corrected QT dispersion were significantly decreased at the sixth month in the TAVI group. The incidence of malignant arrhythmias was smaller in the TAVI group than in the medical treatment group. The mortality rate was lower at the first-year follow-up in the TAVI group than in the medical treatment group. Conclusion: Increased QT dispersion is associated with severe symptomatic AS. After TAVI, QT dispersion reduces.

Asunto(s)

Humanos , Masculino , Femenino , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Arritmias Cardíacas/fisiopatología , Ecocardiografía/métodos , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Válvula Aórtica/fisiopatología , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Electrocardiografía

RESUMEN

OBJECTIVE: The aim of this study was to evaluate the QT dispersion and echocardiographic parameters in patients before and after transcatheter aortic valve implantation (TAVI). METHODS: One hundred and fifty-two patients with severe aortic valve stenosis (AS) were included in our study. Ninety five patients who underwent aortic valve replacement with TAVI were included in the TAVI group and 57 patients, who refused TAVI, were included in the medical treatment group. The QT interval and echocardiographic parameters of all patients were assessed before and after the procedure (first and sixth months and first year). The QT intervals were taken from the onset of the QRS to the end of the T wave. RESULTS: All patients had severe AS. The average mean aortic valve gradient was 46.1±12. Left ventricular internal diastolic diameter (LVIDD) and interventricular septum diastolic thickness (IVSDT) did not change significantly after TAVI (P>0.05). QT dispersion, corrected QT dispersion, and mean aortic valve gradient changed significantly six months after TAVI (P<0.05). Compared to the medical treatment group, QT dispersion and corrected QT dispersion were significantly decreased at the sixth month in the TAVI group. The incidence of malignant arrhythmias was smaller in the TAVI group than in the medical treatment group. The mortality rate was lower at the first-year follow-up in the TAVI group than in the medical treatment group. CONCLUSION: Increased QT dispersion is associated with severe symptomatic AS. After TAVI, QT dispersion reduces.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Arritmias Cardíacas/fisiopatología , Ecocardiografía/métodos , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Válvula Aórtica/cirugía , Electrocardiografía , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino

Asunto(s)

Arritmias Cardíacas/etiología , Arritmias Cardíacas/patología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/patología , Adulto , Válvula Aórtica/anomalías , Válvula Aórtica/patología , Válvula Aórtica/fisiopatología , Arritmias Cardíacas/fisiopatología , Enfermedad de la Válvula Aórtica Bicúspide , Cardiomiopatía Dilatada/etiología , Cardiomiopatía Dilatada/patología , Cardiomiopatía Dilatada/fisiopatología , Progresión de la Enfermedad , Insuficiencia Cardíaca/fisiopatología , Trasplante de Corazón , Enfermedades de las Válvulas Cardíacas/patología , Enfermedades de las Válvulas Cardíacas/fisiopatología , Humanos , Masculino , Miocardio/patología

RESUMEN

OBJECTIVE: Long-term outcomes of prosthetic aortic valve/root replacement in patients aged 30 years or younger are not well understood. We report our single institutional experience in this young cohort. METHODS: From 1998 to 2016, 99 patients (age range, 16-30 years) underwent aortic valve replacement (n = 57), aortic valve replacement and supracoronary ascending aorta replacement (n = 6), or aortic root replacement (n = 36). A prospectively maintained aortic valve database was retrospectively reviewed to complete longitudinal functional and clinical data. Total follow-up was 493 patient years. RESULTS: Surgical indications included primary stenosis/insufficiency (52% [n = 51]), Marfan syndrome (10% [n = 10]), and endocarditis (33.3% [n = 33]). Fifty-eight patients (59%) underwent mechanical valve replacement, with 41 patients (41%) receiving a biologic/bioprosthetic valve. Twenty-five patients underwent aortic valve reoperation after index procedure with following indications: prosthesis-patient mismatch 1.0% (n = 1), prosthetic valve degeneration/dysfunction 10% (n = 10), connective tissue 2% (n = 2), and endocarditis 12% (n = 12). Mortality (30-day/in-hospital) and stroke rate were 3.0% (n = 3) and 1% (n = 1), respectively. One-, 5-, and 10-year actuarial freedom from aortic valve reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). Replacement valve size ≤21 mm was a significant risk factor for reoperation, and was associated with progression of mean aortic valve transvalvular gradients over follow-up. Valve type had no effect. CONCLUSIONS: The choice of mechanical versus biologic/bioprosthetic valve does not affect freedom from reoperation or survival rates in this young cohort during mid- to long-term follow-up. Smaller aortic valve replacement size (≤21 mm) is a significant risk factor for reoperation and progression of mean aortic valve gradients.

Asunto(s)

Aorta/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Aorta/diagnóstico por imagen , Aorta/fisiopatología , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Diseño de Prótesis , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven

RESUMEN

BACKGROUND: The impact of preexisting left bundle branch block (LBBB) in transcatheter aortic valve replacement (TAVR) recipients is unknown. The aim of this study was to determine the impact of preexisting LBBB on clinical outcomes after TAVR. METHODS AND RESULTS: This multicenter study evaluated 3404 TAVR candidates according to the presence or absence of LBBB on baseline ECG. TAVR complications and causes of death were defined according to Valve Academic Research Consortium-2 definitions. Follow-up outpatient visits or telephone interviews were conducted at 30 days, 12 months, and yearly thereafter. Echocardiography examinations were performed at baseline, at hospital discharge, and at 1-year follow-up. Preexisting LBBB was present in 398 patients (11.7%) and was associated with an increased risk of permanent pacemaker implantation (PPI; 21.1% versus 14.8%; adjusted odds ratio, 1.51; 95% CI, 1.12-2.04) but not death (7.3% versus 5.5%; adjusted odds ratio, 1.33; 95% CI, 0.84-2.12) at 30 days. At a mean follow-up of 22±21 months, there were no differences between patients with and without preexisting LBBB in overall mortality (adjusted hazard ratio, 0.94; 95% CI, 0.75-1.18) and cardiovascular mortality (adjusted hazard ratio, 0.90; 95% CI, 0.68-1.21). In a subanalysis of 2421 patients without PPI at 30 days and with complete follow-up about the PPI, preexisting LBBB was not associated with an increased risk of PPI or sudden cardiac death. Patients with preexisting LBBB had a lower left ventricular ejection fraction (LVEF) at baseline and at 1-year follow-up ( P <0.001 for both), but those with low LVEF exhibited a similar increase in LVEF over time after TAVR compared with patients with no preexisting LBBB ( P=0.327). CONCLUSIONS: Preexisting LBBB significantly increased the risk of early (but not late) PPI after TAVR, without any significant effect on overall mortality or cardiovascular mortality. Preexisting LBBB was associated with lower LVEF pre-TAVR but did not prevent an increase in LVEF post-TAVR similar to patients without LBBB.

Asunto(s)

Válvula Aórtica/cirugía , Bloqueo de Rama/terapia , Estimulación Cardíaca Artificial , Enfermedades de las Válvulas Cardíacas/cirugía , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Brasil/epidemiología , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/mortalidad , Bloqueo de Rama/fisiopatología , Canadá/epidemiología , Estimulación Cardíaca Artificial/efectos adversos , Estimulación Cardíaca Artificial/mortalidad , Ecocardiografía , Electrocardiografía , Europa (Continente)/epidemiología , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/fisiopatología , Humanos , Masculino , Marcapaso Artificial , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento

RESUMEN

OBJECTIVES: To explore the rate, the determinants of success, and the hemodynamic impact of balloon postdilatation (BPD) of self-expanding transcatheter heart valves (SE-THVs) BACKGROUND: BPD is commonly used to optimize valve expansion and reduce paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) without clearly knowing its hemodynamic benefits. METHODS: Patients (n = 307) who received a SE-THV were stratified according to whether a BPD was performed or not. Patients who received BPD were stratified according to the severity of PVL remaining after BPD into two groups: Successful BPD (≤mild PVL + BPD) and Failed BPD (moderate-severe PVL + BPD). RESULTS: BPD was performed in 121 patients (39.4%) and was successful in 106 patients (87.6% of attempts). A ratio of the postdilatation balloon diameter to the annulus diameter ≤0.95 was an independent predictor of BPD failure (OR: 10.72 [2.02-56.76], P = .005). Peak transvalvular pressure gradient (PG) was lower in the Successful BPD group (14[12-22] mm Hg) than in the Failed BPD group (18[16-23] mm Hg, P = .029), and did not rise in either group during follow-up (median [IQR], 364[161-739] days). CONCLUSION: BPD was performed in 39% of patients who received a SE-THV, and was successful in the majority of attempts. BPD failure was more likely in patients with a small postdilatation balloon-to-annulus diameter ratio. Effective BPD improved THV hemodynamic performance, and this was maintained in the intermediate-term post-TAVI.

Asunto(s)

Insuficiencia de la Válvula Aórtica/prevención & control , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Valvuloplastia con Balón , Prótesis Valvulares Cardíacas , Hemodinámica , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/fisiopatología , Valvuloplastia con Balón/efectos adversos , Brasil , Femenino , Humanos , Masculino , Diseño de Prótesis , Recuperación de la Función , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Simplified projected aortic valve area (EOAproj) is a valuable echocardiographic parameter in the evaluation of low flow low gradient aortic stenosis (LFLG AS). Its widespread use in clinical practice is hampered by the laborious process of flow rate (Q) calculation. OBJETIVE: This study proposes a less burdensome, alternative method of Q calculation to be incorporated in the original formula of EOAproj and measures the agreement between the new proposed method of EOAproj calculation and the original one. METHODS: Retrospective observational single-institution study that included all consecutive patients with classic LFLG AS that showed a Q variation with dobutamine infusion ≥ |15|% by both calculation methods. RESULTS: Twenty-two consecutive patients with classical LFLG AS who underwent dobutamine stress echocardiography were included. Nine patients showed a Q variation with dobutamine infusion calculated by both classical and alternative methods ≥ |15|% and were selected for further statistical analysis. Using the Bland-Altman method to assess agreement we found a systematic bias of 0,037 cm2 (95% CI 0,004 - 0,066), meaning that on average the new method overestimates the EOAproj in 0,037 cm2 compared to the original method. The 95% limits of agreement are narrow (from -0,04 cm2 to 0,12 cm2), meaning that for 95% of individuals, EOAproj calculated by the new method would be between 0,04 cm2 less to 0,12 cm2 more than the EOAproj calculated by the original equation. CONCLUSION: The bias and 95% limits of agreement of the new method are narrow and not clinically relevant, supporting the potential interchangeability of the two methods of EOAproj calculation. As the new method requires less additional measurements, it would be easier to implement in clinical practice, promoting an increase in the use of EOAproj.

Asunto(s)

Estenosis de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Ecocardiografía de Estrés/métodos , Agonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Velocidad del Flujo Sanguíneo , Dobutamina/administración & dosificación , Ecocardiografía Doppler/métodos , Femenino , Hemodinámica , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Función Ventricular Izquierda

RESUMEN

Abstract Background: Simplified projected aortic valve area (EOAproj) is a valuable echocardiographic parameter in the evaluation of low flow low gradient aortic stenosis (LFLG AS). Its widespread use in clinical practice is hampered by the laborious process of flow rate (Q) calculation. Objetive: This study proposes a less burdensome, alternative method of Q calculation to be incorporated in the original formula of EOAproj and measures the agreement between the new proposed method of EOAproj calculation and the original one. Methods: Retrospective observational single-institution study that included all consecutive patients with classic LFLG AS that showed a Q variation with dobutamine infusion ≥ -15-% by both calculation methods. Results: Twenty-two consecutive patients with classical LFLG AS who underwent dobutamine stress echocardiography were included. Nine patients showed a Q variation with dobutamine infusion calculated by both classical and alternative methods ≥ -15-% and were selected for further statistical analysis. Using the Bland-Altman method to assess agreement we found a systematic bias of 0,037 cm2 (95% CI 0,004 - 0,066), meaning that on average the new method overestimates the EOAproj in 0,037 cm2 compared to the original method. The 95% limits of agreement are narrow (from -0,04 cm2 to 0,12 cm2), meaning that for 95% of individuals, EOAproj calculated by the new method would be between 0,04 cm2 less to 0,12 cm2 more than the EOAproj calculated by the original equation. Conclusion: The bias and 95% limits of agreement of the new method are narrow and not clinically relevant, supporting the potential interchangeability of the two methods of EOAproj calculation. As the new method requires less additional measurements, it would be easier to implement in clinical practice, promoting an increase in the use of EOAproj.

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Resumo Fundamento: A área valvular aórtica projetada simplificada (AEOproj) é um parâmetro ecocardiográfico valioso na avaliação da estenose aórtica de baixo fluxo e baixo gradiente (EA BFBG). Sua utilização na prática clínica é limitada pelo trabalhoso processo de cálculo da taxa de fluxo (Q). Objetivos: Este estudo propõe um método alternativo, menos complexo, para o cálculo da Q para ser incorporado na fórmula original da AEOproj, e mede a concordância entre o novo método proposto para o cálculo da AEOproj em comparação ao método original. Métodos: Estudo retrospectivo, observacional, unicêntrico que incluiu todos os pacientes com AE BFBG clássica com variação da Q com infusão de dobutamina ≥ -15-% por ambos os métodos. Resultados: Foram incluídos 22 pacientes consecutivos com AE BFBG clássico, que se submeteram à ecocardiografia sob estresse com dobutamina. Nove pacientes apresentaram uma variação da Q com infusão de dobutamina calculada tanto pelo método clássico como pelo método alternativo ≥ -15-%, e foram selecionados para análise estatística. Utilizando método Bland-Altman para avaliar a concordância, encontramos um viés sistemático de 0,037 cm2 (IC 95% 0,004 - 0,066), o que significa que, em média, o novo método superestima a AEOproj em 0m037 cm2 em comparação ao método original. Os limites de concordância de 95% são estreitos (de -0,04 cm2 a 0,12 cm2), o que significa que para 95% dos indivídios, a AEOproj calculada pelo novo método estaria entre 0,04 cm2 menos a 0,12 cm2 mais que a AEOproj calculada pela equação original. Conclusão: O viés e os limites de 95% de concordância do novo método são estreitos e não são clinicamente relevantes, o que corrobora a intercambialidade dos dois métodos de cálculo da AEOproj. Uma vez que o novo método requer menos medidas, seria mais fácil de ser implementado na prática clínica, promovendo um aumento na utilização da AEOproj.

Asunto(s)

Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Ecocardiografía de Estrés/métodos , Válvula Aórtica/fisiopatología , Índice de Severidad de la Enfermedad , Velocidad del Flujo Sanguíneo , Infusiones Intravenosas , Ecocardiografía Doppler/métodos , Estudios Retrospectivos , Función Ventricular Izquierda , Dobutamina/administración & dosificación , Agonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Hemodinámica

RESUMEN

BACKGROUND AND AIM OF THE STUDY: The aim of this retrospective study was to evaluate the inflammatory response in patients with aortic and/or mitral prostheses, and to correlate the level of inflammatory markers with prosthesis functionality. METHODS: A total of 48 patients with biological or mechanical prostheses was included in the study, in which levels of tumor necrosis factor-alpha (TNFα), interleukin (IL)-1, -4, and -6, interferon-gamma (IFNγ), osteopontin (OPN), intercellular adhesion molecule (ICAM), vascular cell adhesion molecule (VCAM), endothelin-1 and C-reactive protein were analyzed. Functionality of the prosthesis was evaluated using transthoracic echocardiography at three years after surgery. RESULTS: The mean period from the date of surgery was seven years. High levels of IL-1 were found in patients with mechanical prostheses compared to those with bioprostheses (p = 0.04). Patients with aortic bioprostheses and stenosis had higher levels of OPN and endothelin-1, those with aortic mechanical prostheses with stenosis had increased levels of matrix metalloproteinase (MMP)-9, OPN and ICAM, and those with aortic mechanical leakage had increased levels of MMP-1 and endothelin-1. In mitral bioprostheses with leakage of endothelin-1, ICAM and MMP-9 levels were increased, while in mechanical prostheses with leakage there were increases of ICAM and endothelin-1. Tricuspid bioprostheses with double lesions had increased levels of OPN and endothelin-1. CONCLUSIONS: Valvular dysfunction was similar across the types of prosthesis material. IL-1 was increased in subjects with mechanical prostheses independently of dysfunction, while in biological prostheses there were increases in OPN and endothelin-1, and these were related to valvular dysfunction. Given that in the analysis of durability and functionality there were no significant differences between biological and mechanical prostheses, biological prostheses may represent the first treatment option in patients with low economic resources, the elderly, and even young patients.

Asunto(s)

Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas , Mediadores de Inflamación/inmunología , Inflamación/inmunología , Válvula Mitral/cirugía , Pericardio/trasplante , Anciano , Anciano de 80 o más Años , Animales , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/inmunología , Válvula Aórtica/fisiopatología , Bovinos , Ecocardiografía Transesofágica , Femenino , Xenoinjertos , Humanos , Inflamación/sangre , Inflamación/diagnóstico , Mediadores de Inflamación/sangre , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/inmunología , Válvula Mitral/fisiopatología , Pericardio/diagnóstico por imagen , Pericardio/inmunología , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Baseline comorbidities including renal dysfunction are frequently found in patients treated with transcatheter aortic valve replacement (TAVR) and may increase the risks of acute kidney injury (AKI), although some of them may actually improve renal function. We aimed to evaluate the potential of TAVR to acutely improve post-procedure renal function. METHODS: This is a prospective single-center registry of consecutive patients with severe symptomatic aortic stenosis treated by transfemoral TAVR. Creatinine levels were determined at baseline and daily until hospital discharge. AKI was defined according to VARC-2 criteria. Patients who had improvement of creatinine levels >25% were classified as having TAVR induced renal function improvement (TIRFI). RESULTS: A total of 69 patients undergoing TAVR were included, with a mean age of 83.0±7.4 years, being 24.6% diabetics, with a median STS score of 9.2 (5.1-21.6). Using the VARC-2 criteria, the majority of patients (64.6%) did not have renal impairment, while AKI was detected in 35.4% of the patients. Importantly, in those with prior severe renal dysfunction (clearance <30mL/min/1.73m2) or diabetes, AKI reached up to 50% and 56.3% of the patients, respectively. Conversely, acute kidney recovery (TIRFI) occurred in 12 patients (18.5%) being >50% in 1 patient (1.5%), and at hospital discharge the majority of the patients (88.6%) left the hospital in their original or better renal function categories. CONCLUSION: Despite multiple comorbidities in a selected TAVR-population and the use of contrast media, TAVR did not impair renal function in a majority of patients, with a significant proportion of them rather having acute renal function improvement.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Enfermedades Renales/fisiopatología , Riñón/fisiopatología , Reemplazo de la Válvula Aórtica Transcatéter , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/fisiopatología , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/fisiopatología , Biomarcadores/sangre , Brasil/epidemiología , Comorbilidad , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Hemodinámica , Humanos , Enfermedades Renales/diagnóstico , Enfermedades Renales/epidemiología , Masculino , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento

RESUMEN

OBJECTIVES: This study sought to assess the influence of baseline right bundle branch block (RBBB) on all-cause and cardiovascular mortality as well as sudden cardiac death (SCD) among patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: Few data exist regarding the late clinical impact of pre-existing RBBB in TAVR recipients. METHODS: A total of 3,527 patients (mean age 82 ± 8 years, 50.1% men) were evaluated according to the presence of RBBB on baseline electrocardiography. Intraventricular conduction abnormalities were classified according to the American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society recommendations for standardization and interpretation of the electrocardiogram. TAVR complications and causes of death were defined according to Valve Academic Research Consortium 2 definitions. RESULTS: RBBB was present on baseline electrocardiography in 362 patients (10.3%) and associated with higher 30-day rates of permanent pacemaker implantation (PPI) (40.1% vs. 13.5%; p < 0.001) and death (10.2% vs. 6.9%; p = 0.024). At a mean follow-up of 20 ± 18 months, pre-existing RBBB was independently associated with all-cause mortality (hazard ratio [HR]: 1.31; 95% confidence interval [CI]: 1.06 to 1.63; p = 0.014) and cardiovascular mortality (HR: 1.45; 95% CI: 1.11 to 1.89; p = 0.006) but not with SCD (HR: 0.71; 95% CI: 0.22 to 2.32; p = 0.57). Patients with pre-existing RBBB and without PPI at discharge from the index hospitalization had the highest 2-year risk for cardiovascular death (27.8%; 95% CI: 20.9% to 36.1%; log-rank p = 0.007). In a subanalysis of 1,245 patients without PPI at discharge from the index hospitalization and with complete follow-up regarding the need for PPI, pre-existing RBBB was independently associated with the composite of SCD and PPI (HR: 2.68; 95% CI: 1.16 to 6.17; p = 0.023). CONCLUSIONS: Pre-existing RBBB was found in 10% of TAVR recipients and was associated with poorer clinical outcomes. Patients with baseline RBBB without permanent pacemakers at hospital discharge may be at especially high risk for high-degree atrioventricular block and/or SCD during follow-up. Future studies should evaluate strategies aimed at the early detection of patients at risk for late development of high-degree atrioventricular block.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bloqueo de Rama/mortalidad , Muerte Súbita Cardíaca/epidemiología , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Brasil/epidemiología , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Canadá/epidemiología , Causas de Muerte , Ecocardiografía , Electrocardiografía , Europa (Continente)/epidemiología , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento

RESUMEN

Loeffler endocarditis is a complication of hypereosinophilic syndrome resulting from eosinophilic infiltration of heart tissue. We report a case of Loeffler endocarditis in which three-dimensional transthoracic and transesophageal echocardiography provided additional information to what was found by two-dimensional transthoracic echocardiography alone. Our case illustrates the usefulness of combined two- and three-dimensional echocardiography in the assessment of Loeffler endocarditis. In addition, a summary of the features of hypereosinophilic syndrome and Loeffler endocarditis is provided in tabular form.

Asunto(s)

Válvula Aórtica/diagnóstico por imagen , Ecocardiografía Tridimensional/métodos , Síndrome Hipereosinofílico/diagnóstico por imagen , Adulto , Anticoagulantes/uso terapéutico , Válvula Aórtica/fisiopatología , Ecocardiografía/métodos , Ecocardiografía Transesofágica/métodos , Femenino , Humanos , Síndrome Hipereosinofílico/tratamiento farmacológico , Síndrome Hipereosinofílico/fisiopatología

RESUMEN

Low cardiac output syndrome (LCOS) after surgical aortic valve replacement (SAVR) is related to increased mortality and treatment related costs. We aimed to evaluate whether echocardiography-derived left ventricular global longitudinal strain (LV-GLS) relates to the occurrence of postoperative LCOS in patients undergoing SAVR. We prospectively enrolled 75 patients with symptomatic severe aortic stenosis, left ventricular ejection fraction (LVEF) >40%, NYHA Class

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Gasto Cardíaco Bajo/diagnóstico por imagen , Ecocardiografía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Función Ventricular Izquierda , Función Ventricular Derecha , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Área Bajo la Curva , Fenómenos Biomecánicos , Gasto Cardíaco Bajo/etiología , Gasto Cardíaco Bajo/mortalidad , Gasto Cardíaco Bajo/fisiopatología , Distribución de Chi-Cuadrado , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Variaciones Dependientes del Observador , Oportunidad Relativa , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Estrés Mecánico , Factores de Tiempo , Resultado del Tratamiento