RESUMO
Introdução: Stress is associated with cardiovascular diseases.O implante percutâneo da válvula pulmonar é uma alternativa para condutos com disfunção. Descrevemos aqui a primeira experiência com o implante da válvula Melody® no Brasil. Métodos: Foram selecionados pacientes com estenose ou insuficiência pulmonar significativa em condutos de 16 a 22 mm. Foram empregadas técnicas padronizadas. Factibilidade, segurança e eficácia desse procedimento foram avaliadas. Resultados: Desde dezembro de 2013, dez pacientes (média de idade e peso de 16,5 anos e 49 kg, respectivamente) foram submetidos ao procedimento com intervalo médio de 11,9 ± 8,6 anos desde a última cirurgia. Insuficiência pulmonar foi indicação para o tratamento em três pacientes, estenose em dois e lesão mista em cinco. A válvula Melody® foi implantada com sucesso em todos os casos. A média da pressão sistólica do ventrículo direito e a relação ventrículo direito/ventrículo esquerdo diminuíram de 49,2 ± 15,9 para 35,8 ± 5,7 mmHg e de 0,55 ± 0,18 para 0,39 ± 0,08 mmHg (p < 0,01 para ambos). Não observamos estenose e nem insuficiência pulmonar residual significativa. Um paciente teve extravasamento contido requerendo um stent coberto e um segundo implante valvular. Todos os pacientes receberam alta do hospital em 72 horas. As válvulas funcionaram adequadamente ...
Background: Transcatheter pulmonary valve implantation is an alternative for dysfunctional conduits. We report the first experience with the MelodyTM valve implantation in Brazil. Methods: Patients with significant pulmonary stenosis or significant pulmonary insufficiency in conduits measuring 16 to 22 mm were enrolled. Standardized techniques were employed. The feasibility, safety and efficacy of this procedure were assessed. Results: From December 2013, ten patients (mean age and weight of 16.5 years and 49 kg, respectively) have undergone the procedure with a mean interval of 11.9 ± 8.6 years since the last surgery. Pulmonary insufficiency was an indication for treatment in three patients, pulmonary stenosis in two, and mixed lesion in five. The MelodyTM valve was successfully implanted in all cases. Mean right ventricular systolic pressure and right ventricle/left ventricle ratio decreased from 49.2 ± 15.9 to 35.8 ± 5.7 mmHg and from 0.55 ± 0.18 to 0.39 ± 0.08 mmHg (p < 0.01 for both). Significant residual pulmonary stenosis or pulmonary insufficiency was not observed. One patient had a contained conduit tear requiring a covered stent and a second valve implantation. All patients were discharged within 72 hours. The valves were properly functioning in a mean follow-up of 4.1 ± 2.2 months with no complications. Conclusions: Transcatheter MelodyTM valve implantation was feasible, safe and effective ...
RESUMO
PURPOSE OF REVIEW: To provide an overview of the various modalities that have emerged in the last years as adjunctive tools to provide detailed imaging of the cardiovascular system in the catheterization laboratory. RECENT FINDINGS: Completion angiography after cardiac surgery for congenital heart disease using a dedicated hybrid operating cardiac suite may aid in early diagnosis and therapy of postsurgical abnormalities. The application of three-dimensional rotational digital angiography results in a more precise delineation of the three-dimensional anatomy of vascular structures outside the heart with rapid image processing and reduction of the amount of contrast used and ionizing radiation dose. Combined catheterization/magnetic resonance (MR) hybrid laboratories have the potential to accurately assess changes in the anatomy and physiology pretranscatheter and posttranscatheter interventions. Fully MR-guided transcatheter procedures have become possible in animal models. Real-time three-dimensional transesophageal echocardiography (TEE) has helped to guide transcatheter procedures in septal and valvar structures. Miniaturization of probes has expanded the applications of TEE for smaller neonates. The use of intravascular ultrasound has helped to better understand the mechanisms of vascular diseases and transcatheter treatments. SUMMARY: Knowledge and proper application of new imaging modalities during interventions in the catheterization laboratory may improve the outcomes of patients with congenital and acquired structural heart disease.
Assuntos
Cateterismo Cardíaco/instrumentação , Cardiopatias Congênitas/diagnóstico , Angiografia Digital/instrumentação , Angiografia Digital/métodos , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Cateterismo Cardíaco/métodos , Sistemas Computacionais , Diagnóstico por Imagem/instrumentação , Diagnóstico por Imagem/métodos , Ecocardiografia Transesofagiana/instrumentação , Ecocardiografia Transesofagiana/métodos , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/terapia , Humanos , Laboratórios , Imageamento por Ressonância Magnética/instrumentação , Imageamento por Ressonância Magnética/métodos , Ultrassonografia de IntervençãoRESUMO
To provide an overview of the various modalities that have emerged in the last years as adjunctive tools to provide detailed imaging of the cardiovascular system in the catheterization laboratory.RECENT FINDINGS: Completion angiography after cardiac surgery for congenital heart disease using a dedicated hybrid operating cardiac suite may aid in early diagnosis and therapy of postsurgical abnormalities. The application of three-dimensional rotational digital angiography results in a more precise delineation of the three-dimensional anatomy of vascular structures outside the heart with rapid image processing and reduction of the amount of contrast used and ionizing radiation dose. Combined catheterization/magnetic resonance (MR) hybrid laboratories have the potential to accurately assess changes in the anatomy and physiology pretranscatheter and posttranscatheter interventions. Fully MR-guided transcatheter procedures have become possible in animal models. Real-time three-dimensional transesophageal echocardiography (TEE) has helped to guide transcatheter procedures in septal and valvar structures. Miniaturization of probes has expanded the applications of TEE for smaller neonates. The use of intravascular ultrasound has helped to better understand the mechanisms of vascular diseases and transcatheter treatments.SUMMARY: Knowledge and proper application of new imaging modalities during interventions in the catheterization laboratory may improve the outcomes of patients with congenital and acquired structural heart disease.
Assuntos
Doença das Coronárias , Ecocardiografia , Ecocardiografia Tridimensional , Espectroscopia de Ressonância Magnética , UltrassomRESUMO
INTRODUCTION: Since the 1980s, stent implantation has evolved as an important therapeutic strategy for coarctation of the aorta. However, available data is frequently flawed by short follow-up, lack of adequate follow-up imaging, and retrospective nature of data collection. METHODS: Data was prospectively collected using a multicenter registry congenital cardiovascular interventional study consortium (CCISC). Between 2000 and 2009, 302 patients from 34 centers with a median weight of 58 kg underwent stent implantation for coarctation. Eligible patients (44%) completed intermediate follow-up (3-18 months) with integrated imaging (cath, CT, MRI), whereas 21% completed long-term follow-up (>18-60 months). Procedural success was defined as UL/LL systolic gradient of less than 20 mm Hg, lack of significant recurrent obstruction, and freedom from unplanned repeat intervention. RESULTS: Acute procedural success was 96%. Cumulative intermediate success was 86%, and cumulative long-term success was 77%. Unplanned repeat interventions were required in 4%, and aortic wall complications were seen in 1% of patients (dissection n = 1 and aneurysm n = 3). Other adverse events (n = 15) occurred mainly acutely and included technical complications such as stent malposition (n = 9). At long-term follow-up, 23% of patients continued to have systolic blood pressure above the 95th centile, 9% had an upper-to-lower limb blood pressure gradient in excess of 20 mm Hg, and 32% were taking antihypertensive medication. CONCLUSIONS: This study documented acute, intermediate, and long-term outcome data comparable or superior with other surgical or interventional series. However, even with successful initial stent therapy, patients continue to require long-term follow-up and have associated long-term morbidity, relating to aortic wall complications, systemic hypertension, recurrent obstruction as well as need for repeat intervention.
Assuntos
Coartação Aórtica/terapia , Procedimentos Endovasculares/instrumentação , Stents , Adolescente , Adulto , Anti-Hipertensivos/uso terapêutico , Coartação Aórtica/complicações , Coartação Aórtica/diagnóstico , Coartação Aórtica/fisiopatologia , Argentina , Canadá , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Procedimentos Endovasculares/efeitos adversos , Feminino , Hemodinâmica , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/etiologia , Hipertensão/fisiopatologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Recidiva , Sistema de Registros , Retratamento , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: We report a multiinstitutional study on intermediate-term outcome of intravascular stenting for treatment of coarctation of the aorta using integrated arch imaging (IAI) techniques. METHODS AND RESULTS: Medical records of 578 patients from 17 institutions were reviewed. A total of 588 procedures were performed between May 1989 and Aug 2005. About 27% (160/588) procedures were followed up by further IAI of their aorta (MRI/CT/repeat cardiac catheterization) after initial stent procedures. Abnormal imaging studies included: the presence of dissection or aneurysm formation, stent fracture, or the presence of reobstruction within the stent (instent restenosis or significant intimal build-up within the stent). Forty-one abnormal imaging studies were reported in the intermediate follow-up at median 12 months (0.5-92 months). Smaller postintervention of the aorta (CoA) diameter and an increased persistent systolic pressure gradient were associated with encountering abnormal follow-up imaging studies. Aortic wall abnormalities included dissections (n = 5) and aneurysm (n = 13). The risk of encountering aortic wall abnormalities increased with larger percent increase in CoA diameter poststent implant, increasing balloon/coarc ratio, and performing prestent angioplasty. Stent restenosis was observed in 5/6 parts encountering stent fracture and neointimal buildup (n = 16). Small CoA diameter poststent implant and increased poststent residual pressure gradient increased the likelihood of encountering instent restenosis at intermediate follow-up. CONCLUSIONS: Abnormalities were observed at intermediate follow-up following IS placement for treatment of native and recurrent coarctation of the aorta. Not exceeding a balloon:coarctation ratio of 3.5 and avoidance of prestent angioplasty decreased the likelihood of encountering an abnormal follow-up imaging study in patients undergoing intravascular stent placement for the treatment of coarctation of the aorta. We recommend IAI for all patients undergoing IS placement for treatment of CoA.
Assuntos
Angioplastia com Balão/instrumentação , Aorta Torácica , Coartação Aórtica/terapia , Aortografia/métodos , Cateterismo Cardíaco , Angiografia por Ressonância Magnética , Stents , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/etiologia , Dissecção Aórtica/patologia , Angioplastia com Balão/efeitos adversos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/patologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/etiologia , Aneurisma Aórtico/patologia , Coartação Aórtica/diagnóstico por imagem , Coartação Aórtica/patologia , Brasil , Criança , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/etiologia , Constrição Patológica/patologia , Europa (Continente) , Seguimentos , Humanos , Guias de Prática Clínica como Assunto , Falha de Prótese , Projetos de Pesquisa , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: We report a multi-institutional experience with intravascular stenting (IS) for treatment of coarctation of the aorta. METHODS AND RESULTS: Data was collected retrospectively by review of medical records from 17 institutions. The data was broken down to prior to 2002 and after 2002 for further analysis. A total of 565 procedures were performed with a median age of 15 years (mean=18.1 years). Successful reduction in the post stent gradient (<20 mm Hg) or increase in post stent coarctation to descending aorta (DAo) ratio of >0.8 was achieved in 97.9% of procedures. There was significant improvement (P<0.01) in pre versus post stent coarctation dimensions (7.4 mm+/-3.0 mm vs. 14.3+/-3.2 mm), systolic gradient (31.6 mm Hg+/-16.0 mm Hg vs. 2.7 mm Hg+/-4.2 mm Hg) and ratio of the coarctation segment to the DAo (0.43+/-0.17 vs. 0.85+/-0.15). Acute complications were encountered in 81/565 (14.3%) procedures. There were two procedure related deaths. Aortic wall complications included: aneurysm formation (n=6), intimal tears (n=8), and dissections (n=9). The risk of aortic dissection increased significantly in patients over the age of 40 years. Technical complications included stent migration (n=28), and balloon rupture (n=13). Peripheral vascular complications included cerebral vascular accidents (CVA) (n=4), peripheral emboli (n=1), and significant access arterial injury (n=13). Older age was significantly associated with occurrence of CVAs. A significant decrease in the technical complication rate from 16.3% to 6.1% (P<0.001) was observed in procedures performed after January 2002. CONCLUSIONS: Stent placement for coarctation of aorta is an effective treatment option, though it remains a technically challenging procedure. Technical and aortic complications have decreased over the past 3 years due to, in part, improvement in balloon and stent design. Improvement in our ability to assess aortic wall compliance is essential prior to placement of ISs in older patients with coarctation of the aorta.
Assuntos
Angioplastia com Balão/efeitos adversos , Coartação Aórtica/terapia , Doenças da Aorta/etiologia , Migração de Corpo Estranho/etiologia , Doenças Vasculares Periféricas/etiologia , Stents , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Angioplastia com Balão/instrumentação , Angioplastia com Balão/mortalidade , Coartação Aórtica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Aortografia , Brasil/epidemiologia , Criança , Pré-Escolar , Inglaterra/epidemiologia , Falha de Equipamento , Migração de Corpo Estranho/diagnóstico por imagem , Humanos , Modelos Logísticos , Razão de Chances , Doenças Vasculares Periféricas/diagnóstico por imagem , Desenho de Prótese , Recidiva , Projetos de Pesquisa , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
La colocación de "stents" endovascular provee de una fuerza de oposición al retroceso elástico de estenosis vasculares después del fracaso de una angioplastia por balón, además de servir de soporte a la pared del vaso. Por otra parte, permite el crecimiento de la capa endotelial y de esta manera, se reduce el riesgo de trombosis. Múltiples estudios han demostrado la utilidad y efectividad inmediata después de la colocación de "stents" para coartación o re coartación de aorta. Sin embargo, el uso de estructuras rígidas en un niño en crecimiento hace pensar en una importante limitante puesto que se trata de la adquisición de una estenosis por implante de un dispositivo con diámetro fijo. Más aún, estos pacientes pudieran desarrollar gradientes inducidos por ejercicio, a nivel de la lesión puesto que se trata de una estructura no dispensable. Como si esto no fuera suficiente, aún se desconoce el impacto de estos materiales en la vasculatura periférica y en la dinámica de flujo sanguíneo. En contrapartida, estos no son problemas cuando nos enfrentamos con un paciente en la edad adulta puesto que no esperamos realizar una nueva intervención después de haber logrado la completa abertura de malla metálica utilizada. En este artículo reflejamos la primera experiencia en el país con la utilización del "CP Numed stent" para este tipo de patología en una mujer de 26 años de edad. La paciente en cuestión presentaba un gradiente entre la aorta transversal y la aorta decendente de 59 mmHg. Después del procedimiento no se encontró gradiente alguno. El seguimiento de la misma seis meses después, por Doppler, pone de manifiesto estos excelentes resultados (eliminación del gradiente y de la necesidad de drogas antihipertensivas)