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RESUMEN Introducción: En el tratamiento de la estenosis aórtica grave ha habido un cambio en la elección del tipo de prótesis valvular, con priorización de la utilización de válvulas biológicas. En la actualidad, a nivel mundial, en el 80% de los recambios valvulares aórticos se utilizan prótesis biológicas, cuya menor durabilidad alejada representa su mayor limitación. No contamos con evaluación reciente en nuestro medio de la durabilidad de las válvulas biológicas y la incidencia de eventos a largo plazo. Objetivos: Evaluar el comportamiento alejado de las prótesis valvulares aórticas biológicas, respecto de su sobrevida e incidencia ecocardiográfica de deterioro valvular estructural (DVE). Material y Métodos: Estudio retrospectivo sobre 2365 pacientes operados entre enero de 2003 y diciembre de 2023. Se evaluó la sobrevida alejada y la incidencia de DVE de acuerdo con las modificaciones del gradiente medio transprotésico (GMt) según la edad (dicotomizada en 60 años) y el tamaño de la prótesis utilizada (dicotomizado en 23 mm). Resultados: La edad promedio fue de 73 ± 3,05 años (105 pacientes < 60 años y 2530 pacientes ≥60 años). Sexo masculino en 63,4 %. Seguimiento alejado en el 92 % de los pacientes, media de 5,9 ± 3,2 años. Sobrevida a 5 y 10 años según edad: en < 60 años: 98,3 y 91,7 % vs. ≥ 60 años: 81,7 y 65,7 % (p=0,007) respectivamente. Seguimiento ecocardiográfico global en 1399 (59,7 %) pacientes. Valores del GMt basal, y a 5 y 10 años: a) según edad: en < 60 años: 16 ±3 mmHg, 16 ± 6 mmHg y 19 ± 5 mmHg, vs. en ≥ 60 años: 15 ± 5 mmHg, 16 ± 7 mmHg y 18± 7 mmHg (p=NS); b) según tamaño de la prótesis: en < 23 mm: 17±6 mmHg, 19±7 mmHg y 22± 7 mmHg, vs. en ≥ 23 mm: 15± 5 mmHg, 16± 6 mmHg y 18± 6 mmHg (p= 0,001). Conclusiones: Los pacientes con prótesis valvulares biológicas presentaron una elevada sobrevida alejada con diferencias según el grupo etario. Se registraron en el seguimiento diferencias del GMt (<10 mmHg) en las válvulas < 23 mm, demostrando baja incidencia de DVE grave.

ABSTRACT Background: In the treatment of severe aortic stenosis there has been a shift in the choice of the valve prosthesis type toward the use of biological valves. At present, bioprosthetic valves are used in 80% of aortic valve replacements worldwide. Their main limitation is their reduced long-term durability. No assessment has been yet performed in our setting regarding the durability of bioprosthetic valves and the incidence of long-term events. Objectives: To evaluate the long-term performance of bioprosthetic aortic valves related to survival and echocardiographic incidence of structural valve deterioration (SVD). Methods: A retrospective study of 2365 patients undergoing aortic valve replacement with biological prosthesis between January 2003 and December 2023. We analyzed the long-term survival and the incidence of SVD pursuant to changes in the mean transprosthetic gradient (mTPG) according to age (< or ≥60 years) and prosthetic valve size (< or ≥ 23 mm). Results: Mean age was 73±3.05 years (105 patients <60 years and 2530 patients ≥60 years). A total of 63.4% was male. Of patients, 92% completed a long-term follow-up, mean 5.9±3.2 years. Survival at 5 and 10 years according to age was: in patients <60 years: 98.3 and 91.7% vs. patients ≥60 years: 81.7 and 65.7% (p=0.007), respectively. A total of 1399 (59.7%) patients had an overall echocardiographic follow-up. The values of mTPG at baseline, 5 and 10 years were: a) according to age: in patients <60 years: 16±3 mmHg, 16±6 mmHg and 19±5 mmHg, vs. in patients ≥60 years: 15±5 mmHg, 16±7 mmHg and 18±7 mmHg (p=NS); b) according to prosthesis size: <23 mm: 17±6 mmHg, 19±7mmHg and 22±7 mmHg, vs. ≥23 mm: 15±5 mmHg, 16±6 mmHg and 18±6 mmHg (p= 0.001). Conclusions: Patients with bioprosthetic valves experienced high long-term survival with some differences according to age group. At follow-up, differences in mTPG (<10 mmHg) were observed in prosthetic valve sizes <23 mm, showing low incidence of severe SVD.

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INTRODUCTION: Diabetes mellitus (DM) in patients undergoing cardiac transcatheter or surgical interventions usually is correlated with poor outcomes. Transcatheter aortic valve implantation (TAVI) has been developed as a therapy choice for inoperable, high-, or intermediate-risk surgical patients with severe aortic stenosis (AS). OBJECTIVE: To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI. METHODS: Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually. RESULTS: The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis. CONCLUSION: In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.

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Resumo Fundamento Dados robustos sobre a curva de aprendizagem (LC) da substituição da válvula aórtica transcateter (TAVR) são escassos nos países em desenvolvimento. Objetivo Avaliar a LC da TAVR no Brasil ao longo do tempo. Métodos Analisamos dados do registro brasileiro de TAVR de 2008 a 2023. Pacientes de cada centro foram numerados cronologicamente em número sequencial de caso (NSC). A LC foi realizada usando um spline cúbico restrito ajustado para o EuroSCORE-II e o uso de próteses de nova geração. Ainda, os desfechos hospitalares foram comparados entre grupos definidos de acordo com o nível de experiência, com base no NSC: 1º ao 40º caso (experiência inicial), 41º ao 80º caso (experiência básica), 81º ao 120º caso (experiência intermediária) e 121º caso em diante (experiência alta). Análises adicionais foram conduzidas de acordo com o número de casos tratados antes de 2014 (>40 e ≤40 procedimentos). O nível de significância adotado foi p <0,05. Resultados Foram incluídos 3194 pacientes de 25 centros. A idade média foi 80,7±8,1 anos e o EuroSCORE II médio foi 7±7,1. A análise da LC demonstrou uma queda na mortalidade hospitalar ajustada após o tratamento de 40 pacientes. Um patamar de nivelamento na curva foi observado após o caso 118. A mortalidade hospitalar entre os grupos foi 8,6%, 7,7%, 5,9%, e 3,7% para experiência inicial, básica, intermediária e alta, respectivamente (p<0,001). A experiência alta foi preditora independente de mortalidade mais baixa (OR 0,57, p=0,013 vs. experiência inicial). Centros com baixo volume de casos antes de 2014 não mostraram uma redução significativa na probabilidade de morte com o ganho de experiência, enquanto centros com alto volume de casos antes de 2014 apresentaram uma melhora contínua após o caso de número 10. Conclusão Observou-se um fenômeno de LC para a mortalidade hospitalar do TAVR no Brasil. Esse efeito foi mais pronunciado em centros que trataram seus 40 primeiros casos antes de 2014 que naqueles que o fizeram após 2014.

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR's LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

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Aortic valve stenosis is a congenital heart defect that causes a fixed left ventricular outflow obstruction with a progressive course. Symptomatology in neonates and young infants resembles congestive heart failure. In addition, the diagnosis of this condition is made by imaging, through echocardiography. On the other hand, treatment can be surgical or interventional under fluoroscopic guidance, depending on the hospital in which it is performed. We describe the case of a minor infant patient who presented severe aortic valve stenosis; however, the fluoroscopy equipment was not available at the time of the emergency to perform the appropriate procedure, therefore, an aortic valvuloplasty was performed under echocardiographic guidance without complications.

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Resumo Fundamento O implante valvar aórtico transcateter (TAVI) apresenta crescimento exponencial de suas indicações e foi incorporado ao Sistema Único de Saúde em 2022, sendo necessário avaliar seu uso no Brasil. Objetivo Conhecer os fatores associados a mortalidade e complicações não fatais intra-hospitalares, em ambos os gêneros, na população do Registro Brasileiro de Implante de Bioprótese Aórtica por Cateter e Novas Tecnologias (RIBAC-NT). Método Análise do banco de dados RIBAC-NT de 2008 a 2022. Aplicados modelos logísticos e machine learning na avaliação estatística da associação das variáveis com os desfechos, empregando o software R e nível de significância de 5%. Resultados Analisados 2.588 pacientes (mulheres, 51,2%; óbito intra-hospitalar, 8,2%). Mortalidade associou-se a complicações do procedimento, dentre elas destacam-se complicações vasculares (CV) maiores e insuficiência renal aguda (IRA) (p< 0,001). A CV maior ocorreu em 6%, com 34% de mortalidade; IRA ocorreu em 8,8%, com 13% de mortalidade, que aumentou até 8 vezes quando IRA coexistiu com outras complicações. Complicações não fatais ocorreram em 50,5% do total de pacientes, acometendo 63% daqueles com bioprótese de 1a geração (1G) e 39% daqueles com bioprótese de 2a geração (2G) p<0,001. O acesso não femoral e o ritmo cardíaco influenciaram as complicações não fatais nas próteses 1G, enquanto complicações das próteses 2G associaram-se ao gênero feminino (39,6% vs. 30,4%, p= 0,003). Conclusão A mortalidade intra-hospitalar na população do RIBAC-NT associou-se diretamente a complicações do procedimento, principalmente CV maior e IRA. A ocorrência de complicações não fatais diferiu conforme o gênero e o tipo da bioprótese.

Abstract Background Transcatheter aortic valve implantation (TAVI) has had an exponential increase of its indication, being incorporated into the Brazilian Unified Public Health System in 2022, thus requiring assessment of its use in Brazil. Objeticve To assess the factors associated with in-hospital mortality and non-fatal complications in both genders in the Brazilian Registry of Transcatheter Aortic Valve Implantation and New Technologies (RIBAC-NT) population. Method Analysis of the RIBAC-NT database from 2008 to 2022 was performed. Logistic models and machine learning were used for statistical assessment of the association between variables and outcomes. The software R was used and a 5% significance level, adopted. Results Analysis of 2588 patients (women, 51.2%; in-hospital death, 8.2%). Mortality was associated with procedural complications, of which major vascular complication (VC) and acute kidney injury (AKI) stood out (p<0.001). Major VC occurred in 6% of the patients, with 34% mortality; AKI occurred in 8.8%, with 13% mortality, which increased up to 8 times when AKI coexisted with other complications. Non-fatal complications occurred in 50.5% of all patients, affecting 63% of those with 1st generation (1G) bioprosthesis and 39% of those with 2nd generation (2G) bioprosthesis (p<0,001). Non-femoral access and heart rhythm influenced non-fatal complications in patients with 1G prostheses, while complications in patients with 2G prosthesis associated with the female gender (39.6% vs. 30.4%, p=0.003). Conclusion In-hospital mortality in the RIBAC-NT population was directly associated with procedural complications, mainly major VC and AKI. The occurrence of non-fatal complications differed according to gender and bioprosthesis type.

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

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

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ABSTRACT Introduction: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). Objective: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. Methods: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. Results: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). Conclusion: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

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ABSTRACT Introduction: Diabetes mellitus (DM) in patients undergoing cardiac transcatheter or surgical interventions usually is correlated with poor outcomes. Transcatheter aortic valve implantation (TAVI) has been developed as a therapy choice for inoperable, high-, or intermediate-risk surgical patients with severe aortic stenosis (AS). Objective: To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI. Methods: Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually. Results: The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis. Conclusion: In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.

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INTRODUCTION: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). OBJECTIVE: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. METHODS: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. RESULTS: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). CONCLUSION: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

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Se presenta el caso de una paciente de 35 años, femenina, con antecedentes de presentar un soplo desde la infancia y que debía ser intervenida quirúrgicamente por fibroma uterino. El anestesiólogo, durante la consulta preoperatoria, constató el soplo ya mencionado por lo que se decidió posponer la cirugía e interconsultar con un cardiólogo. El examen ecocardiográfico demostró que la paciente era portadora de una estenosis aórtica severa con fracción de eyección conservada, prueba ergométrica: clase funcional I, sin isquemia. Mediante anestesia general orotraqueal, se realizó histerectomía total abdominal sin complicaciones. Es de vital importancia para el anestesiólogo el manejo perioperatorio de la estenosis aórtica.

The case of a 35-years-old female patient with a history of presenting a murmur since childhood and who had to undergo surgery for uterine fibroid is presented. The anesthesiologist, during the preoperative consultation, verified the aforementioned murmur, so it was decided to postpone surgery and consult with a cardiologist. The echocardiographic examination showed that the patient had severe aortic stenosis with preserved ejection fraction, stress test: functional class I, without ischemia. Using orotracheal general anesthesia, a total abdominal hysterectomy was performed without complications. The perioperative management of aortic stenosis is of vital importance for the anesthesiologist.

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Resumen: La estenosis carotídea (EC) ocurre en 13% de los pacientes con estenosis valvular aórtica (EVA). El riesgo de evento vascular cerebral (EVC), en los pacientes con EC significativa sometidos a cirugía valvular cardíaca, puede aumentar hasta 11%. Someter a un paciente con EVA crítica y fracción de eyección del ventrículo izquierdo (FEVI) disminuida a endarterectomía carotídea es todo un reto anestésico, cuyo principal objetivo es evitar la hipotensión y el bajo gasto cardíaco. La anestesia regional es una opción para estos pacientes. Presentamos el caso de un hombre de 70 años con diagnóstico de EC significativa y EVA crítica con disfunción ventricular izquierda, al que se realizó endarterectomía carotídea con bloqueo del plexo cervical superficial por alto riesgo de colapso circulatorio. Dicha estrategia anestésica permitió mantener al paciente despierto durante la cirugía, al valorar continuamente su estado neurológico. Asimismo, se documentaron los cambios transoperatorios en el NIRS (Near-infrared spectroscopy) cerebral y Doppler transcraneal (DTC), los cuales se correlacionaron con el estado clínico del paciente. En un segundo tiempo se hizo cambio valvular aórtico sin complicaciones. En este caso destaca la importancia de la anestesia regional y el monitoreo neurológico con Doppler transcraneal, en pacientes sometidos a endarterectomía carotídea con alto riesgo quirúrgico por EVA crítica.

Abstract: Carotid stenosis occurs in 13% of patients with aortic valve stenosis. The risk of stroke in patients with significant carotid stenosis undergoing heart valve surgery may increase to 11%. Proposing a patient with critical aortic valve stenosis and left ventricular dysfunction to carotid endarterectomy is an anesthetic challenge, where the objective is to avoid hypotension and low cardiac output. Regional anesthesia is an option for these patients. Due to the high incidence of intraoperative stroke during carotid endarterectomy, continuous neurological monitoring is of relevance. We present the case of a 70-year-old man diagnosed with significant carotid stenosis and critical aortic valve stenosis and left ventricular dysfunction who underwent carotid endarterectomy with superficial cervical plexus block due to a high risk of circulatory collapse. In addition, this anesthetic strategy made it possible to keep the patient awake during surgery, and to continuously assess their neurological status. Likewise, transoperative changes in brain NIRS and transcranial Doppler were documented, which correlated with the patient's clinical status. In a second time, aortic valve replacement was performed without complications. This case highlights the importance of regional anesthesia and neurological monitoring in patients undergoing carotid endarterectomy with high surgical risk due to critical aortic valve stenosis.

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RESUMEN Introducción : La indicación de reemplazo valvular aórtico (RVA) en pacientes con estenosis aórtica (EA) grave asintomáticos con función conservada es motivo de creciente debate. Objetivos : Evaluar si la elevación de la fracción aminoterminal del pro-péptido natriurético tipo B (NT-proBNP) predice la aparición de síntomas y la indicación de reemplazo valvular en pacientes inicialmente asintomáticos, con EA grave y fracción de eyección ventricular izquierda (FEVI) conservada. Material y métodos : Se incluyeron en forma prospectiva pacientes con EA grave, FEVI conservada (≥55%) que fueron considerados asintomáticos, sin indicación inicial de RVA. A todos se les realizó laboratorio con medición de NT-proBNP en forma basal y ecocardiograma con Doppler tisular consignando la onda S de la pared lateral (S lat) y la relación E/e´. Se consideró como punto final el requerimiento de reemplazo valvular durante el seguimiento. Resultados : Se incluyeron 133 pacientes con una edad de 69 ± 8 años, 49% mujeres. Luego de un seguimiento de 570 (rango intercuartilo 380-680) días, el 23,3% (n = 31) de los pacientes presentaron requerimiento de reemplazo valvular. En el aná lisis multivariado, el NT-proBNP y la relación E/e´ fueron predictores independientes de requerimiento de cirugía (HR 1,02, IC95% 1,001-1,03, p <0,001; y HR 1,42, IC95% 1,21-2,45, p<0,001, respectivamente). El NT-proBNP presentó un Área Bajo la Curva (ABC) mayor que la relación E/e´ (0,88 versus 0,64, p = 0,02). Se estableció como mejor punto de corte de NT-proBNP un valor >350 pg./mL (HR ajustado 1,55, IC95% 1,38-2,01, p <0,001). Conclusiones : El NT-proBNP y la relación E/e´ fueron predictores independientes de requerimiento de cirugía. El NT-proBNP presentó una muy buena capacidad de discriminación, mayor que la relación E/e´.

ABSTRACT Background : The aortic valve replacement (AVR) indication in asymptomatic patients with severe aortic stenosis (AS) and preserved function is being increasingly discussed. Objective : The aim of this study was to evaluate whether the elevation of the N-terminal fraction of the pro-B-type natriuretic peptide (NT-proBNP) predicts the occurrence of symptoms and the AVR indication in patients with severe AS and preserved left ventricular ejection fraction (LVEF), initially asymptomatic. Methods : Asymptomatic patients with severe AS, preserved EF (≥55%) and no initial AVR indication were prospectively included. All patients underwent laboratory tests measuring NT-proBNP at baseline and an echocardiogram with tissue Doppler recording the lateral wall S wave (lat. S) and the E/e´ ratio. The endpoint was the aortic valve replacement indication at follow-up. Results : We included 133 patients aged 69 ± 8 years, 49% of which were women. After a follow-up of 570 (interquartile range 380-680) days, 23.3% (n=31) of them required aortic valve replacement. In the multivariate analysis, NT-proBNP value and the E/e´ ratio were 2 independent predictors of surgery (HR 1.02, 95% CI 1.001-1.03) p<0.001 and HR 1.42, 95% CI 1.21- 2.45, p< 0.001, respectively). NT-proBNP presented an area under the curve (AUC) greater than the E/e' ratio (0.88 versus 0.64, p=0.02). The best NT-proBNP cut-off point was determined >350 pg/mL (adjusted HR 1.55, 95% CI 1.38-2.01, p<0.001) Conclusion : NT-proBNP value and the E/e´ ratio were independent predictors of the AVR requirement. NT-proBNP had a very good discrimination capacity, greater than the E/e´ ratio.

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AIMS: Left ventricular remodelling occurs during the chronic course of aortic regurgitation (AR) and aortic stenosis (AS), leading to myocardial hypertrophy and fibrosis. Several studies have shown that extracellular volume fraction (ECV) and indexed extracellular volume (iECV) are important surrogate markers of diffuse myocardial fibrosis (MF). Postoperative data on these cardiovascular magnetic resonance (CMR) extracellular expansion parameters for either AS or AR are scarce. This study aimed to demonstrate the postoperative changes that occur in diffuse MF, and the influence of preoperative MF on the reversal of LV remodelling, in patients with AR or AS. METHODS AND RESULTS: Patients with severe AR or AS and indications for surgery were prospectively enrolled. Patients underwent pre- and postoperative CMR, and ECV and iECV were quantified. Data from 99 patients were analysed (32 with AR and 67 with AS). After surgery, the left ventricle mass index decreased in both groups (AR: 110 vs. 91 g/m2; AS: 86 vs. 68 g/m2, both P < 0.001). The late gadolinium enhancement fraction (AR: preoperative 1.9% vs. postoperative 1.7%, P = 0.575; AS: preoperative 2.4% vs. postoperative 2.4%, P = 0.615) and late gadolinium enhancement mass (AR: preoperative 3.8 g vs. postoperative 2.5 g, P = 0.635; AS: preoperative 3.4 g vs. postoperative 3.5 g, P = 0.575) remained stable in both groups. Preoperative iECV and ECV were greater in the AR group (iECV: 30 mL/m2 vs. 22 mL/m2, P = 0.001; ECV: 28.4% vs. 27.2%, P = 0.048). Indexed extracellular volume decreased after surgery in both groups (AR: 30-26.5 mL/m2, AS: 22-18.2 mL/m2, both P < 0.001); it was still greater in the AR group (AR: 26.5 mL/m2 vs. AS: 18.2 mL/m2, P < 0.001). Postoperative ECV remained stable in the AR group (preoperative 28.4% vs. postoperative 29.9%; P = 0.617) and increased in the AS group (preoperative 27.2% vs. postoperative 28.6%; P = 0.033). CONCLUSION: Patients with both AR or AS presented reduction in iECV after surgery, unfolding the reversible nature of diffuse MF. In contrast to patients with AS, those with AR developed postoperative iECV regression with stable ECV, suggesting a balanced reduction in both intracellular and extracellular myocardial components.

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INTRODUCTION: Due to Brazilian population aging, prevalence of aortic stenosis, and limited number of scores in literature, it is essential to develop risk scores adapted to our reality and created in the specific context of this disease. METHODS: This is an observational historical cohort study with analysis of 802 aortic stenosis patients who underwent valve replacement at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, from 1996 to 2018. With the aid of logistic regression, a weighted risk score was constructed based on the magnitude of the coeficients ß of the logistic equation. Two performance statistics were obtained: area under the receiver operating characteristic curve and the chi-square (χ2) of Hosmer-Lemeshow goodness-of-fit with Pearson's correlation coeficient between the observed events and predicted as a model calibration estimate. RESULTS: The risk predictors that composed the score were valve replacement surgery combined with coronary artery bypass grafting, prior renal failure, New York Heart Association class III/IV heart failure, age > 70 years, and ejection fraction < 50%. The receiver operating characteristic curve area was 0.77 (95% confidence interval: 0.72-0.82); regarding the model calibration estimated between observed/predicted mortality, Hosmer-Lemeshow test χ2 = 3,70 (P=0.594) and Pearson's coeficient r = 0.98 (P<0.001). CONCLUSION: We propose the creation of a simple score, adapted to the Brazilian reality, with good performance and which can be validated in other institutions.

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INTRODUCTION: Congenital heart diseases (CHDs) constitute the most prevalent congenital pathology, and they are a consequence of structural and functional abnormalities during fetal development. The etiology of CHD involves the interaction of genetic and environmental factors. Fetal cardiac surgery aims at preventing natural pathways of CHD in utero, mitigating progression to more complex abnormalities. The goal of this review was to demonstrate the benefits and risks of fetal interventions in the two most prevalent CHDs, pulmonary stenosis and pulmonary atresia with an intact ventricular septum, but also critical aortic stenosis and hypoplastic left heart syndrome. METHODS: Original and relevant articles were selected by meta-aggregation to perform a qualitative analysis of fetal cardiac interventions for pulmonary stenosis and critical aortic stenosis. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument (or JBI-QARI) was used for data quality appraisal. RESULTS: Of 61 potential articles, 13 were selected, and nine were finally included. Discussion: The present review demonstrated that fetal cardiac surgery increases right ventricular growth and hemodynamic flow in pulmonary stenosis, whereas in critical aortic stenosis it enables growth of the left ventricle and increases left ventricular pressure. However, it has a high complication rate, along with considerable morbidity and mortality. CONCLUSION: The benefits of fetal cardiac surgery for pulmonary stenosis and critical aortic stenosis are well-described in the literature; however, there is a significant risk of complications which can be reduced by the surgeon's technical expertise and well-structured hospital facilities.

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Introdução: Com o envelhecimento populacional brasileiro, esperase que a incidência de doenças cardiovasculares, como a estenose e insuficiência da válvula aórtica, eleve-se. Desde 2002, o implante valvar aórtico transcateter demonstrou-se método de alta eficácia no seu tratamento. No entanto, o procedimento está sujeito ao regurgitamento paravalvar. Objetivo: Avaliar quantitativamente a prevalência dessa regurgitação em pacientes submetidos ao Implante valvar aórtico transcateter. Métodos: Estudo observacional, transversal, retrospectivo que analisou 38 casos de Implante valvar aórtico transcateter. Os dados foram coletados dos prontuários, que incluíram informações antropométricas, comorbidades e procedimentos prévios à operação, e analisou-se a presença de refluxo paravalvar no 1° mês e 1° ano pós-Implante valvar aórtico transcateter. Resultados: A idade média foi de 74 ±11,2 anos; 15 pacientes dos analisados, possuíam classificação NYHA igual a III, e 1 NYHA IV, previamente à operação. Do total, 36,32% (n=8) tinham refluxo paravalvar no 1° mês e 1º. ano após o procedimento cirúrgico. Conclusão: A prevalência de refluxo paravalvar pós-operatório em pacientes submetidos ao Implante valvar aórtico transcateter, foi igual a 36,3% tanto para a avaliação realizada no 1° mês quanto no 1° ano.

Introduction: With the aging of the Brazilian population, it is expected that the incidence of cardiovascular diseases, such as stenosis and insufficiency of the aortic valve, will increase. Since 2002, transcatheter aortic valve implantation has proved to be a highly effective method of treatment. However, the procedure is subject to paravalvular regurgitation. Objective: To quantitatively assess the prevalence of paravalvular regurgitation in patients undergoing Transcatheter aortic valve implantation. Methods: Observational, cross-sectional, retrospective study that analyzed 38 Transcatheter aortic valve implantation cases. Data were collected from medical records, which included anthropometric information, comorbidities and procedures prior to the operation, and the presence of paravalvular regurgitation in the 1st month and 1st year after Transcatheter aortic valve implantation was analyzed. Results: Mean age was 74 ±11.2 years; 15 of the analyzed patients had NYHA classification equal to III, and 1 NYHA IV, prior to the operation. Of the total, 36.32% (n=8) of the patients had paravalvular regurgitation in the 1st and 1st month. year after the surgical procedure. Conclusion: The prevalence of postoperative paravalvular regurgitation in patients undergoing Transcatheter aortic valve implantation was equal to 36.3% both for the assessment carried out in the 1st month and in the 1st year

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Resumo Fundamento A extensão do dano cardíaco associada à estenose aórtica tem importantes implicações prognósticas após a substituição da valva aórtica transcateter (TAVR). Contudo, ainda não está claro qual é o papel da insuficiência tricúspide (IT) nesse cenário clínico. Objetivos Explorar a associação entre IT e mortalidade em pacientes submetidos a TAVR e avaliar as alterações na gravidade da IT após a TAVR e sua relação com mortalidade de curto e médio prazo. Métodos Foram feitas pesquisas em bases de dados relevantes de artigos publicados do início até agosto de 2020. Dos 414 estudos triados, selecionamos 24 que relataram o grau de IT pré- ou pós-TAVR. O desfecho primário foi mortalidade por todas as causas, e foram conduzidos modelos de metanálise de efeitos aleatórios (a um nível de significância de 5%). Resultados Dezessete estudos relataram associações entre IT pré-TAVR e mortalidade por todas as causas (> 45.000 participantes), e 13 avaliaram a gravidade da IT pós-TAVR (709 participantes). A IT basal moderada/grave foi associada a maior mortalidade por todas as causas em 30 dias [razão de risco (RR) 1,65; intervalo de confiança (IC) 95% 1,20-2,29] e 1,2 ano (RR 1,56; IC95% 1,31-1,84). Após a TAVR, 43% dos pacientes apresentaram redução de pelo menos um grau na IT (30 dias, IC95% 30-56%), que se sustentou em 12,5 meses em 44% dos participantes (IC95% 35-52%).A persistência de IT significativa foi associada a um aumento de duas vezes na mortalidade por todas as causas (RR 2,12; IC95% 1,53-2,92). Conclusões A IT significativa pré-TAVR está associada a maior mortalidade. Ainda que a gravidade da IT possa melhorar, a persistência de IT significativa após a TAVR está fortemente associada ao aumento da mortalidade. Nossos achados destacam a importância de uma avaliação detalhada da IT pré- e pós-TAVR e podem ajudar a identificar pacientes que possam se beneficiar de uma vigilância mais cuidadosa nesse cenário.

Abstract Background The extent of cardiac damage associated with aortic stenosis has important prognostic implications after transcatheter aortic valve replacement (TAVR). However, the role of tricuspid regurgitation (TR) in this clinical setting is still unclear. Objectives To explore the association between TR and mortality in patients undergoing TAVR and assess changes in TR severity post TAVR and its relationship with short and mid-term mortality. Methods Relevant databases were searched for articles published from inception until August 2020. Out of 414 screened studies, we selected 24 that reported the degree of TR pre or post TAVR. The primary outcome was all-cause mortality, and random effects meta-analysis models were conducted (at a significance level of 5%). Results Seventeen studies reported associations between pre-TAVR TR and all-cause mortality (> 45,000 participants) and thirteen accessed TR severity post TAVR (709 participants). Moderate/severe baseline TR was associated to higher all-cause mortality both at 30 days (HR 1.65; 95% CI, 1.20-2.29) and 1.2 years (HR 1.56; 95% CI, 1.31-1.84). After TAVR, 43% of patients presented a decrease of at least one grade in TR (30 days, 95% CI, 30-56%), sustained at 12.5 months in 44% of participants (95% CI, 35-52%). Persistence of significant TR was associated with a two-fold increase in all-cause mortality (HR 2.12; 95% CI, 1.53-2.92). Conclusions Significant TR pre TAVR is associated with higher mortality. Although TR severity may improve, the persistence of significant TR post TAVR is strongly associated with increased mortality. Our findings highlight the importance of a detailed assessment of TR pre and post TAVR and might help identify patients who may benefit from more careful surveillance in this scenario.

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A insuficiência mitral moderada a grave é observada em 17 a 35% dos pacientes submetidos a implante transcateter de válvula aórtica. Estudo que reporta a insuficiência mitral pós- realização de implante transcateter de válvula aórtica por estenose aórtica demonstra que 50% dos pacientes com refluxo moderado a grave apresentaram melhora da regurgitação, e 8,7% evidenciam piora do quadro. Nesses pacientes com piora, houve aumento da mortalidade. Essa progressão sugere que condutas convencionais, baseadas em otimização medicamentosa, podem não ser capazes de prevenir quadros negativos. Relatamos um caso sobre a evolução da insuficiência mitral após implante transcateter de válvula aórtica e o uso do MitraClip® como alternativa de tratamento e benefícios.

Moderate to severe mitral regurgitation is observed in 17 to 35% of patients undergoing transcatheter aortic valve implantation. A study reporting mitral regurgitation after transcatheter aortic valve implantation due to aortic stenosis demontrated 50% of patients with moderate to severe reflux showed improvement in regurgitation, and 8.7% showed worsening of the condition, which led to increased mortality. This progression suggested conventional management, based on medication optimization, may not be able to prevent poor outcomes. We report a case on the clinical course of a patient with mitral regurgitation after transcatheter aortic valve implantation, and the use of MitraClip® as an alternative treatment and its benefits.