Auristela Ramos

Effectiveness of percutaneous balloon mitral valvotomy during pregnancy

During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class III or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 +/- 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 +/- 0.3 cm2 before to 2.1 +/- 0.3 cm2 after valvotomy. The mean mitral valve gradient decreased from 20 +/- 7 to 4 +/- 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 +/- 24 to 32 +/- 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 +/- 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Eleven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 48 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Consequences of the Prolonged Waiting Time for Patients Candidates for Heart Surgery

OBJECTIVE To assess mortality and the psychological repercussions of the prolonged waiting time for candidates for heart surgery. METHODS From July 1999 to May 2000, using a standardized questionnaire, we carried out standardized interviews and semi-structured psychological interviews with 484 patients with coronary heart disease, 121 patients with valvular heart diseases, and 100 patients with congenital heart diseases. RESULTS The coefficients of mortality (deaths per 100 patients/year) were as follows: patients with coronary heart disease, 5.6; patients with valvular heart diseases, 12.8; and patients with congenital heart diseases, 3.1 (p<0.0001). The survival curve was lower in patients with valvular heart diseases than in patients with coronary heart disease and congenital heart diseases (p<0.001). The accumulated probability of not undergoing surgery was higher in patients with valvular heart diseases than in the other patients (p<0.001), and, among the patients with valvular heart diseases, this probability was higher in females than in males (p<0.01). Several patients experienced intense anxiety and attributed their adaptive problems in the scope of love, professional, and social lives, to not undergoing surgery. CONCLUSION Mortality was high, and even higher among the patients with valvular heart diseases, with negative psychological and social repercussions.

Fibrinolytic therapy for thrombosis in cardiac valvular prosthesis short and long term results

OBJECTIVE To assess the short- and long-term results of the use of streptokinase (SK) for the treatment of thromboses in cardiac valvular prostheses. METHODS Seventeen patients with cardiac prosthetic thrombosis diagnosed by clinical, echocardiographic, and radioscopic findings underwent fibrinolytic treatment with a streptokinase bolus of 250,000 U followed by 100.000 U/hour. Short- and long-term results were assessed by radioscopy and echocardiography. RESULTS Of the 17 patients, 12 had mechanical double-disk prostheses (4 aortic, 6 mitral, 2 tricuspid), 4 had single-disk prostheses (2 aortic, 1 mitral, and 1 tricuspid), and 1 had a tricuspid bioprosthesis. The success rate was 64.8%, the partial success rate was 17.6%, and the nonsuccess rate was 17.6%. All patients with a double-disk prosthesis responded, completely or partially, to the treatment. None of the patients with a single-disk prosthesis had complete resolution of the thrombosis. The time of streptokinase infusion ranged from 6 to 80 hours (mean of 56 h). The mortality rate due to the use of streptokinase was 5.8% and was secondary to cerebral bleeding. During streptokinase infusion, 3 (17.6%) embolic episodes occurred as follows: 1 cerebral, 1 peripheral, and 1 coronary. The rethrombosis index was 33% in a mean follow-up of 42 months. CONCLUSION The use of fibrinolytic agents was effective and relatively safe in patients with primary thrombosis of a double-disk prosthesis. A fatal hemorrhagic complication occurred in 1 (5.8%) patient, and embolic complications occurred in 3 (17.6%) patients. In a mean 42-month follow-up, 67% of the patients were free from rethrombosis.

Paravalvular Regurgitation: Clinical Outcomes in Surgical and Percutaneous Treatments

Background Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair. Objectives To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure. Methods This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure. Results The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08). Conclusion Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk.

Early Improvement in Left Atrial Remodeling and Function after Mitral Valve Repair or Replacement in Organic Symptomatic Mitral Regurgitation Assessed by Three‐Dimensional Echocardiography

Left atrial (LA) dilation is associated with worse prognosis in various clinical situations including chronic mitral regurgitation (MR). Real time three‐dimensional echocardiography (3DE) has allowed a better assessment of LA volumes and function. Little is known about LA size and function in early postoperative period in symptomatic patients with chronic organic MR. We aimed to investigate these aspects.

Análise da incidência e preditores clínicos e ecocardiográficos do refluxo paraprotético aórtico após o implante de prótese aórtica transcateter

INTRODUCAO: A incidencia de refluxo paraprotetico (RPP) parece maior entre os pacientes submetidos a implante de protese aortica transcateter e sua potencial associacao com aumento da mortalidade tardia tem suscitado preocupacao na comunidade cientifica. Nosso objetivo foi avaliar a incidencia e o impacto clinico e estabelecer preditores do RPP em nossa casuistica. METODOS: Entre julho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de protese aortica transcateter. O grau do RPP pos-procedimento foi avaliado segundo os criterios do VARC 2. Dividiu-se a populacao em grupo RPP ausente/RPP discreto e grupo RPP moderado/RPP grave. RESULTADOS: A media da idade foi de 82,5 ± 3,9 anos, 58,9% eram do sexo feminino e o EuroSCORE logistico foi de 23,6 ± 13,4. Houve queda do gradiente sistolico medio (54,7 ± 15,3 mmHg vs. 11,7 ± 4 mmHg; P < 0,01) e ganho da area valvar aortica (0,66 ± 0,15 cm2 vs. 1,8 ± 0,3 cm2; P < 0,01). Ao final do procedimento, 46,4% nao apresentaram RPP, e RRP discreto ou moderado foi observado em 42% e 11,6% dos pacientes. Nenhum paciente apresentou RPP grave. A analise multivariada identificou sexo masculino [odds ratio (OR) 5,85, intervalo de confianca (IC] 1,29-26,7; P = 0,022), valvoplastia aortica percutânea previa (OR 18,44, IC 2,30-147,85; P = 0,006), fracao de ejecao < 35% (OR 4,160, IC 1,014-17,064; P = 0,048) e presenca de hipertensao pulmonar grave (OR 7,649, IC 1,86-31,51; P = 0,005) como preditores independentes de RPP moderado/grave. CONCLUSOES: A incidencia de RPP moderado/grave foi baixa e comparavel a de outras casuisticas. Sexo masculino, antecedente de valvoplastia aortica percutânea previa, presenca de hipertensao pulmonar grave e disfuncao ventricular esquerda grave foram preditores independentes dessa complicacao.

DESIGN METHODOLOGY FOR THE DEVELOPMENT OF LONG-TERM HIP PROSTHESIS SURVIVAL

More than 80% of failures following Total Hip Arthroplasty (THR) procedures are due to implant loosening, which is strongly related with weak osseointegration. Current instrumented prostheses were designed to store only physiologic data [Damm, 2010; Heinlein, 2009]. The design of failure detection systems for hip implants is been performed [Marschner, 2009; Alpuim., 2008]. The current methodology to optimize such implants collects real-time data from the internal environment of the implant and uses the information for the research of new designs, materials and surgical techniques [Stansfield, 2003; Dayton, 2005]. However, proposals that ensure long-term implant survival have not been reported yet. This paper proposes a new methodology to avoid irreversible aseptic loosening, which may prevent to a certain extent revision surgical procedures. Through remotely controlled and monitored osteoblast mechanical micro-stimulation, real-time supervision of the osteointegration process may be ensured through tools for telemedicine.

Valvotomia Mitral Percutânea: da Primeira à Terceira Dilatação

INTRODUCAO: As causas de reestenose pos-valvotomia mitral percutânea dependem principalmente das caracteristicas da populacao submetida a tecnica. O objetivo deste trabalho foi comparar os resultados imediatos e tardios dos pacientes submetidos a dois ou mais procedimentos de valvotomia mitral percutânea (VMP) a um grupo de pacientes submetidos apenas a uma dilatacao para o tratamento da estenose mitral grave. METODO: Os pacientes foram divididos em dois grupos: o grupo A incluiu 90 pacientes submetidos a uma primeira VMP e que, em decorrencia de reestenose ecocardiografica e clinica, foram encaminhados a uma segunda intervencao, e 9 pacientes que, pelo mesmo motivo, foram submetidos a um terceiro procedimento; e grupo B, composto de 90 pacientes selecionados por amostra aleatoria simples submetidos a apenas uma dilatacao, todas com sucesso. As variaveis ecocardiograficas analisadas para comparacao dos resultados dentro do mesmo grupo e entre os grupos A e B foram a area valvar mitral (AVM), os gradientes diastolicos maximo (GDM) e medio (GDm), o diâmetro do atrio esquerdo e a incidencia de reestenose. RESULTADOS: Nos pacientes do grupo A, a primeira dilatacao foi realizada com sucesso em 87 (96,7%) pacientes. Comparativamente, a media das areas valvares apos a primeira dilatacao dos pacientes que compoem o grupo A foi menor que a dos pacientes do grupo B (1,97 ± 0,17 cm2 vs. 2,10 ± 0,33 cm2; P = 0,011). Em ambos os grupos, nao se observou diferenca estatisticamente significante, pre e imediatamente apos o primeiro procedimento, na reducao da media do GDM e do GDm e na media dos diâmetros do atrio esquerdo. Nos pacientes do grupo A, apos a segunda valvotomia, os criterios de sucesso foram alcancados em 77 (85,5%) pacientes. A media das areas valvares, nessa oportunidade, foi menor que apos a primeira intervencao (1,83 ± 0,28 cm2 vs. 1,97 ± 0,17 cm2; P < 0,005). Ainda dentro desse mesmo grupo, observou-se queda significativa do GDM e do GDm quando comparados os valores apos o primeiro e o segundo procedimentos. Uma terceira dilatacao foi realizada com 100% de sucesso nos 9 pacientes do grupo A. Resultados semelhantes aos anteriores foram obtidos na comparacao das mesmas variaveis apos a segunda e a terceira dilatacoes. O tempo medio para o aparecimento da reestenose ecocardiografica entre a primeira, a segunda e a terceira dilatacoes foi de 54,12 meses, 25,23 meses e 29,30 meses, respectivamente. CONCLUSAO: A obtencao de areas valvares e o tempo para o aparecimento da reestenose significativamente menores imediatamente apos uma segunda ou terceira valvotomias mitrais percutâneas, quando comparadas a primeira, nao devem ser fatores para contraindicacao do procedimento. Apesar de menores, as AVMs obtidas apos uma segunda ou terceira intervencao enquadram-se, na maioria dos casos, dentro dos parâmetros de sucesso do procedimento, justificando assim sua indicacao em casos selecionados.

Incidência de trombo intracardíaco e de tromboembolismo nos três primeiros meses após o implante de bioprótese valvar

OBJETIVO: Avaliar a incidencia de trombo intracardiaco e de tromboembolismo nos tres primeiros meses apos a troca valvar por bioprotese e identificar fatores de risco para a formacao de trombo. METODO:Incluidos 184 pacientes, entre 15 e 75 anos de idade, submetidos a implante de bioprotese e realizados ecocardiogramas transtoracico e transesofagico (ETE) na fase hospitalar, media 8,4±3 dias, e tres meses apos, media 97,4±21,7 dias. RESULTADOS: Incidencia de trombo foi significativamente mais elevada nos pacientes com protese em posicao mitral ou mitroaortica (21,0%) do que em posicao aortica (2,8%), p<0,001. A analise de regressao logistica multivariada identificou a protese em posicao mitral ou mitroaortica como a unica variavel independente para a formacao de trombo. No seguimento de tres meses o ETE evidenciou trombo em 35 (20,7%) dos 169 pacientes com evolucao ecocardiografica, 31,7% nos mitrais e 3,1% nos aorticos, p<0,001. No 3o mes a analise de regressao logistica multivariada tambem identificou a protese em posicao mitral ou mitroaortica como a unica variavel independente para a formacao de trombo. Durante os tres meses de seguimento, tres (1,6%) pacientes faleceram e oito (4,3%) apresentaram fenomeno embolico, todos para territorio cerebral. CONCLUSAO: A incidencia de trombo nos tres primeiros meses, apos o implante da bioprotese foi 14,1% nos 10 primeiros dias e 20,7% em tres meses; a protese em posicao mitral ou mitroaortica foi identificada como fator de risco para a formacao de trombo; a incidencia de fenomenos embolicos diagnosticados clinicamente foi inferior a proporcao de trombo atrial documentado pelo ecocardiograma.

Experiência Inicial de Dois Centros Nacionais no Implante de Prótese Aórtica Transcateter

Background Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk. Objectives To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation. Methods From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation. Results Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly. Conclusions Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up.