Henrique Faria

Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes

INTRODUCTION AND AIM Percutaneous mitral valvuloplasty (PMV) is an effective treatment option for mitral stenosis (MS), but its success is assessed on the basis of clinical and echocardiographic outcomes in studies with relatively short follow-up. We aimed to characterize a cohort of patients undergoing PMV with long-term follow-up and to determine independent predictors of post-PMV mitral re-intervention and event-free survival. METHODS We studied 91 consecutive patients with MS who underwent PMV with a median clinical follow-up duration of 99 months. Two endpoints were considered: post-PMV mitral re-intervention (PMV or mitral surgery) and a composite clinical events endpoint including cardiovascular death, mitral valve re-intervention and hospital admission due to decompensated heart failure. We compared patients who required post-PMV mitral re-intervention with those who did not during follow-up. RESULTS The study population included 83.5% females and mean age was 48.9±13.9 years. The 1-, 3-, 5-, 7- and 9-year rates of clinical event-free survival were 93.0±2.8%, 86.0±3.9%, 81.0±4.4%, 70.6±5.6%, and 68.4±5.8%, respectively. The 1-, 3-, 5-, 7- and 9-year rates of mitral re-intervention-free survival were 98.8±1.2%, 97.5±1.7%, 92.1±3.1%, 85.5±4.5%, and 85.5±4.5%, respectively. The median time to mitral re-intervention was 6.2 years. Patients who required mitral re-intervention during follow-up were younger (43.3 vs. 51.2 years, p=0.04) and had higher pre- and post-PMV mitral gradient (14.9 vs. 11.5 mmHg, p=0.02 and 6.4 vs. 2.1 mmHg, p<0.001) and higher post-PMV mean pulmonary artery pressure (mPAP) (30.0 vs. 23.2 mmHg, p=0.01). In a Cox proportional hazards model, mPAP ≥25 mmHg was the sole predictor of both mitral re-intervention (HR 5.639 [1.246-25.528], p=0.025) and clinical events (HR 3.622 [1.070-12.260], p=0.039). CONCLUSION In our population, immediate post-PMV mPAP was the sole predictor of post-PMV mitral intervention. These findings may help identify patients in need of closer post-PMV follow-up.

Posição sobre suportes vasculares restaurativos transitórios coronários em Portugal

BACKGROUND Bioresorbable vascular scaffolds (BVS) were recently approved for percutaneous coronary intervention in Europe. The aim of this position statement is to review the information and studies on available BVS, to stimulate discussion on their use and to propose guidelines for this treatment option in Portugal. METHODS AND RESULTS A working group was set up to reach a consensus based on current evidence, discussion of clinical case models and individual experience. The evidence suggests that currently available BVS can produce physiological and clinical improvements in selected patients. There are encouraging data on their durability and long-term safety. Initial indications were grouped into three categories: (a) consensual and appropriate - young patients, diabetic patients, left anterior descending artery, long lesions, diffuse disease, and hybrid strategy; (b) less consensual but possible - small collateral branches, stabilized acute coronary syndromes; and (c) inappropriate - left main disease, tortuosity, severe calcification. CONCLUSION BVS are a viable treatment option based on the encouraging evidence of their applicability and physiological and clinical results. They should be used in appropriate indications and will require technical adaptations. Outcome monitoring and evaluation is essential to avoid inappropriate use. It is recommended that medical societies produce clinical guidelines based on high-quality registries as soon as possible.

Pulmonary Hypertension in Mitral Stenosis: An Optical Coherence Tomography Study

A 65-year old woman with a prior history of surgical mitral comissurotomy 30 years ago presented with a 6-month history of worsening fatigue and exertional dyspnea. On physical examination, she had a mitral stenosis murmur, a loud P2, with an irregular pulse and mild peripheral edema. The electrocardiogram showed atrial fibrillation; the echocardiogram was notable for a fibro-calcified mitral valve, with severe restriction of leaflet mobility and an area of 1.1 cm. Biventricular function was normal. As the valve anatomy was considered suitable for percutaneous intervention, the patient was scheduled a balloon valvuloplasty. The pre-intervention right heart catheterization showed a pulmonary artery pressure of 45/17/29 mmHg. After successful mitral dilatation, optical coherence tomography (LightLab Imaging Inc., Westford, Massachusetts, United States) was performed on a distal segmental branch of the right pulmonary artery (Fig. 1). Optical coherence tomography images showed diffuse thickening of the distal pulmonary arterial wall (Figs. 2 and 3). We registered a pulmonary artery wall thickness between 0.28 mm and 0.31 mm, higher when compared to reports from subjects without pulmonary hypertension (0.16 [0.03] mm for vessels with 2.14 [0.33] mm of diameter). No complications arose during or after the procedure. Optical coherence tomography is a safe and potentially useful tool for characterize, with high resolution, the pulmonary vessels and may contribute to investigate the mechanisms of vascular remodeling in pulmonary hypertension.

Multiple coronary artery aneurysms

A 71-year-old woman was admitted electively to our hospital in October 2013 for vascular surgery of an abdominal aortic aneurysm, diagnosed two months before through abdominal ultrasound performed on an outpatient basis due to recurrent abdominal pain. Her medical history included hypertension and dyslipidemia. No other cardiovascular disease was known. During the surgical procedure, the patient developed acute pulmonary edema and was transferred to the intensive care unit. The physical exam was notable for a harsh, grade IV/VI mitral systolic murmur and diffuse lung crackles. Transthoracic echocardiography performed at the patient’s bedside showed moderate depression of left ventricular systolic function (40% ejection fraction) and severe mitral regurgitation. Since abdominal aortic aneurysms are frequently associated with clinically significant coexisting coronary artery disease, after hemodynamic stabilization coronary angiography was performed. This showed multiple aneurysms involving all the main coronary arteries without significant stenosis (Figure 1). To better assess the coronary arteries cardiac computed tomography was performed, which showed a large aneurysm involving the anterior descending and circumflex arteries. The right coronary artery also had an aneurysm, smaller than in the left coronary (Figures 2 and 3). It is still not known how best to handle such aneurysms, and the type of surgical intervention should be

Optical coherence tomography on the right side: pulmonary vascular disease in mitral stenosis

A 59-year-old woman presented with a 6-month history of worsening fatigue and exertional dyspnoea. On physical examination, she had a mitral stenosis murmur, a loud P2, an irregular pulse and mild peripheral oedema. The electrocardiogram showed atrial fibrillation and the echocardiogram was notable for a fibro-calcified mitral valve, with severe restriction of leaflet mobility and an area of …