A cirurgia de substituição valvular aórtica melhora a qualidade de vida dos octogenários com estenose aórtica severa

IntroductionAortic stenosis (AS) is the most common valvular disease in the elderly, affecting around 8.1% by the age of 85, with a negative impact on quality of life.ObjectiveTo determine the impact of surgical aortic valve replacement (SAVR) on quality of life in octogenarians.MethodsIn a single‐center retrospective study of octogenarians undergoing isolated SAVR for symptomatic AS between 2011 and 2015, quality of life was assessed using the Medical Outcomes Study Short Form (SF‐36) at baseline and at three, six and 12 months after surgery. Scores for the eight domains and two components of the SF‐36 were compared at baseline and in the postoperative period by one‐way analysis of variance.ResultsOver a five‐year period, 163 octogenarians underwent SAVR, of whom 3.1% died in the hospital. Deceased patients and those who did not complete the SF‐36 were excluded. A total of 81 patients were included, mean age 83 ± 2 years, 63% female, 60.5% in NYHA class II or higher and 19.7% with left ventricular systolic dysfunction. The mean logistic EuroSCORE was 10.7 ± 5.1%. In the hospital, 1.2% suffered stroke, 1.2% received a permanent implantable pacemaker and 23.5% presented atrial fibrillation. In the assessment of quality of life, improvement was seen in all SF‐36 domains (p< 0.002) and in the physical component (p< 0.001) at three, six and 12 months compared to baseline. The mental component also showed improvement, which was significant at six months (p = 0.011).ConclusionSAVR improved the physical and mental health status of octogenarians with severe AS. This improvement was evident at three months and consistent at six and 12 months.     

Registo de encerramento percutâneo do apêndice auricular esquerdo e experiência inicial com ecografia intracardíaca

Introduction

Percutaneous closure of the left atrial appendage (LAA) is a promising therapy in patients with atrial fibrillation with high risk for stroke and contraindication for oral anticoagulation (OAC). Intracardiac echocardiography (ICE) may make this percutaneous procedure feasible in patients in whom transesophageal echocardiography (TEE) is inadvisable. Our aim was to assess the efficacy and safety of LAA closure and the feasibility of ICE compared to TEE to guide the procedure.

Utilização da cintigrafia com iodo-123-metaiodobenzilguanidina na estratificação do risco de morte súbita na insuficiência cardíaca

Metaiodobenzylguanidine (MIBG) is a false neurotransmitter noradrenaline analogue that is taken up by the ‘uptake 1’ transporter mechanism in the cell membrane of presynaptic adrenergic neurons and accumulates in catecholamine storage vesicles. Since it is practically unmetabolized, it can be labeled with a radioisotope (iodine-123) in scintigraphic exams to noninvasively assess the functional status of the sympathetic innervation of organs with a significant adrenergic component, including the heart. Studies of its application in nuclear cardiology appear to confirm its value in the assessment of conditions such as coronary artery disease, heart failure, arrhythmias and sudden death.Heart failure is a global problem, with an estimated prevalence of 2% in developed countries. Sudden cardiac death is the main cause of its high mortality. The autonomic nervous system dysfunction, including sympathetic hyperactivity, that accompanies chronic heart failure is associated with progressive myocardial remodeling, declining left ventricular function and worsening symptoms, and contributes to the development of ventricular arrhythmias and sudden death.Since 123I-MIBG cardiac scintigraphy can detect changes in the cardiac adrenergic system, there is considerable interest in its role in obtaining diagnostic and prognostic information in patients with heart failure.In this article we present a literature review on the use of 123I-MIBG scintigraphy for risk stratification of sudden death in patients with heart failure.     

Expressão fenotípica da miocardiopatia hipertrófica e realce tardio na ressonância magnética cardíaca

Introduction and AimThe prognostic value of late gadolinium enhancement (LGE) for risk stratification of hypertrophic cardiomyopathy (HCM) patients is the subject of disagreement. We set out to examine the association between clinical and morphological variables, risk factors for sudden cardiac death and LGE in HCM patients.MethodsFrom a population of 78 patients with HCM, we studied 53 who underwent cardiac magnetic resonance. They were divided into two groups according to the presence or absence of LGE. Ventricular arrhythmias and morbidity and mortality during follow‐up were analyzed.ResultsPatients with LGE were younger at the time of diagnosis (p=0.046) and more often had a family history of sudden death (p=0.008) and known coronary artery disease (p=0.086). On echocardiography they had greater maximum wall thickness (p=0.007) and left atrial area (p=0.037) and volume (p=0.035), and more often presented a restrictive pattern of diastolic dysfunction (p=0.011) with a higher E/É ratio (p=0.003) and left ventricular systolic dysfunction (p=0.038). Cardiac magnetic resonance supported the association between LGE and previous echocardiographic findings: greater left atrial area (p=0.029) and maximum wall thickness (p<0.001) and lower left ventricular ejection fraction (p=0.056). Patients with LGE more often had an implantable cardioverter‐defibrillator (ICD) (p=0.015). At follow‐up, no differences were found in the frequency of ventricular arrhythmias, appropriate ICD therapies or mortality.ConclusionsThe presence of LGE emerges as a risk marker, associated with the classical predictors of sudden cardiac death in this population. However, larger studies are required to confirm its independent association with clinical events.     

Implantação percutânea de válvula aórtica: a anatomia é (ainda) o fator limitante?

IntroductionDespite rapid advances in transcatheter aortic valve prostheses, anatomical constraints remain that can limit access to this treatment for patients with severe aortic stenosis. The objective of this study was to determine the proportion of patients anatomically suitable for this technique using the different devices and approaches available.MethodsWe retrospectively analyzed 145 consecutive patients referred to our center for transcatheter aortic valve implantation. Aortic annulus diameter was measured by transesophageal echocardiography and minimum iliofemoral diameter was determined by multidetector computed tomography. We determined the proportion of patients anatomically suitable for current devices (26-mm, 29-mm and 31-mm Medtronic CoreValve for transfemoral, transaxillary or transaortic approaches, and 23-mm, 26-mm and 29-mm Edwards Sapien XT for transfemoral or transapical approaches).ResultsThe Medtronic CoreValve was suitable for 89% of patients via transfemoral access and 93.8% via transaxillary or transaortic approaches, while the Edwards Sapien XT was suitable for 82.1% of patients via transfemoral and 97.2% via transapical approaches. Only 1.4% of patients were anatomically unsuitable for all devices and approaches.ConclusionsIn this population, most patients were anatomically suitable for transcatheter aortic valve implantation if assessed on the basis of multiple devices and multiple access approaches.     

Utilidade do doseamento do peptídeo natriurético tipo B em doentes ambulatórios com insuficiência cardíaca com fração de ejeção preservada

IntroductionHeart failure with preserved ejection fraction (HFPEF) is a highly prevalent syndrome that is difficult to diagnose in outpatients. The measurement of B-type natriuretic peptide (BNP) may be useful in the diagnosis of HFPEF, but with a different cutoff from that used in the emergency room. The aim of this study was to identify the BNP cutoff for a diagnosis of HFPEF in outpatients.Methods and ResultsThis prospective, observational study enrolled 161 outpatients (aged 68.1 ± 11.5 years, 72% female) with suspected HFPEF. Patients underwent ECG, tissue Doppler imaging, and plasma BNP measurement, and were classified in accordance with algorithms for the diagnosis of HFPEF. HFPEF was confirmed in 49 patients, who presented higher BNP values (mean 144.4 pg/ml, median 113 pg/ml, vs. mean 27.6 pg/ml, median 16.7 pg/ml, p < 0.0001). The results showed a significant correlation between BNP levels and left atrial volume index (r=0.554, p < 0.0001), age (r = 0.452; p < 0.0001) and E/E′ ratio (r = 0.345, p < 0.0001). The area under the ROC curve for BNP to detect HFPEF was 0.92 (95% confidence interval: 0.87-0.96; p < 0.001), and 51 pg/ml was identified as the best cutoff to detect HFPEF, with sensitivity of 86%, specificity of 86% and accuracy of 86%.ConclusionsBNP levels in outpatients with HFPEF are significantly higher than in those without. A cutoff value of 51 pg/ml had the best diagnostic accuracy in outpatients.     

Implantação percutânea de válvula aórtica em doente muito jovem

Transcatheter aortic valve implantation (TAVI) is the standard treatment for patients with severe aortic stenosis and unacceptable surgical risk. These are usually elderly patients with multiple comorbidities.We report the case of a 20-year-old man with mandibuloacral dysplasia, an extremely rare premature ageing syndrome, and severe symptomatic aortic stenosis, referred to our center for TAVI after being considered unsuitable for surgical aortic valve replacement. TAVI by a transfemoral approach was performed successfully. Severe acute respiratory failure that did not respond to optimal conventional treatment led us to employ venovenous extracorporeal membrane oxygenation. The device was removed after 10 days, and the patient was discharged home 27 days later. At one-year follow-up he is in NYHA class I with full functional autonomy. To the best of our knowledge, this is the youngest patient to undergo TAVI reported in the literature.     

Encerramento percutâneo do apêndice auricular esquerdo para profilaxia de tromboembolismo na fibrilhação auricular

Atrial fibrillation is a common arrhythmia in clinical practice. It is associated with high morbidity and mortality due to its thromboembolic potential, which makes thromboembolic prevention particularly important. Warfarin has been the first-line therapy for this purpose, but it has various limitations and is often contraindicated or underutilized. The fact that thrombi are frequently located in the left atrial appendage in atrial fibrillation led to the development of percutaneous closure for thromboembolic prevention. This article examines the current evidence on percutaneous closure of the left atrial appendage by reviewing the results of the numerous clinical trials on the technique.     

Biomarcadores da classe funcional na insuficiência cardíaca sistólica. Relevância da copeptina

IntroductionFunctional class is an important predictor of prognosis in chronic heart failure (CHF). However, it is often subjective and poorly reproducible.ObjectiveWe sought to identify diagnostic markers of high functional class.MethodsWe prospectively studied 37 patients with symptomatic CHF and ejection fraction < 40%. The study protocol included clinical evaluation, echocardiography (M-mode, 2D, Doppler and tissue Doppler) and laboratory tests including copeptin, vasopressin and NT-proBNP. We compared patients in NYHA class II with those in NYHA class > II. Overall mortality was assessed at 18 months.ResultsMortality was higher in the more advanced symptomatic stages (p < 0.05). Patients in NYHA class > II had higher creatinine, copeptin and NT-proBNP levels (p < 0.05). E/E’, E-septum distance, pulmonary artery systolic pressure (PASP) and inferior vena cava (IVC) dimensions were also significantly greater (p < 0.05). The biomarkers copeptin (area under the curve [AUC] = 0.76, p < 0.01) and NT-proBNP (AUC = 0.81, p < 0.01) and the echocardiographic parameters PASP (AUC = 0.88, p < 0.01) and IVC inspiratory diameter (AUC = 0.91, p < 0.01) showed the best performance for diagnosis of functional class > II. In multivariate regression analysis only PASP and serum creatinine were independent predictors of NYHA functional class > II.ConclusionCopeptin and NT-proBNP have high sensitivity and specificity in the diagnosis of functional classes with prognostic impact and may be useful in defining a standardized functional classification.The structural and hemodynamic echocardiographic changes associated with NYHA class > II were left ventricular filling pressure, PASP and central venous pressure.     

Os benefícios da reabilitação cardíaca na doença coronária: uma questão de género?

Introduction and ObjectivesCoronary heart disease is the leading cause of death in women worldwide and several studies have shown that they are under‐represented in cardiac rehabilitation therapy. The objectives of this study were to assess the prevalence of women in a cardiac rehabilitation program and to assess their response to this intervention.MethodsThis is a retrospective study of 858 patients who attended an exercise‐based cardiac rehabilitation program after an acute coronary syndrome or elective percutaneous coronary intervention, between January 2008 and December 2012. The patients were analyzed by gender, and the impact of the intervention on cardiovascular risk factors and NT‐proBNP was studied. In a subgroup of 386 patients the impact on functional capacity, resting heart rate, chronotropic index and heart rate recovery was also analyzed.ResultsOnly 24% of the 858 patients who attended the program were women. Women showed statistically significant improvements in all cardiovascular risk factors, NT‐proBNP, functional capacity and heart rate recovery (p<0.05) after the program. There were also improvements in resting heart rate and chronotropic index, but these were not statistically significant (p=0.08 and p=0.40, respectively) and when the improvements in these two parameters were compared between genders, there was no statistically significant difference (p=0.33 and p=0.17, respectively).ConclusionsOnly 24% of the patients attending the program were women. We found that they benefited from cardiac rehabilitation therapy, with significant improvements in cardiovascular risk factors and in most of the prognostic markers studied.     

A evolução histórica do envolvimento dos sistemas neuro‐humorais no conhecimento da fisiopatologia e do tratamento da insuficiência cardíaca

Our knowledge of the pathophysiology of heart failure (HF) underwent profound changes during the 1980s. Once thought to be of exclusively structural origin, HF began to be seen as the consequence of hormonal imbalance. A number of seminal studies were published in that decade focusing on the impact of neurohormonal activation in HF. Presently, eight neurohormonal systems are known to have a key role in HF development: four stimulate vasoconstriction and sodium/water retention (the sympathetic nervous system, the renin‐angiotensin‐aldosterone system [RAAS], endothelin, and the vasopressin‐arginine system), while the other four stimulate vasodilation and natriuresis (the prostaglandin system, nitric oxide, the dopaminergic system, and the natriuretic peptide system [NPS]). These systems are strongly interconnected and are subject to intricate regulation, functioning together in a delicate homeostasis. Disruption of this homeostasis is characteristic of HF. This review explores the historical development of knowledge on the impact of the neurohormonal systems on HF pathophysiology, from the first studies to current understanding. In addition, the therapeutic potential of each of these systems is discussed, and currently used neurohormonal antagonists are characterized. Special emphasis is given to the latest drug approved for use in HF with reduced ejection fraction, sacubitril/valsartan. This drug combines two different molecules, acting on two different systems (RAAS and NPS) simultaneously.     

Síndrome cardiorrenal na insuficiência cardíaca aguda: um círculo vicioso?

Introduction and ObjectiveWorsening renal function has an unquestionably negative impact on prognosis in patients with acute heart failure (HF). In Portugal there is little information about the importance of this entity in HF patients admitted to hospital. The objective of this work was to assess the prevalence of cardiorenal syndrome and to identify its key predictors and consequences in patients admitted for acute HF.MethodsThis was a retrospective study of 155 patients admitted for acute HF. Cardiorenal syndrome was defined as an increase in serum creatinine of ≥26.5 μmol/l. Clinical, laboratory and echocardiographic parameters were analyzed and compared. Mortality was assessed at 30 and 90 days.ResultsCardiorenal syndrome occurred in 46 patients (29.7%), 5.4±4.4 days after admission; 66.7% (n=24) did not recover baseline creatinine levels. The factors associated with cardiorenal syndrome were older age, chronic renal failure, moderate to severe mitral regurgitation, higher admission blood urea nitrogen, creatinine and troponin I, and lower glomerular filtration rate. Patients who developed cardiorenal syndrome had longer hospital stay, were treated with higher daily doses of intravenous furosemide, and more often required inotropic support and renal replacement therapy. They had higher in‐hospital and 30‐day mortality, and multivariate analysis identified cardiorenal syndrome as an independent predictor of in‐hospital mortality.ConclusionsRenal dysfunction is common in acute HF patients, with a negative impact on prognosis, which highlights the importance of preventing kidney damage through the use of new therapeutic strategies and identification of novel biomarkers.