Implantação Percutânea de Válvulas Pulmonares: Experiência Inicial

Os doentes com cardiopatias submetidos a intervenção cirúrgica com implantação de condutos entre o ventrículo direito e a artéria pulmonar (VD-AP) podem desenvolver estenose e/ou insuficiência pulmonares ao longo do tempo. Nestas situações, associadas a arritmias cardíacas, disfunção ventricular direita e morte súbita, a re-intervenção cirúrgica permanece um desafio pela complexidade, mortalidade e morbilidade significativas. A implantação percutânea de válvulas pulmonares (IPVP), recentemente desenvolvida, representa uma abordagem alternativa para estes doentes. Objectivo: Reportar a experiência inicial com a IPVP, analisando o seu impacto no manejo destes doentes. Material e Métodos: Avaliação prospectiva dos dados clínicos, ecocardiográficos, da ressonância magnética, hemodinâmicos e angiográficos dos doentes submetidos a IPVP. Resultados: Seis doentes em classe funcional igual ou superior a II com disfunção do conduto VD-AP foram submetidos a IPVP. Tinham todos evidência de insuficiência e 5/6 de estenose. O procedimento consistiu na implantação de stents não cobertos no conduto para reforçar a sua rigidez e prevenir fracturas dos stents valvulados pulmonares Melody ® (Medtronic), que foram em seguida implantados com sucesso em todos. Obteve-se uma redução da pressão ventricular direita (94±27 para 44±7mmHg), da relação entre a pressão ventricular direita e esquerda (94±27 para 44±7%), do gradiente do conduto (65±28 para 11±4mmHg) e ausência de regurgitação pulmonar. O procedimento teve uma duração mediana de 180 minutos e decorreu sem complicações major. Os doentes tiveram alta em mediana dois dias após o procedimento. Na última avaliação, em mediana 7,8 meses após o procedimento, os doentes encontramse em classe funcional I (5) ou II (1), sem evidência não invasiva de disfunção do conduto. Conclusões: Os nossos resultados acompanham a experiência actual com esta modalidade terapêutica, com excelentes resultados nestes grupo de doentes complexos. A implementação da IPVP em doentes com cardiopatia congénita que requerem re-intervenção no tracto de saída do ventrículo direito tem-se revelado uma técnica promissora, embora complexa, alternativa a mais uma intervenção cirúrgica.

Reparação Híbrida do Arco Aórtico: Experiência Inicial do Hospital de Santa Marta

Objectives: To retrospectively review the hybrid treatment of the aortic arch with supra-aortic debranching and endo- vascular stent-graft repair in a single institution. Methods: From 2007 to 2010, all patients submitted to aortic debranching procedures were entered into a prospective database analysis. For the present study, only patients with sealing zones 0 and 1, according to the Ishimaru classification, were included. Procedure-related morbimortality was analysed for the open and endovascular procedures. Results: During the study period, we electively performed 6 total aortic debranching and 4 partial aortic debranching procedures in 10 patients. According to the etiology the indications were: 6 aortic arch aneurysms, 2 post-dissection aneu- rysms, 1 false aneurysm and 1 type I endoleak following TEVAR. The proximal sealing zone was Ishimaru zone 0 in six patients and zone 1 in four patients. The TEVAR procedure was delayed in all patients with a completion success of 80% (1 patient died from ruptured aortic aneurysm; 1 patient denied the second procedure and was lost to follow-up). The 30d mortality rate was 10% (patient mentioned above). The main morbidity was: 1 axillar venous thrombosis, 1 case of subclinical myocardial infarction, 1 case of terminal renal insufficiency and 1 case of prolonged ventilation. No permanent cerebral or peripheral neurologic deficit was noted. Conclusions: The hybrid repair of the aortic arch is a feasible and reproducible procedure, and our results are similar to the previously published series. Medium and long-term results are necessary to confirm whether the technique can be regarded as a safe alternative to open surgery in high-risk patients.

Prognostic Value of VEGF in Patients Submitted to Percutaneous Coronary Intervention

We examined the longitudinal changes of VEGF levels after percutaneous coronary intervention for predicting major adverse cardiac events (MACE) in coronary artery disease (CAD) patients. VEGF was measured in 94 CAD patients' serum before revascularization, 1-month and 1-year after. Independently of clinical presentation, patients had lower VEGF concentration than a cohort of healthy subjects (median, IQ: 15.9, 9.0-264 pg/mL versus 419, 212-758 pg/mL; P < 0.001) at baseline. VEGF increased to 1-month (median, IQ: 276, 167-498 pg/mL; P < 0.001) and remained steady to 1-year (median, IQ: 320, 173-497 pg/mL; P < 0.001) approaching control levels. Drug eluting stent apposition and previous medication intake produced a less steep VEGF evolution after intervention (P < 0.05). Baseline VEGF concentration <40.8 pg/mL conveyed increased risk for MACE in a 5-year follow-up. Results reflect a positive role of VEGF in recovery and support its importance in CAD prognosis.

Mid-Term Results of EVAR in Severe Proximal Aneurysm Neck Angulation.

OBJECTIVE: To determine if mid-term outcome following endovascular aneurysm repair (EVAR) with the Endurant Stent Graft (Medtronic, Santa Rosa, CA, USA) is influenced by severe proximal neck angulation. METHODS: A retrospective case-control study was performed using data from a prospective multicenter database. All measurements were obtained using dedicated reconstruction software and center-lumen line reconstruction. Patients with neck length >15 mm, infrarenal angle (β) >75°, and/or suprarenal angle (α) >60°, or neck length >10 mm with β >60°, and/or α >45° were compared with a matched control group. Primary endpoint was primary clinical success. Secondary endpoints were freedom from rupture, type 1A endoleak, stent fractures, freedom from neck-related reinterventions, and aneurysm-related adverse events. Morphological neck variation over time was also assessed. RESULTS: Forty-five patients were included in the study group and were compared with a matched control group with 65 patients. Median follow-up time was 49.5 months (range 30.5-58.4). The 4-year primary clinical success estimates were 83% and 80% for the angulated and nonangulated groups (p = .42). Proximal neck angulation did not affect primary clinical success in a multivariate model (hazard ratio 1.56, 95% confidence interval 0.55-4.41). Groups did not differ significantly in regard to freedom from rupture (p = .79), freedom from type 1A endoleak (p = .79), freedom from neck-related adverse events (p = .68), and neck-related reinterventions (p = .68). Neck angle reduction was more pronounced in patients with severe proximal neck angulation (mean Δα -15.6°, mean Δβ -30.6°) than in the control group (mean Δα -0.39°, mean Δβ -5.9°) (p < .001). CONCLUSION: Mid-term outcomes following EVAR with the Endurant Stent Graft were not influenced by severe proximal neck angulation in our population. Despite the conformability of the device, moderate aortic neck remodeling was identified in the group of patients with angulated neck anatomy on the first computed tomography scan after implantation with no important further remodeling afterwards. No device integrity failures were encountered.

The Hybrid Approach for Palliation of Hypoplastic Left Heart Syndrome: Intermediate Results of a Single-Center Experience

INTRODUCTION: Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS: We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS: Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS: In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.

Clinical Outcome and Morphologic Determinants of Mural Thrombus in Abdominal Aortic Endografts

OBJECTIVE:Endograft mural thrombus has been associated with stent graft or limb thrombosis after endovascular aneurysm repair (EVAR). This study aimed to identify clinical and morphologic determinants of endograft mural thrombus accumulation and its influence on thromboembolic events after EVAR. METHODS: A prospectively maintained database of patients treated by EVAR at a tertiary institution from 2000 to 2012 was analyzed. Patients treated for degenerative infrarenal abdominal aortic aneurysms and with available imaging for thrombus analysis were considered. All measurements were performed on three-dimensional center-lumen line computed tomography angiography (CTA) reconstructions. Patients with thrombus accumulation within the endograft's main body with a thickness >2 mm and an extension >25% of the main body's circumference were included in the study group and compared with a control group that included all remaining patients. Clinical and morphologic variables were assessed for association with significant thrombus accumulation within the endograft's main body by multivariate regression analysis. Estimates for freedom from thromboembolic events were obtained by Kaplan-Meier plots. RESULTS: Sixty-eight patients (16.4%) presented with endograft mural thrombus. Median follow-up time was 3.54 years (interquartile range, 1.99-5.47 years). In-graft mural thrombus was identified on 30-day CTA in 22 patients (32.4% of the study group), on 6-month CTA in 8 patients (11.8%), and on 1-year CTA in 17 patients (25%). Intraprosthetic thrombus progressively accumulated during the study period in 40 patients of the study group (55.8%). Overall, 17 patients (4.1%) presented with endograft or limb occlusions, 3 (4.4%) in the thrombus group and 14 (4.1%) in the control group (P = .89). Thirty-one patients (7.5%) received an aortouni-iliac (AUI) endograft. Two endograft occlusions were identified among AUI devices (6.5%; overall, 0.5%). None of these patients showed thrombotic deposits in the main body, nor were any outflow abnormalities identified on the immediately preceding CTA. Estimated freedom from thromboembolic events at 5 years was 95% in both groups (P = .97). Endograft thrombus accumulation was associated with >25% proximal aneurysm neck thrombus coverage at baseline (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3), neck length ≤ 15 mm (OR, 2.4; 95% CI, 1.3-4.2), proximal neck diameter ≥ 30 mm (OR, 2.4; 95% CI, 1.3-4.6), AUI (OR, 2.2; 95% CI, 1.8-5.5), or polyester-covered stent grafts (OR, 4.0; 95% CI, 2.2-7.3) and with main component "barrel-like" configuration (OR, 6.9; 95% CI, 1.7-28.3). CONCLUSIONS: Mural thrombus formation within the main body of the endograft is related to different endograft configurations, main body geometry, and device fabric but appears to have no association with the occurrence of thromboembolic events over time.