Transcatheter Aortic Valve Implantation and Morbidity and Mortality-Related Factors: a 5-Year Experience in Brazil

Abstract Background: Transcatheter aortic valve implantation has become an option for high-surgical-risk patients with aortic valve disease. Objective: To evaluate the in-hospital and one-year follow-up outcomes of transcatheter aortic valve implantation. Methods: Prospective cohort study of transcatheter aortic valve implantation cases from July 2009 to February 2015. Analysis of clinical and procedural variables, correlating them with in-hospital and one-year mortality. Results: A total of 136 patients with a mean age of 83 years (80-87) underwent heart valve implantation; of these, 49% were women, 131 (96.3%) had aortic stenosis, one (0.7%) had aortic regurgitation and four (2.9%) had prosthetic valve dysfunction. NYHA functional class was III or IV in 129 cases (94.8%). The baseline orifice area was 0.67 ± 0.17 cm2 and the mean left ventricular-aortic pressure gradient was 47.3±18.2 mmHg, with an STS score of 9.3% (4.8%-22.3%). The prostheses implanted were self-expanding in 97% of cases. Perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and one-year mortality, 15.5%. Blood transfusion (relative risk of 54; p = 0.0003) and pulmonary arterial hypertension (relative risk of 5.3; p = 0.036) were predictive of in-hospital mortality. Peak C-reactive protein (relative risk of 1.8; p = 0.013) and blood transfusion (relative risk of 8.3; p = 0.0009) were predictive of 1-year mortality. At 30 days, 97% of patients were in NYHA functional class I/II; at one year, this figure reached 96%. Conclusion: Transcatheter aortic valve implantation was performed with a high success rate and low mortality. Blood transfusion was associated with higher in-hospital and one-year mortality. Peak C-reactive protein was associated with one-year mortality.

Incidência do reumatismo (febre reumática, reumatismo infecioso específico) no Rio de Janeiro

1 – A close inquiry into 6700 post mortem examinations reveals amongst them 589 cases of endocarditis which, as causa mortis, thus concur with an 8.82% score. 2 – As to their etiology, the endocarditis cases are classified in: Rheumatic E………………417cases or 6.22% of the necropsies; Syphilitic E……………….106 cases or 1.58% of the necropsies; Malignant E………………….66 cases or 0.98% of the necropsies . 3 – With the exception of the cases of syphilitic endocarditis, or aortic endocarditis connected with syphilitic changes, as well as of malignant (bacterial) endocarditis, 417 cases of rheumatic endocarditis are left which constitute 6.22% of the total amount of the post mortem examinations and 70.79% of the endocarditis cases. 4 – As to their anatomical location, the cases of rheumatic endocarditis are distributed as follows: Valvular E………..396 cases or 94.96% of the endocarditis cases; Mural E………..21 cases or 5.04% of the endocarditis cases; 5 – As to valvular changes, the following location was observed: Mitral E…………….156 cases or 39.39%; Aortic E……………120 cases or 30.30%; Tricuspid E…………10 cases or 2.51%; Pulmonary E…………2 cases or 0.50%; Mitral-aortic E……….88 cases or 22.22%; Mitral-tricuspid E………….10 cases or 2.51%; Mitral-tricuspid-aortic E…………9 cases or 2.27%; Mitral-tricuspid-pulmonary E………….1 cases or 0.25%. 6 – As to sex, 59.21% are males and 40.70% females. As regards mitral endocarditis, the incidence for both sexes is practically one and the same (49.55% of males and 50.47% of females), whilst as regards aortic endocarditis 74.16% of males and 26.84% of females are affected by. 7 – As to colour: White……..50.24% of the cases; Black……………28.50% of the cases; Brown……………21.25% of the cases. 8 – As to nationality: Brazilians…………81.86% of the cases; Aliens…………..18.13% of the cases. 9 – As to age: 0 to 10 years…………7 cases, 51 to 60 years……57 cases; 11 to 20 years……..33 cases, 61 to 70 years……51 cases; 21 to 30 years……..64 cases, 71 to 80 years……..21 cases; 31 to 40 years……..79 cases, 81 to 90 years……1 cases; 41 to 50 years…………58 cases, 91 to 100 years……..2 cases.

Estudo morfométrico do coração fetal: sua utilização como parâmetro para análise ecocardiográfica

OBJETIVO: Avaliar o diâmetro, o perímetro e a área das valvas atrioventriculares do coração fetal, bem como a espessura das paredes ventriculares e os diâmetros das cavidades ventriculares. MATERIAIS E MÉTODOS: Foram dissecados 20 corações de fetos com idade gestacional entre 28 e 36 semanas. Em seguida foram medidos os diâmetros ântero-posterior e transverso e aferidos as áreas e os perímetros das valvas mitral e tricúspide, bem como foram medidas as espessuras das paredes ventriculares e os diâmetros de suas cavidades, utilizando-se um paquímetro com acurácia de1/10 mm. RESULTADOS: Os diâmetros ântero-posterior e transverso da valva atrioventricular esquerda mediram, em média, 10,35 ± 1,62 mm e 9,90 ± 1,79 mm, respectivamente, e os diâmetros ântero-posterior e transverso da valva atrioventricular direita, 10,98 ± 1,90 mm e 9,51 ± 1,81 mm, respectivamente. A área e o perímetro da valva mitral foram de 84,06 ± 25,09 mm² e 29,87 ± 3,96 mm, respectivamente. A área e o perímetro da valva tricúspide mediram, respectivamente, 84,49 ± 26,79 mm² e 28,44 ± 3,85 mm. No ventrículo direito a espessura da parede anterior foi de 5,00 ± 1,70 mm e a da parede posterior foi de 3,83 ± 0,91 mm; no ventrículo esquerdo a espessura da parede anterior foi de 4,25 ± 0,87 mm e a da parede posterior foi de 4,14 ± 0,89 mm. O septo interventricular teve espessura de 4,10 ± 1,13 mm. O ventrículo direito teve como diâmetro ântero-posterior 9,25 ± 0,85 mm, e como diâmetro transverso 8,24 ± 0,42 mm. O ventrículo esquerdo mediu 9,95 ± 0,37 mm para o diâmetro ântero-posterior e 9,20 ± 0,40 mm para o diâmetro transverso. CONCLUSÃO: O conhecimento dos dados morfométricos do coração do feto é de grande importância para o diagnóstico ecocardiográfico de possíveis malformações cardíacas.

Redundant nerve roots of the cauda equina: review of the literature

In imaging diagnosis, redundant nerve roots of the cauda equina are characterized by the presence of elongated, enlarged and tortuous nerve roots in close relationship with a high-grade lumbar spinal canal stenosis. This is not an independent entity, but it is believed to be a consequence of the chronic compression at the level of the lumbar canal stenosis and thus may be part of the natural history of lumbar spinal stenosis. The present paper is aimed at reviewing the histopathological, electrophysiological and imaging findings, particularly at magnetic resonance imaging, as well as the clinical meaning of this entity. As the current assessment of canal stenosis and root compression is preferably performed by means of magnetic resonance imaging, this is the imaging method by which the condition is identified. The recognition of redundant nerve roots at magnetic resonance imaging is important, particularly to avoid misdiagnosing other conditions such as intradural arteriovenous malformations. The literature approaching the clinical relevance of the presence of redundant nerve roots is controversial. There are articles suggesting that the pathological changes of the nerve roots are irreversible at the moment of diagnosis and therefore neurological symptoms are less likely to improve with surgical decompression, but such concept is not a consensus.

Portal cholangiopathy: case report

The present report describes the case of a child that after blunt abdominal trauma presented with portal thrombosis followed by progressive splenomegaly and jaundice. Ultrasonography and percutaneous cholangiography revealed biliary dilatation secondary to choledochal stenosis caused by dilated peribiliary veins, characterizing a case of portal biliopathy. The present case report is aimed at presenting an uncommon cause of this condition.

Estenose arterial pós-transplante hepático: tratamento com angioplastia transluminal percutânea

Vascular complications after liver transplantation include oclusion or stenosis at the sites of anastomosis in the hepatic artery, portal vein, and vena cava. Balloon angioplasty of these stenosis carries little risk and is a useful procedure for the treatment of these problems. The purpose of this paper was to assess whether percutaneous transluminal angioplasty can help to prolong allograft survival and impruve allograft function in patient with hepatic artery stenosis after liver transplantation. We report a 43-year-old mate with stenosis of hepatic artery anastomosis after liver transplantation. An abrupt elevation of liver enzymes and serum bilirrubin levels was noted on the fifth postoperative month. The patient underwent percutaneous liver biopsy, which revealed important ductal depletion due to hypoperfusion, even though Doppler ultrasound examination demonstrated arterial flow. An angiogram confirmed severe stenosis of the arterial anastomosis with poor intraparenchymal arterial perfusion pattern. In an attempt to preserve the graft, a percutaneous transluminal angioplasty was performed using microballoons mounted on a hydrophylic micro guidewire. Intervention proceeded without complications. Liver enzimes and bilirrubin levels decreased within twenty-four hours of angioplasty. Normal levels were achieved after one week. Seven month after angioplasty, the patient is in a optimal clinical condition with no signs of graft impairment. We conclude that percutaneous transluminal angioplasty of hepatic artery stenosis after liver transplantation is relatively safe and may help decrease allograft loss.

Fistula gastrocólica

A case of gastrocolic fistula(GCF) in a patient with duodenal stenosis who had previously undergone gastroenteric anastomosis is reported. The patient went through hemigastrectomy, partial colectomy and segmental enterectomy with bloc resection. Reconstruction was carried out through Billroth II gastrojejunostomy, jejunojejunostomy and end-to-end anastomosis of the colon. The patient had good post-operative evolution and was discharged from hospital seven days after surgery. GCF should be suspected in patients presenting weight loss, diarrhea and fecal vomiting, mainly with history of peptic ulcer surgery, gastric or colonic malignancy and use of steroidal and nonsteroidal antiinflamatory drugs. Barium enema is the choice test for diagnosis, however, the benign or malignant nature of the lesion should always be evaluated through high digestive endoscopy. Clinical treatment with oral H2-antagonists and discontinuing ulcerogenic medications might be indicated in some cases; surgical treatment is indicated in cases of malignant disease and might be indicated in cases of peptic disease as it treats GCF and also the baseline disease. Some advise upwards colostomy at first. The most used technique is bloc resection, including the fistulous tract, hemigastrectomy and partial colectomy. Gastrectomy, fistulous tract excision and colon suturing may be performed in some cases. The mortality rate is related to metabolic disorders and the recurrence with the use of antiinflammatory drugs.

Estenose esofagiana congênita por coristoma

Oesophageal choristomas are a very uncommon cause of congenital oesophageal stenosis. A high index of suspection is necessary for differential diagnosis with commoner causes of oesophageal suboclusion in childhood, mainly acquired oesophageal obstruction caused by gastroesophageal reflux. We present a case report and review the clinical, endoscopic and radiologic features of the disease and consider the need for padronization of surgical techniques to treat this condition, which is still controversial.

Migração de clipe metálico para úlcera duodenal após colecistectomia videolaparoscópica: Ligaclip migration into a duodenal ulcer following laparoscopic cholecystectomy

We report a rare cause of pyloric stenosis caused by migration of surgical clips into a duodenal ulcer following laparoscopic cholecystectomy. Even after endoscopic removal of the clips the inflammatory reaction during the healing process caused a stenosis of the pylorus that eventually required a truncal vagotomy and gastroenterostomy.

Angioplastia com implante de "stent" na artéria mesentérica superior

Endovascular techniques have been used to treat arterial stenosis throughout the vascular system. The goal of this work is to report one case of percutaneous transluminal angioplasty with primary stenting of the ostial segment of the superior mesenteric artery for treatment of chronic mesenteric ischemia.

Emprego da submucosa intestinal suína em uretroplastias complexas

We report the use of Porcine Intestinal Submucosa (PIS) in association with Johanson technique for urethroplasty, in the treatment of recurring urethral stenosis. The patient had obliterans xerotica balanitis and had previously undergone 15 internal uretotomies as well as various unsuccessful urethral dilations. As a result of stenotic extension, another surgery was planned using Johanson technique. During the first part of the surgery, intense local fibrosis was observed, which required greater care and protection to avoid fistulae formation. PIS was interposed to reduce the chances of the occurrence of this dreaded complication. During the second part of the surgery, a skin flap obtained from tissue parallel to the urethral plateau was used to prepare a neourethra according to the norms of this technique. PIS was fixed at its extremities, and interposed between the neourethral suture and the skin suture to prevent any contact between them. The procedure was completed with the use of meatoplasty and glandulaplasty. After 6-month follow up, clinical and urodynamic improvement could be seen. If these results can be confirmed by more extensive studies, PIS will provide new perspectives for complex urethroplasties.

Obstrução intestinal após uso de infliximab no tratamento de fístula êntero-cutânea na doença de Crohn

Crohn's disease is often complicated by the development of fistulas. Infliximab, a monoclonal antibody that binds tumor necrosis factor a have shown to be successful in the treatment of fistulizing Crohn's disease. It's possible complications and side effects have not been completely elucidated. Our objective is to report a case of a patient who developed intestinal obstruction after treatment of fistulizing Crohn's disease with infliximab. A 50 years-old female with Crohn's disease presented with spontaneous enterocutaneous fistula. She was successfully treated with the infusion of 5mg/kg infliximab at weeks 0, 2, and 6, with complete closure of the fistula after the first infusion. Eight weeks after treatment she developed small bowel obstruction secondary to stenosis of the ileum. She was subjected to exploratory laparotomy and resection of the stenotic ileum. The patient had good recovery, with no complications, and was discharged on the 5th postoperative day. Although a faster and complete healing of enterocutaneous fistula was induced by infliximab, this treatment may have caused intestinal obstruction in this case.

Condroma de laringe: apresentação atípica

The authors report a case of laryngeal chondroma , a rare benign larynx tumor in the cricoid and arytenoid cartilages. There are aproximately 250 cases previously described in literature. A male, 41 year-old patient, presented a severe and progressive dyspnea leading to tracheostomy. Direct microlaryngoscopy revealed arytenoid enlargement and subglottic stenosis and the endoscopical biopsy was inconclusive, since the tumor present a hard gnistency. We performed surgical excision by laringofissura and total resection of the tumor, with good result. The histopathological examination showed a chondroma with no malignance.

Síndrome de estenose pilórica por adenocarcinoma de piloro

We present a case of primary malignant pylorus neoplasia, emphasizing its rarity, the difficulty of diagnosis and the importance of an adequate prepare before the endoscopic procedure. Literature shows that tumors compromising the first, third and fourth segments of duodenum are rare, especially those of the pyloric area, representing only 0.35% of all malignant tumors of the gastrointestinal tract. Adenocarcinoma is the most common histological type, representing 50% of all malignant neoplasias at this site. The most common symptoms are weight loss, nausea, vomiting, abdominal pain, abdominal mass, sudden changes in intestinal habits and iron deficiency anemia secondary to chronic intestinal hemorrhage. Survival after five years is only 18%. We report a case of a seventy-one year-old male referring early satiety, epigastric pain, retrosternal burning and dyspepsia, with unspecific results in complementary exams, since complete gastric emptying was not achieved. As symptoms worsened, the patient was submitted to laparotomy, with identification of gastric dilation and severe pyloric stenosis, macroscopically suggesting malignancy. The chosen procedure was a subtotal gastrectomy. Adjuvant radiotherapy and chemotherapy were not used. The patient is been followed-up without tumor recurrence so far.