Estratégia antitrombótica nos três meses iniciais após implante de bioprótese valvar cardíaca

A prótese valvar cardíaca indiscutivelmente melhora a qualidade de vida e a sobrevida de pacientes com valvulopatias severas, mas a necessidade de uma terapia antitrombótica para prevenir complicações tromboembólicas promove grandes desafios aos clínicos e aos seus pacientes. Dos artigos pesquisados, a maioria foi composta de séries retrospectivas de casos ou de coortes históricas extraídas de banco de dados. Os raros estudos randomizados publicados não apresentaram poder estatístico para se avaliar o desfecho primário de morte ou evento tromboembólico. Neste artigo, optamos por realizar uma revisão sistemática da literatura, tentando responder a seguinte pergunta: qual a melhor estratégia antitrombótica nos três primeiros meses após implante de bioprótese valvar cardíaca (mitral e aórtica)? Após aplicar-se os critérios de extração por dois revisores, encontrou-se 1968 referências, selecionando-se 31 artigos (foram excluídos artigos truncados, que combinaram prótese mecânica, ou sem follow-up). Baseado nesta revisão de literatura, observou-se um baixo nível de evidência para qualquer estratégia terapêutica antitrombótica avaliada. Sendo assim, é interessante utilizar aspirina 75 a 100 mg/dia como estratégia antitrombótica após implante de bioprótese na posição aórtica, independente da etiologia, para pacientes sem outros fatores de risco, como fibrilação atrial ou evento tromboembólico anterior. Já para o implante de bioprótese na posição mitral, o risco de embolia, apesar de baixo, é mais relevante do que na posição aórtica, segundo as séries publicadas e coortes retrospectivas composta principalmente de pacientes idosos não reumáticos.

Obstrucao Coronaria apos Implante por Cateter de Protese Valvar Aortica

Fundamentos: O implante por cateter de bioprótese valvar aórtica (TAVI) consolidou-se como alternativa para o tratamento de pacientes com estenose aórtica importante de alto risco cirúrgico. Contudo, há poucos dados na literatura com respeito à obstrução coronária que, apesar de rara, trata-se de grave complicação do TAVI. Objetivo: Avaliar, no contexto brasileiro, a presença dessa importante complicação. Métodos: Foram avaliados todos os casos de obstrução coronária incluídos no Registro Brasileiro de TAVI. Foram coletados dados clínicos, do procedimento, do manejo e de evolução intra-hospitalar. Resultados: Entre 418 pacientes consecutivos do registro, ocorreram três casos de obstrução coronária (incidência de 0,72%). Em sua totalidade, os pacientes eram do sexo feminino, sem cirurgia de revascularização miocárdica (CRM) prévia, com idade média de 85 ± 3 anos, EuroSCORE logístico de 15 ± 6% e STS de 9 ± 4%. Todos os casos foram realizados com a válvula balão-expansível Sapien XT. Em um dos pacientes, com dados de tomografia computadorizada pré-procedimento, verificaram-se origem das artérias coronárias baixa e seio de Valsalva estreito. Todos os pacientes apresentaram-se clinicamente com hipotensão importante e mantida, imediatamente após o implante da válvula, e, apesar de angioplastia com implante de stent, todos os pacientes foram a óbito, sendo dois periprocedimento e um durante hospitalização. Conclusão: A obstrução coronária como complicação do TAVI, apesar de rara, é potencialmente fatal, podendo ocorrer mais frequentemente em mulheres e com as próteses expansíveis por balão. Fatores anatômicos podem estar relacionados com sua ocorrência, ressaltando-se a importância de boa avaliação pré-procedimento no sentido de evitar essa grave complicação.

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

Fundamento: O implante de prótese aórtica transcateter é uma alternativa efetiva para o tratamento cirúrgico para a correção de estenose aórtica grave em pacientes inoperáveis ou de alto risco cirúrgico. Objetivos: Apresentar os resultados clínicos e ecocardiográficos imediatos e no médio prazo da experiência inicial do implante de prótese aórtica transcateter. Métodos: Entre junho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de prótese aórtica transcateter. Resultados: A idade média foi 82,5 ± 6,5 anos e o Euro SCORE logístico foi 23,6 ± 13,5. O sucesso do procedimento foi de 84%. Após o implante, houve queda do gradiente sistólico médio (pré = 54,7 ± 15,3 mmHg vs. pós = 11,7 ± 4,0 mmHg; p < 0,01). Acidente vascular cerebral ocorreu em 3,6% dos pacientes, complicações vasculares em 19%, e foi necessário o implante de marca-passo definitivo em 13% dos pacientes nos primeiros 30 dias pós-implante. A mortalidade aos 30 dias e no seguimento médio de 16 ± 11 meses foi, respectivamente, de 14 e de 8,9%. A presença de doença pulmonar obstrutiva crônica foi o único preditor de mortalidade em 30 dias e no seguimento. A área valvar aórtica e o gradiente sistólico médio não apresentaram variações significativas durante o seguimento. Conclusões: O implante de prótese aórtica transcateter é um procedimento eficaz e seguro para o tratamento da estenose aórtica em pacientes de alto risco cirúrgico ou inoperáveis. A presença de doença pulmonar obstrutiva crônica foi o único preditor independente de mortalidade identificado, tanto no primeiro mês pós-intervenção quanto no seguimento mais tardio.

Augmentation cystoplasty using pedicled and de-epithelialized gastric patches in the mini-pig model.

PURPOSE: The most common methods of bladder augmentation are gastrocystoplasty and enterocystoplasty. Gastrocystoplasty is advantageous due to minimal mucous secretion and a well developed muscular wall as well as good urodynamic properties of the patch. However, the permanent contact of urine with the gastric mucosa is not free of complications. We report the urodynamic, macroscopic and histological outcomes of a pedicled de-epithelialized gastric patch incorporated in the bladder. We compared the results to those of our previous study, which sought to analyze these techniques of patch coverage using sigmoid patches. MATERIALS AND METHODS: We performed 20 augmentation cystoplasties in the mini-pig model using a pedicled de-epithelialized gastric patch and 5 techniques of patch coverage. RESULTS: Three months after surgery all bladders had an increase in volume except those in which the auto-augmentation technique was used. However, all gastric patches were smaller compared to preoperative size. Many had irregular fibrosed inner surfaces and histological evaluation revealed a fibrosed newly formed submucosal layer with a complete urothelial coverage in every patch. No gastric mucosal remnant was found. CONCLUSIONS: De-epithelialized gastrocystoplasty is an attractive procedure that can increase bladder capacity as well as provide a complete urothelial lining without mucosal remnants. However, the success of this procedure seems to be limited by increased morbidity and fibrotic changes, and decreased surface of the patch.

Testing low-altitude infrared digital photography from a mini-UAV to retrieve information for biological conservation

Satellite remote sensing imagery is used for forestry, conservation and environmental applications, but insufficient spatial resolution, and, in particular, unavailability of images at the precise timing required for a given application, often prevent achieving a fully operational stage. Airborne remote sensing has the advantage of custom-tuned sensors, resolution and timing, but its price prevents using it as a routine technique for the mentioned fields. Some Unmanned Aerial Vehicles might provide a “third way” solution as low-cost techniques for acquiring remotely sensed information, under close control of the end-user, albeit at the expense of lower quality instrumentation and instability. This report evaluates a light remote sensing system based on a remotely-controlled mini-UAV (ATMOS-3) equipped with a color infra-red camera (VEGCAM-1) designed and operated by CATUAV. We conducted a testing mission over a Mediterranean landscape dominated by an evergreen woodland of Aleppo pine (Pinus halepensis) and (Holm) oak (Quercus ilex) in the Montseny National Park (Catalonia, NE Spain). We took advantage of state-of-the-art ortho-rectified digital aerial imagery (acquired by the Institut Cartogràfic de Catalunya over the area during the previous year) and used it as quality reference. In particular, we paid attention to: 1) Operationality of flight and image acquisition according to a previously defined plan; 2) Radiometric and geometric quality of the images; and 3) Operational use of the images in the context of applications. We conclude that the system has achieved an operational stage regarding flight activities, although with meteorological limits set by wind speed and turbulence. Appropriate landing areas can be sometimes limiting also, but the system is able to land on small and relatively rough terrains such as patches of grassland or short matorral, and we have operated the UAV as far as 7 km from the control unit. Radiometric quality is sufficient for interactive analysis, but probably insufficient for automated processing. A forthcoming camera is supposed to greatly improve radiometric quality and consistency. Conventional GPS positioning through time synchronization provides coarse orientation of the images, with no roll information.

Mini-review: Specificity and expression of CIITA, the master regulator of MHC class II genes.

The class II transactivator (CIITA) has been referred to as the "master control factor" for the expression of MHC class II (MHCII) genes. As our knowledge on the specificity and function of CIITA grows, it is becoming increasingly evident that this sobriquet is entirely justified. First, despite extensive investigations, the major target genes of CIITA remain those implicated in the presentation of antigenic peptides by MHCII molecules. Although other putative target genes have been reported, the contribution of CIITA to their expression remains indirect, controversial or comparatively minor relative to its decisive role as a regulator of MHCII and related genes. Second, the most important parameter dictating MHCII expression is by far the expression pattern of the gene encoding CIITA (MHC2TA). The vast majority of signals that activate or repress MHCII expression under physiological and pathological situations converge on one or more of the three alternative promoters that drive transcription of the MHC2TA gene. In short, with respect to its specificity and its exquisitely controlled pattern of expression, CIITA is by a long stretch the single most important transcription factor for the regulation of genes required for MHCII-restricted antigen-presentation.

Mini-review: the ultrasonographical and serological chanbges and their improvement after praziquantel treatment Schistosoma japonicum infected patients in Leyete, Philippines

We have identified the specific ultrasonographical (US) changes in Schistosoma japonicum infected patients with the serological changes in general liver function markers. The US examination with the following haematological and biochemical serum analysis was performed on 102 patients in Shistosomiasis Hospital, Leyte, Philippines. The US liver images were classified into 4 patterns according to the development of periportal fibrosis and the patterns of echogenic bands. Among various haematological and biochemical serum parameters of liver damage. The serum levels of total bile acid (TBA) and procollagen-III-peptide (P-III-P) correlated well with the development of hepatic fibrosis and the portal hypertension. These patients were subsequently treated with praziquantel (3 x 20 mg/kg), and improvement of the thickening of the portal vein wall and the dintensity of the echogenic band formation was detected 6 months after treatment. The significant US changes could not be detected in the patients with severe hepatic fibrosis caused in the long term infection. The results revealed that the US examination with the serum TBa level would provider a sensitive tool monitor the severity of the infection and also the improvement occured shortly after praziquantel treatment.

Chirurgie viscérale. Chirurgie mini-invasive: encore moins invasive? Chirurgie oncologique: multidisciplinaire d'abord [Minimally-invasive surgery: even less invasive? Oncological surgery: multidisciplinary first]

Despite advertising for NOTES in 2009, single trocart laparoscopic surgery is about to become a new standard in selected indications. As other important topics, the limits of oncological surgery are extended due to a systematic multidisciplinary approach. To discuss every publication would be difficult and our review will focus on a selected number of papers of importance for daily practice. As examples, the management of acute calculous cholecystitis, gastro-esophageal reflux, inguinal and incisional hernia repair as well as colorectal surgery are presented.

Use of molecular probes and PCR for detection and typing of Leishmania - a mini-review

The use of molecular tools to detect and type Leishmania species in humans, reservoirs or sandflies has been pursued using different approaches. The polymerase chain reaction provided sensitivity to case this task, since the use of hybridization procedures alone employing specifics probes is hampered due to the low detection limit. In this report, we describe the different molecular targets used in our laboratory, aiming at the detection and specific typing of these protozoa. Different kits based on hybridization assays and PCR amplification using kinetoplast and nuclear targets are described and the results obtained from their use are reported.

Cirugía combinada de facoemulsificación de la catarata y esclerectomía profunda no perforante con implante supracoroideo: resultados a un año

S’ha avaluat l’efectivitat de la cirurgia combinada de facoemulsificació i esclerectomia profunda no perforant amb implant supracoroideu en 20 ulls de 16 pacients. Als 12 mesos de la cirurgia, s’ha observat una reducció significativa de la pressió intraocular mitjana de 22,8mmHg a 18mmHg, un descens del número de col•liris de 2,5 de mitjana en el preoperatori a 0,9 a l’any, així com una milloria significativa de l’agudesa visual sense un augment de complicacions relacionades amb l’implant utilitzat.

Incidencia de hipertensión ocular y glaucoma agudo por bloqueo pupilar tras implante de lente intraocular fáquica tipo ICL. Resultados anatómicos y funcionales a corto y medio plazo. Resultados preliminares

L'implant d’una lent intraocular fàquica tipus ICL (Implantable Collamer Lens) pot produir glaucoma agut per tancament angular degut a un bloqueig pupil•lar amb el consegüent augment de la pressió intraocular, el mecanisme i epidemiologia del qual no són ben coneguts. Aquest estudi preliminar pretén avaluar la incidència d'hipertensió ocular i glaucoma agut per tancament angular degut a bloqueig pupil·lar després de l'implant d'una lent posterior fàquica tipus ICL i plantejar hipòtesis sobre el seu mecanisme fisiopatològic.

Resolution of foveal detachment in dome-shaped macula after treatment by spironolactone: report of two cases and mini-review of the literature.

Dome-shaped macula (DSM) was recently described in myopic patients as a convex protrusion of the macula within a posterior pole staphyloma. The pathogenesis of DSM and the development of associated serous foveal detachment (SFD) remain unclear. The obstruction of choroidal outflow and compressive changes of choroidal capillaries have been proposed as causative factors. In this paper, we report two cases of patients with chronic SFD associated with DSM treated with oral spironolactone. After treatment, there was a complete resolution of SFD in both patients. To the best of our knowledge, this is the first report of successful treatment of SFD in DSM by a mineralocorticoid receptor antagonist.