We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during ...a twenty-year period, through a memorandum of agreement of international cooperation.
A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22-29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048).
In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy.
Cardiac catheterization laboratories (cath labs) are commonly designed to achieve the best clinical outcomes while being efficient. This study develops methods to support healthcare managers in ...analyzing the added value of improvement measures, following a value-based healthcare (VBHC) framework.
Based on a sociotechnical approach, the applied methods aimed to increase efficiency, reduce duplication of tasks, cut costs, and improve patient care, while creating a more inclusive and trusting decision making process. Within the process of building a multicriteria evaluation model, meetings, interviews, and a decision conference were designed. In parallel, a workflow discrete event simulation model was built to replicate current patient flow and activities and to reproduce the impact of implementing improvement measures and variations in human resources.
Four evaluation criteria were considered for workflow improvement: contribution to the efficiency of the admission process, compliance with schedules, agility among procedures, and human resources training. The designed improvement measures sought to 1) improve the start-up of the day, 2) improve pre-exam assessment, and 3) improve staff training. Results prioritize ‘Measure 2’ and demonstrate that improving human resources allocation increases efficiency and offers significant cost savings.
The proposed solution is in line with VBHC principles, as it improves efficiency and care delivery while optimizing costs. Simulation was an effective tool to replicate and explore possible changes. Multicriteria modeling proved to be a useful approach for a transparent prioritization and redesign of improvements in the healthcare sector.
Os laboratórios de hemodinâmica são comummente projetados para alcançar os melhores resultados clínicos de forma eficiente. Este estudo desenvolve métodos que visam apoiar gestores da saúde a analisar o valor acrescentado da implementação de medidas de melhoria, segundo uma estrutura de saúde baseada em valor.
Tendo por base uma abordagem sociotécnica, os métodos aplicados visam aumentar a eficiência, reduzir a duplicação de tarefas, diminuir custos e melhorar o atendimento ao paciente, ao mesmo tempo tornando a tomada de decisões mais inclusiva e clara. No seguimento do processo de construção de um modelo multicritério, foram organizadas reuniões, entrevistas e uma conferência de decisão. Em paralelo, foi construído um modelo de simulação de eventos discretos (DES) para replicar o atual fluxo de pacientes e atividades e reproduzir o impacto da implementação de medidas de melhoria e variações nos recursos humanos.
Foram considerados quatro critérios de avaliação para melhoria do fluxo de trabalhos: contribuição para a eficiência do processo de admissão, para o cumprimento de horários, para a agilidade entre procedimentos e para a formação dos recursos humanos. As medidas de melhoria desenhadas procuraram: 1) melhorar o início da atividade diária, 2) melhorar a avaliação pré-exame, e 3) melhorar a formação do staff. Os resultados priorizam a «Medida 2» e demonstram que a melhoria da alocação de recursos humanos aumenta a eficiência e resulta em reduções significativas nos custos.
A solução proposta está em linha com os princípios da saúde baseados em valor, pois melhora a eficiência e a prestação de cuidados, ao mesmo tempo que otimiza os custos. A simulação foi uma ferramenta eficaz para replicar e explorar possíveis mudanças. O modelo multicritério provou ser uma abordagem útil para uma priorização transparente e para o desenho de melhorias no setor da saúde.
We describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical ...outcomes will be addressed, as will its current position compared to surgical myectomy.
To assess the results of ASA in all patients treated in the first four years of activity at our center.
We retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013.
In the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22 ± 14 months) cardiovascular mortality was 2.5% and overall mortality was 5%.
The results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment.
The Portuguese National Registry of Transcatheter Aortic Valve Implantation records prospectively the characteristics and outcomes of transcatheter aortic valve implantation (TAVI) procedures in ...Portugal.
To assess the 30-day and one-year outcomes of TAVI procedures in Portugal.
We compared TAVI results according to the principal access used (transfemoral (TF) vs. non-transfemoral (non-TF)). Cumulative survival curves according to access route, other procedural and clinical variables were obtained. The Valve Academic Research Consortium-2 (VARC-2) composite endpoint of early (30-days) safety was assessed. VARC-2 predictors of 30-days and 1-year all-cause mortality were identified.
Between January 2007 and December 2018, 2346 consecutive patients underwent TAVI (2242 native, 104 valve-in-valve; mean age 81±7 years, 53.2% female, EuroSCORE-II - EuroS-II, 4.3%). Device success was 90.1% and numerically lower for non-TF (87.0%). Thirty-day all-cause mortality was 4.8%, with the TF route rendering a lower mortality rate (4.3% vs. 10.1%, p=0.001) and higher safety endpoint (86.4% vs. 72.6%, p<0.001). The one-year all-cause mortality rate was 11.4%, and was significantly lower for TF patients (10.5% vs. 19.4%, p<0.002). After multivariate analysis, peripheral artery disease, previous percutaneous coronary intervention, left ventricular dysfunction and NYHA class III-IV were independent predictors of 30-day all-cause mortality. At one-year follow-up, NYHA class III-IV, non-TF route and occurrence of life-threatening bleeding predicted mortality. Kaplan-Meier survival analysis of the first year of follow-up shows decreased survival for patients with an EuroS-II>5% (p<0.001) and who underwent non-TF TAVI (p<0.001).
Data from our national real-world registry showed that TAVI was safe and effective. The use of a non-transfemoral approach demonstrated safety in the short term. Long-term prognosis was, however, adversely associated with this route, with comorbidities and the baseline clinical status.
O Registo Nacional de Cardiologia de Intervenção de Válvulas Aórticas Percutâneas (RNCI-VaP) documenta prospetivamente as características e resultados da VAP em Portugal.
Avaliar os resultados a 30 dias e um ano da VAP em Portugal.
Comparação dos resultados da VAP de acordo com o acesso (transfemoral – TF versus não transfemoral – não TF). Obtiveram-se curvas de sobrevivência cumulativa de acordo com o acesso, variáveis do procedimento e clínicas. Avaliou-se a segurança precoce (30 dias) do procedimento, de acordo com os critérios Valve Academic Research Consortium-2 (VARC-2). Identificaram-se preditores de mortalidade a 30 dias e um ano.
Entre janeiro 2007 e dezembro 2018, realizaram-se 2346 VAP (2242 nativas, 104 Valve-in-Valve VIV; idade média 81±7 anos, 53,2% mulheres, EuroSCORE-II EuroS-II 4,3%). Sucesso do dispositivo foi obtido em 90,1%, inferior para o não TF (87,0%). Aos 30 dias, a mortalidade global foi de 4,8%, apresentando o TF menor mortalidade (4,3% versus 10,1%, p=0,001) e maior segurança (86,4% versus 72,6%, p<0,001). A mortalidade a um ano foi 11,4%, significativamente menor para o TF (10,5% versus 19,4%, p<0,002). Após análise multivariável, identificaram-se como preditores de mortalidade a 30 dias doença arterial periférica, angioplastia prévia, disfunção ventricular esquerda e classe NYHA III-IV. A um ano, NYHA III-IV, o acesso não TF e a hemorragia com risco de vida foram preditores de mortalidade. A análise de sobrevivência a um ano evidenciou menor sobrevivência para EuroS-II>5% (p<0,001) e VAP não TF (p<0,001).
Dados do RNCI-VaP mostram que a VAP foi segura e eficaz. O acesso não TF mostrou segurança em curto prazo. O prognóstico em longo prazo foi influenciado negativamente por este acesso, assim como comorbilidades e o estado clínico de base do doente.
To evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal.
The working group analyzed the epidemiology ...of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal. The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams. TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency. The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe. From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used.
TAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk. Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes.
In obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA) can lead to gradient reduction and symptom improvement. We aimed to assess the efficacy and safety of ASA in a ...long-term outcome study.
We analyzed patients who underwent ASA over a seven-year period in a tertiary center. The primary echocardiographic endpoint was >50% reduction in left ventricular outflow tract (LVOT) gradient within a year of the procedure. The primary clinical endpoints were improvement in functional capacity and a combined endpoint of cardiac death and rehospitalization for cardiac cause. The follow-up period was 4.17±2.13 years.
A total of 80 patients, mean age 63.9±12.3 years, 30.0% male, were analyzed. Baseline LVOT gradient was 96.3±34.6 mmHg and interventricular septal thickness was 21.6±3.1 mm. Minor complications were observed in 6.3% and major complications in 2.5%, and 8.8% received a permanent pacemaker.
The primary echocardiographic endpoint was achieved by 85.7%. At three-month follow-up, LVOT gradient was 25.8±26.0 mmHg in the successful procedure group, compared to 69.2±35.6 mmHg in the other patients (p=0.001). At six months, LVOT gradient was 27.1±27.4 vs. 58.2±16.6 mmHg (p=0.024). Among 74 patients in NYHA class III/IV before the procedure, 57 (77%) improved to NHYA class I/II. The combined primary clinical endpoint (cardiac death and rehospitalization for cardiac cause) was observed in 27.5% (n=22). In the unsuccessful group, the combined endpoint was observed in 54.5%, compared to only 22.7% in the successful group. Only two patients died of cardiac causes.
ASA is a safe procedure with a high success rate. Patients who achieved significant reductions in LVOT gradient suffered less cardiac death and rehospitalization for cardiac cause.
Na miocardiopatia hipertrófica obstrutiva (MCHO), ablação septal alcoólica (ASA) pode levar a redução do gradiente e melhoria sintomática. O objetivo foi avaliar a eficácia e segurança da ASA no desfecho a longo prazo.
Análise de doentes submetidos a ASA, durante sete anos, num centro terciário. Endpoint primário ecocardiográfico: redução >50% do gradiente na câmara de saída do ventrículo esquerdo (CSVE) durante o primeiro ano após o procedimento. Endpoints primários clínicos: a) melhoria da capacidade funcional; b) endpoint combinado: morte de causa cardíaca+hospitalização de causa cardíaca. Tempo de seguimento 4,17±2,13 anos.
Oitenta doentes, idade média de 63,9±12,3 anos, 30,0% homens. De base, o gradiente na CSVE era 96,3±34,6 mmHg, espessura do septo interventricular 21,6±3,1 mm. Complicações minor foram verificadas em 6,3%, complicações major em 2,5% e 8,8% receberam um pacemaker definitivo. O endpoint primário ecocardiográfico foi atingido em 85,7%. Aos três meses, o gradiente na CSVE foi de 25,8±26,0 mmHg no grupo com sucesso no procedimento contrastando com 69,2±35,6 mmHg nos restantes doentes (p=0,001). Aos seis meses, os gradientes na CSVE foram 27,1±27,4 versus 58,2±16,6 mmHg (p=0,024).
De entre os 74 doentes em classe NYHA III/IV antes do procedimento, 57 (77%) melhoraram para classe NYHA I/II. O endpoint primário combinado (morte de causa cardíaca+hospitalização de causa cardíaca) verificou-se em 27,5% (n=22). No grupo sem sucesso, o endpoint primário composto verificou-se em 54,5%, contrastando com apenas 22,7% no grupo com sucesso. Apenas dois doentes apresentaram morte de causa cardíaca.
A ASA é um procedimento seguro com elevada taxa de sucesso. Doentes que atingiram redução significativa do gradiente na CSVE apresentam menor morte de causa cardíaca e hospitalização de causa cardíaca.
The aim of this study was to analyze the incidence of drug-eluting stent thrombosis (sirolimus or everolimus) in patients with chronic total coronary occlusions (CTO) and to determine its clinical ...implications and related factors.
Data from the 12-month follow-up of the 207 patients included in the CIBELES trial with CTO were analyzed.
Stent thrombosis occurred in three patients, two definite and one probable (overall thrombosis rate: 1.4%). However, there were no cases of death or Q-wave myocardial infarction. In univariate analysis, patients with a higher incidence of stent thrombosis were those in whom the target vessel was the left anterior descending, who had single-vessel disease, were assigned to treatment with sirolimus-eluting stents, and those with smaller minimum luminal diameter immediately after the procedure. In multivariate analysis, the only independent predictor of stent thrombosis was minimal luminal diameter immediately after the procedure.
The rate of drug-eluting stent thrombosis in patients with CTO is relatively low (1.4%). The only independent predictor of stent thrombosis in this context was minimal luminal diameter after the procedure and the clinical presentation was in all cases relatively benign.
o objetivo do nosso estudo foi analisar a incidência de trombose de stent com eluição de fármaco (sirolimus ou everolimus) em pacientes com oclusões coronárias crónicas e identificar as suas implicações clínicas e fatores relacionados.
12 meses de acompanhamento dos 207 pacientes incluídos no ensaio Cibeles com oclusão total coronária crónica.
a trombose de stent ocorreu em três doentes: duas definitivas e uma provável (taxa global de trombose 1,4%). No entanto, não surgiu nenhum caso de morte ou enfarte do miocárdio com onda Q. Na análise univariada, os doentes com maior incidência de trombose de stent foram aqueles em que o vaso-alvo foi a descendente anterior, os que tinham a doença de um vaso, os que foram considerados para tratamento com stent com sirolimus, e aqueles com diâmetro luminal mínimo menor imediatamente após o procedimento. Na análise multivariada, o único preditor independente de trombose do stent foi o diâmetro luminal mínimo imediatamente após o procedimento.
a taxa de trombose de stent farmacológico em pacientes com oclusão coronária crónica foi relativamente baixa (1,4%).
O único preditor independente de trombose de stent neste contexto foi o diâmetro luminal mínimo após o procedimento, tendo a apresentação clínica em todos os casos sido relativamente benigna.
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.
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.
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.
Spontaneous coronary artery dissection: Still a lot to learn Neves, David; Bento, Ângela; Fernandes, Renato ...
Revista portuguesa de cardiologia,
January 2017, 2017-Jan, 2017-01-00, 20170101, 2017-01-01, Letnik:
36, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is an uncommon but probably underdetected pathological substrate for acute coronary syndrome. Clinical associations have been noted, ...like female gender and young age, but its pathophysiology is not yet fully understood. In this report we describe the case of a 50-year-old woman, without cardiovascular risk factors presenting with non-ST segment elevation myocardial infarction, in whom SCAD was diagnosed. Treatment was initially conservative but due to aggravation of the dissection she eventually underwent a complex percutaneous coronary intervention, requiring implantation of multiple stents, but with a good clinical outcome. The procedure was guided by optical coherence tomography (OCT). Carefully analyzing the combined pictures of OCT and angiography, the dissection appeared to be filled with a clear fluid, but not contrast.
A disseção espontânea de artéria coronária (DEAC) é uma causa pouco frequente, mas provavelmente sub-diagnosticada, de síndrome coronária aguda. Estão descritas algumas associações clínicas, como o sexo feminino e a idade jovem, mas ainda não está estabelecida a completa fisiopatologia desta entidade. Neste trabalho apresentamos o caso de uma mulher de 50 anos, sem fatores de risco conhecidos, que se apresenta com um enfarte agudo do miocárdio sem supra-desnivelamento de ST, e em quem é diagnosticada uma DEAC. O tratamento foi inicialmente conservador, no entanto, devido a agravamento da disseção, acabou por realizar uma angioplastia complexa, requerendo implantação de vários stents, com bom resultado clínico. O procedimento foi guiado com tomografia de coerência óptica (OCT). Na análise cuidada das imagens de OCT e angiografia, constata-se que a disseção aparenta estar preenchida com um fluido translúcido, mas não contraste.
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