Aspectos clínicos e de sobrevida em pacientes submetidos a troca valvar mecânica, com ênfase na incidência e fatores associados à trombose de prótese
Aspectos clínicos e de sobrevida em pacientes submetidos a troca valvar mecânica, com ênfase na incidência e fatores associados à trombose de prótese
Data
2020
Autores
Tagliari, Fabio
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução : As doenças orovalvares tem prevalência expressiva, afetando mais de 100 milhões de pessoas no mundo. Com o implante de próteses valvares houve clara melhora da sobrevida e qualidade de vida. Entretanto, o procedimento resultou em novas entidades patológicas, como o pannus, a endocardite infecciosa e a trombose de prótese valvar mecânica.Objetivos:Descrever aspectos clínicos e laboratoriais de pacientes que foram submetidos a troca valvar mecânica no período de 2011 a 2017 no Instituto Nacional de Cardiologia (INC), Rio de Janeiro; determinar a incidência de trombose de próteses valvares mecânicas (TPV); traçar o perfil dos pacientes com TPV e descrever os fatores associados a este desfecho; descrever o tratamento dispensado aos pacientes com trombose de prótese valvar mecânica e os desfechos desses casos. Métodos: Este é um estudo de coorte retrospectivo com seguimento de até nove anos. Os pacientes foram identificados no banco de dados do Serviço de Doenças Orovalvares do INC e do registro de cirurgias do Serviço de Cirurgia, INC. As variáveis de estudo foram buscadas em prontuários físicos e eletrônicos. Os cálculos foram feitos pelo programa Jamovi 1.2.2.; p<0,05 foi considerado estatisticamente significante. Curvas de Kaplan Meier para óbito e trombose de prótese foram construídas. Resultados: Foram incluídos 473 pacientes no período de estudo, sendo 231 (48,8%) homens. A idade média foi 46,9 ±11,3 anos. Etiologias primárias da doença valvar foram reumática(57,7%), degenerativa (12,9%) e válvula aórtica bicúspide (12,1%). Pacientes com prótese aórtica St. Jude tiveram taxa de sobrevida estatisticamente superior àqueles com ATS. Houve diferença estatística na sobrevida de próteses valvares em posição aórtica comparativamente à posição mitroaórtica. A mortalidade dos pacientes com implante de prótese mecânica foi de 16,1% no seguimento. A incidência de TPV foi de 1.4% (7 eventos), e de 1,1% por paciente (5 pacientes). A taxa anual de TPV foi de 0,24/100 pacientes-ano, em média de acompanhamento de 4,43 anos. O primeiro evento de TPV se deu após 1000 dias de observação. O tabagismo foi estatisticamente associado a TPV (p<0,001; IC 95%) assim como a presença de pannus. Houve diferença estatística apenas para o valor de INR do mês precedendo o evento trombose em 6 avaliações. Não houve diferença estatística para a variabilidade entre os valores de INR para os pacientes com e sem trombose de prótese por posição protética Quando comparado o INR no último mês de aferição nos pacientes que fizeram TPV, houve diferença estatística ( INR de 2.20[1.80-2.20] vs 2.80[2.20-3.40]; p 0,040). A frequência de acidentes vasculares cerebrais (AVC) após o implante protético foi de 4,4%. A frequência de eventos de sangramento, maiores e menores, foi de 5,2%. Conclusões: A população do estudo mostrou-se jovem e com prevalência de etiologia reumática. Os índices de trombose valvar protética mecânica encontram-se dentro daquelas relatadas pela literatura, e não houve desfecho do evento precocemente ao implante valvar.
Introduction: Valvular heart diseases are highly prevalent, affecting more than 100 million people worldwide. Heart valve replacement surgery with bioprosthetic or mechanical valves clearly improved patients’ quality of life and survival. However, the procedure resulted in new pathological entities, which can cause prosthetic dysfunction, such as pannus, infective endocarditis and mechanical prosthetic valve thrombosis (PVT). Objectives: To describe clinical and laboratory features of patients who underwent heart valve replacement with mechanical valves, from 2011 to 2017, at the Instituto Nacional de Cardiologia (INC), Rio de Janeiro; to determine the incidence of PVT; to describe the features of patients with PVT and factors associated to this outcome; to describe treatment strategies implemented for PVT and related outcomes. Methods: This is a retrospective cohort study with a follow-up time of up to nine years. Patients were identified in the Heart Valve Department database as well as in the Cardiovascular Surgery registry at INC. Study variables were obtained in patients’ records, both physical and electronic. A datasheet was created for the study variables. A p value <0,05 was considered statistically significant. Kaplan Meier curves for death and prosthetic thrombosis were constructed. Calculations were made utilizing the Jamovi program version 1.2.2. Results: Four hundred and seventy-three patients were included in the study period; 231(48.8%) were male and 242(51.2%) female. Mean age (±SD) was 46.9± 11.3 years. Primary etiologies of valve disease were rheumatic (57.7%), degenerative (12.9%), and bicuspid aortic valve (12,1%). The incidence of PVT was 1.4% (7 episodes) and 1.1% if thrombosis in patients were taken into account (5 patients had PVT). The mean annual rate of thrombosis was 0.24%, in a 9- year follow up period. The first episode of PVT occurred after 1000 days of valve implantation. There was an association between smoking and PVT that reached statistical significance as well as the presence of pannus. Differences in INR values were observed only in the last month in the 6-month period preceding the event (2.20[1.80-2.20] for patients with PVT vs 2.80[2.20-3.40]; p 0,040) . There was no difference in the variability of INR values for patients with and without PVT. Patients presented INR values in the target range (between 2.0-and 3.5) for only 40.6% of the evaluated time. The incidence of cerebral vascular events after mechanical valve replacement was 4.4%. Bleeding events, both major and minor, were seen in 5.1%. Overall mortality of patients with mechanical valve replacement was 16.1%. Conclusions: Our study population was young and had predominantly rheumatic valvulopathy as the primary cause for heart valve surgery. The incidence of PVT was similar to the literature and was seen only late after the implant. Keywords: mechanical valve prosthesis; prosthetic thrombosis; cardiac surgery; heart valve replacement surgery; mortality; anticoagulation.
Introduction: Valvular heart diseases are highly prevalent, affecting more than 100 million people worldwide. Heart valve replacement surgery with bioprosthetic or mechanical valves clearly improved patients’ quality of life and survival. However, the procedure resulted in new pathological entities, which can cause prosthetic dysfunction, such as pannus, infective endocarditis and mechanical prosthetic valve thrombosis (PVT). Objectives: To describe clinical and laboratory features of patients who underwent heart valve replacement with mechanical valves, from 2011 to 2017, at the Instituto Nacional de Cardiologia (INC), Rio de Janeiro; to determine the incidence of PVT; to describe the features of patients with PVT and factors associated to this outcome; to describe treatment strategies implemented for PVT and related outcomes. Methods: This is a retrospective cohort study with a follow-up time of up to nine years. Patients were identified in the Heart Valve Department database as well as in the Cardiovascular Surgery registry at INC. Study variables were obtained in patients’ records, both physical and electronic. A datasheet was created for the study variables. A p value <0,05 was considered statistically significant. Kaplan Meier curves for death and prosthetic thrombosis were constructed. Calculations were made utilizing the Jamovi program version 1.2.2. Results: Four hundred and seventy-three patients were included in the study period; 231(48.8%) were male and 242(51.2%) female. Mean age (±SD) was 46.9± 11.3 years. Primary etiologies of valve disease were rheumatic (57.7%), degenerative (12.9%), and bicuspid aortic valve (12,1%). The incidence of PVT was 1.4% (7 episodes) and 1.1% if thrombosis in patients were taken into account (5 patients had PVT). The mean annual rate of thrombosis was 0.24%, in a 9- year follow up period. The first episode of PVT occurred after 1000 days of valve implantation. There was an association between smoking and PVT that reached statistical significance as well as the presence of pannus. Differences in INR values were observed only in the last month in the 6-month period preceding the event (2.20[1.80-2.20] for patients with PVT vs 2.80[2.20-3.40]; p 0,040) . There was no difference in the variability of INR values for patients with and without PVT. Patients presented INR values in the target range (between 2.0-and 3.5) for only 40.6% of the evaluated time. The incidence of cerebral vascular events after mechanical valve replacement was 4.4%. Bleeding events, both major and minor, were seen in 5.1%. Overall mortality of patients with mechanical valve replacement was 16.1%. Conclusions: Our study population was young and had predominantly rheumatic valvulopathy as the primary cause for heart valve surgery. The incidence of PVT was similar to the literature and was seen only late after the implant. Keywords: mechanical valve prosthesis; prosthetic thrombosis; cardiac surgery; heart valve replacement surgery; mortality; anticoagulation.
Description
Palavras-chave
Prótese valvar mecânica, Trombose, Cirurgia de troca valvar, Mortalidade, Cirurgia cardíaca, Anticoagulação, Mortality, Mechanical valve prosthesis, prosthetic thrombosis, Cardiac surgery, Heart valve replacement surgery, Anticoagulation
Citação
Tagliari F. Aspectos clínicos e de sobrevida em pacientes submetidos a troca valvar mecânica, com ênfase na incidência e fatores associados à trombose de prótese. Dissertação [Mestrado Profissional em Ciências Cardiovasculares] - Instituto Nacional de Cardiologia; 2020.