Remodelamento reverso do ventrículo esquerdo pós-implante de válvula aórtica transcateter: análise de uma coorte do Sistema Único de Saúde
Remodelamento reverso do ventrículo esquerdo pós-implante de válvula aórtica transcateter: análise de uma coorte do Sistema Único de Saúde
Data
2020-04
Autores
Simões, Luciana Silveira
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
A disfunção sistólica do ventrículo esquerdo (DSVE) está associada a aumento da mortalidade na
estenose aórtica (EA) grave. A substituição valvar aórtica transcateter (TAVR) é uma alternativa para a
correção da EA grave em pacientes com alto risco operatório e sua indicação tem sido ampliada para
condições de risco intermediário e baixo. Poucos estudos avaliaram a ocorrência de remodelamento
reverso (RR) do ventrículo esquerdo (VE) após TAVR em indivíduos com EA grave e DSVE. Objetivos:
Verificar a ocorrência de RR do VE comparando o ecocardiograma transtorácico (ETT) pré e pós-TAVR
em 1 ano. Descrever a mortalidade dos pacientes com DSVE, classe funcional (CF) e perfil
hemodinâmico pelo Echo em até 1 ano após a realização da TAVR. Método: Estudo retrospectivo de
pacientes submetidos a TAVR em hospital do sistema único de saúde, entre novembro de 2011 a maio
de 2018. Considerado como DSVE pelo ETT(Teicholz): fração de ejeção do ventrículo esquerdo (FEVE)
≤ 51% em homens e ≤ 53 % em mulheres. Foi registrada mortalidade dos paciente com DSVE em 30
dias e 1 ano. Foi considerado RR a ocorrência de um aumento absoluto da FEVE de 10% ou mais para
uma FEVE final > 35% ao final do primeiro ano. A CF da New York Heart Association (NYHA), as
dimensões do VE e o gradiente transaórtico médio (GM) pelo ETT também foram coletados.
Resultados:Trinta pacientes eram portadores de DSVE, porém 5 (17%) pacientes foram excluídos do
estudo por morte antes de 1 ano pós TAVR; óbito em 30 dias ocorreu em 2 pacientes( 6,6%). Dessa
forma, 25 pacientes foram avaliados com DSVE, sendo onze (44%)do sexo feminino, idade média de
73,8 ± 16,8 anos e 22 (88%) estavam em CF III ou IV pré-intervenção. EuroSCORE logístico 19,2[10,2-
22,4], escore STS 4,40[3,3 ±12,6], FEVE 40,88[35,5 ±5%],GM 43,5 ± 15,3mmHg, área valvar aórtica
0,6±0,3 cm². Dezoito pacientes (72%) preencheram os critérios de RR. Houve melhora significativa da
CF comparativamente antes e após o implante (CF por NYHA III ou IV 88% versus 4%). Em relação
a evolução do ETT após 1 ano do TAVR, houve significância estatística entre os seguintes dados:
diâmetro diastólico final VE (56 [50 – 63] versus 51 [49 - 62]; P = 0,008), volume diastólico final VE(172
[156- 210] versus 132 [115-172]; P = 0,04) e volume sistólico final VE (110 [88-141] versus 81,4 [44-
118] P = 0,04). As complicações mais frequentes neste estudo foram o implante de novo marca-passo
definitivo, que foi necessário em 6(24%) casos, seguido de insuficiência periprotética moderada a
grave, presente em 5(20%) casos. Houve associação significativa entre implante de novo marca-passo
definitivo após o TAVR com a não remodelação reversa do VE em 1 ano (P = 0,032).Conclusão: O
TAVR em uma população com DSVE foi seguido de RR na maioria dos casos, melhora da CF e perfil
hemodinâmico. Este estudo sugere que o implante de marca passo definitivo após TAVR está
relacionado ao não RR do VE. Novos estudos podem trazer maior robustez à avaliação da remodelação
reversa do VE em pacientes com DSVE que receberam TAVR.
Palavras-chave: Estenose da válvula aórtica, insuficiência cardíaca, Remodelação ventricular,
Substituição da Valva Aórtica Transcateter
ABSTRACT Left ventricular systolic dysfunction (LVSD) is associated to increased mortality in severe aortic stenosis (SAS). Transcatheter aortic valve replacement (TAVR) is an alternative for the correction of severe SAS in patients with high operative risk and the indications are increasing. Few studies have evaluated the occurrence of left ventricular reverse remodeling after TAVR in subjects with SAS and heart failure (HF). Goals: To ascertain the occurrence of left ventricular (LV) reverse remodeling by comparing pre and post-TAVR echocardiography (Echo) within 1 year. To describe one year mortality, functional class and hemodynamic profile one year after TAVR. Method: A retrospective study of patients submitted to TAVR For isolated SAS in a tertiary hospital between November 2011 and May 2018. Pre-TAVR Echo performed for LVFE(Teicholz) evaluation and considered as having HF: LVEF≤ 51% in men and ≤53% in women. Recorded mortality at 30 days and 1 year. The occurrence of an absolute increase in left ventricular ejection fraction (LVEF) of 10% or more was considered reverse remodeling for a final LVEF > 35%. New York Heart Association Functional Class, left ventricular dimensions and mean transaortic gradient by echocardiogram (MG) were also collected. Results: 30 patients had LVSD, but 5 (17%) patients were excluded from the study due to death before 1 year after TAVR, with 2 patients (6.6%) in 30 days. Thus, 25 patients with LVSD, eleven (44%) were female, with a mean age of 73.8 ± 16.8 years and 22 (88%) were in pre-intervention functional class III or IV. EuroSCORE logistical 19.2 [10.2-22.4], STS score 4.40 [3.3 ± 12.6], LVEF 40.88 [35.5 ± 5%], GM 43.5 ± 15, 3mmHg, aortic valve area 0.6±0.3 cm². Eighteen patients (72%) met the reverse remodeling criteria after one year. There was a significant improvement in functional class comparatively before and after implantation (NYHA class III or IV 88% versus 4%). Regarding the evolution of Echo after 1 year of TAVR, there was statistical significance between the following data: LV end diastolic diameter (56 [50 - 63] versus 51 [49 x 62]; P = 0.008), LV end diastolic volume (172 [156-210] versus 132 [115-172]; P = 0.04) and LV stroke volume (110 [88- 141] versus 81.4 [44-118]; P = 0.04). The most frequent complications in this study were the implantation of a new permanent pacemaker, present in 6 (24%) cases, followed by moderate to severe periprosthetic insufficiency, present in 5 (20%) cases. There was a significant association between the implantation of a new permanent pacemaker after the procedure with reverse LV remodeling (P = 0.032). Conclusion: TAVR in a population with LVSD was followed by reverse remodeling in most cases, improvement of functional class an hemodynamic profile. This study suggests that the implantation new pacemaker after TAVR is related to the non-reverse remodeling of the LV. Further studies may bring greater robustness to the evaluation of LV reverse remodeling in LVSD patients who received TAVR. Keywords: Aortic valve stenosis, heart failure, ventricular remodeling, transcatheter aortic valve replacemen
ABSTRACT Left ventricular systolic dysfunction (LVSD) is associated to increased mortality in severe aortic stenosis (SAS). Transcatheter aortic valve replacement (TAVR) is an alternative for the correction of severe SAS in patients with high operative risk and the indications are increasing. Few studies have evaluated the occurrence of left ventricular reverse remodeling after TAVR in subjects with SAS and heart failure (HF). Goals: To ascertain the occurrence of left ventricular (LV) reverse remodeling by comparing pre and post-TAVR echocardiography (Echo) within 1 year. To describe one year mortality, functional class and hemodynamic profile one year after TAVR. Method: A retrospective study of patients submitted to TAVR For isolated SAS in a tertiary hospital between November 2011 and May 2018. Pre-TAVR Echo performed for LVFE(Teicholz) evaluation and considered as having HF: LVEF≤ 51% in men and ≤53% in women. Recorded mortality at 30 days and 1 year. The occurrence of an absolute increase in left ventricular ejection fraction (LVEF) of 10% or more was considered reverse remodeling for a final LVEF > 35%. New York Heart Association Functional Class, left ventricular dimensions and mean transaortic gradient by echocardiogram (MG) were also collected. Results: 30 patients had LVSD, but 5 (17%) patients were excluded from the study due to death before 1 year after TAVR, with 2 patients (6.6%) in 30 days. Thus, 25 patients with LVSD, eleven (44%) were female, with a mean age of 73.8 ± 16.8 years and 22 (88%) were in pre-intervention functional class III or IV. EuroSCORE logistical 19.2 [10.2-22.4], STS score 4.40 [3.3 ± 12.6], LVEF 40.88 [35.5 ± 5%], GM 43.5 ± 15, 3mmHg, aortic valve area 0.6±0.3 cm². Eighteen patients (72%) met the reverse remodeling criteria after one year. There was a significant improvement in functional class comparatively before and after implantation (NYHA class III or IV 88% versus 4%). Regarding the evolution of Echo after 1 year of TAVR, there was statistical significance between the following data: LV end diastolic diameter (56 [50 - 63] versus 51 [49 x 62]; P = 0.008), LV end diastolic volume (172 [156-210] versus 132 [115-172]; P = 0.04) and LV stroke volume (110 [88- 141] versus 81.4 [44-118]; P = 0.04). The most frequent complications in this study were the implantation of a new permanent pacemaker, present in 6 (24%) cases, followed by moderate to severe periprosthetic insufficiency, present in 5 (20%) cases. There was a significant association between the implantation of a new permanent pacemaker after the procedure with reverse LV remodeling (P = 0.032). Conclusion: TAVR in a population with LVSD was followed by reverse remodeling in most cases, improvement of functional class an hemodynamic profile. This study suggests that the implantation new pacemaker after TAVR is related to the non-reverse remodeling of the LV. Further studies may bring greater robustness to the evaluation of LV reverse remodeling in LVSD patients who received TAVR. Keywords: Aortic valve stenosis, heart failure, ventricular remodeling, transcatheter aortic valve replacemen
Description
Palavras-chave
Estenose da válvula aórtica, insuficiência cardíaca, Remodelação ventricular, Substituição da Valva Aórtica Transcateter, Aortic valve stenosis, Heart failure, Ventricular remodeling, Transcatheter aortic valve replacement
Citação
Simões LS. Remodelamento reverso do ventrículo esquerdo pós-implante de válvula aórtica transcateter: análise de uma coorte do Sistema Único de Saúde. Dissertação [Mestrado Profissional em Ciências Cardiovasculares]. Instituto Nacional de Cardiologia; 2020.