Jornada do Hospital Santa Izabel - Estimulação Cardíaca

Teremos um tópico sobre o Ecocardiograma no papel da terapia de ressincronização ventricular. Estamos todos convidados.

Colchicine halves incidence of postpericardiotomy syndrome - from Heartwire

Stockholm, Sweden - The first large-scale double-blind, placebo-controlled trial to test the efficacy of colchicine to prevent the development of postpericardiotomy syndrome (PPS) after heart surgery has shown that the drug is very effective, with only eight people needing to be treated to prevent one from developing the syndrome.

"Colchicine halves the risk of postpericardiotomy syndrome following cardiac surgery, and not only is it efficacious but it is safe," said lead author of the study, Dr Massimo Imazio (Maria Vittoria Hospital, Turin, Italy), who presented the findings at the European Society of Cardiology 2010 Congress today. The results were also published simultaneously in the European Heart Journal.

Discussant for the study, Dr Andre Keren (Hadassah University Hospital, Jerusalem, Israel), concurred. He said this was "a carefully performed trial in which colchicine proved an effective and safe treatment modality—it halved the risk of developing postpericardiotomy syndrome without major side effects, and I would like to congratulate the study authors."

Impressive reduction of primary end point with colchicine

 

Imazio explained that PPS is a relatively common and troublesome complication following cardiac surgery, occurring a few days to several weeks after the surgical operation in 10% to 40% of patients. PPS can have a difficult course and complicate the postoperative period with life-threatening events such as cardiac tamponade; moreover, it may prolong the hospital stay and increase management costs, he said. Treatment is based on aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), with steroids being considered in the case of contraindications to or failure of NSAIDs. At present, no pharmacological strategies have been proven to be efficacious in the prevention of the syndrome, he noted. Anecdotal reports have suggested that colchicine may be useful for the treatment of patients with PPS, and it has also been proposed for the primary prevention of the condition on the basis of a preliminary report from Israel. However, this study was insufficiently powered to show a benefit of colchicine in this indication, Imazio explained. The new trial, Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS), is the first prospective, randomized, multicenter trial to test colchicine for the primary prevention of PPS using intention-to-treat analysis, he added.  In the study, 360 cardiac-surgery patients were randomized to colchicine or placebo on the third postoperative day, with those receiving the active drug taking 1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for one month in those >70 kg; doses were halved for those <70 kg or intolerant to the higher dose. The primary efficacy end point was the incidence of PPS at 12 months. The secondary end point was the combined rate of disease-related hospitalization, cardiac tamponade, constrictive pericarditis, and relapses. There was an "impressive" relative risk reduction with colchicine of 57.9% for the primary end point, Imazio said. Colchicine also significantly reduced the rate of the secondary end point, although Keren observed in his discussion that this was not as great a reduction as that seen with the primary end point.

The rate of side effects (mainly related to gastrointestinal intolerance) was similar in the colchicine and placebo groups (respectively, 8.9% vs 5.0%; p=0.212). The relative lack of side effects seen in this trial could be due to the fact that Imazio and colleagues used a much lower dose of colchicine, around a third of that used in the earlier preliminary Israeli trial, Keren said. In their paper, the Italian researchers say the exact mechanism of colchicine action is not fully understood. Most of the pharmacological effects of the drug on inflammation appear to be related to its capacity to disrupt microtubules, and by this mechanism, colchicine is able to inhibit various leukocyte functions, they note, adding that this effect is likely the most significant for the anti-inflammatory action.

Definition of PPS still problematic

Imazio added that the major limitation of the study relates to the definition of PPS, "because there is no general agreement on how to diagnose the syndrome," with the only published criteria having been proposed in the preliminary study from Israel.

"We adopted the same diagnostic criteria for PPS. They can be criticized and considered weak," he and his colleagues state in the paper. "Nevertheless, they represent the first attempt to have an objective approach to the diagnosis."

Massimo Imazio M, Trinchero R, Brucato A, et al. Colchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): A multicentre, randomized, double-blind, placebo-controlled trial. Eur Heart J 2010; DOI:10.1093/eurheartj/ehq319. Available at: http://eurheartj.oxfordjournals.org.

 

Trombose de Prótese Mecânica - by Fábio Soares

Há exatos alguns minutos atrás estávamos discutindo um caso na UTI. Tratava-se de uma paciente feminina, 56 anos, com passado de trova valvar mitral há 18 anos (3 trocas prévias por por disfunção), evoluindo há 30 dias com dispnéia aos esforços. Quando do início dos sintomas, realizou ECO transtorácico que evidenciou prótese mecânica normofuncionante (gradiente médio AE/VE 6mmHg e PSAP estimada em 30mmHg). Os sintomas agravaram-se, sendo admitida na UTI há 48h com franca insuficiência respiratória devido a edema agudo de pulmão. Realizou ecocardiograma transtorácico e transesofágico que evidenciou disfunção de prótese, com restrição da mobilidade de um de seus folhetos, com diferença de velocidade na abertura dos discos, determinando gradiente AE/VE máximo 34mmHg e médio 16mmHg, com PSAP estimada em 90mmHg. Não foram visuaizados trombos. A paciente encontra-se em VM, em uso de baixas drogas de vasoativas, com edema agudo de pulmão refratário. O que fazer? Este foi o motivo de muita discussão entre Ecocardiografistas, Cardiologistas clínicos e Cirurgião Cardiovascular.

Pontos a lembrar

- Idade 56 anos

- Fibrilação atrial permanente

- HP grave

- 4 cirurgias prévias para troca de próteses em posição mitral

- Edema agudo de pulmão refratário /IC CF IV

- TP fora da faixa terapêutica

- Ecocardiograma há 30 dias, sem evidências de disfunção de prótese

O que fazer? Trombolítico? Cirurgia Cardíaca?

Conforme a literatura...

The Thrombosed Prosthetic Valve Current Recommendations Based on Evidence From the Literature

Joseph S. Alpert, MD, FACC
 
1. All patients with suspected TPVs should undergo echocardiographic study. If adequate visualization of the

prosthetic valve is not obtained by a transthoracic study, then a transesophageal echocardiographic study should be undertaken (level of evidence I).

2. Patients with right-sided TPVs should be treated with intravenous rtPA (100 mg administered as 10 mg immediate intravenous bolus followed by 90 mg infused over 90 min) or SK (500,000 IU over 20 min followed by 1.5 million IU infused over 10 h). Reduced doses should be employed in children and very small adults (level of evidence IIa).

3. Patients who are critically ill on presentation with TPV (pulmonary edema, hypotension, NYHA class III/IV symptoms) should receive immediate intravenous thrombolytic therapy as outlined earlier following appropriate echocardiographic confirmation of TPV (level of evidence IIa).

a. Serial echocardiographic studies should be performed in these individuals, and repeated infusions of trombolytic therapy should be administered if complete resolution of prosthetic valve thrombus is not achieved (level of evidence IIa).

b. Concomitant intravenous unfractionated heparin should be administered along with thrombolytic therapy to achieve an activated partial thromboplastin time that is 1.5 to 2.0 times control (level of evidence IIb).

c. Cardiac surgical consultation should be sought urgently. Valve replacement should be seriously considered

if repeated infusions of thrombolytic therapy fail to adequately dissolve the thrombus on the prosthetic valve (level of evidence IIa).

4. Patients with TPV who are clinically stable, that is, in NYHA clinical class I or II, may be managed medically with thrombolytic/antithrombotic therapy or surgically with valve replacement depending on physician/patient preference (level of evidence IIa).

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Echocardiographic signs of obstructive prosthetic valve thrombosis

 

• Reduced valve mobility
• Presence of thrombus
• Abnormal transprosthetic flow
• Central prosthetic regurgitation
• Elevated transprosthetic gradients
• Reduced effective prosthetic area

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 THROMBOSIS OF PROSTHETIC HEART VALVES: DIAGNOSIS AND THERAPEUTIC CONSIDERATIONS
Raymond Roudaut, Karim Serri, Stephane Lafitte

Heart 2007;93:137–142. doi: 10.1136/hrt.2005.071183

Para descontrair...

Já tinha visto este vídeo antes, mas tinha esquecido até rever no site Cardiopapers.

Gordura Epicárdica - by Fábio Soares

Epicardial Fat: An Additional Measurement for Subclinical Atherosclerosis and Cardiovascular Risk Stratification?

Matthew R. Nelson, MD, Farouk Mookadam, MD, FACC, MSc(HRM), Venkata Thota, MD, Usha Emani, MD, Mohsen Al Harthi, MD, FACC, Steven J. Lester, MD, FACC, FRCPC, FASE, Stephen Cha, MSc, Jan Stepanek, MD, MPH, and R. Todd Hurst, MD, FACC, FASE, Scottsdale, Arizona; Rochester, Minnesota

Background: The value of epicardial adipose tissue (EAT) thickness as determined by echocardiography in cardiovascular risk assessment is not well understood. The aim of this study was to determine the associations between EAT thickness and Framingham risk score, carotid intima media thickness, carotid artery plaque, and computed tomographic coronary calcium score in a primary prevention population.

Methods: Patients presenting for cardiovascular preventive care (n = 356) who underwent echocardiography

as well as carotid artery ultrasound and/or coronary calcium scoring were included.

Results: EAT thickness was weakly correlated with Framingham risk score. The prevalence of carotid plaque

was significantly greater in those with EAT thickness >5.0 mm who either had low Framingham risk scores or had body mass indexes >25 kg/m2, compared with those with EAT thickness <;5.0 mm. No significant association between EAT thickness and carotid intima-media thickness or coronary calcium score existed.

Conclusion: EAT thickness >5.0 mm may identify an individual with a higher likelihood of having detectable carotid atherosclerosis. (J Am Soc Echocardiogr 2011;24:339-45.)

Resposta do caso clínico da semana - by Fábio Soares

Megaesôfago Chagásico + Cardiomiopatia Dilatada Grave (MCC) + Trombo móvel em VE

Abaixo, um relato de caso semelhante, porém com acalásia ao invés de megaesôfago, mas usando contraste.

Para todo benefício, há um preço... - by Fábio Soares

Background—Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model.

Methods and Results—Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3 6.7 years of age; 50.6% were male. QRS duration increased from 105 23 to 135 29 milliseconds (P 0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (P 0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM.

 

Conclusion—One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM. (Circulation. 2011;123:951-960.)

Caso Clínico da Semana - by Fábio Soares

Alguém arrisca o diagnóstico somente baseado nas imagens, sem a história clínica?
Uma dica, não é um cisto pericárdico (como o do post anterior), nem um aneurisma da aorta torácica.