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INTRODUCTION AND OBJECTIVES Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI) and is associated with higher mortality. However, the impact of AKI on long-term outcomes remains controversial. Therefore, we sought to evaluate the impact of AKI on short- and long-term outcomes following TAVI using the Valve Academic Research Consortium 2 criteria. METHODS Consecutive patients (n = 794) with severe aortic stenosis who underwent TAVI were included in a multicenter Brazilian registry. Logistic regression analysis was used to identify predictors of AKI. Four-year outcomes were determined as Kaplan-Meier survival curves, and an adjusted landmark analysis was used to test the impact of AKI on mortality among survivors at 12 months. RESULTS The incidence of AKI after TAVI was 18%. Independent predictors of AKI were age, diabetes mellitus, major or life-threatening bleeding and valve malpositioning. Acute kidney injury was independently associated with higher risk of all-cause death (adjusted HR, 2.8; 95%CI, 2.0-3.9; P < .001) and cardiovascular mortality (adjusted HR, 2.9; 95%CI, 1.9-4.4; P < .001) over the entire follow-up period. However, when considering only survivors at 12 months, there was no difference in both clinical endpoints (adjusted HR, 1.2; 95%CI, 0.5-2.4; P = .71, and HR, 0.7; 95%CI, 0.2-2.1; P = .57, respectively). CONCLUSIONS Acute kidney injury is a frequent complication after TAVI. Older age, diabetes, major or life-threatening bleeding, and valve malpositioning were independent predictors of AKI. Acute kidney injury is associated with worse short- and long-term outcomes. However, the major impact of AKI on mortality is limited to the first year after TAVI.

Resumen Introduccion y objetivos El dano renal agudo (DRA) ocurre con frecuencia tras el implante percutaneo de valvula aortica (TAVI) y se asocia con una mayor mortalidad. Sin embargo, el impacto del DRA en la evolucion a largo plazo continua siendo controvertida. Por dicho motivo se evalua el impacto del DRA el resultado a corto y largo plazo tras el TAVI usando los criterios Valve Academic Research Consortium 2. Metodos Se incluyeron 794 pacientes consecutivos con estenosis aortica grave en un registro multicentrico brasileno. Para la identificacion de los predictores de DRA se utilizo el analisis de regresion logistica. La supervivencia a 4 anos se determino mediante las curvas de Kaplan-Meier y para determinar el impacto del DRA en la mortalidad entre los supervivientes a 12 meses se uso un analisis de punto de referencia ajustado. Resultados La incidencia de DRA tras el TAVI fue del 18%. Los predictores independientes de DRA fueron: edad, diabetes mellitus, hemorragia mayor o amenazante para la vida y la malaposicion valvular. El DRA se asocio independientemente con un riesgo mayor de muerte total (HR ajustada = 2,8; IC95%, 2,0-3,9; p Conclusiones El DRA es una complicacion frecuente tras el TAVI. La edad avanzada, la diabetes, la hemorragia mayor o amenazante para la vida y la malaposicion valvular eran factores predictivos de DRA. El DRA se asocio con el pronostico a corto y largo plazo, sin embargo, el impacto del DRA sobre la mortalidad se limito al primer ano tras el TAVI.

Resumo: Introdução: Nefropatia induzida por contraste (NIC) após intervenção coronária percutânea (ICP) em pacientes com taxa de filtração glomerular (TFG) ≥ 60 mL/min, estimada pela equação de Cockcroft‐Gault (C‐G), não é infrequente. O objetivo desse estudo foi avaliar a capacidade da equação CKD‐EPI (Chronic Kidney Disease Epidemiology Collaboration) em predizer NIC em indivíduos sem disfunção renal significativa basal pela fórmula C‐G. Métodos: Incluídos pacientes submetidos a ICP entre 2008‐2013, com TFG basal ≥ 60 mL/min pela equação de C‐G. Estes indivíduos foram divididos em dois grupos, conforme ocorrência ou não de NIC. Para todos os casos, foi calculada a TFG basal conforme a equação do CKD‐EPI. Resultados: A amostra consistiu de 140 pacientes. A TFG C‐G basal foi de 87,5 ± 21,3 mL/min e de 77,1 ± 15,0 mL/min/1,73 m2 para CKD‐EPI. NIC ocorreu em 84,6% dos pacientes com TFG CKD‐EPI basal

Introduction: Individuals with glomerular filtration rate (GFR) ≥60 ml/min/1.73 m2 estimated by the Cockcroft-Gault formula (CG) who undergo percutaneous coronary intervention (PCI) frequently develop contrast-induced nephropathy (CIN). This study aimed to assess whether individuals with significant renal impairment assessed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, but not by CG, more often develop CIN following PCI than those without renal impairment by either formula. Methods: In this cross-sectional study analyzing patients with baseline CG GFR ≥60 ml/min/1.73 m2 before PCI, subjects were divided into two groups according to CIN occurrence. Baseline CKD-EPI GFR was calculated for all patients. Results: We analyzed 140 patients. Baseline GFR was 87.5±21.3 and 77.1±15.0 ml/min/1.73 m2 for CG and CKD-EPI, respectively. CIN occurred in 84.6% of individuals with baseline CKD-EPI GFR

Objectives This study aimed to compare gender-related differences in outcomes of patients undergoing TAVI over a long-term follow-up period. Background Transcatheter aortic valve implantation (TAVI) has been considered the standard therapy for patients with inoperable or high-risk symptomatic aortic stenosis. The influence of gender-related differences in outcomes of patients undergoing TAVI is currently on debate. Methods From January 2008 to January 2015, 819 patients (49% men) underwent TAVI and were included in a multicenter Brazilian registry. Patients were followed-up and clinical outcomes were evaluated according to the updated Valve Academic Research Consortium-2 criteria. Results Mean follow-up was 497 ± 478 days. Compared with women, men had a lower rate of major or life-threatening bleeding (12.0% vs. 20.6%; HR = 0.57 [95CI% 0.40–0.81]; P = 0.001), and major vascular complications (6% vs. 11.7%; HR = 0.50 [95CI% 0.31–0.82]; P = 0.004). At 30 days, all-cause mortality was lower in men than in women (6.5% vs. 11.5%; P = 0.013), however, cumulative all-cause mortality was similar between groups (25.9% vs. 29.7%, men and women, respectively, HR = 0.92 [95CI% 0.71–1.19]; P = 0.52) over the entire follow-up period. By adjusted Cox regression model, renal function, diabetes, peripheral artery disease, and chronic obstructive pulmonary disease (COPD) remained independently predictors of all-cause mortality. Conclusions In this large-scale study evaluating patients undergoing TAVI, 30-day mortality was higher among women than men driven by significant higher rates of major or life-threatening bleeding and major vascular complications. However, all-cause mortality on long-term follow-up was similar between groups. © 2016 Wiley Periodicals, Inc.

This study aimed to compare gender-related differences in outcomes of patients undergoing TAVI over a long-term follow-up period.Transcatheter aortic valve implantation (TAVI) has been considered the standard therapy for patients with inoperable or high-risk symptomatic aortic stenosis. The influence of gender-related differences in outcomes of patients undergoing TAVI is currently on debate.From January 2008 to January 2015, 819 patients (49% men) underwent TAVI and were included in a multicenter Brazilian registry. Patients were followed-up and clinical outcomes were evaluated according to the updated Valve Academic Research Consortium-2 criteria.Mean follow-up was 497 ± 478 days. Compared with women, men had a lower rate of major or life-threatening bleeding (12.0% vs. 20.6%; HR = 0.57 [95CI% 0.40-0.81]; P = 0.001), and major vascular complications (6% vs. 11.7%; HR = 0.50 [95CI% 0.31-0.82]; P = 0.004). At 30 days, all-cause mortality was lower in men than in women (6.5% vs. 11.5%; P = 0.013), however, cumulative all-cause mortality was similar between groups (25.9% vs. 29.7%, men and women, respectively, HR = 0.92 [95CI% 0.71-1.19]; P = 0.52) over the entire follow-up period. By adjusted Cox regression model, renal function, diabetes, peripheral artery disease, and chronic obstructive pulmonary disease (COPD) remained independently predictors of all-cause mortality.In this large-scale study evaluating patients undergoing TAVI, 30-day mortality was higher among women than men driven by significant higher rates of major or life-threatening bleeding and major vascular complications. However, all-cause mortality on long-term follow-up was similar between groups. © 2016 Wiley Periodicals, Inc.

Background: Predicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge. Objectives: To evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI. Methods: The Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer–Lemeshow test) and discrimination [area under the receiver–operating characteristic curve (AUC)]. Results: The mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer–Lemeshow test indicated acceptable calibration for all scores (p > 0.05). Conclusions: In this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

Incisional hernia is an uncommon complication in laparoscopic surgery. The majority of the hernias are located in the umbilical site. Nevertheless, they can occur in the lateral trocar site, although they are rarely diagnosed. We report a case of a 55 year-old patient who underwent a videolaparoscopic hysterectomy and developed small bowel obstruction on the third postoperative day. This initially gave rise to the diagnosis of paralytic ileum. The definitive diagnosis of incarcerated hernia in the lateral trocar site was established after an abdominal computed tomography was performed.

Introdução: A cirurgia carotídea é uma possível estratégia para a prevenção do acidente vascular encefálico (AVE) em determinados pacientes, porém o perfil intrínseco de morbidade da operação também deve ser avaliado. Além do risco de infarto do miocárdio e AVE perioperatórios, os pacientes, em virtude de estímulo direto ao seio carotídeo, podem desenvolver hipotensão e/ou bradicardia no pós-operatório, caracterizando-se a \"depressão hemodinâmica\" (DH), que pode estar associada a desfechos cardiovasculares adversos graves. Objetivo: Estimar a incidência de DH após cirurgia carotídea, identificando seus fatores de risco. De maneira secundária, avaliar a associação entre DH e desfechos cardiovasculares adversos. Métodos: Análise retrospectiva dos prontuários de 220 pacientes submetidos a 237 procedimentos de angioplastia e/ou endarterectomia entre Janeiro de 2014 e Dezembro de 2018 em dois hospitais de nível terciário e quaternário. Depressão hemodinâmica foi definida como a ocorrência de bradicardia ou hipotensão nas primeiras 24h após o procedimento cirúrgico. Considerou-se bradicardia como frequência cardíaca < 50bpm; hipotensão como pressão arterial sistólica (PAS) < 90mmHg ou necessidade de vasopressor contínuo ou queda da PAS >= 20% em relação ao basal. Os eventos cardiovasculares adversos considerados foram infarto do miocárdio, acidente vascular encefálico e morte por causa cardiovascular. Resultados: Em nossa população, 62,0% dos pacientes eram do sexo masculino; a média de idade foi 68,66 anos; 92,4% hipertensos; 42,2% diabéticos; 31,2% portadores de doença arterial coronariana; 48,5% com história pregressa de AVE e 31,2% com estenose carotídea sintomática. Ao todo, foram realizadas 178 endarterectomias (75,10%) e 59 angioplastias (24,90%) carotídeas. A incidência de DH foi 54,4% (hipotensão em 50,2%; bradicardia em 11%; hipotensão e bradicardia em 6,8%). Em relação aos desfechos adversos avaliados, ocorreram em 11% do total de procedimentos, sendo 16 infartos do miocárdio, 14 AVEs e 2 mortes cardiovasculares. Após análise multivariada, os fatores de risco independentes para DH encontrados foram estenose carotídea assintomática (OR: 1,824; IC 95%: 1,014 - 3,280; p = 0,045), angioplastia carotídea (OR: 3,319; IC 95%: 1,675 - 6,576; p = 0,001) e hipotensão ou bradicardia no intraoperatório (OR: 2,144; IC 95%: 1,222 - 3,762; p = 0,008). Apenas a DH com necessidade de uso de vasopressor contínuo no pós- operatório esteve associada a desfechos cardiovasculares adversos (OR: 5,504; IC 95%: 1,729 - 17,529; p = 0,004). Conclusões: A incidência de DH é alta e é influenciada pela técnica cirúrgica, pela presença de sintomas decorrentes da estenose carotídea e pela ocorrência de hipotensão ou bradicardia no intraoperatório. Acreditamos que o tratamento imediato da DH oferecido rotineiramente aos pacientes possa explicar a ausência de correlação com os desfechos adversos cardiovasculares pesquisados, tendo sido detectada associação apenas no subgrupo mais extremo da Depressão Hemodinâmica que necessitou de infusão contínua de vasopressor. Destarte, reforça-se a necessidade de monitorização cardiovascular nas primeiras 24 horas após cirurgia carotídea como prática habitual. Background: Although carotid surgery can improve stroke prevention in selected patients, its intrinsic morbidity must be considered. Besides the perioperative risk of myocardial infarction and stroke, patients may develop hypotension and/or bradycardia due to direct carotid sinus stimuli after surgery, characterizing haemodynamic depression (HD), which may be associated to severe cardiovascular outcomes. Purpose: Evaluate the incidence of HD after carotid surgery and identify its risk factors. Secondarily, assess the association between HD and cardiovascular events. Methods: Retrospective analysis of 220 charts (237 surgical procedures) of patients submitted to carotid surgery between January 2014 and December 2018 in two tertiary hospitals. Haemodynamic depression was defined as the presence of bradycardia or hypotension in the first 24h after the surgical procedure. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure (SBP) = 20% compared to preoperative values. Myocardial infarction, stroke and cardiovascular death were the adverse events registered. Results: Demographic characteristics: 62.0% male; mean age 68.66 years; 92,4% hypertensive; 42.2% diabetic; 31.2% coronary heart disease patients; 48.5% had a past medical history of stroke and 31.2% had symptomatic carotid stenosis. Overall, 178 endarterectomies and 59 endovascular procedures were performed. The incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0% and hypotension and bradycardia in 6.8%). Cardiovascular events occurred in 11% of procedures: 16 myocardial infarctions, 14 strokes and 2 deaths. The independent predictors of HD were asymptomatic carotid stenosis (OR: 1.824; CI 95%: 1.014 - 3.280; p = 0.045), endovascular surgery (OR: 3.319; CI 95%: 1.675 - 6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR: 2.144; CI 95%: 1.222 - 3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor associated to adverse cardiovascular events (OR: 5,504; CI 95%: 1,729 - 17,529; p = 0,004). Conclusions: The incidence of HD is high and influenced by the surgical technique, symptomatic repercussion of the carotid stenosis and intraoperative hypotension or bradycardia. We believe that the prompt treatment of HD in our routine assistance may explain why we did not find correlation between Hemodynamic Depression and cardiovascular events, although there was an association with adverse events on the subgroup with extreme DH that required continuous infusion of vasopressors after surgery. Hence, we reinforce the need of cardiovascular monitoring in the first 24h after carotid surgery as a routine.

Introdução: Por possibilitar melhor expansão dos stents e maiores áreas luminais finais, intervenção coronária percutânea (ICP) guiada por ultrassom intracoronário (USIC) associou-se com menor ocorrência de eventos cardíacos adversos maiores (ECAM) do que ICP guiada apenas por angiografia. Recentemente introduzida, a tomografia de coerência óptica (TCO) possui resolução 10 vezes maior do que o USIC; possui maior precisão em quantificar dimensões vasculares, melhores sensibilidade/especificidade para caracterizar o ateroma e aspectos de vulnerabilidade, e maior sensibilidade para avaliar a interação stent-vaso. Estudos iniciais, com uso subótimo da TCO, sugeriram que esta é inferior ao USIC para guia da ICP. Estudos randomizados, propondo protocolos dedicados para ICP guiada por TCO ainda são esparsos. Objetivos: Avaliar a não inferioridade da ICP guiada por TCO em comparação com a ICP guiada por USIC quanto a expansão dos stent ao final do procedimento. O objetivo secundário é avaliar o papel adicional da ICP com métodos de imagem invasivos em comparação com um protocolo bastante otimizado de ICP guiada por angiografia. Métodos: Pacientes com >= 1 lesão em >= 1 coronária com diâmetros entre 2,25 a 4,0 mm, foram randomizados 1:1:1, em blocos de 9, para ICP guiada por TCO, USIC ou angiografia. Desenvolvemos algoritmo específico para guia da ICP por TCO. Protocolos pré-definidos e otimizados para guia dos procedimentos com USIC e angiografia foram adotados. Todas as modalidades de imagem foram realizadas ao final dos procedimentos em todos os pacientes. Angiografias, USIC e TCO foram analisadas, de forma cega quanto ao grupo de randomização, em um laboratório de análise central. A margem de não inferioridade para a expansão dos stents na ICP guiada por TCO versus USIC foi estabelecida em 6,85%. Caso a não inferioridade fosse alcançada, testamos a superioridade da ICP guiada por TCO versus angiografia e da ICP guiada por USIC versus angiografia, para o mesmo desfecho. Resultados: Entre 2015 e 2016, randomizamos 151 pacientes para ICP guiada por TCO (n=51 pacientes; 51 lesões), USIC (n=51 pacientes, 51 lesões) e angiografia (n=49 pacientes, 53 lesões). A expansão dos stents foi 98,01 ± 16,14% nas ICP guiadas por TCO, 91,69 ± 15,75% nas guiadas por USIC e 90,53 ± 14,84% nas guiadas por angiografia (p=0,035). A expansão dos stents sob guia da TCO foi não inferior à obtida com USIC (diferença TCO - USIC: 7,00; IC 95% unicaudal: -0,39, p= 1 lesion in >= 1 coronary artery with reference vessel diameter ranging between 2.25 to 4.0 mm were randomized 1:1:1, in blocks of 9, to PCI guided by OCT, IVUS or angiography. We developed a specific algorithm for OCT-guided PCI. Specific pre-defined optimized guidance protocols were also used to guide PCI by IVUS and angiography. All imaging modalities were performed in all groups at the end of the procedures. All angiography, IVUS and OCT images were analyzed in an independent core laboratory, by analysts blinded to the randomization groups. The estimated non inferiority margin for stent expansion was 6.85%. If OCT-guided PCI reached the non-inferiority criteria, we tested, in a hierarchical manner, the superiority of OCT guided PCI versus angiography-guided PCI and IVUS-guided PCI versus angiography-guided PCI for the same endpoint. Results: Between 2015 and 2016, we randomized 151 patients to OCT-guided PCI (n=51 patients; 51 lesions), IVUS guided PCI (n=51 patients, 51 lesions) and angiography-guided (n=49 patients, 53 lesions). Stent expansion was 98.01 ± 16.14% in the OCT-guided PCI, 91.69 ± 15.75% IVUS-guided PCI and 90.53 ± 14.84% in the angiography-guided PCI (p=0,035). Stent expansions obtained by OCT guidance were non-inferior to those obtained by IVUS (estimated difference between OCT and IVUS: 7.00; one-sided 95% CI: -0.39, p

Introdução: Nas últimas décadas, a reestenose tem sido o \"calcanhar de Aquiles\" da intervenção coronária percutânea (ICP), limitando seus resultados no médio e longo prazo. Estudos preliminares demonstraram que após a injúria inicial com catéter balão e/ou com stents coronarianos, há desnudação endotelial, dissecção, deposição plaquetária e atração de leucócitos como resposta imediata, podendo levar à reestenose no seguimento mais tardio. A injúria local na parede arterial após implante de stent pode promover a expressão genética e liberação de mediadores inflamatórios, interleucinas, proteínas de fase aguda e fatores de coagulação, deposição de plaquetas e formação de trombos. Estes processos podem estar diretamente relacionados ao prognóstico da doença cardiovascular, porém são escassos os estudos que caracterizem a resposta inflamatória aguda pós-implante de stent coronariano e à ocorrência de eventos adversos. Objetivos: Neste estudo, pretendeu-se avaliar os efeitos de dose de ataque de Rosuvastatina (40mg) sobre a resposta inflamatória aguda após implante de stent coronariano, bem como correlacionar as variações das concentrações de citocinas e a respectiva expressão gênica. Métodos: Pacientes portadores de doença coronária estável sem uso de estatina (há mais de 7 dias), submetidos à intervenção coronária percutânea eletiva em artéria coronária nativa foram randomizados para receberem dose única de ataque de rosuvastatina (40 mg via oral, 3 horas prévias ao procedimento; Grupo Tratado (GT); n=63) versus Grupo Controle (GC) (Ausência da administração de rosuvastatina); n=61. Foram obtidas amostras do sangue periférico antes da administração via oral da medicação (A), 3 horas após medicação (B) e 3 horas após implante do stent coronariano (C). Avaliou-se hemograma completo, dosagem de proteína C reativa (PCR), óxido nítrico (NO) e análise da expressão dos genes e das proteínas, por meio de RT-qPCR e multiplex luminex, dos mediadores IL-1 ?, IL-6, IL-8, PAI-1, MCP- 1, TNF-? e TGF-?. Os pacientes foram acompanhados clinicamente por doze meses após o procedimento. Resultados: Os grupos não apresentaram diferenças significantes em relação às características clínicas, angiográficas e técnicas, com exceção da ICP para lesões em bifurcação, mais comum no GC (19,7% versus 6,2%; p=0,032). Para a expressão gênica, observou-se redução para IL-6 (p=7 days) undergoing elective PCI to de novo lesions in the native coronary arterywere randomized to receive a loading dose of 40 mg of rosuvastatin [N = 63] versus a control group (CG) (absence of loading dose); [N = 61]. Blood samples were obtained prior to oral administration of the statin (A), 3 hours after medication (B) and 3 hours after PCI (C). The following laboratory tests were conducted: complete blood count, C-reactive protein (CRP), nitric oxide (NO) and analysis of gene and protein expression by means of RT-qPCR and multiplex luminex, IL-1 mediators, IL-6, IL-8, PAI-1, MCP-1, TNF-? and TGF-?. Clinical follow up was achieved up to 12 months after the procedure. Results: The groups did not significantly differ regarding clinical, angiographic and procedure characteristics, except for the higher amount of bifurcation lesions in the CG (19.7% versus 6.2%, p = 0.032). Among patients pre treated wit the statin, there was a reduction in gene expression for IL-6 (p