Aspectos clínicos e ecocardiográficos da incompatibilidade paciente-prótese em pacientes com próteses valvares cardíacas
Data
2022-11-22
Autores
Bispo, Irving Gabriel Araújo 
Orientadores
Moisés, Valdir Ambrósio
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
INTRODUÇÃO: A incompatibilidade paciente-prótese (IPP) é considerada se uma prótese de valva cardíaca tem gradiente de pressão transprotético elevado e área valvar indexada reduzida, mas funcionamento normal dos folhetos ou discos. A IPP pode ocorrer nas próteses em posição mitral ou aórtica, pode causar repercussão clínica e hemodinâmica e modificar o prognóstico dos pacientes. Na posição mitral os dados ainda são restritos e com controvérsias. O objetivo deste estudo foi analisar a incidência e as características clínicas e ecocardiográficas da IPP em pacientes com prótese em posição mitral ou aórtica. MÉTODO: Foram incluídos pacientes de ambos os gêneros com mais de 18 anos de idade com prótese valvar biológica ou mecânica em posição mitral ou aórtica em acompanhamento ambulatorial desde fevereiro de 2010. Na posição mitral a IPP foi considerada discreta se a área valvar indexada era superior a 1,2 cm2/m2, moderada se entre 0,9 cm2/m2 e 1,2 cm2/m2 e importante se menor ou igual a 0,9 cm2/m2. Na posição aórtica a IPP era discreta se a área valvar indexada fosse maior 0,85 cm2/m2, moderada se entre 0,65 e 0,85 cm2/m2 e importante se menor a 0,65 cm2/m2. Variáveis clínicas e ecocardiográficas foram comparadas entre os grupos de pacientes com IPP moderada ou importante (IPPM2 para prótese em posição mitral ou IPPAO2 para prótese em posição aórtica) e os com IPP discreta (IPPM1 para prótese em posição mitral ou IPPAO1 para prótese em posição aórtica). Os dados foram analisados com os testes de Mann-Whitney, teste t-Student para amostras independentes, Qui-quadrado de Pearson e extensão do teste Exato de Fisher; significante se p 5%.
RESULTADOS: no total, 119 pacientes foram incluídos no estudo. Entre os 60 pacientes (64 +/- 9 anos; 36 mulheres) com prótese em posição aórtica 29 eram biológicas (1 por implante percutâneo) e 31 mecânicas. A IPPAO2 foi diagnosticada em 12 pacientes (20%). Os pacientes com IPPAO2 tiveram área valvar (média de 0,66 cm²/m²) e gradiente de pressão médio (média de 24 mmHg) maiores que os com IPPAO1 (área valvar de 1,2 cm²/m² e gradiente médio de 16 mmHg). Não houve diferença da idade, da superfície corpórea e na incidência de fibrilação atrial entre os pacientes com IPPAO2 e IPPAO1. A proporção de pacientes em classe funcional II e III no grupo IPPAO2 (8 pacientes; 67%) foi significantemente maior que no grupo IPPAO1 (10 pacientes; 17%) (p<0,001). Não houve diferença significante na proporção de estenose ou insuficiência aórtica pré-operatória nem de prótese mecânica ou biológica. O tamanho (medianas de 23 x 25 mm) e a área efetiva prevista (medianas de 1,68 x 2,03 cm2) das próteses dos pacientes com IPPAO2 foram menores (p=0,0038; p=0,0013) que os pacientes com IPPAO1. O volume do átrio esquerdo foi maior nos pacientes com IPPAO2 que no grupo IPPAO1 (51 +/- 16 mL/m2 x 40 +/- 12 mL/m2; p= 0,002) assim como a espessura septal (10,9 +/- 1,2 mm x 10 +/- 1,5 mm; p= 0,018) e da parede do ventrículo esquerdo (10,8 +/- 1,3 mm x 0,99 +/- 1,4 mm; p= 0,046). Não houve diferença significante do índice de massa (121 +/- 38 mg/m2 x 104 +/- 25 mg/m2; p=0,058) e da fração de ejeção (55,6 +/- 6% x 57,5 +/- 8,7%; p=0,11) do VE. Entre os 66 pacientes com prótese mitral (55,18 ± 9,24 anos, 39 mulheres) a IPPM2 foi diagnosticada em 26 pacientes (39%); 17 eram próteses biológicas e 49 eram mecânicas. Os pacientes com IPPM2 tiveram as médias da área valvar indexada (1,0 cm²/m²) e do gradiente médio (6,73 mmHg) maiores que nos pacientes com IPPM1 (1,31 cm²/m² e 4,63 mmHg); p<0,001 para ambos. Não houve diferença na superfície corpórea entre os grupos. A proporção de classe funcional II ou III nos pacientes com IPPM2 (10 pacientes; 38,26%) foi significantemente maior que nos com IPPM1 (2 pacientes; 5%) (p < 0,001). Não houve diferença significante na proporção de estenose ou insuficiência mitral pré-operatória nem de fibrilação atrial entre os grupos. A proporção de pacientes com prótese mecânica no grupo IPPM2 (24 pacientes; 92,3%) foi maior que no grupo IPPM1 (23; 57,5%) (p=0,002). O tamanho (medianas de 25 x 25 mm) e a área efetiva prevista (medianas de 1,76 x 1,93 cm2) das próteses dos pacientes com IPPM2 não foram diferentes (p=0,93; p=0,80) dos pacientes com IPPM1. Não houve diferença significante das medidas ecocardiográficas das cavidades esquerdas e direitas incluindo função sistólica de ambos os ventrículos, veia cava inferior e pressão pulmonar entre os grupos IPPM2 e IPPM1.
CONCLUSÕES:
O percentual de IPP moderada ou importante de prótese aórtica foi de 20% e da mitral de 39%. Os pacientes com IPP moderada ou importante de prótese mitral ou aórtica eram mais sintomáticos que os com IPP discreta. A IPP de prótese aórtica ou mitral não teve relação com o tipo de doença valvar que era a razão da cirurgia. Os pacientes com IPP moderada ou importante de prótese mitral tinham mais próteses mecânicas que os com IPP discreta. O tamanho e a área efetiva prevista da prótese tiveram relação com IPP de prótese aórtica. As variáveis ecocardiográficas não foram diferentes nos pacientes com IPP mitral.
Os pacientes com IPP moderada ou importante de prótese aórtica tiveram espessura miocárdica do ventrículo esquerdo maior que os pacientes com IPP discreta.
INTRODUCTION: Patient-prosthesis mismatch (PPI) is defined when a prosthetic heart valve has a high trans prosthetic pressure gradient and reduced indexed valve area, but with normal leaflet or disks function. PPI can occur in prostheses in the mitral or aortic position, can cause clinical and hemodynamic repercussions and modify the patient’s prognosis. In the mitral position, the data are still restricted and controversial. The aim of this study was to analyze the incidence, clinical and echocardiographic characteristics of PPI in patients with prostheses in the mitral or aortic position. METHODS: Patients of both genders over 18 years of age with biological or mechanical valve prostheses in the mitral or aortic position in follow-up since February 2010 were included. In the mitral position, PPI was considered mild if the indexed valve area was greater than 1.2 cm2/m2, moderate if between 0.9 cm2/m2 and 1.2 cm2/m2and important if less than or equal to 0.9 cm2/m2. In the aortic position, PPI was mild if the indexed valve area was 0.85 cm2/m2, moderate if between 0.65 and 0.85 cm2/m2 and important if to 0.65 cm2 /m2. Clinical and echocardiographic variables were compared between groups of patients with moderate or severe PPI (IPPM2 for mitral prosthesis or IPPAO2 for aortic prosthesis) and those with mild PPI (IPPM1 for mitral prosthesis or IPPAO1 for aortic prosthesis). Data were analyzed using the Mann-Whitney test, Student's t test for independent samples, Pearson's Chi-square and Fisher's Exact test extension; significant if p < 5%. RESULTS: In total, 119 patients were included in the study. Among the 60 patients (64 9 years; 36 women) with prosthesis in the aortic position, 29 were biological (1 percutaneous implant) and 31 were mechanical. IPPAO2 was diagnosed in 12 patients (20%). Patients with IPPAO2 had valve area (mean 0.66 cm²/m²) and mean pressure gradient (mean 24 mmHg) greater than those with IPPAO1 (valve area 1.2 cm²/m² and mean gradient 16 mmHg). There was no difference in age, body surface area and incidence of atrial fibrillation between patients with IPPAO2 and IPPAO1. The proportion of patients in functional class II and III in the IPPAO2 group (8 patients; 67%) was significantly higher than in the IPPAO1 group (10 patients; 17%) (p<0.001). There was no significant difference in the proportion of preoperative aortic stenosis or insufficiency in mechanical or biological prosthesis. The size (medians of 23 x 25 mm) and the predicted effective area (medians of 1.68 x 2.03 cm2) of the prostheses of the patients with IPPAO2 were smaller (p=0.0038; p=0.0013) than the patients with IPPAO1. Left atrial volume was greater in patients with IPPAO2 than in the IPPAO1 group (51 16 mL/m2 x 40 12 mL/m2 ; p=0.002) as well as septal thickness (10.9 1.2 mm x 10 1.5 mm; p=0.018) and the left ventricular wall (10.8 1.3 mm x 0.99 1.4 mm; p= 0.046). There was no significant difference in mass index (121 38 mg/m2 x 104 25 mg/m2; p=0.058) and ejection fraction (55.6 6% x 57.5 8.7%; p =0.11) of the LV. Among the 66 patients with mitral valve prosthesis (55.18 ± 9.24 years) IPPM2 was diagnosed in 26 patients (39%); 17 were biological prostheses, 49 were mechanical carriers. Patients with IPPM2 had the means of indexed valve area (1.0 cm²/m²) and mean gradient (6.73 mmHg) higher than in patients with IPPM1 (1.31 cm²/m² and 4.63 mmHg); p<0.001 for both. There was no difference in body surface between the groups. The proportion of functional class II or III in patients with IPPM2 (10 patients; 38.26%) was significantly higher than in those with IPPM1 (2 patients; 5%) (p < 0.001). There was no significant difference in the proportion of preoperative mitral stenosis or regurgitation or atrial fibrillation between the groups. The proportion of patients with mechanical prosthesis in the IPPM2 group (24 patients; 92.3%) was higher than in the IPPM1 group (23; 57.5%) (p=0.002). The size (medians of 25 x 25 mm) and the predicted effective area (medians of 1.76 x 1.93 cm2 ) of the prostheses of the patients with IPPM2 were not different (p=0.93; p=0.80) of the patients with IPPM1. There was no significant difference in echocardiographic measurements of the left and right cavities including systolic function of both ventricles, inferior vena cava and pulmonary pressure between IPPM2 and IPPM1 groups. CONCLUSION: The percentage of moderate or important PPI of aortic prosthesis was 20% and of the mitral valve was 39%. Patients with moderate or severe PPI from mitral or aortic prostheses were more symptomatic than those with mild PPI. Aortic or mitral prosthesis PPI was not related to the type of valve disease that was the reason for the surgery. Patients with moderate or severe PPI of mitral prosthesis had more mechanical prosthesis than those with mild PPI. The size and predicted effective area of the prosthesis were related to the PPI of the aortic prosthesis. Echocardiographic variables were not different in patients with mitral PPI. Patients with moderate or severe PPI of aortic prosthesis had greater left ventricular myocardial thickness than patients with mild PPI.
INTRODUCTION: Patient-prosthesis mismatch (PPI) is defined when a prosthetic heart valve has a high trans prosthetic pressure gradient and reduced indexed valve area, but with normal leaflet or disks function. PPI can occur in prostheses in the mitral or aortic position, can cause clinical and hemodynamic repercussions and modify the patient’s prognosis. In the mitral position, the data are still restricted and controversial. The aim of this study was to analyze the incidence, clinical and echocardiographic characteristics of PPI in patients with prostheses in the mitral or aortic position. METHODS: Patients of both genders over 18 years of age with biological or mechanical valve prostheses in the mitral or aortic position in follow-up since February 2010 were included. In the mitral position, PPI was considered mild if the indexed valve area was greater than 1.2 cm2/m2, moderate if between 0.9 cm2/m2 and 1.2 cm2/m2and important if less than or equal to 0.9 cm2/m2. In the aortic position, PPI was mild if the indexed valve area was 0.85 cm2/m2, moderate if between 0.65 and 0.85 cm2/m2 and important if to 0.65 cm2 /m2. Clinical and echocardiographic variables were compared between groups of patients with moderate or severe PPI (IPPM2 for mitral prosthesis or IPPAO2 for aortic prosthesis) and those with mild PPI (IPPM1 for mitral prosthesis or IPPAO1 for aortic prosthesis). Data were analyzed using the Mann-Whitney test, Student's t test for independent samples, Pearson's Chi-square and Fisher's Exact test extension; significant if p < 5%. RESULTS: In total, 119 patients were included in the study. Among the 60 patients (64 9 years; 36 women) with prosthesis in the aortic position, 29 were biological (1 percutaneous implant) and 31 were mechanical. IPPAO2 was diagnosed in 12 patients (20%). Patients with IPPAO2 had valve area (mean 0.66 cm²/m²) and mean pressure gradient (mean 24 mmHg) greater than those with IPPAO1 (valve area 1.2 cm²/m² and mean gradient 16 mmHg). There was no difference in age, body surface area and incidence of atrial fibrillation between patients with IPPAO2 and IPPAO1. The proportion of patients in functional class II and III in the IPPAO2 group (8 patients; 67%) was significantly higher than in the IPPAO1 group (10 patients; 17%) (p<0.001). There was no significant difference in the proportion of preoperative aortic stenosis or insufficiency in mechanical or biological prosthesis. The size (medians of 23 x 25 mm) and the predicted effective area (medians of 1.68 x 2.03 cm2) of the prostheses of the patients with IPPAO2 were smaller (p=0.0038; p=0.0013) than the patients with IPPAO1. Left atrial volume was greater in patients with IPPAO2 than in the IPPAO1 group (51 16 mL/m2 x 40 12 mL/m2 ; p=0.002) as well as septal thickness (10.9 1.2 mm x 10 1.5 mm; p=0.018) and the left ventricular wall (10.8 1.3 mm x 0.99 1.4 mm; p= 0.046). There was no significant difference in mass index (121 38 mg/m2 x 104 25 mg/m2; p=0.058) and ejection fraction (55.6 6% x 57.5 8.7%; p =0.11) of the LV. Among the 66 patients with mitral valve prosthesis (55.18 ± 9.24 years) IPPM2 was diagnosed in 26 patients (39%); 17 were biological prostheses, 49 were mechanical carriers. Patients with IPPM2 had the means of indexed valve area (1.0 cm²/m²) and mean gradient (6.73 mmHg) higher than in patients with IPPM1 (1.31 cm²/m² and 4.63 mmHg); p<0.001 for both. There was no difference in body surface between the groups. The proportion of functional class II or III in patients with IPPM2 (10 patients; 38.26%) was significantly higher than in those with IPPM1 (2 patients; 5%) (p < 0.001). There was no significant difference in the proportion of preoperative mitral stenosis or regurgitation or atrial fibrillation between the groups. The proportion of patients with mechanical prosthesis in the IPPM2 group (24 patients; 92.3%) was higher than in the IPPM1 group (23; 57.5%) (p=0.002). The size (medians of 25 x 25 mm) and the predicted effective area (medians of 1.76 x 1.93 cm2 ) of the prostheses of the patients with IPPM2 were not different (p=0.93; p=0.80) of the patients with IPPM1. There was no significant difference in echocardiographic measurements of the left and right cavities including systolic function of both ventricles, inferior vena cava and pulmonary pressure between IPPM2 and IPPM1 groups. CONCLUSION: The percentage of moderate or important PPI of aortic prosthesis was 20% and of the mitral valve was 39%. Patients with moderate or severe PPI from mitral or aortic prostheses were more symptomatic than those with mild PPI. Aortic or mitral prosthesis PPI was not related to the type of valve disease that was the reason for the surgery. Patients with moderate or severe PPI of mitral prosthesis had more mechanical prosthesis than those with mild PPI. The size and predicted effective area of the prosthesis were related to the PPI of the aortic prosthesis. Echocardiographic variables were not different in patients with mitral PPI. Patients with moderate or severe PPI of aortic prosthesis had greater left ventricular myocardial thickness than patients with mild PPI.