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Doctoral Thesis
DOI
https://doi.org/10.11606/T.98.2020.tde-19042022-152115
Document
Author
Full name
Rafael Alexandre Meneguz Moreno
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2020
Supervisor
Committee
Costa Junior, José de Ribamar (President)
Braga, Sergio Luiz Navarro
Mangione, José Armando
Ribeiro, Henrique Barbosa
Title in Portuguese
Preditores prognósticos no longo prazo após valvuloplastia mitral percutânea em pacientes com estenose valvar mitral reumática
Keywords in Portuguese
Dilatação com balão
Doença reumática
Estenose da valva mitral
Evolução clínica
Seguimento no longo prazo
Abstract in Portuguese
Nesta dissertação foram avaliados os resultados e preditores prognósticos no longo prazo após valvuloplastia mitral percutânea por balão (VMPB), tratamento preferido para pacientes com estenose mitral reumática sintomática grave e anatomia adequada. Todos os pacientes consecutivos com valva mitral sem intervenção prévia que foram submetidos à VMPB com sucesso entre 1987 e 2010 foram incluídos. O desfecho primário foi o combinado de mortalidade por todas as causas, necessidade de cirurgia de troca valvar mitral ou redilatação até 24 anos. Considerando os 1.582 pacientes consecutivos submetidos a VMPB, o sucesso imediato foi alcançado em 90,9% (1.438 pacientes). Os preditores independentes de sucesso imediato incluíram o menor tamanho do átrio esquerdo [OR (Razão dos riscos): 0,96; IC (intervalo de confiança) de 95%: 0,93-0,99; p = 0,045)], Wilkins-score 8 (OR: 1,66; IC 95%: 0,48-0,93; p = 0,02), menor idade (OR: 0,97; IC 95%: 0,96-0,99; p = 0,006) e menor gradiente transmitral médio pré-procedimento (OR: 0,93; IC 95%: 0,86-0,96; p = 0,009). A acompanhamento de longo prazo (mediana de 8,3 anos; média de 15,6 anos) foi obtido em 79,1% dos casos de sucesso. A incidência do desfecho primário foi de 19,1% (IC 95%: 17,0%-21,1%). As taxas de mortalidade geral, necessidade de cirurgia valvar mitral ou nova VMPB foram de 0,6% (IC 95%: 0,3%-1,2%), 8,3% (IC 95%: 7,0%-9,9%) e 10,0% (95% IC: 8,5%-11,7%), respectivamente. Na análise multivariada, classe funcional New York Heart Association III ou IV [RR (risco relativo): 1,62; IC 95%: 1,26-2,09; p < 0,001); maior idade (RR: 0,97; IC 95%: 0,96-0,98; p = 0,028)] e área valvar mitral 1,75 cm2 após o procedimento (RR: 1,67; IC 95%: 1,28-2,11; p = 0,028) foram preditores independentes do desfecho primário. A incidência acumulada de reestenose no longo dos 24 anos foi de aproximadamente 26%. Em conclusão, no seguimento no muito longo prazo, mais de 75% dos pacientes apresentaram manutenção de bons resultados. A previsão de resultados favoráveis tardios é multifatorial e fortemente determinada pela idade, gravidades dos sintomas prévios e área valvar mitral pós-procedimento.
Title in English
Long-term prognostic predictors after percutaneous mitral balloon commissurotomy in patients with rheumatic mitral valve stenosis
Keywords in English
Balloon dilation
Clinical evolution
Long-term follow-up
Mitral valve stenosis
Rheumatic disease
Abstract in English
In this dissertation, there were evaluated the long-term results and predictors after percutaneous balloon mitral comissurotomy (PMBC), the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and favorable anatomy. All consecutive patients without mitral valve intervention who underwent successful PMBC between 1987 and 2010 were included. The primary endpoint was the composite of mortality from all causes, need for mitral valve replacement surgery or redilatation for up to 24 years. Considering the 1,582 consecutive patients undergoing PMBC, immediate success was achieved in 90.9% (1,438 patients). Independent predictors of immediate success included small left atrium size [OR (odds ratio): 0.96; 95% CI (confidence interval): 0.93-0.99; p = 0.045)], Wilkins-score 8 (OR: 1.66; 95% CI: 0.48-0.93; p = 0.02), lower age (OR: 0.97; 95% CI: 0, 96-0.99; p = 0.006) and lower pre-procedure mean transmitral gradient (OR: 0.93; 95% CI: 0.86-0.96; p = 0.009). Long-term follow-up (median 8.3 years; mean 15.6 years) was obtained in 79.1% of successful cases. The incidence of primary outcome was 19.1% (95% CI: 17.0%-21.1%). The rates of general mortality, need for mitral valve surgery or new PMBC were 0.6% (95% CI: 0.3%-1.2%), 8.3% (95% CI: 7.0%-9.9%) and 10.0% (95% CI: 8.5%-11.7%), respectively. In the multivariate analysis, New York Heart Association functional class III or IV [RR (relative risk): 1.62; 95% CI: 1.26-2.09; p <0.001); older age (RR: 0.97; 95% CI: 0.96-0.98; p = 0.028)] and mitral valve area 1.75 cm2 after the procedure (RR: 1.67; 95 CI %: 1.28-2.11; p = 0.028) were independent predictors of primary outcome. The accumulated incidence of restenosis over 24 years was approximately 26%. In conclusion, in long-term follow-up, more than 75% of the patients maintained good results. The prediction of favorable late results is multifactorial and strongly determined by age, severity of previous symptoms and post-procedure mitral valve area.
 
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Publishing Date
2022-05-23
 
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