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Master's Dissertation
DOI
https://doi.org/10.11606/D.98.2020.tde-26122019-155118
Document
Author
Full name
Wanessa Nakamura Guimarães
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2019
Supervisor
Committee
Bihan, David Costa de Souza Le (President)
Machado, Cristiano Vieira
Júnior, Fábio Sandoli de Brito
Siqueira, Dimytri Alexandre de Alvim
Title in Portuguese
Comportamento e valor prognóstico da função atrial esquerda em pacientes com estenose aórtica tratados com implante transcateter de valva aórtica
Keywords in Portuguese
Ecocardiografia
Estenose da Valva Aórtica
Função do Átrio Esquerdo
Substituição da Valva Aórtica Transcateter
Abstract in Portuguese
Introdução: A estenose aórtica (EAo) é uma patologia que vem aumentando em incidência, decorrente do fenômeno de envelhecimento populacional. O implante valvar aórtico transcateter (TAVI) promove reversão do remodelamento ventricular esquerdo e melhora da função sistólica desta cavidade. Os efeitos sobre o átrio esquerdo (AE) ainda são discutíveis e alvo de estudos para melhor compreensão do seu comportamento, que tem sido aventado como parâmetro preditor de desfechos cardiovasculares. Objetivos: avaliar o comportamento da função atrial esquerda antes e após o tratamento percutâneo da EAo grave sintomática e correlacionar a função atrial esquerda com os desfechos clínicos - mortalidade, insuficiência cardíaca, reinternações cardiovasculares e início de fibrilação atrial. Métodos: foi avaliada a função atrial de 66 pacientes submetidos ao TAVI, por meio do strain atrial esquerdo (técnica utilizando o speckle tracking bidimensional) e análise de curvas volumétricas com a ecocardiografia tridimensional (E3D), antes e após o procedimento. Foram incluídos pacientes submetidos ao TAVI no período de dezembro de 2009 a junho de 2016 e excluídos pacientes com fibrilação atrial, estenose mitral, insuficiência mitral moderada ou superior e com janelas acústicas inadequadas para análise. Resultados: após o TAVI, houve regressão dos volumes do AE; a função desta cavidade pelo strain melhorou significativamente nas fases de reservatório (18,4 ± 5,9% vs. 21,1 ± 7,9%; p=0,001; 19,5 ± 6,3% vs. 23,0 ± 8,0%; p<0,001, respectivamente para as janelas apicais de quatro e duas câmaras) e de contração (11,0 ± 4,7% vs. 12,7 ± 5,5%; p=0,004, 11,6 ± 4,3% vs. 14,1 ± 5,9%; p=0,001; respectivamente para quatro e duas câmaras) e pela E3D em ambas as fases, de reservatório (33,8 ± 9,1% vs. 37,8 ± 9,6%; p=0,005) e de contração (19,8 ± 12,1% vs. 24,9 ± 11,8%; p=0,012). No entanto, não houve melhora na funções relativas ao conduto pelo strain (7,5% ± 2,7% vs. 8,6% ± 4,1%; p=0,110 e 8,1% ± 3,8% vs. 9,1% ± 4,5%; p=0,079, respectivamente para quatro e duas câmaras) e pela E3D (17,0% ± 7,1% vs. 16,7% ± 7,4%; p=0,812). Quanto aos desfechos, a fração de esvaziamento total do AE apresentou associação com mortalidade global (HR = 0,896; p = 0,008) e cardiovascular (HR = 0,817; p = 0,004), e com a ocorrência de fibrilação atrial (OR = 0,915; IC 95% 0,857-1,001; p = 0,041). Conclusão: Houve melhora das funções de reservatório de contração do AE após o TAVI. A fração de esvaziamento total do AE associou-se à mortalidade e à fibrilação atrial após o procedimento.
Title in English
Behavior and prognostic significance of left atrial function in patients with aortic stenosis treated with transcatheter aortic valve implantation
Keywords in English
Aortic Valve Stenosis
Atrial Function Left
Echocardiography
Transcatheter Aortic Valve Replacement
Abstract in English
Introduction: Aortic stenosis (AoS) is a pathology that has been increasing in incidence, due to the phenomenon of population aging. Transcatheter aortic valve implantation (TAVI) promotes reversion of left ventricular remodeling and improves left ventricular systolic function. Effects on the left atrium (LA) are still debatable and aim of studies for a better understanding of this cavity's behavior, which has been proposed as a predictor of cardiovascular outcomes. Objectives: To evaluate the behavior of left atrial function before and after percutaneous treatment of symptomatic severe aortic stenosis and to correlate left atrial function with clinical outcomes - mortality, heart failure, cardiovascular readmissions and onset of atrial fibrillation. Methods: The atrial function of 66 patients submitted to transcatheter aortic valve implantation was evaluated by means of left atrial strain (technique using two-dimensional speckle tracking) and volumetric curve analysis with three-dimensional echocardiography (3DE), before and after the procedure. Patients submitted to TAVI from December 2009 to June 2016 were included and patients with atrial fibrillation, mitral stenosis, more than moderate mitral regurgitation and with inadequate acoustic windows were excluded. Results: after TAVI, there was a regression of the LA volumes; the function of this cavity showed a significant improvement in the reservoir (18.4 ± 5.9% vs. 21.1 ± 7.9%, p = 0.001, 19.5 ± 6.3% vs. 23.0 ± 8,0%; P <0.001, respectively for the apical four and two chamber views) and contraction phases (11.0 ± 4.7% vs. 12.7 ± 5.5%, p = 0.004, 11.6 ± 4 ,3 vs. 14.1 ± 5.9, p = 0.001, respectively for the apical four and two chamber views) by LA strain and by 3DE also in both phases, reservoir (33.8 ± 9.1% vs. 37.8 ± 9.6%, p=0.005) and contraction (19.8±12.1% vs. 24.9±11.8%, p=0.012). However, there was no improvement in the functions related to the conduit phase using the LA strain (7.5% ± 2.7% vs. 8.6 ± 4.1%; p=0.110 and 8.1% ± 3.8% vs. 9.1% ± 4.5%, p=0.079, respectively for the apical four and two chamber views) and the 3DE (17.0% ± 7.1% vs. 16.7% ± 7.4%, p=0.812). In the evaluation of the outcomes, the LA total emptying fraction was associated with global mortality (HR = 0.896, p = 0.008), cardiovascular death (HR = 0.817, p = 0.004) and atrial fibrillation (OR = 0.915, CI 95% 0.857-1.001, p = 0.041). Conclusion: There was an improvement of LA reservoir and contraction function after TAVI. LA total emptying fraction was associated with mortality and atrial fibrillation after procedure.
 
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Publishing Date
2020-02-27
 
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