ABSTRACT As transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) became widespread, the need for a Heart Team (HT) arose to choose the best treatment. There are few reports regarding its usefulness. Objectives: To analyze treatment outcomes in patients with AS evaluated by a HT for 10 years. Methods: Consecutive enrollment of all patients with AS who were candidates for TAVI between January 2012 and July 2021 to choose the best treatment, including surgical aortic valve replacement (SAVR) and conservative medical management (CMM). Results: Out of 841 patients, 455 were assigned to TAVI (53%), 213 to SAVR (24%), and 183 to CMM (23%). The percentage assigned to TAVI has increased from 48% to 62% over time (p <0.05). Patients who underwent TAVI versus those who underwent SAVR were older (86 ± 7 vs. 83 ± 7 years), had a higher EUROSCORE II (6.2, 95% CI 5.7-6.6 vs. 5.6; 95% CI 4.4-6.5) and were frailer (1.62 ± 1 vs. 0.91 ± 1), in all cases p <0.01. Actuarial survival (95% CI) at 1 and 2 years was 88% (84-91%) and 82% (77-86%) for TAVI, 83% (76-88%) and 78% (70-84%) for SAVR, and 70% (60-87%) and 59% (48-68%) for CMM, respectively (p <0.001). Conclusions: For the first 10 years after a Heart Team was established for AS decision-making, approximately half of the patients were assigned to TAVI, and the rest were equally assigned in halves to either surgery or observation. Survival for patients who received interventions was similar at 2 years and higher than in those who did not.

RESUMEN La difusión del reemplazo valvular aórtico percutáneo (TAVI) en la estenosis aórtica (EAo) generó la creación de un Heart Team (HT), para elegir el mejor tratamiento. Existen pocos reportes sobre su utilidad. Objetivos: analizar los resultados del tratamiento de los pacientes con EAo evaluados por un HT durante 10 años Material y métodos: Inclusión consecutiva de todos los pacientes con EAo candidatos a TAVI entre enero del 2012 y julio del 2021 para seleccionar el mejor tratamiento, incluyendo además Cirugía de reemplazo valvular aórtico (CRVA) y Tratamiento médico conservador (TMC). Resultados: De 841 pacientes, se asignaron a TAVI 455 (53%), CRVA 213 (24%) y TMC 183 (23%). El porcentaje asignado a TAVI aumentó con el tiempo de 48 a 62% (p < 0,05). Los pacientes que fueron a TAVI, con respecto a los enviados a CRVA, eran mayores (86 ± 7 vs 83 ± 7 años), con mayor EUROSCORE II (6,2, IC95% 5,7-6,6 vs 5,6, IC95% 4,4-6,5) y más frágiles (1,62 ± 1 vs 0,91 ± 1), en todos los casos p <0,01. La sobrevida actuarial (IC 95%) a 1 y a 2 años fue, para TAVI 88% (84-91%) y 82% (77-86%), para CRVA 83% (76-88%) y 78% (70-84%) y para TMC 70% (60-87%) y 59% (48-68%) respectivamente (p <0,001). Conclusiones: Durante los primeros 10 años de establecido un Heart Team para la toma de decisiones en EAo, se asignaron a TAVI aproximadamente la mitad y el resto se asignó por mitades a cirugía u observación. La sobrevida de los pacientes intervenidos fue similar a 2 años y mayor que la de los no intervenidos.

Abstract: Background: Currently, there is no consensus about the most adequate anesthetic management in transfemoral transcatheter aortic valve replacement. Although it has been shown that local anesthesia (LA) with or without conscious sedation is feasible, clinical results are controversial. Objective: The aim of this study was to evaluate the safety and efficacy of transfemoral transcatheter aortic valve replacement performed under general anesthesia versus local anesthesia with conscious sedation. Methods: This was a single-center, retrospective study of high risk patients with severe aortic stenosis undergoing transfemoral transcatheter aortic valve replacement between March 2009 and December 2016. The population was divided according to anesthetic management. Safety and efficacy outcomes were evaluated at 30-days and were classified according to definitions of the Valve Academic Research Consortium-2. In addition, key times during hospitalization were evaluated. Results: A total of 121 patients undergoing transfemoral transcatheter aortic valve replacement under general anesthesia (n=55, 45.5%) or local anesthesia with conscious sedation (n=66, 54.5%). were included in this analysis. Mean age was 83.2±5.7 years and 48.8% were men. There were no differences in either the procedural result or in the 30-day efficacy and safety outcomes. The rate of death at 30-days was 7.3% in the group with general anesthesia and 3% in the local anesthesia with conscious sedation group (log-rank p 0.28). The need of conversion to general anesthesia was 3% (2 patients), in all cases due to major vascular complications during the procedure. In the local anesthesia with conscious sedation group shorter procedural time, intensive care unit and hospital length of stay were observed. Conclusions: Transfemoral transcatheter aortic valve replacement performed under local anesthesia with conscious sedation seems to be a safe and effective alternative to the use of general anesthesia.

RESUMEN: Introducción: Actualmente no hay consenso sobre el manejo anestésico más adecuado en el implante valvular aórtico percutáneo por vía transfemoral. Aunque se ha demostrado la factibilidad de concretar el procedimiento bajo anestesia local con sedación consciente o sin esta, los resultados clínicos reportados son controvertidos. Objetivos: Evaluar la seguridad y eficacia del implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia general versus anestesia local con sedación consciente. Material y métodos: Análisis unicéntrico y retrospectivo de los pacientes con estenosis aórtica grave sintomática con alto riesgo quirúrgico sometidos a un implante valvular aórtico percutáneo por vía transfemoral desde marzo de 2009 a diciembre de 2016, según el manejo anestésico. Los desenlaces de seguridad y eficacia fueron evaluados a 30 días según las definiciones del Valve Academic Research Consortium-2. Además, se evaluaron los principales tiempos durante la internación. Resultados: Se incluyeron 121 pacientes (Edad 83,2 ± 5,7 años, hombres 48,8%), tratados con un implante valvular aórtico percutáneo por vía transfemoral bajo anestesia general (n = 55, 45,5%) o anestesia local con sedación consciente (n = 66, 54,5%). No se observaron diferencias significativas en los resultados intraprocedimiento ni en los desenlaces de seguridad y eficacia a 30 días. La mortalidad a 30 días fue del 7,3% en el grupo AG y del 3% en el grupo anestesia local con sedación consciente 3%, p log-rank 0,28 (mortalidad global 5%). La necesidad de conversión a anestesia general se presentó en 2 pacientes (3%), por complicaciones vasculares mayores durante el procedimiento. El grupo anestesia local con sedación consciente presentó menor tiempo total de procedimiento, internación en unidad de cuidados intensivos e internación total. Conclusión: El implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia local con sedación consciente, parece ser una alternativa segura y eficaz al uso de anestesia general.

RESUMO: O controle de plantas daninhas utilizando herbicidas com o mesmo mecanismo de ação pode favorecer o aparecimento de biótipos resistentes ou plantas tolerantes. Exemplo disso é a ocorrência de cordas-de-viola (Ipomoeasp.) em lavouras de soja na região Sul do Brasil. Nesse sentido, objetivou-se quantificar os prejuízos decorrentes da competição de duas espécies de corda-de-viola em convivência com a soja. O estudo foi realizado em campo, na safra agrícola 2013/2014. O delineamento experimental foi de blocos ao acaso com quatro repetições, com os tratamentos sendo distribuídos em arranjo fatorial (2x2x5), em que se avaliou o efeito da competição sobre dois cultivares de soja (TEC6029 e TEC7849), das espécies de corda-de-viola (I. triloba e I. purpurea), em diferentes densidades de infestação (0, 4, 8, 16 e 32 plantas m-2). A convivência da soja com diferentes densidades de corda-de-viola afetou os componentes de produtividade. As primeiras oito plantas de corda-de-viola mostraram uma competição mais intensa, tendo reduzido a produtividade em 45% e 27% para os cultivares TEC6029 e TEC7849, respectivamente.

ABSTRACT: Weed control using herbicides with the same mechanism of action can encourage the emergence of resistant biotypes or tolerant plants. An example of this is the occurrence of morning-glory (Ipomoea sp.) in soybean crops in southern Brazil. In this sense, the aim of this study was to quantify the losses arising from two species of morning-glory weeding coexisting with soybean crop. A field study was conducted in the 2013/2014 season. The experimental design was a randomized block with four replications, with treatments being distributed in a factorial arrangement (2x2x5), which assessed the effect of competition on two soybean cultivars (TEC6029 and TEC7849) of morning-glory species (I. triloba and I. purpurea) in different population (0, 4, 8, 16 and 32 plants m-2). The interaction of soybean with different densities of morning-glory affects yield components. The first eight morning glory plants have a more intense competition, reducing productivity by 45% and 27% for TEC6029 and TEC7849 cultivars, respectively.

As plantas daninhas interferem negativamente no desenvolvimento, na produtividade e na qualidade da soja. O controle inadequado das plantas daninhas pelo uso de herbicidas pode selecionar biótipos resistentes e/ou plantas tolerantes, provocando mudança na flora de plantas daninhas. Objetivou-se com este trabalho determinar a competitividade da soja em convivência com plantas de I. triloba, I. indivisa e I. purpurea, por meio de experimentos em série de substituição. Os experimentos foram realizados em casa de vegetação, no delineamento inteiramente casualizado com quatro repetições. O primeiro experimento foi realizado com a finalidade de obter a população de plantas a partir da qual a massa seca total das plantas permanecesse constante; já os demais experimentos foram realizados em série de substituição com proporções entre soja e corda-de-viola de 100:0, 75:25, 50:50, 25:75 e 100:0, com população definida no experimento preliminar de 250 plantas m-2. As variáveis avaliadas foram área foliar, massa de matéria seca de raiz e massa de matéria seca da parte aérea. A análise da competitividade foi feita por diagramas de competitividade e por interpretações dos índices. Os resultados indicam a soja como competidor superior às espécies de cordas-de-viola (I. triloba, I. indivisa e I. purpurea) para as variáveis área foliar, massa de matéria seca de raiz e massa de matéria seca da parte aérea e que para soja predomina a competição intraespecífica, enquanto para as cordas-de-viola prevalece a competição interespecífica.

Weeds interfere negatively on development, yield and quality of soybeans (Glycine max). Inadequate weed control by herbicide use can select for resistant or tolerant biotypes, leading to a shift in the weed flora. An example is the increase of incidence of morning glory (Ipomoea spp.) in soybeans growing areas in South Brazil. The aim of this study was to determine the competitiveness of soybeans intercropped with I. triloba, I. indivisa and I. purpurea through a replacement experiments series. Greenhouse experiments were conducted in a completely randomized design with four replications. The first experiment was carried out aiming to get the plant population while total plant dry mass remained constant. Other experiments were done under replacement series experiments with soybeans and morning glory ratios of 100:0, 75:25, 50:50, 25:75 and 100:0 using the 250 plant m-2 defined by the preliminary experiment. Leaf area, root and shoots dry mass were assessed. Diagrams along with index interpretation were used to performed a competitiveness analysis. Soybeans showed greater competitiveness as I. triloba, I. purpurea and I. indivisa species for the leaf area, root and shoots dry mass variables. Intraspecific competition prevails between soybean plants whilst interspecific competition prevails for morning glory.

Objective: The aim of this study is to compare the clinical and echocardiographic outcome of mitral valve repair secondary to degenerative mitral valve regurgitation in patients with posterior versus anterior or bileaflet mitral valve prolapse. Methods: Between April 1997 and July 2013, 255 patients underwent surgery for moderate to severe degenerative mitral valve regurgitation: 175 had posterior mitral valve prolapse (Group 1) and 80 had anterior or bileaflet mitral valve prolapse (Group 2). There were no differences in age or sex between the groups. Clinical follow-up was completed in 95% of the cases with a mean follow-up period of 5.6 ± 3.8 years and 77% completed echocardiographic follow-up with a mean of 4.8 ± 3.7 years. Results: The procedure was successful in 87% of cases (33 intraoperative conversions to mitral valve replacement) (Group 1: 98% vs. Group 2: 62.5%; p < 0.01). Overall in-hospital mortality was 2.3% (6/255), and 10-year survival was 92.0 ± 2.1% (Group 1: 94.4% ± 2.2% vs. Group 2: 86.3 ± 5.1%; p = 0.036). At 10-year follow-up, 95.6 ± 1.6% of patients were free from reoperation (Group 1: 97.1 ± 1.4% vs. Group 2: 89.7 ± 5.0%; p = 0.035), 79.0 ± 4.4% remained free from moderate to severe mitral regurgitation (Group 1: 80.8 ± 4.8% vs. Group 2: 71.9 ± 9.6%; p = 0.14) and 91.2% were asymptomatic (92% Group 1 vs. 89.3% Group 2; p = 0.5). Conclusions: Patients undergoing mitral valve repair secondary to degenerative posterior mitral valve prolapse had higher survival and lower incidence or reoperation in the long-term follow-up. There were no differences in freedom from moderate to severe mitral regurgitation between both groups at 10-year follow-up.

Objetivo: Comparar la evolución clínica y ecocardiográfica de la plástica mitral secundaria a insuficiencia mitral degenerativa en pacientes con prolapso de la valva posterior versus prolapso anterior o bivalvar. Material y métodos: Entre abril de 1997 y julio de 2013 fueron intervenidos 255 pacientes por insuficiencia mitral moderada/ grave degenerativa. De ellos, 175 tenían compromiso de la valva posterior exclusivamente (Grupo 1) y 80 de la valva anterior 0 bivalvar (Grupo 2). No hubo diferencias en edad ni predominio de sexo entre los grupos. El seguimiento clínico se completó en el 95% de los casos con un promedio de 5,6 ± 3,8 años y el ecocardiográfico en el 77% con un promedio de 4,8 ± 3,7 años. Resultados: El éxito del procedimiento se alcanzó en el 87% de los casos (33 conversiones intraoperatorias a reemplazo valvular) (Grupo 1: 98% vs. Grupo 2: 62,5%; p < 0,01). La mortalidad hospitalaria global fue del 2,3% (6/255). La sobrevida a los 10 años fue del 92,0 ± 2,1% (Grupo 1: 94,4% ± 2,2% vs. Grupo 2: 86,3 ± 5,1%; p = 0,036). La libertad de reoperación a 10 años de seguimiento fue del 95,6 ± 1,6% (Grupo 1: 97,1 ± 1,4% vs. Grupo 2: 89,7 ± 5,0%; p = 0,035). La libertad de insuficiencia mitral moderada/grave en el ecocardiograma a los 10 años fue del 79,0 ± 4,4% (Grupo 1: 80,8 ± 4,8% vs. Grupo 2: 71,9 ± 9,6%; p = 0,14). El 91,2% de los pacientes se encontraban libres de síntomas a los 10 años (92% Grupo 1 vs. 89,3% Grupo 2; p = 0,5). Conclusiones: Los pacientes con plástica mitral secundaria a enfermedad degenerativa de la valva posterior tuvieron mayor sobrevida y una incidencia menor de reoperación en el seguimiento alejado. No hubo diferencias en libertad de insuficiencia mitral moderada/grave entre ambos grupos a 10 años de seguimiento.

Background Patients with severe degenerative mitral regurgitation (SDMR) referred to surgery present diverse clinical presentations; while some patients are asymptomatic with preserved ventricular function, others have functional class IV dyspnea and systolic dysfunction. Current guidelines are helpful to recognize timing of mitral valve surgery; however, reality is sometimes far from ideal and defines daily practice. Objective To analyze the impact of preoperative functional class (FC) on in-hospital and on long-term outcomes of patients undergoing surgery for SDMR. Material and Methods We conducted a retrospective analysis of 254 consecutive patients who underwent surgery due to SDMR between July 1997 and July 2007. Patients were divided into two groups according to their NYHA FC for dyspnea. Group 1 included 87 patients in FC I-II and group 2 included 167 patients in FC III-IV. Results Patients in group 1 were more likely to undergo mitral valve repair (56.3% versus 37.7%; p=0.005); conversely, associated myocardial revascularization was less frequent (10.3% versus 27.5%; p=0.002). During postoperative, patients in group 2 presented greater morbidity and mortality rates (27.5% versus 13.7%; p=0.01) and greater in-hospital mortality (9.5% versus 2.3%; p=0.03). Global actuarial survival at 10 years was 92.9% with a median follow-up of 1,182 days/ patient. During long-term follow-up, more patients in group 1 were free of associated events (mortality and readmission) than subjects in group 2 (HR 3.3; p=0.01, 95% CI 1.27-8.99). The degree of preoperative dyspnea was an independent predictor of adverse outcomes in multivariate analysis. The sub-analysis of patients without coronary artery disease also demonstrated that the severity of preoperative dyspnea is an independent predictor of in-hospital and long-term morbidity and mortality. Conclusion In patients with SDMR, preoperative FC III-IV dyspnea is associated with worse outcomes during hospitalization and long-term follow-up.

Introducción Los pacientes que padecen insuficiencia mitral grave degenerativa (IMGD) son derivados a cirugía con diferentes presentaciones clínicas, desde asintomáticos con función ventricular conservada hasta pacientes en clase funcional IV y disfunción ventricular. A pesar de que existen guías que ayudan a conocer el momento oportuno para indicar la cirugía de la valvulopatía mitral, la realidad a veces dista de lo ideal y define la práctica diaria. Objetivos Analizar el impacto de la clase funcional (CF) preoperatoria en la evolución intrahospitalaria y en el seguimiento alejado de los pacientes operados por IMGD. Material y métodos Se analizaron retrospectivamente 254 pacientes consecutivos operados por IMGD entre julio de 1997 y julio de 2007 y se dividieron en dos grupos según la CF NYHA preoperatoria para disnea. El grupo 1 estuvo conformado por 87 pacientes en CF I-II y el grupo 2 por 167 pacientes en CF III-IV. Resultados Los pacientes del grupo 1 tuvieron mayor posibilidad de reparación valvular (56,3% versus 37,7%; p = 0,005) y menos revascularización miocárdica asociada (10,3% versus 27,5%; p = 0,002). En el posoperatorio, el grupo 2 tuvo mayor morbimortalidad (27,5% versus 13,7%; p = 0,01) y mayor mortalidad hospitalaria (9,5% versus 2,3%; p = 0,03). La sobrevida actuarial global fue del 92,9% a los 10 años con una mediana de seguimiento de 1.182 días/paciente. En el seguimiento alejado, el grupo 1 tuvo mayor libertad de eventos asociados (mortalidad y reinternación) que el grupo 2 (HR 3,3; p = 0,01, IC 95% 1,27-8,99). El grado de disnea preoperatoria fue un predictor independiente de mala evolución en el análisis multivariado. El subanálisis de pacientes sin enfermedad coronaria demostró también que la gravedad de la disnea preoperatoria es un predictor independiente de morbimortalidad hospitalaria y alejada. Conclusión La disnea CF III-IV preoperatoria en los pacientes con IMGD se asocia con peor evolución intrahospitalaria y alejada.

Introduction It is well known that antiplatelet agents administered prior to cardiac surgery increase the risks of bleeding and reoperation. Coronary surgery without extracorporeal circulation is a feasible and reproducible technique which could reduce such risks. Nevertheless, clopidogrel administered prior to surgery could reduce these advantages. Objective To assess the effect of clopidogrel administered prior to coronary surgery on the incidence of reoperation due to bleeding, transfusion, morbidity and mortality, in patients with coronary surgery without extracorporeal circulation. Material and Methods Between January 2003 and December 2006, 1104 consecutive patents underwent coronary surgery without ECC. Patients were divided into two groups: patients treated with clopidogrel 7 days prior to surgery (clopidogrel group) and patients not treated with clopidogrel (control group). Perioperative characteristics were analyzed with a tendency score. Results The tendency analysis selected 97 patients for each group. Patients in the clopidogrel group presented a greater incidence of transfusions (59% versus 39%; p=0.009) and of reoperations due to bleeding (5% versus 0%; p=0.02). There were no significant differences regarding in-hospital stay and mortality. Conclusion Patients previously treated with clopidogrel and cardiac surgery without ECC presented greater incidence of transfusion and reoperations due to bleeding, with similar mortality rates.

Introducción Es conocido que las drogas antiplaquetarias administradas en el preoperatorio de cirugía cardíaca aumentan los riesgos de sangrado y reoperación. La cirugía coronaria sin circulación extracorpórea es una técnica segura y reproducible y además permitiría disminuir los riesgos de sangrado y reoperación. No obstante ello, la administración previa a la cirugía de clopidogrel podría reducir estas ventajas. Objetivo Evaluar el efecto del clopidogrel preoperatorio sobre la incidencia de reoperación por sangrado, transfusión y morbimortalidad posoperatoria en pacientes con CRM sin CEC. Material y métodos En el período comprendido entre enero de 2003 y diciembre de 2006 se efectuó CRM aislada sin CEC a 1.104 pacientes consecutivos. Se definieron dos grupos según la administración preoperatoria de clopidogrel: grupo clopidogrel (clopidogrel < 7 días) y grupo control (sin clopidogrel). Se analizaron las características perioperatorias con un score de propensión. Resultados Mediante el análisis de propensión se seleccionaron 97 pacientes para cada grupo. En el grupo clopidogrel hubo una incidencia mayor de transfusiones (59% versus 39%; p = 0,009) y de reoperación por sangrado (5% versus 0%; p = 0,02). No hubo diferencias significativas en días de estada y en mortalidad. Conclusión Los pacientes premedicados con clopidogrel y CRM sin CEC presentaron una incidencia mayor de transfusión y de reoperación por sangrado, con igual mortalidad.

The presence of a pseudoaneurism of the ascending aorta is an infrequent pathology that requires a highly complex surgical resolution. Surgical treatment is urgent since its natural evolution is progressive expansion and rupture, compression and erosion of the adjacent structures, overinfection and embolism.We present the case of a 46 year old male patient who developed a symptomatic giant pseudoaneurism of the ascending aorta infected with methicillin-sensitive Staphylococcus aureus, after isolated aortic valve replacement which required surgical treatment.

La presencia de un seudoaneurisma de la aorta ascendente es una patología infrecuente que requiere resolución quirúrgica de alta complejidad. El tratamiento quirúrgico es imperioso, ya que su evolución natural es la expansión progresiva y la rotura, la compresión y la erosión de las estructuras adyacentes, la sobreinfección y la embolia. Se presenta un paciente varón de 46 años que en el posoperatorio alejado de reemplazo valvular aórtico aislado presenta un seudoaneurisma gigante de la aorta ascendente infectado por Staphylococcus aureus, sintomático, y que requiere resolución quirúrgica.