Background: Severe valve disease, which requires intervention, remains strongly associated with mortality in patients with rheumatic heart disease. Percutaneous mitral commissurotomy (PMC) is the procedure of choice for the treatment of patients with isolated or predominantly rheumatic mitral stenosis. This procedure has been performed under sedation to avoid the potential effects of general anesthesia on intracardiac pressure measurements. However, there are limited data on sedation during PMC, especially using easily available medications in low-and middle-income countries.Objectives: This study was designed to evaluate the efficacy and hemodynamic effects of conscious sedation during PMC in patients with significant mitral stenosis.Methods: This study prospectively enrolled 23 patients who underwent PMC with the Inoue balloon technique for hemodynamically significant mitral stenosis. For conscious sedation, midazolam 25 mg/kg and fentanyl 1 mg/kg were administered, and 5 min after the infusion, the level of sedation was evaluated by Ramsay sedation scale. A range of invasive hemodynamic measurements, including cardiac output and pulmonary artery pressures, were recorded before and immediately after sedation.Results: The mean age was 44.9 AE 10.8 years, and 19 patients (83%) were women. After sedation, the majority of patients were in categories 2 and 3 of the Ramsay sedation scale (cooperative, orientated, tranquil, and responding to commands). Oxygen saturation dropped from an average of 98.5% to 96.0% without supplementary oxygen. Left ventricular systolic pressure and central aortic pressures decreased after sedation. However, none of the other parameters changed significantly after sedation, including pulmonary artery pressures, pulmonary vascular resistance, and cardiac index.Conclusions: This simple model of conscious sedation was able to promote anxiolysis, analgesia, and comfort for the procedure without serious hemodynamic effects, which can be a reasonable choice in developing countries. pala, Uganda. Correspondence: M. C. P. Nunes (

Background: Pulmonary hypertension (PH) is a marker of poor outcome in mitral stenosis (MS), which improves after percutaneous mitral valvuloplasty (PMV). However, mechanical interventions for relief of valve obstruction often but not always reduce pulmonary pressures. This study aimed to assess the parameters associated with abnormal pulmonary artery pressure (PAP) response immediately after a successful PMV, and also its impact on long-term outcome.Methods: A total of 181 patients undergoing PMV for rheumatic MS were prospectively enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Abnormal PAP response was defined as the mean PAP (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. Results:The mean age was 44.1 ± 12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4 ± 13.1 mmHg pre to 27.6 ± 9.8 mmHg post (p < 0.001). Following PMV, 52 patients (28.7%) did not have any reduction of mPAP immediately after the PMV. Multivariable analysis adjusting for baseline values of PAP and mitral valve area revealed that AF (Odds ratio[OR] 2.7, 95% [confidence interval] CI 1.3 to 6.7), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and post-procedural left ventricular compliance (OR 0.7, 95% CI 0.5 to 0.9) were predictors of a lack of improvement in mPAP.During a median follow-up of 4.4 years, the endpoint was reached in 56 patients (31%). The pulmonary pressure response to PMV was not an independent predictor of long-term events.

As oclusões coronárias crônicas (OCC) estão presentes em aproximadamente 15% das coronariografias, com taxas de sucesso das intervenções coronarianas percutâneas (ICP) entre 55 e 80%. Tem-se observado um aumento da utilização da via radial, inclusive em contextos mais complexos, como nas OCC. Objetivamos comparar o perfil e os resultados de pacientes com OCC submetidos à ICP pela via radial vs. femoral, e avaliar os preditores independentes de mortalidade hospitalar. Métodos: Foram incluídos dados do registro CENIC de junho de 2006 a março de 2016 de pacientes submetidos a tratamento de OCC, comparados de acordo com a via de acesso. Definiu-se a ocorrência de óbito, reinfarto ou revascularização de emergência na fase hospitalar como eventos cardiovasculares adversos maiores (ECAM). Um modelo de regressão logística foi ajustado para avaliação dos preditores de mortalidade hospitalar. Resultados: Foram incluídos 3.768 pacientes (radial: 905), com idade de 60,4 ± 11,0 anos, 68,4% do sexo masculino, perfazendo 3.799 procedimentos. O sucesso angiográfico foi semelhante entre os grupos radial e femoral (96,9% vs. 96,6%; p = 0,61), assim como os índices de ECAM (0,6% vs. 0,7%; p = 0,71) e seus componentes individuais. A via de acesso radial não teve associação com óbito (OR = 0,57; IC 95% 0,13-2,50; p = 0,46), sendo idade, sexo feminino, extensão da doença coronariana e utilização de inibidores de glicoproteína IIb/IIIa os preditores independentes de mortalidade hospitalar. Conclusões: Os índices de sucesso no tratamento de OCC foram excepcionalmente elevados e semelhantes entre os grupos. Os índices de ECAM hospitalares foram baixos e também similares, e a via de acesso não teve associação com a mortalidade hospitalar.

Introduction Pulmonary hypertension (HP) has long been known to be a marker of poor outcome in patients with mitral stenosis (MS). Percutaneous mitral valvuloplasty (PMV) is currently the treatment of choice for MS, which results in improvement in HP. However, despite the successful valve opening, the regression of PH may be incomplete. This has been attributed to irreversible morphologic changes within the pulmonary vasculature. Purpose To assess the clinical, echocardiographic and hemodynamic parameters associated with an inadequate response of the pulmonary artery pressure (PAP) immediately after a successful PMV, and also the impact of residual PH on long-term outcome in these patients. Methods 181 patients undergoing PMV for rheumatic MS were enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Inadequate response of PAP was defined as the mean pulmonary artery pressure (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. Results The mean age was 44.1±12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4±13.1 mmHg pre to 27.6±9.8 mmHg post (p<0.001), as mitral valve increased from 0.96±0.2 cm2 pre to 1.68±0.2 cm2 post (p<0.001) PMV. Following PMV, 10 patients developed severe mitral regurgitation and were excluded from the analysis. Of the 171 patients analyzed, 52 (30%) did not present reduction of mPAP immediately after the PMV. Transmitral pressure gradients were significantly greater and mitral valve area was smaller in those patients with unchanged mPAP after PMV than in those whose PAP had decreased. Systolic, diastolic and mPAP pressures as well as left atrial pressure were higher in those patients who had improvement in pulmonary pressures after PMV. Multivariate analysis revealed the following independent predictors of unchanged mPAP: AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.1 to 6.4), mitral valve area (OR 1.3, 95% CI 1.1 to 1.5), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and left ventricular compliance after PMV (OR 0.8, 95% CI 0.6 to 0.9). During a mean follow-up of 28 months, the endpoint was reached in 48 patients (26%). The pulmonary pressure response to PMV was not predictor of long-term events. Conclusions In a large cohort of patients with MS undergoing PMV, mean pulmonary artery pressure values do not reduce immediately after the procedure in 30% of the cases, despite adequate opening of the valve. The factors associated with inadequate PAP response following PMV were presence of AF, larger mitral valve area, reduced valve leaflets mobility and post procedural low left ventricular compliance. The early non-reduction of mPAP after PMV is not associated with adverse outcome.