BackgroundPredicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge.ObjectivesTo evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI.MethodsThe Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer–Lemeshow test) and discrimination [area under the receiver–operating characteristic curve (AUC)].ResultsThe mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer–Lemeshow test indicated acceptable calibration for all scores (p > 0.05).ConclusionsIn this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

Neurofibromatosis type I and antiphospholipid syndrome Neurofibromatosis tipo I y síndrome antifosfolípidos To the Editor: neurofibromatosis type i (nF-1), an autosomal dominant disorder, can be considered as a pseudovasculitis. 1 Vascular abnormalities, mostly aneurysms or stenosis of the aortic, renal, and mesenteric circulation, are well-recognized in nF-1 patients 2. the relationship of nF-1 with the so-called antiphospholipid syndrome (APS) 3 is enigmatic. We herein report an interesting case of nF-1 followed by typical features of APS. the patient, a 38-year-old woman, had biopsyproven nF-1 at the age of 16 years. in 2000, at the age of 28 years, she presented preeclampsia with subsequent fetal death. Six months after the obstetric event, an ischaemic cerebrovascular accident was diagnosed, resulting in mild hemiparesis and disartry. Antiphospholipid antibodies (APA) were not tested at that time. in January 2010 the patient had an acute myocardial infarction requiring angioplasty. igG anticardiolipin (acl) antibodies were present in significant levels (44 GPl). no lupus anticoagulant (lA) was found. Warfarin was therefore started. in May 2010, the patient, although anticoagulated (international normalized ratio 2.5) was re-admitted to our hospital due to a new coronary obstruction. A coronary bypass surgery was recently performed. the igG acl test remained positive (37 GPl). A diagnosis of APS was therefore supported by obstetric morbidity, recurrent arterial thrombosis and laboratory criteria 4. the prevalence of APA in patients with nF-1 is unknown. Only one report on the association of nF-1 with APS has been described to date. the case, published in 1989, concerned a young woman with nF-1 and a history of recurrent fetal loss; the patient developed a cerebrovascular accident and was found to be positive for lA and acl antibodies 5. if intrinsic vascular abnormalities proper of nF-1 predispose to APA and APS, it is plausible. Alternatively, nF-1 and APS might have coexisted by chance in these cases. Our patient with APS developed progressive coronary disease despite of anticoagulation, which brings attention to a persistent endothelial damage perhaps linked to nF-1. the relationship of nF-1 with APS should be clarified in larger casuistics.

Background: Although much is known about the prognostic value of the GRACE risk score, there are few studies investigating how it relates with the angiographic complexity of coronary artery disease. For this reason, in this study, we aimed to assess the predictive capacity of the GRACE score in acute coronary syndrome in respect to the angiographic complexity based on the SYNTAX score. Methods: A cross-sectional study of patients with acute coronary syndrome undergoing coronary angiography during hospitalization, with at least one ≥50% stenotic lesion in vessels ≥1.5mm in diameter. Complex coronary artery disease was defined as SYNTAX ≥23. Results: This study investigated 183 patients. A positive correlation was observed between the GRACE and the SYNTAX scores (p=0.005), however the association was weak (r=0.20). The GRACE score showed discriminatory capacity between patients with and without complex coronary artery disease, however the relevance was low, with an area under the ROC curve of 0.59 (95%CI: 0.51-0.67; p=0.042). Conclusion:The GRACE risk score is not a sufficiently accurate predictor of angiographic complexity in acute coronary syndrome.

Silva et al. Panorama das ICPs em Oclusões Crônicas no Brasil ResumoFundamento: Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento.Objetivos: Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil.Métodos: Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução.Resultados: Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. Conclusões: As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica. Palavras-chave: Doença da Artéria Coronariana; Intervenção Coronária Percutânea/tendências; Oclusão Coronária; Hospitais/tendências; Equipamentos e Provisões Hospitalares/tendências.