Left ventricular remodelling occurs during the chronic course of aortic regurgitation (AR) and aortic stenosis (AS), leading to myocardial hypertrophy and fibrosis. Several studies have shown that extracellular volume fraction (ECV) and indexed extracellular volume (iECV) are important surrogate markers of diffuse myocardial fibrosis (MF). Postoperative data on these cardiovascular magnetic resonance (CMR) extracellular expansion parameters for either AS or AR are scarce. This study aimed to demonstrate the postoperative changes that occur in diffuse MF, and the influence of preoperative MF on the reversal of LV remodelling, in patients with AR or AS. Patients with severe AR or AS and indications for surgery were prospectively enrolled. Patients underwent pre- and postoperative CMR, and ECV and iECV were quantified. Data from 99 patients were analysed (32 with AR and 67 with AS). After surgery, the left ventricle mass index decreased in both groups (AR: 110 vs. 91 g/m²; AS: 86 vs. 68 g/m², both P < 0.001). The late gadolinium enhancement fraction (AR: preoperative 1.9% vs. postoperative 1.7%, P = 0.575; AS: preoperative 2.4% vs. postoperative 2.4%, P = 0.615) and late gadolinium enhancement mass (AR: preoperative 3.8 g vs. postoperative 2.5 g, P = 0.635; AS: preoperative 3.4 g vs. postoperative 3.5 g, P = 0.575) remained stable in both groups. Preoperative iECV and ECV were greater in the AR group (iECV: 30 mL/m² vs. 22 mL/m², P = 0.001; ECV: 28.4% vs. 27.2%, P = 0.048). Indexed extracellular volume decreased after surgery in both groups (AR: 30–26.5 mL/m², AS: 22–18.2 mL/m², both P < 0.001); it was still greater in the AR group (AR: 26.5 mL/m² vs. AS: 18.2 mL/m², P < 0.001). Postoperative ECV remained stable in the AR group (preoperative 28.4% vs. postoperative 29.9%; P = 0.617) and increased in the AS group (preoperative 27.2% vs. postoperative 28.6%; P = 0.033). Patients with both AR or AS presented reduction in iECV after surgery, unfolding the reversible nature of diffuse MF. In contrast to patients with AS, those with AR developed postoperative iECV regression with stable ECV, suggesting a balanced reduction in both intracellular and extracellular myocardial components. Diffuse myocardial fibrosis measures and changes in ECV and iECV. Panels A, B, and C demonstrate automatic native T1, post-contrast T1, and extracellular volume (ECV) measures, respectively, in the postoperative cardiovascular magnetic resonance of a patient with severe aortic stenosis (Global ECV with LGE = 26.1%; iECV = 17.4 mL/m2). Graphics D and E show comparisons between the pre- and postoperative measures of the global ECV with late gadolinium enhancement (LGE) and the indexed extracellular volume (iECV), respectively, in aortic valvular heart diseases. Solid horizontal lines indicate median values; boxes indicate p25 and p75; and vertical lines indicate the highest and lowest values. P values indicate differences between measures (significant if <0.05). NS, non-significant.

OBJETIVO: Correlacionar os níveis séricos do peptídeo natriurético tipo B e da fração N-terminal do pró-peptídeo natriurético tipo B, além de analisar a influência de idade, obesidade, insuficiência renal, fração da ejeção do ventrículo esquerdo, disfunção diastólica e anemia nos níveis séricos de ambos os marcadores. MÉTODOS: Estudo observacional, no qual se comparou a concordância entre esses marcadores em amostras consecutivas de 138 pacientes. Para a correlação, utilizou-se o teste de Pearson e foi considerado estatisticamente significante p<0,05. RESULTADOS: Observou-se associação linear entre peptídeo natriurético tipo B e fração N-terminal do pró-peptídeo natriurético tipo B (r=0,907; p<0,001). Ao se avaliarem as medidas categorizadas como normais e alteradas, encontrou-se boa concordância, com 90,6% de classificações concordantes (p<0,001), sendo que valores alterados da fração N-terminal do pró-peptídeo natriurético tipo B e normais de peptídeo natriurético tipo B representaram 8,7% do total, e o contrário representou 1% do total. A avaliação da influência dos fatores clínicos e laboratoriais nos níveis dos peptídeos natriuréticos mostrou que eles se elevam de acordo com a idade, mas que diminuem conforme aumenta a fração de ejeção. Pacientes com anemia (p<0,001) ou com insuficiência renal (p=0,007) apresentaram valores maiores de ambos os marcadores. Não houve associação entre obesidade e peptídeo natriurético tipo B. CONCLUSÃO: Houve concordância satisfatória entre peptídeo natriurético tipo B e a fração N-terminal do pró-peptídeo natriurético tipo B. Idade, níveis de creatinina e hemoglobina, assim como função ventricular, influenciam os níveis séricos de ambos os peptídeos natriuréticos.

Background: Mitral valve diseases are a common medical condition, and surgery is the most used therapeutic approach. The need for less invasive interventions led to the development of transcatheter valve implantation in high-risk patients. However, the treatment to the dysfunctions of these prosthetic valves is still uncertain, and the yield and safety of repeated transcatheter valve implantations remain unclear. Cases summary: A 69-year-old Caucasian woman with three previous mitral valve procedures performed due to rheumatic valve disease (currently with a biological prosthetic mitral valve) and a 76-year-old Latin woman with previous liver transplantation (due to metabolic-associated fatty liver disease) and biological mitral prosthesis due to mitral valve prolapse with severe regurgitation underwent mitral valve-in-valve (ViV) transcatheter implantation at the time of dysfunction of their surgical prostheses. Later, these patients developed prosthetic valve dysfunction and clinical worsening, requiring another invasive procedure. Due to maintained high-risk status and unfavourable clinical conditions for surgery, re-valve-in-valve (re-ViV) was performed. Discussion: Valve-in-valve transcatheter mitral valve implantation was approved in 2017, and, since then, it has been used in several countries, mainly in high-risk patients. Nevertheless, these prosthetic valves may complicate with stenosis or regurgitation, demanding reinterventions. Although there are favourable data for mitral ViV, re-ViV still lacks robust data to support its performance, with only case reports in the literature so far. It is possible that in high-risk patients, there is a greater benefit from re-ViV when compared with the surgical strategy. However, this hypothesis must be studied in future controlled trials.

Sumário […] Diretriz Brasileira de Valvopatias – 2026 Sumário […] Diretriz Brasileira de Valvopatias – 2026

Background: Pulmonary hypertension (PH) often complicates mitral stenosis (MS). The prognostic impact of pulmonary vascular resistance (PVR) in MS patients remains unclear. Previous study has demonstrated the prognostic impact of right atrial pressure (RAP) in patients with primary PH. We aim to determine the prognostic impact of PVR and RAP in patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV). Methods: A total of 58 patients with symptomatic severe rheumatic MS who underwent PMBV between 2016 and 2020 were included. Patients were divided into two groups: PVR ≤ 2WU (N = 26) and PVR > 2WU (N = 32). The composite endpoint included death, reintervention or persistent NYHA functional class III-IV during follow-up. Results: The median age was 50 (42–60) years, with 82.8% being female. Median pulmonary artery systolic pressure (PASP) was 42 (35–50.5) mmHg. Patients with PVR ≤ 2WU had lower PASP on both echocardiogram and catheterization. The PMBV success rate was 75.9%. Multivariate analysis, adjusted for PVR, showed RAP as the only independent predictor of the composite endpoint (HR:1.507, 95% CI:1.015–2.237, p = 0.042). The optimal RAP cutoff was 9.5 mmHg (HR:3.481, 95% CI:1.041–11.641; p = 0.043). Conclusions: RAP was an independent predictor of adverse outcomes in patients with rheumatic MS undergoing PMBV, while PVR did not show prognostic significance. These findings suggest that the prognostic value of PVR may be lower than expected.

Pulmonary hypertension (PH) has a well-known impact on the prognosis of patients with rheumatic mitral stenosis (MS). Some patients can present pre-capillary PH, defined as a pulmonary vascular resistance (PVR) ≥3.0 woods, and there is few data regarding the prognostic value of invasive measures of PVR in this context. To assess the impact of PVR on the long-term outcomes of patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV). Unicentric, retrospective study, including patients with rheumatic MS undergoing PMBV from 2016 to 2020. All patients underwent clinical and laboratorial evaluation, and transthoracic echocardiogram before and after the procedure. During PMBV, transesophageal echocardiogram and hemodynamic measures were performed. The composite endpoint included death, reintervention and persistent NYHA FC III–IV in long-term follow-up. 58 patients were included with a median age of 50.5 [42–60.5] years and 82.8% were female. Most important comorbidities were hypertension (55.2%), previous valvular intervention (22.4%), diabetes (20.7%), atrial fibrillation (18%), previous stroke/transient ischemic attack (3.4%), coronary artery disease (1.7%). Median mitral valve area was 1.2 [0.9–1.3] cm², mean transmitral gradient was 8 [6–12] mmHg and pulmonary artery systolic pressure (PASP) was 42 [35–51] mmHg. Pre-procedure hemodynamic right atrium pressure (RAP) was 8 [6–10] mmHg, pulmonary artery mean pressure (mPAP) was 26 [21–31] mmHg, pulmonary capillary pressure (PCP) was 18 [15–22] mmHg and PVR was 2.15 [1.5–3.46] mmHg/min. Thirty-five (60.3%) patients underwent 1 balloon dilation, 10 (17.2%) 2 dilations, 3 (5.3%) 3 dilations and 1 (1.7%) 4 dilations. Only 1 (1.7%) case need conversion to open surgery. Post-procedure hemodynamic Δ mPAP was 4 [1–8] mmHg, Δ PCP was 5 [2–7] mmHg and Δ PVR was 0.03 [−0.072–0.99] mmHg/min. Median follow-up was 32.9 [20.2–43] months. Need for reintervention (surgery or PMBV) was 6.9%, mortality during follow-up was 1.7% and the composite endpoint occurred in 13 (22.4%) patients. By univariate analysis, echocardiographic PSAP (HR: 1.069, 95% CI 1.010–1.130, p=0.021), RAP (HR: 1.267, 95% CI 1.028–1.562, p=0.027), Δ hemodynamic PASP (HR: 0.927, 95% CI 0.866–0.991, p=0.026) and moderate or severe tricuspid regurgitation (HR: 6.318, 95% CI 1.734–23.023, p=0.005) were associated with the composite endpoint. By multivariate analysis adjusted by RVP, RAP (HR: 1.626, 95% CI 1.005–2.630, p=0.047) was the only independent predictor of the composite endpoint. The RAP cutoff found through the Youden index was 9.5 mmhg (Figure 1). In patients with severe MS undergoing PMBV, RAP measurement in cardiac catheterization was the only independent predictor of combined outcome of death, reintervention and persistent NYHA FC III–IV in long-term follow-up. PVR had no impact on long-term outcomes. Type of funding sources: None. Figure 1