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        "titulo" => "Abordagem da <span class="elsevierStyleItalic">Heart Team</span> &#224; TAVI&#58; o que tem sido feito e o que se espera"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Aortic stenosis is the most common acquired valvular heart disease in Europe&#46; Its importance is growing not only because of its prevalence&#44; but also because percutaneous treatment options have emerged in the last fifteen years that provide validated and effective treatment for previously untreatable patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">1&#44;2</span></a> Although a variety of devices are now available for treating patients of advanced age and with complex disease&#44; not all patients are suitable candidates for transcatheter aortic valve implantation &#40;TAVI&#41;&#44; and patient selection remains a challenge&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The world&#39;s first TAVI procedure was performed by Alan Cribier in 2002&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> The technique was first used in Portugal five years later in August 2007&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> and since then many other centers have developed a TAVI program&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> There are now as many as eleven functioning TAVI centers in Portugal&#44; which annually perform over 56 procedures per million population&#44; a figure that is growing&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Comorbidity&#44; disability&#44; and frailty are three entities that are particularly associated with elderly candidates&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> The STS&#47;ACC TVT Registry reports that TAVI patients are elderly&#44; highly symptomatic and frail&#44; with multiple comorbidities and advanced functional class&#44; a high Society of Thoracic Surgeons-predicted risk of mortality&#44; and poor self-reported health status&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Considering all these factors&#44; it is not surprising that a significant percentage of patients die or fail to show improved quality of life in follow-up&#46; The need to optimize the decision-making process in these complex patients has led to increased interaction between different specialties&#46; Thus the concept of the heart team was born and has been widely applied ever since&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The value of a dedicated heart team assessment prior to TAVI is best shown by the team&#39;s ability to bring multidisciplinary clinical expertise to bear on two aspects of patient eligibility&#58; risk stratification and analysis of futility&#46; Integrating these two aspects should allow for better performance in assessing how the patient&#39;s quality of life and survival may be influenced by the valve disease and associated conditions&#44; and in determining the treatment option that best balances risk and benefit&#46; The importance of a heart team assessment is acknowledged in current practice guidelines&#44; but is not reflected in a substantial quantity of publications on real-life applications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> address the advantages of a systematic multidisciplinary approach to TAVI patients and provide insight into the heart team&#39;s assessment of TAVI candidates in a single large-volume national center&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The authors describe three steps for patient assessment&#58; clinical assessment&#44; non-invasive and invasive tests&#44; and finally a multidisciplinary discussion&#46; For the latter&#44; a multidisciplinary team composed of clinical and interventional cardiologists&#44; experts in cardiac imaging&#44; heart failure specialists and cardiac surgeons meet regularly to define treatment strategies&#46; Notably&#44; the article is co-authored by a multidisciplinary team from different medical centers composed of the above-mentioned areas of expertise&#44; as well as a researcher at the Chronic Diseases Research Center &#40;CEDOC&#41; of Nova Medical School&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The sample included 473 patients from 2008 to 2015&#44; in 383 of whom a heart team assessment was completed&#46; A significant number of patients were selected for surgical aortic valve replacement &#40;SAVR&#41; &#40;20&#46;9&#37;&#41; or for medical therapy alone &#40;23&#46;2&#37;&#41; &#40;overall 169 of 383&#44; 44&#46;1&#37;&#41;&#44; reflecting the wide range of patient complexity&#46; Those undergoing SAVR or TAVI were followed at 30 days&#44; six months and one year after the procedure&#44; and then annually&#59; the authors do not mention a systematic follow-up of patients under medical therapy alone&#44; which was presumably performed by the clinical cardiologist&#46; The criteria for TAVI included inoperability or high surgical risk&#44; and a subjective assessment of lack of futility&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A simple dedicated TAVI risk score remains an unmet clinical need&#46; Most risk scores were designed for surgical risk&#44; and patients under analysis for TAVI are beyond that stage&#46; Integration with variables such as frailty &#40;including muscle strength&#44; gait speed&#44; weight loss&#44; exhaustion&#44; and level of activity&#41;&#44; the patient&#39;s capacity for self-care&#44; and home oxygen use appear to contribute to more precise stratification&#46; The TAVI<span class="elsevierStyleInf">2</span>-SCORe by Debonnaire et al&#46; stratifies patients into five risk groups for one-year mortality based on a retrospective analysis of 511 individuals who underwent TAVI&#44; with better results than the logistic EuroSCORE&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> Hermiller et al&#46; published a novel score for early and late mortality in extreme-risk and high-risk patients that accurately stratified patients into low&#44; moderate and high risk&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> while Capodanno et al&#46; proposed a simple seven-factor risk tool &#40;the OBSERVANT score&#41; for prediction of 30-day mortality after TAVI&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In parallel with risk stratification is the development of new tools for predicting clinical futility&#44; and this entails looking at the patient from a different angle&#46; Futility can be defined by the combination of death and&#47;or absence of improvement in functional class during short-term follow-up post-procedure &#40;six months to one year&#41;&#46; Other definitions are possible and this is still a hotly debated topic&#46; Factors influencing futility of treatment include non-cardiovascular conditions such as chronic lung disease &#40;CLD&#41;&#44; advanced chronic kidney disease and frailty&#44; and various cardiovascular conditions&#44; including reduced left ventricular ejection fraction&#44; pulmonary hypertension&#44; low trans-aortic gradient&#44; low-flow state or severe organic mitral regurgitation&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> An analysis of futility has been performed for a Portuguese TAVI population of 340 patients with a mean STS score of 5&#46;67&#177;4&#46;17&#37;&#46; The authors found that age&#44; CLD&#44; New York Heart Association functional class &#8805;III prior to the procedure and a non-transfemoral approach were predictors of futility for this population&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> Apart from its clinical impact&#44; analysis of futility is also closely related to the healthcare costs of TAVI&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Although the TAVI and SAVR groups appear to have performed well in the population analyzed by Costa et al&#46;&#44; there is still room for improvement&#44; as the authors recognize&#46; The fact that many patients died &#40;12&#37; of the study population&#41; while awaiting heart team assessment or TAVI itself is a reminder of the severity of these patients and that appropriate strategies need to provide a more timely response from the healthcare system&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Heart team assessment should not only help clarify which patients are unlikely to benefit from TAVI&#44; but should also translate into a positive effect on healthcare costs&#46; Perhaps one of the most important statements by Costa et al&#46; is that results are continuously monitored and all clinical and procedural data are collected in a dedicated database &#40;Cardiobase&#41; and included in an ongoing registry&#44; the Valve Catheter Restorative Operation on Santa Cruz Hospital &#40;VCROSS&#41;&#46; It is reassuring to know that monitoring of results is taking place&#46; This is critical for self-evaluation and improvement in any system and should be highlighted as a reference for currently implemented systems at other intervention centers&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To conclude&#44; the accurate measurement of procedural outcomes for TAVI patients should include procedure-related clinical events&#44; and also an assessment of quality of life and functional capacity&#46; In the population analyzed by Costa et al&#46;&#44; an analysis of quality of life and characterization of patients for whom the procedure was deemed futile could expand the analysis of the quality of treatment&#46; Performing this analysis for the population of the national TAVI registry and determining predictors of futility could result in a valuable tool for heart teams in the future&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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