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Por outro lado&#44; dos pacientes submetidos &#224; cirurgia&#44; apenas em 34&#8208;53&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> &#233; efetuada uma plastia por oposi&#231;&#227;o &#224; implanta&#231;&#227;o duma pr&#243;tese valvular&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A IM severa conduz&#44; num lapso de tempo vari&#225;vel&#44; a uma disfun&#231;&#227;o ventricular esquerda e consequente insufici&#234;ncia card&#237;aca congestiva&#46; A terap&#234;utica m&#233;dica&#44; aliviando os sintomas&#44; n&#227;o altera a progress&#227;o da doen&#231;a&#44; o que se traduz numa mortalidade anual &#8805;<span class="elsevierStyleHsp" style=""></span>5&#37; na popula&#231;&#227;o sintom&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A IM divide&#8208;se em dois tipos&#58; a anat&#243;mica&#44; na qual a disfun&#231;&#227;o est&#225; num dos elementos do aparelho valvular mitral &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; anel&#44; folhetos ou cordas&#41;&#44; e a funcional&#44; em que a altera&#231;&#227;o reside numa altera&#231;&#227;o geom&#233;trica e&#47;ou funcional do ventr&#237;culo esquerdo que altera a normal rela&#231;&#227;o dos elementos desse aparelho&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Existe um fator adicional que explica a dimens&#227;o desta popula&#231;&#227;o com IM grave que n&#227;o &#233; referenciada para cirurgia&#58; o benef&#237;cio desta na IM funcional permanece controverso&#46; Al&#233;m de ter uma preval&#234;ncia 5&#8208;10 vezes superior &#224; IM anat&#243;mica ou &#224; estenose a&#243;rtica<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a>&#44; a IM funcional n&#227;o tem uma indica&#231;&#227;o cir&#250;rgica caucionada pelas <span class="elsevierStyleItalic">guidelines</span> europeias ou americanas&#58; indica&#231;&#227;o <span class="elsevierStyleSmallCaps">II</span>b&#44; a n&#227;o ser que tenha indica&#231;&#227;o para cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a>&#46; Isto &#233;&#44; um procedimento percut&#226;neo na IM <span class="elsevierStyleItalic">funcional</span> n&#227;o concorre&#44; em termos fatuais&#44; com a cirurgia&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">O tratamento da IM foi&#44; at&#233; recentemente&#44; exclusivamente cir&#250;rgico&#46; Contudo&#44; nos &#250;ltimos anos desenvolveram&#8208;se v&#225;rias abordagens percut&#226;neas&#44; a mais aceite e consistente &#233; efetuada atrav&#233;s da implanta&#231;&#227;o dum sistema de fixa&#231;&#227;o designado por MitraClip &#40;Abbott Laboratories&#44; Abbott Park&#44; IL&#44; EUA&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A abordagem percut&#226;nea da IM tem sido efetuada por v&#225;rias abordagens&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">A&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Anel&#58; esta estrutura&#44; que na realidade &#233; a jun&#231;&#227;o auriculoventricular esquerda<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a>&#44; tem a forma dum D e n&#227;o &#233; planar&#44; apresentando uma eleva&#231;&#227;o dos segmentos septal e lateral&#46; O objetivo da anuloplastia cir&#250;rgica &#233; a diminui&#231;&#227;o do di&#226;metro septal&#8208;lateral em &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">B&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Folhetos valvulares&#58; o folheto anterior est&#225; em continuidade fibrosa com os folhetos coron&#225;rio esquerdo e n&#227;o coron&#225;rio da v&#225;lvula a&#243;rtica e tem uma superf&#237;cie maior&#44; mas uma base menor &#8211; compreende apenas um ter&#231;o do per&#237;metro do anel &#8211; que o folheto posterior&#46; A superf&#237;cie de ambos os folhetos &#233; cerca de 2&#44;5 vezes a &#225;rea do orif&#237;cio valvular e&#44; durante a sua excurs&#227;o sist&#243;lica&#44; coaptam numa altura que em m&#233;dia &#233; de 8<span class="elsevierStyleHsp" style=""></span>mm o que constitui uma &#171;reserva de coapta&#231;&#227;o&#187; em caso de dilata&#231;&#227;o do anel<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">C&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cordas tendinosas&#58; elementos de conex&#227;o entre os folhetos valvulares e a parede livre ventricular via m&#250;sculos papilares ou diretamente da parede ventricular &#40;cordas basais&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">D&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Geometria ventricular&#58; altera&#231;&#245;es da geometria ventricular esquerda&#44; isqu&#233;micas ou de outra natureza podem produzir disrup&#231;&#245;es graves na din&#226;mica de coapta&#231;&#227;o mitral<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a>&#46; A discinesia pode alterar a orienta&#231;&#227;o das cordas basais produzindo um efeito de repuxamento <span class="elsevierStyleItalic">&#40;tethering&#41;</span> no folheto posterior e a dilata&#231;&#227;o ventricular pode produzir um movimento apical dos m&#250;sculos papilares&#44; com um estiramento apical <span class="elsevierStyleItalic">&#40;tenting</span>&#41; dos folhetos e perda de coapta&#231;&#227;o&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">A cirurgia de Alfieri &#233; uma cirurgia para a IM grave por deficiente coapta&#231;&#227;o dos folhetos e consiste na sutura dos bordos livres dos segmentos m&#233;dios dos folhetos anterior e posterior &#40;<span class="elsevierStyleItalic">scallops</span> A2 e P2&#41;&#44; associada a uma anuloplastia<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a>&#44; configurando a v&#225;lvula num duplo orif&#237;cio&#46; Contudo&#44; o mesmo grupo que introduziu esta cirurgia verificou que a omiss&#227;o da anuloplastia produz muitas vezes um bom resultado hemodin&#226;mico&#44; o que veio a constituir o racional para a interven&#231;&#227;o percut&#226;nea com MitraClip<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">M&#233;todos</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dum total de 20 doentes referenciados para este procedimento no decurso de dois anos selecionaram&#8208;se seis para in&#237;cio desta terap&#234;utica&#44; ap&#243;s estudo ecocardiogr&#225;fico transtor&#225;cico e transesof&#225;gico&#44; Todos os pacientes tinham que ter uma IM 4<span class="elsevierStyleHsp" style=""></span>&#43; funcional&#44; estarem em classe <span class="elsevierStyleSmallCaps">III</span> ou <span class="elsevierStyleSmallCaps">IV</span> da <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41;&#44; terem admiss&#245;es pr&#233;vias em insufici&#234;ncia card&#237;aca e terem esgotado as op&#231;&#245;es terap&#234;uticas&#44; cir&#250;rgicas ou outras &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; <span class="elsevierStyleItalic">Cardiac Resynchronization Therapy Defibrillator</span> &#8211; CRTD&#41;&#46; A maioria dos pacientes referenciados estava a ser seguida em consultas de insufici&#234;ncia card&#237;aca&#46; Verificados os crit&#233;rios cl&#237;nicos&#44; os potenciais candidatos tinham que cumprir os crit&#233;rios anat&#243;micos &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41; para a implanta&#231;&#227;o deste dispositivo&#46; Embora com a dissemina&#231;&#227;o da t&#233;cnica se tenha vindo a verificar algum desvio face aos crit&#233;rios anat&#243;micos inicialmente propostos&#44; estes devem ser escrupulosamente cumpridos nos centros que iniciam este procedimento&#58; 1&#41; o jato de regurgita&#231;&#227;o deve ser central&#44; 2&#41; comprimento de coapta&#231;&#227;o &#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm&#44; 3&#41; profundidade de coapta&#231;&#227;o acima do anel mitral &#60;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm&#44; 4&#41; se um dos folhetos for <span class="elsevierStyleItalic">flail</span> o hiato e a largura do segmento <span class="elsevierStyleItalic">flail</span> n&#227;o deve ser &#8805;<span class="elsevierStyleHsp" style=""></span>10 e &#8805;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm&#44; respetivamente&#46; Estes crit&#233;rios t&#234;m como consequ&#234;ncia que os pacientes com uma extrema dilata&#231;&#227;o ventricular esquerda se autoexcluem deste procedimento&#44; uma vez que a dilata&#231;&#227;o anular produz um grau de separa&#231;&#227;o tal dos folhetos que anatomicamente se torna muito dif&#237;cil a implanta&#231;&#227;o do <span class="elsevierStyleItalic">clip</span>&#46; Todos os registos ecocardiogr&#225;ficos foram revistos por um <span class="elsevierStyleItalic">Proctor</span> que decidiu da exequibilidade da t&#233;cnica&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Demograficamente &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41; esta experi&#234;ncia inicial envolveu um grupo et&#225;rio claramente baixo &#40;m&#233;dia de idades 58&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;1 anos&#41;&#44; com uma fra&#231;&#227;o de eje&#231;&#227;o &#40;FEj&#41; m&#233;dia de 29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;36&#37; e um <span class="elsevierStyleItalic">European System for Cardiac Operative Risk Evaluation</span> &#40;<span class="elsevierStyleItalic">EuroSCORE</span>&#41; log&#237;stico de 20&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;86&#46; Quatro dos pacientes j&#225; tinham sido avaliados em consulta de transplanta&#231;&#227;o card&#237;aca &#40;e um deles recusado para transplante por resist&#234;ncias pulmonares fixas&#41;&#46; Tr&#234;s dos pacientes teriam sido exclu&#237;dos do EVEREST II<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> &#40;Endovascular Valve Edge&#8208;to&#8208;Edge Repair Study&#41; por terem uma FEj &#60;<span class="elsevierStyleHsp" style=""></span>25&#37; e&#47;ou por terem uma dimens&#227;o telessist&#243;lica do ventr&#237;culo esquerdo &#62;<span class="elsevierStyleHsp" style=""></span>55<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#233;dia dos pacientes 55&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;19<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Os pacientes selecionados efetuaram ecocardiograma transtor&#225;cico antes do procedimento&#44; &#224; altura da alta&#44; ao 1&#176;&#44; 6&#176; e 12&#176; m&#234;s&#44; al&#233;m de avalia&#231;&#227;o cl&#237;nica presencial&#44; determina&#231;&#227;o de proBNP &#40;pro Brain Natriuretic Peptide&#41; e teste de marcha dos seis minutos na v&#233;spera do procedimento e ao 1&#46;&#176;&#44; 6&#46;&#176; e 12&#46;&#176; m&#234;s p&#243;s&#8208;implanta&#231;&#227;o&#46; Todos os pacientes assinaram o Consentimento Informado&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Definiu&#8208;se sucesso do procedimento a redu&#231;&#227;o da IM para um grau &#8804;<span class="elsevierStyleHsp" style=""></span>2 na aus&#234;ncia de complica&#231;&#245;es<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">O MitraClip &#233; um <span class="elsevierStyleItalic">clip</span> &#8211; em portugu&#234;s a analogia mais aproximada seria uma mola de prender roupa &#8211; de cr&#243;mio&#8208;cobalto com 4<span class="elsevierStyleHsp" style=""></span>mm de largura cujas duas extremidades s&#227;o abertas e fechadas &#40;o &#226;ngulo de abertura varia entre 0&#8208;240&#176;&#41; atrav&#233;s dum sistema de entrega com v&#225;rios man&#237;pulos &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figuras 2 e 3</a>&#41; que permitem n&#227;o s&#243; a abertura e encerramento dos bra&#231;os&#44; mas tamb&#233;m a rota&#231;&#227;o e o deslocamento anterior&#44; posterior&#44; lateral e mediano do dispositivo &#40;manobrabilidade tridimensional&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">O procedimento &#233; efetuado sob anestesia geral&#44; atrav&#233;s duma veia femoral e introdu&#231;&#227;o dum sistema de entrega 24<span class="elsevierStyleHsp" style=""></span>F que &#233; conduzido at&#233; &#224; aur&#237;cula esquerda ap&#243;s pun&#231;&#227;o transeptal&#44; sob monitoriza&#231;&#227;o fluorosc&#243;pica e&#44; fundamentalmente&#44; por ecocardiografia transesof&#225;gica&#46; A disponibilidade de ecocardiografia tridimensional &#233; imprescind&#237;vel j&#225; que&#44; entre outros&#44; permite a visualiza&#231;&#227;o de dois planos ortogonais simult&#226;neos <span class="elsevierStyleItalic">&#40;x&#8208;plane&#41;</span> e assim o <span class="elsevierStyleItalic">fine&#8208;tuning</span> da descida&#44; coloca&#231;&#227;o e preens&#227;o nos folhetos&#46; O <span class="elsevierStyleItalic">clip</span> &#233; conduzido at&#233; &#224; base do fluxo regurgitante e prendido aos segmentos m&#233;dios de ambos os folhetos&#44; aproximando&#8208;os&#44; sendo libertado apenas quando a diminui&#231;&#227;o do jato for considerada adequada &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41;&#46; Se n&#227;o se consegue uma adequada preens&#227;o de ambos os folhetos&#44; os bra&#231;os do <span class="elsevierStyleItalic">clip</span> podem ser novamente abertos&#44; os folhetos libertos e o <span class="elsevierStyleItalic">clip</span> retirado para a aur&#237;cula esquerda para novo reposicionamento&#46; O n&#250;mero de <span class="elsevierStyleItalic">clips</span> implantado varia normalmente entre 1 a 4 e&#44; ap&#243;s a sua implanta&#231;&#227;o&#44; forma&#8208;se uma ponte fibrosa entre os dois folhetos constituindo um refor&#231;o adicional que diminui o potencial de distens&#227;o septal&#8208;lateral&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Os procedimentos foram realizados no laborat&#243;rio de hemodin&#226;mica do Servi&#231;o de Cardiologia do Hospital de Santa Marta&#44; em Lisboa&#44; sob anestesia geral&#44; com monitoriza&#231;&#227;o ecocardiogr&#225;fica transesof&#225;gica bi e tridimensional &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figura 5</a>&#41;&#44; com a presen&#231;a de tr&#234;s <span class="elsevierStyleItalic">Proctors</span> &#40;cardiologista de interven&#231;&#227;o&#44; cardiologista ecocardiografista e t&#233;cnico do dispositivo&#41; nos dois primeiros casos e com um &#40;t&#233;cnico do dispositivo&#41; nos restantes&#46; Ap&#243;s a pun&#231;&#227;o transeptal &#233; administrada heparina endovenosa de forma a obtermos um tempo de ativa&#231;&#227;o da coagula&#231;&#227;o &#62;<span class="elsevierStyleHsp" style=""></span>250&#8221;&#59; enquanto o sistema de entrega 22<span class="elsevierStyleHsp" style=""></span>F do MitraClip &#233; posicionado na aur&#237;cula esquerda atrav&#233;s da bainha 24<span class="elsevierStyleHsp" style=""></span>F colocada na veia femoral direita&#46; Inicialmente colocamos um MitraClip na base do jato de regurgita&#231;&#227;o dividindo&#8208;o em dois&#59; se estes fossem de pequena dimens&#227;o implantar&#237;amos o <span class="elsevierStyleItalic">clip</span>&#44; caso mantivessem uma dimens&#227;o razo&#225;vel adotar&#237;amos uma estrat&#233;gia de dois <span class="elsevierStyleItalic">clips</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Figura 6</a>&#41;&#44; implantando o primeiro numa posi&#231;&#227;o mais mediana e o segundo mais lateral &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Figura 7</a>&#41;&#44; confirmando a inexist&#234;ncia dum gradiente transmitral significativo antes de o libertarmos&#46; Se nos defront&#225;ssemos com uma excessiva dificuldade na preens&#227;o dos folhetos&#44; induz&#237;amos um breve per&#237;odo de apneia &#8211; desconectando por alguns segundos o paciente do ventilador &#8211; e&#47;ou um per&#237;odo de bradic&#225;rdia mais intensa com administra&#231;&#227;o dum &#946;&#8208;bloqueante de semivida curta &#40;esmolol&#41;&#46; Por protocolo o paciente era extubado ainda na sala de hemodin&#226;mica donde sa&#237;a j&#225; acordado&#44; permanecendo na UCI por 24 horas&#44; ap&#243;s o que era transferido para a enfermaria&#46; Dado que cinco pacientes faziam j&#225; anticoagula&#231;&#227;o oral com acenocumarol ou varfine e que o remanescente estava j&#225; sob &#225;cido acetilsalic&#237;lico&#44; apenas neste se associou clopidogrel durante um m&#234;s ap&#243;s o procedimento&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica das vari&#225;veis quantitativas destes seis casos foi expressa em m&#233;dia &#177; DP&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0105" class="elsevierStylePara elsevierViewall">Nos seis pacientes obteve&#8208;se um sucesso do procedimento de 100&#37; sem qualquer complica&#231;&#227;o quer durante a interven&#231;&#227;o quer durante o seu internamento &#40;m&#233;dia 6&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;48 dias&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Apesar de ser um procedimento moroso &#40;115&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;7<span class="elsevierStyleHsp" style=""></span>mins&#41;&#44; o tempo de fluoroscopia &#233; relativamente baixo &#40;49&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;38<span class="elsevierStyleHsp" style=""></span>mins&#41;&#44; o que reflete o facto de este ser um procedimento que &#233; sobretudo guiado por ecocardiografia transesof&#225;gica &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o ecocardiogr&#225;fica &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tabelas 3 e 4</a>&#41; revelou uma melhoria dos volumes ventriculares diast&#243;licos &#40;229&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>118&#44;53 <span class="elsevierStyleItalic">versus</span> 182&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>88&#44;24<span class="elsevierStyleHsp" style=""></span>ml&#41; e sist&#243;licos &#40;158&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>100&#44;28 <span class="elsevierStyleItalic">versus</span> 127&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>57&#44;71<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; da FEj &#40;31&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;2 <span class="elsevierStyleItalic">versus</span> 37&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;11&#37;&#41; e da press&#227;o sist&#243;lica da art&#233;ria pulmonar &#40;44&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;75 <span class="elsevierStyleItalic">versus</span> 41&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;97<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">No <span class="elsevierStyleItalic">follow&#8208;up</span> ao m&#234;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41; destaca&#8208;se clinicamente uma melhoria do est&#225;dio funcional de cinco dos seis pacientes&#44; com regress&#227;o de 1&#8208;2 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; est&#225;dios da classe funcional NYHA&#46; No <span class="elsevierStyleItalic">follow&#8208;up</span> total constataram&#8208;se tr&#234;s admiss&#245;es hospitalares &#40;um doente com duas admiss&#245;es&#41; e dois &#243;bitos&#44; envolvendo dois dos pacientes avaliados em consulta de transplanta&#231;&#227;o card&#237;aca&#44; um dos quais tinha sido recusado por resist&#234;ncias pulmonares fixas&#58; um outro&#44; o que objetivamente se encontrava num est&#225;dio mais terminal de insufici&#234;ncia card&#237;aca antes do procedimento de MitraClip&#44; foi readmitido cerca dum m&#234;s depois em insufici&#234;ncia card&#237;aca congestiva vindo a falecer 84 dias ap&#243;s a admiss&#227;o&#44; n&#227;o se tendo encontrado um dador compat&#237;vel nesse lapso de tempo&#46; Este foi&#44; ali&#225;s&#44; o &#250;nico paciente que revelou um aumento substancial do proBNP ao m&#234;s de <span class="elsevierStyleItalic">follow&#8208;up</span>&#59; todos os outros demonstraram uma diminui&#231;&#227;o deste par&#226;metro laboratorial &#40;557&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>376&#44;73 <span class="elsevierStyleItalic">versus</span> 494&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>249&#44;5<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#41;&#46; O segundo paciente&#44; recusado para transplante&#44; teve duas breves admiss&#245;es hospitalares nos primeiros seis meses &#40;antes da implanta&#231;&#227;o do MitraClip a frequ&#234;ncia de admiss&#245;es era virtualmente mensal&#41;&#44; tendo vindo a falecer em ambulat&#243;rio ao 9&#176; m&#234;s por morte s&#250;bita&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">O teste da marcha ao m&#234;s revelou uma melhoria em todos os pacientes &#40;329&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>98&#44;42 <span class="elsevierStyleItalic">versus</span> 385&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>109&#44;95<span class="elsevierStyleHsp" style=""></span>m&#41;&#46; Os quatro pacientes vivos no <span class="elsevierStyleItalic">follow&#8208;up</span> total &#40;290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>140 dias&#41; mant&#234;m uma melhoria da classe funcional em um ou dois est&#225;dios &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discuss&#227;o</span><p id="par0130" class="elsevierStylePara elsevierViewall">Os seis casos descritos constituem a nossa experi&#234;ncia inicial com o MitraClip&#46; Este n&#250;mero representa&#44; a par dum ainda curto <span class="elsevierStyleItalic">follow&#8208;up</span> e da n&#227;o adjudica&#231;&#227;o das avalia&#231;&#245;es ecocardiogr&#225;ficas a um laborat&#243;rio independente&#44; a principal limita&#231;&#227;o deste artigo e impede&#44; <span class="elsevierStyleItalic">per se</span>&#44; quaisquer generaliza&#231;&#245;es&#46; Ainda assim&#44; o dado que mais ressalta &#233; a seguran&#231;a deste tipo de interven&#231;&#227;o&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">O in&#237;cio deste procedimento ocorreu ap&#243;s cerca de dois anos de sele&#231;&#227;o ativa de doentes&#44; incluindo estudo detalhado da anatomia mitral por ecocardiografia transtor&#225;cica e transesof&#225;gica&#44; havendo atualmente uma lista de oito pacientes em lista de espera&#44; todos com IM grave e cl&#237;nica de insufici&#234;ncia card&#237;aca&#46; A experi&#234;ncia mundial entretanto acumulada com este dispositivo parece demonstrar que numa fase inicial de experi&#234;ncia apenas um em cada tr&#234;s doentes referenciados para MitraClip &#233; considerado adequado&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Este dispositivo tem marca CE desde 2008&#44; mas o ensaio que esteve na base da aceita&#231;&#227;o pela FDA em 2013 foi o EVEREST II&#44; que aleatorizou 279 doentes com IM 3<span class="elsevierStyleHsp" style=""></span>&#43; ou 4<span class="elsevierStyleHsp" style=""></span>&#43; para MitraClip <span class="elsevierStyleItalic">versus</span> cirurgia &#40;repara&#231;&#227;o ou substitui&#231;&#227;o&#41;&#46; A randomiza&#231;&#227;o foi de 2&#58;1&#44; isto &#233;&#44; dois pacientes para Mitraclip para um referenciado para cirurgia&#46; Os <span class="elsevierStyleItalic">endpoints</span> prim&#225;rios compostos foram divididos em efic&#225;cia e em seguran&#231;a&#59; o primeiro englobava aus&#234;ncia de morte&#44; aus&#234;ncia de cirurgia por disfun&#231;&#227;o valvular mitral ou aus&#234;ncia de IM 3<span class="elsevierStyleHsp" style=""></span>&#43; ou 4<span class="elsevierStyleHsp" style=""></span>&#43; aos 12 meses&#59; o segundo os eventos adversos <span class="elsevierStyleItalic">major</span> aos 30 dias&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Na efic&#225;cia demonstrou&#8208;se uma taxa de 55&#37; no grupo do MitraClip <span class="elsevierStyleItalic">versus</span> 73&#37; na cirurgia &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#44; com uma mortalidade de 6&#37; em ambos os grupos&#44; cirurgia por disfun&#231;&#227;o mitral 20 <span class="elsevierStyleItalic">versus</span> 2&#37; e IM 3<span class="elsevierStyleHsp" style=""></span>&#43; ou 4<span class="elsevierStyleHsp" style=""></span>&#43; 21 <span class="elsevierStyleItalic">versus</span> 20&#37;&#46; No <span class="elsevierStyleItalic">endpoint</span> de seguran&#231;a o resultado foi de 15 <span class="elsevierStyleItalic">versus</span> 48&#37; &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Aos 12 meses ambos os grupos tinham diminui&#231;&#245;es nos volumes ventriculares&#44; melhoria da classe funcional da NYHA e nos &#237;ndices de qualidade de vida&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Em 23&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#41; dos pacientes submetidos a MitraClip verificou&#8208;se que mantinham uma IM 3<span class="elsevierStyleHsp" style=""></span>&#43; ou 4<span class="elsevierStyleHsp" style=""></span>&#43; antes da alta&#44; tendo 28 sido referenciados para cirurgia&#46; Dos pacientes submetidos inicialmente a cirurgia&#44; 14&#37; foram submetidos &#224; implanta&#231;&#227;o de pr&#243;tese valvular e 86&#37; a repara&#231;&#227;o mitral&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">A transfus&#227;o de &#8805;<span class="elsevierStyleHsp" style=""></span>2 unidades de sangue &#8211; fator com grande influ&#234;ncia no progn&#243;stico a longo prazo<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> &#8211; constituiu o maior determinante dos eventos adversos <span class="elsevierStyleItalic">major</span> aos 30 dias&#46; Contudo&#44; mesmo excluindo estes&#44; a taxa de eventos adversos permaneceu inferior no grupo do MitraClip&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Dois subgrupos do MitraClip revelaram uma efic&#225;cia n&#227;o inferior &#224; cirurgia&#58; regurgita&#231;&#227;o mitral funcional e pacientes com &#8805;<span class="elsevierStyleHsp" style=""></span>70 anos&#46; Os dados entretanto publicados do <span class="elsevierStyleItalic">follow&#8208;up</span> de quatro anos do EVEREST II revelam uma sobreviv&#234;ncia de 83&#37; no grupo percut&#226;neo e de 82&#37; no grupo cir&#250;rgico&#44; al&#233;m de aus&#234;ncia de diferen&#231;a significativa no n&#250;mero de pacientes com IM 3<span class="elsevierStyleHsp" style=""></span>&#43; e 4<span class="elsevierStyleHsp" style=""></span>&#43;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; A efic&#225;cia e seguran&#231;a deste dispositivo&#44; comparada com a terap&#234;utica m&#233;dica em pacientes de alto risco&#44; foram entretanto confirmadas pelos registos europeus ACCESS&#8208;EU<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> e alem&#227;o <span class="elsevierStyleItalic">TRAnscatheter Mitral valve Interventions</span> &#40;TRAMI&#41;<span class="elsevierStyleItalic">&#41;</span><a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a>&#46; Com o mesmo objetivo&#44; isto &#233;&#44; comparando o MitraClip com o <span class="elsevierStyleItalic">standard&#8208;of&#8208;care</span> da terap&#234;utica m&#233;dica&#44; mas j&#225; sob a forma de ensaio aleatorizado&#44; foram lan&#231;ados nos EUA o estudo <span class="elsevierStyleItalic">Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for Extremely High&#8208;Surgical&#95;Risk Patients</span> &#40;COAPT&#41; e na Europa <span class="elsevierStyleItalic">A Randomized Study of the MitraClip Device of Heart Failure Patients with Clinically Significant Functional Mitral Regurgitation</span> &#40;RESHAPE&#8208;HF&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">O dado demogr&#225;fico que mais ressalta da nossa s&#233;rie &#233; o baixo escal&#227;o et&#225;rio &#40;apenas um octogen&#225;rio&#59; m&#233;dia de idades 58&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;1 anos&#41;&#44; o que &#233; fundamental para determinar um <span class="elsevierStyleItalic">EuroSCORE</span> log&#237;stico de 20&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;86&#46; Atendendo &#224; import&#226;ncia da idade na determina&#231;&#227;o deste preditor de risco&#44; a situa&#231;&#227;o real destes casos poder&#225; estar subestimada&#44; como o parecem provar os dois &#243;bitos n&#227;o relacion&#225;veis com o procedimento nos 12 meses subsequentes&#46; Esta op&#231;&#227;o teve por base a inten&#231;&#227;o de disponibilizar este dispositivo a um grupo com uma maior sobrevida expect&#225;vel&#44; no intuito de retirar o maior benef&#237;cio poss&#237;vel do procedimento&#46; A escolha de pacientes j&#225; avaliados em consulta de transplanta&#231;&#227;o card&#237;aca&#44; por natureza mais jovens&#44; pretendeu adiar substancialmente &#8211; idealmente por anos &#8211; a entrada em lista de espera de dador&#46; Os resultados obtidos sugerem&#44; por&#233;m&#44; que alguns destes pacientes j&#225; estar&#227;o muito no extremo da hist&#243;ria da natural da doen&#231;a para virem a retirar benef&#237;cio&#46; A sele&#231;&#227;o dos pacientes constitui&#44; de resto&#44; o elemento mais importante j&#225; que o MitraClip existe para melhorar os sintomas e a evid&#234;ncia atual revela que em cerca de 25&#37; dos casos n&#227;o existe al&#237;vio sintom&#225;tico com o MitraClip pelo que &#233; importante tentar definir pr&#233; implanta&#231;&#227;o quais os pacientes que n&#227;o ir&#227;o obter qualquer benef&#237;cio do procedimento&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A an&#225;lise de outras s&#233;ries com predom&#237;nio de IM funcional<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a>&#44; incluindo o maior registo europeu e o que porventura mais se aproxima da nossa realidade&#44; o ACCESS&#8208;EU<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a>&#44; revelam que 72&#8208;83&#37; dos pacientes que atingem o ano de <span class="elsevierStyleItalic">follow&#8208;up</span> mant&#234;m&#8208;se com IM &#8804;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>&#43; e 79&#8208;83&#37; permanecem em classe <span class="elsevierStyleSmallCaps">I</span> ou <span class="elsevierStyleSmallCaps">II</span> da NYHA&#46; O ACCESS&#8208;EU revela um internamento um pouco superior ao nosso &#40;7&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;2 dias&#44; incluindo 2&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;5 dias na UCI&#41;&#44; com uma melhoria consistente&#44; tal como nos nossos casos&#44; dos par&#226;metros ecocardiogr&#225;ficos e do teste da marcha dos seis minutos&#44; cujo ganho m&#233;dio de cerca de 60 metros &#233;&#44; ali&#225;s&#44; semelhante ao da nossa s&#233;rie &#40;55<span class="elsevierStyleHsp" style=""></span>m&#41;&#46; As s&#233;ries europeias t&#234;m tempos de internamento superiores &#224;s americanas&#44; cuja m&#233;dia &#233; de cerca de tr&#234;s dias&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Em termos hist&#243;ricos houve uma diverg&#234;ncia na abordagem norte&#8208;americana e europeia&#46; O EVEREST I<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a> e II s&#227;o estudos americanos e a credibilidade inicial do MitraClip adv&#233;m destes ensaios&#46; Envolveram pacientes que teriam que ser tamb&#233;m candidatos cir&#250;rgicos&#46; Contudo&#44; a Europa interessou&#8208;se sobretudo pelos pacientes que&#44; <span class="elsevierStyleItalic">a priori</span>&#44; seriam recusados para esses ensaios&#44; isto &#233;&#44; pelos pacientes com IM funcional severa e insufici&#234;ncia card&#237;aca congestiva&#44; n&#227;o considerados para cirurgia&#44; muitos deles <span class="elsevierStyleItalic">non&#8208;responders</span> da terap&#234;utica de ressincroniza&#231;&#227;o&#44; a maioria dos quais seguidos em consultas de insufici&#234;ncia card&#237;aca e alguns&#44; como foram ali&#225;s quatro dos nossos pacientes&#44; recusados ou em listas de pr&#233;&#8208;transplante&#46; Isto &#233;&#44; os europeus posicionaram o MitraClip como um procedimento n&#227;o concorrencial da cirurgia&#44; num grupo de pacientes que n&#227;o tinha alternativa n&#227;o farmacol&#243;gica&#46; Neste sentido e contrariamente ao EVEREST II&#44; em que 73&#37; dos pacientes randomizados apresentavam uma IM degenerativa&#44; todos os nossos seis casos tinham uma etiologia funcional&#46; Deste facto decorre que&#44; contrariamente ao que aconteceu na implanta&#231;&#227;o de pr&#243;teses a&#243;rticas por via percut&#226;nea&#44; a possibilidade duma guerra de territ&#243;rio <span class="elsevierStyleItalic">&#40;turf war&#41;</span> com a cirurgia &#233; virtualmente inexistente&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Existem dois grupos que se destacam como particularmente atraentes para um procedimento de MitraClip&#58; os pacientes com uma calcifica&#231;&#227;o extensa do anel&#44; uma vez que esta calcifica&#231;&#227;o pode funcionar como um anel prot&#233;sico em termos de sustentabilidade e impedir uma dilata&#231;&#227;o progressiva do anel&#44; e os doentes com IM funcional severa com insufici&#234;ncia card&#237;aca refrat&#225;ria &#224; terap&#234;utica farmacol&#243;gica e de ressincroniza&#231;&#227;o <span class="elsevierStyleItalic">&#40;non&#8208;responders&#41;</span><a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Apesar do sucesso e dissemina&#231;&#227;o deste procedimento&#44; existem v&#225;rias limita&#231;&#245;es potenciais<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> desta abordagem&#58; 1&#41; o MitraClip reproduz duma forma incompleta a cirurgia de Alfieri ao n&#227;o intervir no anel&#44; o que poder&#225; explicar a m&#233;dio ou longo prazo o reaparecimento duma IM importante&#59; 2&#41; a quantifica&#231;&#227;o da IM &#8211; sobretudo a residual ap&#243;s implanta&#231;&#227;o do <span class="elsevierStyleItalic">clip</span> &#8211; durante um procedimento com anestesia geral nem sempre &#233; f&#225;cil&#44; mas aqui o problema &#233; comum &#224; cirurgia&#59; 3&#41; o potencial de substituirmos uma IM por uma estenose mitral&#44; embora at&#233; &#224; data n&#227;o existam casos descritos<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a>&#59; 4&#41; aus&#234;ncia de informa&#231;&#227;o de durabilidade e efic&#225;cia a longo prazo&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Entretanto&#44; com a generaliza&#231;&#227;o deste procedimento&#44; os crit&#233;rios anat&#243;micos iniciais come&#231;am a ser expandidos com a publica&#231;&#227;o de casos de IM exc&#234;ntrica e de varia&#231;&#245;es &#224; t&#233;cnica inicial proposta &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; <span class="elsevierStyleItalic">the zipping procedure</span>&#44; com implanta&#231;&#227;o de quatro ou cinco <span class="elsevierStyleItalic">clips</span>&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Al&#233;m do MitraClip existe um crescente n&#250;mero de abordagens da IM por via percut&#226;nea&#44; algumas das quais em fase ativa de implanta&#231;&#227;o&#46; Estes dispositivos dividem&#8208;se em duas grandes classes conforme atuem no anel ou noutro dos componentes do aparelho valvular mitral&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Na maioria das cirurgias da IM procede&#8208;se a uma interven&#231;&#227;o sobre os dois principais componentes valvulares&#58; folhetos e anel&#46; N&#227;o &#233; pois de estranhar a extensa investiga&#231;&#227;o sobre interven&#231;&#245;es percut&#226;neas no anel&#44; que ali&#225;s antecede o desenvolvimento do MitraClip&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Existem duas formas de anulopastia percut&#226;nea&#44; a indireta e a direta&#46; O Carillon Mitral Contour System <span class="elsevierStyleItalic">&#40;Cardiac Dimensions&#41;</span> &#233; um dispositivo de anuloplastia indireta&#44; atrav&#233;s do seio coron&#225;rio&#44; composto por duas &#226;ncoras de nitinol nas extremidades unidas por um elemento central tamb&#233;m de nitinol&#46; Envolve um cateter de entrega 9<span class="elsevierStyleHsp" style=""></span>F&#44; com acesso pela veia jugular interna e exige um movimento de tens&#227;o manual de 4&#8208;5<span class="elsevierStyleHsp" style=""></span>cm antes da liberta&#231;&#227;o final&#44; sendo o procedimento monitorizado quer com ecocardiografia transesof&#225;gica &#40;grau de IM&#41; quer sob coronariografia esquerda &#40;exclus&#227;o de compress&#227;o coron&#225;ria&#41;&#46; Atualmente &#233; o &#250;nico dispositivo de anuloplastia percut&#226;neo aprovado na Uni&#227;o Europeia&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Contrariamente aos <span class="elsevierStyleItalic">devices</span> de anulopastia indireta&#44; feita atrav&#233;s do seio coron&#225;rio&#44; existem abordagens de anuloplastia direta em que se acede diretamente ao anel&#44; tal como a t&#233;cnica cir&#250;rgica&#46; Mais complexa do que a abordagem pelo seio coron&#225;rio&#44; o acesso &#233; feito retrogradamente pela art&#233;ria femoral&#44; colocando&#8208;se o cateter no ventr&#237;culo esquerdo por baixo do folheto posterior&#44; procedendo&#8208;se &#224; aplica&#231;&#227;o duma esp&#233;cie de &#226;ncoras em volta do anel&#44; unidas por uma sutura&#46; A tens&#227;o exercida nesta sutura aproxima as &#226;ncoras&#44; diminuindo assim a circunfer&#234;ncia do anel &#40;sistema <span class="elsevierStyleItalic">Mitralign</span>&#41;&#46; Outro sistema de anuloplastia direta &#233; o Cardioband&#44; que utiliza um acesso transeptal e tem sido utilizado exclusivamente na IM funcional&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Dado o potencial dos pacientes submetidos a MitraClip virem a m&#233;dio ou a longo prazo a refazerem o grau original de IM&#44; a associa&#231;&#227;o dum procedimento de anuloplastia parece conceptualmente atrativa&#46; Esta associa&#231;&#227;o reproduziria com maior precis&#227;o o procedimento cir&#250;rgico&#46; Este parece ser o conceito mais promissor<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> enquanto se desenvolve uma pr&#243;tese mitral percut&#226;nea para implanta&#231;&#227;o numa v&#225;lvula mitral nativa&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclus&#227;o</span><p id="par0220" class="elsevierStylePara elsevierViewall">A nossa experi&#234;ncia inicial com o dispositivo MitraClip confirmou a extrema seguran&#231;a do procedimento num grupo de pacientes com insufici&#234;ncia card&#237;aca e IM funcional 4<span class="elsevierStyleHsp" style=""></span>&#43; n&#227;o considerados para cirurgia&#44; tr&#234;s dos quais teriam sido exclu&#237;dos do EVEREST II e quatro tamb&#233;m j&#225; avaliados em consulta de pr&#233;&#8208;transplante&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">O curto <span class="elsevierStyleItalic">follow&#8208;up</span> impede uma adequada an&#225;lise da efic&#225;cia&#44; mas a aus&#234;ncia de reinterven&#231;&#227;o&#44; cir&#250;rgica ou n&#227;o&#44; a melhoria da classe funcional&#44; dos volumes ventriculares e do teste da marcha dos seis minutos e a regress&#227;o consistente do valor de proBNP sugere que esta n&#227;o &#233; despicienda&#46; Contudo&#44; a implanta&#231;&#227;o de MitraClip em pacientes j&#225; avaliados em consulta de transplanta&#231;&#227;o parece n&#227;o alterar a hist&#243;ria natural da doen&#231;a&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Responsabilidades &#233;ticas</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prote&#231;&#227;o dos seres humanos e animais</span><p id="par0230" class="elsevierStylePara elsevierViewall">Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos respons&#225;veis da Comiss&#227;o de Investiga&#231;&#227;o Cl&#237;nica e &#201;tica e de acordo com os da Associa&#231;&#227;o M&#233;dica Mundial e da Declara&#231;&#227;o de Helsinki&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidade dos dados</span><p id="par0235" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Direito &#224; privacidade e consentimento escrito</span><p id="par0240" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0245" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A insufici&#234;ncia valvular mitral &#40;IM&#41; &#233; a valvulopatia mais comum e come&#231;a agora a ser alvo de abordagens percut&#226;neas&#46; O dispositivo MitraClip &#233; virtualmente o &#250;nico dispositivo com uma experi&#234;ncia consider&#225;vel&#44; ultrapassando atualmente as 20<span class="elsevierStyleHsp" style=""></span>000 implanta&#231;&#245;es&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrever a experi&#234;ncia inicial da terap&#234;utica percut&#226;nea da IM com o dispositivo MitraClip&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descrevem&#8208;se os primeiros seis casos de MitraClip realizados nesta institui&#231;&#227;o &#40;idade 58&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;1 anos&#41;&#44; com IM 4<span class="elsevierStyleHsp" style=""></span>&#43; de etiologia funcional e insufici&#234;ncia card&#237;aca classe <span class="elsevierStyleSmallCaps">III</span> ou <span class="elsevierStyleSmallCaps">IV</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; da <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41;&#44; sem indica&#231;&#227;o cir&#250;rgica ou recusados para cirurgia&#44; com um <span class="elsevierStyleItalic">follow&#8208;up</span> m&#233;dio 290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>145 dias avaliado clinicamente pela sobreviv&#234;ncia&#44; classe funcional&#44; teste da marcha dos seis minutos&#44; estudo ecocardiogr&#225;fico e determina&#231;&#227;o do proBNP&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O sucesso do procedimento &#40;IM &#8804;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>&#43;&#41; foi de 100&#37;&#44; com um tempo de procedimento de 115&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;7<span class="elsevierStyleHsp" style=""></span>mins&#44; sem intercorr&#234;ncias intra&#8208;hospitalares&#44; alta entre o 4&#46;&#176; e 8&#46;&#176; dia e uma melhoria consistente no teste da marcha dos seis minutos &#40;329&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>98&#44;42 <span class="elsevierStyleItalic">versus</span> 385&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>106&#44;95<span class="elsevierStyleHsp" style=""></span>m&#41; e da classe funcional &#40;tr&#234;s dos pacientes com melhoria de duas classes funcionais NYHA&#41;&#46; Na totalidade do <span class="elsevierStyleItalic">follow&#8208;up</span> &#40;290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>145 dias&#41; constatam&#8208;se dois &#243;bitos&#44; em dois dos quatro pacientes que tinham sido considerados para transplanta&#231;&#227;o card&#237;aca&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclus&#245;es</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O procedimento de implanta&#231;&#227;o do dispositivo MitraClip &#233; seguro&#44; com uma alta taxa de sucesso imediato nos pacientes com IM funcional&#46; A m&#233;dio prazo o benef&#237;cio cl&#237;nico parece esbater&#8208;se ou anular&#8208;se nos pacientes com insufici&#234;ncia card&#237;aca mais terminal&#44; nomeadamente nos pacientes a aguardar ou recusados para transplante&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mitral regurgitation &#40;MR&#41; is the most common valvular disease and has recently become the target of a number of percutaneous approaches&#46; The MitraClip is virtually the only device for which there is considerable experience&#44; with more than 20 000 procedures performed worldwide&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">To describe our initial experience of the percutaneous treatment of MR with the MitraClip device&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">We describe the first six MitraClip cases performed in this institution &#40;mean age 58&#46;5&#177;13&#46;1 years&#41;&#44; with functional MR grade 4&#43; and New York Heart Association &#40;NYHA&#41; heart failure class III or IV &#40;n&#61;3&#41;&#44; with a mean follow&#8208;up of 290&#177;145 days&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Procedural success &#40;MR &#8804;2&#43;&#41; was 100&#37;&#46; Total procedure time was 115&#46;8&#177;23&#46;7 min&#44; with no in&#8208;hospital adverse events and discharge between the fourth and eighth day&#44; and consistent improvement in the six&#8208;minute walk test &#40;329&#46;8&#177;98&#46;42 vs&#46; 385&#46;33&#177;106&#46;95 m&#41; and in NYHA class &#40;three patients improved by two NYHA classes&#41;&#46; During follow&#8208;up there were two deaths&#44; in two of the four patients who had been initially considered for heart transplantation&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">In patients with functional MR the MitraClip procedure is safe&#44; with both a high implantation and immediate in&#8208;hospital success rate&#46; A longer follow&#8208;up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease&#44; namely those denied transplantation or on the heart transplant waiting list&#46;</p></span>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Ever II&#58; crit&#233;rios do EVEREST II&#59; ES log&#58; <span class="elsevierStyleItalic">EuroSCORE</span> log&#237;stico&#59; ES II&#58; EuroSCORE II&#59; FEj&#58; fra&#231;&#227;o de eje&#231;&#227;o&#59; Func&#58; etiologia funcional&#59; LVES diam&#58; di&#226;metro telessist&#243;lico do VE em mm&#59; Org&#58; etiologia org&#226;nica ou degenerativa&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Paciente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Idade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fej &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ever <span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESdiam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ES log&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ES <span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Func&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Org&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiologia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Miocardite&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilatada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilatada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilatada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Tempo de procedimento&#58; tempo decorrido entre a pun&#231;&#227;o transeptal e a remo&#231;&#227;o do cateter guia orient&#225;vel&#59; Tempo de dispositivo&#58; tempo decorrido entre a entrada do cateter guia orient&#225;vel na aur&#237;cula esquerda atrav&#233;s do septo interauricular e o momento em que o cateter de entrega do MitraClip &#233; retirado para o interior do cateter guia orient&#225;vel</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Paciente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tempo de fluoroscopia &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tempo de procedimento &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">155&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">115&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tempo de dispositivo &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dose acumulada &#40;mGy&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2680&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1487&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1962&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1362&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">N&#46;&#176; de clips&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dias internamento p&#243;s&#8208;procedimento&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
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