Azacitidine-induced massive pericardial effusion in a child with myelodysplastic syndrome.

INTRODUCTION: Pericardial effusions are rare yet potentially fatal conditions in children. Azacitidine is a DNA-hypomethylating agent used in the treatment of myelodysplastic syndrome. Although seldomly described in adults, no cases of azacitidine-induced pericardial effusion have been reported in children. CASE REPORT: A 7-year-old boy with myelodysplastic syndrome presented with a large pericardial effusion with risk for cardiac tamponade after his first azacitidine cycle. MANAGEMENT & OUTCOME: The patient was admitted to a pediatric ICU, antibiotic and steroid therapy were initiated. Pericardiocentesis was done due to hemodynamic instability. Serum and pericardial fluid complementary evaluation excluded infectious and malignant causes. The pericardial effusion did not reappear and additional pleural and ascitic slight effusions responded well to diuretics. Follow-up azacitidine cycles were administered by tapering daily dosages and using adjunctive steroid therapy, with no additional adverse events. DISCUSSION: We report the first pediatric case of large pericardial effusion secondary to azacitidine therapy in a child with MDS. This adverse reaction has not been described in pediatric patients, in which this therapeutic option has been increasingly used. We seek to raise awareness on the potential life-threatening cardiotoxicity of azacitidine in pediatric patients.

Surgical versus transcatheter aortic valve replacement in low-risk patients: A long-term propensity score-matched analysis.

BACKGROUND: Recent studies suggest the use of transcatheter aortic valve implantation (TAVI) as an alternative to surgical aortic valve replacement (SAVR) in lower risk populations, but real-world data are scarce. METHODS: Single-center retrospective study of patients undergoing SAVR (between June 2009 and July 2016, n = 682 patients) or TAVI (between June 2009 and July 2017, n = 400 patients). Low surgical risk was defined as EuroSCORE II (ES II) < 4% for single noncoronary artery bypass graft procedure. TAVI patients were propensity score-matched in a 1:1 ratio with SAVR patients, paired by age, New York Heart Association class, diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, creatinine clearance, and left ventricular ejection fraction < 50%. RESULTS: A total of 158 patients (79 SAVR and 79 TAVI) were matched (mean age 79 ± 6 years, 79 men). TAVI patients had a higher incidence of permanent pacemaker implantation (0% vs. 19%, p < 0.001) and more than mild paravalvular leak (4% vs. 18%, p = 0.009), but comparable rates of stroke, major or life-threatening bleeding, emergent cardiac surgery, new-onset atrial fibrillation, and need for renal replacement therapy. Hospital length-of-stay and 30-day mortality were similar. At a median follow-up of 4.5 years (IQR 3.0-6.9), treatment strategy did not influence all-cause mortality (HR 1.19, 95% CI 0.77-1.83, log rank p = 0.43) nor rehospitalization (crude subdistribution HR 1.56, 95% CI 0.71-3.41, p = 0.26). ES II remained the only independent predictor of long-term all-cause mortality (adjusted HR 1.40, 95% CI 1.04-1.90, p = 0.029). CONCLUSION: In this low surgical risk severe aortic stenosis population, we observed similar rates of 30-day and long-term all-cause mortality, despite higher rates of permanent pacemaker implantation and more than mild paravalvular leak in TAVI patients. The results of this small study suggest that both procedures are safe and effective in the short-term, while the Heart Team remains essential to assess both options on the long-term.

Complete surgical revascularization: Different definitions, same impact?

BACKGROUND: There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. METHODS: All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. EXCLUSION CRITERIA: emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. RESULTS: Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.

Cardiac Surgery in Patients with Dialysis-dependent End Stage Renal Failure: Single Centre Experience.

BACKGROUND: Patients under dialysis have a high cardiovascular risk and they are at increased risk when submitted to cardiac surgery. AIM OF THE STUDY: to evaluate morbidity, early and late mortality, and predictive factors of mortality in patients under dialysis who underwent cardiac surgery. METHODS: A retrospective observational study was performed including all dialysis dependent patients who underwent cardiac surgery (coronary, valvular or combined procedures) in our institution between 2007 and 2014. A population of 95 consecutive patients was obtained (no exclusions). Perioperative variables and predictors of mortality were analysed and the endpoints were early and late mortality. Propensity score matching, with a control group of patients with creatinine clearance >90mL/min, was performed by logistic regression, with a 1:1 matching. Kaplan Meier curves were performed for late mortality. RESULTS: Early mortality was 9.4% (EuroSCORE II 4.1%). In univariate analysis, mean time of cardiopulmonary bypass (CPB) (p=0.016) and EuroSCORE II (p=0.02) were related with early mortality. In a multivariate analysis model, combined procedures (OR 138.09; CI95% 1.82-10498.4; p=0.03) and CCS (Canadian Cardiovascular Society) 3-4 (OR 70.951; CI 95% 1.32-3810.11; p=0.037) were predictors of mortality. In multivariable analysis, CPB time >152 min was a predictor of early mortality (p=0.001). After propensity score matching, 30 day, one year and late mortality were higher in the dialysis group. CONCLUSIONS: Early and late mortality were significantly higher in dialysis dependent patients. Predictive factors of mortality were CPB time and EuroSCORE II in univariable analysis, and CCS 3-4 and combined procedures in multivariable analysis.

Patient prosthes is mismatch in stented biologic aortic valve prosthesis: 10 years' results.

OBJECTIVES: The goal of this study is to establish the relation between aortic bio prosthesis, patient prosthesis mismatch (PPM) and short-term mortality and morbidity as well as and long-term mortality. METHODS: This is a single center retrospective study with 812 patients that underwent isolated stented biologic aortic valve replacement between 2007 and 2016. The projected indexed orifice area was calculated using the in vivo previously published values. Outcomes were evaluated with the indexed effective orifice area (iEOA) as a continuous variable and/or nominal variable. Multivariable models were developed including clinically relevant co-variates. RESULTS: In the study population 65.9% (n=535) had no PPM, 32.6% (n=265) had moderate PPM and 1.5% (n=12) severe PPM. PPM was related with diabetes (OR:1.738, CI95:1.333-2.266; p<0.001), heart failure (OR:0.387, CI95:0.155-0.969; p=0.043) and older age (OR:1.494, CI95:1.171-1.907; p=0.001). iEOA was not an independent predictor of in-hospital mortality (OR 1.169, CI 0.039-35.441) or MACCE (OR 2.753, CI 0.287-26.453). Long term survival is significantly inferior with lower iEOA (HR 0.116, CI 0.041-0.332) and any degree of PPM decreases survival when compared with no PPM (Moderate: HR 1.542, CI 1.174-2.025; Severe HR 4.627, CI 2.083-10.276). CONCLUSIONS: PPM appears to have no impact on short-term outcomes including mortality and morbidity. At ten years follow-up, moderate or severe PPM significantly reduces the long-term survival.

Benign Presentation of a Potentially Fatal Disease.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiovascular defect that can range from being fatal early in life to presenting in adulthood asymptomatically. We report the case of a teenager whose diagnosis was incidental and underwent surgery, consisting in coronary artery button transfer, with excellent result.

A origem anómala da artéria coronária esquerda a partir da artéria pulmonar é uma cardiopatia congénita que pode ser fatal precocemente ou apresentar-se na vida adulta de forma assintomática. Apresentamos o caso clínico de um adolescente cujo diagnóstico foi incidental e que foi submetido a cirurgia, com translocação da artéria coronária, com excelente resultado.

Pulmonary Hypertension in Valvular Heart Disease Surgery: Risk and Prognosis.

INTRODUCTION: Left heart disease is the most common cause of pulmonary hypertension (PH), and when present is associated with higher surgical risk. OBJECTIVES: Analyze the effect of PH severity on morbidity, early and late mortality in patients with pulmonary artery systolic pressure (PASP) over 30mmHg that underwent valvular heart surgery. METHODS: Retrospective observational study including all patients with PH, defined as PASP>30 mmHg that underwent isolated valvular heart surgery, between 2007 and 2016. Exclusion criteria were: active endocarditis, congenital heart disease, transcatheter aortic valve implantation, reoperations and emergent surgery. The study population included 607 patients with a mean age of 69.6 years and a mean PASP of 52.5 mmHg. Mean follow-up for all-cause mortality was 4.4(0-11) years in 99.7% of patients. MACCE (Major Adverse Cardiac and Cerebrovascular event) was defined as at least one of the following: in-hospital mortality, stroke, post-operative myocardial infarction, severe arrhythmia or multiple organ failure. PASP was evaluated as a continuous variable. Simple and multivariable logistic regression was performed to evaluate the in-hospital mortality and MACCE. Cox regression was used for long term follow-up and one-sample log-rank test for comparison with age adjusted general population. RESULTS: The in-hospital mortality was 3.2% and PASP was an independent predictor on univariable analysis (OR:1.06; 95%CI:1.03- 1.09; p<0.001). On multivariable logistic regression PH remains an independent predictor of in- -hospital mortality (OR:1.08; 95%CI:1.04-1.12; p<0.001) in addition to age (OR:1.08; 95%CI:1.01-1.17; p=0.044). MACCE was observed in 11.4% and PASP was an independent predictor on univariable analysis (OR:1.03; 95%CI:1.01- 1.04; p<0.001). On multivariable logistic regression PASP remains an independent predictor of MACCE (OR:1.02; 95%CI:1.01-1.04; p=0.011) as well as hemodialysis (OR:7.16; 95%CI:1.73-29.63; p=0.007). The independent predictors of long term mortality were male gender (p=0.011), older age (p<0.001), higher body mass index (p=0.013), urgent surgery (p=0.027), pulmonary disease (p=0.042) and more than one valve procedure (p=0.004 for 2 valves and p=0.006 for 3 valves). PASP was not an independent predictor of long term mortality (p=0.142). Compared with an age adjusted general population, patients with PH had a significantly lower survival rate(p<0.001), more evident 4 years after the procedure. CONCLUSIONS: Higher PASP is a risk factor for in-hospital mortality and MACCE, but there was no significant impact on long term mortality.

Mechanical Thrombectomy for Stroke After Cardiac Surgery.

Stroke after cardiac surgery remains a devastating complication and its treatment options are limited. Systemic fibrinolysis is a relative contraindication, because it raises the risk of systemic hemorrhage. Endovascular therapy, mechanical thrombectomy, and intra-arterial fibrinolysis have emerged as safer options. We present three patients who developed strokes following cardiac surgery who underwent successful mechanical thrombectomy and review the literature on this subject. doi: 10.1111/jocs.12776 (J Card Surg 2016;31:517-520).

Elective and urgent coronary surgery in octogenarians.

OBJECTIVES: To analyze the influence of surgical myocardial revascularization on early and late mortality in octogenarians and compare the survival rates with age adjusted general population. METHODS: Between 2007 and 2014, 182 octogenarian patients underwent elective or urgent coronary artery bypass grafting surgery. Logistic regression was performed to evaluate the in-hospital mortality predictors. The comparison of long term survival between our population and age adjusted general population was made using one-sample log-rank test. RESULTS: The in-hospital mortality was 4,4% and its predictors on univariable analysis were non sinus rhythm (p=0,001), acute coronary syndrome less than 7 days prior to surgery (p=0,021), ejection fraction less than 50% (p=0,04) and the need for conversion to on pump surgery (p=0,04). On multivariate logistic regression non sinus rhythm and acute myocardial infarction less than 7 days before surgery were independent predictors of in-hospital mortality. Follow-up at one-year showed survival rate of 86,2% and at five years 58,4%. There was no significant difference in survival rates between the study group and the age adjusted standard population (p=0,96). The group was divided in two groups: (1) complete revascularization and (2) incomplete revascularization. There was no significant difference in survival (p=0,32 and p=0,19, respectively) compared to the age adjusted standard population. CONCLUSIONS: Coronary artery bypass grafting in octogenarians is safe and has an important impact on long term survival, with five-year survival being similar to the age adjusted standard population.

Objetivos: Analisar o impacto da revascularização miocárdica cirúrgica na mortalidade precoce e tardia em octogená- rios e comparar a sobrevida com a população geral ajustada para a idade. Métodos: Entre 2007 e 2014, 182 octogenários foram submetidos a cirurgia de revascularização miocárdica eletiva ou urgente. Utilizou-se regressão logística para avaliar os preditores de mortalidade intra-hospitalar. A comparação da sobre- vivência a longo prazo entre a população em estudo e a população ajustada para a idade efetuou-se com o teste one sample log-rank. Resultados: A mortalidade intra-hospitalar foi 4,4% e os seus preditores, na análise univariável, foram ritmo não sinusal (p=0,001), síndrome coronário agudo menos de 7 dias antes da cirurgia (p=0,021), fração de ejeção menos de 50% (p=0,04) e conversão em cirurgia on pump (p=0,04). Na análise multivariada, o ritmo não sinusal e síndrome coronário agudo menos de 7 dias antes da cirurgia foram preditores independentes de mortalidade intra-hospitalar. No seguimento a um ano a sobrevivência foi de 86,2% e a cinco anos de 58,4%. Não se verificou diferença significativa na sobrevivência entre o grupo de estudo e a população geral ajustada para a idade (p=0,96). A população em estudo foi dividida em dois grupos: (1) revascula- rização completa e (2) revascularização incompleta. Não se verificou diferença significativa (p=0,32 e p=0,19, respetivamente) quando comparados com a população geral ajustada para a idade. Conclusão: A cirurgia de revascularização miocárdica em octogenários é segura e tem um importante impacto na sobrevida a longo prazo, com sobrevivência a cinco anos semelhante à população geral ajustada para a idade.

Biventricular Takotsubo syndrome complicated with cardiogenic shock and ventricular septal rupture: a case report.

Background: Takotsubo syndrome (TTS) mimics acute coronary syndromes but can lead to serious cardiac complications, emphasizing the need for improved understanding and management. Case summary: We describe a TTS case presented with cardiogenic shock due to ventricular septal rupture (VSR). Successful treatment involved mechanical circulatory support followed by VSR surgical closure. Discussion: Ventricular septal rupture is the rarest and deadliest complication associated with TTS. Prompt recognition and a multidisciplinary approach are crucial to achieve the best possible outcome.

The Risk Of Waiting Up To One Year For Cardiac Surgery.

INTRODUCTION: Cardiac disease is associated with a risk of death, both by the cardiac condition and by comorbidities. The waiting time for surgery begins with the onset of symptoms and includes referral, completion of the diagnosis and surgical waiting list (SWL). This study was conducted during the COVID-19 pandemic, which affected surgical capacity and patients' morbidities. METHODS: The cohort includes 1914 consecutive adult patients (36.6% women, mean age 67 ±11 years), prospectively registered in the official SWL from January 2019 to December 2021. We analyzed waiting times ranging from 4 days to one year to exclude urgencies and outliers. Priority was classified by the national criteria for non-oncologic or oncology surgery. RESULTS: During the study period, 74% of patients underwent surgery, 19.2% were still waiting, and 4.3% dropped out. Most cases were valvular (41.2%) or isolated bypass procedures (34.2%). Patients were classified as non-priority in 29.7%, priority in 61.8%, and high priority in 8.6%, with significantly different SWL mean times between groups (p<0.001). The overall mean waiting time was 167 ± 135 days. Mortality on SWL was 2.5%, or 1.1 deaths per patient/weeks. There were two mortality independent predictors: age (HR 1.05) and the year 2021 versus 2019 (HR 2.07) and a trend toward higher mortality in priority patients versus non-priority (p=0.065). The overall risk increased with time with different slopes for each year. Using the time limits for SWL in oncology, there would have been a significant risk reduction (p=0.011). CONCLUSION: The increased risk observed in 2021 may be related to the pandemic, either by increasing waiting time or by direct mortality. Since risk stratification is not entirely accurate, waiting time emerges as the most crucial factor influencing mortality, and implementing stricter time limits could have led to lower mortality rates.

Repair of a gigantic ascending aortic pseudoaneurysm - A challenging approach.

Aortic pseudoaneurysms can be a potentially fatal, yet rare, complication of heart surgery. Surgery is indicated but is high risk during sternotomy. Therefore, careful planning is required. We report the case of a 57-year-old patient who underwent heart surgery twice in the past and who presented with an ascending aortic pseudoaneurysm. A successful repair of the pseudoaneurysm was performed under deep hypothermia, left ventricular apical venting, periods of circulatory arrest and endoaortic balloon occlusion.

Quantitative assessment of myocardial fibrosis by digital image analysis: An adjunctive tool for pathologist "ground truth".

AIMS: Myocardial fibrosis (MF) is a common pathological process in a wide range of cardiovascular diseases. Its quantity has diagnostic and prognostic relevance. We aimed to assess if the complementary use of an automated artificial intelligence software might improve the precision of the pathologist´s quantification of MF on endomyocardial biopsies (EMB). METHODS AND RESULTS: Intraoperative EMB samples from 30 patients with severe aortic stenosis submitted to surgical aortic valve replacement were analysed. Tissue sections were stained with Masson´s trichrome for collagen/fibrosis and whole slide images (WSI) from the experimental glass slides were obtained at a resolution of 0.5 µm using a digital microscopic scanner. Three experienced pathologists made a first quantification of MF excluding the subendocardium. After two weeks, an algorithm for Masson´s trichrome brightfield WSI (at QuPath software) was applied and the automatic quantification was revealed to the pathologists, who were asked to reassess MF, blinded to their first evaluation. The impact of the automatic algorithm on the inter-observer agreement was evaluated using Bland-Altman type methodology. Median values of MF on EMB were 8.33% [IQR 5.00-12.08%] and 13.60% [IQR 7.32-21.2%], respectively for the first pathologist´s and automatic algorithm quantification, being highly correlated (R2: 0.79; p < 0.001). Interobserver discordance was relevant, particularly for higher percentages of MF. The knowledge of the automatic quantification significantly improved the overall pathologist´s agreement, which became unaffected by the degree of MF severity. CONCLUSIONS: The use of an automated artificial intelligence software for MF quantification on EMB samples improves the reproducibility of measurements by experienced pathologists. By improving the reliability of the quantification of myocardial tissue components, this adjunctive tool may facilitate the implementation of imaging-pathology correlation studies.

Infective Endocarditis: A Prospective Registry Of Surgical Lesions.

INTRODUCTION: Infective endocarditis morbidity and mortality remains high. Surgery is performed in about half of endocarditis cases, being the ideal setting to evaluate endocarditis lesions. The aim of this study was to register and describe endocarditis lesions found during surgery; find predictors of morbidity and mortality and correlate lesions found in echocardiogram vs. surgery. MATERIALS AND METHODS: One hundred consecutive patients with endocarditis lesions seen during surgery were included between June 2014 and August 2018. Pathological lesions were coded prospectively using a coding form published by Pettersson et al. Other data were collected retrospectively. RESULTS: Prosthetic endocarditis accounted for 23% of cases. Embolic events had occurred in 41% of cases, mainly to the brain (22%). The most frequent lesions found in echocardiogram were vegetations (77%). Vegetations and valve integrity anomalies were the main lesions described during surgery (70% and 71% respectively). Invasion was present in 39% of patients. In-hospital mortality was 9%. In univariable analysis, predictors of early mortality included chronic kidney disease (P= .005), prosthetic valve endocarditis (P <.001), EuroSCORE II (P <.001) and valve integrity anomalies (P=.016). Predictors of embolic events included aortic valve vegetations seen during surgery (P= .026). Sensitivity and specificity of echocardiogram findings for identification of vegetations were 84% and 40%, for valve integrity anomalies 42% and 97% and for invasion 54% and 95%, respectively. CONCLUSIONS: Diversity of lesions found in endocarditis precludes obtaining significant predictors of morbidity or mortality with small numbers of patients. Echocardiogram lacks sensitivity for valve integrity anomalies and invasion but is highly specific.

Masson's Lesion: A Very Rare Cardiac Mass.

Masson lesion is a rare type of vascular tumour usually found in the skin and soft tissues. Histologic examination remains the gold standard for diagnosis. Treatment involves complete surgical excision, and correct diagnosis is essential to avoid unnecessary aggressive therapy. A unique case of Masson lesion presenting as an asymptomatic pericardial mass is reported for the first time. Multimodality imaging was used for a comprehensive noninvasive mass characterization. Relevant imagiologic and pathologic findings for differential diagnosis are discussed. The importance of close coordination among different medical specialties for optimal care of this unusual clinical condition is highlighted.

Triple valve surgery: long-term follow-up from a single centre.

AIMS: The aims of this study were to analyze early and late outcomes of TVS and identify predictors of short and long- term poor prognosis. METHODS: Single centre retrospective study with 130 patients who underwent TVS between 2007 and 2020. Most of the patients were female (72.3%), mean age of 64.4 years; 61.1% were in New York Heart Association class III/IV, with a EuroSCORE II of 7.5%. Univariable and Multivariable analyses were undertaken to identify predictors of perioperative mortality and morbidity and long-term mortality. RESULTS: In-hospital mortality was 10.8%, of which 7.6% were due to a cardiac cause. Diabetes Mellitus was an in- dependent predictor of increased perioperative mortality. This group had 27.7% rate of major perioperative complications. Elevated systolic pulmonary pressure and obesity were predictors of early morbidity. All-cause mortality was 43.1% for 14 years. The survival at 1, 5 and 10 years was 83%, 60% and 43%, respectively. Diabetes Mellitus was a risk factor for long-term mortality. CONCLUSIONS: Patients undergoing TVS have a high surgical risk making TVS an operation associated with high mor- tality and morbidity. This research suggests Diabetes Mellitus, pulmonary hypertension and obesity as risk factors for mortality in TVS.

The role of extracorporeal membrane oxygenation in an acute basal ventricular septal rupture.

A 74-year-old man was admitted with a post-acute myocardial infarction basal ventricular septal rupture. Onset of cardiogenic shock led to the implantation of a percutaneous veno-arterial extracorporeal membrane oxygenation (ECMO) system with an additional venous drainage cannula into the right ventricle. The ventricular septal defect was repaired with concomitant tricuspid valvuloplasty and mitral bioprosthesis implantation after 14 days. ECMO support was temporarily converted into a veno-venous system to wean the patient off cardiopulmonary bypass. The patient was discharged 3 weeks after surgery. This case illustrates the role of this extracorporeal life support system in the setting of postinfarction ventricular septal rupture.

Analysis of a 10-year period of lead removal in a referral centre.

OBJECTIVES: Our goal was to analyse all lead extraction procedures (transvenous or open surgery) performed in our centre and the short- and long-term follow-up data from these patients. METHODS: All lead extractions performed from 2008 to 2017 were retrospectively reviewed for patient characteristics and indications for device implantation; indications for lead extraction; techniques used; peri- and postprocedural complications and short- and long-term follow-up data. RESULTS: A total of 159 patients (282 leads) were included [age 70 (62-78) years; 72% men]. The median follow-up time was 57 (25-90) months. Patients with lead explants were excluded. The most common indication for lead removal was infection (77%). A surgical approach was necessary in 14 patients (9%) owing to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indications for open surgery (n = 4) and complicated transvenous removal (n = 1). Removal was tried for 282 leads. Of those, 256 were completely removed. Clinical success was achieved in 155 individual patients (98%). Complications occurred in 6 patients: 3 persistent infections, 1 stroke and 2 blood vessel ruptures. The procedure-related mortality rate was 2% (n = 3). CONCLUSIONS: Lead removal was associated with a high success rate and low all-cause complication and mortality rates. Emergency surgery because of acute complications was rare, and open-heart surgery was most frequently elective and not associated with a worse outcome.

Long-term assessment of the Ross procedure in adults: Clinical and echocardiographic follow-up at 20 years.

INTRODUCTION: The Ross procedure is an alternative to standard aortic valve (AV) replacement in young and middle-aged patients. However, durability and incidence of reoperation remain a concern for most cardiac surgeons. Our aim was to assess very long-term clinical and echocardiographic outcomes of the Ross procedure. METHODS: We conducted a single-center retrospective analysis of 56 consecutive adult patients who underwent the Ross procedure. Mean age at surgery was 44±12 years (range, 16-65 years) and 55% were male. Clinical endpoints included overall mortality and the need for valve reoperation due to graft failure. The echocardiographic endpoint was the presence of any graft deterioration. Median clinical follow-up was 20 years (1120 patient/years). RESULTS: Indications for surgery were dominant aortic stenosis in 50% and isolated aortic regurgitation in 21%. Concomitant mitral valve repair was performed in 21% and a subcoronary technique was most commonly used (86%). Overall long-term survival was 91%, 80% and 77% at 15, 20 and 24 years, respectively. The survival rate was similar to the age- and gender-matched general population (p=0.44). During the follow-up period, freedom from graft reoperation was 80%. Eleven patients (31%) developed moderate AV regurgitation, three (8.6%) developed moderate pulmonary regurgitation and one (2.9%) presented moderate pulmonary stenosis. CONCLUSION: The Ross procedure, mostly using a subcoronary approach, proved to have good clinical and hemodynamic results, with low reoperation rates in long-term follow-up. Moderate autograft regurgitation was a frequent finding but had no significant clinical impact.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Myocardial Infarction and Left Main or Multivessel Coronary Disease.

Current recommendations on the optimal revascularization strategy in Non-ST-elevation myocardial infarction (NSTEMI) with left main (LM) or multivessel coronary disease (MVD) are based upon randomized clinical trials conducted in stable coronary artery disease. In a real-world contemporary observational registry, we compared the long-term outcome of NSTEMI patients with LM/MVD (n = 1,104) submitted to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimized medical therapy (OMT). The primary end point was 5-year all-cause mortality. Results were assessed in the entire population (CABG 289, PCI 399, and OMT 416) and in a propensity score-matched cohort of CABG (n = 159) and PCI (n = 159). Crude 5-year mortality rates in CABG and PCI were 25.3% versus 29.6%, respectively (unadjusted hazard ratio [HR] 1.2; 95% confidence intervals [CI] 0.9 to 1.6; p = 0.212); OMT, however, was associated with a twofold higher risk of mortality when compared with any revascularization strategy (unadjusted HR 2.0; 95% CI 1.7 to 2.5; p < 0.001). After propensity score-matching and multivariate analysis, there was a trend toward a higher incidence of the primary end point in patients who underwent PCI versus CABG (31% vs 21%; adjusted HR 1.52; 95% CI 0.93 to 2.50; p = 0.094). This was a consistent finding over subgroups deemed clinically relevant, such as in patients with LM or proximal left anterior descending disease, SYNergy between percutaneous coronary intervention with TAXus ≥23 and left ventricle ejection fraction <40%. In conclusion, in a real-world cohort of NSTEMI patients with LM/MVD, those selected for OMT had a dire outcome. Although adjusted 5-year mortality was statistically similar between revascularization strategies, there was a trend favoring CABG, which might be the preferred option in LM, proximal LAD, SYNergy between percutaneous coronary intervention with TAXus ≥23, and left ventricle ejection fraction <40% subgroups.