Cardiac magnetic resonance patterns of left ventricular remodeling in patients with severe aortic stenosis referred to surgical aortic valve replacement.

Left ventricular (LV) hypertrophy is a common finding in patients with severe aortic stenosis (AS). Cardiac magnetic resonance (CMR) is the gold-standard technique to evaluate LV remodeling. Our aim was to assess the prevalence and describe the patterns of LV adaptation in AS patients before and after surgical aortic valve replacement (AVR). Prospective study of 130 consecutive patients (71y [IQR 68-77y], 48% men) with severe AS, referred for surgical AVR. Patterns of LV remodeling were assessed by CMR. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling. At baseline CMR study: mean LV indexed mass: 81.8 ± 26.7 g/m2; mean end-diastolic LV indexed volume: 85.7 ± 23.1 mL/m2 and median geometric remodeling ratio: 0.96 g/mL [IQR 0.82-1.08 g/mL]. LV hypertrophy occurred in 49% of subjects (concentric 44%; eccentric 5%). Both normal LV structure and concentric remodeling had a prevalence of 25% among the cohort; one patient had an adverse remodeling pattern. Asymmetric LV wall thickening was present in 55% of the patients, with predominant septal involvement. AVR was performed in 119 patients. At 3-6 months after AVR, LV remodeling changed to: normal ventricular geometry in 60%, concentric remodeling in 27%, concentric hypertrophy in 10%, eccentric hypertrophy in 3% and adverse remodeling (one patient). Indexes of AS severity, LV systolic and diastolic function and NT-proBNP were significantly different among the distinct patterns of remodeling. Several distinct patterns of LV remodelling beyond concentric hypertrophy occur in patients with classical severe AS. Asymmetric hypertrophy is a common finding and LV response after AVR is diverse.

Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry.

BACKGROUND: Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI. AIMS: This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV). METHODS: For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. RESULTS: From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation. CONCLUSIONS: Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.

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.

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.

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.

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.

Extracorporeal Membrane Oxygenation: The First 10 Years Experience of a Portuguese Pediatric Intensive Care Unit.

INTRODUCTION: In Portugal, extracorporeal membrane oxygenation (ECMO) is used in pediatric patients since 2010. The aim of this study was to describe the clinical characteristics of patients, indications, complications and mortality associated with the use of ECMO during the first 10-years of experience in the Pediatric Intensive Care Unit located in Centro Hospitalar Universitário Lisboa Norte. MATERIAL AND METHODS: Retrospective observational cohort study of all patients supported with ECMO in a Pediatric Intensive Care Unit, from the 1st of May 2010 up to 31st December 2019. RESULTS: Sixty-five patients were included: 37 neonatal (≤ 28 days of age) and 28 pediatric patients (> 28 days). In neonatal cases, congenital diaphragmatic hernia was the main reason for ECMO (40% of neonatal patients and 23% of total). Among pediatric patients, respiratory distress was the leading indication for ECMO (47% of total). The median length of ECMO support was 12 days. Clinical complications were more frequent than mechanical complications (65% vs 35%). Among clinical complications, access site bleeding was the most prevalent with 38% of cases. The overall patient survival was 68% at the time of discharge (65% for neonatal and 71% for pediatric cases), while the overall survival rate in Extracorporeal Life Support Organization registry was 61%. The number of ECMO runs has been increasing since 2011, even though in a non-linear way (three cases in 2010 to 11 cases in 2019). DISCUSSION: In the first 10 years we received patients from all over the country. Despite continuous technological developments, circuitrelated complications have a significant impact. The overall survival rate in the Pediatric Intensive Care Unit was not inferior to the one reported by the Extracorporeal Life Support Organization. CONCLUSION: The overall survival of our Pediatric Intensive Care Unit is not inferior to one reported by other international centers. Our experience showed the efficacy of the ECMO technique in a Portuguese centre.

Introdução: Em Portugal, a oxigenação por membrana extracorporal (ECMO) é utilizado em doentes pediátricos de forma consistente desde 2010. O nosso objetivo é descrever as características clínicas, indicações, complicações e sobrevivência associadas à utilização da ECMO nos primeiros 10 anos de experiência na nossa unidade. Material e Métodos: Estudo de coorte retrospetivo dos doentes tratados com ECMO na Unidade de Cuidados Intensivos Pediátricos do Hospital de Santa Maria, de 1 de maio de 2010 a 31 de dezembro de 2019. Resultados: Foram incluídos 65 doentes: 37 neonatais (≤ 28 dias de idade) e 28 pediátricos (> 28 dias). Nos neonatais, a hérnia diafragmática congénita foi a principal indicação (40% dos recém-nascidos e 23% do total). Relativamente aos doentes pediátricos, a insuficiência respiratória constituiu a principal indicação para ECMO (47% do total). A mediana de duração da técnica foi de 12 dias. As complicações clínicas foram mais frequentes do que as mecânicas (65% vs 35%). Entre as complicações clínicas, a hemorragia no local de acesso foi a mais frequente (38% dos casos). A sobrevivência global do total da amostra foi de 68% no momento da alta (65% nos neonatais e 71% nos pediátricos), enquanto que a sobrevivência descrita no registo da Extracorporeal Life Support Organization é de 61%. O número de casos de utilização de ECMO tem vindo a aumentar desde 2011, embora de forma não linear (três casos em 2010 para 11 casos em 2019). Discussão: Nos primeiros 10 anos de experiência em ECMO na Unidade de Cuidados Intensivos Pediátricos recebemos doentes oriundos de várias partes do país. Apesar da evolução tecnológica contínua, as complicações relacionadas com o circuito têm um impacto significativo. A taxa de sobrevida global no nosso centro não foi inferior à reportada no relatório da Extracorporeal Life Support Organization. Conclusão: A sobrevida global na Unidade de Cuidados Intensivos Pediátricos não é inferior à descrita no registo internacional. A nossa experiência demonstra a eficácia da ECMO num centro Português.

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.

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.