Assessment of Individualized Mean Perfusion Pressure Targets for the Prevention of Cardiac Surgery-Associated Acute Kidney Injury-The PrevHemAKI Randomized Controlled Trial.

BACKGROUND: Retrospective studies support that mean perfusion pressure (MPP) deficit in cardiac surgery patients is associated with a higher incidence of acute kidney injury (CS-AKI). The aim of our study was to apply an algorithm based on MPP in the postoperative period to determine whether management with an individualized target reduces the incidence of CS-AKI. METHODS: Randomized controlled trial of patients undergoing cardiac surgery with extracorporeal circulation. Adult patients submitted to valve replacement and/or bypass surgery with a high risk of CS-AKI evaluated by a Leicester score >30 were randomized to follow a target MPP of >75% of the calculated baseline or a standard hemodynamic management during the first postoperative 24 h. RESULTS: Ninety-eight patients with an eGFR of 54 mL/min were included. There were no differences in MAP and MPP in the first 24 h between the randomized groups, although a higher use of noradrenaline was found in the intervention arm (38.78 vs. 63.27, p = 0.026). The percentage of time with MPP < 75% of measured baseline was similar in both groups (10 vs. 12.7%, p = 0.811). MAP during surgery was higher in the intervention group (73 vs. 77 mmHg, p = 0.008). The global incidence of CS-AKI was 36.7%, being 38.6% in the intervention group and 34.6% in the control group (p = 0.40). There were no differences in extrarenal complications between groups as well. CONCLUSION: An individualized hemodynamic management based on MPP compared to standard treatment in cardiac surgery patients was safe but did not reduce the incidence of CS-AKI in our study.

Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Percutaneous or mini-invasive surgical radiofrequency re-ablation of atrial fibrillation: Impact on atrial function and echocardiographic predictors of short and long-term success.

Objectives: The aim of this study was to compare percutaneous catheter ablation vs. minimally invasive surgical ablation, evaluating the impact of repeated ablation on atrial function, and evaluating predictors of atrial fibrillation (AF) recurrence. Background: When AF ablation fails, re-ablations are required in up to 40% of patients to treat recurrent arrhythmia; surgical ablation is more effective than catheter ablation. Methods: Thirty-two patients with failed prior catheter ablation and referred for a second ablation (18 catheter and 14 surgical) were included in a descriptive observational study. Left atrial volumes, strain, and strain rate were measured with 2D speckle tracking echocardiography at baseline and 6 months after the procedures to assess left atrial functions. Patients received up to 1 year of clinical and Holter follow-up. Results: At the 12-month follow-up, catheter ablation was effective in 56% and surgical ablation in 72% of patients (OR 2 (CI 0.45-8.84), p 0.36). Left atrial booster function was similar in all patients, but left atrial reservoir function was more impaired in those patients who underwent surgical ablation. Left atrial booster function was predictive of arrhythmia recurrence after both catheter and surgical ablation: late diastolic strain rate (LASRa) cut-off ≤ -0.89 s-1 (sensitivity 88%, specificity 70%, AUC 0.82) and ≤ -0.85 s-1 (sensitivity 60%, specificity 100%, AUC 0.82), respectively. Conclusion: Surgical ablation has a more negative impact on LA reservoir function despite being slightly more effective in arrhythmia suppression. LA booster function is not significantly impaired by either procedure. LA booster function predicts arrhythmia elimination after a re-ablation (catheter or surgical).

Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction.

Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension: the Spanish experience.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) can be cured by pulmonary endarterectomy (PEA). It is considered the best and only curable treatment option for patients with accessible lesions evaluated as optimal candidates. We describe the experience of the two reference centers in Spain, in order to reinforce the need for referring CTEPH patients to a specialized center to be assessed by a Multidisciplinary Expert Team. Methods: We included a population of 338 patients who met the definition for CTEPH and underwent PEA between January 2007 and December 2019. The surgery was indicated in almost 60% of patients assessed. Demographic, anthropometric, hemodynamic and echocardiographic features are listed for PEA patients. Immediate and one-year postoperative outcomes as well as overall mortality were analyzed. Results: Mean age was 53.5±15.0 years, 53.8% were men; a total of 68.5% were in WHO functional class III-IV; and most of them were in a preoperative hemodynamic condition: mean pulmonary arterial pressure (mPAP) was 46.5±13.1 mmHg and mean pulmonary vascular resistance (PVR) was 764.5±392.8 dyn·s·cm-5. PEA surgery was performed with cardiopulmonary bypass (CBP) and circulatory arrest, with very few complications [including neurological, postoperative reperfusion edema, extracorporeal membrane oxygenation (ECMO) implant and cardiac failure] and optimal postoperative results, where exercise capacity increased and mPAP and PVR values decreased significantly. Presence of persistent pulmonary hypertension (PH) at the six-month right heart catheterization was evaluated. A 3.3% perioperative mortality was achieved. Overall, one-, three- and five-year survival rates were analyzed by Kaplan-Meier's method (94.8%, 93.3% and 90.5% respectively), as well as for residual PH patients. Mortality risk factors were assessed. Conclusions: Outstanding PEA results were seen in the immediate, one-year and long-term outcomes. The incidence of complications, including in-hospital mortality and long-term mortality were also below European rates.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Biventricular fibroma resection in an adult.

Cardiac fibromas are the second most common primary cardiac tumors in childhood. They only rarely present in adults. They are mainly located in the free wall of the ventricles and attached to the interventricular septum. Despite their benign pathology, fibromas in some locations can cause significant complications. This video tutorial illustrates the resection of a septo-apical cardiac fibroma in an asymptomatic 26-year-old woman, diagnosed with transthoracic echocardiography and cardiac magnetic resonance imaging after an abnormal ECG on an occupational medical examination. Surgery was performed through a median sternotomy using cardiopulmonary bypass. A nodular intramyocardial mass was found at the left ventricular apex and resection was carried out. After removing the fibroma, a defect was found at the apex affecting both ventricles. The defects were closed using a direct suture of 4-0 polypropylene "U" stitches reinforced with a Teflon patch to exclude the ventricular cavity.  Pathology confirmed the diagnosis of benign cardiac fibroma with tumor-free surgical margins. The patient recovered uneventfully and was discharged on postoperative day 5. The outpatient follow-up cMRI 10 months after surgery showed no signs of tumor recurrence and normal biventricular function.

Valvular Heart Disease Epidemics.

BACKGROUND AIM OF THE STUDY: The real burden of valvular heart disease (VHD) is scarcely known, as several factors may potentially lead to its increased prevalence. The study aim was to assess the prevalence of VHD and its treatment in the authors' environment to plan the healthcare requisites for optimal management of the condition. METHODS: A retrospective analysis was conducted of data acquired from patients who had been assessed at different consultation levels for cardiovascular disorders during a six-month period between January and June 2014 in public health referral area of 500,00 inhabitants. Patients included were those admitted to hospital cardiology, cardiac surgery and geriatric care units (n = 1,083), as well as ambulatory patients attending cardiology-specific outpatient clinics at the authors' hospital or at two ascribed primary care centers (n = 852). Data were registered regarding the epidemiology, etiology, echocardiography and treatment of patients in whom VHD was detected. RESULTS: Among a total of 1,935 adult patients, moderate or severe valve disease was identified in 453 cases (23.4%) who were evaluated for cardiovascular disease. The prevalence of VHD increased with age. Multivalvular moderate-severe dysfunction was present in two valves in 33% and in three valves in 5.7% of patients. Significant mitral valve disease was present in 39% and aortic valve disease in 48% of patients. The etiology of the valvular lesions was degenerative in 60%, functional in 15.5%, rheumatic in almost 10%, congenital in 6%, due to endocarditis in only 3%. Patients with VHD represented up to 24.2% of the in-hospital admissions. An interventional treatment was required in 55% of the patients (mostly surgical valve procedures). CONCLUSION: The present study results showed that VHD is a frequent occurrence and is increasingly prevalent with age, constituting up to one-fourth of all in-hospital admissions for cardiovascular disease. VHD is a growing public health problem that should be addressed with appropriate resources to improve research into its nature, diagnosis and treatment.

Vascular smooth muscle cell phenotypic changes in patients with Marfan syndrome.

OBJECTIVE: Marfan's syndrome is characterized by the formation of ascending aortic aneurysms resulting from altered assembly of extracellular matrix microfibrils and chronic tissue growth factor (TGF)-ß signaling. TGF-ß is a potent regulator of the vascular smooth muscle cell (VSMC) phenotype. We hypothesized that as a result of the chronic TGF-ß signaling, VSMC would alter their basal differentiation phenotype, which could facilitate the formation of aneurysms. This study explores whether Marfan's syndrome entails phenotypic alterations of VSMC and possible mechanisms at the subcellular level. APPROACH AND RESULTS: Immunohistochemical and Western blotting analyses of dilated aortas from Marfan patients showed overexpression of contractile protein markers (α-smooth muscle actin, smoothelin, smooth muscle protein 22 alpha, and calponin-1) and collagen I in comparison with healthy aortas. VSMC explanted from Marfan aortic aneurysms showed increased in vitro expression of these phenotypic markers and also of myocardin, a transcription factor essential for VSMC-specific differentiation. These alterations were generally reduced after pharmacological inhibition of the TGF-ß pathway. Marfan VSMC in culture showed more robust actin stress fibers and enhanced RhoA-GTP levels, which was accompanied by increased focal adhesion components and higher nuclear localization of myosin-related transcription factor A. Marfan VSMC and extracellular matrix measured by atomic force microscopy were both stiffer than their respective controls. CONCLUSIONS: In Marfan VSMC, both in tissue and in culture, there are variable TGF-ß-dependent phenotypic changes affecting contractile proteins and collagen I, leading to greater cellular and extracellular matrix stiffness. Altogether, these alterations may contribute to the known aortic rigidity that precedes or accompanies Marfan's syndrome aneurysm formation.

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score.

OBJECTIVES: To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery. METHOD: A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump). RESULTS: Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG. CONCLUSIONS: PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study.

OBJECTIVES: To determine the effect of the off-pump technique in preventing stroke development during the early perioperative period after coronary artery bypass graft surgery (CABG). METHODS: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish cardiac-surgery centres. Baseline variables related to perioperative stroke risk were recorded in the preoperative (age, gender, diabetes mellitus, arterial hypertension, prior stroke, cardiac failure: preoperative New York Heart Association class III-IV and/or left ventricular ejection fraction <40%, non-elective priority of surgery, peripheral arteriopathy, chronic renal failure) and intraoperative periods (on/off-pump performance). The Northern New England Cardiovascular Disease Study Group (NNECDSG) stroke risk schema was used to stratify stroke risk and compare observed neurological outcomes in this study. RESULTS: A total of 26 347 patients were included in the study. Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (OR = 2.37), peripheral arteriopathy (OR = 1.62), cardiac failure (OR = 2.98), prior stroke (OR = 1.57) and chronic renal failure (OR = 6.16) were found to be independent risk factors for perioperative stroke in uni- and multivariate models; Hosmer-Lemeshow test: χ(2) = 4.62, P = 0.59. Perioperative stroke incidence increased whenever NNECDSG score or the number of preoperative risk factors increased. However, on- vs off-pump surgery did not show statistical differences in NNECDSG strata. For patients with two or more preoperative independent risk factors, off-pump surgery showed a significant reduction in perioperative stroke incidence (4.29 vs 6.76%, P < 0.05), particularly when one of these factors was chronic renal failure or preoperative cardiac failure. However, when both factors were present concomitantly there was no difference between on and off-pump techniques, P < 0.0001. CONCLUSIONS: Off-pump surgery has a lower perioperative stroke incidence than on-pump only in cases associated with cardiovascular stroke-risk factors, in particular, with chronic renal failure and preoperative cardiac failure, but also with peripheral arteriopathy, prior stroke and non-elective surgery. The perioperative stroke rate remains high in cases with two or more preoperative stroke risk factors, even when using the off-pump technique, particularly when chronic renal failure is present.

[Implementation of safety devices: biological accident prevention]. / Implantación de material de biosegurida: prevención de accidentes biológicos.

UNLABELLED: Accidental exposures to blood and biological material were the most frequent and potentially serious accidents in healthcare workers, reported in the Prevention of Occupational Risks Unit within 2002. BACKGROUND: Evaluate the biological percutaneous accidents decrease after a progressive introduction of safety devices. Biological accidents produced between 2.002 and 2.006 were analyzed and reported by the injured healthcare workers to the Level 2b Hospital Prevention of Occupational Risk Unit with 238 beds and 750 employees. The key of the study was the safety devices (peripheral i.v. catheter, needleless i.v. access device and capillary blood collection lancet). Within 2002, 54 percutaneous biological accidents were registered and 19 in 2006, that represents a 64.8% decreased. There has been no safety devices accident reported involving these material. Accidents registered during the implantation period occurred because safety devices were not used at that time. Safety devices have proven to be effective in reducing needle stick percutaneous accidents, so that they are a good choice in the primary prevention of biological accidents contact.

New insights in the management of cardiogenic shock complicating myocardial infarction: role of urgent heart transplantation.

OBJECTIVE: This study assessed the role of heart transplantation (HTx) in the management of patients with acute myocardial infarction (MI) complicated by refractory cardiogenic shock despite percutaneous coronary intervention (PCI). The primary end-point of the study was mortality at the 1-year follow-up. METHODS: Between January 2001 and December 2005, 74 consecutive patients with acute MI complicated with cardiogenic shock were retrospectively analyzed. Thirty-nine patients did not have a contraindication for HTx and qualified for the study (age < 65 years, no comorbidities). RESULTS: Urgent HTx was performed in 10 patients. The remaining 29 patients served as controls. The HTx vs no HTx groups were well balanced in age (50 vs 53 years), proportion of multivessel disease (30% vs 10%), cardiac index (2.2 vs 2.4 liters/min/m(2)), and left ventricular ejection fraction (23% vs 25%). Mortality rates were significantly lower in the HTx group, both in the hospital (10% vs 45%, p < 0.03) and at 1 year (10% vs 52%, p < 0.03). Survival at 1 year among patients alive at hospital discharge was 100% in the HTx group vs 94% in the no HTx group. CONCLUSIONS: Urgent HTx dramatically improves survival of acute MI patients presenting with refractory cardiogenic shock despite early PCI. Therefore, this approach--wherever feasible--needs to be considered in the management of this particular subset of patients.