Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty.

INTRODUCTION AND OBJECTIVES: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. METHODS: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. RESULTS: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. CONCLUSIONS: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.

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.

Eradication of Staphylococcus aureus Post-Sternotomy Mediastinitis Following the Implementation of Universal Preoperative Nasal Decontamination With Mupirocin: An Interrupted Time-Series Analysis.

BACKGROUND: Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. METHODS: An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990-2003) and postintervention (2005-2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. RESULTS: 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P < .0001). Interrupted time-series analysis demonstrated a statistically significant annual reduction in S. aureus PSM of -9.85 cases per 1000 sternotomies (-13.17 to -6.5; P < .0001) in 2005, with a decreasing trend maintained over the following 5 years and an estimated relative reduction of 84.8% (95% confidence interval [CI], 89.25-74.09%). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio, 3.7; 95% CI, 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre- or postintervention periods. CONCLUSIONS: Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

Masa auricular derecha: la importancia del ecocardiograma al momento del diagnóstico de fibrilación auricular en el enfoque terapéutico / Right atrial mass: The importance of cardiac ultrasound at the time of diagnosis of atrial fibrillation in the therapeutic approach

Resumen Se presenta el caso de un varón de 70 años de edad, quien debutó con fibrilación auricular no valvular, en quien, dos meses después y mediante ecocardiografía, se objetivaron dos masas contiguas en la aurícula derecha. Las masas eran dependientes de la válvula de Eustaquio, alcanzaban el septo interauricular y se asemejaban a un mixoma. Ambas fueron resecadas mediante cirugía, sin complicaciones intraoperatorias ni postoperatorias. El estudio anatomo-patológico concluyó que eran compatibles con trombos sin componente tumoral. Durante el seguimiento permaneció asintomático y en ritmo de fibrilación auricular.

Abstract The case is presented on a 70 year-old male who debuted with non-valvular atrial fibrillation. Two months later, and using cardiac ultrasound, two contiguous masses were observed in the right atrium. The masses were hanging from the Eustachian (inferior vena cave) valve, reached the interatrial septum and resembled a myxoma. Both were surgically resected, with no intra- or post-operative complications. The patient remained asymptomatic and in atrial fibrillation rhythm during follow-up.

Oclusión iatrogénica de la arteria coronaria derecha durante sustitución valvular tricuspídea / Iatrogenic occlusion of the right coronary artery during tricuspid valve replacement

Resumen Se describe el caso de una mujer de 68 años que presentaba insuficiencia tricuspídea severa con ventrículo derecho dilatado, función sistólica levemente deprimida y ventrículo izquierdo no dilatado con fracción de eyección del 47%. Se intervino mediante cirugía realizándose una sustitución valvular tricúspide por prótesis mecánica ATS n( 33 e implante de electrodo de marcapasos epicárdico definitivo. En el postoperatorio inmediato presentó ascenso persistente del segmento ST en la cara inferior. Se implantó balón de contrapulsación intraaórtico y en el ecocardiograma urgente se observó disfunción ventricular global con aquinesia de la cara inferior. Se realizó coronariografía urgente observándose una imagen de angulación y deformidad a nivel distal de la arteria coronaria derecha no presente en la coronariografía prequirúrgica que sugería tracción externa del vaso, probablemente en relación con la sutura quirúrgica. Se intervino en forma percutánea implantándose stent farmacoactivo con lo cual se recuperó el flujo distal y se normalizó el segmento ST. La proximidad del anillo tricúspide a estructuras anatómicas como la arteria coronaria derecha hace posible su lesión durante la cirugía. El daño iatrogénico de la arteria coronaria derecha requiere diagnóstico y tratamiento precoz. Por ello esta complicación se debe incluir en el diagnóstico diferencial de disfunción ventricular derecha tras cirugía cardiaca.

Abstract The case is presented on a 68 year-old woman with severe tricuspid insufficiency. She also had a dilated right ventricle, a slightly depressed systolic function, and an undilated left ventricle with an ejection fraction of 47%. We treated her surgically, the tricuspid valve replacement was carried out with an ATS Nº 33 mechanical prosthesis and implanted a permanent epicardial pacemaker lead. In the immediate post operative period, she presented a persistent ST segment elevation on the inferior wall. An intra-aortic balloon pump was implanted; the urgent echocardiogram showed a global ventricular dysfunction with akinesia of the inferior wall. An urgent coronary angiography was performed, with an image of angulation and deformity being observed at distal level of the right coronary artery that was not present in the pre-surgical coronary angiography, which suggested an external traction of the vessela probably associated with a surgical suture. Percutaneous intervention was carried out, with a drug-eluting stent being implanted. It was percutaneously treated by implanting a drug-eluting stent restoring distal blood flow and normalizing the ST segment. The proximity of the tricuspid ring to anatomical structures like the right coronary artery means that it could be damaged during surgery. The iatrogenic damage to the right coronary artery requires an early diagnosis and treatment. For this reason, this complication must be included in the differential diagnosis of right ventricular dysfunction after cardiac surgery.

Incidence, Risk Factors and Outcomes of Early Acute Kidney Injury After Heart Transplantation: An 18-year Experience.

BACKGROUND: Little is known about the incidence of acute kidney injury (AKI), as defined using the Kidney Disease Improving Global Outcome classification, after heart transplantation (HT). Our objective was to evaluate the impact of AKI in a cohort of HT recipients. (Setting: University Hospital.) METHODS: We studied 310 consecutive HT recipients from 1999 to 2017, with AKI being defined according to the Kidney Disease Improving Global Outcome criteria. Risk factors were analyzed by multivariable analyses, and survival by Kaplan-Meier curves and a risk-adjusted Cox proportional hazards regression model. RESULTS: One hundred twenty-five (40.3%) patients developed AKI, with 73 (23.5%), 18 (5.8%), and 34 (11%) patients having AKI stages 1, 2, and 3, respectively. Cardiac tamponade (odds ratio [OR], 16.82; 95% confidence interval [CI], 1.06-138), acute right ventricular failure (OR, 3.54; 95% CI, 1.82-6.88), and major bleeding (OR, 2.46; 95% CI, 1.18-5.1) were the principal risk factors for AKI. Patients with AKI had a greater hospital mortality (3.8% vs 16%, P < 0.05), especially those requiring renal replacement therapy (46.9% vs 5.4%, P = 0.006). Acute kidney injury requiring renal replacement therapy was independently associated with hospital mortality (OR, 11.03; 95% CI, 4.08-29.8). With a median follow-up after hospital discharge of 6.7 years (interquartile range, 2.4-11.6), overall survival at 1, 5, and 10 years was 95.4%, 85.1%, and 75.4% versus 85.2%, 69.8% and 63.5% among patients without AKI and with AKI stages 2 to 3, respectively (P = 0.08). CONCLUSIONS: The onset of AKI after HT is mainly associated with postoperative complications. Only severe AKI stage predicts worse short-term outcome, with this impact appearing to be lost at long-term follow-up.

Pulmonary endarterectomy outputs in chronic thromboembolic pulmonary hypertension. / Resultados de la tromboendarterectomía pulmonar en la hipertensión pulmonar tromboembólica crónica.

BACKGROUND AND OBJECTIVE: Pulmonary thromboendarterectomy surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension; extremely high pulmonary vascular resistance constitutes a risk factor for hospital mortality. The objective of this study was to analyze the immediate and long-term results of the surgical treatment of chronic thromboembolic pulmonary hypertension in patients with very severe pulmonary hypertension. MATERIAL AND METHODS: Since February 1996, we performed 160 pulmonary thromboendarterectomies. We divided the patient population in 2 groups: group 1, which included 40 patients with pulmonary vascular resistance≥1090dyn/sec/cm-5, and group 2, which included the remaining 120 patients. RESULTS: Hospital mortality (15 vs. 2.5%), reperfusion pulmonary edema (33 vs. 14%) and heart failure (23 vs. 3.3%) were all higher in group 1; however, after one year of follow-up, there were no significant differences in the clinical, hemodynamic and echocardiographic conditions of both groups. Survival rate after 5 years was 77% in group 1 and 92% in group 2 (P=.033). After the learning curve including the 46 first patients, there was no difference in hospital mortality (3.8 vs. 2.3%) or survival rate after 5 years (96.2% in group 1 and 96.2% in group 2). CONCLUSIONS: Pulmonary thromboendarterectomy is linked to significantly higher morbidity and mortality rates in patients with severe chronic thromboembolic pulmonary hypertension. Nevertheless, these patients benefit the same from the procedure in the mid-/long-term. In our experience, after the learning curve, this surgery is safe in severe pulmonary hypertension and no level of pulmonary vascular resistance should be an absolute counter-indication for this surgery.

Pulmonary thromboendarterectomy in 106 patients with chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique. METHODS: Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described. RESULTS: Subjects' mean age was 53±14 years. A total of 89% were WHO functional class III-IV, presurgery mean pulmonary pressure was 49±13mmHg and mean pulmonary vascular resistance was 831±364 dynes.s.cm(-5). In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (p=0.015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90 and 84%. At 1 year, 91% were WHO functional class I-II; mean pulmonary pressure (27±11mmHg) and pulmonary vascular resistance (275±218 dynes.s.cm(-5)) were significantly lower (p<0.05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91 and 73%, respectively. CONCLUSIONS: Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients.

Staphylococcus aureus poststernotomy mediastinitis: description of two distinct acquisition pathways with different potential preventive approaches.

OBJECTIVE: Determining the acquisition routes of infection is crucial to designing specific preventive approaches against Staphylococcus aureus poststernotomy mediastinitis. METHODS: From 2002 to 2004, a nasal sample was obtained from patients before cardiac surgery. We collected clinical and microbiologic data of all episodes of S aureus poststernotomy mediastinitis. A case-control study (3:1) was performed to confirm the role of previous preoperative nasal colonization by S aureus as a risk factor for S aureus poststernotomy mediastinitis. Pulsed field gel electrophoresis molecular analysis of nasal and surgical site S aureus isolates was performed to analyze their relatedness in each patient with poststernotomy mediastinitis and with other patients of the study cohort. RESULTS: S aureus nasal cultures were positive in 228 (15.9%) of 1432 patients: methicillin-susceptible S aureus in 222 (15.5%) and meticillin-resistant S aureus in 6 (0.4%). S aureus poststernotomy mediastinitis was diagnosed in 17 (1.2%) of 1432 patients: 9 (3.95%) of 228 in colonized patients versus 8 (0.66%) of 1204 in noncolonized patients (P < .0001). Seven of 9 patients (1.2%) with methicillin-susceptible S aureus had an identical isolate by pulsed field gel electrophoresis in preoperative nasal and surgical-site cultures, but no clonal relatedness was shown among the isolates from these 9 patients. None of the 8 patients with methicillin-resistant S aureus poststernotomy mediastinitis had an identical isolate by pulsed field gel electrophoresis in preoperative nasal and surgical-site cultures, and the same clone of methicillin-resistant S aureus was responsible for all these cases. CONCLUSIONS: Endogenous [corrected] nasal colonization often precedes methicillin-resistant S aureus poststernotomy mediastinitis, which suggests that preoperative [corrected] decontamination is adequate for preventing methicillin-susceptible [corrected] S aureus poststernotomy mediastinitis, whereas hospital infection control measures seem to be the major factor for preventing methicillin-resistant S aureus poststernotomy mediastinitis.

An unusual indication for cardiac transplantation: isolated myocardial tuberculosis.

We report a case of myocardial tuberculosis in an 18-year-old male. He had been diagnosed with isolated asymmetrical septal hypertrophy cardiomyopathy and presented severe congestive heart failure for 4 months. Echocardiography and magnetic resonance studies showed localized echodense shadows and cavities in the thickness of the left ventricle myocardium with severe myocardial dysfunction. No contraindications for cardiac transplantation were found and this was planned and performed. Histology of the myocardium was consistent with the diagnosis of myocardial tuberculosis. The patient's post-operative course was uneventful, and he was discharged with anti-tuberculosis medication.