Were they inoperable? Really?

The MitraClip technique has been increasingly used for correction of mitral valve regurgitation in patients in whom surgical mitral repair is considered contraindicated or very risky, but off label use occurs often. Failure of the procedure, translated into moderate to severe rates of residual or recurrent mitral regurgitation, is observed in up to one-third of the patients, and surgery has been used to correct it in a number of cases, in what can be called an "operation for the inoperable." That is precisely the subtitle of a paper published in this issue of the JOCS by Gerfen and colleagues, who analyse their institutional experience with a series of 17 patients. In this Editorial, I comment on this series and the possible reasons for failure of the MitraClip, and on the indications for reintervention and its constraints, which I hope can contribute to the discussion about "further exploration and refinement of patient selection criteria and identify predictors for MitraClip failure," as the authors suggest.

Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association.

The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.

Left ventricular free wall rupture: A real nightmare.

Left ventricular free wall rupture (LVFWR) is a rarest but often lethal mechanical complication of acute myocardial infarction (AMI). The mortality rate for LVFWR is described from 75% to 90% and it is the cause for 20% of in-hospital deaths after AMI. Death results essentially from the limited time available for emergent intervention after onset of symptoms. Emergency surgery is indicated and normally the rupture site is easily identified, but it may not be apparent macroscopically, corresponding to transmyocardial or subepicardial dissection with an external rupture far from the infarction site, or already thrombosed and contained. Repair of the ventricular wall is usually achieved either by suturing the edges of the tear or closing it with patches of artificial material or biological tissues, usually using some kind of biological glue. However, several cases of successful conservative management have been described. In this Editorial, I comment on the metanalysis conducted by Matteucci et al, published in this issue of the Journal, including 11 nonrandomized studies and enrolling a total of 363 patients, which brings a great deal of new knowledge that can help not only in the prevention but also in the management of this dreadful complication of AMI.

Rheumatic heart disease: The role of global cardiac surgery.

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicated in high-income countries due to timely detection and treatment of acute rheumatic fever, RHD remains highly prevalent in low- and middle-income countries (LMICs) and among indigenous and disenfranchised populations in high-income countries. As a result, over 30 million people in the world have RHD, of which approximately 300,000 die each year despite this being a preventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, and Southeast Asia, access to cardiac surgical care for RHD remains limited, impacting countries' population health and resulting economic growth. Humanitarian missions play a role in this context but can only make a difference in the long term if they succeed in training and establishing autonomous local surgical teams. This is particularly difficult because these populations are typically young and largely noncompliant to therapy, especially anticoagulation required by mechanical valve prostheses, while bioprostheses have unacceptably high degeneration rates, and valve repair requires considerable experience. Devoted and sustained leadership and local government and public health cooperation and support with the clinical medical and surgical sectors are absolutely essential. In this review, we describe historical developments in the global response to RHD with a focus on regional, international, and political commitments to address the global burden of RHD. We discuss the surgical and clinical considerations to properly manage surgical RHD patients and describe the logistical needs to strengthen cardiac centers caring for RHD patients worldwide.

Enlargement of the narrow aortic root: Fear of what?

Prosthesis-patient mismatch (PPM) associated with aortic valve replacement, especially of aortic stenosis, is a common problem. Severe PPM is known to increase perioperative morbidity and mortality and to negatively affect late survival. Surgical enlargement of the narrow aortic root enlargement (ARE) is now increasingly accepted as a method of facilitating implantation of a larger valve prosthesis, hence decreasing the risk of PPM. There are diagnostic methods and tables that help to predict the risk of this complication and assist in the planning of the surgery. Still, many surgeons are afraid or reluctant to perform ARE because of potential technical complications of a procedure perceived to increase the complexity of the surgery. However, these procedures have been proven safe and effective, and are at the reach of almost any cardiac surgeon, including less experienced ones. In addition, there are modifications to the techniques that make them even simpler and more reproducible.

Tricuspid annuloplasty: Too many, too few? Virtue may be in the middle!

BACKGROUND: Significant secondary tricuspid regurgitation, often accompanied by right ventricular dilation and dysfunction, occurs in a significant proportion of patients submitted to surgery for severe mitral valve disease. It appears a vicious circle that is not interrupted by the treatment of the left heart valve alone, hence it requires concomitant intervention on the tricuspid valve. AIMS: In this commentary I will discuss a paper published in this issue of the Journal by Calafiore et al from Riyadh - Saudi Arabia, reporting a retrospective study that evaluated the influence of preoperative right ventricular and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and RV in 423 patients undergoing TA for functional TR operated on from May 2009 to December 2015 at their institution. MATERIALS & METHODS: Current guidelines and other consensus documents recommend that tricuspid valve surgeryshould be considered (class IIa) in patients with mild/moderate secondary regurgitation and/or significant annular dilatation. However, rates of tricuspid annuloplasty performed during operations to left-heart valves are very variable, depending also on the etiology of the mitral disease. RESULTS & DISCUSSION: Different methods of annuloplasty are used by the surgical community - suture, rings, bands - with widely variable results with regard to the recurrence of regurgitation and long-term survival. Not all these techniques are standardised and this may also be a cause for the disparate results. CONCLUSION: In the absence of randomized studies, which are highly unlikely to be undertaken in this situation, more information is required from large series with longer follow-ups.

Vasomotion as an oscillatory sign of functional impairment in the human internal thoracic artery: A study based on risk factors and vessel reactivity.

NEW FINDINGS: What is the central question of this study? Vasomotion has been viewed as a rhythmic oscillation of the vascular tone that is physiologically important for optimal tissue perfusion. Also, it has been studied primarily in the microcirculation. However, the precise underlying mechanisms and the physiological significance remain unknown. What is the main finding and its importance? Vasomotion is not specific to the microcirculation, as shown by our findings. In human arteries from patients undergoing cardiac surgery, an increased incidence was associated with endothelial dysfunction settings. Therefore, this oscillatory behaviour might be a signal of functional impairment and not of integrity. ABSTRACT: Vasomotion has been defined as the rhythmic oscillation of the vascular tone, involved in the control of the blood flow and subsequent tissue perfusion. Our aims were to study the incidence of vasomotion in the human internal thoracic artery and the correlation of this phenomenon with the clinical profile and parameters of vascular reactivity. In our study, vasomotion was elicited with a single-dose contractile stimulation of noradrenaline (10 µm) in internal thoracic artery segments, from patients undergoing coronary artery bypass grafting, mounted in tissue organ bath chambers. The incidence was 29.1%. Vessel samples with vasomotion presented significantly higher contractility in response to both potassium chloride (maximal response or Emax of 7.65 ± 5.81 mN versus 4.52 ± 3.73 mN in control vessels, P = 0.024) and noradrenaline (Emax of 7.60 ± 5.93 mN versus 2.96 ± 4.41 mN in control vessels, P < 0.001). Predictive modelling through multivariable logistic regression analysis showed that female sex (odds ratio = 9.82) and increasing maximal response to noradrenaline (odds ratio = 1.19, per 1 mN increase) were associated with a higher probability of the occurrence of vasomotion, whereas increasing kidney function (expressed as estimated glomerular filtration rate) was associated with a lower probability (odds ratio = 0.97, per 1 ml min-1  (1.73 m)-2 ]. Our results provide a characterization of the phenomenon of vasomotion in the internal thoracic artery and suggest that vasomotion might be associated with endothelial dysfunction settings, as determined by a multivariable analysis approach. Considering the associations observed in our results, vasomotion might be a signal of functional impairment and not of integrity.

[Single versus multiple bypass grafts to each diseased coronary territory: impact on survival and major adverse cardiovascular and cerebrovascular events].

BACKGROUND: Complete revascularization is the gold standard of coronary artery bypass grafting (CABG). However, the rationale for revascularization of all diseased vessels is questionable. We aimed at evaluating the impact of multiple versus single grafts in each diseased coronary territory in the long-term survival and incidence of major adverse cardiac and cerebrovascular events (MACCE). METHODS: From January/00 to November/15, 5.694 consecutive patients were submitted to isolated CABG, of whom 4.243 (74.5%) had complete anatomical revascularization and constituted the study population. Patients were divided into two groups: multiple grafts to each major territory (RCA, LAD, Cx, n=755) a single graft to each territory (n=3.488). Mean follow-up time was 8.5±4.4 years and complete for 96.4% of patients. RESULTS: No differences were found concerning major immediate postoperative complications (cardiogenic shock, acute myocardial infarction or stroke) and thirty-day mortality was similar (0.7%; p=0.871). Long-term survival was 64.4±1.3% vs. 67.7±2.9%, p=0.232. Older age (HR:1.07; 1.06-1.08, p<0.001), diabetes mellitus (HR:1.44; 1.24-1-66, p<0.001), peripheral vascular disease (HR: 1.52; 1.29-1.81, p<0.001), chronic obstructive pulmonary disease (HR:1.38; 1.01-1.89, p=0.042), moderate/ severe cardiac dysfunction (HR:1.95; 1.60-2.38, p<0.001) and moderate/severe renal impairment (HR:1.65; 1.40-1.94, p<0.001) were independent predictors for late mortality. Freedom from MACCE was higher in multiple graft group (79.4±2.0% vs. 90.7±2.7%; p=0.026, respectively) at 4 years. CONCLUSION: Isolated CABG can be performed safely and with very low mortality. The number of bypass grafts did not adversely affect the perioperative results and long-term survival. However, implantation of multiple grafts was associated with lower incidence of major adverse events.

Introdução: A revascularização completa representa o gold standard para a cirurgia de revascularização miocárdica. No entanto, a pontagem de todas as artérias com doença significativa no mesmo território coronário é controversa. Deste modo, objetivamos avaliar o impacto, na sobrevivência a longo e na incidência de eventos cardio e cerebrovascular major (MACCE), da colocação de um enxerto único versus múltiplos enxertos coronários no mesmo território. Métodos: de Janeiro/00 a Novembro15, 5.694 doentes foram consecutivamente submetidos a CABG isolada, dos quais 4.243 (74.5%) tiveram revascularização anatómica completa, constituindo a população em estudo. Os doentes foram dividos em dois grupos: os que receberam enxertos múltiplos para cada território (CD, DA, CX, n=755) e os que receberam um enxerto único (n=3.488). O tempo médio de seguimento foi de 8.5±4.4 anos e completo em 96.4% dos doentes. Resultados: não foram observadas diferenças no que respeita às complicações major pós-operatórias (choque cardiogénico, enfarte agudo do miocárdio ou acidente vascular cerebral) bem como na mortalidade aos 30 dias (0.7%; p=0.871). A sobrevivência a longo prazo foi 64.4±1.3% vs. 67.7±2.9%, p=0.232. A idade avançada (HR:1.07; 1.06-1.08, p<0.001), diabetes (HR:1.44; 1.24-1-66, p<0.001), doença vascular periférica (HR:1.52; 1.29-1.81, p< 0.001), doença pulmonar crónica obstrutiva (HR:1.38; 1.01-1.89, p=0.042), disfunção cardíaca moderada/severa (HR:1.95; 1.60-2.38, p< 0.001) e disfunção renal moderada/severa (HR:1.65; 1.40-1.94, p< 0.001) foram preditores de mortalidade a longo prazo. A taxa livre de MACCE foi superior no grupo com múltiplos enxertos aos 4 anos (79.4±2.0% vs. 90.7±2.7%; p=0.026, respetivamente). Conclusão: a CABG é realizada com segurança e com baixa mortalidade. O número de enxertos não afetou os resultados perioperatorios e a sobrevivência a longo prazo. No entanto, a confecção de múltiplos enxertos foi associada a menor incidência de MACCE.

Cardiac Surgery, with Synchronous Carotid Angioplasty, our Experience.

INTRODUCTION: The identification of carotid stenosis in patients proposed for coronary artery bypass grafting, proves that atherosclerosis is a systemic disease. In patients with carotid disease and in need of cardiac surgery, there are still questions about the best method of treatment - medical, surgical or percutaneous, the degree of stenosis considered for intervention and the best time for treatment (pre, peri or postoperative heart surgery). The surgical treatment of the carotid stenosis is currently the gold standard. However, percutaneous treatment has expanded its indications. It is our goal to present the initial results of our experience in the implementation of a synchronous strategy for the treatment of percutaneous carotid disease treatment, followed by cardiac surgery. METHODS: Between July/2013 and August/2017, 37 patients were eligible for this procedure. Demographic, perioperative and postoperative data were collected to evaluate the incidence of cerebrovascular complications (severe stroke, death due to stroke, transient ischemic stroke), cardiac complications (acute myocardial infarction (AMI)), or renal impairment. RESULTS: The majority of patients (83.7%) were male, with a mean age of 74 years (51-90). Coronary artery disease was the most prevalent surgical indication (59%). Hypertension, dyslipidemia, and smoking, in this order of magnitude, were the most prevalent risk factors. One patient had documented previous stroke. The efficacy of carotid angioplasty was 97.3%, as in one patient it was impossible due to technical reasons. In six patients, the carotid procedure was associated with percutaneous treatment of coronary disease. The interval between both procedures was 1 hour, in average. In- hospital mortality was 5,4% (2 patients) and 1 AMI was documented. Renal injury and atrial fibrillation were the most common complications, found in 27% and 19%, respectively. The mean follow-up time was 523 days (50-1525 days). Two deaths were documented during follow-up. No re-stenosis was found. CONCLUSION: The approach presented here (percutaneous treatment of carotid stenosis, concomitant treatment of coronary disease and proximity between procedures) is feasible and effective in reducing the risk of cerebrovascular complications in patients in need of cardiac surgery. Long-term follow-up results, associated with permeability studies, may boost this technique for clinical acceptance, with changes in guidelines, in this set of patients.

Heart transplantation: Early Results of Two Different Regimes of Immnunosuppression.

INTRODUCTION: The management of induction and maintenance immunosuppression therapy after heart transplantation (HT) remains a controversial issue. The dosage and the timing has been a changing target. We aimed at evaluate the incidence of acute cellular rejection (ACR) [≥1R grade], major infection and survival in first year after HT in patients receiving two different induction immunosuppression regimes and with a reduction in intensity of triple maintenance immunosuppression dose. METHODS: From November-2003 to June-2016, 317 patients were submitted to HT. After excluding those with pediatric age (n=8), those with previous renal or hepatic transplantation (n=2), those submitted to retransplantation (n=2), patients with early death without endomiocardial biopsy (n=10) and those in a transition maintenance regime (n=26), the study population resulted in 269 patients. These patients were divided in two groups: patients receiving the previous regime of two doses of basiliximab (group A, n=211) and those receiving a single dose of basiliximab (group B, n=58). All the patients were treated with a maintenance standard triple immunosuppressive regimen of corticosteroids, an inhibitor of calcineurin and mycophenolate mofetil but more immunosuppressive load in group A. RESULTS: Mean age of the recipients (group A vs. group B) was 54.6±10.6vs.55.0±9.8 years (p=0.808); 77.3%vs.75.9% were male (p=0.861); 28.4%vs.28.1% were diabetic (p=0.957); and ischemic etiology was present in 39.8%vs 41.0% of the patients (p=0.798), respectively. No differences were found, at first year, between the two groups concerning global ACR incidence (55.0%vs.56.9%, p=0.882, respectively) but major ACR (≥2R grade) was slightly superior in group B (16.6%vs.27.6%, p=0.080, respectively). Time-free from major ACR at 3rd, 6th and 12th months was, respectively 91.0±2.0%vs.84.5%±4.8%; 86.7±2.3%vs.74.1±5.7%; and 83.4±2.6%vs.72.4±5.9% (p=0.048). Time-free from major infection at 3rd, 6th and 12th months was, respectively 89.6±2.1%vs.82.8±5.0%; 87.7±2.3%vs.79.3±5.3%; and 84.4±2.5%vs.79.3±5.3% (p=0.253). No differences were found concerning survival at 3rd, 6th and 12th months (94.3±1.6%vs.94.8±2.9%; 92.4±1.8%vs.93.1±3.3%; and 90.0±2.1%vs.91.4±3.7%, (p=0.771) respectively). CONCLUSION: With this study, we verified that lowering doses of induction and maintenance therapy was responsible for increase cases of major ACR at first year of heart transplant. However, no differences were found concerning the incidence of major infection and early survival. Hence, effective immunosuppression induction regimen can apparently be done safely with a single dose regime without compromising survival at first year after HT.

Coronary Allograft Vasculopathy after Cardiac Transplantation: Prevalence, Prognostic and Risk Factors.

INTRODUCTION: Coronary allograft vasculopathy (CAV) is still a serious long-term complication after cardiac transplantation. PURPOSE: To evaluate the prevalence of CAV in a single institution, its impact on survival and to explore associated risk factors. METHODS: From November-2003 through June-2016, 316 patients were submitted to cardiac transplantation. After excluding those with paediatric age (n=8), those with previous renal or hepatic transplantation (n=2) and those who didn't survive the first year after cardiac transplantation (n=40), the study population resulted in 266 patients. Forty two patients (15.8%) with CAV, diagnosed by a new >50% coronary artery stenosis in any vessel during follow-up, were compared with a non-CAV group. RESULTS: Both groups share de same median age (54+10years). Recipient male sex predominated in the CAV group (93% vs. 74%), as did ischemic etiology (52% vs. 37%). Although not reaching statistical significance, CAV patients also had more dyslipidemia (60% vs. 50%), history of smoking (52% vs. 44%) and peripheral vascular disease (45% vs. 29%). The incidence of celular acute rejection 1R is more frequent in CAV group (69% vs. 60%) such as 2R or 3R (29% vs. 27%). Prolonged use of inotropic support and mechanical assistance after cardiac transplantation were comparable between both groups. The survival of this patients, who were submitted to cardiac transplantation and had lived at least 1 year, between CAV and non-CAV group was comparable at 5-year (91% vs. 85%), but tended to be lower for CAV patients in 10-year interval (52% vs. 73%). CONCLUSION: This data confirms CAV as a common long-term complication following cardiac transplantation. Although short to mid-term survival seems not to be affected by CAV, long-term survival appears lower, hence a longer follow-up is needed.

Risk Factors for Postoperative Transfusion in Cardiac Surgery with CPB.

INTRODUCTION: The use of blood products is routine in cardiac surgery. Use of blood derivates may vary among institutions and entail high costs and possible complications. This study aims to identify predictors of the need for postoperative blood products transfusion after cardiac surgery with cardiopulmonary bypass (CPB), in order to focus on preventive measures for high-risk populations. METHODS: Observational retrospective study carried out in 104 consecutive adults who underwent cardiac surgery using CPB in our hospital. Blood products used were categorized according to the Universal Definition of Perioperative Bleeding (UDPB) in adult cardiac surgery1 (table 1). Clinical, demographic and surgical variables were analyzed. Statistical analysis was performed using SPSSv23. Quantitative variables are expressed as mean ± standard deviation and qualitative variables as proportions (%). Values of p<0.05 were considered statistically significant. RESULTS: 104 patients, 74 males (71,2%), with an average age of 67,2±13,4 years were included. Mean body mass index (BMI) was 26,1±4,2Kg/m2, and 5,8% were ASA II, 92,3 % ASA III and 1,9% ASA IV. Operative procedures included coronary artery bypass in 32 (30,8%) patients, valvar operations in 59 (56,7%), and combined procedures in 7 (6,7%), with 6 omissions. Forty patients (38,5%) received at least one blood product in final postoperative 24h. The distribution of blood products used according to UDPB in adult cardiac surgery is expressed in table 2. There were no significant statistical differences in blood products transfusion between gender, age, BMI, diabetes, Left Ventricular Ejection Fraction (EFLV) and CBP duration. Although there was no significant correlation between hypertension and postoperative use of blood products, there was a strong positive association between the absence of hypertension and UDPB class 0. In our population, there was a significant association between the type of surgery and UDPB score. There seems to be a strong positive association between valvular surgery and UDPB class 0 and between combined procedures and UDPB class1. Reoperation for bleeding within 24h was required in 3,8%. CONCLUSIONS: In our population, the independent predictor of postoperative bleeding was the type of surgery, with a strong positive association between valvular surgery and combined procedures and UDPB class 0 and 1, respectively. The percentage of reoperations due to bleeding after cardiac surgery is in accordance with the literature.

Glucose uptake and lipid metabolism are impaired in epicardial adipose tissue from heart failure patients with or without diabetes.

Type 2 diabetes mellitus is a complex metabolic disease, and cardiovascular disease is a leading complication of diabetes. Epicardial adipose tissue surrounding the heart displays biochemical, thermogenic, and cardioprotective properties. However, the metabolic cross-talk between epicardial fat and the myocardium is largely unknown. This study sought to understand epicardial adipose tissue metabolism from heart failure patients with or without diabetes. We aimed to unravel possible differences in glucose and lipid metabolism between human epicardial and subcutaneous adipocytes and elucidate the potential underlying mechanisms involved in heart failure. Insulin-stimulated [(14)C]glucose uptake and isoproterenol-stimulated lipolysis were measured in isolated epicardial and subcutaneous adipocytes. The expression of genes involved in glucose and lipid metabolism was analyzed by reverse transcription-polymerase chain reaction in adipocytes. In addition, epicardial and subcutaneous fatty acid composition was analyzed by high-resolution proton nuclear magnetic resonance spectroscopy. The difference between basal and insulin conditions in glucose uptake was significantly decreased (P= 0.006) in epicardial compared with subcutaneous adipocytes. Moreover, a significant (P< 0.001) decrease in the isoproterenol-stimulated lipolysis was also observed when the two fat depots were compared, and it was strongly correlated with lipolysis, lipid storage, and inflammation-related gene expression. Moreover, the fatty acid composition of these tissues was significantly altered by diabetes. These results emphasize potential metabolic differences between both fat depots in the presence of heart failure and highlight epicardial fat as a possible therapeutic target in situ in the cardiac microenvironment.

Surgical Treatment of Posterior Mitral Valve Prolapse: Towards 100% Repair.

BACKGROUND: The study aim was to evaluate the immediate and long-term results of surgical treatment of isolated posterior mitral valve leaflet prolapse (PLP), focusing on survival and freedom from recurrent mitral regurgitation (MR). METHODS: Between January 1998 and December 2012, a total of 492 consecutive patients (375 males, 117 females; mean age 61.8 ± 12.1 years; range: 13-86 years) with isolated PLP [304 (61.8%) with myxomatous degeneration; 188 (38.2%) with fibroelastic deficiency] were treated at the authors' institution. Of these patients, 202 (41.1%) were in NYHA class III-IV, and atrial fibrillation was present in 104 (21.1%). Mitral valve repair was achieved in 484 patients (98.4%), resection was performed in 419 (85.2%), and prosthetic ring annuloplasty was used in 436 (88.6%). Concomitant procedures were performed in 153 patients (31.1%), including tricuspid valve repair in 50 (10.2%), aortic valve surgery in 34 (6.9%), and coronary artery bypass grafting (CABG) in 64 (13%). RESULTS: The hospital mortality rate was 0.2%, and the mean follow up was 7.1 ± 3.9 years. There were 71 late deaths (14.4%), and overall survival at five, 10 and 15 years was 91.7 ± 1.3%, 82.1 ± 2.3% and 64.7 ± 6.1%, respectively. There was no significant difference in long-term survival compared with the age- and gender-matched general population (p = 0.146). Multivariate Cox-proportional hazard analysis showed older age (HR 1.03 per annum), left ventricular dysfunction (HR 2.44), atrial fibrillation (HR 1.96), left ventricular end-diastolic dimension (HR 1.05 per mm) and non-use of prosthetic ring (HR 3.03) as significant predictors of late mortality. Recurrence of moderate or severe MR occurred in 31 patients, six of whom underwent mitral valve reoperation. Predictors of late recurrence of MR were fibroelastic deficiency (HR 2.38), mitral calcification (HR 5.26), posterior leaflet plication (HR 3.58), absence of complete ring annuloplasty (HR 3.84) and systolic pulmonary artery pressure at discharge (HR 1.10 per mmHg). Freedom from mitral valve reoperation at 15 years was 97.4 ± 1.1% CONCLUSIONS: Mitral valve repair in isolated PLP can be achieved in virtually all cases with a very low operative risk and a high durability of repair. Atrial fibrillation or large left ventricles are associated with a poor prognosis. Failure to use a complete ring annuloplasty carries a risk not only for the return of MR but also for survival.

Heart Transplantation in Patients Older than 65 Years: Worthwhile or Wastage of Organs?

BACKGROUND: Patients older than 65 years have traditionally not been considered candidates for heart transplantation. However, recent studies have shown similar survival. We evaluated immediate and medium-term results in patients older than 65 years compared with younger patients. METHODS: From November 2003 to December 2013, 258 patients underwent transplantation. Children and patients with other organ transplantations were excluded from this study. Recipients were divided into two groups: 45 patients (18%) aged 65 years and older (Group A) and 203 patients (81%) younger than 65 years (Group B). RESULTS: Patients differed in age (67.0 ± 2.2 vs. 51.5 ± 9.7 years), but gender (male 77.8 vs. 77.3%; p = 0.949) was similar. Patients in Group A had more cardiovascular risk factors and ischemic cardiomyopathy (60 vs. 33.5%; p < 0.001). Donors to Group A were older (38.5 ± 11.3 vs. 34.0 ± 11.0 years; p = 0.014). Hospital mortality was 0 vs. 5.9% (p = 0.095) and 1- and 5-year survival were 88.8 ± 4.7 versus 86.8 ± 2.4% and 81.5 ± 5.9 versus 77.2 ± 3.2%, respectively. Mean follow-up was 3.8 ± 2.7 versus 4.5 ± 3.1 years. Incidence of cellular/humoral rejection was similar, but incidence of cardiac allograft vasculopathy was higher (15.6 vs. 7.4%; p = 0.081). Incidence of diabetes de novo was similar (p = 0.632), but older patients had more serious infections in the 1st year (p = 0.018). CONCLUSION: Heart transplantation in selected older patients can be performed with survival similar to younger patients, hence should not be restricted arbitrarily. Incidence of infections, graft vascular disease, and malignancies can be reduced with a more personalized approach to immunosuppression. Allocation of donors to these patients does not appear to reduce the possibility of transplanting younger patients.

Surgery on pancoast tumours. Casuistic of a cardiothoracic surgery center.

OBJECTIVES: The authors' objective is to report their experience in the treatment of this rare and challenging condition. METHODS: Retrospective study including all patients diagnosed with Pancoast tumour submitted to surgery, between April 2006 and July 2015. Data concerning the patients submitted to resection surgery with curative intent and statistical analysis. RESULTS: The sample consists of nine patients, five of which underwent diagnostic thoracoscopy and the other four, resection surgery with curative intent. The mean age was 61,5 ± 13.5 years, with predominance of the male gender (n=3). The most common presenting symptom was omalgia irradiating to the ipsilateral arm (n=3). Three patients underwent induction chemoradiotherapy (CRT) with tumour downstaging and all patients were submitted to superior lobectomy with en bloc resection of the invaded structures. The surgical approaches chosen where Dartevelle (n=2) and Shawn-Paulson (n=2). A complete resection was achieved in all patients and no cases of major complications and perioperative mortality were registered. Only non-small cell lung carcinomas (NSCLC) were registered. Two mortality cases were documented before the five years follow-up. CONCLUSIONS: The results obtained are accordant with those registered on the literature. Portuguese data on this matter are scarce and the authors hope that the publication of this article will raise awareness and enhance knowledge regarding the management of Pancoast tumours.

Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.

We intended to evaluate the influence of sex mismatch between donor and recipient, which is still under much debate, on survival and comorbidities after cardiac transplantation. From November 2003 to December 2013, a total of 258 patients were transplanted in our center. From these, 200 receptors were male (77.5%) and constituted our study population, further divided into those who received the heart from a female donor (Group A) - 44 patients (22%) and those who received it from a male donor (Group B) - 156 (78%). Median follow-up was 4.2 ± 3.0 years (1-10 years). The two groups were quite comparable with each other, except for body mass index, systolic pulmonary artery pressure, and transpulmonary gradient, which were significantly lower in Group A. A low donor/recipient weigh ratio (<0.8) was avoided whenever possible. Hospital mortality was not different in the two groups. During follow-up, global survival was similar, as was survival free from acute cellular rejection and cardiac allograft vasculopathy. However, patients in Group A had decreased survival free from serious infections and malignant tumors. Allocation of female donors to male receptors can be done safely, at least in receptors without pulmonary hypertension and when an adequate donor/recipient weigh ratio is ensured.

Cardiac surgery capacity in sub-saharan Africa: quo vadis?

BACKGROUND: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. METHODS: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). RESULTS: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. CONCLUSION: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.