A Bicentric Propensity Matched Analysis of 158 Patients Comparing Porcine Versus Bovine Stented Bioprosthetic Valves in Pulmonary Position.

BACKGROUND AND OBJECTIVES: Pulmonary valve replacement (PVR) is the most common operation in adults with congenital heart disease (CHD). There is controversy regarding the best bioprosthesis. We compare the performance of stented bioprosthetic valves (the Mosaic [Medtronic™] porcine pericardial against Carpentier Perimount Magna Ease [Edwards™] bovine) in pulmonary position in patients with CHD. METHODS: Between January 1999 and December 2019, all the PVRs were identified from hospital databases in 2 congenital heart centres in Spain. Valve performance was evaluated using clinical and echocardiographic criteria. Propensity score matching was used to balance the 2 treatment groups. RESULTS: Three hundred nineteen patients were retrospectively identified. After statistical adjustment, 79 propensity-matched pairs were available for comparison Freedom from reintervention for the porcine cohort was 98.3%, 96.1%, and 91.9% at 3, 5, and 10 years and 100%, 98%, and 90.8% for the bovine cohort (p=0.88). Freedom from structural valve degeneration (SVD) for the porcine cohort was 96.9%, 92.8% and 88.7% at 3, 5, and 10 years and 100%, 98%, and 79.1% for the bovine cohort (p=0.38). Bovine prosthesis was associated with a reintervention hazard ratio (HR), 1.12; 95% confidence intervals (CIs), 0.24-5.26; p=0.89 and SVD HR, 1.69 (0.52-5.58); p=0.38. In the first 5 years, there was no difference in outcomes. After 5 years, the recipients of the bovine bioprosthesis were at higher risk for SVD (reintervention HR, 2.08 [0.27-16.0]; p=0.49; SVD HR, 6.99 [1.23-39.8]; p=0.03). CONCLUSIONS: Both bioprosthesis have similar outcomes up to 5 years, afterwards, porcine bioprosthesis seem to have less SVD.

External Validation of 3 Risk Scores in Adults with Congenital Heart Disease.

BACKGROUND AND OBJECTIVES: Adults with congenital heart disease (CHD) are an increasing group of patients thanks to the survival of over 85% of children with CHD. 20% of these patients shall warrant a surgical procedure during their life span. However, currently there is no one risk score that assess correctly the mortality of these procedures. Thus, we analyse the risk scores used at our institution. METHODS: From May 1991 till June 2017, 608 procedures in adults with CHD were performed. The 3 risk scores (risk adjustment for congenital heart surgery [RACHS-1], Aristotle, and Euroscore I) of each procedure were analysed. We used area under the receiver operating characteristic curve (c-index) to measure model discrimination, and Hosmer-Lemeshow (H-L) statistic along with calibration plots to measure calibration. RESULTS: There was no statistical difference between the area under the curve for the 3 scores (χ²=0.58 with 2 df, p=0.750). There was no evidence of lack of fit for RACHS-1 (H-L, χ²=2.61; p=0.271) and Aristotle score (H-L, χ²=5.69; p=0.459). However, there was evidence in lack of calibration in the Euroscore I scoring system (H-L, χ²=33.69; p<0.001). The calibration slope for RACHS-1 was 0.912, for Aristotle (stratified in risk groups) was -0.14 and for Euroscore 1 (stratified in risk groups) was 0.46. CONCLUSIONS: RACHS-1 seems to be best risk scoring system for calculating mortality applied to surgery in adults with CHD.

Chimney technique for mitral valve replacement in children.

Severe mitral stenosis is unusual in children, but it represents an important challenge for surgeons because of the scarcity of solutions. Several mitral percutaneous and surgical valvuloplasties are performed repetitively to delay mitral valve replacement. Most of the time these procedures show discouraging results. When mitral valve replacement is performed, the annulus may not be large enough to fit a substitute. We present, to our best knowledge, a new technique to implant a large prosthesis in a small annulus without negatively affecting the opening of the leaflets.

Impact of preoperative anemia on cardiac surgery in octogenarians.

OBJECTIVES: Preoperative anemia has been related with adverse outcomes in elective valve replacement and CABG surgery. Impact of preoperative anemia on outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet been precisely described. METHODS: We analyzed association between preoperative hemoglobin level, minimum intraoperative and immediate postoperative hematocrit (HCT), and other co-morbidities and occurrence of adverse outcomes in 227 octogenarians who underwent cardiac surgery. RESULTS: Frequency of preoperative anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of patients suffered at least one postoperative adverse outcome (43.1% non-anemic vs. 46.3% anemic). In multivariate analysis (after adjusting independent preoperative risk factors for operative mortality and EuroSCORE) preoperative creatinine level [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.06-4.98; P=0.035], immediate postoperative HCT <24% (OR, 2.78; 95% CI, 1.04-7.38; P=0.039), perioperative red blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24-2.00; P=0.0001), peripheral vascular disease (OR, 4.92; 95% CI, 1.45-16.69; P=0.012) and urgent surgery (OR, 10.57; 95% CI, 2.54-43.91; P=0.0001) were identified as independent predictors for in-hospital mortality. CONCLUSIONS: Mortality and adverse postoperative outcome increase in anemic octogenarians undergoing cardiac surgery. Although mortality is directly related to immediate postoperative anemia, adverse outcomes mainly depend on associated co-morbidities.

Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus.

We describe the rationale, methodology, and our preliminary experience with a new surgical technique for mitral valve replacement in patients with severe calcification of the mitral annulus in which the conventional techniques can not be applied. In contrast with other procedures published in the literature for these patients, in which the placement of the prosthesis is supra-annular, we plicate both mitral leaflets and the atrial wall creating a new annulus that allows the intra-annular placement of the prosthesis.

[Cardiac surgery with extracorporeal circulation in cancer patients: influence on surgical morbidity and mortality and on survival]. / Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia.

INTRODUCTION AND OBJECTIVES: Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. METHODS: Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. RESULTS: Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. CONCLUSIONS: We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer.