Functional anatomy of aortic regurgitation. Role of transesophageal echocardiography in aortic valve-sparing surgery.

INTRODUCTION AND OBJECTIVES: The aim was to evaluate the usefulness of transesophageal echocardiography (TEE) for the preoperative functional anatomical assessment of patients with aortic regurgitation (AR) to identify those eligible for valve-sparing surgery (VSS). METHODS: We determined the accuracy and diagnostic value of TEE for identifying underlying lesions and mechanisms in 66 patients who underwent surgery for severe AR by comparing TEE findings with those obtained on surgical inspection. The usefulness of TEE for predicting the feasibility of VSS was determined. RESULTS: The overall diagnostic accuracy of TEE was excellent (87%, kappa=0.82), with valve prolapse being the principle cause of discrepancy between the methods (in 23/27 cases; 85%). Three anatomical forms of dilatation of the ascending aorta (AA) were correctly classified (accuracy >88%; kappa 0.83): supratubal aneurysm (19 patients), aortic root aneurysm (4), and annuloaortic ectasia (24). The mechanism underlying AR was identified with an accuracy of 85% (kappa 0.8) and there was a significant association between the type of mechanism identified by TEE and the success of VSS (P< .001): VSS was successful in 73% of patients with dilatation of a functional annulus (i.e. with tethering), but aortic valve replacement was required in 78% with prolapses, 90% with thickened leaflets with restricted movement, and 100% with perforation. There was also a relationship between the type of aneurysm and the technique required for AA replacement (P=.004). CONCLUSIONS: Use of TEE enabled the mechanism underlying AR to be accurately identified. There was a high level of agreement with surgical inspection and the technique was useful for predicting the feasibility of VSS and the surgical procedure for AA replacement.

Replacement of A2 and A3 by pericardium due to endocarditis of the anterior leaflet of the mitral valve.

We present a case of acute endocarditis due to enterococcus faecalis involving partially A2 and completely A3 (Carpentier classification) with destruction of the free margin of the mitral valve. Repair was performed by using glutaraldehyde treated porcine pericardium to replace the defect and neochordae of polytetrafluoroethylene sutured to the free margin of the pericardium to achieve competence. Intraoperative and follow-up echocardiogaphies showed no regurgitation.

Ventricular tachycardia in a man with spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute ischemic coronary events. It is more prevalent in young women, particularly in the peripartum period. In men it is an extremely rare cause. We described the clinical course of a patient, man, presenting pain chest and ventricular malignant arrhythmias. Four days after admission the patient underwent coronary angiography, showing a large SCAD. After this, he had undergone coronary artery bypass surgery. He presented an angiography and clinical resolution and he was still asymptomatic at a 6-month clinical follow up. Pathophysiologic aspects and treatment options of spontaneous coronary artery dissection are discussed.

Aortic valve endocarditis by Capnocytophaga haemolytica.

We report a case of a 51-year-old patient with suspected prosthetic valve endocarditis. Capnocytophaga haemolytica was isolated in blood cultures and the repeated echocardiograms showed growth of vegetations and disruption of the proximal prosthetic valve suture line with progressive aortic regurgitation. The patient underwent a root debridement and replacement with a stentless bioprosthesis.

[Valve repair for bicuspid aortic valve regurgitation: an option?]. / Reparación valvular en la insuficiencia aórtica por válvula bicúspide: una alternativa?

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre.

Anatomía funcional de la insuficiencia aórtica. Papel de la ecocardiografía transesofágica en la cirugía conservadora de válvula aórtica / Functional anatomy of aortic regurgitation. Role of transesophageal echocardiography in aortic valve-sparing surgery

Introducción y objetivos. Intentamos determinar el papel de la ecocardiografía transesofágica (ETE) en la descripción preoperatoria de la anatomía funcional de la insuficiencia aórtica (IAo) para identificar candidatos a cirugía conservadora (CCVAo). Métodos. En 66 pacientes intervenidos de IAo severa se determinan precisión y valores diagnósticos de la ETE en la descripción de lesiones y mecanismos, empleando la observación quirúrgica como referencia. Se valora la utilidad de la ETE para predecir aplicabilidad de técnicas de CCVAo. Resultados. La exactitud diagnóstica general de la ETE es excelente (87%, índice kappa = 0,82); el prolapso presenta la principal discrepancia (23/27 casos; 85%) entre los métodos. Tres formas anatómicas de dilatación de aorta ascendente (AA) fueron correctamente clasificadas (precisión, > 88%; kappa = 0,83): aneurisma de AA supratubular (19), aneurisma de raíz (4) o anuloectasia aórtica (24). La precisión en el diagnóstico del mecanismo fue del 85% (kappa = 0,8) y éste presentó una asociación significativa con el éxito de la CCVAo (p < 0,001) en el 73% de los casos de dilatación de los anillos funcionales (tethering). El 78% de prolapsos, el 90% de movimiento restrictivo de velos engrosados y el 100% de perforaciones requirieron sustitución valvular aórtica. Las formas de aneurisma también se relacionaron con el procedimiento de sustitución de AA (p = 0,004). Conclusiones. La ETE permite una descripción precisa de los mecanismos de la IAo, tiene una elevada tasa de acuerdo con las observaciones quirúrgicas y predice adecuadamente la aplicabilidad de la CCVAo y el procedimiento de sustitución de AA (AU)

Introduction and objectives. The aim was to evaluate the usefulness of transesophageal echocardiography (TEE) for the preoperative functional anatomical assessment of patients with aortic regurgitation (AR) to identify those eligible for valve-sparing surgery (VSS). Methods. We determined the accuracy and diagnostic value of TEE for identifying underlying lesions and mechanisms in 66 patients who underwent surgery for severe AR by comparing TEE findings with those obtained on surgical inspection. The usefulness of TEE for predicting the feasibility of VSS was determined. Results. The overall diagnostic accuracy of TEE was excellent (87%, kappa=0.82), with valve prolapse being the principle cause of discrepancy between the methods (in 23/27 cases; 85%). Three anatomical forms of dilatation of the ascending aorta (AA) were correctly classified (accuracy >88%; kappa 0.83): supratubal aneurysm (19 patients), aortic root aneurysm (4), and annuloaortic ectasia (24). The mechanism underlying AR was identified with an accuracy of 85% (kappa 0.8) and there was a significant association between the type of mechanism identified by TEE and the success of VSS (P < .001): VSS was successful in 73% of patients with dilatation of a functional annulus (i.e. with tethering), but aortic valve replacement was required in 78% with prolapses, 90% with thickened leaflets with restricted movement, and 100% with perforation. There was also a relationship between the type of aneurysm and the technique required for AA replacement (P=.004). Conclusions. Use of TEE enabled the mechanism underlying AR to be accurately identified. There was a high level of agreement with surgical inspection and the technique was useful for predicting the feasibility of VSS and the surgical procedure for AA replacement (AU)

Reparación valvular en la insuficiencia aórtica por válvula bicúspide: ¿una alternativa? / Valve repair for bicuspid aortic valve regurgitation: an option?

La válvula aórtica bicúspide es la cardiopatía congénita más frecuente. Se asocia tanto a enfermedad valvular como a enfermedad aórtica. La insuficiencia aórtica por válvula aórtica bicúspide es susceptible de corregirse mediante técnicas de reparación quirúrgica, con buenos resultados a corto plazo. Sin embargo, la tasa de recurrencia de insuficiencia aórtica en el seguimiento continúa siendo un problema, en parte motivado por la dilatación aórtica progresiva propia de esta entidad. Presentamos 3 casos distintos de válvula aórtica bicúspide tratados mediante reparación en nuestro centro

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre

Transplante capilar: transplante folicular total / Capilar transplant

Se presenta una revisión sobre transplante capilar, especificamente sobre la técnica de transplante folicular total. Esta técnica es de gran interés ya que deja atrás las técnicas antiguas que se realizaban con punch y mostraban una cirugía muy artificial sobre todo con los implantes de mechones. Es por esto que el transplante folicular total es muy interesante ya que se trata de una cirugía ambulatoria, sin complicaciones y de acabado muy sutil, más armónico y estético, dándole naturalidad. La gran ventaja de esta técnica es que no necesitamos de un vendaje posterior a la cirugía, el paciente sale de alta con la cabeza decubierta y regresa a los quince días para el retiro de puntos.