Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adults: Collateral circulation does not preclude direct reimplantation.

BACKGROUND: The adult type of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is characterized by late presentation due to collateral coronary flow. Patients often present with long time recurrent angina or dyspnea. Surgical correction can be a challenge due to the vast collateral coronary circulation. CASE PRESENTATION: A previously healthy 41-year-old male presented in the emergency room referring typical angina and dyspnea. Coronary angiography revealed ALCAPA. Surgical correction was indicated. Under cardiopulmonary bypass, the left main coronary artery ostium was isolated and directly reimplanted in the aorta. The patient was discharged from the hospital without complications and asymptomatic. Control coronary angiography showed enlarged left main coronary artery and regression of the collateral circulation. CONCLUSION: Even with a well-developed collateral circulation, detachment of the left coronary artery and direct implantation in the aorta is feasible, achieving good long-term results.

Percutaneous closure of left ventricular pseudoaneurysm in a patient with concomitant true left ventricular aneurysm.

BACKGROUND: Left ventricular aneurysms (LVA) are serious complications of myocardial infarction, being divided into true and false type. The false one-pseudoaneurysm (PA), is a life-threatening condition that requires urgent treatment due to the high risk of rupture. CASE PRESENTATION: An 84-year-old female presented with progressive heart failure symptoms. Investigation showed a small true LVA and a large PA. Open surgical repair was ruled out as Euroscore and Society of Thoracic Surgeons (STS) score were 42.80% and 39.97%, respectively. After discussion at our Heart Team meeting, percutaneous approach was found to be the best option. Guided by transesophageal echocardiography, we used an interventricular septal defect occluder to close the gap between the LV and the PA. Control ventriculography showed full closure of the gap, with no residual flow to the PA cavity. The patient was discharged from the hospital on the fifth postoperative day and has remained asymptomatic since then. CONCLUSION: Percutaneous approach proved to be a safe and effective modality to treat LV PA. The device implanted achieved the goal of blocking blood flow through the communication between LV and the PA.

Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications.

PURPOSE OF REVIEW: This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment. RECENT FINDINGS: Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm.

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis-zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch-from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk-zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.

The influence of sex on left ventricular remodeling in patients with aortic dissection.

AIMS: Patients with aortic dissection have a high prevalence of left ventricular structural alterations, including left ventricular hypertrophy (LVH), but little is known about the impact of sex on this regard. This study compared clinical, cardiac, and prognostic characteristics between men and women with aortic dissection. METHODS: We retrospectively assessed clinical and echocardiographic characteristics, and 1-year mortality in 367 aortic dissection patients (30% women; 66% with Stanford-A) who underwent echocardiography 60 days before or after the diagnosis of aortic dissection from three Brazilian centers. RESULTS: Men and women had similar clinical characteristics, except for higher age (59.4 ±â€Š13.4 vs. 55.9 ±â€Š11.6 years; P = 0.013) and use of antihypertensive classes (1.4 ±â€Š1.3 vs. 1.1 ±â€Š1.2; P = 0.024) and diuretics (32 vs. 19%; P = 0.004) in women compared with men. Women had a higher prevalence of LVH (78 vs. 65%; P = 0.010) and lower prevalence of normal left ventricular geometry (20 vs. 10%; P = 0.015) than men. Logistic regression analysis adjusted for confounding factors showed that women were less likely to have normal left ventricular geometry (odds ratio, 95% confidence interval = 0.42, 0.20-0.87; P = 0.019) and were more likely to have LVH (odds ratio, 95% confidence interval = 1.91, 1.11-3.27; P = 0.019). Conversely, multivariable Cox-regression analysis showed that women had a similar risk of death compared to men 1 year after aortic dissection diagnosis (hazard ratio, 95% confidence interval = 1.16, 0.77-1.75; P = 0.49). CONCLUSION: In aortic dissection patients, women were typically older, had higher use of antihypertensive medications, and exhibited a greater prevalence of LVH compared with men. However, 1-year mortality after aortic dissection diagnosis did not differ between men and women.

Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation.

INTRODUCTION: Ischemic mitral regurgitation (IMR) is associated with increased mortality. Even after coronary artery bypass grafting (CABG), IMR reduces survival. Several studies have shown increased perioperative mortality for mitral valve replacement (MVR) in this situation, but the subject remains controversial. OBJECTIVE: To investigate the impact of MVR on immediate outcomes in patients with moderate-to-severe IMR undergoing concomitant CABG compared with those undergoing CABG only. METHODS: We performed a retrospective study of 42 patients undergoing CABG+MVR (n=16) or CABG only (n=26) at the Division of Cardiovascular Surgery of PROCAPE, between May 2007 and April 2010. Preoperative clinical characteristics, procedural characteristics, major and minor complications after surgery, preoperative and postoperative left ventricular ejection fraction (LVEF) by echocardiography, and outcome (survivor or death) were assessed. RESULTS: Mean patient age was 63.4 ± 8.5 years, and 64.8% (n=23) were male. The CABG+MVR group showed lower rates of postoperative low cardiac output (6.3% vs. 42.3%, p=0.014) and atrial fibrillation (6.3% vs. 38.5%, p=0.021). Both groups had higher mean LVEF in the postoperative compared with the preoperative period, but the average gain in LVEF in the CABG+MVR group was higher than in the CABG-only group (8.88 ± 2.39 vs. 4.31 ± 1.23, p<0.001). There was no significant difference in operative mortality (6.3% vs. 7.7%, p=0.679). CONCLUSIONS: CABG+MVR can be performed safely in patients with moderate-to-severe IMR. CABG+MVR resulted in lower rates of complications than CABG only. Both surgical approaches resulted in significant improvement of postoperative LVEF. However, there was greater improvement in the CABG+MVR group.

Impact of Aortic Annulus Enlargement on the Outcomes of Aortic Valve Replacement: A Meta-analysis.

We sought to evaluate the impact of surgical aortic annulus enlargement (ARE) on the perioperative outcomes of surgical aortic valve replacement. Databases were searched for articles published by October 2019 in order to carry out a systematic review followed by meta-analysis. Thirteen studies with 40,447 patients (aortic valve replacement [AVR] with aortic annulus enlargement [AAE]: 4686 patients; AVR without AAE: 35,761 patients) were included. The total rate of AAE was 11.6%, ranging from 4.1%-28.1%. The overall unadjusted odds ratio (OR) (95% confidence interval [CI]) for operative mortality showed a statistically significant difference between the groups, with higher risk in the "AVR with AAE" group (OR 1.388; 95% CI 1.049-1.836, P < 0.001), but not for isolated AVR+AAE (OR 1.341; 95% CI 0.920-1.956, P = 0.127) and also not in matched populations (OR 1.003; 95% CI 0.773-1.300, P = 0.984). The "AVR with AAE" group showed an overall lower risk of significant patient-prosthesis mismatch (PPM) (OR 0.567; 95% CI 0.376-0.854, P = 0.007) and a higher overall difference in means of indexed effective orifice area (iEOA) (random effect model: 0.058 cm2/m2; 95% CI 0.024-0.092, P < 0.001). The overall ORs for myocardial infarction, stroke, complete heart block/permanent pacemaker implantation and reoperation for bleeding showed no statistically significant difference between the groups. AAE is a useful adjunct to AVR, but the benefit of reduced PPM must be balanced against a possibly higher risk of perioperative mortality.

Impact of Hypertension History and Blood Pressure at Presentation on Cardiac Remodeling and Mortality in Aortic Dissection.

OBJECTIVE: This study compared clinical, echocardiographic, and prognostic characteristics among patients with aortic dissection (AD) with (HypHist) and without (No-HypHist) hypertension history and evaluated the association of blood pressure (BP) at presentation with 1-year mortality, left ventricular (LV) remodeling and renal dysfunction. METHODS: We investigated clinical and echocardiographic characteristics and 1-year mortality among 367 patients with AD (81% HypHist, 66% Type-A) from three Brazilian centers. RESULTS: Patients with No-HypHist were more likely to have Marfan syndrome, bicuspid aortic valve, to undergo surgical therapy, were less likely to have LV hypertrophy and concentricity, and had similar mortality compared with HypHist patients. Adjusted restricted cubic spline analysis showed that systolic BP (SBP) and diastolic BP (DBP) at presentation had a J-curve association with mortality among patients with No-HypHist, but did not associate with death among patients with HypHist (p for interaction = 0.001 for SBP and = 0.022 for DBP). Conversely, the association between SBP at presentation and mortality was influenced by previous use of antihypertensive medications in the HypHist group (p for interaction = 0.002). Results of multivariable logistic regression analysis comprising the whole sample showed direct associations of SBP and DBP at presentation with LV hypertrophy (p = 0.009) and LV concentricity (p = 0.015), respectively, and an inverse association between pulse pressure at presentation and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (p = 0.008). CONCLUSION: Combined information on BP at presentation, previous diagnosis of hypertension, and use of antihypertensive medications might be useful to predict mortality risk and to estimate extra-aortic end-organ damage among patients with AD.

Left Ventricular Concentric Geometric Patterns Are Associated With Worse Prognosis Among Patients With Type-A Aortic Dissection.

Background This study compared left ventricular (LV) characteristics between patients with type-A and type-B aortic dissection (AD) and evaluated the ability of LV remodeling phenotypes (hypertrophy, concentricity, or geometric patterns) to predict mortality in both AD types. Methods and Results We evaluated 236 patients with type A and 120 patients with type B who had echocardiograms within 60 days before or after AD diagnosis (median [25th, 75th percentiles] time difference between echocardiogram and AD diagnosis=1 [0, 6] days) from 3 centers. Patients were stratified according to LV phenotypes, and early (90-day) and late (1-year) mortality after AD diagnosis were assessed. In adjusted logistic regression analysis, patients with type A had higher and lower odds of concentric and eccentric hypertrophy (odds ratio [OR], 2.56; 95% CI, 1.50-4.36; P<0.001; and OR, 0.55; 95% CI, 0.31-0.97; P=0.039, respectively) than those with type B. Results of multivariable Cox-regression analysis showed that LV remodeling phenotypes were not related to mortality in patients with type B. By contrast, LV concentricity was associated with greater early and late mortality (hazard ratio [HR], 2.22; 95% CI, 1.24-3.96; P=0.007 and HR, 2.06; 95% CI, 1.20-3.54; P=0.009, respectively) in type A. In further analysis considering normal LV geometry as reference, LV concentric remodeling and concentric hypertrophy were associated with early mortality (HR, 7.78; 95% CI, 2.35-25.78; P<0.001 and HR, 4.38; 95% CI, 1.47-13.11; P=0.008, respectively), whereas concentric remodeling was associated with late mortality (HR, 5.40; 95% CI, 1.91-15.26; P<0.001) among patients with type A. Assessment of LV geometric patterns and concentricity provided incremental prognostic value in predicting early and late mortality beyond clinical variables in patients with type A based on net reclassification improvement and integrated discrimination improvement. Conclusions LV geometric patterns derived from LV concentricity were associated with greater mortality among patients with type A and may be markers of adverse prognosis in this population.

German Aortic Valve Score in Risk Assessment for Surgical Aortic Valve Replacement in a Brazilian Center.

OBJECTIVE: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). METHODS: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. RESULTS: The mortality rate was 8.04% (18 patients). The patients' mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff "1.8" turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. CONCLUSION: The GAV score applies to our population with high predictive accuracy.

German aortic valve score in risk assessment for surgical aortic valve replacement in a brazilian center

Abstract Objective: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. Results: The mortality rate was 8.04% (18 patients). The patients' mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff "1.8" turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. Conclusion: The GAV score applies to our population with high predictive accuracy.

Prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass surgery: a meta-analysis of randomized controlled trials.

OBJECTIVES: The aim of this study was to assess the efficacy of a prophylactic intra-aortic balloon pump (IABP) in high-risk patients undergoing coronary artery bypass graft surgery. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar, and reference lists of relevant articles were searched. We included only randomized controlled trials. Assessments for eligibility, relevance, and study validity and data extraction were performed in duplicate using prespecified criteria. Meta-analysis was carried out using fixed-effect and random-effect models. RESULTS: Seven publications fulfilled our eligibility criteria. There was no important statistical heterogeneity or publication bias among included studies. In total, 177 patients received prophylactic IABP and 168 did not. Overall relative risk (RR) for hospital mortality in patients treated with prophylactic IABP was 0.255 [95% confidence interval (CI), 0.122-0.533; P<0.001; same results for both effect models]. Pooled RR for postoperative low cardiac output syndrome was 0.206 (95% CI, 0.109-0.389; P<0.001) for the fixed-effect model and 0.219 (95% CI, 0.095-0.504; P<0.001) for the random-effect model. Patients treated with prophylactic IABP presented an overall difference in means for length of intensive care unit stay and hospital stay, which was lower than that in the control group (P<0.001 for both effect models). Only 7.4% (13/177) of patients who received prophylactic IABP developed complications at an insertion site, with no IABP-related death. CONCLUSION: This meta-analysis supports the use of prophylactic IABP in high-risk patients to reduce hospital mortality.