Short- and long-term outcomes of surgery for severe tricuspid regurgitation.

INTRODUCTION AND OBJECTIVES: There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation. The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. METHODS: Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. RESULTS: A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty (P=.04). CONCLUSIONS: Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.

[Effect of exercise on systolic left ventricular outflow velocity in healthy adults]. / Efecto del ejercicio sobre las velocidades de flujo sistólico ventricular izquierdo en adultos sanos.

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults.

[Morphologic study of the pulmonary veins by magnetic resonance angiography]. / Estudio morfológico de las venas pulmonares por angiorresonancia magnética.

Accurate knowledge of the anatomy of the pulmonary veins is important in clinical electrophysiology. In order to evaluate the usefulness of magnetic resonance angiography for this purpose, we studied 17 unselected patients. All the pulmonary veins were visualized in each individual. The diameters of the ostia ranged between 9 mm and 22 mm. The cross-section of the ostium was elliptical in 35% of cases. In 14 patients (82%), the 4 veins each had independent drainage. In 2 patients (12%), there was an additional intermediate right vein and, in 1 patient (6%), both left veins had a common ostium. In 74% of patients, the right pulmonary veins had a short common trunk with early branching. This pattern was seen in only 10% of left veins. Magnetic resonance angiography using a contrast medium is an excellent technique for studying the anatomy of the pulmonary veins and for identifying variants. The resulting information is potentially useful for electrophysiologists.

[Systolic ventricular dysfunction, a new marker of coronary artery disease in patients with aortic stenosis without previous myocardial infarction]. / Disfunción ventricular sistólica, un nuevo marcador de enfermedad coronaria en pacientes con estenosis aórtica sin infarto de miocardio previo.

Identification of clinical factors associated with coronary artery disease could obviate the need for coronary angiography in selected patients with severe aortic stenosis. We studied 315 patients (68 [8] years) with severe aortic stenosis without previous infarction who underwent coronary angiography. In the univariate analysis, age (P = .001), dyslipidemia (P = .003), angina (P = .018), aortic gradient (P = .001) and reduced ejection fraction (P = .006) were predictors of coronary artery disease. After multivariate analysis, age (OR = 1.079, P = .01), ejection fraction < 40% (OR = 2.685, P = .02), angina (OR = 2.518, P = .04) and dyslipidemia (OR = 2.34, P = .008) were the factors independently associated with coronary artery disease. Left ventricular dysfunction correlated independently with the presence of coronary artery disease.

[Dynamic left ventricular outflow tract obstruction induced by exercise]. / Obstrucción dinámica intraventricular izquierda inducida por esfuerzo.

INTRODUCTION AND OBJECTIVES: Dynamic left intraventricular outflow tract obstruction occurs occasionally in patients without hypertrophic cardiomyopathy. We hypothesized that dynamic intraventricular obstruction might occur during effort in patients with angina or dyspnea without evident disease. The objective of this prospective study was to investigate: a) whether it appears with effort; b) its incidence, magnitude and determining factors, and c) its clinical course. PATIENTS AND METHOD: We performed baseline and stress Doppler echocardiography in 211 patients with angina, dyspnea or both with exercise. Patients with previous myocardial infarction, valvular heart disease, ventricular dysfunction or ventricular hypertrophy without hypertension were excluded. Dynamic intraventricular obstruction was defined as intracavitary flow velocity > or =2.5 m/s. RESULTS: 134 patients (59 women) were included: mean age was 58 (9) years; history of hypertension was present in 69.7%, dyslipidemia in 35.8% and diabetes in 24.6%. Dynamic intraventricular obstruction appeared in 18 patients (13.4%), with gradients ranging between 25 and 53 mmHg (mean 32.19 [6.6]). Demographic variables, cardiovascular risk factors and exercise performed were similar in group A (with obstruction) and group B (without obstruction). No patient in group A had evidence of ischemia. Five patients in this group had symptoms during exercise; the gradients were greater in these patients (42.65 [10.5] vs 28.15 [2.37] mmHg; P<.0001) than in the remaining group A patients. Left ventricular outflow tract size was found to be the only independent predictive factor in the multivariate analysis. After 369.9 (133.5) days of follow-up, no cardiac events were recorded. CONCLUSIONS: Our study suggests that some patients with angina or dyspnea without evidence of ischemia may develop dynamic left ventricular outflow tract obstruction induced by effort.

Should we treat patients with moderately severe stenosis of the left main coronary artery and negative FFR results?

BACKGROUND: The prognostic importance of significant left main coronary artery disease is unequivocal. However, moderate lesions of the left main coronary artery (LMCA) are sometimes found in patients presenting significant stenosis in other coronary arteries or equivocal symptoms. The ability of myocardial fractional flow reserve (FFR) to predict coronary events could be useful in the decision-making process in these patients. The present study was designed to investigate the occurrence of cardiac events in patients with coronary syndromes and LMCA stenosis of moderate severity in whom FFR failed to show an haemodynamic significant repercussion of the LMCA. METHODS AND RESULTS: We studied 27 consecutive patients (mean age 62.7 +/- 10.5 years) with moderate stenoses (30-50%) of the LMCA. In seven patients who presented significantly reduced FFR (< 0.75) at the LMCA level (Group A), coronary revascularization of this vessel was performed. In 20 patients with negative FFR (greater than or equal to 0.75) at the LMCA level (Group B), the LMCA stenosis was not revascularized, being the revascularization procedures (if any) limited to other arteries with significant obstructions. During a mean follow-up period of 26.2 +/- 12.1 months, clinical events occurred in 3 patients in the whole group. One patient with positive FFR died during coronary bypass surgery. Two group B patients were surgically revascularized 4 months and 4 years after the initial coronariography. CONCLUSIONS: Patients with coronary lesions of moderate severity on the LMCA and negative FFR may constitute a subgroup of good prognosis in the follow-up. Our findings suggest that negative FFR is a potentially useful indicator of the likelihood of cardiac events, and thus represents a useful aid in clinical decision-making in the hemodynamics laboratory.