Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Surgical management of embolized Amplatzer septal occluder into the left ventricle tangled with the mitral valve.

Device embolization is a rare major complication of atrial septal defect percutaneous closures which requires surgical management if noninvasive retrieval fails. We report a symptomatic delayed embolization of an Amplatzer septal occluder device into the left ventricle outflow tract tangled with the mitral valve, complicated with ventricular arrhythmias and cardiac tamponade during percutaneous retrieval attempt. Emergent surgical treatment was performed, requiring a combined approach through the right atrium and the aorta for surgical removal.

Internal Banding to Reduce Paravalvular Leaks for Open Transcatheter Valve Implantation.

Transcatheter valve implantation has become an alternative to open-heart conventional surgery in high-risk patients. We describe a new surgical technique that allows the implantation of a transcatheter valvular prosthesis through an open surgical approach to prevent the appearance of paravalvular leaks in patients with large native rings.

Emergent aortic surgery in octogenarians: is the advanced age a contraindication?

Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.

Sutureless aortic bioprosthesis.

Aortic valve replacement (AVR) is the treatment of choice for aortic valve disease, with excellent results reported in the short- and long-term follow-up. Due to the increasing number of patient comorbidities and older age, various technical alternatives have been developed such as transcatheter aortic valve implantation and, more recently, sutureless valve bioprostheses. For patients with very high surgical risk, transcatheter implantation is becoming the top therapeutic option. However, the percutaneous technique still has major disadvantages including those related to implantation without excision of the diseased native valve without direct view of the annulus, which increases the probability of developing perivalvular leaks and a high percentage of atrioventricular block. Due to the need for aggressive crimping of pericardial layers, there is uncertainty about their long-term durability. A new technique for AVR using sutureless bioprosthesis has recently been developed. The main advantages of this technique are the excellent haemodynamic performance and fast deployment under direct view, thereby avoiding the knotting of surgical stitches, which is especially advantageous in more technically demanding procedures (e.g. minimally invasive surgery, calcified aortic root and reoperations). The good clinical results of these valves have been supported by scientific evidence, making it a feasible option for patients who are candidates for AVR using biologic prosthesis, especially for those with mid-high surgical risk for standard AVR and percutaneous transcatheter valve implantation. In this article, we review the latest evidence on these new prostheses, including their advantages and possible disadvantages.

Insertion of an Edwards Sapien 3 prosthesis as a mitral valve in valve implantation via a transapical approach.

We report a case of transapical mitral valve-in-valve implantation for a deteriorated bioprosthesis using the Edwards Sapien 3 prosthesis via the transapical approach. This case demonstrates the safety and feasibility of using the Edwards Sapien 3 prosthesis in treating degenerated bioprosthetic mitral valves.

Crioablación biauricular frente a la ablación aislada de la aurícula izquierda en fibrilación auricular persistente. Recurrencia a medio-largo plazo / Biatrial vs. isolated left atrial cryoablation for the treatment of long-lasting permanent atrial fibrillation. Midterm recurrence rate

Resumen Los resultados a largo plazo del procedimiento de maze con criotermia en pacientes con fibrilación auricular durante procedimientos quirúrgicos concomitantes son todavía inciertos. Método Entre 2006 y 2011, 150 pacientes consecutivos con fibrilación auricular persistente y cardiopatía asociada fueron sometidos a cirugía de ablación mediante criotermia asociada a cirugía concomitante. El procedimiento de Cox-Maze biauricular fue realizado en 67 pacientes y ablación aislada de la aurícula izquierda en 83 pacientes. Los resultados a tres años en estos grupos fueron comparados mediante seguimiento clínico, electrocardiográfico y mediante Holter 24 horas y ecocardiografía con medición de la onda A transmitral al mes, a los 6 y 12 meses y después anualmente. Resultados Los pacientes sometidos a ablación Cox-Maze presentaron una libertad de fibrilación auricular del 97, 94, 89, 80 y 54% a 1, 6, 12, 24 y 36 meses respectivamente. En el seguimiento de los 12 meses estas diferencias resultaron significativas (p < 0.05). Como factor de riesgo de recurrencia de fibrilación auricular se identificó la ablación aislada de la aurícula izquierda. Conclusiones La ablación mediante criotermia tiene un elevado porcentaje de éxitos a dos años; la recurrencia se incrementa a partir de entonces independientemente de la técnica realizada. Para el tratamiento de la fibrilación auricular persistente asociada a otra patología quirúrgica cardiaca se debe realizar un tratamiento intensivo mediante ablación biauricular.

Abstract The long-term results of cryomaze in patients with longstanding persistent atrial fibrillation during concomitant surgical procedures are still uncertain. Methods Between 2006 and 2011, 150 consecutive patients with associated long-lasting permanent atrial fibrillation and associated heart disease underwent heart surgery were treated by biatrial Cox-Maze (63 patients) or by isolated endocardial or epicardial left atrial cryoablation (83 patients) concomitantly. The results at 3 years in these groups were compared with clinical monitoring, electrocardiography, 24-hour Holter, and echocardiography with measurement of the transmitral A wave at 1, 6 and 12 months and annually thereafter in all patients. Results Patients undergoing Cox-Maze IV ablation presented rates of freedom from atrial fibrillation of 97, 94, 89, 80 and 54% at 1, 6, 12, 24 and 36 months, respectively. In the 12-month follow-up, these differences were significant (p < .05). The independent risk factors of atrial fibrillation recurrence was isolated ablation of left atrium. Conclusions Atrial fibrillation by cryothermia ablation had a high success rate before 2 years postoperatively. Recurrence of atrial fibrillation increased thereafter regardless of the technique used, although it was more intense and developed earlier in cases of monoatrial ablation. For the treatment of other long-lasting permanent atrial fibrillation cardiac surgery-associated pathology, an aggressive biatrial treatment with Cox maze ablation should be performed.

[Biatrial vs. isolated left atrial cryoablation for the treatment of long-lasting permanent atrial fibrillation. Midterm recurrence rate]. / Crioablación biauricular frente a la ablación aislada de la aurícula izquierda en fibrilación auricular persistente. Recurrencia a medio-largo plazo.

UNLABELLED: The long-term results of cryomaze in patients with longstanding persistent atrial fibrillation during concomitant surgical procedures are still uncertain. METHODS: Between 2006 and 2011, 150 consecutive patients with associated long-lasting permanent atrial fibrillation and associated heart disease underwent heart surgery were treated by biatrial Cox-Maze (63 patients) or by isolated endocardial or epicardial left atrial cryoablation (83 patients) concomitantly. The results at 3 years in these groups were compared with clinical monitoring, electrocardiography, 24-hour Holter, and echocardiography with measurement of the transmitral A wave at 1, 6 and 12 months and annually thereafter in all patients. RESULTS: Patients undergoing Cox-Maze IV ablation presented rates of freedom from atrial fibrillation of 97, 94, 89, 80 and 54% at 1, 6, 12, 24 and 36 months, respectively. In the 12-month follow-up, these differences were significant (p<.05). The independent risk factors of atrial fibrillation recurrence was isolated ablation of left atrium. CONCLUSIONS: Atrial fibrillation by cryothermia ablation had a high success rate before 2 years postoperatively. Recurrence of atrial fibrillation increased thereafter regardless of the technique used, although it was more intense and developed earlier in cases of monoatrial ablation. For the treatment of other long-lasting permanent atrial fibrillation cardiac surgery-associated pathology, an aggressive biatrial treatment with Cox maze ablation should be performed.

Subclinical Hypothyroidism Might Increase the Risk of Postoperative Atrial Fibrillation after Aortic Valve Replacement.

Background To evaluate the influence of subclinical hypothyroidism (SCH) on the development of postoperative atrial fibrillation (AF) in patients undergoing aortic valve replacement surgery with extracorporeal circulation. Methods A prospective study in a tertiary hospital between July 2005 and December 2013 in which all patients undergoing aortic valve replacement with no other valve surgery were consecutively included. Patients who were in preoperative sinus rhythm were selected and they underwent thyroxine (T4) and thyroid-stimulating hormone determination in the month before surgery. Postoperative AF was defined as the development of AF during hospital admittance. Descriptive analysis and binary logistic regression were performed for the target variable. Results A total of 467 patients were studied, with 35 cases of SCH. The incidence of postoperative AF was 57% in the group with SCH versus 30.3% (p = 0.001) in the group without hypothyroidism, without significant differences in other postoperative complications. In the logistic regression analysis, the independent predictors of postoperative AF were SCH, age, and aortic clamping time. SCH multiplies the odds ratio of postoperative AF by 3.14 (95% confidence interval: 1.24-7.96). Conclusion SCH behaves like a risk factor for the development of postoperative AF in patients undergoing aortic valve replacement with extracorporeal circulation. Other studies are needed to determine whether preoperative T4 replacement therapy and/or more aggressive AF prophylaxis can prevent this complication in patients undergoing aortic valve replacement.

A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma.

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.

Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique.

OBJECTIVES: Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'. METHODS: Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. RESULTS: All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR. CONCLUSIONS: MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score.

OBJECTIVES: To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery. METHOD: A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump). RESULTS: Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG. CONCLUSIONS: PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

Impact of increasing degrees of renal impairment on outcomes of coronary artery bypass grafting: the off-pump advantage.

OBJECTIVES: Increasing degrees of renal impairment are associated with higher rates of morbimortality after coronary artery bypass grafting (CABG). This incremental risk has not been well studied in off-pump procedures (OPCAB). We assessed its impact on OPCAB and on-pump CABG (ONCAB). METHODS: A total of 1769 patients undergoing primary CABG (January 1995 through June 2011) had complete data on glomerular filtration rate (eGFR). 930 patients had Stage 2 renal insufficiency, 330 Stage 3, 27 Stage 4 and 465 normal renal function (Stage 1). Seventeen patients with end-stage disease (Stage 5) were excluded. The OPCAB technique was selectively used in 350 high-risk patients. Preoperative variables and postoperative outcomes were compared among eGFR subgroups and between matched and unmatched OPCAB vs ONCAB groups. RESULTS: Stages 3-4 patients were older (P < 0.0001), with higher prevalence of diabetes (36.8, 35.0, 39.7 and 74.1%, P < 0.01, 1-4 eGFR groups) peripheral arteriopathy (6.0, 9.0, 15.8 and 29.6%, P < 0.0001) and lower left ventricular ejection fraction (LVEF) (GFR-LVEF correlation: Pearson: 0.12, P < 0.0001). On-pump GFR groups had increasingly higher in-hospital mortality (1.0, 1.2, 3.5 and 15.4%, P < 0.0001), but no differences were observed in OPCAB (5.5, 4.8, 5.4 and 7.1%, P = 0.97). Similar trends on in-hospital morbidity were observed in ONCAB vs OPCAB groups: low cardiac output (P < 0.01), pneumonia (P < 0.01) and stroke (P < 0.05). GFR only predicted mortality in ONCAB patients (odds ratio (OR): 0.96, 95% CI: 0.94-0.98; P < 0.01). Patients with higher eGFR stages had statistically more reduced long-term survival, and this pattern was similar in the three treatment groups, also including the OPCAB group, who had the lowest survival in patients with eGFR stage 4. CONCLUSIONS: Patients with low GFR (Stages 3-4) undergoing ONCAB were at increased risk of early morbimortality. In contrast, there were no significant differences in operative morbimortality among eGFR groups in OPCAB patients. This 'off-pump advantage' on early outcomes was not observed at the long-term follow-up.

Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study.

OBJECTIVES: To determine the effect of the off-pump technique in preventing stroke development during the early perioperative period after coronary artery bypass graft surgery (CABG). METHODS: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish cardiac-surgery centres. Baseline variables related to perioperative stroke risk were recorded in the preoperative (age, gender, diabetes mellitus, arterial hypertension, prior stroke, cardiac failure: preoperative New York Heart Association class III-IV and/or left ventricular ejection fraction <40%, non-elective priority of surgery, peripheral arteriopathy, chronic renal failure) and intraoperative periods (on/off-pump performance). The Northern New England Cardiovascular Disease Study Group (NNECDSG) stroke risk schema was used to stratify stroke risk and compare observed neurological outcomes in this study. RESULTS: A total of 26 347 patients were included in the study. Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (OR = 2.37), peripheral arteriopathy (OR = 1.62), cardiac failure (OR = 2.98), prior stroke (OR = 1.57) and chronic renal failure (OR = 6.16) were found to be independent risk factors for perioperative stroke in uni- and multivariate models; Hosmer-Lemeshow test: χ(2) = 4.62, P = 0.59. Perioperative stroke incidence increased whenever NNECDSG score or the number of preoperative risk factors increased. However, on- vs off-pump surgery did not show statistical differences in NNECDSG strata. For patients with two or more preoperative independent risk factors, off-pump surgery showed a significant reduction in perioperative stroke incidence (4.29 vs 6.76%, P < 0.05), particularly when one of these factors was chronic renal failure or preoperative cardiac failure. However, when both factors were present concomitantly there was no difference between on and off-pump techniques, P < 0.0001. CONCLUSIONS: Off-pump surgery has a lower perioperative stroke incidence than on-pump only in cases associated with cardiovascular stroke-risk factors, in particular, with chronic renal failure and preoperative cardiac failure, but also with peripheral arteriopathy, prior stroke and non-elective surgery. The perioperative stroke rate remains high in cases with two or more preoperative stroke risk factors, even when using the off-pump technique, particularly when chronic renal failure is present.

Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits.

INTRODUCTION AND OBJECTIVES: The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. METHODS: Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). RESULTS: No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. CONCLUSIONS: In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.

Resultados a corto y mediano plazo del tratamiento de la obstrucción al tracto de salida del ventrículo izquierdo mediante miectomía videoasistida / Video assisted myectomy for relief of left ventricular tract obstruction in patients with Obstructive Hypertrophic Cardiomyopathy

Objetivo: Describir nuestra experiencia y evaluar los resultados a corto y mediano plazo de la miecto-mía videoasistida en el tratamiento de la obstrucción del tracto de salida del ventrículo izquierdo (OTSVI) en pacientes con miocardiopatía hipertrófica. Materiales y métodos: 52 pacientes con edad media de 56,2 (rango 12 - 83) y Euroscore de riesgo de 4,1 +/- 1,92 con diagnóstico de OTSVI fueron intervenidos de manera consecutiva en un mismo centro mediante miectomía videoasistida. Se realizó seguimiento clínico y ecocardiográfico con controles al mes y al año del postoperatorio. Resultados: Entre las patologías asociadas encontramos 11 pacientes con valvulopatía aórtica, 2 con valvulopatía mitral, 3 con cardiopatía isquémica, 1 con aneurisma de aorta ascendente y 1 con foramen oval permeable resueltos en el mismo acto quirúrgico. La mortalidad hospitalaria global fue de 5,8 por ciento (3 pacientes). En el momento de la intervención, 8 (15,4 por ciento) se encontraban en clase funcional II de la NYHA, 42 (80,8 por ciento) en clase III y 2 (3,8 por ciento) en clase IV. El gradiente máximo subaórtico disminuyó de 80,7 mmHg +/- 29,43 en el preoperatorio a 19,0 mmHg +/- 15,57 (p<0,001) en el postoperatorio inmediato, manteniéndose en 14,6 mmHg +/- 8,88 al mes (p<0,001 en relación al preoperatorio) y al año en 13,9 mmHg +/- 7,69 (p<0,001 en relación al preoperatorio). Además, se registró una disminución del grosor del tabique interventricular en diástole de 19,4 mm +/- 3,78 en el preoperatorio a 12,9 mm +/- 2,35 (p<0,001) en el postoperatorio. Todos los pacientes se encontraban en clase funcional I-II al final del seguimiento. Conclusión: Los resultados demuestran que la miectomía videoasistida es un tratamiento seguro para la OTSVI con el que se obtienen resultados favorables a corto y mediano plazo, tanto en parámetros clínicos, como ecocardiográficos.

Aim: To report a clinical experience and to evaluate early and mid term results of video assisted myec-tomy for relief of left ventricular tract obstruction (LVOTO) in patients with Obstructive Hypertrophic Cardiomyopathy. Methods: 52 patients with Obstructive Car-diomyopathy and a mean age 56.2 years (12 - 83) carrying a Euro score risk of 4.1 +/- (SD 1.92), were consecutively operated on in a single center. Relief of LVOTO was performed with video assisted myec-tomy. Clinical and echocardiographic follow up to 1 year postoperatively was carried out. Results: Apart from the Obstructive Cardiomyo-pathy, 11 patients had aortic valve disease, 2 mitral valve disease, 3 ischemic heart disease, 1 an ascending aortic aneurysm and 1 a patent foramen ovale. All these lesions were surgically repaired in the same surgical act. In hospital mortality was 5.8 percent (3 patients). Pre-operatively 15.4 percent of patients were in NYHA Class II, 80.8 per cent in Class III and 3.8 percent in Class IV. After surgery peak sub aortic gradient decreased from 80.7+/-29.43mmHg to 19.0 +/- 15.57 (p<0.001). Corresponding values were 14.6 +/- 8.88 at 1month and 13.9 +/- 7.69 at 1 year post operatively. Interven-tricular septal thickness in diastole decreased from 19.4 +/- 3.78 mm to 12.9 +/- 2.35 mm after surgery (p<0.001). All patients were Class I or II at the end of follow up. Conclusion: Video assisted myectomy is safe and effective for relief of LVOTO in patients with hypertrophic cardiomyopathy. Good results are maintained one year after surgery.

Stroke after coronary artery bypass grafting: preoperative predictive accuracies of CHADS2 and CHA2DS2VASc stroke risk stratification schemes.

OBJECTIVE: Neurologic events after coronary artery bypass grafting are an infrequent but devastating complication. This study analyzed the preoperative predictive abilities of the CHADS(2) and CHA(2)DS(2)VASc stroke scores in patients undergoing isolated coronary artery bypass grafting. METHODS: Included in the study were 2910 patients who underwent isolated coronary artery bypass grafting during a 19-year period. CHADS(2) and CHA(2)DS(2)VASc scores were computed for all patients, and outcomes were evaluated in terms of perioperative stroke and compared with 2 specific models for predicting surgical coronary artery bypass grafting stroke (Northern New England Cardiovascular Disease Study Group and Multicenter Study of Perioperative Ischemia Research Group). Perioperative stroke discrimination was quantified by computing the area under the receiver operating characteristic curve. RESULTS: Overall, 62 (2.1%) had perioperative strokes. Areas under the curve were 0.71 (95% confidence interval, 0.64-0.78) for CHADS(2), 0.72 (95% confidence interval, 0.65-0.79) for CHA(2)DS(2)VASc, 0.69 (95% confidence interval, 0.61-0.76) for Northern New England Cardiovascular Disease Study Group, and 0.73 (95% confidence interval, 0.67-0.80) for Multicenter Study of Perioperative Ischemia Research Group scores. Northern New England Cardiovascular Disease Study Group and CHA(2)DS(2)VASc scores were better at discriminating patients with particularly low or high risk of stroke. CONCLUSIONS: CHADS(2) and CHA(2)DS(2)VASc scores predicted perioperative coronary artery bypass grafting strokes with discriminatory abilities similar to those of specific predictive surgical coronary artery bypass grafting stroke models. All schemes tested showed similar limitations in discriminating patients with high postoperative stroke risk, with a high proportion being classified as having intermediate stroke risk.