RESUMEN
OBJECTIVES: Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness. METHODS: In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS: More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20-3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76-5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64-1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321-£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS: Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term. Study registration: ISRCTN82731440 (project number 07/01/34).
Asunto(s)
Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca/fisiología , Calidad de Vida , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/economía , Fibrilación Atrial/fisiopatología , Procedimientos Quirúrgicos Cardíacos/economía , Análisis Costo-Beneficio , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Resultado del TratamientoRESUMEN
BACKGROUND: We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality. METHODS AND RESULTS: Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007-2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 µmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome. CONCLUSIONS: We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors.
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Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/epidemiología , Comorbilidad , Diabetes Mellitus/epidemiología , Grupos Diagnósticos Relacionados , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Enfermedades Renales/epidemiología , Curva de Aprendizaje , Enfermedades Pulmonares/epidemiología , Masculino , Complicaciones Posoperatorias/epidemiología , Pronóstico , Modelos de Riesgos Proporcionales , Recurrencia , Sistema de Registros/estadística & datos numéricos , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Reemplazo de la Válvula Aórtica Transcatéter/tendencias , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
OBJECTIVE: The aim of the current study was to identify predictors of paraprosthetic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and examine its influence on short/medium-term mortality using the UK TAVI Registry. TAVI is an effective treatment for high-risk patients with severe symptomatic aortic stenosis (AS), but paraprosthetic AR has been associated with increased in-hospital and mid-term mortality. METHODS: Between January 2007 and December 2011, 2584 TAVI procedures were performed in the UK. Patients undergoing 'valve-in-valve' procedures, patients with aortic regurgitation as the primary pathology and with no recorded severity of AR were excluded from this analysis (n=144). In total, therefore, 2440 patients were included. Balloon-expandable and self-expanding devices were implanted in 52.7 and 47.2%, respectively, using either transfemoral (67.7%) or non-transfemoral, surgical access (32.3%). RESULTS: Postprocedural AR was observed in 68%, mild AR in 57% and moderate-severe in 10%. A large aortic annulus, high preprocedural transaortic gradient, and use of self-expanding valve were independent predictors of moderate-severe AR. Moderate-severe (but not mild) AR was associated with increased mortality, and this relationship appeared significant for the balloon-expandable but not the self-expanding device. CONCLUSIONS: Our data suggest that a large aortic annulus, high preprocedural transaortic gradient, and use of the self-expanding valve predict moderate-severe AR after TAVI. Such a degree of AR is associated with a significantly worse outcome with the balloon-expandable, but not with the self-expanding valve. Further studies are needed to verify this and explore potential mechanisms.
Asunto(s)
Insuficiencia de la Válvula Aórtica/etiología , Válvula Aórtica/patología , Prótesis Valvulares Cardíacas/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano de 80 o más Años , Análisis de Varianza , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/patología , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/cirugía , Valvuloplastia con Balón/efectos adversos , Valvuloplastia con Balón/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/patología , Estudios Prospectivos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidadRESUMEN
AIMS: Transcatheter aortic valve replacement (TAVR) is established as a treatment strategy for patients with end-stage aortic stenosis, many of whom are suffering from severe pulmonary hypertension (PH). In cardiac surgery patients, PH is associated with less symptomatic improvement and increased late mortality. This study elucidates the impact of PH on outcome after TAVR. METHODS AND RESULTS: Pre and 90 days post-TAVR, pulmonary artery systolic pressure (PASP) was determined non-invasively by echocardiography in 353 patients undergoing TAVR. PH was classified as absent (<30 mmHg), mild-to-moderate (30-60 mmHg), and severe (>60 mmHg). Three hundred and fifty-three patients at high surgical risk, indicated by a logistic EuroSCORE of 26.6±16.5%, underwent TAVR. The severity of PH before TAVR was related to outcome with two-year mortality rates of 13.9%, 27.3%, and 48.4% for PASP <30 mmHg, 30-60 mmHg, and >60 mmHg, respectively (p=0.001). In patients with baseline PASP >60 mmHg, PASP decreased from 65.6±7.6 mmHg to 49.5±14.0 mmHg (p<0.001) at 90 days after TAVR. Patients with persistent severe PH had a worse prognosis than patients with a decrease of PASP below 60 mmHg (two-year mortality rate: 50.0% vs. 18.6%; p=0.001). CONCLUSIONS: Severe pulmonary hypertension predicts adverse outcome after TAVR. Reduction of PASP after the procedure is associated with favourable prognosis.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Hipertensión Pulmonar/cirugía , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Hipertensión Pulmonar/mortalidad , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to evaluate the performance of the aortic regurgitation (AR) index as a new hemodynamic parameter in an independent transcatheter aortic valve implantation (TAVI) cohort and validate its application. BACKGROUND: Increasing evidence associates more-than-mild periprosthetic aortic regurgitation (periAR) with increased mortality and morbidity; therefore precise evaluation of periAR after TAVI is essential. The AR index has been proposed recently as a simple and reproducible indicator for the severity of periAR and predictor of associated mortality. METHODS: The severity of periAR was evaluated by echocardiography, angiography, and periprocedural measurement of the dimensionless AR index = ([diastolic blood pressure - left ventricular end-diastolic pressure]/systolic blood pressure) × 100. A cutoff value of 25 was used to identify patients at risk. RESULTS: One hundred twenty-two patients underwent TAVI by use of either the Medtronic CoreValve (Medtronic, Minneapolis, Minnesota) (79.5%) or the Edwards-SAPIEN bioprosthesis (Edwards Lifesciences, Irvine, California) (20.5%). The AR index decreased stepwise from 29.4 ± 6.3 in patients without periAR (n = 26) to 28.0 ± 8.5 with mild periAR (n = 76), 19.6 ± 7.6 with moderate periAR (n = 18), and 7.6 ± 2.6 with severe periAR (n = 2) (p < 0.001). Patients with AR index <25 had a significantly increased 1-year mortality rate compared with patients with AR index ≥ 25 (42.3% vs. 14.3%; p < 0.001). Even in patients with none/mild periAR, the 1-year mortality risk could be further stratified by an AR index <25 (31.3% vs. 14.3%; p = 0.04). CONCLUSIONS: The validity of the AR index could be confirmed in this independent TAVI cohort and provided prognostic information that was complementary to the severity of AR.
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Insuficiencia de la Válvula Aórtica/etiología , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoAsunto(s)
Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/anomalías , Anciano , Ecocardiografía Transesofágica , Femenino , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/métodos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Prótesis e ImplantesRESUMEN
We sought to determine the significance of incomplete stent frame expansion after transcatheter aortic valve implantation with the Medtronic-CoreValve device. Incomplete coronary stent expansion is a well-described phenomenon. Transcatheter valves are mounted on stents; however, the incidence of incomplete stent expansion after transcatheter aortic valve implantation, its sequelae and predictors are poorly elucidated. The 18Fr CoreValve revalving system was used to treat anatomically and clinically suitable patients with severe calcific aortic stenosis. The postdeployment stent dimensions were measured on fluoroscopic images at multiple levels of the stent frame. Incomplete expansion at each was defined as <100% expected and complete expansion as ≥100%. These parameters were correlated to the hemodynamic and clinical end points. A total of 50 consecutive patients underwent transcatheter aortic valve implantation with the Medtronic-CoreValve at a single center from January 2007 to December 2008. For the inflow portion, incomplete expansion was seen in 54% of patients and was unrelated to the aortic valve area, peak or mean aortic valve gradients, or measures of aortic regurgitation, although it was paradoxically associated with a lower incidence of prosthesis-patient mismatch. Incomplete expansion of the constrained portion was seen in 62% of the patients and displayed a trend toward a greater incidence of aortic regurgitation grade 2 or greater, although this was rare. Incomplete expansion of the Medtronic CoreValve stent frame is common. For the most part, valvular hemodynamic function was satisfactory, regardless of the degree of expansion of the stent frame that carries it and a strategy of reluctant postdilation in the context of incomplete stent frame expansion was supported.
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Estenosis de la Válvula Aórtica/fisiopatología , Válvula Aórtica/cirugía , Cateterismo Periférico , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Hemodinámica , Humanos , Masculino , Falla de PrótesisRESUMEN
OBJECTIVES: This study sought to assess the proportion of patients anatomically suitable for transcatheter aortic valve implantation by multiple access approaches. BACKGROUND: The devices currently in mainstream use for transcatheter treatment of severe aortic stenosis are those of Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (M-C) (Luxembourg City, Luxembourg). The range of patients that these can presently treat requires elucidation to guide the necessary evolution of these technologies and increase their scope of therapy. METHODS: A consecutive series of patients were assessed with transthoracic or transesophageal echocardiography and invasive angiography to assess anatomical suitability by different approaches. The transfemoral access requirements for Edwards and M-C (Edwards currently 22- and 24-F, soon to be 18- and 19-F; M-C 18-F) as well as the aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively) were incorporated in this assessment. Patients unsuitable for the transfemoral approach were considered for Edwards transapical and M-C transaxillary and direct ascending aortic access. Patients suitable for these devices and access approaches were identified. RESULTS: Data were analyzed for 100 consecutive patients. Edwards suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using additional transaxillary and direct aortic approaches. Of the 12 patients unsuitable for Edwards-based procedures, 8 were suitable for M-C. Of the 11 patients unsuitable for M-C-based techniques, 8 were suitable for Edwards. Only 3% were anatomically unsuitable for all approaches. CONCLUSIONS: In this series, 97% of patients were anatomically suitable for a complementary approach to treatment.
Asunto(s)
Aorta , Estenosis de la Válvula Aórtica/terapia , Válvula Aórtica , Cateterismo Cardíaco , Arteria Femoral , Implantación de Prótesis de Válvulas Cardíacas/métodos , Selección de Paciente , Anciano , Anciano de 80 o más Años , Angiografía , Aorta/patología , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico , Cateterismo Cardíaco/instrumentación , Ecocardiografía Transesofágica , Inglaterra , Arteria Femoral/diagnóstico por imagen , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Humanos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Quebec , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
AIMS: Prosthesis-patient mismatch (P-PM) is an important determinant of morbidity and mortality following open aortic valve replacement. The aims of this study were to report its incidence and determinants following transcatheter aortic valve implantation (TAVI) with the Corevalve bioprosthesis, which have-thus far-not been described. METHODS AND RESULTS: Patients with severe calcific aortic stenosis received TAVI with the Corevalve bioprosthesis via transfemoral route. Following TAVI, moderate P-PM was defined as indexed aortic valve effective orifice area (AVAi) < or =0.85 cm(2)/m(2) and severe P-PM as AVAi < or =0.65 cm(2)/m(2). Clinical, echocardiographic, and procedural factors relating to P-PM were studied. Optimal device position was defined on fluoroscopy as final position of the proximal aspect of the Corevalve stent frame 5-10 mm below the native aortic annulus. Between January 2007 and January 2009, 50 consecutive patients underwent TAVI in a single centre with the Corevalve bioprosthesis. Mean age was 82.8 years (SD 5.9; 70-93) and 48% were male. P-PM occurred in 16 of 50 cases (32%). Optimal position was achieved in 50% of cases. P-PM was unrelated to age, annulus size, LVOT size, Corevalve size, aortic angulation, ejection fraction, and sex. It was inversely correlated to optimal position (Spearman rho r = -0.34, P = 0.015). Those with optimal positioning had a 16% incidence of P-PM relative to 48% of those with suboptimal positioning (Pearson chi(2) P = 0.015). CONCLUSION: The incidence of P-PM following TAVI with the Corevalve bioprosthesis is compared favourably with that seen after AVR with conventional open stented bioprostheses and its occurrence is influenced by device positioning.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Calcinosis/cirugía , Implantación de Prótesis de Válvulas Cardíacas/normas , Prótesis Valvulares Cardíacas , Anciano , Anciano de 80 o más Años , Válvula Aórtica , Estenosis de la Válvula Aórtica/fisiopatología , Competencia Clínica/normas , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Hemodinámica/fisiología , Humanos , Masculino , Diseño de Prótesis , Falla de Prótesis , Ajuste de Prótesis/métodosRESUMEN
Previous studies have suggested that South Asian (SA) ethnicity is a predictor of poorer outcome after coronary artery bypass grafting (CABG). Our aim was to identify potential reasons for the higher postoperative mortality in SA patients and investigate all these reasons. All individuals undergoing isolated CABG in a tertiary cardiac centre from April 2002 to September 2007. In total, there were 2897 subjects (2623 white subjects; 274 SA subjects) who were included in an observational study showing the effect of ethnicity on the medium-term survival following CABG. Survival at 30 days and survival up to five years (median 2.7 years) were measured. SA subjects undergoing CABG were younger (62+/-9 vs. 66+/-9 years, P<0.001), less obese [body mass index (BMI) 26+/-4 vs. 28+/-4 kg/m(2), P<0.001] and had a higher prevalence of diabetes mellitus (58% vs. 33%, P<0.001) compared with white subjects. Thirty-day mortality was higher in SA subjects (2.6% vs. 1.0%, P=0.02). Non-diabetic SA had similar 30-day mortality, five-year survival and life expectancy compared to non-diabetic white subjects. In contrast, diabetic SA had a higher 30-day mortality (3.8% vs. 1.4%, P=0.01) and worse life expectancy compared to diabetic white subjects. The higher early postoperative mortality observed in SA patients is related to higher incidence of diabetes among them. SA diabetics have a significantly higher postoperative mortality and worse overall life expectancy. Ethnicity per se is not an independent predictor of short- or medium-term survival after CABG.
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Pueblo Asiatico/estadística & datos numéricos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Diabetes Mellitus/mortalidad , Esperanza de Vida/etnología , Sobrevivientes/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Anciano , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/etnología , Diabetes Mellitus/etnología , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Prevalencia , Modelos de Riesgos Proporcionales , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
BACKGROUND/AIMS: Severe aortic stenosis (AS) is associated with hypertrophy of the left ventricle (LVH), which is linked to adverse clinical outcomes. To date, the effects of the novel technology of percutaneous aortic valve replacement (PAVR) on LVH in severe AS have not been described. We sought to test the hypothesis that PAVR would result in regression of LVH associated with severe AS. METHODS: Patients were recruited as part of a single-arm, prospective, safety, feasibility and clinical outcome study of the third-generation CoreValve percutaneous aortic bioprosthesis. To assess hypertrophy at baseline and at 1 month, the parasternal long-axis view in end-diastole was used to assess interventricular septal dimension and left ventricular posterior wall dimension. RESULTS: 15 patients were studied. There were significant periprocedural reductions in peak (76.6 +/- 28.1 mmHg to 16.3 +/- 7.5 mmHg; p < 0.001) and mean (45.3 +/- 18.4 mmHg to 8.2 +/- 3.7 mmHg; p = 0.001) transvalvular gradients and increases in calculated aortic valve areas (0.73 +/- 0.19 cm2 to 1.5 +/- 0.3 cm2). Septal wall thickness regressed by 13% from 1.54 +/- 0.30 cm at baseline to 1.35 +/- 0.27 cm at 1 month (for difference; p = 0.002). CONCLUSION: We demonstrate an early regression of septal hypertrophy after PAVR for severe AS which is comparable to that seen at 1 year after conventional surgical aortic valve replacement.
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Angioplastia Coronaria con Balón , Válvula Aórtica/cirugía , Cardiomiopatía Hipertrófica/prevención & control , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Ventrículos Cardíacos/patología , Hipertrofia Ventricular Izquierda/prevención & control , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/patología , Proteína C-Reactiva , Cardiomiopatía Hipertrófica/fisiopatología , Cardiomiopatía Hipertrófica/cirugía , Progresión de la Enfermedad , Estudios de Factibilidad , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/fisiopatología , Hipertrofia Ventricular Izquierda/cirugía , Masculino , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , UltrasonografíaRESUMEN
INTRODUCTION: Changes in atrioventricular (AV) conduction and need for permanent pacemaker (PPM) are a recognized complication after open aortic valve replacement. We hypothesized that the need for PPM after CoreValve (Corevalve Inc, Irvine, CA) can be predicted with a combination of baseline variables. METHODS: In patients undergoing transcatheter aortic valve implantation, potential clinical, electrocardiographic and echocardiographic predictors of permanent pacing requirement were studied. RESULTS: Between January 2007 and March 2008, 34 patients with severe symptomatic aortic stenosis were recruited in a single center. Mean age was 84.4 years (SD 5.4, range 71-93). Of 34 cases paced at baseline, 3 (8.8%) were excluded from this analysis, as was the single periprocedural mortality. Of the remaining 30, 10 underwent permanent pacemaker implantation during the same admission (33.3%). PPM was for prolonged high-grade AV block in 4 cases, episodic high-grade AV block in 5, and sinus node disease in 1. Need for pacemaker was correlated to left axis deviation at baseline (P = .004, r = 0.508) and left bundle-branch block with left axis deviation (P = .002, r = 0.548). It was related to diastolic interventricular septal dimension on transthoracic echocardiography >17 mm (P = .045, r = 0.39) and the baseline thickness of the native noncoronary cusp (P = .002, r = 0.655). A susceptibility model was generated, and if at least one of (1) left bundle-branch block with left axis deviation, (2) interventricular septal dimension >17 mm, or (3) noncoronary cusp thickness >8 mm was present, the likelihood of PPM could be predicted with 75% sensitivity and 100% specificity and a receiver operating characteristic curve area of 0.93 +/- 0.055 (P < .001). CONCLUSIONS: After transcatheter aortic valve implantation with CoreValve, permanent pacing was performed in around a third of patients and we present preliminary concepts towards a predictive model for this phenomenon.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Bloqueo de Rama/epidemiología , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas , Marcapaso Artificial , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Bloqueo de Rama/etiología , Bloqueo de Rama/terapia , Estimulación Cardíaca Artificial/métodos , Ecocardiografía , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias , Pronóstico , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Reino Unido/epidemiologíaRESUMEN
Percutaneous aortic valve replacement (PAVR) offers considerable promise in treating high risk patients with aortic valve disease. Two devices are currently clinically available for transfemoral delivery: the Edwards-Sapien balloon-expandable bioprosthesis and the Corevalve self-expanding bioprosthesis, both of which require careful sizing of the peripheral vasculature. Through a case based discussion, we illustrate that these limits of PAVR technology can be stretched in cases of extraordinary clinical need. We demonstrate that, following a learning curve of "optimal cases," successful PAVR is also possible in diffusely diseased peripheries of borderline small size or with focal aortoiliofemoral disease amenable to a separate intervention beforehand.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Cateterismo Cardíaco , Cateterismo Periférico , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Enfermedades Vasculares Periféricas/complicaciones , Anciano , Anciano de 80 o más Años , Aorta/patología , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/patología , Cateterismo Cardíaco/efectos adversos , Cateterismo Periférico/efectos adversos , Competencia Clínica , Constricción Patológica , Ecocardiografía Doppler en Color , Femenino , Arteria Femoral/patología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Arteria Ilíaca/patología , Masculino , Selección de Paciente , Enfermedades Vasculares Periféricas/patología , Enfermedades Vasculares Periféricas/cirugía , Diseño de Prótesis , Radiografía Intervencional , Medición de Riesgo , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
Following intraoperative superior vena cava injury, venous drainage of the head, neck and upper extremities can be re-established with bovine jugular vein (Contegra) conduits. Inadequate anticoagulation, however, may lead to conduit thrombosis and superior vena cava obstruction syndrome. This can be successfully treated with percutaneous dilatation and stenting of the failed conduit.
Asunto(s)
Bioprótesis , Implantación de Prótesis Vascular , Prótesis Vascular , Venas Braquiocefálicas/cirugía , Stents , Síndrome de la Vena Cava Superior/cirugía , Trombosis/complicaciones , Anciano , Anticoagulantes/uso terapéutico , Venas Braquiocefálicas/lesiones , Femenino , Atrios Cardíacos/cirugía , Humanos , Complicaciones Intraoperatorias , Síndrome de la Vena Cava Superior/etiología , Trombosis/tratamiento farmacológicoRESUMEN
OBJECTIVE: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. METHODS: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. RESULTS: The patients in the AF group were older than their counterparts in the SR group (66+/-7 vs 62+/-9 years) (p=0.01), had a higher mean NYHA class score (2.4+/-0.6 vs 2.2+/-0.7) (p=0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p<0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p=0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p=0.04), and operative morbidity was 27% versus 17%, respectively (p=0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p=0.8) and MV re-operation (2.6% vs 2.5%) (p=1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75+/-6% versus 90+/-3% (p=0.005). On Cox proportional hazards regression model, impaired LV function [(p=0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p=0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. CONCLUSIONS: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival.
Asunto(s)
Fibrilación Atrial/fisiopatología , Insuficiencia de la Válvula Mitral/mortalidad , Válvula Mitral/cirugía , Cuidados Preoperatorios/métodos , Anciano , Fibrilación Atrial/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias , Resultado del TratamientoRESUMEN
CONTEXT: Although left atrial radiofrequency ablation (RFA) is increasingly used for the treatment of chronic atrial fibrillation during mitral valve surgery, its efficacy to restore sinus rhythm and any resulting benefits have not been examined in the context of an adequately powered randomized trial. OBJECTIVE: To determine whether intraoperative RFA of the left atrium increases the long-term restoration of sinus rhythm and improves exercise capacity. DESIGN, SETTING, AND PATIENTS: Randomized, double-blind trial performed in a single UK tertiary referral center with enrollment between December 2001 and November 2003. A total of 101 patients referred for mitral valve surgery with at least 6 months' history of uninterrupted atrial fibrillation were assessed for eligibility; 97 were enrolled. Patients were followed up for 12 months. INTERVENTION: Patients were randomly assigned to undergo mitral valve surgery and RFA of the left atrium (n = 49) or mitral valve surgery alone (controls; n = 48). MAIN OUTCOME MEASURES: The primary outcome measure was presence of sinus rhythm at 12 months; secondary measures were patient functional status and exercise capacity (assessed by shuttle-walk test), left atrial contractility, and left atrial and left ventricular dimension and function and plasma levels of B-type natriuretic peptide. RESULTS: At 12 months, sinus rhythm was present in 20 (44.4%) of 45 RFA patients and in 2 (4.5%) of 44 controls (rate ratio, 9.8; 95% CI, 2.4-86.3; P<.001). Restoration of sinus rhythm in the RFA group was accompanied by a greater improvement in mean (SD) shuttle-walk distance compared with controls (+94 [102] m vs +48 [82] m; P = .003) and a greater reduction in the plasma level of B-type natriuretic peptide (-104 [87] fmol/mL vs -51 [82] fmol/mL; P = .03). Patients randomized to receive RFA had similar rates of postoperative complications and deaths as control patients. CONCLUSIONS: Radiofrequency ablation of the left atrium during mitral valve surgery for continuous atrial fibrillation significantly increases the rate of sinus rhythm restoration 1 year postoperatively, improving patient exercise capacity. On the basis of its efficacy and safety, routine use of RFA of the left atrium during mitral valve surgery may be justified. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00238706.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter , Válvula Mitral/cirugía , Anciano , Fibrilación Atrial/sangre , Fibrilación Atrial/fisiopatología , Procedimientos Quirúrgicos Cardíacos , Método Doble Ciego , Femenino , Atrios Cardíacos , Pruebas de Función Cardíaca , Frecuencia Cardíaca , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/sangre , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to define the early and midterm results obtained after the use of edge-to-edge repair with mitral annuloplasty in the setting of Barlow's disease. METHODS: Between 1998 and 2004, 41 patients having Barlow's disease had an edge-to-edge repair creating a double-lumen mitral valve orifice in our unit. In 38 patients (93%), an annuloplasty band was also inserted. RESULTS: Preoperatively, all patients had severe mitral regurgitation (MR), 12 were in New York Heart Association (NYHA) class I, 15 in class II, and 14 in class III. One patient died in hospital (2.4%) and 5 experienced complications (12.5%). There were no late deaths. At follow-up, 2 patients had severe MR and underwent valve replacement, 1 exhibited moderate MR, and 5 had mild MR. Kaplan-Meier 5-year survival, freedom from reoperation and recurrent moderate-severe MR was 97.6% +/- 2.4%, 94% +/- 4.4%, and 90.6% +/- 5.1%, respectively. At latest echocardiographic evaluation (mean 35 +/- 12 months) the mean left ventricular end-systolic and end-diastolic diameters, and the mitral valve area decreased (p = 0.0001) compared with baseline. The mean mitral valve gradient increased (p = 0.001) without clinical evidence of mitral stenosis whereas ejection fraction did not change. Currently, 35 patients are in NYHA class I and 5 are in class II. CONCLUSIONS: In the setting of Barlow's disease, use of edge-to-edge repair with mitral annuloplasty is safe and provides lasting restoration of mitral valve competence with measurable hemodynamic and clinical benefits. In our unit, it is the procedure of choice for correction of MR in patients having Barlow's disease.
Asunto(s)
Insuficiencia de la Válvula Mitral/cirugía , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Evaluación de Procesos y Resultados en Atención de Salud , Reoperación/estadística & datos numéricos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: The studies showing the superior characteristics of ITA graft and its impact on the clinical results of coronary artery surgery were performed with ITA harvested almost exclusively as a pedicle. This study assesses the impact of ITA skeletonization on its innervation and reactivity. METHODS: Segments of skeletonized and non-skeletonized ITA were stained with antibodies against protein S-100 to look for the presence of sympathetic nerve fibers. The functional studies were performed on segments of discarded human pedicled ITA that were divided into two 3mm rings, one skeletonized and another non-skeletonized. We compared concentration-effect relationships for the contraction to norepinephrine and endothelium-dependent relaxation to acetylcholine and bradykinin, as well as endothelium-independent relaxation to sodium nitroprusside in skeletonized and non-skeletonized segments of the same ITA. RESULTS: Skeletonized ITA was devoid of protein S-100 positive nerve fibers. It contracted stronger (maximal response 37.0+/-2.04 vs. 25.4+/-1.83mN (P<0.001)) and was twice as sensitive to norepinephrine: pD(2) 6.03+/-0.10 vs. 5.70+/-0.12 (P=0.035). The endothelium-dependent relaxation responses did not differ between skeletonized and non-skeletonized ITA rings. The skeletonized ITA rings appeared over 10 times more sensitive to sodium nitroprusside: pD(2) 6.66+/-0.20 vs. 5.59+/-0.37 (P=0.012)-potency ratio 11.61. The maximal responses did not differ significantly: 112.0+/-6.71 vs. 129.4+/-16.4% (P=0.33). CONCLUSIONS: Skeletonization results in sympathectomy of ITA. It has no effect on endothelium-dependent relaxation but increases reactivity of ITA to norepinephrine. This augmented response to alpha-agonist is small, in comparison with over a ten-fold increase in sensitivity to sodium nitroprusside. Pedicled and skeletonized ITA are functionally significantly different vessels when studied in vitro.
Asunto(s)
Enfermedad de la Arteria Coronaria/cirugía , Arterias Mamarias/patología , Recolección de Tejidos y Órganos/efectos adversos , Acetilcolina/farmacología , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/fisiopatología , Relación Dosis-Respuesta a Droga , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/fisiopatología , Humanos , Inmunohistoquímica/métodos , Arterias Mamarias/efectos de los fármacos , Arterias Mamarias/fisiopatología , Arterias Mamarias/trasplante , Fibras Nerviosas , Nitroprusiato/farmacología , Norepinefrina/farmacología , Recolección de Tejidos y Órganos/métodos , Vasoconstrictores/farmacología , Vasodilatadores/farmacologíaRESUMEN
BACKGROUND: Preservation of the native mitral valve provides important advantages over valve replacement. The aim of this study was to evaluate the effect of training for mitral valve repair on the outcome. METHODS: Between 1997 and 2004, 471 patients underwent mitral valve repair procedures in a single firm. Of these procedures, 300 (64%) were performed by a consultant (TJS) (consultant group) and 171 (36%) by trainees supervised by the same consultant (trainees group). RESULTS: Atrial fibrillation was more prevalent in the consultant group (p = 0.02) but there were no significant differences in the demographics, etiology of mitral regurgitation, and other comorbidity between the groups. Posterior leaflet prolapse was more prevalent in the trainees group (p < 0.0001) and anterior leaflet prolapse (p < 0.0001), bileaflet prolapse (p = 0.003), and Barlow's syndrome (p = 0.0003) in the consultant group. The consultant performed a higher proportion of concomitant coronary artery bypass grafting (p = 0.04), aortic valve replacement (p = 0.02), procedures, and nonelective cases (p = 0.03) with shorter bypass (p = 0.01) and ischemic times (p = 0.0004) than trainees. The complication rate was similar in the two groups (26% vs 22%), but the consultant had a higher operative mortality than the trainees (5% vs 0.6%) (p = 0.01). A similar proportion in the two groups exhibited recurrent mitral regurgitation (8% vs 9%). Kaplan-Meier five-year freedom from reoperation (95.6 +/- 1.6 vs 95.7 +/- 2.2%) (p = 0.7) and survival (82 +/- 4% vs 88 +/- 4%) (p = 0.09) were similar in the two groups. CONCLUSIONS: With appropriate patient selection, cardiothoracic trainees can be taught mitral valve repair surgery without a negative effect on the early or late outcome.