Stretch-induced compliance mechanism in pregnancy-induced cardiac hypertrophy and the impact of cardiovascular risk factors.

Pressure overload-induced hypertrophy compromises cardiac stretch-induced compliance (SIC) after acute volume overload (AVO). We hypothesized that SIC could be enhanced by physiological hypertrophy induced by pregnancy's chronic volume overload. This study evaluated SIC-cardiac adaptation in pregnant women with or without cardiovascular risk (CVR) factors. Thirty-seven women (1st trimester, 1stT) and a separate group of 31 (3rd trimester, 3rdT) women [healthy or with CVR factors (obesity and/or hypertension and/or with gestational diabetes)] underwent echocardiography determination of left ventricular end-diastolic volume (LVEDV) and E/e' before (T0), immediately after (T1), and 15 min after (T2; SIC) AVO induced by passive leg elevation. Blood samples for NT-proBNP quantification were collected before and after the AVO. Acute leg elevation significantly increased inferior vena cava diameter and stroke volume from T0 to T1 in both 1stT and 3rdT, confirming AVO. LVEDV and E/e' also increased immediately after AVO (T1) in both 1stT and 3rdT. SIC adaptation (T2, 15 min after AVO) significantly decreased E/e' in both trimesters, with additional expansion of LVEDV only in the 1stT. NT-pro-BNP increased slightly after AVO but only in the 1stT. CVR factors, but not parity or age, significantly impacted SIC cardiac adaptation. A distinct functional response to SIC was observed between 1stT and 3rdT, which was influenced by CVR factors. The LV of 3rdT pregnant women was hypertrophied, showing a structural limitation to dilate with AVO, whereas the lower LV filling pressure values suggest increased diastolic compliance.NEW & NOTEWORTHY The sudden increase of volume overload triggers an acute myocardial stretch characterized by an immediate rise in contractility by the Frank-Starling mechanism, followed by a progressive increase known as the slow force response. The present study is the first to characterize echocardiographically the stretch-induced compliance (SIC) mechanism in the context of physiological hypertrophy induced by pregnancy. A distinct functional adaptation to SIC was observed between first and third trimesters, which was influenced by cardiovascular risk factors.

Metabolomics and Cardiovascular Risk in Patients with Heart Failure: A Systematic Review and Meta-Analysis.

The associations of plasma metabolites with adverse cardiovascular (CV) outcomes are still underexplored and may be useful in CV risk stratification. We performed a systematic review and meta-analysis to establish correlations between blood metabolites and adverse CV outcomes in patients with heart failure (HF). Four cohorts were included, involving 83 metabolites and 37 metabolite ratios, measured in 1158 HF patients. Hazard ratios (HR) of 42 metabolites and 3 metabolite ratios, present in at least two studies, were combined through meta-analysis. Higher levels of histidine (HR 0.74, 95% CI [0.64; 0.86]) and tryptophan (HR 0.82 [0.71; 0.96]) seemed protective, whereas higher levels of symmetric dimethylarginine (SDMA) (HR 1.58 [1.30; 1.93]), N-methyl-1-histidine (HR 1.56 [1.27; 1.90]), SDMA/arginine (HR 1.38 [1.14; 1.68]), putrescine (HR 1.31 [1.06; 1.61]), methionine sulfoxide (HR 1.26 [1.03; 1.52]), and 5-hydroxylysine (HR 1.25 [1.05; 1.48]) were associated with a higher risk of CV events. Our findings corroborate important associations between metabolic imbalances and a higher risk of CV events in HF patients. However, the lack of standardization and data reporting hampered the comparison of a higher number of studies. In a future clinical scenario, metabolomics will greatly benefit from harmonizing sample handling, data analysis, reporting, and sharing.

Cardiovascular risk factors during pregnancy impact the postpartum cardiac and vascular reverse remodeling.

Pregnant women with cardiovascular risk (CVR) factors are highly prone to develop cardiovascular disease later in life. Thus, recent guidelines suggest extending the follow-up period to 1 yr after delivery. We aimed to evaluate cardiovascular remodeling during pregnancy and determine which CVR factors and potential biomarkers predict postpartum cardiac and vascular reverse remodeling (RR). Our study included a prospective cohort of 76 healthy and 54 obese and/or hypertensive and/or with gestational diabetes pregnant women who underwent transthoracic echocardiography, pulse-wave velocity (PWV), and blood collection at the 1st trimester (1T) and 3rd trimester (3T) of pregnancy as well as at the 1st/6th/12th mo after delivery. Generalized linear mixed-effects models was used to evaluate the extent of RR and its potential predictors. Pregnant women develop cardiac hypertrophy, as confirmed by a significant increase in left ventricular mass (LVM). Moreover, ventricular filling pressure (E/e') and atrial volume increased significantly during gestation. Significant regression of left ventricular (LV) volume, LVM, and filling pressures was observed as soon as 1 mo postpartum. The LV global longitudinal strain worsened slightly and recovered at 6 mo postpartum. PWV decreased significantly from 1T to 3T and normalized at 1 mo postpartum. We found that arterial hypertension, smoking habits, and obesity were independent predictors of increased LVM during pregnancy and postpartum. High C-reactive protein (CRP) and low ST2/IL33-receptor levels are potential circulatory biomarkers of worse LVM regression. Arterial hypertension, age, and gestational diabetes positively correlated with PWV. Altogether, our findings pinpoint arterial hypertension as a critical risk factor for worse RR and CRP, and ST2/IL33 receptors as potential biomarkers of postpartum hypertrophy reversal.NEW & NOTEWORTHY This study describes the impact of cardiovascular risk factors (CVR) in pregnancy-induced remodeling and postpartum reverse remodeling (up to 1 yr) by applying advanced statistic methods (multivariate generalized linear mixed-effects models) to a prospective cohort of pregnant women. Aiming to extrapolate to pathological conditions, this invaluable "human model" allowed us to demonstrate that arterial hypertension is a critical CVR for worse RR and that ST2/IL33-receptors and CRP are potential biomarkers of postpartum hypertrophy reversal.

Clinical relevance of the blanking period on late recurrence after catheter ablation of atrial fibrillation.

INTRODUCTION: Recurrence of atrial fibrillation (AF) within the blanking period after catheter ablation (CA) is traditionally classified as a transient and benign event. However, recent findings suggest that early recurrence (ER) is associated with late recurrence (LR), challenging the predefined "blanking period". We aimed to determine the clinical and procedural predictors of ER and LR after CA and establish the risk of LR in patients who experience ER. METHODS AND RESULTS: Retrospective single-centre study including all patients who underwent a first procedure of AF CA between 2017 and 2019. ER was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 s within 90 days after CA and LR as any recurrence after 90 days of CA. A total of 399 patients were included, 37% women, median age of 58 years [49-66] and 77% had paroxysmal AF. Median follow-up was 33 months (from 13 to 61). ER after CA was present in 14% of the patients, and LR was reported in 32%. Among patients who experienced ER, 84% also had LR (p < .001). Patients with ER had a higher prevalence of moderate/severe valvular heart disease, persistent AF, previous electrical cardioversion, a larger left atrium, higher coronary artery calcium score, and higher rates of intraprocedural electrical cardioversion and cardiac fibrosis on eletroanatomical mapping compared with patients without ER. After covariate adjustment, ER and female sex were defined as independent predictors of LR (hazard ratio [HR] 4.69; 95% confidence interval [CI], 2.99-7.35; p < .001 and HR 2.73; 95% CI, 1.47-5.10; p = .002, respectively). CONCLUSION: The risk of LR after an index procedure of CA was significantly higher in patients with ER (five-fold increased risk). These results support the imperative need to clarify the clinical role of the blanking period.

Glucagon-like peptide 1 receptor agonists in patients with type 2 diabetes with and without chronic heart failure: A meta-analysis of randomized placebo-controlled outcome trials.

AIM: Glucagon-like peptide 1 receptor agonists (GLP1-RA) reduce atherosclerotic events in patients with type 2 diabetes (T2D) and a high cardiovascular risk. The effect of GLP1-RA to reduce heart failure (HF) has been inconsistent across T2D trials, and individual trials were underpowered to assess the effect of GLP1-RA according to HF history. In this meta-analysis we aim to assess the effect of GLP1-RA in patients with and without HF history in stable ambulatory patients with T2D. METHODS: Random-effects meta-analysis of placebo-controlled trials. The hazard ratio (HR) and 95% confidence intervals (95% CI) were extracted from the treatment effect estimates of HF subgroup analyses reported in each individual study. The primary outcome was a composite of HF hospitalization or cardiovascular death. RESULTS: In total, 54 092 patients with T2D from seven randomized controlled trials were included, of whom 8460 (16%) had HF history. Compared with placebo, GLP1-RA did not reduce the composite of HF hospitalization or cardiovascular death in patients with HF history: HR 0.96, 95% CI: 0.84-1.08, but reduced this outcome in patients without HF history: HR 0.84, 95% CI: 0.76-0.92. GLP1-RA did not reduce all-cause death in patients with HF history: HR 0.98, 95% CI: 0.86-1.11, but reduced mortality in patients without HF history: HR 0.85, 95% CI: 0.79-0.92. GLP1-RA reduced atherosclerotic events regardless of HF history: HR 0.85, 95% CI: 0.75-0.97 with HF, and HR 0.88, 95% CI: 0.83-0.93 without HF. CONCLUSIONS: Treatment with GLP1-RA did not reduce HF hospitalizations and mortality in patients with concomitant T2D and HF, but may prevent new-onset HF and mortality in patients with T2D without HF. The reduction of atherosclerotic events with GLP1-RA was not influenced by HF history status.

Clinical and Pathophysiologic Insights of Free triiodothyronine/Free thyroxine Ratio in Patients with Heart Failure with Preserved Ejection Fraction: Data from the NETDiamond Cohort.

BACKGROUND: Thyroid dysfunction is common in patients with heart failure (HF). Impaired conversion of free T4 (FT4) into free T3 (FT3) is thought to occur in these patients, decreasing the availability of FT3 and contributing to HF progression. In HF with preserved ejection fraction (HFpEF), it is not known whether changes in conversion of thyroid hormones (THs) are associated with clinical status and outcomes. OBJECTIVES: The objective of this study was to evaluate the association of FT3/FT4 ratio and TH with clinical, analytical, and echocardiographic parameters, as well as their prognostic impact in individuals with stable HFpEF. METHODS: We evaluated 74 HFpEF participants of the NETDiamond cohort without known thyroid disease. We performed regression modeling to study the associations of TH and FT3/FT4 ratio with clinical, anthropometric, analytical, and echocardiographic parameters, and survival analysis to evaluate associations with the composite of diuretic intensification, urgent HF visit, HF hospitalization, or cardiovascular death over a median follow-up of 2.8 years. RESULTS: The mean age was 73.7 years and 62% were men. The mean FT3/FT4 ratio was 2.63 (standard deviation: 0.43). Subjects with lower FT3/FT4 ratio were more likely to be obese and have atrial fibrillation. Lower FT3/FT4 ratio was associated with higher body fat (ß = -5.60 kg per FT3/FT4 unit, p = 0.034), higher pulmonary arterial systolic pressure (PASP) (ß = -10.26 mm Hg per FT3/FT4 unit, p = 0.002), and lower left ventricular ejection fraction (LVEF) (ß = 3.60% per FT3/FT4 unit, p = 0.008). Lower FT3/FT4 ratio was associated with higher risk for the composite HF outcome (HR = 2.50, 95% CI: 1.04-5.88, per 1-unit decrease in FT3/FT4, p = 0.041). CONCLUSIONS: In patients with HFpEF, lower FT3/FT4 ratio was associated with higher body fat, higher PASP, and lower LVEF. Lower FT3/FT4 predicted a higher risk of diuretic intensification, urgent HF visits, HF hospitalization, or cardiovascular death. These findings suggest that decreased FT4 to FT3 conversion might be a mechanism associated with HFpEF progression.

Early And Midterm Outcomes Following Aortic Valve Replacement With Mechanical Versus Bioprosthetic Valves In Patients Aged 50 To 70 Years.

OBJECTIVES: To compare 7-year survival and freedom from reoperation, as well as early clinical and hemodynamic outcomes, after surgical aortic valve replacement (SAVR) with mechanical or bioprosthetic valves in patients aged 50-70 years. METHODS: single-center retrospective cohort study including adults aged 50-70 years who underwent SAVR in 2012 with a mechanical or bioprosthetic valve. Median follow-up was 7 years. Univariable analyses were performed using Kaplan-Meier curves and Log-Rank tests for survival and freedom from reoperation analyses. Multivariable time-to-event analyses were conducted using Cox Regression. RESULTS: Of a total of 193 patients, 76 (39.4%) received mechanical valves and 117 (60.6%) received bioprosthetic valves. A trend for better survival was found for mechanical prostheses when adjusting for EuroSCORE II (HR: 0.35; 95%CI: 0.12-1.02, p=0.054), but using a backward stepwise Cox regression prosthesis type was not retained by the model as an independent predictor of survival. Moreover, mechanical prostheses showed trends for higher freedom from reoperation (100% vs. 95.5%, Log-Rank, p=0.076), higher median EuroSCORE II (2.52% vs. 1.95%, p=0.06) and early mortality (7.9% vs. 2.6%, p=0.086). However, after adjusting for EuroSCORE II, there was no significant difference in early mortality (OR: 2.3, 95%CI: 0.5-10.5, p=0.272). Regarding hemodynamic performance at follow-up echocardiogram, there were no differences other than left ventricular mass regression, which was not as pronounced in the mechanical group (-12% vs. -21%, p=0.002). CONCLUSION: Mechanical and bioprosthetic aortic valves prostheses showed similar mid-term survival in the 50-70 age group. Further prospective and larger studies are needed to provide evidence-based recommendations on this topic.

[Safety and feasibility of conservative aortic valve surgery: single center experience]. / Segurança e Exequibilidade da Cirurgia Conservadora da Válvula Aórtica: Experiência de um Centro Cirúrgico Nacional.

BACKGROUND: In selected cases, aortic valve repair (RVAo) is an alternative to prostesic aortic valve replacement. AIM: To compare mid-term survival, need of reoperation and echocardiographic findings associated with RVAo. METHODS: Retrospective single-center cohort study including consecutive patients younger than 70 years-old, with non-stenotic aortic valve disease, who underwent RVAo between 2012 and 2017. A comparison was made with a group of patients who underwent mechanical aortic valve replacement (SVAo) in the same period. The groups were characterized and compared using Chi-Square and t-tests for independent samples and survival and reoperation were analyzed using Kaplan-Meier curves and Cox regressions. RESULTS: We included 72 patients submitted to RVAo. Mean follow-up time was 4 years, maximum 7. Although the mean age was relatively low (47±13 years), patients undergoing RVAo presented a lower prevalence of rheumatic etiology (3%). The cardiopulmonary bypass (148±74 minutes) and cross clamping aortic times (108±52 minutes) are the usual times for this type of surgery and similar to those of the comparing group (SVAo). In the echocardiographic follow-up (median of 3 months), we verified a left ventricular mass regression of 21% and a prevalence of aortic insufficiency of 4%. At 7 years, cumulative survival and freedom from reoperation of patients undergoing RVAo were 98.8% and 97.6%, respectively. CONCLUSION: RVAo can be a safe and effective alternative, with good mid-term results if patient selection is judicious.

Introdução: Em casos selecionados, a reparação da válvula aórtica (RVAo) constitui uma alternativa à substituição por prótese. Objetivo: Avaliar a sobrevida e necessidade de reoperação a médio prazo, bem como o resultado funcional após RVAo. Métodos: Estudo de coorte retrospetivo, unicêntrico incluindo consecutivamente doentes com idade ≤70 anos, submetidos a RVAo por doença da válvula aórtica não-estenótica, entre 2012-2017. Os resultados foram comparados com os obtidos após substituição valvular aórtica por prótese mecânica (SVAo) no mesmo período. Os grupos foram caracterizados e comparados utilizando testes Qui-Quadrado e t para amostras independentes e a sobrevida e reoperações foram analisadas através de curvas de Kaplan-Meier e regressões de Cox. Resultados: Foram incluídos 72 indivíduos submetidos a RVAo. O follow-up médio foi de 4 anos, máximo de 7. Apesar da idade média relativamente baixa à data da intervenção (47±13 anos), os doentes submetidos a RVAo apresentam uma baixa prevalência de etiologia reumática (3%). Os tempos de circulação extracorporal (148±74 minutos) e de clampagem aórtica (108±52 minutos) são os habituais para este tipo de cirurgias e semelhantes aos do grupo SVAo. Durante o seguimento ecocardiográfico (mediano de 3 meses) verificou-se uma regressão de massa do ventrículo esquerdo de 21% e uma prevalência de insuficiência aórtica de 4%. Aos 7 anos, a sobrevida cumulativa e a sobrevida livre de reoperação dos doentes submetidos a RVAo foram, respetivamente, 96,4% e 94,4%. Conclusões: Com uma seleção adequada dos doentes, a RVAo pode ser uma alternativa segura e efetiva, com bons resultados a médio prazo.

Mini-sternotomy versus full sternotomy aortic valve replacement: a single-centre experience.

BACKGROUND: full sternotomy (FS) is the gold standard approach to perform surgical aortic valve replacement (AVR). However, potential advantages of a less traumatic approach fomented the development of so-called minimally invasive procedures, which include upper mini-sternotomy (MS). OBJECTIVE: to compare immediate postoperative clinical results and mid-term mortality after AVR through MS and FS. METHODS: single-centre retrospective study including all patients who underwent isolated AVR through MS between January 1, 2011 and July 31, 2017. These were then matched with patients who underwent the same procedure through FS and by the same surgeons who performed MS, using coarsened exact matching for the variables age, gender, body mass index and diabetes mellitus. Groups were later characterized and compared regarding postoperative results using Qui- -squared and Mann-Whitney tests and regarding mid-term mortality through Kaplan-Meier curves. RESULTS: we included 82 patients (n=41 in each group). Aortic cross clamp [78 vs. 63 minutes, p=0.001] and cardiopulmonary bypass times [107 vs. 90 minutes, p=0.002] were significantly longer in the MS group vs. FS group, respectively. Although without reaching statistical significant difference, a smaller percentage of patients from the MS group required red blood cells transfusions during surgery (39.0% vs. 53.7%, p=0.184). Similar results were found regarding mechanical ventilation, inotropic support, morphine infusion, intensive care unit length of stay and incidence of de novo atrial fibrillation. Cumulative survival at 6 years was 86.7% after MS and 88.5% after FS (p=0.650). CONCLUSIONS: Aortic valve replacement through MS seems to be a safe alternative to the gold standard FS.

Introdução: a esternotomia completa (EC) é a abordagem gold standard da cirurgia de substituição valvular aórtica (SVA). Contudo, as potenciais vantagens de uma abordagem menos traumática promoveram o desenvolvimento de procedimentos minimamente invasivos, incluindo a mini-esternotomia (ME). Objetivo: comparar resultados clínicos no pós-operatório imediato e mortalidade, após SVA por ME e EC. Métodos: estudo retrospetivo unicêntrico incluindo todos os doentes submetidos a SVA isolada por ME, de 1 de janeiro de 2011 a 31 de julho de 2017, emparelhados com doentes submetidos ao mesmo procedimento, pelos mesmos cirurgiões por EC. Utilizou-se o método de emparelhamento coarsened exact matching para as variáveis idade, género, índice massa-corporal e diabetes mellitus. Os grupos foram caracterizados e comparados quanto aos resultados no pós-operatório imediato através de testes Qui-quadrado e Mann-Whitney e quanto à sobrevida através de curvas de Kaplan-Meier. Resultados: foram incluídos 82 doentes (n=41 em cada grupo). Os tempos de clampagem aórtica [78 vs. 63 minutos, p=0,001] e de circulação extracorporal [107 vs. 90 minutos, p=0.002] foram significativamente superiores no grupo ME vs. EC, respetivamente. Embora a frequência de transfusões sanguíneas durante a cirurgia fosse menor no grupo ME, essa diferença não foi estatisticamente significativa (39,0% vs. 53,7%, p=0,184). Os resultados foram semelhantes relativamente ao tempo de ventilação mecânica, suporte inotrópico, infusão de morfina, tempo de permanência em unidade de cuidados intensivos e incidência de fibrilação auricular de novo. A sobrevida cumulativa aos 6 anos foi de 86,7% após ME e 88,5% após EC (p=0,650). Conclusões: a SVA por ME parece ser uma alternativa segura comparativamente ao gold standard EC.

Survival After Bilateral Internal Mammary Artery In Coronary Artery Bypass Grafting: Are Women at Risk?

INTRODUCTION: To compare survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center. METHODS: Single-center retrospective cohort including consecutive patients with at least 2 left coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS between 2004 and 2013. All-cause mortality was the primary outcome, secondary outcomes were in-hospital mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed by subgroup analysis. RESULTS: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P<0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95%CI: 1.56-6.29, P=0.001). BIMA CABG showed a higher incidence of reoperations due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that were mostly ascribable to males (weighted OR in males: 3.10; 95%CI: 1.74-5.51, P<0.001). CONCLUSION: Females may experience higher mortality after BIMA CABG which should be further explored.

Freedom Solo Versus Trifecta Bioprotheses: Clinical and Hemodynamic Evaluation after Propensity Score Matching.

INTRODUCTION: To compare stentless Freedom Solo and stented Trifecta aortic bioprostheses regarding hemodynamic profile, left ventricular mass regression, early and late postoperative outcomes and survival. METHODS: Longitudinal cohort study of consecutive patients undergoing aortic valve replacement (from 2009 to 2016) with either Freedom Solo or Trifecta at one centre. Local databases and national records were queried. Postoperative echocardiography (3-6 months) was obtained for hemodynamic profile (mean transprosthetic gradient and effective orifice area) and left ventricle mass determination. After propensity score matching (21 covariates), Kaplan-Meier analysis and cumulative incidence analysis were performed for survival and combined outcome of structural valve deterioration and endocarditis, respectively. Hemodynamics and left ventricle mass regression were assessed by a mixed- -effects model including propensity score as a covariate. RESULTS: From a total sample of 397 Freedom Solo and 525 Trifecta patients with a median follow-up time of 4.0 (2.2- 6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Well-balanced matched groups showed no difference in survival (hazard ratio=1.04, 95% confidence interval=0.69-1.56) or cumulative hazards of combined outcome (subhazard ratio=0.54, 95% confidence interval=0.21-1.39). Although Trifecta showed improved hemodynamic profile compared to Freedom Solo, no differences were found in left ventricle mass regression. CONCLUSION: Trifecta has a slightly improved hemodynamic profile compared to Freedom Solo but this does not translate into differences in the extent of mass regression, postoperative outcomes or survival, which were good and comparable for both bioprostheses. Long-term follow-up is needed for comparisons with older models of bioprostheses.

Cardiac Catheterization After CABG With BIMA Grafting: Independent Predictors and Mid-term Bypass Viability.

INTRODUCTION: Coronary artery bypass graft (CABG) patency is an important variable, but rarely studied as the main outcome. The best use of bilateral internal mammary artery (BIMA) grafting regarding configuration type or combination with saphenous vein graft (SVG) is still debated. PURPOSE: To find independent predictors for need of cardiac catheterization and for significant lesions in CABG follow-up. METHODS: Retrospective cohort including all patients who underwent isolated CABG with BIMA grafts between 2004 and 2013 in a tertiary center. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Kaplan-Meier curves, Cox regression and logistic regression were used to find predictors for the need of catheterization and for significant angiographic lesions after CABG. Secondary end-points studied were mid- term survival and need of re-revascularization either surgically or percutaneously. RESULTS: We included 1030 patients in this analysis. Median follow-up time was 5.5 years and 150 (15%) patients were re-catheterized in that period. Most of these procedures was due to ischemia suspicion (74%) and 61 (41%) were positive for significant angiographic lesions of conduits (IMA: 3.2% and SVG: 3.8%, p=0.488). In multivariate analysis, SVG use was found as an independent predictor of cardiac catheterization on follow-up (HR: 1.610, CI 95%: 1.038-2.499, p=0.034). On the other side, independent predictors of graft lesions were younger age (OR: 0.951, CI 95%: 0.921-0.982, p=0.002), female gender (OR: 2.231, CI 95%: 1.038-4.794, p=0.040), arterial hypertension (OR: 1.968, CI 95%: 1.022-3.791, p=0.043) and 3-vessel disease (OR: 2.820, CI 95%: 1.155-6.885, p=0.023). Among the patients with significant angiographic lesions, 48 underwent repeat revascularization (44 PCI e 4 CABG). Arterial hypertension and younger age were independent predictors of re-revascularization. CONCLUSION: In BIMA patients the addition of SVG predicts the need of catheterization; however prevalence of significant angiographic lesions was similar in IMA and SVG. Our results suggest that arterial hypertension is an independent predictor of graft patency and re-revascularization rate.

Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting Surgery.

INTRODUCTION: Postoperative atrial fibrillation (PoAF) is the most common arrhythmia following cardiac surgery, which increase the patient's morbidity and mortality. PURPOSE: The aim of this study was to evaluate new onset of atrial fibrillation (AF) after isolated coronary artery bypass grafting (CABG) surgery, its clinical and surgical predictors, and its impact in immediate and long-term outcomes. METHODS: Retrospective study including all CABG surgeries performed in a tertiary centre, between 2004 and 2011. Patients with documented episodes of AF or pacing rhythm before cardiac surgery were excluded. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Qui-square tests and independent t-tests were used to compare categorical and continuous data, respectively, between patients with and without PoAF. A multivariate logistic regression model was used to identify independent risk factors of PoAF. To determine the effect of PoAF in long-term survival, we used Kaplan-Meier curves, Log Rank test and multivariate Cox regression (maximum follow-up time: 13 years). RESULTS: We included 2511 patients, mean age of 63±10 years, 78.7% being male. PoAF occurred in 450 patients (18.0%), 3±3 days after surgery, the majority pharmacologically cardioverted with amiodarone (96.2%). These patients were older (67±9 vs. 62±10 years, p<0.001), more frequently obese (27.8% vs. 22.9%, p=0.026), hypertensive (76.7% vs. 69.7%, p=0.003) and had lower preoperative creatinine clearance (CC) values (73.2±27.4 vs. 81.4±28.3 ml/min, p<0.001), longer cardiopulmonary bypass time (60.0% vs. 54.8%, p=0.043) compared with patients without PoAF. In multivariate analysis, older age (OR: 1.035, 95% CI: 1.015-1.056, p=0.001), lower preoperative CC values (OR: 0.992, 95% CI: 0.985-0.999, p=0.032) and larger left atrial diameter (OR: 1.058, 95% CI: 1.024-1.093, p=0.001) were determined as independent predictors of PoAF. These patients also revealed longer hospitalization time (8 [4 to 193] vs. 6 [4 to 114] days, p<0.001) and higher hospital mortality (2.9% vs. 0.8%, p<0.001). Regarding long-term survival, patients with PoAF showed lower cumulative survival than patients without AF events (52% vs. 66%, p<0.001). PoAF was also found as an independent predictor of mortality in multivariate Cox regression (HR: 1.394, 95% CI: 1.147- 1.695, p=0.001). CONCLUSION: PoAF incidence after CABG surgery was 18%. Older age, lower CC values and larger left atrial diameter were settled as PoAF independent predictors. Additionally, the occurrence of this arrhythmia was independently associated with lower long-term survival, after CABG surgery.

Endothelial Function and Vascular Properties in Severe Aortic Stenosis Before and After Aortic Valve Replacement Surgery.

INTRODUCTION: The degenerative process that results in aortic valve stenosis (AS) has pathophysiological features similar to the atherosclerotic process. We therefore hypothesized that, as in atherosclerosis, endothelial and vascular dysfunction could be a pathophysiologic feature of AS. AIM: To evaluate endothelial function before and after aortic valve replacement (AVR) surgery in patients with severe AS. To correlate endothelial function with severity of AS and clinical profile. METHODS: Two noninvasive methods were used to evaluate endothelial function (Reactive Hyperemia Index (RHI) measure with EndoPATTM2000 system) and vascular properties (carotid-femoral Pulse Wave Velocity (PWV) measured by Complior® Analyse) in 13 patients with severe AS undergoing AVR. Sample was collected by convenience in a single-center between February and July of 2017. Pre- -operative, surgical and post-operative data were collected through clinical files and informatics databases. PWV, RHI, Augmentation Index (AI) were assessed at the day of surgery and 2.4±1.2 months post-operatively. Mean transvalvular gradients (MTG), aortic valve area (AVA) and left ventricular function were evaluated by transthoracic echocardiography at 3.4±1.6 months of follow-up. Wilcoxon or paired t-tests were used to compare pre- and post-operative values of continuous variables. Spearman correlations (rho) were done to find associations between endothelial/ vascular function parameters and clinical data. RESULTS: In our sample, mean age was 70±8 years and 69% were females. Arterial hypertension was present in 11 (85%) patients, diabetes in 3 (23%) and pre-operative NYHA functional class ≥III in 4 (31%). No patient was currently smoker and only 2 had previous history of smoking. No significant changes were observed between pre- and post-operative endothelial/vascular function values. PWV (m/s), AI (%) and RHI before and after AVR surgery were: 10.5 (6.1 to 16) vs. 9.4 (4.7 to 21.6), p=0.701; 33% [-24 to 54] vs. 23% [0 to 47], p=0.116 and 1.83 (1.08 to 3.13) vs. 1.71 (1.06 to 3.12), p=0.638, respectively. We found a significant inverse correlation between pre- operative AVA and AI (rho= -0.652, p=0.016) and a positive correlation between age and post-operative PWV (rho= 0.639, p=0.019). Pre- and post-operative MTG and AVA were 54±5 mmHg and 0.7± 0.1 cm2 vs.12±4 mmHg and 2.0±0.5 cm2, respectively (p<0.001). CONCLUSION: Considering small sample size, no differences were found in indices of endothelial/vascular function before and after AVR surgery due to AS. However, it seems that endothelial dysfunction is associated with severity of AS assessed by AVA.

Aortic valve replacement with the Carpentier-Edwards Perimount bioprosthesis: Clinical and hemodynamic evaluation.

INTRODUCTION: The number of aortic valve replacement (AVR) surgeries has increased recently, along with the number of bioprosthetic valves implantations. Several studies reported excellent durability and low incidence of valve-related complications with the Carpentier-Edwards Perimount (CEP) pericardial bioprosthesis. The aim of this study is to evaluate the hemodynamic performance and clinical outcomes of the CEP in the aortic position. METHODS: This retrospective study included all patients who underwent AVR using the CEP valve from January 2010 to December 2010 at our institution. Clinical, surgical and early echocardiographic data were retrospectively collected. Survival was the primary endpoint. Median follow-up was 6.5 years. Hemodynamic profile was evaluated by echocardiography 3±1 months after AVR. RESULTS: Out of 175 patients, 50% were male and the mean age was 70.8+8.8 years. We registered a relatively low rate of complications: 2.2% permanent pacemaker implantation; 32.2% post-operative atrial fibrillation episodes; 1.1% stroke. The 30-day mortality rate was 5.1%. One patient underwent reoperation to replace the CEP bioprosthesis due to endocarditis (0.6%). Overall survival rates at 1, 3, 5 and 7 years were 93.4, 82.5, 75.3, and 62.3%, respectively. No significant differences were found between 7-year survival rates for isolated AVR and multiple procedures (67.8% vs. 61.8%, Log-Rank test, p=0.286). Post-operative mean transvalvular gradient was 15.5±4.8 mmHg and EOA 1.6±0.3 cm2. CONCLUSION: The CEP bioprosthesis in the aortic position shows acceptable mid-term clinical results and hemodynamic profile that support its clinical use.

Introdução: O número de cirurgias de substituição valvular aórtica (SVA) tem aumentado recentemente, assim como o número de biopróteses implantadas. Vários estudos com a bioprótese pericárdica Carpentier-Edwards Perimount (CEP) repor- taram excelente durabilidade e baixa incidência de complicações relacionadas com a prótese. O objetivo deste estudo é avaliar o desempenho hemodinâmico e os outcomes clínicos da CEP na posição aórtica. Métodos: Este estudo retrospectivo incluiu todos os doentes submetidos a SVA por CEP de janeiro a dezembro de 2010 na nossa instituição. Os dados clínicos, cirúrgicos e ecocardiográficos precoces foram recolhidos retrospectivamente. O endpoint primário foi a sobrevida global. O seguimento mediano foi 6,5 anos. O perfil hemodinâmico foi avaliado no ecocar- diograma realizado 3±1 meses após a SVA. Resultados: Dos 175 doentes, 50% eram homens e a idade média foi 70,8±8,8 anos. Registámos uma taxa de com- plicações relativamente baixa: implante de pacemaker definitivo (2,2%); episódios de fibrilhação auricular pós-operatórios (32,2%); acidente vascular cerebral (1,1%). A mortalidade aos 30 dias foi de 5,1%. Um doente foi reoperado por endocardite da bioprótese valvular CEP (0,6%). A sobrevida global a 1, 3, 5 e 7 anos foi 93,4, 82,5, 75,3 e 62,3%, respectivamente. Não encontrámos diferenças significativas na sobrevida aos 7 anos entre SVA isolada e procedimentos múltiplos (67,8% vs. 61,8%, teste Log-Rank, p=0,286). O gradiente transvalvular médio pós-operatório foi 15,5±4,8 mmHg e a EOA foi 1,6±0,3 cm2. Conclusão: A Carpentier-Edwards Perimount na posição aórtica mostra resultados clínicos a médio-prazo e perfil hemo- dinâmico aceitáveis que sustentam seu uso clínico.

[Surgical treatment of type A acute aortic syndrome: a single-center 10-year experience]. / Tratamento cirúrgico do síndrome aórtico agudo do tipo A: experiência de um centro hospitalar em 10 anos.

INTRODUCTION: Acute Aortic Syndrome (AAS) affecting the ascending aorta still represents a challenge to cardiologists and cardiothoracic surgeons, being associated with high mortality even with early surgery. AIMS: To describe the immediate post-operative results and long-term survival after the surgical treatment of type A AAS. Secondary outcomes include hospital mortality, length of hospital stay and long-term mortality. METHODS: Retrospective longitudinal study, including all patients who underwent ascending aorta replacement for surgical treatment of type A AAS, in a tertiary center, between January 2005 and December 2015. Preoperative, surgical and postoperative characteristics were evaluated. In addition to the descriptive analysis, the impact of some variables on long-term mortality, hospital mortality and length of hospital stay was evaluated. RESULTS: We included 78 patients, the most common type of AAS was aortic dissection (92,3%). 6 patients died at operation room and 12 in the immediate post-operative period, completing 23,1% of in-hospital mortality. Considering 60 survivors who were followed by a mean time of 5 years, maximum of 12, we registered a cumulative survival at 1, 3, 5, 10-years of 93,5%, 84,3%, 77% and 69,5%, respectively. Marfan Syndrome was found to be a risk factor of higher long term mortality (HR: 3,85, p=0,045). CONCLUSION: Our study confirms previous observations associating AAS type A with high rates of morbidity and mortality, despite significant advances in diagnostic and therapeutic techniques.

Introdução: O Síndrome Aórtico Agudo (SAA) é frequentemente um desafio para cardiologistas e cirurgiões cardioto- rácicos já que mesmo com cirurgia atempada confere uma mortalidade elevada. Objetivos: Descrever os resultados clínicos no pós-operatório imediato e mortalidade a longo-prazo após abordagem cirúrgica do SAA tipo A. O objetivo secundário é identificar que fatores estão associados com a mortalidade hospitalar, internamento prolongado e mortalidade a longo prazo. Métodos: Estudo retrospetivo longitudinal incluindo todos os doentes submetidos a substituição da aorta ascendente para tratamento cirúrgico de SAA tipo A, num centro terciário, entre janeiro de 2005 e dezembro de 2015. Foram excluídos SAA de causa traumática. Avaliaram-se retrospetivamente as características pré-operatórias, cirúrgicas e pós-operatórias. Para além da análise descritiva, foi estimado o impacto de determinadas variáveis na mortalidade a longo prazo através da regres- são de Cox e relativamente aos resultados secundários através de regressão logística. Resultados: Foram incluídos 78 indivíduos cujo principal tipo de SAA foi a disseção da aorta (92,3%). Registaram-se 6 mortes intraoperatórias e 12 no pós-operatório imediato, sendo a mortalidade hospitalar de 23,1%. Dos 60 indivíduos sobreviventes, o tempo médio de seguimento foi de 5 anos, máximo de 12 anos, com sobrevida cumulativa aos 1, 3, 5 e 10 anos de 93,5%, 84,3%, 77% e 69,5%, respetivamente. O Síndrome de Marfan foi preditor de maior risco de mortalidade a longo prazo (HR: 3,85, p=0,045). Conclusões: O nosso estudo confirma observações prévias associando o SAA tipo A a altas taxas de morbi-mortalidade, apesar dos avanços significativos em termos diagnósticos e terapêuticos.

[De novo atrial fibrillation following aortic valve replacement surgery]. / Fibrilação auricular de novo em doentes submetidos a cirurgia de substituição valvular aórtica isolada.

Objetives: The present study aimed to explore the risk factors associated with de novo atrial fibrillation following isolated aortic valve replacement surgery and its prevalence in a high volume cardiothoracic surgery center. METHODS: This is a cross-sectional retrospective observational study including all patients submitted to isolated aortic valve replacement surgery during 2014 and the corresponding data. Patients with previous history of atrial fibrillation, endocarditis or aortic valve prosthesis were excluded. The statistical analysis was conducted according to the type of variables concerned. RESULTS: One hundred and seventy-three patients were included and 45.1% had de novo atrial fibrillation, with a median occurrence on 2.4 ±1.5 days of the postoperative period. Age was significantly associated with the arrhythmia (p=0.028). Atrial fibrillation patients had a significantly lower minimum of postoperative creatinine clearance (p=0.026) and a higher postoperative plasmatic C-reactive protein peak (p=0.025). Arrhythmic patients had a median time of hospital stay significantly superior to those who did not develop atrial fibrillation (p=0.008). Hospital mortality was low and similar between groups (3%, p=0.796). DISCUSSION/CONCLUSION: This study confirms the high prevalence of atrial fibrillation following aortic valve replacement surgery. The increased C-reactive protein and decreased creatinine clearance reinforce the importance of inflammation in its pathophysiology. The longer hospital stay in these patients also contributes to the importance of atrial fibrillation prevention and risk stratification.

Objetivos: O presente estudo teve como objetivos estudar os fatores preditores clínicos de incidência de fibrilação auricular pós-operatória e a sua prevalência num centro de cirurgia cardiotorácica de grande volume. Métodos: Estudo transversal analítico que inclui doentes submetidos a cirurgia de substituição valvular aórtica isolada por estenose aórtica no ano de 2014. Os dados clínicos, analíticos e ecocardiográficos foram recolhidos retrospetivamente. Foram excluídos doentes com história prévia de fibrilação auricular, endocardite ou com prótese valvular aórtica prévia. Os testes estatísticos realizados tiveram em conta a classificação e distribuição das variáveis. Resultados: Foram incluídos 173 doentes, dos quais 45,1% apresentaram fibrilação auricular pós-operatória de novo, com o seu pico de ocorrência aos 2,4 ±1,5 dias do período pós-operatório. A idade foi significativamente superior nos grupos com fibrilação auricular pós-operatória (p=0,028). A ocorrência da arritmia associou-se de forma significativa a uma diminuição no clearance de creatinina pós-operatória (p=0,026), bem como a uma elevação da proteína C-reativa (p=0,025). Os doentes com fibrilação auricular pós-operatória demonstraram uma mediana de tempo de internamento aumentada (p=0,008). A mortalidade hospitalar revelou uma prevalência baixa e foi semelhante entre os grupos comparados (3%, p=0,796). Discussão: O nosso estudo confirma a elevada prevalência de fibrilação auricular após cirurgia cardíaca. O aumento da proteína C-reativa e a diminuição do clearance de creatinina nos doentes com a arritmia reforçam a importância da inflamação na sua fisiopatologia. O maior tempo de internamento nestes doentes, pelo aumento dos custos de saúde e outras complicações, frisa a importância de adotar medidas preventivas e de estratificação de risco.

[Do diabetic patients benefit from bilateral internal mammary artery?] / O Benefício na Sobrevida da Dupla Artéria Torácica Interna Prevalece nos Pacientes com Diabetes?

INTRODUCTION: Bilateral internal mammary artery (BIMA) grafting has been associated with increased long term survival when compared to single IMA, but its benefit on diabetic patients remains controversial. AIMS: To compare long-term survival following BIMA versus single internal mammary artery (SIMA) grafting between diabetic and non-diabetic patients. METHODS: We retrospectively reviewed all the patients who underwent isolated CABG and received two or more grafts with at least one IMA graft between 2004 and 2013. Mean follow-up was 4 years and maximum 10. Kaplan-Meier analysis was used to compare long-term survival between BIMA and SIMA in both groups (diabetic vs. non-diabetic). Propensity score matching was used to adjust for treatment selection bias. RESULTS: 1259 out of 3045 eligible patients were diabetic. BIMA was associated with better long-term survival than SIMA on unadjusted analysis in both groups (cumulative survival of 87% vs. 70% in diabetic patients and 89% vs. 79% in non-diabetic patients, respectively). After propensity score matching, BIMA was associated with increased long-term survival in the non-diabetic cohort (n=1042, HR: 0.570 CI95%: 0.342-0.950), but there was no statistically significant difference in the diabetic cohort (n=850, HR: 0.774 CI95% 0.447-1.339). In-hospital mortality and sternal wound infection were low in matching cohorts irrespectively of the number of IMA grafts or diabetes status. CONCLUSIONS: BIMA grafting appears to be safe for diabetic patients, despite the apparent lack of significant survival advantage.