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BACKGROUND: Intraoperative and postoperative bleeding associated with allogeneic blood transfusion and reoperation is still a common and feared complication in patients undergoing surgery due to acute Type A Aortic Dissection (aTAAD). The aim of our study was to identify risk factors for higher transfusion rates. METHODS: In this retrospective single center study we evaluated pre -, intra-, and postoperative data of 121 patients with aTAAD. Depending on the median of received packed red blood cells (PRBCs), patients were divided into Group A (<8 PRBC, n = 53) and Group B (≥8 PRBC n = 68). Statistical analyses (descriptive statistics, univariable and multivariable logistic regression) were performed using SPSS software 25.0. Statistical significance was assumed at p-value <0.05. RESULTS: A total of 120 patients received a blood product during their perioperative course. Among others we identified age, hemorrhagic pericardial effusion, and dual antiplatelet therapy as preoperative risk factors, low rectal temperature as intraoperative risk factor and low body temperature, positive fluid balance, high lactate level and beginning development of acute renal failure as postoperative risk factors. CONCLUSION: Our study identifies several factors which predict a higher likelihood of bleeding and consecutive blood transfusion. Knowledge of these factors could influence the therapy to reduce transfusion requirements and lead to a targeted and more efficient use of coagulation products.
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Transfusión Sanguínea , Hemorragia Posoperatoria , Humanos , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/terapia , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina. METHODS: Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression. RESULTS: Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG. CONCLUSIONS: Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.
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Síndrome Coronario Agudo , Infarto del Miocardio , Síndrome Coronario Agudo/cirugía , Anciano , Femenino , Alemania/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/cirugía , Revascularización Miocárdica , Sistema de Registros , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an alternative treatment option to surgical aortic valve replacement (SAVR) in selected high-risk patients. In this study, we aimed to evaluate the prognostic value of right ventricular (RV) functional imaging to predict clinical response to TAVR and SAVR. METHODS: One hundred and ten patients with symptomatic severe aortic valve stenosis (AVS) undergoing successful TAVR and 32 controls undergoing SAVR were prospectively enrolled. Six months follow up (FU) included two-dimensional (2D) transthoracic echocardiography (TTE) with RV deformation imaging. RESULTS: Baseline TTE showed no significant differences between groups (TAVR and SAVR) in conventional left ventricular (LV) and RV functional parameters (LV ejection fraction [LV-EF]: p = .21; tricuspidal annular plane systolic excursion [TAPSE]: 1.8 ± 0.5 cm, 1.9 ± 0.4 cm, p = .21), and RV strain (right ventricular-global longitudinal strain [RV-GLS] -11.6 ± 5.2%, -11.5 ± 6.5%, p = .70). At FU LV function was unchanged in both groups (p > .05); RV function was significantly improved after TAVR (RV-GLS: -11.6 ± 5.2%, -13.4 ± 6.1%, p = .005; TAPSE: 1.8 ± 0.5 cm, 1.9 ± 0.3 cm, p = .05), and worsened after SAVR (RV-GLS: -11.5 ± 6.5%, -8.9 ± 5.2%, p = .04; TAPSE: 1.9 ± 0.4 cm, 1.5 ± 0.3 cm, p < .001). Functional New York Heart Association (NYHA) class remained unchanged in patients after SAVR (p = .21), and improved after TAVR (p < .001). Baseline RV function was linked with clinical response to TAVR (TAPSE, p < .0001; RV-GLS, p = .04), and the development of RV-GLS was associated with functional worsening after SAVR (p = .05). CONCLUSION: Baseline RV function and changes of right heart mechanics are closely associated with functional improvements after AVR. SAVR, but not TAVR, seems to have detrimental effects on RV-function.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Ecocardiografía Doppler , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Función Ventricular Derecha , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Fenómenos Biomecánicos , Estudios de Casos y Controles , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , Recuperación de la Función , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock ( CS ) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non- ST -segment-elevation myocardial infarction ( NSTEMI ) and ST -segment-elevation myocardial infarction ( STEMI ). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in-hospital mortality ( IHM ) and major adverse cardiocerebral events ( MACCEs ). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI ( P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On-pump surgery with cardioplegia was the preferred surgical technique in CS . IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI ( IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.
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Puente de Arteria Coronaria , Infarto del Miocardio sin Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/cirugía , Choque Cardiogénico/complicaciones , Anciano , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Femenino , Alemania , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/complicaciones , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/mortalidad , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
The use of left-ventricular (LV) hemodynamic support might facilitate high-risk percutaneous coronary interventions (PCI) in patients with complex coronary artery disease. The impact on outcome is a matter of ongoing debate. We assessed the outcome of high-risk patients who underwent protected PCI in comparison to patients who underwent unprotected high-risk PCI. One hundred and thirty nine patients underwent nonemergent high-risk PCI; 24 (17%) patients underwent protected PCI. To address selection bias, we performed a propensity score matched subanalysis. The primary end point was the occurrence of a major adverse cardiac event during the first year. Patients with protected PCI had a higher logistic EuroSCORE (logES) (protected PCI: 19% vs unprotected PCI: 12%; pâ¯=â¯0.01), a higher SYNTAX score (45 vs 36, pâ¯=â¯0.07), and significantly more often reduced LV function (40% vs 55%; p < 0.001). In protected PCI patients, complete revascularization was more often achieved (87% vs 58%, pâ¯=â¯0.007) without the occurrence of death at 30 days of follow-up (0% vs 4%, pâ¯=â¯0.31). After propensity score matching, patients who underwent protected PCI had a similar 1-year major adverse cardiac event rate compared with patients who underwent unprotected PCI (21% vs 17%, pâ¯=â¯0.67), despite significantly higher procedural complexity for example, more often complex left main bifurcation lesions (71% vs 29%; pâ¯=â¯0.004). In conclusion, 1-year outcome of patients who underwent protected PCI was not different from that in patients with less complex procedures without hemodynamic support, despite more complex coronary anatomy, a higher comorbidity burden, and more often reduced LV function.
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Enfermedad de la Arteria Coronaria/cirugía , Corazón Auxiliar , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/complicaciones , Disfunción Ventricular Izquierda/terapiaRESUMEN
OBJECTIVES: Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). METHODS: A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value <0.05. RESULTS: Lower blood product requirements were observed for the RAP group regarding the transfusion of intraoperative RBC (0.87 ± 1.33 vs 1.97 ± 2.43, P = 0.013), postoperative RBC (0.57 ± 1.4 vs 1.32 ± 1.82, P = 0.002) and postoperative fresh frozen plasma (0.52 ± 1.63 vs 1.48 ± 3.32, P = 0.036). The postoperative drainage loss showed significantly lower measurements for the RAP group after 6 h (295.9 ± 342.6 vs 490.6 ± 414.4 ml, P ≤ 0.001), 12 h (450.1 ± 415.5 vs 652.1 ± 463.9 ml, P < 0.001) and 24 h (693.1 ± 483.9 vs 866.4 ± 508.4 ml, P = 0.004). CONCLUSIONS: RAP is a safe and easy method to reduce RBC transfusion in TAA surgery without any adverse effects on the clinical outcome. We were also able to show beneficial effects on fresh frozen plasma requirements and postoperative chest drainage volume. Furthermore, improved microcirculation can be suspected. In consequence, we have implemented RAP as a clinical standard during thoracic aortic surgery.
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Aneurisma de la Aorta Torácica/cirugía , Puente Cardiopulmonar/métodos , Transfusión de Eritrocitos/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Torácicos/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Ventricular tachycardia (VT) is the most common and potentially lethal complication following myocardial infarction (MI). Biological correction of the conduction inhomogeneity that underlies re-entry could be a major advance in infarction therapy. As minimal increases in conduction of infarcted tissue markedly influence VT susceptibility, we reasoned that enhanced propagation of the electrical signal between non-excitable cells within a resolving infarct might comprise a simple means to decrease post-infarction arrhythmia risk. We therefore tested lentivirus-mediated delivery of the gap-junction protein Connexin 43 (Cx43) into acute myocardial lesions. Cx43 was expressed in (myo)fibroblasts and CD45+ cells within the scar and provided prominent and long lasting arrhythmia protection in vivo. Optical mapping of Cx43 injected hearts revealed enhanced conduction velocity within the scar, indicating Cx43-mediated electrical coupling between myocytes and (myo)fibroblasts. Thus, Cx43 gene therapy, by direct in vivo transduction of non-cardiomyocytes, comprises a simple and clinically applicable biological therapy that markedly reduces post-infarction VT.
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Arritmias Cardíacas/genética , Cicatriz/genética , Conexina 43/genética , Terapia Genética , Infarto del Miocardio/genética , Animales , Arritmias Cardíacas/complicaciones , Arritmias Cardíacas/patología , Arritmias Cardíacas/terapia , Cicatriz/patología , Cicatriz/terapia , Conexina 43/administración & dosificación , Modelos Animales de Enfermedad , Fibroblastos/metabolismo , Vectores Genéticos/uso terapéutico , Células HEK293 , Humanos , Lentivirus/genética , Ratones , Células Musculares/metabolismo , Células Musculares/patología , Mioblastos/metabolismo , Mioblastos/patología , Infarto del Miocardio/complicaciones , Infarto del Miocardio/patología , Infarto del Miocardio/terapia , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/genética , Taquicardia Ventricular/patología , Taquicardia Ventricular/terapiaRESUMEN
Cardiovascular disease and in particular, heart failure are still main causes of death; therefore, novel therapeutic approaches are urgently needed. Loss of contractile substrate in the heart and limited regenerative capacity of cardiomyocytes are mainly responsible for the poor cardiovascular outcome. This is related to the postmitotic state of differentiated cardiomyocytes, which is partly due to their polyploid nature caused by cell cycle variants. As such, the cardiomyocyte cell cycle is a key player, and its manipulation could be a promising strategy for enhancing the plasticity of the heart by inducing cardiomyocyte proliferation. This review focuses on the cardiac cell cycle and its variants during postnatal growth, the different regenerative responses of the heart in dependance of the developmental stage and on manipulations of the cell cycle. Because a therapeutic goal is to induce authentic cell division in cardiomyocytes, recent experimental approaches following this strategy are also discussed.
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Ciclo Celular , Corazón/fisiología , Miocitos Cardíacos/fisiología , Regeneración , Animales , Humanos , Miocitos Cardíacos/citologíaRESUMEN
Cell replacement in the heart is considered a promising strategy for the treatment of post-infarct heart failure. Direct intramyocardial injection of cells proved to be the most effective application route, however, engraftment rates are very low (<5%) strongly hampering its efficacy. Herein we combine magnetic nanoparticle (MNP) loading of EGFP labeled embryonic cardiomyocytes (eCM) and embryonic stem cell-derived cardiomyocytes (ES-CM) with application of custom designed magnets to enhance their short and long-term engraftment. To optimize cellular MNP uptake and magnetic force within the infarct area, first numerical simulations and experiments were performed in vitro. All tested cell types could be loaded efficiently with SOMag5-MNP (200 pg/cell) without toxic side effects. Application of a 1.3 T magnet at 5 mm distance from the heart for 10 min enhanced engraftment of both eCM and ES-CM by approximately 7 fold at 2 weeks and 3.4 fold (eCM) at 8 weeks after treatment respectively and also strongly improved left ventricular function at all time points. As underlying mechanisms we found that application of the magnetic field prevented the initial dramatic loss of cells via the injection channel. In addition, grafted eCM displayed higher proliferation and lower apoptosis rates. Electron microscopy revealed better differentiation of engrafted eCM, formation of cell to cell contacts and more physiological matrix formation in magnet-treated grafts. These results were corroborated by gene expression data. Thus, combination of MNP-loaded cells and magnet-application strongly increases long-term engraftment of cells addressing a major shortcoming of cardiomyoplasty.
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Infarto del Miocardio/terapia , Miocitos Cardíacos/citología , Animales , Nanopartículas de Magnetita/efectos adversos , Trasplante de Células MadreRESUMEN
BACKGROUND: The aim of this study was to evaluate long-term dilatation of Hemashield Gold and Hemashield Platinum vascular prostheses in ascending aortic position using different measurement methods to obtain precise results. METHODS: Between 1999 and 2007, 73 patients with Stanford type A dissection received ascending aortic replacement with Hemashield Gold and Hemashield Platinum prostheses. Measurements were performed using multiplanar reconstruction mode of electrocardiogram (ECG)-gated, multislice spiral computed tomography (MSCT) in strictly orthogonal cross-sectional planes. Different methods of measurement were compared and maximum dilatation was estimated for different time spans. RESULTS: Diameters calculated from the measured circumference showed a significant (p = 0.037) but clinically not relevant difference (0.1 mm) to the mean between the largest and the shortest cross-sectional diameter of the prosthesis. Dilatation after 24.2 ± 10.2 months was 8.5 ± 4.5%. Long-term dilatation after 91.8 ± 34 months amounted to 11.8 ± 4.2%. CONCLUSION: Based on ECG-gated MSCT images, the presented methods of measurement provided reliable results. Long-term analysis shows low dilatation rates for Hemashield prostheses, which therefore can be considered as safe from this point of view. Nevertheless, a maximal dilatation of 20% could be relevant in valve sparing root replacement. It remains unclear if a dilatation like this contributes to the formation of suture aneurysms.
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Aorta/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Angiografía por Tomografía Computarizada/métodos , Tomografía Computarizada Multidetector/métodos , Falla de Prótesis , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Aorta/diagnóstico por imagen , Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Técnicas de Imagen Sincronizada Cardíacas , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Diseño de Prótesis , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The German Aortic Valve Score (GAVS) was developed for national quality assurance regarding the in-hospital mortality rate of patients following isolated aortic valve replacement. The goal of this work was the recalibration of the GAVS in the context of increased numbers of transcatheter aortic valve implantations. METHODS: In 2011 and 2012, 36 183 cases were documented who had either surgical aortic valve replacement or transcatheter aortic valve implantation (45%). All cases were randomly assigned to the study or to the validation group. All items of the data set were checked for significance by developing a multiregression risk model using iterative backward elimination. Calibration was ascertained using the Hosmer-Lemeshow method. To define the quality of discrimination, the area under the receiver operating characteristic curve (C-statistic) was calculated. RESULTS: The randomized study cohort comprised 18 054 patients. After modelling with multiple regression algorithms, 18 of the initial 28 risk factors entered the risk model. When applied to the validation group, the newly developed GAVS II showed good calibration with a P-value of 0.411 in the Hosmer-Lemeshow test and good discrimination with a C-statistic of 0.741. CONCLUSIONS: The GAVS II is a new risk model that is applicable to cohorts having surgical aortic valve replacement or transcatheter aortic valve implantation procedures.
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Válvula Aórtica/cirugía , Medición de Riesgo/normas , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Alemania/epidemiología , Enfermedades de las Válvulas Cardíacas/cirugía , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Curva ROC , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVES: The aims of this study were to determine plasma elevations of biomarkers of myocardial injury associated with transfemoral (TF) transcatheter aortic valve replacement (TAVR) and to evaluate their prognostic value. BACKGROUND: Increases in biomarkers of myocardial injury are a common finding after TAVR, but their clinical significance is unclear. METHODS: In 756 consecutive TF TAVR patients, cardiac high-sensitivity troponin I (hsTnI) and creatine kinase MB (CK-MB) levels were measured at pre-defined time points to assess the occurrence of myocardial injury (defined as 15 times the upper reference limit for hsTnI [≥1.5 ng/ml] or 5 times the upper reference limit for CK-MB [≥18 µg/l]) during the first 72 h. The primary endpoint was all-cause mortality at 1 year. RESULTS: After uneventful TF TAVR, hsTnI was elevated in 51.6% and CK-MB in 7.4% of patients, respectively. Myocardial injury was associated with transcatheter heart valve (THV) type: patients who received the LOTUS THV more frequently had myocardial injury compared with those who received other THVs (LOTUS, 81.6%; Direct Flow Medical, 56.4%; CoreValve, 51.2%; Evolut R, 42.7%; SAPIEN XT, 40.4%; SAPIEN 3, 36.6%; p < 0.001). Myocardial injury defined by hsTnI was not associated with adverse outcomes at 30 days (3.1% vs. 2.7%; p = 0.778) or 1 year (16.7% vs. 17.2%; p = 0.841). Likewise, a CK-MB increase was not associated with 30-day mortality (5.5% vs. 2.8%; p = 0.258) or 1-year mortality (16.4% vs. 17.3%; p = 0.856). CONCLUSIONS: Myocardial injury is common following TF TAVR. The extent of cardiac biomarker elevation depends on THV type but is not associated with adverse short- and long-term outcomes after uneventful TAVR.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Miocardio/patología , Diseño de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Biomarcadores/sangre , Forma MB de la Creatina-Quinasa/sangre , Femenino , Arteria Femoral , Humanos , Estimación de Kaplan-Meier , Masculino , Miocardio/enzimología , Punciones , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Troponina I/sangre , Regulación hacia ArribaRESUMEN
BACKGROUND: The impact of coronary artery disease (CAD) and revascularization on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) has not been fully elucidated so far. OBJECTIVES: To assess whether the degree of CAD influences the prognosis of patients undergoing TAVI. METHODS: Before TAVI, all patients underwent revascularization of the proximal vessels or the left main stem if indicated (stenosis ≥70% or 50%, respectively). In 666 patients, we calculated the baseline (bSS) and residual SYNTAX Score (rSS) prior to TAVI. In patients with revascularization, we determined the SYNTAX Revascularization Index (SRI=(1-(rSS/bSS))∗100). We also assessed the SYNTAX Score II (SS-II), combining anatomical and clinical variables. The primary endpoint was 3-year all-cause mortality. RESULTS: Higher baseline and residual SYNTAX Score were associated with increased 3-year mortality (no CAD 26.2%, low bSS 34.8%, high bSS 46.8%; p=0.001, respectively, no CAD 25.9%, low rSS 31.4%, high rSS 41.5%; p=0.01). The extent of revascularization represented by the SRI was not associated with outcome. The SYNTAX Score II was also associated with increased 3-year mortality. However, baseline and residual SYNTAX Score as well as SYNTAX Score II did not independently predict mortality. CONCLUSION: The anatomic severity of CAD as assessed by the baseline and residual SYNTAX Score is associated with survival after TAVI. Coronary artery disease seems to reflect general comorbidity burden and is associated with a higher risk profile of the patient.
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Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Arteria Femoral/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Mortalidad/tendencias , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/tendencias , Estudios Retrospectivos , Método Simple Ciego , Reemplazo de la Válvula Aórtica Transcatéter/tendenciasRESUMEN
Background Transcatheter valve-in-ring strategies have been developed to treat recurrent mitral regurgitation (MR) after failing surgical annuloplasty. However, suboptimal THV expansion with consecutive paravalvular leakage (PVL) is a procedure-immanent issue. Methods A rigid, saddle-shaped ring was cut at four locations. The segments were reconnected with pull-springs, rearranged to the original shape, and covered with a sewing cuff. The length of the annuloplasty ring construct, including extended pull-springs, was defined by the perimeter of an appropriate THV. We deployed a Sapien XT within the new ring, expanded it to its maximum extent, and investigated the geometrical changes. Results Fluoroscopy confirmed oval, saddle-shaped ring before dilation. After THV implantation, the ring segments spread apart and pull-springs were stretched. The extended ring changed its configuration from "oval" to "round" and anchored the THV leaving no paravalvular or central gaps as potential source for PVL. Conclusion We developed an expandable annuloplasty ring that is perfectly concerted to THV implantation. This proof-of-concept study revealed no PVL and good oversizing ability that might impact future annuloplasty ring design. Further studies have to evaluate durability and device safety.
Asunto(s)
Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Complicaciones Posoperatorias/prevención & control , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Complicaciones Posoperatorias/etiología , Diseño de Prótesis , Falla de Prótesis , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND/OBJECTIVES: The acute and long-term effects of interventional edge-to-edge repair on the mitral valve (MV) geometry are unclear. We sought to assess MV-annular geometry and the association of changes in MV-diameters with functional response one year after MitraClip implantation. METHODS: Consecutive patients (n=84; age 81.2±8.3years, logistic EuroSCORE 21.7±17.9%) with symptomatic moderate-to-severe mitral regurgitation (MR) underwent MitraClip-procedure. MV-annular geometry was assessed with 3D TOE before, immediately and one year after clip implantation. RESULTS: 96.7% of secondary mitral regurgitation (SMR) patients presented with moderate-to-severe MR, 3.3% with severe SMR, respectively. 66.7% of primary MR (PMR) patients had moderate-to-severe MR, and 33.3% severe PMR respectively. When analyzing immediate effects of MitraClipC on mitral geometry, only patients with SMR (n=60, 71.4%) experienced significant reductions of the diastolic MV anterior-posterior diameters (AP: 3.9±0.5cm, 3.5±0.7cm; p<0.001), and annulus-areas (2D: 12.9±3.8cm2, 12.6±3.7cm2; p<0.001; 3D: 13.4±3.8, 13.1±3.2cm2; p<0.001). All measures on MV annular geometry were not significantly altered in patients with PMR (p>0.05). After one year of follow-up, MV annular parameters remained significantly reduced in SMR patients (p<0.05) and remained unchanged in subjects with PMR (p>0.05). Only SMR patients experienced significant increase in 6min walking distances (p=0.004), decrease in pulmonary pressures (p=0.007) and functional NYHA-class (p<0.001); in patients with PMR only NYHA class improved after one year (p<0.001). CONCLUSION: Edge-to-edge repair with the MitraClip-system impacts on MV-geometry in patients with SMR with stable results after 12months. Reduction of MV-annular dimensions was associated with higher rates of persisting MR reduction and better functional status in patients with SMR.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Válvula Mitral/patología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/patología , Resultado del TratamientoRESUMEN
AIMS: Tricuspid regurgitation (TR) in patients with mitral valve disease is associated with poor outcome and mortality. Only limited data on the impact of TR on functional outcome and survival in patients undergoing MitraClip procedures are available. METHODS AND RESULTS: 261 patients (mean age 76.6 ± 10, EuroScore 15.9 ± 15.1%) with symptomatic mitral regurgitation (MR) (75.2% functional MR) undergoing MitraClip procedure were included and followed for 721 ± 19.4 days. At baseline 54.7% presented with TR grade 0/I, 29.5% with grade II, 13.4% with grade III and 2.3% with grade IV. When dividing groups according to baseline TR grades, follow-up (FU)-NYHA class was significantly improved only in patients with TR ≤ II (p = 0.05). FU-6-min walking distance increased significantly in the overall cohort (p = 0.05), in patients with TR ≤ II (p = 0.007), but not in patients with TR > II (p = 0.4). Moreover, FU-NT-pro-BNP levels were higher in patients with TR > II (p = 0.05), compared to patients with TR ≤ II. There was a higher mortality according to baseline TR > II and multivariate Cox regression revealed TR > II as the strongest independent predictor for mortality (hazard ratio 2.04). CONCLUSIONS: Concomitant TR at baseline negatively influences functional outcome and mortality in patients undergoing MitraClip procedures. Our results underline the need for dedicated interventional strategies for the treatment of TR in patients with symptomatic MR.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Anuloplastia de la Válvula Mitral/instrumentación , Anuloplastia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/mortalidad , Insuficiencia de la Válvula Tricúspide/mortalidad , Anciano , Causalidad , Comorbilidad , Femenino , Alemania/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Incidencia , Estudios Longitudinales , Masculino , Anuloplastia de la Válvula Mitral/métodos , Anuloplastia de la Válvula Mitral/estadística & datos numéricos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/prevención & control , Factores de Riesgo , Instrumentos Quirúrgicos/estadística & datos numéricos , Análisis de Supervivencia , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/prevención & controlRESUMEN
OBJECTIVES: This study sought to analyze health-related quality-of-life (HrQoL) outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) based on data from GARY (German Aortic Valve Registry). BACKGROUND: Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities, and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality in this high-risk patient population. METHODS: In 2011, 3,875 patients undergoing TAVR were included in the GARY registry. HrQoL was prospectively measured using the EuroQol 5 dimensions questionnaire self-complete version on paper at baseline and 1 year. RESULTS: Complete follow-up EuroQol 5 dimensions questionnaire evaluation was available for 2,288 patients (transvascular transcatheter aortic valve replacement [TAVR-TV]: n = 1,626 and transapical TAVR [TAVR-TA]: n = 662). In-hospital mortality was 5.9% (n = 229) and the 1-year mortality was 23% (n = 893). The baseline visual analog scale score for general health status was 52.6% for TAVR-TV and 55.8% for TAVR-TA and, in parallel to an improvement in New York Heart Association functional class, improved to 59.6% and 58.5% at 1 year, respectively (p < 0.001). Between baseline and 1 year, the number of patients reporting no complaints increased by 7.8% (TAVR-TV) and by 3.5% within the mobility dimension, and by 14.1% (TAVR-TV) and 9.2% within the usual activity dimension, whereas only moderate changes were found for the self-care, pain or discomfort, and anxiety or depression dimensions. In a multiple linear regression analysis several pre- and post-operative factors were predictive for less pronounced HrQoL benefits. CONCLUSIONS: TAVR treatment led to improvements in HrQoL, especially in terms of mobility and usual activities. The magnitude of improvements was higher in the TAVR-TV group as compared to the TAVR-TA group. However, there was a sizable group of patients who did not derive any HrQoL benefits. Several independent pre- and post-operative factors were identified being predictive for less pronounced HrQoL benefits.