Outcomes of rapid deployment aortic valve replacement with concomitant cardiac procedures.

Background: Rapid deployment aortic valve replacement (RD-AVR) has been recently introduced with encouraging results. Outcomes of isolated RD-AVR include good hemodynamic profile, facilitation of minimally invasive techniques, and reduction of surgical times. However, role of this prosthesis in concomitant surgery is not well known. Methods: In 2016, we formed a registry to monitor the introduction of this prosthesis, RApid Deployment Aortic Replacement (RADAR). We aim to report mid-term outcomes focusing on patients who had RD-AVR combined with other surgical procedures. Results: Between July 2012 and February 2021, 370 patients were included in this registry (mean age, 75.8±8.0 years; 64.32% male; mean EuroSCORE II, 3.5±2.8). Of these, 128 (34.59%) had concomitant procedures including myocardial revascularization surgery in 69 patients (53.91%), surgery on the ascending aorta in 34 (26.56%), and procedures on other valves in 10 patients (7.81%). There were no significant differences between the isolated AVR and concomitant AVR groups in postoperative complications, in-hospital mortality (4.72% vs. 3.32%, P=0.524), or hemodynamic behavior of these prostheses. Three-year survival was 83.73% and 89.89% in the isolated and concomitant AVR group respectively. There was no difference in survival between the two groups (log-rank test, P=0.4124). Conclusions: Our results support the safety and efficacy of the Edwards INTUITY valve system even in complex aortic valve disease with additional cardiac procedures. RD-AVR could become a useful tool for concomitant surgeries where surgical times are expected to be prolonged.

Evidence for a lack of inotropic and chronotropic effects of glucagon and glucagon receptors in the human heart.

BACKGROUND: Glucagon is thought to increase heart rate and contractility by stimulating glucagon receptors and increasing 3',5'-cyclic adenosine monophosphate (cAMP) production in the myocardium. This has been confirmed in animal studies but not in the human heart. The cardiostimulatory effects of glucagon have been correlated with the degree of cardiac dysfunction, as well as with the enzymatic activity of phosphodiesterase (PDE), which hydrolyses cAMP. In this study, the presence of glucagon receptors in the human heart and the inotropic and chronotropic effects of glucagon in samples of failing and nonfailing (NF) human hearts were investigated. METHODS: Concentration‒response curves for glucagon in the absence and presence of the PDE inhibitor IBMX were performed on samples obtained from the right (RA) and left atria (LA), the right (RV) and left ventricles (LV), and the sinoatrial nodes (SNs) of failing and NF human hearts. The expression of glucagon receptors was also investigated. Furthermore, the inotropic and chronotropic effects of glucagon were examined in rat hearts. RESULTS: In tissues obtained from failing and NF human hearts, glucagon did not exert inotropic or chronotropic effects in the absence or presence of IBMX. IBMX (30 µM) induced a marked increase in contractility in NF hearts (RA: 83 ± 28% (n = 5), LA: 80 ± 20% (n = 5), RV: 75 ± 12% (n = 5), and LV: 40 ± 8% (n = 5), weaker inotropic responses in the ventricular myocardium of failing hearts (RV: 25 ± 10% (n = 5) and LV: 10 ± 5% (n = 5) and no inotropic responses in the atrial myocardium of failing hearts. IBMX (30 µM) increased the SN rate in failing and NF human hearts (27.4 ± 3.0 beats min-1, n = 10). In rat hearts, glucagon induced contractile and chronotropic responses, but only contractility was enhanced by 30 µM IBMX (maximal inotropic effect of glucagon 40 ± 8% vs. 75 ± 10%, in the absence or presence of IBMX, n = 5, P < 0.05; maximal chronotropic response 77.7 ± 6.4 beats min-1 vs. 73 ± 11 beats min-1, in the absence or presence of IBMX, n = 5, P > 0.05). Glucagon receptors were not detected in the human heart samples. CONCLUSIONS: Our results conflict with the view that glucagon induces inotropic and chronotropic effects and that glucagon receptors are expressed in the human heart.

Incidence and predictors of sternal surgical wound infection in cardiac surgery: A prospective study.

Sternal surgical wound infection (SSWI) in cardiac surgery is associated with increased morbidity. We investigated the incidence of SSWI, the main germs implicated and predictors of SSWI. Prospective study including patients undergoing full median sternotomy between January 2017 and December 2019. Patients were followed-up for 3 months after hospital discharge. All sternal wound infections up to 90 days after discharge were considered SSWI. 1004 patients were included. During follow-up, 68 (6.8%) patients presented SSWI. Patients with SSWI had a higher incidence of postoperative renal failure (29.4% vs 17.1%, P = .007), a higher incidence of early postoperative reoperation for non-infectious causes (42.6% vs 9.1%, P < .001), longer ICU stay (3 [2-9] days vs 2 [2-4] days, P = .006), and longer hospital stay (24.5 [14.8-38.3] days vs 10 [7-18] days, P < .001). Gram-positive germs were presented in 49% of the cultures, and gram-negative bacteria in 35%. Early reoperation for non-infectious causes (OR 4.90, 95% CI 1.03-23.7), and a longer ICU stay (OR 1.37 95% CI 1.10-1.72) were independent predictors of SSWI. SSWI is rare but leads to more postoperative complications. The need for early reoperation because of non-infectious cause and a longer ICU stay were independently associated with SSWI.

Hematic Antegrade Repriming Reduces Emboli on Cardiopulmonary Bypass: A Randomized Controlled Trial.

Particulate and gaseous microemboli (GME) are side effects of cardiac surgery that interfere with postoperative recovery by causing endothelial dysfunction and vascular blockages. GME sources during surgery are multiple, and cardiopulmonary bypass (CPB) is contributory to this embolic load. Hematic antegrade repriming (HAR) is a novel procedure that combines the benefits of repriming techniques with additional measures, by following a standardized procedure to provide a reproducible hemodilution of 300 ml. To clarify the safety of HAR in terms of embolic load delivery, a prospective and controlled study was conducted, by applying Doppler probes to the extracorporeal circuit, to determine the number and volume of GME released during CPB. A sample of 115 patients (n = 115) was considered for assessment. Both groups were managed under strict normothermia, and similar clinical conditions and protocols, receiving the same open and minimized circuit. Significant differences in GME volume delivery (control group [CG] = 0.28 ml vs. HAR = 0.08 ml; p = 0.004) and high embolic volume exposure (>1 ml) were found between the groups (CG = 30.36% vs. HAR = 4.26%; p = 0.001). The application of HAR did not represent an additional embolic risk and provided a four-fold reduction in the embolic volume delivered to the patient (coefficient, 0.24; 95% CI, 0.08-0.72; p = 0.01), which appears to enhance GME clearance of the oxygenator before CPB initiation.

Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus.

OBJECTIVES: The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19-21 mm) in comparison to larger Intuity prostheses (>21 mm). METHODS: This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19-21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups. RESULTS: A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62). CONCLUSIONS: This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.

Comparison of Aortic Gradient and Ventricular Mass after Valve Replacement for Aortic Stenosis with Rapid Deployment, Sutureless, and Conventional Bioprostheses.

BACKGROUND: The use of rapid deployment and sutureless aortic prostheses is increasing. Previous reports have shown promising results on haemodynamic performance and mortality rates. However, the impact of these bioprostheses on left ventricular mass (LVM) regression remains unknown. We decided to study the changes in remodelling and LVM regression in isolated severe aortic stenosis treated with conventional or Perceval® or Intuity® valves. METHOD AND RESULTS: From January 2011 to January 2016, 324 bioprostheses were implanted in our centre. The collected characteristics were divided into 3 groups: conventional valves, Perceval®, and Intuity®, and they were analysed after 12 months. There were 183 conventional valves (56%), 72 Perceval® (22%), and 69 Intuity® (21.2%). The statistical analysis showed significant differences in transprosthetic postoperative peak gradient (23 [18-29] mm Hg vs. 21 [16-29] mm Hg and 18 [14-24] mm Hg, p < 0.001), ventricular mass electrical criteria regression (Sokolow and Cornell products), and 1-year survival (90 vs. 93% and 97%, log rank p value = 0.04) in conventional, Perceval®, and Intuity® groups. CONCLUSIONS: We observed differences in haemodynamic, electrocardiographic, and echocardiographic parameters related to the different types of prosthesis. Patients with the Intuity® prosthesis had the highest reduction in peak aortic gradient and the higher ventricular mass regression. Besides, patients with the Intuity® prosthesis had less risk of mortality during follow-up than the other two groups. Further studies are needed to confirm these findings.

Hematic Antegrade Repriming: A Reproducible Method to Decrease the Cardiopulmonary Bypass Insult.

The current practice of cardiopulmonary bypass (CPB) requires a preoperative priming of the circuit that is frequently performed with crystalloid solutions. Crystalloid priming avoids massive embolism but is unable to eliminate all microbubbles contained in the circuit. In addition, it causes a sudden hemodilution which is correlated with transfusion requirements and an increased risk of cognitive impairment. Several repriming techniques using autologous blood, collectively termed retrograde autologous priming (RAP), have been demonstrated to reduce the hemodilutional impact of CPB. However, the current heterogeneity in the practice of RAP limits its evidence and benefits. Here, we describe hematic antegrade repriming as an easy and reliable method that could be applied with any circuit in the market to decrease transfusion requirements, emboli, and inflammatory responses, reducing costs and the impact of CPB on postoperative recovery.

Epidemiología del mixoma cardiaco en una población española. Una serie quirúrgica de 30 años / Epidemiology of cardiac myxoma in a Spanish population. A 30-year surgical series

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Obstrucción intestinal secundaria a aneurisma de arteria hipogástrica / Intestinal obstruction secondary to hypogastric artery aneurysm

No disponible

Cirugía cardiaca mediante mínimo acceso. Registro multicéntrico español / Miniaccess heart surgery. A spanish multicenter registry

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Perceval Less Invasive Aortic Replacement Register: multicentric Spanish experience with the Perceval S bioprosthesis in moderate-high-risk aortic surgery.

OBJECTIVES: The development of new percutaneous and surgical techniques has reduced the risk associated with aortic valve replacement procedures. We present the results of a Spanish register after initiating a programme for sutureless prostheses in moderate-high-risk patients. METHODS: This prospective multicentre study was carried out from November 2013 to November 2016. Data were obtained from 448 patients in whom a Perceval S prosthesis was implanted. RESULTS: The mean age was 79.24 (standard deviation [SD] 4.1) years, and 61.2% were women. The estimated EuroSCORE I log risk was 11.15% (SD 7.6), with an observed mortality of 4.4% (20 patients). Isolated aortic valve replacement was performed on 69.26% of patients, with 64% involving ministernotomy. The incidence of neurological events was 2%, with 2 permanent cerebrovascular accidents, and 41 (9.2%) patients were implanted with a permanent endocavitary pacemaker. At discharge, 12 (2.6%) patients presented minimal periprosthetic leakage, and 4 (0.89%) patients had moderate leakage. There were 3 reinterventions during follow-up (2 endocarditis and 1 dysfunction due to periprosthetic leak progression). The mean gradient at discharge, 6 months and 1 year was 12.94 (SD 5.3) mmHg, 12.19 (SD 4.7) mmHg and 11.77 (SD 4.7) mmHg, respectively; 59.4% of the patients were octogenarians, with a survival rate of 98% at both 6 months and 1 year at discharge. There was neither valve migration nor early structural degeneration. The mean follow-up was 12 ± 3 months. The 6-month and 1-year mortality was 1.4% and 2.1%, respectively. CONCLUSIONS: This is a prospective multicentric study on the largest cohort of patients with sutureless valves conducted in Spain to date. It is a reproducible procedure that has enabled surgery on patients with a moderate-high risk with low morbidity and mortality, providing good haemodynamic results.

[Surgical treatment of renal tumours with venous extension]. / Tratamiento quirúrgico del tumor renal con extensión venosa.

OBJECTIVES: Renal carcinoma accounts for 3% of malignant urological tumors. The existence of tumor thrombus in the venous system is more infrequent, and, despite it was believed until recently its presence worsened the diagnosis of the disease, currently it is accepted that in the absence of metastatic or lymph node disease, surgery is the treatment of choice and potentially curative for these tumors. METHODS: Between June 2003 and November 2007 eight patients with renal disease and venous thrombus underwent surgery; two of them wereT3c and six T3b; in five of them surgery was carried out in association with the heart surgery team in our centre. Three of them underwent surgery with extracorporeal circulation. Mean patient age was 56 years. RESULTS: Tumor thrombus was grade I in one patient, grade II in 4 patients, grade III in one patient, and grade IV in two patients. In all patients with tumor grade > or = III, as well as two with grade II, surgery was performed in conjunction with the department of heart surgery. The operation with extracorporeal circulation, deep hypothermia, cardioplegia, and antegrade and retrograde brain perfusion was performed in grades III and IV. Midline incision was performed, with or without sternotomy, depending on the level of the thrombus. Hemorrhage was the most frequent perioperative complication. DISCUSSION: It is essential to know the exact level of the cephalic extreme of the tumor thrombus to design the proper surgical strategy; for that, we can use MRI, CT scan or ultrasound. Therefore, surgical approach, multidisciplinary cooperation and use of extracorporeal circulation will depend on such extension of the thrombus and concurrent factors of the patient. A good surgical strategy, as well as early surgery may avoid the use of venous filters preoperatively. CONCLUSIONS: Venous wall invasion seems to be related with a greater incidence of lymph node disease, but these patients are candidates to intention-to-cure radical surgery. Thrombus level is not a prognostic factor per se, but it should be taken into consideration for surgical planning. After radical surgery survival rates achieved are similar to those of tumors without venous thrombus.

Tratamiento quirúrgico del tumor renal con extensión venosa / Our experience in treatment of renal tumours with venous involvement

OBJETIVO: El carcinoma renal supone un 3% de los tumores malignos urol¨®gicos. M¨¢s infrecuente es la existencia de trombo tumoral dentro del sistema venoso y, si bien hasta hace poco se pensaba que su existencia ensombrec¨ªa el pron¨®stico de esta enfermedad, actualmente se acepta que en ausencia de enfermedad metast¨¢sica o ganglionar, la cirug¨ªa es el tratamiento de elecci¨®n y potencialmente curativo para estos tumores.MÉTODOS: Entre junio de 2003 y noviembre de 2007 hemos intervenido un total de 8 pacientes con enfermedad renal y trombo venoso, de los cuales 2 eran T3c y seis T3b, cinco de ellos fueron intervenidos junto con el servicio de cirug¨ªa cardiaca de nuestro centro. Tres de ellos fueron intervenidos con circulaci¨®n extracorp¨®rea (CEC). La media de edad de los pacientes fue de 56 años.RESULTADOS: El trombo tumoral era grado I en un paciente, grado II en 4 pacientes, grado III en 1 paciente y grado IV en dos pacientes. Todos los pacientes con grado tumoral igual o mayor de III, as¨ª como dos grado II, fueron intervenidos conjuntamente con el servicio de cirug¨ªa cardiaca, realizando en los grado III y IV la intervenci¨®n con circulaci¨®n extracorp¨®rea, hipotermia profunda con parada cardiorrespiratoria y perfusi¨®n cerebral anter¨®grada y retr¨®grada. Se realiz¨® incisi¨®n media con o sin estereotom¨ªa media dependiendo del nivel del trombo. La complicaci¨®n m¨¢s frecuente acaecida peroperatoriamente fue la hemorragia.DISCUSIÓN: Es esencial conocer el nivel exacto de la extensi¨®n cef¨¢lica del trombo tumoral para diseñar una adecuada estrategia quir¨²rgica, para lo que nos podemos valer de la resonancia magn¨¦tica (RM), de la tomograf¨ªa computerizada (TC) y de la ecocardiograf¨ªa. As¨ª el abordaje quir¨²rgico, la colaboraci¨®n multidisciplinar y el empleo de CEC depender¨¢ de dicha extensi¨®n y de los factores concomitantes presentes en el enfermo. Una buena estrategia quir¨²rgica, as¨ª como una cirug¨ªa temprana pueden evitar el uso de filtros venosos de forma preoperatoria

CONCLUSIONES: La invasión de la pared venosa parece estar relacionada con una mayor incidencia de enfermedad ganglionar, pero estos pacientes son candidatos a la cirugía radical con intención curativa. El nivel del trombo, si bien puede dificultar la cirug¨ªa, no es un factor pron¨®stico per se, y si debe ser tenido en cuenta para la planificaci¨®n quir¨²rgica. Tras la cirug¨ªa radical se alcanzan cifras de supervivencia superponibles a los tumores sin trombo venoso tumoral(AU)

OBJECTIVES: Renal carcinoma accounts for 3% of malignant urological tumors. The existence of tumor thrombus in the venous system is more infrequent, and, despite it was believed until recently its presence worsened the diagnosis of the disease, currently it is accepted that in the absence of metastatic or lymph node disease, surgery is the treatment of choice and potentially curative for these tumors.METHODS: Between June 2003 and November 2007 eight patients with renal disease and venous thrombus underwent surgery; two of them wereT3c and six T3b; in five of them surgery was carried out in association with the heart surgery team in our centre. Three of them underwent surgery with extracorporeal circulation. Mean patient age was 56 years.RESULTS: Tumor thrombus was grade I in one patient, grade II in 4 patients, grade III in one patient, and grade IV in two patients. In all patients with tumor grade ¡Ý III, as well as two with grade II, surgery was performed in conjunction with the department of heart surgery. The operation with extracorporeal circulation, deep hypothermia, cardioplegia, and antegrade and retrograde brain perfusion was performed in grades III and IV. Midline incision was performed, with or without sternotomy, depending on the level of the thrombus. Hemorrhage was the most frequent perioperative complication.DISCUSSION: It is essential to know the exact level of the cephalic extreme of the tumor thrombus to design the proper surgical strategy; for that, we can use MRI, CT scan or ultrasound. Therefore, surgical approach, multidisciplinary cooperation and use of extracorporeal circulation will depend on such extension of the thrombus and concurrent factors of the patient. A good surgical strategy, as well as early surgery may avoid the use of venous filters preoperatively(AU)

CONCLUSIONS: Venous wall invasion seems to be related with a greater incidence of lymph node disease, but these patients are candidates to intention-to-cure radical surgery. Thrombus level is not a prognostic factor per se, but it should be taken into consideration for surgical planning. After radical surgery survival rates achieved are similar to those of tumors without venous thrombus(AU)

Tratamiento quírúrgico de carcinoma renal con trombo y filtro en vena cava / Surgical treatment of the renal carcinoma with inferior vena cava thrombus and filter

Objetivo: La invasión vascular en forma de trombo tumoral sucede en un no desdeñable porcentaje de las neoplasias renales, la importancia de la extensión cefálica del trombo en el pronóstico es discutida actualmente pero en ausencia de metástasis a distancia, el tratamiento quirúrgico es mandatorio. Método: Presentamos el caso de un paciente de 56 años al que intervenimos en nuestro centro, portador de filtro en vena cava inferior mediante abordaje toraco-abdominal con circulación extracorpórea (CEC), hipotermia profunda (por debajo de los 18ºC) y retroperfusión cerebral. Resultados: Si bien tiempo atrás se pensaba que la presencia de trombo tumoral ensombrecía el pronóstico de estos pacientes, actualmente sabemos que con tratamiento quirúrgico, en casos seleccionados, se obtienen buenos resultados en términos de supervivencia y tiempo libre de enfermedad. Conclusión: Pensamos que el implante de filtros venosos, puede incrementar la complejidad de la cirugía (AU)

Objective: Vascular invasion in the form of tumour thrombus appears in a significant percentage of renal neoplasias. The importance of cephalic extension of the thrombus in prognosis is currently under discussion, but surgical treatment is mandatory in the absence of distant metastasis. Methods: We report the case of a 56-year-old male patient with a filter in the inferior vena cava, who underwent surgery in our department through a thoracoabdominal approach with extracorporeal circulation, deep hypothermia (below 18ºC) and cerebral retrograde perfusion. Results: Although in the past it was believed tumour thrombus worsened prognosis in these patients, currently we know that surgical treatment, in selected cases, gives good results in terms of survival and disease-free time. Conclusions: We think the implementation of venous filters may increase the complexity of surgery (AU)

Left ventricular mass index as a prognostic factor in patients with severe aortic stenosis and ventricular dysfunction.

Ventricular dysfunction and high hypertrophy may influence surgical outcome in aortic stenosis. Our aim was to determine whether an excessive left ventricular mass index (LVMI) discriminates different risk profiles in aortic stenosis with low ventricular ejection fraction (LVEF). Three hundred and thirty-nine patients with severe aortic stenosis underwent valve replacement (Mar-1994 and Nov-2001). LVMI values over the superior quartile were considered increased. Mortality models were constructed in global and LVEF

[Ablation of permanent atrial fibrillation in cardiac surgery. Short-term and mid-term results]. / Ablación de la fibrilación auricular permanente en la cirugía cardíaca. Resultados a corto y medio plazo.

INTRODUCTION: Surgical ablation of atrial fibrillation is currently a simple procedure that can be done during cardiac surgery in most patients. A number of different energy sources now available allow to easily create ablation lines in the atria. We describe our experience during the previous three years. PATIENTS AND METHOD: In 93 patients with cardiac problems treated with surgery and permanent atrial fibrillation (longer than 3 months), surgical ablation of the arrhythmia was done at the same time. Mean duration of the atrial fibrillation was 6 years (range 0.3 to 24 years). Mean (SD) preoperative size of the atrium as measured echocardiographically was 51.7 (8.8) mm (range 35 to 77 mm). RESULTS: Five patients died in the hospital (5.3% in-hospital mortality). After a mean follow-up of 10 months, 83.8% of the patients had recovered and maintained sinus rhythm, and 16.1% of the patients remained in atrial fibrillation. A permanent pacemaker was implanted in 3 of these patients. Among the 82 patients followed for more than 6 months, the prevalence of sinus rhythm was 84.1%. Echocardiographically documented contractility in both atria was observed in 50% of the patients. Major complications related to the ablation procedure occurred in 3.5% of the patients, and consisted of a perivalvular leak 2 months after surgery, a circumflex artery spasm, and an atrio-esophageal fistula. CONCLUSIONS: Surgical ablation of permanent atrial fibrillation is a simple procedure associated with low morbidity and mortality, and with recovery of sinus rhythm in most patients. The main problem with the procedure is the incidence of early postoperative arrhythmias.