Predictive Factors for Pulmonary Homograft Dysfunction After Ross Surgery: A 20-Year Follow-up.

BACKGROUND: We studied the determinants of hemodynamics and analyzed the incidence, risk factors, and clinical impact of pulmonary homograft dysfunction following Ross surgery, after a 20-year follow-up at our referral center. METHODS: From 1997 to 2017, a total of 142 patients underwent surgery using the Ross procedure. The development of moderate-severe stenosis (peak transhomograft pressure gradient 36 mm Hg or greater) and surgical or percutaneous Ross homograft reinterventions were evaluated by echocardiography in the immediate postoperative period and at annual intervals. RESULTS: After 20 years of follow-up, 31% of patients had moderate-severe homograft stenosis, and 9.1% had had to undergo one or two reinterventions, of which, six were valve replacements and seven were percutaneous interventions. At 1, 5, and 20 years, 89.4%, 74.6%, and 69% of these patients, respectively, were free from moderate-severe stenosis; and 99.3%, 95.7%, and 90.9%, respectively, had freedom from homograft reintervention. The pediatric group had a higher risk factor for homograft stenosis (hazard ratio 3.70; 95% confidence interval, 1.56 to 7.20, P = .002), whereas donor age behaved as a protective factor (hazard ratio 0.98; 95% confidence interval, 0.95 to 0.99; P = .044). Pulmonary homograft stenosis tended to appear in the first year (10.6%) or at 5 years (25.4%). CONCLUSIONS: Pulmonary homografts implanted in the Ross procedure offer satisfactory long-term results, but the level of homograft dysfunction is not negligible. Young recipient and donor age were associated with a higher rate of homograft stenosis during follow-up. Moreover, homograft dysfunction usually occurred during the first few years of follow-up, and may have been related to immune responses.

Endothelial vascular markers in coronary surgery.

Coronary heart disease is associated with high morbidity and mortality. Endothelial dysfunction in affected patients is linked to long-term atherosclerotic disease progression and cardiovascular event rates. The present paper reports on changes in the levels of endothelial progenitor cells (VEGFR2/CD133/CD34), essential for endothelial repair, and of endothelial microvesicles (CD31/annexin V) as indicators of endothelial lesion, in patients undergoing coronary bypass surgery with respect both to baseline levels and to counts in healthy subjects. In an observational descriptive study, 31 patients scheduled for coronary revascularization surgery were compared with those of 25 healthy controls. In a subsequent longitudinal study, patients undergoing surgery were monitored at 5 timepoints up until 48 h after surgery. Endothelial progenitor cell (VEGFR2/CD133/CD34) and endothelial microvesicle (CD31/annexin V) levels were quantified by flow cytometry. Baseline endothelial progenitor cell counts in coronary patients were significantly lower than those of healthy controls (p < 0.001); however, after surgery, levels rose steadily over all 5 timepoints to 48 h  with statistically significant differences (p < 0.001) between intra-operative and 48 h after surgery (T5). Endothelial microvesicle levels were significantly higher in coronary patients prior to surgery than in healthy controls (p < 0.001), and despite declining at 48 h remained significantly higher than those of controls (p < 0.001). Coronary surgery has had a positive impact on the endothelium in the patients, prompting a decrease in signs of endothelial dysfunction and a considerable improvement in the endothelial repair mechanisms involved in angiogenesis, playing an important role in the inflammatory response and the remodelling process of ischemic myocardium in postoperative period.

Heart transplantation in a patient with recurrent early extensive endocarditis.

Active valvular endocarditis could be considered a contraindication to heart transplantation. Nevertheless, there have been some reports of success with this form of treatment, despite the characteristics of the infection and its aggressive nature. Here, we describe the case of a patient with acute bicuspid aortic valvular endocarditis caused by Staphylococcus aureus and with a periannular abscess. Cryopreserved aortic homograft replacement of the aortic root was initially carried out, in addition to debridement and reconstruction of the interventricular septum with a pericardial patch. Early recurrence occurred, however, with extensive tissue destruction, a periaortic abscess and involvement of multiple valves, associated with severe sepsis. In view of the failure of 'conventional' surgery, an emergency heart transplantation was decided on after discussing the case with the Spanish National Transplant Organization (ONT), because of the theoretical contraindication of transplantation in this case. Transplantation was finally carried out after a waiting period of 3 days, in emergency code conditions, and the postoperative course proved uneventful, with no reinfection during the follow-up period. The present case suggests that heart transplantation may be an alternative option in patients suffering aggressive endocarditis with extensive involvement of the heart structures.

[Incidence and clinical impact of pulmonary homograft dysfunction after the Ross procedure]. / Incidencia e impacto clínico de la estenosis del homoinjerto pulmonar tras el procedimiento de Ross.

INTRODUCTION AND OBJECTIVES: We analyzed the incidence, risk factors and clinical impact of pulmonary homograft dysfunction after the Ross procedure in our patients. PATIENTS AND METHOD: All patients were evaluated at 3, 6 and 12 months, and annually thereafter. Patients with a transhomograft pressure gradient greater than 30 mmHg were referred for cardiac magnetic resonance imaging. RESULTS: At the end of the study, 9 patients (11.8%) showed a transhomograft pressure gradient >30 mmHg after a mean period of 15.3 months post-surgery. Mean transhomograft pressure gradient was 19.8 (16.2%) (range, 2-100 mmHg). All patients were in functional class I, except 2 who were in New York Heart Association class II with severe stenosis. These 2 patients were treated percutaneously with stent placement and no reoperation. No association was found between clinical outcome and sex, age or homograft diameter. We found a trend toward greater perioperative use of plasma, platelets and red cells in the group of patients in comparison to controls, although the difference was significant only for postoperative use of plasma (1.7 [3] vs 5.5 [5.3] units; P<0.05). Cardiac magnetic resonance imaging showed stenosis predominantly in the body of the homograft, whereas the valvular component itself remained competent. Right ventricular hypertrophy was mild or very mild in 7 patients and moderate in 2. CONCLUSIONS: The incidence of some degree of pulmonary homograft dysfunction after the Ross procedure was non-negligible, but its clinical impact seems to be slight. Patients with severe stenosis were treated successfully via a percutaneous approach. The use of blood products might be a risk factor for the development of this complication.

Incidencia e impacto clínico de la estenosis del homoinjerto pulmonar tras el procedimiento de Ross / Incidence and clinical impact of pulmonary homograft dysfunction after the Ross procedure

Introducción y objetivos. Estudiamos la incidencia, los factores de riesgo y el impacto clínico de la estenosis del homoinjerto pulmonar tras la intervención de Ross en nuestra serie clínica. Pacientes y método. El seguimiento se realizó a los 3, 6 y 12 meses, y después anualmente. Los pacientes con gradiente a través del homoinjerto pulmonar > 30 mmHg fueron sometidos a una resonancia magnética cardíaca. Resultados. De los 76 pacientes intervenidos, 9 (11,8 por ciento) presentaron un homoinjerto pulmonar > 30 mmHg una media de 15,3 meses después de la intervención. El gradiente medio fue de 19,8 ñ 16,2 mmHg (rango, 2-100). Todos los pacientes se encontraban en grado funcional I de la New York Heart Association excepto 2, que estaban en grado funcional II con estenosis severa y fueron tratados percutáneamente con stents, sin necesidad de reoperación. No encontramos asociación con el sexo, la edad ni el diámetro del homoinjerto. El uso de hemoderivados (hematíes, plasma y plaquetas) fue mayor en el grupo afectado que en el de control, si bien no alcanzó significación estadística, a excepción del uso de plasma en cuidados intensivos (1,7 ñ 3 frente a 5,5 ñ 5,3 unidades; p < 0,05). El estudio con resonancia magnética cardíaca demostró afección eminentemente del cuerpo de homoinjerto, con aparato valvular competente. La repercusión en el ventrículo derecho fue muy leve-leve (n = 7) o moderada (n = 2).Conclusiones. La incidencia de disfunción del homoinjerto pulmonar no es desdeñable, si bien el impacto clínico parece ser muy discreto y los casos severos se controlan satisfactoriamente de forma percutánea. El uso de hemoderivados podría ser un factor de riesgo para el desarrollo de esta complicación (AU)