Which type of valve should we use in tricuspid position? Long-term comparison between mechanical and biological valves.

BACKGROUND: Nowadays, tricuspid valve replacement (TVR) is much less common than aortic or mitral valve replacement, since repair is almost always preferable. Prosthetic tricuspid valves are associated with high mortality and morbidity, mostly due to thrombotic or hemorrhagic events. Nevertheless, there is lack of evidence of which is the optimal type of valve (biological versus mechanical) in tricuspid position. METHODS: We analyzed all the patients who underwent TVR in our Institution, from 2005 to 2015. Patient baseline characteristics were recorded (such as functional class, previous cardiac surgery, right ventricular dysfunction or pulmonary hypertension), and a clinical long-term follow-up was conducted. We compared the outcomes between mechanical and biological prostheses: in-hospital mortality, long-term mortality, need for reintervention and adverse events (such as stroke or valve thrombosis). RESULTS: During the study period 120 tricuspid prosthetic valves were implanted in 111 patients. 81 of them (67.5%) were bioprostheses, and 39 (32.5%) mechanical valves. 73 patients (60.8%) had undergone a previous cardiac surgery (28.4% had previous tricuspid surgery). Most of the patients (87.1%) were in high functional class (grade III-IV of the NYHA classification), and 85% had moderate to severe pulmonary hypertension. Mean logistic EuroSCORE I was 14.80%. Only 37 cases were isolated TVR (30.6%), as most of the cases were TVR concomitant to mitral valve replacement. In-hospital mortality was 21.7%, and during the follow-up (mean follow-up of 7 years) reached 37.5%. Three mechanical tricuspid valves (7.7%) had to be replaced due to thrombosis, while 7 biological valves (8.6%) had to be replaced due to valve deterioration. The incidence of stroke was 7.5%. CONCLUSIONS: Tricuspid valve replacement is an infrequent procedure with a high incidence of perioperative morbidity and mortality. Biological or mechanical valves have similar mortality, and a reasonably low incidence of need for reintervention due to thrombosis or valve deterioration.

Rotura iatrogénica de electrodos de marcapasos permanente en la realización de esternotomía media: presentación de un caso / Iatrogenic rupture of permanent pacemaker electrodes while performing a median sternotomy: a case report

RESUMEN La esternotomía media continúa siendo el gold-standart de abordaje quirúrgico en cirugía cardiaca. Aún realizada correctamente, la apertura media del esternón presenta complicaciones en el 1-5% de los casos que varían en su gravedad desde la infección de la herida quirúrgica a la lesión de estructuras intratorácicas. En el presente estudio se describe un caso de rotura de electrodos de marcapasos tras esternotomía media por retracción y fibrosis del tronco venoso braquiocefálico. Debido a la ausencia de artículos semejantes en la literatura y al extendido empleo de la esternotomía en pacientes portadores de marcapasos permanente, se pretende disminuir las lesiones asociadas mediante la publicación de un infrecuente caso de lesión iatrogénica durante la apertura esternal, con escasos precedentes en la literatura publicada hasta la fecha. MÉD.UIS. 2016;29(3):95-9.

ABSTRACT Median sternotomy is still the gold-standard surgical approach in cardiac surgery. Even correctly performed, the sternum median opening presents complications in an incidence of 1-5% of cases comprising in severity from infection of the surgical wound to the injury of intrathoracic structures. We describe a case in which the pacemaker leads were broken after median sternotomy because of the brachiocephalic vein fibrosis. Due to the absence of similar items in the literature and the widespread use of sternotomy in patients with permanent pacemakers, we intended to reduce associated injuries by posting a rare case of iatrogenic injury during sternal opening with few precedents in the literature. MÉD.UIS. 2016;29(3):95-9.

Predictors of persistent pulmonary hypertension after mitral valve replacement.

Persistent pulmonary hypertension (P-PH) after mitral valve replacement (MVR) leads to an increased risk of morbidity and mortality. We sought to determine which factors were involved in its occurrence. Patients undergoing MVR for a 3-year period were collected in a retrospective way. We excluded those with an available follow-up shorter than 3 months. Sample size was 111 patients. PH was diagnosed if systolic pulmonary artery pressure (sPAP) estimated by Doppler echocardiography was >40 mmHg. Clinical, echocardiographic, and surgical factors were analyzed. P-PH was present in 42.3 % of patients after 12.6 months of mean follow-up. P-PH was more frequently observed in elderly and female patients, in those with severe degrees of PH before surgery, and significant tricuspid regurgitation (TR). On multivariable analysis, significant TR (OR 1.739; p = 0.01) and more severe degrees of PH before surgery (OR 1.761; p = 0.03) were significantly associated with the presence of P-PH after MVR. Surgical factors related to P-PH were prosthesis size and tricuspid annuloplasty: no need for the performing of tricuspid annuloplasty (OR 0.345; p = 0.025) and the implantation of a smaller prosthesis (OR 0.656; p = 0.004) were related to higher rates of P-PH after MVR. MVR was associated with high prevalence of P-PH after mid-term follow-up. Both PH and significant TR before surgery were associated with P-PH. Our data point out that MVR should be planned before the development of PH and greater TR. Smaller prosthetic size is also a risk factor for P-PH and bigger prostheses are desirable when possible.

Interventricular septal rupture after transcatheter aortic valve implantation: surgical and perioperative management.

Transcatheter aortic valve implantation (TAVI) is associated with various complications, usually related to valve positioning or prosthesis delivery. We report the rare complication of an iatrogenic ventricular septal defect, secondary to aortic annulus disruption after TAVI-transfemoral procedure, generating a significant left-to-right shunt and cardiac failure. Open surgical procedures under cardiopulmonary bypass remain the best option for this lethal complication.

[Percutaneous extraction of pacemaker and defibrillator leads]. / Extracción de electrodos de marcapasos y desfibrilador mediante técnicas percutáneas.

INTRODUCTION AND OBJECTIVES: There is an increasing need for endocardial pacing and defibrillators leads to be removed. However, the procedure can be complex and it is not risk-free. We reviewed our experience between April 1989 and June 2006 with the percutaneous extraction of leads. METHODS: In total, 314 electrodes were extracted from 187 patients. The leads had been implanted over an average period of 69.16 months (range 0.11-234.6 months, median 60.25 months). Some 115 were atrial leads, 196 were ventricular, and three were in the coronary veins; of these, 78 had been abandoned in the vascular bed. RESULTS: Indications for removal were infection (26.1%), dysfunction (22.9%), erosion (25%), endocarditis (20.7%), and bacteremia (2.7%). Overall, 58.8% of patients were referred from other departments. In 96.8%, the electrodes were completely removed. Simple traction was used in 23.4%, and countertraction techniques (with and without radiofrequency current support) were used in 60.7%. For abandoned leads, a biopsy clamp was used in combination with countertraction (4.3%) or a femoral approach with a snare (10.1%). A sternotomy was required in three of the 10 patients with remaining electrode fragments. The complication rate was 4.6% (with major complications in 2.5%). Complications were associated with age < 60 years (odds ratio [OR]=5.38, 95% confidence interval [CI] 1.07-27.23), the presence of endocarditis (OR=4.97: 95%CI, 1.04-23.70), and right side implantation (OR=17.09; 95% CI, 2.15-135.70). CONCLUSIONS: In the majority of cases, pacing and defibrillator leads can be removed without difficulty using modern extraction techniques. However, because there is a risk of complications during extraction, even though it is low, the procedure should be carried out in specialized centers with surgical facilities.

Extracción de electrodos de marcapasos y desfibrilador mediante técnicas percutáneas / Percutaneous extraction of pacemaker and defibrillator leads

Introducción y objetivos. La necesidad de retirar los electrodos endocavitarios del marcapasos o el desfibrilador es cada vez más frecuente, aunque no está exenta de riesgos y complejidad. Revisamos nuestra experiencia en la retirada de electrodos por vía percutánea desde abril de 1989 hasta junio de 2006. Métodos. Se retiraron 314 electrodos en 187 pacientes, implantados durante un período medio de 69,16 meses (intervalo, 0,11-234,6 meses; mediana 60,25 meses). En total, 115 fueron auriculares, 196 ventriculares y 3 de seno coronario, encontrándose 78 de ellos abandonados en el lecho vascular. Resultados. Las indicaciones fueron: infección (26,1%), disfunción (22,9%), decúbito (25%), endocarditis (20,7%) y bacteriemia (2,7%). El 58,8% de los pacientes fue remitido desde otros servicios. El 96,8% de los electrodos se retiró completamente. Se utilizó la tracción simple en el 23,4% de los pacientes y técnicas de contratracción (con y sin radiofrecuencia) en el 60,7%. En caso de que hubiera electrodos abandonados, se utilizó una pinza de biopsia (4,3%) combinada con sistemas de contratracción o lazos femorales (10,1%). Se necesitó una esternotomía media en 3 pacientes de los 10 en los que quedaron restos de electrodos. El porcentaje de complicaciones fue del 4,6% (un 2,5% de complicaciones mayores). Éstas se relacionaron con la edad menor de 60 años (odds ratio [OR] = 5,38; intervalo de confianza [IC] del 95%, 1,07-27,23), la presencia de endocarditis (OR = 4,97; IC del 95%, 1,04-23,70) y la implantación por el lado derecho (OR = 17,09; IC del 95%, 2,15-135,70). Conclusiones. La retirada de electrodos endocavitarios con los modernos sistemas de extracción soluciona el problema en la mayoría de los casos. Debido a la posibilidad, aunque baja, de complicaciones durante la retirada, se aconseja realizar el procedimiento en centros especializados con capacidad quirúrgica (AU)

Introduction and objectives. There is an increasing need for endocardial pacing and defibrillators leads to be removed. However, the procedure can be complex and it is not risk-free. We reviewed our experience between April 1989 and June 2006 with the percutaneous extraction of leads. Methods. In total, 314 electrodes were extracted from 187 patients. The leads had been implanted over an average period of 69.16 months (range 0.11-234.6 months, median 60.25 months). Some 115 were atrial leads, 196 were ventricular, and three were in the coronary veins; of these, 78 had been abandoned in the vascular bed. Results. Indications for removal were infection (26.1%), dysfunction (22.9%), erosion (25%), endocarditis (20.7%), and bacteremia (2.7%). Overall, 58.8% of patients were referred from other departments. In 96.8%, the electrodes were completely removed. Simple traction was used in 23.4%, and countertraction techniques (with and without radiofrequency current support) were used in 60.7%. For abandoned leads, a biopsy clamp was used in combination with countertraction (4.3%) or a femoral approach with a snare (10.1%). A sternotomy was required in three of the 10 patients with remaining electrode fragments. The complication rate was 4.6% (with major complications in 2.5%). Complications were associated with age < 60 years (odds ratio [OR]=5.38, 95% confidence interval [CI] 1.07-27.23), the presence of endocarditis (OR=4.97: 95%CI, 1.04-23.70), and right side implantation (OR=17.09; 95% CI, 2.15-135.70). Conclusions. In the majority of cases, pacing and defibrillator leads can be removed without difficulty using modern extraction techniques. However, because there is a risk of complications during extraction, even though it is low, the procedure should be carried out in specialized centers with surgical facilities (AU)

[A patient with cardiac angiosarcoma who survived for four years. Case report and literature review]. / Angiosarcoma cardíaco. Cuatro años de supervivencia. Revisión a propósito de un caso.

We describe a 57-year-old woman with a diagnosis of primary cardiac angiosarcoma. She underwent emergency surgery with a preoperative diagnosis of atrial myxoma, and pathological analysis confirmed the diagnosis of cardiac angiosarcoma. Two years later she was readmitted to the hospital with recurrence of the tumor in the left atrium and involvement of the mitral valve. Another operation was carried out for mitral valve and left atrial wall reconstruction with a bovine pericardial patch. Two years later a new recurrence of the tumor was discovered, and she died of multiorgan failure. The mortality associated with primary cardiac neoplasm is very high, although aggressive treatment together with appropriate chemotherapy may significantly prolong patient's lifespan.

Angiosarcoma cardíaco. Cuatro años de supervivencia. Revisión a propósito de un caso / A patient with cardiac angiosarcoma who survived for four years. Case report and literature review

Presentamos el caso de una mujer de 57 años intervenida de urgencias con el diagnóstico de mixoma auricular; tras el estudio anatomopatológico se confirmó el diagnóstico de angiosarcoma primario cardíaco. A los 2años, la paciente presentó recidiva del tumor en aurícula izquierda con infiltración de la válvula mitral. Fue reintervenida realizándose una reconstrucción valvular y dela aurícula izquierda con pericardio bovino. Dos años después presentó una nueva recidiva del tumor, falleció en fracaso multiorgánico. Los tumores cardíacos primarios presentan una elevada mortalidad, aunque un tratamiento quirúrgico agresivo combinado con una quimioterapia adecuada puede prolongar la supervivencia

We describe a 57-year-old woman with a diagnosis ofprimary cardiac angiosarcoma. She underwent emergency surgery with a preoperative diagnosis of atrial myxoma, and pathological analysis confirmed the diagnosis of cardiac angiosarcoma. Two years later she was readmitted to the hospital with recurrence of the tumor in the left atrium and involvement of the mitral valve. Another operation was carried out for mitral valve and left atrial wall reconstruction with a bovine pericardial patch. Two years later a new recurrence of the tumor was discovered, and she died of multiorgan failure. The mortality associated with primary cardiac neoplasm is very high, although aggressive treatment together with appropriate chemotherapy may significantly prolong patient’s lifespan