Vein graft preservation with an endothelial damage inhibitor in isolated coronary artery bypass surgery: an observational propensity score-matched analysis.

Background: Preservation solutions may be used intraoperatively during coronary artery bypass grafting (CABG) to flush and preserve vein grafts. The aim of this study is to evaluate the effect of DuraGraft, an endothelial damage inhibitor (EDI) preservation solution on major adverse cardiac events (MACEs) after CABG. Methods: We conducted an observational, prospective, longitudinal, single-center study that included patients who underwent isolated CABG. The cohort treated with an EDI was matched 1:1 with a control group treated with conventional vein preservation, and matching was adjusted for possible confounding factors through propensity score (PS) matching. Three years follow-up was conducted, and the occurrence of MACE [defined as all cause-death, acute coronary syndrome (ACS), and new unplanned revascularization] was analyzed using Kaplan-Meier method. Results: The study included 180 patients, 90 in each group. There were no significant differences in baseline characteristics across study groups. The EDI group had a significantly better event-free survival at 3 years (89% vs. 78%, log-rank test P=0.035), with an incidence rate ratio of 0.41 [95% confidence interval (CI): 0.16-0.96]. In the pre-specified subgroups analysis, the use of an EDI was associated with a significantly better event-free survival in diabetic patients (log-rank test P=0.041) and those with two or more saphenous vein grafts (log-rank test P=0.015). Conclusions: The utilization of an EDI for vein flushing and storage after vein harvest in CABG procedures has been shown to significantly decrease the incidence of MACE at 3 years post-surgery. This protective effect is particularly notable in diabetic patients and in individuals who have multiple vein grafts.

Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Influence of Preoperative Frailty on Health-Related Quality of Life After Cardiac Surgery.

BACKGROUND: Frailty has emerged as one of the main predictors of worse outcomes after cardiac surgery, but scarce evidence is available about its influence on postoperative quality of life. Whether frail patients may improve their quality of life or not after the surgical procedure is a matter that still remains unclear. METHODS: This observational and multicenter cohort study was conducted in 3 university-affiliated hospitals of three different regions of Spain (Madrid, Asturias, and Canary Islands). Patients were categorized into three ordinal levels of frailty (frail, prefrail, robust) using the Fried, FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale, and Clinical Frailty Scale frailty scales. We analyzed the changes on health-related quality-of-life for each level of frailty using the EuroQoL 5-Dimension 5 Level questionnaire before and 6 months after the operation. RESULTS: The study included 137 patients, and 109 completed the 6-month follow-up. Median age of the entire cohort was 78 years (interquartile interval, 72 to 83 years). Frailty prevalence varied between 10% and 29%, depending on which scale was used. There was a statistically significant linear trend in the incidence of death or major morbidity among the different levels of frailty. On one hand, robust patients did not show significant changes in their previously high score of quality of life during follow-up. On the other hand, frail and prefrail patients significantly improved their scores after the operation. These results were comparable regardless the scale used for frailty assessment. CONCLUSIONS: Frail and prefrail patients have a significant improvement in their quality of life 6 months after their cardiac operation, and they have a proportionally greater increase in their postoperative health-related quality of life scores than robust patients.

Mortality risk prediction in infective endocarditis surgery: reliability analysis of specific scores.

OBJECTIVES: We assessed the prognostic utility of risk scores in surgery for infective endocarditis (IE) to evaluate their reliability in mortality risk prediction. METHODS: An observational retrospective study was developed to include all patients who underwent surgery for active IE from 2002 to 2016. Classical and endocarditis-specific risk scores were calculated. RESULTS: A total of 180 patients were included in the study. The 30-day mortality rate was 26.82% [95% confidence interval (CI) 20.26-33.20%]. Classical risk scores were confirmed to have a suboptimal prognostic ability. Therefore, 4 IE-specific risk scores were calculated. Discrimination was evaluated using the area under the receiver operating characteristic curve. It was 0.76 (95% CI 0.68-0.82) for the Society of Thoracic Surgeons-IE (STS-IE) score; 0.68 (95% CI 0.58-0.76) for the De Feo-Cotrufo score; 0.73 (95% CI 0.66-0.79) for the PALSUSE score and 0.65 (95% CI 0.57-0.72) for the Costa score. The STS-IE score had higher discrimination when compared with the De Feo-Cotrufo score (P = 0.055) and the Costa score (P = 0.024); however, there was no significant difference when we compared the STS-IE score with the PALSUSE score (P = 0.58). Calibration was assessed using the Hosmer-Lemeshow test; an adequate calibration was confirmed in all 4 scores. CONCLUSIONS: Specific risk scores had better prognostic performance than classical risk scores. The STS-IE score had the highest discrimination and was adequately calibrated. The PALSUSE score also showed optimal discrimination and calibration. The De Feo-Cotrufo score had a lower discrimination in our sample; however, the De Feo-Cotrufo score is recommended in the current guidelines. The Costa score had the lowest discrimination.

How to Adjust Neochordae Length Accurately in Degenerative Mitral Regurgitation.

We describe a simple technique for the accurate adjustment of polytetrafluoroethylene neochordae length in degenerative mitral regurgitation using the annuloplasty ring's own suture as a reference instead of using sophisticated or less precise maneuvers. Two threads of the annuloplasty ring suture are placed at the level of the mitral valve annulus plane to be used as a reference to tie the neochordae.

La sedación paliativa por sufrimiento existencial en atención primaria: una delgada línea roja / Palliative sedation for existential suffering in primary care: A thin red line

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