Relationships between mitral annular calcification and cardiovascular events: A meta-analysis.

BACKGROUND: Mitral annular calcification (MAC) is prevalent in the aging population, with recent renewed interest regarding its associations with cardiovascular risk factors, outcomes, and influence on valvular heart disease and interventions. This meta-analysis aimed to report the relationships between MAC and cardiovascular mortality and morbidity events. METHODS: Relevant studies were searched from PubMed, Cochrane, and Embase databases until November 30, 2019. Associations between MAC as a binary variable with death and cardiovascular events were pooled using random-effects models. The main outcomes of interest were all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, atrial fibrillation, and procedural outcomes. RESULTS: Among 799 article abstracts and 122 full-text articles screened, 26 (16 prospective and 10 retrospective) studies totaling 35 070 subjects were analyzed. MAC was associated with higher all-cause death, hazard ratio (95% confidence interval) 1.76 (1.43-2.22), and cardiovascular mortality 1.85 (1.45-23.5). It also positively correlated with myocardial infarction 1.48 (1.22-1.79), stroke 1.51 (1.22-2.05), incidental heart failure 1.55 (1.30-1.84), atrial fibrillation 1.75 (1.43-2.15), and their composite, major adverse cardiovascular events (MACE). Finally, conversion to mitral valve replacement at time of cardiac surgery was more in patients with MAC than without MAC, with odds ratio (95% confidence interval) 2.82 (1.28-6.18). CONCLUSION: Mitral annular calcification was overall associated with higher rates of death, and both individual and composite cardiovascular events. The presence of increasingly encountered MAC has significant clinical implications for cardiovascular risk assessment and valvular interventions.

Three-Dimensional Printing Applications in Percutaneous Structural Heart Interventions.

Cardiovascular 3-dimensional printing refers to the fabrication of patients' specific cardiac anatomic replicas based on volumetric imaging data sets obtained by echocardiography, computed tomography, or magnetic resonance imaging. It enables advanced visualization and enhanced anatomic and sometimes hemodynamic understanding and also improves procedural planning and allows interventional simulation. Also, it is helpful in communication with patients and trainees. These key advantages have led to its broad use in the field of cardiology ranging from congenital to vascular and valvular disease, particularly in structural heart interventions, where many emerging technologies are being developed and tested. This review summarizes the process of 3-dimensional printing and the workflow from imaging acquisition to model generation and discusses the cardiac applications of 3-dimensional printing focusing on its use in percutaneous structural interventions, where procedural planning now commonly relies on 3-dimensional printed models.

Long-term mortality in patients with severe secondary mitral regurgitation and normal left ventricular ejection fraction: interventional perspective.

AIMS: Patients with severe secondary mitral regurgitation (MR) and normal ejection fraction are being excluded from clinical trials evaluating transcatheter mitral devices. We sought to evaluate the long-term mortality with medical management alone in this patient population. METHODS AND RESULTS: We retrospectively evaluated patients diagnosed with ≥3+ MR at our institution over 15 years. Only patients with an ejection fraction ≥60% were included in the study. Those with degenerative mitral valve disease, papillary muscle dysfunction, or hypertrophic cardiomyopathy, and those who underwent mitral valve intervention were excluded. The study included 400 patients (age 71.1±14.8, 25.1% male, ejection fraction 62.5±3.6%). Mechanism of secondary MR was restricted valve motion, annular dilation and apical tethering in 91.5, 4.5 and 4%, respectively. One-year and three-year mortality were 19.1 and 26.3%, respectively. On multivariable Cox proportional regression analysis, older age, New York Heart Association functional Class III or IV, >3+ MR and larger left atrium were independent predictors of mortality. CONCLUSIONS: Severe secondary MR with normal left ventricular systolic function has significant mortality with medical management alone. This initial observation needs to be confirmed in larger prospective studies. These patients should be included in future transcatheter clinical trials.

Degenerative Mitral Stenosis: Unmet Need for Percutaneous Interventions.

Degenerative mitral stenosis (DMS) is an important cause of mitral stenosis, developing secondary to severe mitral annular calcification. With the increase in life expectancy and improved access to health care, more patients with DMS are likely to be encountered in developed nations. These patients are generally elderly with multiple comorbidities and often are high-risk candidates for surgery. The mainstay of therapy in DMS patients is medical management with heart rate control and diuretic therapy. Surgical intervention might be delayed until symptoms are severely limiting and cannot be managed by medical therapy. Mitral valve surgery is also challenging in these patients because of the presence of extensive calcification. Hence, there is a need to develop an alternative percutaneous treatment approach for patients with DMS who are otherwise inoperable or at high risk for surgery. In this review, we summarize the available data on the epidemiology of DMS and diagnostic considerations and current treatment strategies for these patients.

Cirugía de control de daño / Surgery of damage control

La atención a los pacientes gravemente lesionados es un riesgo en potencia de muerte, por lo que el actuar debe ser rápido y eficaz. Con el objetivo de conocer cómo se enfrenta el personal médico a los pacientes graves, se realiza una revisión bibliográfica sobre la cirugía de control de daño en los pacientes que han sufrido lesiones traumáticas graves. Se incluye una breve reseña histórica, su fisiopatología, las indicaciones y la conducta a seguir en las diferentes etapas y según la localización de los daños (AU)

The attention to patients seriously injured is a potential risk of death, reason why acting must be faster and effective. With the objective to know how the serious patients face, a bibliographical revision is carried out on the surgery of damage control in patients who have suffered serious traumatic injuries. This paper includes a brief historical review, its pathophysiology, indications and the behavior to be followed in different stages and damages location (AU)

Tratamiento de la hernia inguinal ambulatorio versus hospitalizado / Inguinal hernia ambulatory treatment versus hospitalized

La hernia es una enfermedad que motiva asistencia frecuente a consulta. Con el objetivo de conocer cómo se comporta esta enfermedad en el medio se realizó un estudio retrospectivo para analizar el comportamiento de algunas variables relacionadas con la intervención quirúrgica en el servicio de Cirugía General, tanto ambulatorios como hospitalizados del Hospital General Provincial Docente Capitán Roberto Rodríguez Fernández de Morón en el periodo comprendido entre el 1ro de enero de 2005 y el 31 de diciembre de 2010. Se encontró que la mayoría de los pacientes estaban entre los 30 a 49 años y predominó el sexo masculino sobre el femenino. La mayoría de los individuos están sometidos a esfuerzos físicos. El lado de aparición de la hernia inguinal que más se encontró fue el derecho. Las complicaciones postoperatorias se presentaron en un 22.95 porciento de los casos, y las más frecuentes fueron la sepsis de la herida y los hematomas (AU)

Hernia is a disease that motivates frequently attendance to consultation. With the objective to know how it behaves this disease it was carried out a retrospective study in order to analyze the behavior of some variables related to the surgical intervention the service of General Surgery,as much ambulatory as hospitalized from Teaching General Hospital “Capitán Roberto Rodríguez Fernandez” in Morón between January 1st , 2005 and December 31st , 2010.Most of the patients were between 30 and 49 years and masculine sex predominated on the feminine one. Most of them are put under physical effort. The inguinal hernia appeared more often in the right side. The postoperative complications appeared in a 22,95 percent of the cases, and the most frequent were the wound sepsis and hematomas (AU)

Tratamiento de la hernia inguinal ambulatorio versus hospitalizado / Inguinal hernia ambulatory treatment versus hospitalized

La hernia es una enfermedad que motiva asistencia frecuente a consulta. Con el objetivo de conocer cómo se comporta esta enfermedad en el medio se realizó un estudio retrospectivo para analizar el comportamiento de algunas variables relacionadas con la intervención quirúrgica en el servicio de Cirugía General, tanto ambulatorios como hospitalizados del Hospital General Provincial Docente Capitán Roberto Rodríguez Fernández de Morón en el periodo comprendido entre el 1ro de enero de 2005 y el 31 de diciembre de 2010. Se encontró que la mayoría de los pacientes estaban entre los 30 a 49 años y predominó el sexo masculino sobre el femenino. La mayoría de los individuos están sometidos a esfuerzos físicos. El lado de aparición de la hernia inguinal que más se encontró fue el derecho. Las complicaciones postoperatorias se presentaron en un 22.95 porciento de los casos, y las más frecuentes fueron la sepsis de la herida y los hematomas.

Hernia is a disease that motivates frequently attendance to consultation. With the objective to know how it behaves this disease it was carried out a retrospective study in order to analyze the behavior of some variables related to the surgical intervention the service of General Surgery,as much ambulatory as hospitalized from Teaching General Hospital “Capitán Roberto Rodríguez Fernandez” in Morón between January 1st , 2005 and December 31st , 2010.Most of the patients were between 30 and 49 years and masculine sex predominated on the feminine one. Most of them are put under physical effort. The inguinal hernia appeared more often in the right side. The postoperative complications appeared in a 22,95 percent of the cases, and the most frequent were the wound sepsis and hematomas.

Cirugía de control de daño / Surgery of damage control

La atención a los pacientes gravemente lesionados es un riesgo en potencia de muerte, por lo que el actuar debe ser rápido y eficaz. Con el objetivo de conocer cómo se enfrenta el personal médico a los pacientes graves, se realiza una revisión bibliográfica sobre la cirugía de control de daño en los pacientes que han sufrido lesiones traumáticas graves. Se incluye una breve reseña histórica, su fisiopatología, las indicaciones y la conducta a seguir en las diferentes etapas y según la localización de los daños.

The attention to patients seriously injured is a potential risk of death, reason why acting must be faster and effective. With the objective to know how the serious patients face, a bibliographical revision is carried out on the surgery of damage control in patients who have suffered serious traumatic injuries. This paper includes a brief historical review, its pathophysiology, indications and the behavior to be followed in different stages and damages location.

Outcome and improvement predictors of mitral regurgitation after transcatheter aortic valve implantation.

BACKGROUND AND AIM OF THE STUDY: Mitral regurgitation (MR) is frequently present in patients with calcific aortic stenosis (AS). Yet, the issue of whether to surgically correct the MR during aortic valve replacement (AVR) remains uncertain. The study aim was to define the outcome of MR after transcatheter aortic valve implantation (TAVI) in the TRanscatheter EndoVascular Implantation of VALves (REVIVAL) II trial. METHODS: Echocardiography was performed before and at 24 h, and three and six months after valve implantation. The degree of MR was evaluated by expert readers and by the vena contracta (VC) method. Significant MR was defined as at least mild to moderate MR. Those patients with a 30% reduction in VC were classified as good responders (GR group), and the remainder as poor responders (PR group). RESULTS: The study comprised 35 subjects with at least mild to moderate MR before TAVI. The mean VC of the whole group declined from 0.5 +/- 0.2 cm initially to 0.32 +/- 0.2 cm and 0.38 +/- 0.2 cm at 24 h and three months, respectively (p < 0.05). At three months, 12 patients had > 30% VC reduction; these constituted the GR group, while the remainder constituted the PR group. The percentage of patients with mitral annular calcification with restriction (MACr), defined as calcification encroaching onto the leaflets and restricting leaflet motion, was significantly lower in the GR group compared to the PR group (17% versus 61%, respectively; p < 0.05). The remaining pre-specified parameters did not differ significantly between the GR and PR groups, including age, gender, mitral valve tethering height and area (6 +/- 2 mm versus 5 +/- 3 mm and 10 +/- 4 mm2 versus 13 +/- 9 and 10 +/- 4 mm2, respectively), change in the aortic valve area (336 +/- 130% versus 285 +/- 180%), change in mean systolic aortic valve pressure (-20 +/- 8% versus - 23 +/- 10%), and left ventricular ejection fraction (47 +/- 15% versus 45 +/- 18%). CONCLUSION: MR is improved significantly after TAVI for AS. MACr was the only variable associated with a reduction in MR improvement. These results suggest that a careful echocardiographic evaluation of the mitral valve prior to TAVI may help to predict which patients should experience an improvement in their MR.

Three-dimensional imaging in the context of minimally invasive and transcatheter cardiovascular interventions using multi-detector computed tomography: from pre-operative planning to intra-operative guidance.

The rapid expansion of less invasive surgical and transcatheter cardiovascular procedures for a wide range of cardiovascular conditions, including coronary, valvular, structural cardiac, and aortic disease has been paralleled by novel three-dimensional (3-D) approaches to imaging. Three-dimensional imaging allows acquisition of volumetric data sets and subsequent off-line reconstructions along unlimited 2-D planes and 3-D volumes. Pre-procedural 3-D imaging provides detailed understanding of the operative field for surgical/interventional planning. Integration of imaging modalities during the procedure allows real-time guidance. Because computed tomography routinely acquires 3-D data sets, it has been one of the early imaging modalities applied in the context of surgical and interventional planning. This review describes the continuum of applications from pre-operative planning to procedural integration, based on the emerging experience with computed tomography and rotational angiography, respectively. At the same time, the potential adverse effects of imaging with X-ray-based tomographic or angiographic modalities are discussed. It is emphasized that the role of imaging guidance in this context remains unclear and will need to be evaluated in clinical trials. This is in particular true, because data showing improved outcome or even non-inferiority for most of the emerging transcatheter procedures are still lacking.

Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients.

The clinical implications of patent foramen ovale (PFO) morphology are still debated. Quantitative analysis by transesophageal echocardiography (TEE) is helpful in characterizing PFO morphology. The aim of this study was to determine whether there were differences in the anatomy of PFOs on TEE in patients with and without recurrent cryptogenic stroke or transient ischemic attack. The results of TEE in 58 patients who had PFO closure for cryptogenic cerebrovascular accident (CVA) were compared with those in 58 consecutive asymptomatic patients with PFOs found incidentally on TEE. The data were analyzed for differences in PFO size (maximum separation of the septum primum and septum secundum), tunnel length (maximum overlap of the septum primum and septum secundum), the presence of atrial septal aneurysm (>11 mm mobility), the severity of shunting (mild, 3 to 9 microbubbles; moderate, 10 to 30 microbubbles; severe, >30 microbubbles), the prominence of the Eustachian valve; and the presence of Chiari's network. Patients with CVAs had larger PFOs (3.9 +/- 1.6 vs 2.9 +/- 1.4 mm, p <0.001), longer tunnels (14 +/- 6 vs 12 +/- 6 mm, p = 0.05), and a greater frequency of atrial septal aneurysm (45% vs 21%, p <0.005) compared with controls. They also had a greater proportion of large (>or=4 mm) PFOs (46% vs 17%, p <0.001), long (>or=1 cm) tunnels (78% vs 55%, p <0.01), and severe shunting (16% vs 5%, p <0.06). The frequencies of prominent Eustachian valves and Chiari's network were not significantly different. In conclusion, PFOs in patients with cryptogenic CVAs are larger, have longer tunnels, and are more frequently associated with atrial septal aneurysms. This information should be considered when evaluating patients with cryptogenic CVAs.