Mid-term assessment of structural valve deterioration of perceval S sutureless prosthesis using the last European consensus definition.

OBJECTIVES: Durability of sutureless aortic bioprosthetic valves remains a major issue. The aim of this study was to assess structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) of the Perceval bioprosthesis using the new proposed standardized definitions. METHODS: All patients who underwent aortic valve replacement with sutureless Perceval S prostheses up to September 2016 were included. Clinical and echocardiographic follow-up was performed. New standardized definitions were used to assess the durability of sutureless bioprosthetic valves. From 2013 to 2016, 214 patients were included. RESULTS: The mean age and EuroSCORE II were 79 years and 2.74. Thirty-day mortality was 0.47%. The survival rate was 96.8%, 88.1% and 85.7% at 1, 3 and 4 years, respectively. The median echocardiographic follow-up was 3.28 years. The mean pressure gradient was 11.3 mmHg. No cases showed evidence of severe SVD, 17 patients had moderate SVD with a mean pressure gradient of 24 mmHg and 8 patients had definite late BVF. The incidence of moderate SVD and BVF at 4 years was 8.8% and 2.9%, respectively. CONCLUSIONS: Mid-term follow-up to 6.3 years after aortic valve replacement with the Perceval bioprosthesis documents favourable haemodynamic and clinical outcomes and low rates of SVD and BVF.

Postoperative Plasma Mitochondrial DNA and Cytokine Profiles of Elderly Patients Undergoing Minimally Invasive Aortic Valve Replacement.

INTRODUCTION: Mitochondrial DNA (mtDNA) is gaining increasing interest as a marker of cellular damage and could also act as an inflammatory mediator in cardiopulmonary bypass induced postoperative inflammatory response. Although minimally invasive heart valve surgery reportedly reduces inflammation, the mtDNA and cytokine profile in this context remains unclear. MATERIALS AND METHODS: Here, we report a prospective series of 40 elderly patients with aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR) through upper ministernotomy with either a sutureless (n = 20) or a conventional (n = 20) valve. Primary end points included serial plasma levels of mtDNA (T1: at baseline; T2: 4 hours after surgery; and T3: 24s hour after surgery), cytokines (interleukin-6 [IL-6], tumor necrosis factor-α [TNF-α]), and myocardial necrosis biomarkers (MNBs), whereas secondary end points included clinical and echocardiographic data. RESULTS: Significant increases in the postoperative plasma levels (T2) of mtDNA, cytokines, and MNBs were observed in all patients. The postoperative plasma levels of mtDNA, TNF-α, and MNBs showed no significant differences between the treatment groups, although there was a trend toward lower levels in the sutureless group. The decreases in aortic cross-clamp and cardiopulmonary bypass times seen in the sutureless group were associated with significant lower postoperative levels (T2 and T3) of IL-6. CONCLUSION: AVR through upper ministernotomy was associated with a significant increase in postoperative plasma levels of mtDNA and cytokines. There was no difference in the mtDNA levels between the sutureless and conventional valve groups, suggesting a similar level of inflammation in both groups. However, the shorter operation time observed in the sutureless valve group was associated with significantly lower postoperative levels of IL-6, indicating potential clinical benefits.

Abordaje mínimamente invasivo para la asistencia biventricular con bombas centrífugas: primera experiencia en España / Minimally invasive approach for biventricular assist device with centrifugal pump: first experience in Spain

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Galectina-3 circulante tras el trasplante cardiaco: dinámica a largo plazo y valor pronóstico / Circulating galectin-3 following heart transplant: long-term dynamics and prognostic value

Introducción y objetivos Los valores plasmáticos de galectina-3 (Gal-3) están elevados y se correlacionan con la mortalidad total y cardiovascular en pacientes con insuficiencia cardiaca, pero su correlación con el pronóstico tras el trasplante cardiaco (TxC) es desconocida. El objetivo fue describir la tendencia evolutiva y el valor pronóstico de este biomarcador tras el TxC. Métodos Mediante enzimoinmunoensayo, se midieron las concentraciones plasmáticas de Gal-3 en muestras de suero de 122 receptores de TxC, antes y 1, 3, 6 y 12 meses después de este. Mediante regresión de Cox se analizó el valor pronóstico del valor plasmático de Gal-3 a los 12 meses del TxC. El objetivo primario del estudio fue la variable combinada muerte o disfunción del injerto. Resultados: Las concentraciones de Gal-3 disminuyeron progresivamente durante el primer año tras el TxC (medianas: pretrasplante, 19,1 ng/ml; 1 año postrasplante, 14,6 ng/ml; p<0,001). Los valores de Gal-3 1 año tras el TxC se asociaron con mayor riesgo de muerte o disfunción del injerto (HR por 1 ng/ml: 1.04; IC95%: 1,01-1,08; p=0,008). La capacidad predictiva del biomarcardor fue moderada: área bajo la curva ROC, 0,72 (IC95%: 0,60-0,82; p<0,001). Conclusiones Las concentraciones plasmáticas de Gal-3 disminuyeron progresivamente durante el primer año tras el TxC. Un valor plasmático elevado de Gal-3 1 año tras el TxC se correlacionó con un pronóstico adverso

Introduction and Objectives: Circulating galectin-3 (Gal-3) is elevated and significantly correlates with all-cause and cardiovascular mortality in patients with heart failure. However, the relationship between serum Gal-3 and heart transplant (HT) outcomes is unclear. The aim of this study was to describe the longitudinal trend and prognostic value of Gal-3 levels after HT. Methods: Banked serum samples were available from 122 HT recipients, collected before transplant and at 1, 3, 6, and 12 months posttransplant. Gal-3 levels in these serum samples were measured by enzyme immune assay. Multivariable Cox regression was performed to determine the prognostic value of 12-month posttransplant Gal-3 serum levels. The primary endpoint was the composite variable all-cause death or graft failure over long-term posttransplant follow-up. Results: Circulating Gal-3 concentration steadily decreased during the first year after HT (median values: pretransplant, 19.1 ng/mL; 1-year posttransplant, 14.6 ng/mL; P<.001). Circulating Gal-3 levels 1-year posttransplant were associated with an increased risk of all-cause death or graft failure (adjusted HR per 1 ng/mL, 1.04; 95%CI, 1.01-1.08; P=.008). The predictive accuracy of this biomarker was moderate: (area under the ROC curve, 0.72 (95%CI, 0.60-0.82; P<.001). Conclusions: Circulating Gal-3 steadily decreased during the first year after HT. However, 1-year posttransplant Gal-3 serum levels that remained elevated were associated with increased long-term risk of death and graft failure

Surgical technique modifies the postoperative atrioventricular block rate in sutureless prostheses.

BACKGROUND: The main objective was to analyse the impact of the modification of the Perceval S implantation technique on the prevalence of postoperative atrioventricular block, which requires a permanent pacemaker, in our aortic valve replacement series. In addition, we attempted to identify those risk factors that are related to the appearance of this complication. METHODS: Five hundred and seventy-two valve replacements were carried out with PERCEVAL S in our centre up to July 2018. Use of modified technique (n=302). Minimally invasive approach (n=340). Associated coronary surgery (n=95). Patients with pacemakers prior to surgery (n=27) and associated mitral or tricuspid valve surgery (n=26) were excluded. We analysed variables of interest that could influence the increase in postoperative atrioventricular block. Technique performed, disorders of intraventricular conduction and pre/intraoperative characteristics. The influence of the modified technique was analysed. RESULTS: Five hundred and nineteen aortic valve replacements with PERCEVAL S. Age (years) (median 77, interquartile range 8). Height (cm) (159, 13.5). Euroscore II (%) (2.25, 2.27). Postoperative atrioventricular block standard technique (n=23, 10.14%). Modified technique (n=14, 4.30%) (P=0.009). Multivariate regression analysis. Final model AUC =0.740, maximum model AUC =0.774 (P>0.05). Includes: Technique used (P=0.024), height (P=0.043) and disorders of interventricular conduction, right bundle branch block (P=0.005), trifascicular block (P=0.008). CONCLUSIONS: In our experience, the modified technique significantly decreases the incidence of postoperative atrioventricular block that requires a permanent pacemaker in the aortic valve replacement with PERCEVAL S. The prior electrocardiographic presence of right bundle branch block, trifascicular block and the height of the patient are associated with an increased risk of blocking.

Tratamiento de la obstrucción del tracto de salida en la miocardiopatía hipertrófica mediante reparación mitral: «miectomía sin miectomía» / Mitral repair as a treatment of outflow tract obstruction in hypertrophic cardiomyopathy: "myectomy without myectomy"

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Implante transaxilar del dispositivo de asistencia circulatoria Impella CP como puente al trasplante cardiaco. Primera experiencia en España / Transaxillary implantation of the Impella CP mechanical circulatory support device as a bridge to heart transplant. First experience in Spain

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Circulating Galectin-3 Following Heart Transplant: Long-term Dynamics and Prognostic Value.

INTRODUCTION AND OBJECTIVES: Circulating galectin-3 (Gal-3) is elevated and significantly correlates with all-cause and cardiovascular mortality in patients with heart failure. However, the relationship between serum Gal-3 and heart transplant (HT) outcomes is unclear. The aim of this study was to describe the longitudinal trend and prognostic value of Gal-3 levels after HT. METHODS: Banked serum samples were available from 122 HT recipients, collected before transplant and at 1, 3, 6, and 12 months posttransplant. Gal-3 levels in these serum samples were measured by enzyme immune assay. Multivariable Cox regression was performed to determine the prognostic value of 12-month posttransplant Gal-3 serum levels. The primary endpoint was the composite variable all-cause death or graft failure over long-term posttransplant follow-up. RESULTS: Circulating Gal-3 concentration steadily decreased during the first year after HT (median values: pretransplant, 19.1 ng/mL; 1-year posttransplant, 14.6 ng/mL; P<.001). Circulating Gal-3 levels 1-year posttransplant were associated with an increased risk of all-cause death or graft failure (adjusted HR per 1 ng/mL, 1.04; 95%CI, 1.01-1.08; P=.008). The predictive accuracy of this biomarker was moderate: area under the ROC curve, 0.72 (95%CI, 0.60-0.82; P<.001). CONCLUSIONS: Circulating Gal-3 steadily decreased during the first year after HT. However, 1-year posttransplant Gal-3 serum levels that remained elevated were associated with increased long-term risk of death and graft failure.

The "Auto-sliding Graft" Aortic Wrapping Technique.

We describe the "auto-sliding graft" technique, a different anastomotic option for reconstructive prosthetic procedures on the ascending aorta especially in patients at risk of circulatory arrest with mild aortic dilatation. This simple technique provides not only an important hemostatic reinforcement for the distal aortic graft anastomosis but also a protective effect on the native ascending aorta beyond the suture line.

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.

Estado serológico frente a Toxoplasma gondii en receptores de trasplante cardiaco: ¿un factor pronóstico independiente? / Toxoplasma gondii serostatus in heart transplant recipients: is it an independent prognostic factor?

Introducción y objetivos: Analizar la influencia pronóstica del estado serológico frente a Toxoplasma gondii en receptores de trasplante cardiaco (TC). Métodos: Se realizó un estudio retrospectivo unicéntrico con 657 receptores de TC entre 1991 y 2015. Mediante dos modelos multivariantes de Cox se comparó la supervivencia y la incidencia de episodios clínicos adversos de los receptores seropositivos (n = 481) y los receptores seronegativos (n = 176) frente a T. gondii. El modelo 1 incluyó edad y sexo, y el modelo 2 incluyó otros factores de confusión potenciales. Resultados: Con una mediana de seguimiento de 2.903 días (rango intercuartílico: 898-4.757), fallecieron 250 pacientes seropositivos (52%) y 72 receptores seronegativos (41%) frente a T. gondii. Los pacientes seropositivos presentaron mayor mortalidad no ajustada tras el TC (hazard ratio[HR] = 1,31; intervalo de confianza del 95% [IC95%], 1,00-1,70). Tras el ajuste multivariante, este efecto perdió su significación estadística (modelo 1: HR = 1,09; IC95%, 0,83-1,43; modelo 2: HR = 1,12; IC95%, 0,85-1,47). La seropositividad frente a T. gondii del receptor se asoció de modo independiente con mayor riesgo de rechazo agudo (modelo 1: HR = 1,36; IC95%, 1,06-1,74; modelo 2: HR = 1,29; IC95%, 1,01-1,66). Los modelos multivariantes no pusieron de manifiesto una influencia significativa del estado serológico frente a T. gondii del receptor sobre la incidencia de infección, neoplasias, enfermedad vascular del injerto o el desenlace combinado muerte cardiaca o retrasplante. Tampoco se observó una influencia pronóstica significativa de la concordancia donante-receptor respecto al estado serológico frente a T. gondii. Conclusiones: El presente estudio no ha puesto de manifiesto un efecto pronóstico independiente del estado serológico frente a T. gondii en los receptores de TC (AU)

Introduction and objectives: To assess the potential association between recipient Toxoplasma gondii serostatus and outcomes after heart transplant (HT). Methods: We conducted a retrospective single-center study of 657 HT recipients from 1991 to 2015. Survival and the incidence of adverse clinical events of T. gondii-seropositive (n = 481) vs T. gondii-seronegative (n = 176) recipients were compared by means of 2 different multivariable Cox regression models. Model 1 included solely age and sex, and model 2 included other potential confounders. Results: Over a median follow-up of 2903 days (interquartile range: 898-4757), 250 seropositive recipients (52%) and 72 seronegative recipients (41%) died. Univariable analysis showed increased posttransplant mortality among T. gondii-seropositive recipients (hazard ratio [HR] = 1.31; 95% confidence interval [95%CI], 1,00-1.70). After multivariable adjustment, the statistical significance of this association was lost (model 1: HR = 1.09; 95%CI, 0.83-1.43; model 2:HR = 1.12; 95%CI, 0.85-1.47). Recipient T. gondii seropositivity was independently associated with an increased risk of acute rejection (model 1: HR = 1.36; 95%CI, 1.06-1.74; model 2: HR = 1.29; 95%CI, 1.01-1.66). Multivariable models showed no statistically significant impact of recipient T. gondii serostatus on the incidence of infection, malignancy, coronary allograft vasculopathy, or the composite outcome of cardiac death or retransplant. No significant association was found between donor-recipient T. gondii serostatus matching and posttransplant outcome. Conclusions: In this study, recipient T. gondii serostatus was not an independent predictor of long-term post-HT outcome (AU)

Toxoplasma Gondii Serostatus in Heart Transplant Recipients: Is It an Independent Prognostic Factor?

INTRODUCTION AND OBJECTIVES: To assess the potential association between recipient Toxoplasma gondii serostatus and outcomes after heart transplant (HT). METHODS: We conducted a retrospective single-center study of 657 HT recipients from 1991 to 2015. Survival and the incidence of adverse clinical events of T. gondii-seropositive (n = 481) vs T. gondii-seronegative (n = 176) recipients were compared by means of 2 different multivariable Cox regression models. Model 1 included solely age and sex, and model 2 included other potential confounders. RESULTS: Over a median follow-up of 2903 days (interquartile range: 898-4757), 250 seropositive recipients (52%) and 72 seronegative recipients (41%) died. Univariable analysis showed increased posttransplant mortality among T. gondii-seropositive recipients (hazard ratio [HR] = 1.31; 95% confidence interval [95%CI], 1,00-1.70). After multivariable adjustment, the statistical significance of this association was lost (model 1: HR = 1.09; 95%CI, 0.83-1.43; model 2:HR = 1.12; 95%CI, 0.85-1.47). Recipient T. gondii seropositivity was independently associated with an increased risk of acute rejection (model 1: HR = 1.36; 95%CI, 1.06-1.74; model 2: HR = 1.29; 95%CI, 1.01-1.66). Multivariable models showed no statistically significant impact of recipient T. gondii serostatus on the incidence of infection, malignancy, coronary allograft vasculopathy, or the composite outcome of cardiac death or retransplant. No significant association was found between donor-recipient T. gondii serostatus matching and posttransplant outcome. CONCLUSIONS: In this study, recipient T. gondii serostatus was not an independent predictor of long-term post-HT outcome.

Long-Term Outcomes and Durability of the Mitroflow Aortic Bioprosthesis.

BACKGROUND: This study aims to determine the incidence and causes of structural valve deterioration (SVD) among all models of Mitroflow bioprostheses (A12/LX/DL), as well as to define their long-term clinical and hemodynamic performance. METHODS AND RESULTS: We retrospectively reviewed a series of 1023 patients who underwent aortic valve replacement with Mitroflow bioprostheses between 2001 and 2014. A small aortic root was found in 22.4% of patients. There were two cases of severe patient-prosthesis mismatch. Only 31 patients developed SVD. The rate of incidence was 8.1 cases per 1000 patient-years. Cumulative incidence of SVD was 1.4% and 3% at five and 10 years, respectively. Freedom from SVD was 97.4% and 88.2% at five and 10 years, respectively. Anticalcification phospholipid reduction treatment (PRT) for model DL was a protective factor for SVD. Multivariable analysis confirmed age <70 years and use of 19 mm valve as independent predictors of SVD. Cumulative survival was 76.6% at five years and 42.3% at 10 years (mean follow-up 3.8 ± 3.1 years). In multivariable analysis, neither the use of small aortic prosthesis (p = 0.18) nor the occurrence of SVD (p = 0.85) was found to be independent predictors of long-term survival. CONCLUSIONS: Mitroflow valves demonstrate an acceptable rate of SVD and satisfactory long-term hemodynamic performance, particularly in patients with small aortic roots, age >70 years, and cases with severe left ventricular hypertrophy. PRT might contribute to improved long-term durability. doi: 10.1111/jocs.12726 (J Card Surg 2016;31:264-273).