Outcomes of rapid deployment aortic valve replacement with concomitant cardiac procedures.

Background: Rapid deployment aortic valve replacement (RD-AVR) has been recently introduced with encouraging results. Outcomes of isolated RD-AVR include good hemodynamic profile, facilitation of minimally invasive techniques, and reduction of surgical times. However, role of this prosthesis in concomitant surgery is not well known. Methods: In 2016, we formed a registry to monitor the introduction of this prosthesis, RApid Deployment Aortic Replacement (RADAR). We aim to report mid-term outcomes focusing on patients who had RD-AVR combined with other surgical procedures. Results: Between July 2012 and February 2021, 370 patients were included in this registry (mean age, 75.8±8.0 years; 64.32% male; mean EuroSCORE II, 3.5±2.8). Of these, 128 (34.59%) had concomitant procedures including myocardial revascularization surgery in 69 patients (53.91%), surgery on the ascending aorta in 34 (26.56%), and procedures on other valves in 10 patients (7.81%). There were no significant differences between the isolated AVR and concomitant AVR groups in postoperative complications, in-hospital mortality (4.72% vs. 3.32%, P=0.524), or hemodynamic behavior of these prostheses. Three-year survival was 83.73% and 89.89% in the isolated and concomitant AVR group respectively. There was no difference in survival between the two groups (log-rank test, P=0.4124). Conclusions: Our results support the safety and efficacy of the Edwards INTUITY valve system even in complex aortic valve disease with additional cardiac procedures. RD-AVR could become a useful tool for concomitant surgeries where surgical times are expected to be prolonged.

Prediction of surgical risk in patients with endocarditis: Comparison of logistic EuroSCORE, EuroSCORE II and APORTEI score / Predicción de riesgo de mortalidad quirúrgica en pacientes con endocarditis infecciosa: comparación entre EuroSCORE logístico, EuroSCORE II y APORTEI score

Objectives: APORTEI score is a new risk prediction model for patients with infective endocarditis. It has been recently validated on a Spanish multicentric national cohort of patients. The aim of the present study is to compare APORTEI performances with logistic EuroSCORE and EuroSCORE II by testing calibration and discrimination on a local sample population underwent cardiac surgery because of endocarditis. Methods: We tested three prediction scores on 111 patients underwent surgery from 2014 to 2020 at our Institution because of infective endocarditis. Area under the curves and Hosmer–Lemeshow test were used to analyze discrimination and calibration respectively of logistic EuroSCORE, EuroSCORE II and APORTEI score. Results: The overall observed one-month mortality rate was 21.6%. The observed-to-expected ratio was 1.27 for logistic EuroSCORE, 3.27 for EuroSCORE II and 0.94 for APORTEI. The area under the curve (AUC) value of APORTEI (0.88±0.05) was significantly higher than that one of logistic EuroSCORE (AUC 0.77±0.05; p 0.0001) and of EuroSCORE II (AUC 0.74±0.05; p 0.0005). Hosmer–Lemeshow test showed better calibration performance of the APORTEI, (logistic EuroSCORE: p 0.19; EuroSCORE II: p 0.11; APORTEI: p 0.56). Conclusion: APORTEI risk score shows significantly higher performances in term of discrimination and calibration compared with both logistic EuroSCORE and EuroSCORE II.(AU)

Objetivos: El APORTEI score es un nuevo sistema de predicción de riesgo para pacientes con endocarditis infecciosa. El mismo ha sido recientemente validado en una cohorte de pacientes procedentes de un estudio nacional multicéntrico español. El objetivo del presente estudio es comparar la discriminación y la calibración del APORTEI score con las del EuroSCORE logístico y del EuroSCORE II analizando una población sometida a cirugía cardiaca por endocarditis infecciosa. Métodos: Analizamos las propiedades de 3 sistemas de predicción de riesgo sobre una población de 111 pacientes sometidos a cirugía cardiaca desde 2014 hasta 2020 en un único hospital terciario por endocarditis infecciosa. El área bajo las curvas y la prueba de Hosmer-Lemeshow se usaron para analizar la discriminación y la calibración, respectivamente, del EuroSCORE logístico, del EuroSCORE II y del APORTEI score. Resultados: La mortalidad global observada a un mes fue del 21,6%. La relación mortalidad observada/mortalidad esperada fue de 1,27 para el EuroSCORE logístico, 3,27 para el EuroSCORE II y 0,94 para el APORTEI score. El valor del área bajo la curva (AUC) del APORTEI score (0,88±0,05) fue significativamente mayor que los del EuroSCORE logístico (AUC 0,77±0,05; p 0,0001) y del EuroSCORE II (AUC 0,74±0,05; p 0,0005). La prueba de Hosmer-Lemeshow mostró un mejor rendimiento en cuanto a calibración del APORTEI score, (EuroSCORE logístico: p 0,19; EuroSCORE II: p 0,11; APORTEI score: p 0,56). Conclusión: El sistema de predicción de riesgo APORTEI score muestra un rendimiento significativamente mejor en cuanto a discriminación y calibración en comparación con el EuroSCORE logístico y con el EuroSCORE II.(AU)

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.

Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis.

The aim of the present study was to analyse the incidence of major adverse cardiovascular events in patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with drug-eluting stents for left main stem disease. Five manuscripts publishing 5-year results of 4 trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) were included. Overall meta-analysis with inclusion of the 5-year results from the EXCEL trial using the protocol definition for myocardial infarction showed that CABG is associated with a significant reduction in the risk of major adverse cardiovascular events (MACE) (risk ratio = 0.74; 95% confidence interval = 0.68-0.80). When the universal definition was used to define myocardial infarction in the EXCEL trial, the analysis demonstrated a larger benefit of coronary surgery in terms of reduction in the risk of MACE (risk ratio = 0.70; 95% confidence interval = 0.63-0.76). Non-significant differences were detected in terms of risk of overall mortality, cardiac mortality or stroke. In conclusion, this meta-analysis shows that CABG significantly reduces the risk of MACE in patients with left main stem disease. The inclusion of the 5-year results of the EXCEL trial using third universal definition amplifies the benefit of CABG over percutaneous coronary intervention.

Risk Factors for Postoperative Pacemaker Implantation After Rapid Deployment Aortic Valve Replacement: Results from the RADAR Registry.

INTRODUCTION: Rapid deployment aortic valve replacement has been recently introduced in clinical practice. Different studies have reported a significant reduction in surgical times with excellent hemodynamic profiles and short-term results. However, an increase in permanent pacemaker requirements compared with conventional aortic valve replacement has been described. Nevertheless, risk factors for postoperative pacemaker implantation are not well known. The aim of this study is to report our early outcomes with rapid deployment aortic valve replacement within the RADAR Registry, especially focusing on risk factors for postoperative pacemaker implantation. METHODS: Between April 2012 and January 2016, 164 patients undergoing isolated or combined aortic valve replacement with Edwards INTUITY Elite (Edwards Lifesciences, Irvine, CA, USA) were included in the RADAR Registry. Pre-, intra- and postoperative clinical data results and complications were recorded, especially focusing on risk factors for the development of postoperative complete or high-grade AV block requiring pacemaker implantation. Patients were followed up for up to 1 year with evaluation of clinical and echocardiographic outcomes. RESULTS: A total of 164 consecutive patients were included in this study, where 128 patients (78.05%) had an isolated aortic valve replacement (group 1) and 36 (21.95%) a concomitant procedure (group 2). The surgical approach was ministernotomy in 61 patients (37.20%) and median sternotomy in 100 patients (60.98%). Complications with valve implantation were observed in three patients. Postoperative complete or high-degree AV block requiring a permanent pacemaker implantation developed in ten patients (6.9%). Seven patients died in-hospital (4.27%). No significant differences between groups were found in terms of stroke, postoperative infection, mortality, atrial fibrillation and postoperative atrioventricular block. Seven patients presented acute renal impairment (5.51%) in group 1 versus seven patients (20%) in group 2 (p = 0.007). In multivariate analysis, low weight and preoperative arrhythmia (atrial fibrillation, bifascicular block, left bundle branch block) emerged as risk factors for postoperative AV block requiring a pacer. In median follow-up of 1 year, seven (4.27%) patients died, and no cases of structural valve deterioration or endocarditis were observed. Significant patient-prosthesis mismatch was found in seven (4.27%) patients. CONCLUSION: Initial experience with rapid deployment aortic valve replacement in the RADAR Registry demonstrates low rates of implantation complications and good perioperative and 1-year clinical and echocardiographic outcomes. Incidence of postoperative AV block requiring a pacer correlated with low weight and preoperative arrythmias (atrial fibrillation, bifascicular block and left bundle branch block). Avoidance of oversizing and careful consideration of implantation of this technology in patients with pre-existing arrythmias could minimize the risk for postoperative pacemaker implantation.

Prediction of surgical risk in patients with endocarditis: Comparison of logistic EuroSCORE, EuroSCORE II and APORTEI score.

OBJECTIVES: APORTEI score is a new risk prediction model for patients with infective endocarditis. It has been recently validated on a Spanish multicentric national cohort of patients. The aim of the present study is to compare APORTEI performances with logistic EuroSCORE and EuroSCORE II by testing calibration and discrimination on a local sample population underwent cardiac surgery because of endocarditis. METHODS: We tested three prediction scores on 111 patients underwent surgery from 2014 to 2020 at our Institution because of infective endocarditis. Area under the curves and Hosmer-Lemeshow test were used to analyze discrimination and calibration respectively of logistic EuroSCORE, EuroSCORE II and APORTEI score. RESULTS: The overall observed one-month mortality rate was 21.6%. The observed-to-expected ratio was 1.27 for logistic EuroSCORE, 3.27 for EuroSCORE II and 0.94 for APORTEI. The area under the curve (AUC) value of APORTEI (0.88±0.05) was significantly higher than that one of logistic EuroSCORE (AUC 0.77±0.05; p 0.0001) and of EuroSCORE II (AUC 0.74±0.05; p 0.0005). Hosmer-Lemeshow test showed better calibration performance of the APORTEI, (logistic EuroSCORE: p 0.19; EuroSCORE II: p 0.11; APORTEI: p 0.56). CONCLUSION: APORTEI risk score shows significantly higher performances in term of discrimination and calibration compared with both logistic EuroSCORE and EuroSCORE II.

Impact of the time interval between diagnosis and symptoms on survival of surgical patients with left-sided infective endocarditis: A propensity score analysis / Impacto del intervalo de tiempo entre el diagnóstico y los síntomas en la supervivencia a medio plazo de pacientes quirúrgicos con endocarditis infecciosa del lado izquierdo: un análisis con propensity score

OBJECTIVES: We aimed to explore the impact of the time interval between symptoms and diagnosis on post-operative infective endocarditis (IE) survival. METHODS: From 2014 to 2019, data from 93 consecutive patients undergoing cardiac surgery due to left-sided±right-sided IE were prospectively recorded in our specific electronic database. Patients were classified into 2 groups according to time interval between first clinical symptoms and definitive endocarditis diagnosis: patients with early diagnosis (≤8 days) and patients with late diagnosis (>8 days). Follow-up was 100% complete, and follow-up mean time was 471 days. RESULTS: Among the 93 patients undergoing cardiac surgery due to definite left-sided IE, 48 (51.6%) had early-diagnosed IE whereas 45 (48.4%) presented with a late-diagnosed IE. Unadjusted and propensity score adjusted mid-term survival Kaplan-Meier analysis showed significantly worse survival of patients belonging to the early-diagnosis group (p .019 and .049 respectively). Multivariable Cox regression analysis identified only one predictor of mid-term mortality: EuroSCORE II (Hazard ratio 1.03, 95% CI 1.01-1.05, p .0008). CONCLUSION: The association in the Kaplan-Meier analysis between "early-diagnosis group" and mortality suggests that this group of patients presents clinical characteristics of severity that, on the one hand, speed up the diagnostic process and on the other, converge in the determination of a higher euroSCORE II value, which is the only independent predictor of mid-term mortality according to our analysis

OBJETIVOS: Nuestro objetivo fue explorar el impacto del intervalo de tiempo entre los síntomas y el diagnóstico en la supervivencia postoperatoria de la endocarditis infecciosa (EI). MÉTODOS: De 2014 a 2019, los datos de 93 pacientes consecutivos intervenidos de cirugía cardíaca por EI definitiva izquierda±derecha se registraron prospectivamente en nuestra base de datos electrónica. Los pacientes se clasificaron en 2 grupos según el intervalo de tiempo entre los primeros síntomas clínicos y el diagnóstico definitivo de endocarditis: pacientes con diagnóstico temprano (≤propensity score: 8 días) y pacientes con diagnóstico tardío (>propensity score: 8 días). El seguimiento fue del 100% completo, y el tiempo medio de seguimiento fue de 471 días. RESULTADOS: Entre los 93 pacientes que se sometieron a cirugía por EI definitiva del lado izquierdo, 48 (51,6%) tenían un diagnóstico temprano de EI, mientras que 45 (48,4%) presentaban un diagnóstico tardío de EI. El análisis de Kaplan-Meier no ajustado y el ajustado con propensity score mostró una supervivencia significativamente peor de los pacientes que pertenecen al grupo de diagnóstico temprano (p 0,019 y 0,049, respectivamente). El análisis de regresión de Cox multivariable identificó solo un predictor de mortalidad a medio plazo: EuroSCORE II (razón de riesgo: 1,03; IC 95%: 1,01-1,05; p 0,0008). CONCLUSIÓN: La asociación en el análisis de Kaplan-Meier entre «diagnóstico temprano de EI» y mortalidad sugiere que este grupo de pacientes presenta características clínicas de gravedad que, por un lado aceleran el proceso diagnóstico, y por el otro confluyen en la determinación de un EuroSCORE II más alto, que sí es un predictor independiente de mortalidad

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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Impact of the time interval between diagnosis and symptoms on survival of surgical patients with left-sided infective endocarditis: A propensity score analysis.

OBJECTIVES: We aimed to explore the impact of the time interval between symptoms and diagnosis on post-operative infective endocarditis (IE) survival. METHODS: From 2014 to 2019, data from 93 consecutive patients undergoing cardiac surgery due to left-sided±right-sided IE were prospectively recorded in our specific electronic database. Patients were classified into 2 groups according to time interval between first clinical symptoms and definitive endocarditis diagnosis: patients with early diagnosis (≤8 days) and patients with late diagnosis (>8 days). Follow-up was 100% complete, and follow-up mean time was 471 days. RESULTS: Among the 93 patients undergoing cardiac surgery due to definite left-sided IE, 48 (51.6%) had early-diagnosed IE whereas 45 (48.4%) presented with a late-diagnosed IE. Unadjusted and propensity score adjusted mid-term survival Kaplan-Meier analysis showed significantly worse survival of patients belonging to the early-diagnosis group (p .019 and .049 respectively). Multivariable Cox regression analysis identified only one predictor of mid-term mortality: EuroSCORE II (Hazard ratio 1.03, 95% CI 1.01-1.05, p .0008). CONCLUSION: The association in the Kaplan-Meier analysis between "early-diagnosis group" and mortality suggests that this group of patients presents clinical characteristics of severity that, on the one hand, speed up the diagnostic process and on the other, converge in the determination of a higher euroSCORE II value, which is the only independent predictor of mid-term mortality according to our analysis.

Incidencia, factores de riesgo e impacto pronóstico de la infección por citomegalovirus tras el trasplante cardiaco / Incidence, risk factors and prognostic impact of cytomegalovirus infection after heart transplantation

INTRODUCCIÓN Y OBJETIVOS: Analizar el impacto pronóstico de la infección por citomegalovirus (CMV) durante el primer año tras el trasplante cardiaco (TC) y describir factores de riesgo. MÉTODOS: Se realizó un estudio retrospectivo unicéntrico que incluyó 222 receptores de TC. La identificación de factores de riesgo de infección por CMV se llevó a cabo mediante la regresión multivariable de Cox. A través de los métodos de Kaplan-Meier y Cox se analizó la influencia de la infección por CMV durante el primer año sobre la supervivencia e incidencia de eventos clínicos adversos en el seguimiento a largo plazo. RESULTADOS: En el análisis multivariante, el estado serológico donante/receptor frente a CMV (hazard ratio [HR] 1,92, intervalo de confianza 95% [IC 95%] 1,2-3,09; p = 0,007), la edad del receptor (HR 1,02, IC 95%: 1,00-1,1; p = 0,02), la diabetes (HR 1,86, IC 95%: 1,4-3,05; p = 0,01), el soporte circulatorio mecánico (HR 1,59, IC 95%: 1,06-2,38; p = 0,03) y el uso de tacrolimus (HR 1,64, IC 95%: 1,13-2,36; p = 0,009) resultaron predictores independientes de infección por CMV postrasplante. No se detectó una influencia significativa de la infección por CMV durante el primer año postrasplante sobre la mortalidad, la incidencia de insuficiencia cardiaca, enfermedad vascular del injerto o rechazo agudo. CONCLUSIONES: La infección por CMV durante el primer año postrasplante no se asoció a un peor pronóstico a largo plazo

INTRODUCTION AND OBJECTIVES: To assess the risk factors of cytomegalovirus (CMV) infection after heart transplant (HT) and its influence on long-term prognosis. METHODS: We conducted a retrospective single-centre study of 222 HT recipients. Risk factors for CMV infection were identified by means of multivariable Cox́s regression. Kaplan-Meier analysis and Cox́s regression were used to assess the long-term prognostic impact of CMV infection during the first post-transplant year. RESULTS: Donor-recipient CMV serologic matching (hazard ratio [HR] 1.92, 95% confidence interval [95% CI] 1.2-3.09, p=.007), recipient age (HR 1.02, 95% CI: 1.00-1.1, p=.02), diabetes mellitus (HR 1.86, 95% CI: 1.4-3.05, p=.01), pre-transplant circulatory support (HR 1.59, 95% CI: 1.06-2.38, p=.03) and the use of tacrolimus (HR 1.64, 95% CI: 1.13-2.36, p=.009) were independently associated with increased risk of CMV infection. CMV infection during the first year post-HT was not associated with worse transplant outcomes in terms of mortality, incidence of heart failure, cardiac allograft vasculopathy or acute rejection. CONCLUSIONS: CMV infection was not associated with impaired long-term prognosis after HT

Incidence, risk factors and prognostic impact of cytomegalovirus infection after heart transplantation. / Incidencia, factores de riesgo e impacto pronóstico de la infección por citomegalovirus tras el trasplante cardiaco.

INTRODUCTION AND OBJECTIVES: To assess the risk factors of cytomegalovirus (CMV) infection after heart transplant (HT) and its influence on long-term prognosis. METHODS: We conducted a retrospective single-centre study of 222 HT recipients. Risk factors for CMV infection were identified by means of multivariable Cox́s regression. Kaplan-Meier analysis and Cox́s regression were used to assess the long-term prognostic impact of CMV infection during the first post-transplant year. RESULTS: Donor-recipient CMV serologic matching (hazard ratio [HR] 1.92, 95% confidence interval [95% CI] 1.2-3.09, p=.007), recipient age (HR 1.02, 95% CI: 1.00-1.1, p=.02), diabetes mellitus (HR 1.86, 95% CI: 1.4-3.05, p=.01), pre-transplant circulatory support (HR 1.59, 95% CI: 1.06-2.38, p=.03) and the use of tacrolimus (HR 1.64, 95% CI: 1.13-2.36, p=.009) were independently associated with increased risk of CMV infection. CMV infection during the first year post-HT was not associated with worse transplant outcomes in terms of mortality, incidence of heart failure, cardiac allograft vasculopathy or acute rejection. CONCLUSIONS: CMV infection was not associated with impaired long-term prognosis after HT.

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.

In-hospital postoperative infection after heart transplantation: Risk factors and development of a novel predictive score.

INTRODUCTION: Infection is one of the most significant complications following heart transplantation (HT). The aim of this study was to identify specific risk factors for early postoperative infections in HT recipients, and to develop a multivariable predictive model to identify HT recipients at high risk. METHODS: A single-center, observational, and retrospective study was conducted. The dependent variable was in-hospital postoperative infection. We examined demographic and epidemiological data from donors and recipients, surgical features, and adverse postoperative events as independent variables. Backwards, stepwise multivariable logistic regression with a P-value < 0.05 was used to identify clinical factors independently associated with the risk of in-hospital postoperative infections following HT. RESULTS: Six hundred seventy-seven patients were included in this study. During the in-hospital postoperative period, 348 episodes of infection were diagnosed in 239 (35.9%) patients. Seven variables were identified as independent clinical predictors of early postoperative infection after HT: history of diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, use of mycophenolate mofetil, and use of itraconazole. Based on the results of multivariable models, we constructed a 7-variable (8-point) score to predict the risk of in-hospital postoperative infection in HT recipients, which showed a reasonable ability to predict the risk of in-hospital postoperative infection in this population. Prospective external validation of this new score is warranted to confirm its clinical applicability. CONCLUSIONS: In-hospital postoperative infection is a common complication after HT, affecting 35% of patients who underwent this procedure at our institution. Diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, use of mycophenolate mofetil, and itraconazole were all independent clinical predictors of early postoperative infection after HT.

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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Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction.

OBJECTIVES: Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve-in-valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses. METHODS: Between January 2012 and August 2017, 11 patients (mean age 80.3 ± 5.6 years) were treated for SVD of Mitroflow bioprostheses with transcatheter ViV procedures (six transapical [TA] and five transfemoral [TF]) using balloon expandable bioprostheses. RESULTS: All patients but one were in NYHA class III-IV. Mean STS PROM, euroSCORE I, and euroSCORE II were 8 ± 6.5%, 27.8 ± 11.5%, and 12 ± 5.9%, respectively. Two patients had a "porcelain aorta." The size of implanted valves were 23 mm in 10 cases and 26 mm in one case. One patient suffered a coronary occlusion during a TF approach. The mean volume of contrast used in TF implants was 163 ± 69.8 mL. No contrast media were used in TA procedures. There was one in-hospital death (10%). At 1 year of follow-up, peak and mean aortic gradients were 25.5 ± 5.8 mmHg and 15.5 ± 5.7 mmHg, respectively. One patient had mild paravalvular regurgitation. Cumulative survival was 90.9% at 1 year, 70.7% at 2 years, and 53% at 3 years. CONCLUSIONS: ViV procedures with balloon-expandable aortic valves provide good hemodynamic and clinical mid-term results for treating patients with a degenerated Mitroflow aortic bioprosthesis. Special care must be taken in small aortic roots, when the stented valve is in the supra-annular position to avoid coronary ostial obstruction.

Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows.

OBJECTIVES: The objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy. METHODS: From January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores. RESULTS: All but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, P = 0.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1 year, 68.2%, 80.8% and 79.4% at 5 years and 63.9%, 72.7% and 79.4% at 10 years, respectively (log-rank = 0.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; P = 0.021], Trauma Injury Severity Score >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011). CONCLUSIONS: Minimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage.

Indexed left atrial size predicts all-cause and cardiovascular mortality in patients undergoing aortic valve surgery.

OBJECTIVES: The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery. METHODS: Indexed left atrial diameter was measured in 2011 adult patients (mean age, 70.9 ± 10.8 years; 58.7% were men) who underwent aortic valve surgery between January 2008 and March 2016. RESULTS: On the basis of the criteria of the American Society of Echocardiography, indexed left atrial diameter was normal in 64% of patients, mildly enlarged in 12.4% of patients, moderately enlarged in 9.2% of patients, and severely enlarged in 14.3% of patients. Over a mean follow-up period of 3.2 ± 2.1 years, there were 334 deaths and 97 strokes. Cardiovascular mortality survival at 5 years among patients with normal, mild, moderate, and severe left atrial enlargement was 91.6%, 86.8%, 77.9%, and 77.4%, respectively (P < .001). After covariable adjustment, Cox regression analysis showed indexed left atrial diameter as an independent predictor of all-cause mortality (hazard ratio per 1-cm/m2 increment, 1.545; 95% confidence interval, 1.252-1.906, P < .001), cardiovascular death (hazard ratio per 1-cm/m2 increment, 1.971; 95% confidence interval, 1.541-2.520; P < .001), and the combined event (hazard ratio per 1-cm/m2 increment, 1.673; 95% confidence interval, 1.321-2.119; P < .001). CONCLUSIONS: Indexed left atrial diameter is a strong predictor of long-term outcomes in patients with aortic valve diseases who undergo surgery.