Left ventricular reverse remodeling and function by strain analysis in aortic stenosis: A CMR analysis of the EPICHEART study.

INTRODUCTION AND OBJECTIVES: In severe aortic stenosis (AS), the impact of aortic valve replacement (AVR) on left ventricular (LV) systolic function assessed by strain and measured by echocardiography or cardiac magnetic resonance (CMR) has been controversial. We aimed to investigate LV systolic myocardial function changes six months after AVR using global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain derived from CMR imaging. METHODS: We included 39 severe AS patients (69.3±7.8 years; 61.5% male) with preserved LV ejection fraction (LVEF) who were recruited as part of the EPICHEART study and underwent successful AVR (aortic valvular area: 0.8 cm2 (IQR: 0.2) pre- to 1.8 cm2 (IQR:0.5) post-AVR). Structural and functional parameters were assessed at baseline and six months after AVR, including LV GRS, GCS and GLS analysis by CMR, using cine short-axial and two-, three-, and four-chamber long-axial view. Comparison between baseline and postoperative LV remodeling was performed using Student t-test and Wilcoxon test. RESULTS: At six-month follow-up, LV mass, end-diastolic and end-systolic volumes, stroke volume, cardiac output, lateral E/e', tricuspid annular plane systolic excursion, right ventricular (RV) S wave velocity, GLS [-15.6% (IQR: 4.39) to -13.7% (IQR: 4.62)] and GCS [-17.8±3.58% to -16.1±2.94%] reduced significantly, while LVEF and GRS remained unchanged and lateral e' velocity increased. CONCLUSIONS: Despite favorable reverse LV structural and diastolic functional remodeling six months following AVR, GLS and GCS assessed by CMR reduced compared to baseline, LVEF remained unchanged. The clinical utility and timing of assessment of postoperative strain changes as a marker of systolic function progression needs further research.

Influence of EPICardial adipose tissue in HEART diseases (EPICHEART) study: Protocol for a translational study in coronary atherosclerosis.

INTRODUCTION: Accumulation of epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD) and increased risk of coronary events in asymptomatic subjects and low-risk patients, suggesting that EAT promotes atherosclerosis in its early stage. Recent studies have shown that the presence of CAD affects the properties of adjacent EAT, leading to dynamic changes in the molecular players involved in the interplay between EAT and the coronary arteries over the history of the disease. The role of EAT in late-stage CAD has not been investigated. OBJECTIVES: In a comparative analysis with mediastinal and subcutaneous adipose tissue, we aim to investigate whether the volume of EAT assessed by computed tomography and its proteome assessed by SWATH-MS mass spectrometry are associated with late stages of CAD in an elderly cohort of severe aortic stenosis patients. METHODS: The EPICHEART study (NCT03280433) is a prospective study enrolling patients with severe degenerative aortic stenosis referred for elective aortic valve replacement, whose protocol includes preoperative clinical, nutritional, echocardiographic, cardiac computed tomography and invasive coronary angiographic assessments. During cardiac surgery, samples of EAT and mediastinal and subcutaneous thoracic adipose tissue are collected for proteomics analysis by SWATH-MS. In addition, pericardial fluid and peripheral and coronary sinus blood samples are collected to identify circulating and local adipose tissue-derived biomarkers of CAD. CONCLUSION: We designed a translational study to explore the association of EAT quantity and quality with advanced CAD. We expect to identify new biochemical factors and biomarkers in the crosstalk between EAT and the coronary arteries that are involved in the pathogenesis of late coronary atherosclerosis, especially coronary calcification, which might be translated into new therapeutic targets and imaging tools by biomedical engineering.

Safety And Risk Factors For The Morbidity And Mortality Of Pneumonectomy: A Retrospective 10- Year Study In A Single Institution.

OBJECTIVES: Pneumonectomy is a procedure with high post-operative morbidity and mortality. This study aims to assess and identify possible risk factors that can affect post-operative outcome, therefore determining the safety of pneumonectomy in specific groups. METHODS: A total of 63 patients submitted to pneumonectomy at our centre, from February 2008 to February 2018, were included in our retrospective study. Age, gender, side of intervention, diagnosis, pre-operative symptoms, substance abuse and comorbidities were assessed. Early and late post-operative complications, as well as death were our major outcomes. We analysed the impact of preoperative variables on major outcomes using SPSS statistics. RESULTS: We found a 9,8% surgery-related mortality and 1-year survival rate of 76,2%. The incidence of early complications in our population was of 35% while eleven patients (17,4%) developed late post-operative complications. No statistical difference was found when comparing survival time between genders or age groups. Right sided pneumonectomies seem to be associated with an higher mortality risk. No other association between risk factors and outcomes reached statistical significance in both univariate and multivariate analysis. CONCLUSIONS: Pneumonectomy is a viable option regardless of age whenever the patient has a good functional and cardiopulmonary status. Gender and diagnostic group do not seem to influence adverse event risk, although right-sided pneumonectomies show an increased risk for post-operative death. Care should be taken with patients submitted to neoadjuvant therapy. All patients should be encouraged to cease smoking as early as possible before surgery, given the increased risks for post-operative complications.

Total Aortic Arch Replacement With E-Vita OPEN PLUS Hybrid Prosthesis - Initial Experience From A Single Surgical Center.

We report a rare case of an advanced stage thymoma with right superior pulmonary lobe, superior vena cava, innominate vein and pericardium invasion in a patient with Good's syndrome. In a multidisciplinary discussion, surgical resection was deemed the best initial approach, since invaded structures could be safely managed. The tumor was fully resected and included partial resection of the superior pulmonary lobe, superior vena cava and innominate vein. The encircled right phrenic nerve was dissected from the tumor and preserved. The superior vena cava and innominate vein were reconstructed using autologous pericardium patch. Immunoglobulin replacement and radiotherapy were initiated afterwards. No signs of relapse at 6 months follow-up. In such advanced cases, aggressive surgical intervention should be considered as first line of treatment, as long as full resection can be anticipated, since complete resection is the leading factor for long-term prognosis.

Epicardial adipose tissue volume and annexin A2/fetuin-A signalling are linked to coronary calcification in advanced coronary artery disease: Computed tomography and proteomic biomarkers from the EPICHEART study.

BACKGROUND & AIMS: The role of epicardial adipose tissue (EAT) in the pathophysiology of late stage-coronary artery disease (CAD) has not been investigated. We explored the association of EAT volume and its proteome with advanced coronary atherosclerosis. METHODS: The EPICHEART Study prospectively enrolled 574 severe aortic stenosis patients referred to cardiac surgery. Before surgery, EAT volume was quantified by computed tomography (CT). During surgery, epicardial, mediastinal (MAT) and subcutaneous (SAT) adipose tissue samples were collected to explore fat phenotype by analyzing the proteomic profile using SWATH-mass spectrometry; pericardial fluid and peripheral venous blood were also collected. CAD presence was defined as coronary artery stenosis ≥50% in invasive angiography and by CT-derived Agatston coronary calcium score (CCS). RESULTS: EAT volume adjusted for body fat was associated with higher CCS, but not with the presence of coronary stenosis. In comparison with mediastinal and subcutaneous fat depots, EAT exhibited a pro-calcifying proteomic profile in patients with CAD characterized by upregulation of annexin-A2 and downregulation of fetuin-A; annexin-A2 protein levels in EAT samples were also positively correlated with CCS. We confirmed that the annexin-A2 gene was overexpressed in EAT samples of CAD patients and positively correlated with CCS. Fetuin-A gene was not detected in EAT samples, but systemic fetuin-A was higher in CAD than in non-CAD patients, suggesting that fetuin-A was locally downregulated. CONCLUSIONS: In an elderly cohort of stable patients, CCS was associated with EAT volume and annexin-A2/fetuin-A signaling, suggesting that EAT might orchestrate pro-calcifying conditions in the late phases of CAD.

Predictors of Acute Kidney Injury Associated with Cardiopulmonary Bypass.

OBJECTIVES: To study the incidence of acute kidney injury (AKI) in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with cardiopulmonary bypass (CPB), and to explore the association between the incidence of AKI and predictors related to CPB. METHODS: Observational, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. Kidney Disease: Improving Global Outcomes - Clinical Practice Guideline for Acute Kidney Injury (KDIGO) classification was used to characterize AKI. The analysis included preoperative variables (anthropometric data, cardiovascular risk factors and blood parameters), as well as the type of surgery, intraoperative variables related to CPB, and postoperative creatinine variation. Association between variables was studied with binary logistic regression. RESULTS: We have included 329 patients, of which 62 (19%), developed AKI. There were statistically significant differences between the groups in age (p<0.001; OR (95%)-1.075 (1.037-1.114)), duration of CPB (p=0.011; 1.008 (1.002-1.014)), urine output during CPB (p=0.038; 0.998 (0.996-0.999)), mannitol and furosemide administration during CPB, (respectively, p=0.032; 2.293 (1.075-4.890) and p=0.013; 2.535 (1.214-5.296)). CONCLUSIONS: A significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB, namely: age, duration of CPB, urine output during CPB, mannitol and furosemide administration during CPB.

Uniportal Video-assisted Thoracic Surgery Anatomical Resections - Does Previous Tobacco Exposure Adversely Influence Post-Operative Outcomes?

A high percentage of patients presenting for lung surgery are either current or former smokers, which is typically associated with many anatomical and physiological pulmonary changes. The influence of tobacco on postoperative pulmonary complications remains controversial. The main goal of this study was to analyse the effects of smoking on the risk of post-operative complications and morbidity in patients submitted to lung resection surgery through uniportal VATS. Peri-operative data on all cases of anatomical lung resection surgery through single-port VATS performed between December 2013 and July 2018 at three Portuguese institutions were collected and retrospectively reviewed Demographic data, diagnosis, pre-operative lung function tests, in-hospital length of stay (LOS) and intra and post-operative drainage levels were registered. Patients were divided in two groups according to tobacco exposure. Post-operative complications and morbidity were compared through statistical analysis We performed 313 procedures, 303 of which were evaluated in regard to outcome. Mean age at time of surgery was of 62,85 years (SD=12,24). One hundred and sixty patients (52,81%) had a history of tobacco use, while 47,19% (n=143) had never smoked. Non-smokers had significantly better lung function than smokers (p<0,05). Smoking history showed a contribution to post-operative prolonged air leaks (p=0,025) morbidity (p=0,05), 2-day longer LOS (µ=5,36 days vs. µ =7,53 days; p<0,05), longer operative times and higher intra and post-operative drainage levels. A history of smoking during a patient's life negatively impacts morbidity in patients submitted to uniportal VATS for anatomical lung resection, increasing early post-operative complications and prolonging in-hospital stays.

Correction of adult-type VSD causing aortic valve endocarditis through aortotomy.

Ventricular septal defects are the most common congenital abnormality diagnosed in children but account for only 10 percent of congenital heart defects in adults. Although many defects close spontaneously before adulthood, many others persist, predisposing to endocarditis, and other complications. Herein, we report a case of a known, asymptomatic, perimembranous ventricular septal defects that has complicated at 53 years of age with the need for surgery due to native aortic valve endocarditis and concomitant severe aortic regurgitation. We opted to surgically repair the ventricular septal defects with a pericardial patch through the necessary aortotomy used for aortic valve replacement (Figure 1 and 2). The surgery was straightforward. Postoperative course was only marked by the need of a permanent pacemaker implantation due to a sick sinus syndrome, which was diagnosed before the surgery. Thus, we emphasize the role of surgery in repairing ventricular septal defects and the importance of choosing the appropriate approach, especially when concomitant heart lesions are present.

As comunicações interventriculares são a lesão congénita mais comummente diagnosticada em idade pediátrica mas representam apenas 10% dos defeitos cardíacos congénitos em idade adulta. Apesar da maioria das comunicações interventriculares encerrarem espontaneamente antes da idade adulta, muitas persistem predispondo a endocardite e outras complicações. Apresentamos um caso de comunicação interventricular perimembranosa assintomática até à idade adulta, que complicou aos 53 anos com endocardite da válvula aórtica nativa associada a regurgitação aórtica severa, necessitando, por isso, de correção cirúrgica. Optamos pela correção cirúrgica implantando um retalho de pericárdio heterólogo através da aortotomia necessária para a substituição valvular aórtica (Figure 1 and 2). A cirurgia decorreu sem intercorrências. De referir apenas, no pós-operatório, a necessidade de implantação de um pacemaker permanente dado existência prévia de doença do nó sinusal. É de salientar a importância do papel da cirurgia na correção de comunicações interventriculares e a necessidade de escolher a abordagem cirúrgica mais apropriada, especialmente, quando existem lesões cardíacas concomitantes.

Surgical treatment of concomitant severe heart disease and lung cancer.

The concomitant presentation of lung cancer and severe heart disease requiring intervention is a scenario that many clinicians have to face. Its common physiopathological substratum is unknown and it is believed that tobacco plays a role. From a surgical point of view, these patients pose various technical challenges and medical literature is scarce in providing solid answers. The aim of this report is to review our experience with cases undergoing combined surgical treatment of both heart disease and lung cancer, aiming to analyse patients' characteristics, operative technical considerations and related outcomes. A total of five patients were included, with two synchronous procedures, two cases with lung surgery being performed first and one case commenced with cardiac surgery. All cancers were non-small-cell lung carcinoma or carcinoid tumors and cardiac disease was mostly represented by severe aortic stenosis. Lobectomy was performed in two thirds of patients and minimally invasive techniques were used in 60% of the procedures. All valvular patients received a bioprosthesis. There was one immediate complication, with good recovery on follow-up, and there were no late events (median follow-up of 1,8 ±1,1 months). The analysis of these cases highlights the complex nature of these challenging patients and reinforces the importance of devoting efforts to offer the most suitable solutions for each scenario.

A apresentação concomitante de cancro do pulmão e doença cardíaca severa necessitando intervenção é um cenário frequente na prática clínica. O seu substrato fisiopatológico comum é desconhecido e acredita-se que o tabagismo possa ser um agente associado. Do ponto de vista cirúrgico, estes pacientes colocam vários desafios técnicos e a literatura médica é escassa em providenciar respostas robustas. O objetivo deste relato consiste em rever a nossa experiência com casos submetidos a tratamento cirúrgico combinado das patologias supracitadas, visando analisar as características dos pacientes, considerações das técnicas operatórias e eventos relacionados. Um total de cinco pacientes foram incluídos, com dois procedimentos síncronos, dois casos que tiveram a cirurgia pulmonar como primeiro procedimento e um caso iniciado com cirurgia cardíaca. Histologicamente, todos os cancros eram carcinomas pulmonares de não pequenas células ou tumores carcinóides e a patologia cardíaca mais representativa foi a estenose valvular aórtica. A lobectomia foi executada em 2/3 dos pacientes e em 60% dos casos foram utilizadas técnicas minimamente invasivas. Todos os pacientes valvulares receberam próteses biológicas. Houve uma complicação pós-operatória imediata, com recuperação favorável, e não ocorreram eventos tardios no seguimento (duração mediana de 1,8 ±1,1 meses). A análise destes casos enfatiza a complexa natureza destes pacientes desafiantes e reforça a importância em dedicar esforços para oferecer as soluções mais adequadas para cada cenário.

[In dubio pro malum - a clinical case to reflect]. / In dubio pro malum ­ um caso clínico para reflectir.

Patients with cardiac pathology alone are already complex, when this is associated with oncologic pathology, or it's mere suspicion, the patient becomes even more complex. We present a clinical case of a patient with severe aortic stenosis with suspected cancer disease, whose diagnostic study could not be performed due to the patient's clinical condition. The option to intervene surgically was widely debated, never being a consensus among surgeons. There are many doubts about a clinical case of this type, and it is not easy to make a decision to operate. In case of doubt, the decision must always be in favor of the patient: in dubio pro malum.

Se os doentes com patologia cardíaca, por si só, já são doentes complexos, quando a esta se associa patologia oncológica, ou a sua mera suspeição, o doente torna-se ainda mais complexo. Apresentamos um caso clínico de um doente com estenose aórtica severa, com suspeita de doença oncológica, cujo estudo diagnóstico não se poderia realizar devido ao facto de o estado clínico do doente não permitir tolerar o mesmo. A opção de intervir cirurgicamente foi uma opção amplamente debatida, nunca se encontrando um consenso entre os cirurgiões. São imensas as dúvidas levantadas perante um quadro clínico deste tipo, não sendo fácil a tomada de decisão de operar. Em caso de dúvida, a decisão deve ser sempre a favor do doente: in dubio pro malum.

Alteración del strain auricular izquierdo como predictor de fibrilación auricular de nuevo comienzo tras recambio valvular aórtico, independientemente del tamaño de la aurícula izquierda / Impaired left atrial strain as a predictor of new-onset atrial fibrillation after aortic valve replacement independently of left atrial size

Introducción y objetivos: La disfunción de la aurícula izquierda en la estenosis aórtica puede preceder a la dilatación y predecir la aparición de fibrilación auricular (FA). Para analizar esta hipótesis, se estudió la función auricular izquierda y se determinó su impacto en la incidencia de FA tras recambio valvular aórtico. Métodos: Se estudió mediante ecocardiografía con speckle-tracking a 149 pacientes (74 ± 8,6 años; el 51% varones) con estenosis aórtica grave sin FA previa. La función auricular izquierda se evaluó con el pico de strain longitudinal auricular (PSLA), el pico de strain de la contracción auricular (PSCA) y el volumen de la aurícula izquierda en cada fase de la contracción auricular. En 114 pacientes se detectó la aparición de FA entre la cirugía y el alta hospitalaria. Resultados: En el análisis de regresión lineal múltiple, el PSLA y el PSCA tenían correlación inversa con la dilatación auricular, la hipertrofia ventricular izquierda y la función diastólica; 36 pacientes presentaron FA una media de 3 [intervalo intercuartílico, 1-4] días tras el recambio valvular aórtico. En la regresión de Cox, la incidencia de FA se asoció de manera independiente con ambos parámetros (HR = 0,946; IC95%, 0,910-0,983; p = 0,005; HR = 0,932; IC95%, 0,883-0,984; p = 0,011) incluso después de ajustar los resultados según las dimensiones de la aurícula izquierda. Tanto la reducción del PSLA como del PSCA se asociaron con la incidencia de FA en los pacientes con aurícula izquierda no dilatada (PSLA con las dimensiones de la aurícula izquierda, p = 0,013). Conclusiones: En la estenosis aórtica grave, la disfunción auricular predijo la incidencia de FA posoperatoria independientemente de la dilatación auricular, lo que indica que la ecocardiografía con speckle-tracking antes de la cirugía puede ser de ayuda en la estratificación del riesgo, particularmente en aquellos con aurícula izquierda no dilatada

Introduction and objectives: Left atrial dysfunction in aortic stenosis may precede atrial enlargement and predict the occurrence of atrial fibrillation (AF). To test this hypothesis, we assessed left atrial function and determined its impact on the incidence of AF after aortic valve replacement. Methods: A total of 149 severe aortic stenosis patients (74 ± 8.6 years, 51% men) with no prior AF were assessed using speckle-tracking echocardiography. Left atrial function was evaluated using peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and phasic left atrial volumes. The occurrence of AF was monitored in 114 patients from surgery until hospital discharge. Results: In multiple linear regression, PALS and PACS were inversely correlated with left atrial dilation, left ventricular hypertrophy, and diastolic function. Atrial fibrillation occurred in 36 patients within a median time of 3 days [interquartile range, 1-4] after aortic valve replacement. In multiple Cox regression, PALS and PACS were independently associated with the incidence of AF (HR, 0.946; 95%CI, 0.910-0.983; P = .005 and HR, 0.932; 95%CI, 0.883-0.984; P = .011, respectively), even after further adjustment for left atrial dimensions. Both reduced PALS and PACS were associated with the incidence of AF in patients with nondilated left atria (P value for the interaction of PALS with left atrial dimensions = .013). Conclusions: In severe aortic stenosis, left atrial dysfunction predicted the incidence of postoperative AF independently of left atrial dilation, suggesting that speckle-tracking echocardiography before surgery may help in risk stratification, particularly in patients with nondilated left atria

Impaired Left Atrial Strain as a Predictor of New-onset Atrial Fibrillation After Aortic Valve Replacement Independently of Left Atrial Size.

INTRODUCTION AND OBJECTIVES: Left atrial dysfunction in aortic stenosis may precede atrial enlargement and predict the occurrence of atrial fibrillation (AF). To test this hypothesis, we assessed left atrial function and determined its impact on the incidence of AF after aortic valve replacement. METHODS: A total of 149 severe aortic stenosis patients (74±8.6 years, 51% men) with no prior AF were assessed using speckle-tracking echocardiography. Left atrial function was evaluated using peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and phasic left atrial volumes. The occurrence of AF was monitored in 114 patients from surgery until hospital discharge. RESULTS: In multiple linear regression, PALS and PACS were inversely correlated with left atrial dilation, left ventricular hypertrophy, and diastolic function. Atrial fibrillation occurred in 36 patients within a median time of 3 days [interquartile range, 1-4] after aortic valve replacement. In multiple Cox regression, PALS and PACS were independently associated with the incidence of AF (HR, 0.946; 95%CI, 0.910-0.983; P=.005 and HR, 0.932; 95%CI, 0.883-0.984; P=.011, respectively), even after further adjustment for left atrial dimensions. Both reduced PALS and PACS were associated with the incidence of AF in patients with nondilated left atria (P value for the interaction of PALS with left atrial dimensions=.013). CONCLUSIONS: In severe aortic stenosis, left atrial dysfunction predicted the incidence of postoperative AF independently of left atrial dilation, suggesting that speckle-tracking echocardiography before surgery may help in risk stratification, particularly in patients with nondilated left atria.

Minimally invasive aortic coarctation correction and aortic valve replacement without syetnotomy.

Aortic coarctation and bicuspid aortic valve frequently coexist. Correction frequently require an aggressive, invasive approach. Here we present a case of a two-stage minimally invasive intervention without sternotomy to correct aortic coarctation and replace the native bicuspid aortic valve. This case illustrates the potential of minimally invasive procedures with minimal trauma and fast recovery. Besides, it facilitates future cardiac interventions, such as anticipated surgical prosthesis and/or ascending aorta replacement.

A coartação aórtica e a bicuspidia aórtica coexistem frequentemente. A sua correção obriga frequentemente a uma intervenção agressiva e invasiva. Apresentamos um caso de uma intervenção faseada minimamente invasiva sem esternotomia para corrigir a coartação da aorta e substituir a válvula aórtica bicúspide nativa. Este caso ilustra o potencial de procedimentos minimamente invasivos com trauma mínimo e recuperação rápida. Além disso, facilita futuras intervenções cardíacas, como a substituição da prótese biológica e/ou da aorta ascendente, que se antecipam neste doente.

Gender differences in the association of epicardial adipose tissue and coronary artery calcification: EPICHEART study: EAT and coronary calcification by gender.

BACKGROUND: The association of epicardial adipose tissue (EAT) and coronary artery calcification (CAC) seems to differ by gender. However, few studies have controlled for body size, and the ideal method for body size indexing has not been explored. OBJECTIVES: To analyse the effect of gender related-body size and-body fat differences on the association of EAT with CAC. METHODS: This was a prospective cohort of 371 severe aortic stenosis patients (77±8.5year-old, 51% females) referred to cardiac surgery. Agatston calcium score, EAT volume and visceral abdominal fat (VAF) were obtained by computed tomography. Body composition was determined using bioelectrical impedance analysis. Body weight and height were measured to derive body mass index (BMI), body surface area (BSA), and body surface index (BSI). EAT volume was normalized for BSA, weight and height. RESULTS: Median CAC score was higher in men (887; IQR: 2010) than in women (279: IQR: 145) (p<0.01). Similarly, men had higher volume of EAT than women (137±65.6 vs. 106±65.6mL, p<0.01), even when BSA- or height-indexed, but not if weight-indexed. EAT volume was associated with CAC adjusting for adiposity (BMI or BSI and VAF, or fat mass), but not with further adjustment for gender. In a stratified analysis, absolute- and indexed-volumes of EAT were independently associated with CAC in men while no association was found in women (gender-interaction p<0.05). CONCLUSIONS: In these high-risk patients, we demonstrated that EAT was associated with CAC score irrespective of body size, body fat and cardiovascular risk factors in men but not in women.

Lead Extraction of Cardiac Rhythm Devices: A Report of a Single-Center Experience.

INTRODUCTION AND OBJECTIVES: The rate of implanted cardiac electronic devices is increasing as is the need to manage long-term complications. Lead removal is becoming an effective approach to treat such complications. We present our experience in lead removal using different approaches, analyzing the predictors of the use of mechanical extractors/surgical removal. METHODS: Retrospective analysis of lead extractions in a series of 76 consecutive patients (mean age 70.4 ± 13.8 years, 73.7% men) between January 2009 and November 2015. RESULTS: One hundred thirty-five leads from permanent pacemakers (single chamber 19.7%; dual-chamber 61.8%), implantable cardioverter defibrillators (5.3%), and cardiac resynchronization devices (CRT-P 2.6%; CRT-D 7.9%) were removed, 72.5 ± 73.2 months after implantation. A total of 45.9% were ventricular leads, 40.0% atrial leads, 8.9% defibrillator leads, and 5.2% leads in the coronary sinus; 64.4% had passive fixation. The most common indications for removal were pocket infection (77.8%), infective endocarditis (9.6%), and lead dislodgement (3.7%). A total of 76.3% of the leads were explanted, 20.0% were extracted, and 3.7% were surgically removed. Extraction of the entire lead was achieved in 96.3% of the procedures. After logistic regression (age adjusted), time since implantation was the sole predictor of the need of mechanical extractors/surgical removal. All patients were discharged without major complications. There were no deaths at 30 days. CONCLUSION: Our experience in lead removal was effective and safe. Performing these procedures by experienced electrophysiologists with an adequate cardiothoracic surgery team on standby to cope with any complications is required. Referral of high-risk patients to a high-volume center is recommended to optimize clinical success and minimize procedural complications.

Improvement in left intraventricular pressure gradients after aortic valve replacement in aortic stenosis patients.

NEW FINDINGS: What is the central question of this study? Normal diastolic and systolic intraventricular pressure gradients are decreased when left ventricular filling and/or emptying are compromised. We hypothesized that in patients with severe aortic valve stenosis, a condition that interferes with ventricular filling and emptying, those gradients would be disturbed. What is the main finding and its importance? We showed the existence of intraventricular pressure gradients throughout the cardiac cycle in the human left ventricle. Moreover, we demonstrated, for the first time, that diastolic and systolic gradients, which are markers of normal ventricular filling and emptying, respectively, improved in patients with severe aortic valve stenosis immediately after valve replacement. The present study was conducted to characterize left intraventicular pressure gradients, which are markers of normal cardiac function, in patients with severe aortic stenosis, a condition that interferes with ventricular filling and emptying. In 10 patients (four male; mean age 71.3 ± 4.8 years old) undergoing aortic valve replacement, two high-fidelity pressure catheters were inserted inside the cavity of the left ventricle through an apical puncture and positioned in the apex and outflow tract below the aortic valve. Pressures were continuously acquired and gradients calculated as apical minus outflow tract pressure, before and immediately after aortic valve replacement. During early filling, we recorded a negative intraventricular gradient along the basal portion of the left ventricle in the apical direction (-0.82 ± 0.45 mmHg), which increased to -3.97 ± 0.42 mmHg after aortic valve replacement. In late filling, intraventricular flow was now directed towards the outflow tract, with a positive pressure gradient both before (+1.23 ± 0.37 mmHg) and after surgery (+2.12 ± 0.58 mmHg). During systole, before surgery we observed a positive pressure gradient between the apex and outflow tract during both rapid (+1.60 ± 0.21 mmHg) and slow ejection phases (+1.68 ± 0.12 mmHg), whereas after aortic valve replacement the positive gradient (+1.54 ± 0.15 mmHg) during rapid ejection was inverted (-3.92 ± 0.34 mmHg) during the slow ejection phase. We demonstrated that in patients with severe aortic stenosis both diastolic and systolic intraventricular pressure gradients are significantly attenuated but can be restored immediately after aortic valve replacement. The assessment and measurement of intraventricular pressure gradients and their modulation in pathophysiological conditions may provide novel insights into cardiac physiology.

[Papillary muscle rupture as a manifestation of SLE in the puerperium]. / Rotura de Músculo Papilar como Manifestação de Lupus Eritematoso Sistémico no Puerpério.

Systemic Lupus Erythematosus (SLE) and Antiphospholipid Syndrome (APS) are two autoimmune diseases that may have serious cardiovascular manifestations, especially when associated. We report the clinical case of a young female, in the puerperium, with SLE in acute phase, who developed a sudden heart failure due to rupture of the papillary muscle. She underwent emergent cardiac surgery, with replacement of the mitral valve by a biological prosthesis. The postoperative course had no major intercurrences. Catastrophic SAF was concluded as a final diagnosis, due to the presence of anti-phospholipid antibody, to the attainment of multiple organs by thromboembolic phenomena, with histological documentation of micro-thrombi in cardiac tissue. This condition has a mortality rate of about 50%, despite treatment.

O Lúpus Eritematoso Sistémico (LES) e a Síndrome Antifosfolípido (SAF) são duas doenças auto-imunes que podem ter manifestações cardiovasculares graves, principalmente quando associadas. Apresentamos o caso clínico de uma doente jovem, puérpera, com LES em fase de agudização, que desenvolveu um quadro súbito de insuficiência cardíaca grave, por ruptura de músculo papilar. Foi submetida a cirurgia cardíaca emergente, com substituição da válvula mitral por prótese biológica. O período pós-operatório decorreu sem intercorrências de relevo. Como diagnóstico final concluiu-se SAF catastrófica, devido à presença de anticorpo anti-fosfolípido, ao atingimento de múltiplos órgãos por fenómenos trombo-embólicos, com documentação histológica da presença de micro-trombos no tecido cardíaco. Esta condição tem uma taxa de mortalidade de cerca de 50%, apesar do tratamento.

Aortic Valve Replacement With Perceval® Bioprosthesis: Initial Single-Center Experience.

INTRODUCTION: Aortic valve replacement (AVR) is the gold standard for the treatment of severe or symptomatic aortic valve stenosis. Less invasive procedures have been developed as an alternative to the conventional technique of full sternotomy approach with stented prosthesis. The Perceval® aortic valve (LivaNova, Milan, Italy) is a sutureless bioprosthesis, of which several reports have shown promising results in terms of mortality, morbidity and hemodynamic performance, especially with a less invasive approach. METHODS: Between March 2016 and September 2017, 43 patients underwent AVR with Perceval® bioprosthesis. The mean age was 74.3±6.8 years, 24 (55.8%) patients were female, and the mean EuroSCORE II was 4.1±0.6. Concomitant procedures were CABG (n=11; 25.6%), mitral valve surgery (n=2; 4.7%) and tricuspid valve surgery (n=1; 2.4%). RESULTS: Isolated AVR were performed in 31 patients (72%), with a less invasive approach in 29 cases (67%), of which 20 patients with upper ministernotomy and 9 patients with right anterior mini-thoracotomy. Cardiopulmonary bypass and cross- clamp times were 69.8±26.6 and 49.2±18.1 minutes for isolated AVR and 106.1±32.6 and 82.9±24.9 minutes for combined procedures, respectively. Preoperative peak and mean gradients were 81.6±24.8 and 49.7±16.1 mmHg, decreasing to 22.4±10.2 and 11.9±5.8 mmHg, respectively, during follow up (mean 9.1±6.0 months). The mean effective orifice area improved from 0.77±0.18 to 1.83±0.45 cm2, and mean left ventricular ejection fraction from 55.0±10.0 to 55.2±8.4%; mean left ventricular mass decreased from 221.6±55.7 to 180.2±42.4 g/m2. Trivial paravalvular leakage occurred in 2 patients, without clinical relevance. Five patients (11.6%) needed pacemaker implantation because complete heart-block before discharge (in 4 patients postdilation modelling wasn't performed). In-hospital mortality was 9.3% (n=4), all non-valve related (mean EuroSCORE II of 9.15±4.0). CONCLUSION: AVR with the Perceval bioprosthesis is associated with low mortality rates and excellent hemodynamic performance. Sutureless technology may reduce operative times, especially in combined procedures, making minimally invasive AVR more easily reproducible.