Neurological outcomes of transcatheter aortic valve implantation with or without cerebral embolic protection devices: A meta-analysis.

INTRODUCTION: Cerebral embolic protection devices (CEPDs) are designed to prevent embolization of debris during transcatheter aortic valve implantation (TAVI). Current evidence from randomized clinical trials (RCTs) and observational studies is controversial. AIMS: The purpose of this meta-analysis was to study the influence of CEPDs on stroke, silent ischemic lesions and neurocognitive function. METHODS: A systematic search was conducted including RCTs or adjusted observational studies comparing TAVI with or without CEPDs. Pooled odds ratios, risk ratios or standardized mean differences with 95% confidence intervals were calculated using the inverse of variance method. Risk of bias sensitivity analyses and meta regression for CEPD type were also conducted. RESULTS: Five RCTs and five adjusted observational studies were included (n= 159,865). Mean age of the patients was 81.1 (SD 1.04) years in CEPDs and 81 (SD 1.86) in non-CEPD. The overall quality of evidence using the GRADE system for each endpoint was low to very low, mainly due to serious risk of bias, inconsistency and imprecision. Random effects meta-analysis detected no significant differences between CEPD and non-CEPD (OR= 0.74; 95% CI 0.51-1.07; P= 0.105; I2= 82.1%) for 30-day stroke. This finding was consistent in meta regression for CEPD type and subgroup analyses by study type and CEPD type. No significant differences between groups were observed in cerebral DW-MRI assessment and neurocognitive function evaluation. CONCLUSION: In the present meta- analysis of five RCTs and five adjusted observational studies, the use of a CEPD during TAVI was not associated with a significant benefit on 30- day stroke, total lesion volume per patient, number of ischemic lesions per patient and neurocognitive function assessments.

Thoracic Stent Grafting through Transapical Approach for Type III Endoleak due to Prosthetic Disconnection.

Thoracic endovascular aortic repair is a well-established treatment of descending thoracic aneurysms, and increasingly complex endovascular procedures including aortic arch and ascending aorta are being performed. However, follow-up complications may be expected, which will enhance the need for alternative approaches such as transapical, in case of complex anatomies and reinterventions. We report the case of a man with prior history of ischemic cardiopathy and multiple endovascular aortic interventions with proximal landing in zone 1 and distal landing proximal to celiac trunk. During the follow-up, the patient developed a 9-cm proximal thoracic aneurysm due to type III endoleak secondary to proximal prosthetic disconnection. Because of severe aortic elongation, inadequate usual vessel accesses (transfemoral/subclavian), and proximity to aortic arch, transapical approach was thought to be the best option in this case. The stent graft was correctly deployed without complications, and the postoperative imaging revealed an excellent result.

Off-Pump to On-Pump Emergency Conversion: Incidence, Risk Factors, and Impact on Short- and Long-Term Results.

BACKGROUND AND AIM OF THE STUDY: Emergency conversion to on-pump during off-pump coronary artery bypass surgery (CABG) increases morbidity and mortality. We analyze its risk factors and impact on short- and long-term outcomes. METHODS: All patients undergoing isolated CABG between 2006 and 2012 were included. Postoperative and midterm mortality and the combined event (death, myocardial infarction, cerebrovascular accident, and repeat revascularization) were compared between patients with and without conversion. Multivariate analysis and propensity score matching were performed. RESULTS: A total of 1268 patients were operated off pump and 37 patients required an emergency conversion. Postoperative death and combined event were more frequent among patients who were converted (31.6% vs. 3.31%, p < 0.001 and 43.2% vs. 11.5%, p < 0.001, respectively). Conversion was an independent predictor of both events (OR = 6.22, 95%CI: 2.01 to 19.3 and OR = 5.06, 95%CI: 2.41 to 10.61, respectively). Mean follow-up was 32.5 months. At four years, survival and freedom from the combined event was poorer for conversion (75% vs. 88%, p < 0.001 and 50% vs. 79%, p < 0.001, respectively). Conversion was an independent predictor for late mortality (HR = 2.4, 95%CI: 1.1 to 5.22) and the risk of combined event (HR = 2.97, 95%CI: 1.79 to 4.91). A 3:1 propensity score matching analysis was performed: conversion increased both perioperative and four-year mortality (12.6% vs. 4.5%, p < 0.001 and 25% vs. 12%, p = 0.007); and early and late incidence of the combined event (43.2% vs. 11.7%, p < 0.001 and 53% vs. 24%, p = 0.001). Preoperative atrial fibrillation and previous percutaneous coronary intervention were independent predictors of conversion. CONCLUSIONS: Emergency conversion from off- to on-pump CABG dramatically worsens early and late outcomes. Previous percutaneous coronary intervention and atrial fibrillation increase the risk of conversion.

Ultrafast track versus conventional fast track in patients undergoing cardiac surgery: a propensity score-matched analysis.

OBJECTIVES: We aimed at comparing the risk of major adverse events and length of stay between patients undergoing ultrafast track and conventional fast track. METHODS: Retrospective cohort study adjusted by propensity score matching, including patients operated on between March 2020 and December 2022 of any of the following: coronary, valve surgery or ascending aorta surgery. Patients were divided into 2 groups: ultrafast track: extubation in the operating room and fast track: extubation attempted in the first 6 postoperative hours. The primary objective was to compare the risk of the combined event death, lung respiratory outcomes (reintubation, mechanical ventilation longer than 24 h or pneumonia), or acute renal failure. RESULTS: A total of 1126 patients were included. A total of 579 (51.4%) were extubated in the operating room. A total of 331 pairs were available after matching by propensity score. The risk of the primary outcome was 11.8% (n = 39) in the fast-track group and 6.3% (n = 21) in the ultrafast-track group (P = 0.013), mostly driven by lung adverse events (6.9% vs 2.4%, P = 0.011) while no significant differences were detected in the risk of death (2.4% vs 1.8%, P = 0.77) or acute renal failure (8% vs 6.3%, P = 0.56). The risk of myocardial infarction was higher in the fast-track group (2.7% vs 0%, P = 0.039). The median length of stay in the postoperative intensive care unit was longer in the fast-track group [24.7 h (interquartile range 21.5; 62.9) vs 23.5 h (interquartile range 22; 46), P = 0.015]. CONCLUSIONS: In patients undergoing cardiac surgery, extubation in the operating room is associated to a lower risk of postoperative complications (mostly driven by lung adverse events) and length of stay in intensive care unit as compared to fast track.

Systolic flow displacement using 3D magnetic resonance imaging in an experimental model of ascending aorta aneurysm: impact of rheological factors.

OBJECTIVES: The impact of systolic flow displacement on the development and progression of ascending aorta dilatation in aortic valve disease is a matter of controversy. Our objective was to study the association between rheological stimuli and development of aortic dilatation in a large animal model of supravalvular aortic stenosis and eccentric flow. METHODS: Twenty-four pigs weighing 10-14 kg were randomly allocated (ratio 2:1) to either restrictive ascending aortic banding or sham operation. Aortic diameter and systolic flow displacement were assessed by three-dimensional phase-contrast magnetic resonance imaging at 6 and 18 weeks after surgery. Twenty pigs (n = 14, banded vs n = 6, sham) completed full imaging protocol and were included in the analysis. After the last follow-up, a subset of 14 animals was sacrificed for histological analysis. RESULTS: All banded animals developed significant progressive aortic dilatation both at 6 and 18 weeks, compared with sham-operated pigs: 34.3 ± 4.8 vs 21.4 ± 2.7 mm at 6 weeks (P < 0.001); and 50.0 ± 8.4 vs 38.0 ± 8.3 mm at 18 weeks (P = 0.002). The peak gradient at 6 weeks showed a trend to positively correlate with aortic diameter at 18 weeks (R = 0.50, P = 0.06), whereas the systolic flow displacement at 6 weeks correlated better with aortic diameter at 18 weeks (R = 0.59, P = 0.02). The aortic wall thickness was significantly decreased in the anterior aortic section in banded, compared with sham-operated, pigs (1.5 ± 0.4 vs 2.0 ± 0.1 mm, respectively; P = 0.03). In addition, banded pigs showed a higher degree of cystic medial necrosis and elastin fibre fragmentation, compared with sham-operated animals. CONCLUSIONS: In this preclinical model of supravalvular aortic stenosis and eccentric flow, we found that systolic flow displacement at earlier stages is positively correlated with the degree of aortic dilatation during follow-up as assessed by three-dimensional phase-contrast magnetic resonance imaging. If our findings are confirmed in further studies, this imaging parameter might be useful to identify those subjects with aortic valve disease who are at risk of developing aortic dilatation at a later stage.

SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main complex coronary disease.

OBJECTIVE: The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events. METHODS: All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders. RESULTS: A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively). CONCLUSIONS: SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.

Clinical outcomes with off-pump coronary surgery after angioplasty with stent.

INTRODUCTION AND OBJECTIVES: The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. METHODS: Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization). RESULTS: In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34). CONCLUSIONS: In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Resultados de la cirugía coronaria sin circulación extracopórea tras angioplastia con stent / Clinical outcomes with off-pump coronary surgery after angioplasty with stent

Introducción y objetivos. Evaluar el impacto de la implantación de stents coronarios previa a la cirugía de revascularización miocárdica en los resultados postoperatorios de ésta. Métodos. Desde enero de 2005 hasta abril de 2008, se evaluó retrospectivamente el impacto de la implantación de stents coronarios previa a la cirugía coronaria sin circulación extracorpórea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 días o ingreso hospitalario postoperatorios). Resultados. Se sometió a 796 pacientes consecutivos a revascularización miocárdica quirúrgica; 116 (14,6%) portaban algún stent coronario en el momento de la cirugía. Los grupos con stent y sin stent tenían un perfil de riesgo similar (EuroSCORE). En el análisis multivariable, ajustando el riesgo por las variables de confusión detectadas (fracción de eyección del ventrículo izquierdo preoperatoria < 40%, estado crítico preoperatorio, edad, antecedentes de accidente cerebrovascular agudo, infarto miocárdico agudo previo reciente, número de vasos coronarios enfermos, revascularización quirúrgica incompleta y conversión a circulación extracorpórea) se detectó que el ser portador de stent se asociaba de forma significativa a un mayor riesgo de infarto miocárdico postoperatorio (RR = 3,13; intervalo de confianza [IC] del 95%, 1,75-5,96), mortalidad cardiaca hospitalaria (RR = 4,62; IC del 95%, 1,76-12,11) y mortalidad hospitalaria por todas las causas (RR = 3,65; IC del 95%, 1,6-8,34). Conclusiones. En nuestra experiencia, la implantación previa de stents coronarios se asocia a un mayor riesgo de infarto miocárdico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugía coronaria (AU)

Introduction and Objectives. The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. Methods. Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (ie, at 30 days or during postoperative hospitalization). Results. In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (ie, EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (ie, preoperative left ventricular ejection fraction <40 critical preoperative state age history of cerebrovascular accident recent acute myocardial infarction number diseased coronary vessels incomplete revascularization and on-pump conversion showed that the presence a stent was significantly associated with increased risks postoperative relative risk rr="3.65;" 95 confidence interval ci 1 75-5 96 in-hospital cardiac mortality 76-12 11 all-cause 60-8 34 conclusions in our experience artery implantation prior to surgery period inhospital (AU)