Prosthesis-patient mismatch after surgical aortic valve replacement: neither uncommon nor harmless

Abstract Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) is an issue that has been overlooked (not to say neglected). Cardiac surgeons must bear in mind that this is a real problem that we must tackle. The purpose of this paper is to be a wake-up call to the surgical community by giving a brief overview of what PPM is, its incidence and impact on the outcomes. We also discuss the increasing role played by imaging for predicting and assessing PPM after SAVR (with which surgeons must become more acquainted) and, finally, we present some options to avoid PPM after the surgical procedure.

Current practice of state-of-the-art coronary revascularization in patients with heart failure

Abstract The best treatment for patients with ischemic heart failure (HF) is still on debate. There is growing evidence that coronary artery bypass graft (CABG) benefits these patients. The current recommendations for revascularization in this context are that CABG is reasonable when it comes to decreasing morbidity and mortality rates for patients with severe left ventricular dysfunction (ejection fraction <35%), and significant coronary artery disease (CAD) and should be considered in patients with operable coronary anatomy, regardless whether or not there is a viable myocardium (class IIb). Percutaneous coronary intervention (PCI) does not have enough data to allow the panels to reach a conclusion. The Korean Acute Heart Failure registry (KorAHF) had its data released recently, showing that patients with acute HF who underwent CABG had lower death rates, more complete revascularization and less adverse outcomes compared with patients treated with PCI. Recent ESC/EACTS guidelines on myocardial revascularization clearly recommended CABG as the first choice of revascularization strategy in patients with multivessel disease and acceptable surgical risk to improve prognosis in this scenario of left ventricular dysfunction. However, a high peri-procedural risk must be compared with the benefit of late mortality, and pros and cons of each strategy (either PCI or CABG) must be weighed in the decision-making process. Spurred on by the publication of the above-mentioned article and the release of new guidelines, we went on to write an overview of the current practice of state-of-the-art coronary revascularization options in patients with HF.

Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients / Desfechos de 5 anos do tratamento de lesões de TCE por stents farmacológicos versus CRM: metaanálise e meta-regressão de 2914 pacientes

OBJECTIVE: To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). RESULTS: At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CONCLUSION: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

OBJETIVO: Comparar segurança e eficácia do seguimento a longo prazo da cirurgia de revascularização miocárdica (CRM) com intervenção coronária percutânea (ICP), utilizando stents farmacológicos (SF) em pacientes com lesão de tronco de coronária esquerda não-protegida (TCE). MÉTODOS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar e listas de referências artigos relevantes foram escaneados para estudos clínicos que relataram resultados em 5 anos de seguimento após ICP-SF eCRM para o tratamento de lesão de TCE. Cinco estudos (um de ensaio clínico randomizado e quatro estudos observacionais) foram identificados e incluíram um total de 2914 pacientes (1300 para CRM e 1614 para ICP-SF). RESULTADOS: Aos 5 anos de seguimento, não houve diferença significativa entre os grupos CRM e ICP-SF no risco de morte (odds ratio [OR] 1,159, P=0,168) ou desfecho composto de morte, infarto do miocárdio , ou AVC (OR 1,214, P=0,083). O risco de necessidade de nova revascularização foi significativamente menor no grupo CRM em comparação com o grupo de ICP-SF (OR 0,212, P<0,001). O risco de eventos adversos cardíacos maiores e cerebrovasculares (EACMC) foi significativamente menor no grupo CRM em comparação com o grupo de ICP-SF (OR 0,526, P<0,001). Não foi observado viés de publicação sobre os resultados e considerável heterogeneidade dos efeitos sobre EACMC. CONCLUSÃO: CRM continua sendo a melhor opção de tratamento para pacientes com lesão de TCE, com menos necessidade de novas revascularizações e EACMC no seguimento a longo prazo.