Early Outcomes of Modified De Vega Annuloplasty for Functional Tricuspid Regurgitation at a Brazilian Hospital

Abstract Background: Right valve diseases are not benign, the tricuspid regurgitation has a significant impact on morbidity and mortality of patients. Objectives: This study aimed to report the short-term results of tricuspid annuloplasty using the De Vega technique modified by Manuel Antunes. Methods: A descriptive-analytical study was performed to evaluate the results of the tricuspid valvuloplasty performed at the Instituto de Medicina Integral Professor Fernando Figueira between 2012 and 2017. Data were collected by reviewing charts and databases of the Department of Cardiology and Cardiovascular Surgery of the institution. Those with rheumatic diseases or infective endocarditis with tricuspid valve involvement, or reoperation of the tricuspid valve were excluded. Student's t-test and McNemar's were used for statistical analysis. A p-value < 0.05 was considered statistically significant. Results: A total of 87 patients were studied, most of them were women (56.3%). The most associated heart valve diseases were mitral regurgitation (27.6%) and aortic regurgitation (20.7%). There was a significant decrease in the degree of tricuspid regurgitation in the postoperative period, with 83.3% of patients with none or mild regurgitation and only 1.1% with severe regurgitation (p = 0.0077). Conclusions: In the current study, tricuspid valve annuloplasty using the modified De Vega technique was shown to be effective in the short term. Further studies are needed to evaluate the long-term results.

Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium (ozaki procedure) - a promising surgical technique

Abstract In cases of aortic valve disease, prosthetic valves have been increasingly used for valve replacement, however, there are inherent problems with prostheses, and their quality in the so-called Third World countries is lower in comparison to new-generation models, which leads to shorter durability. Recently, transcatheter aortic valve replacement has been explored as a less invasive option for patients with high-risk surgical profile. In this scenario, aortic valve neocuspidization (AVNeo) has emerged as another option, which can be applied to a wide spectrum of aortic valve diseases. Despite the promising results, this procedure is not widely spread among cardiac surgeons yet. Spurred on by the last publications, we went on to write an overview of the current practice of state-of-the-art AVNeo and its results.

Ruptura traumática de músculo papilar da valva tricúspide com forame oval patente adquirido e ruptura atrial direita oculta / Traumatic tricuspid valve papillary muscle case with concomitant acquired patent foramen ovale and covert right atrial rupture

RESUMO O traumatismo cardíaco é comum em acidentes com veículos automotores. Uma mulher com 50 anos de idade foi transportada para nosso hospital após sofrer múltiplos traumatismos em um acidente de automóvel quando dirigia em alta velocidade. Após admissão à unidade de terapia intensiva, uma ultrassonografia cardíaca revelou ruptura traumática de músculo papilar da valva tricúspide e forame oval patente, enquanto se observou, no exame físico, o sinal de Lancisi. Foi realizado tratamento cirúrgico com anuloplastia da valva e fechamento do forame oval patente; durante o ato cirúrgico, diagnosticou-se ruptura oculta do átrio direito.

ABSTRACT Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.

Fístula aorto-atrial direita: uma complicação pós-endocardite infecciosa. Relato de caso / Right aorto-atrial fistula: a post-infective endocarditis complication. A case report

A fístula aorto-atrial direita é uma comunicação anômala, que representa uma grave e infrequente complicação da endocardite infecciosa. Neste estudo, relata-se o caso de um paciente de 53 anos, do sexo masculino, com histórico evolutivo patológico de endocardite infecciosa e acometimento de valva aórtica. Sob imagem de ecocardiograma, demonstrou-se abscesso perivalvar aórtico, estendendo-se à parede atrial direita, com necessidade de abordagem cirúrgica. Foram realizados a anuloplastia valvar aórtica e implante de valva mecânica. Após 1 mês de evolução pós-cirúrgica, realizou-se novo ecocardiograma, que acusou shunt de débito da raiz da aorta para o átrio direito. A conduta diante do caso foi discutida entre equipe clínica e cirúrgica, visando a possíveis falhas na terapêutica inicial. (AU)

Right aorto-atrial fistula is an anomalous communication that represents a serious and infrequent complication of infective endocarditis. This study reports the case of a 53-year-old male patient, with a pathological evolutionary history of infective endocarditis and aortic valve involvement. The echocardiogram shows an aortic perivalvar abscess extending to the right atrial wall, requiring a surgical approach. Aortic valve annuloplasty and mechanical valve implantation were performed. After a month of post-surgical evolution, a new echocardiogram was performed, which showed aortic root to right atrium shunt. The behavior in this case was discussed between the clinical and surgical teams, aiming at possible failures in the initial therapy. (AU)

Ebstein's anomaly: "The one and a half ventricle heart"

Abstract Objective: Ebstein's anomaly remains a relatively ignored disease. Lying in the 'No Man's land' between congenital and valve surgeons, it largely remains inadequately studied. We report our short-term results of treating it as a 'one and a half ventricle heart' and propose that the true tricuspid annulus (TTA) 'Z' score be used as an objective criterion for estimation of 'functional' right ventricle (RV). Methods: 22 consecutive patients undergoing surgery for Ebstein's anomaly were studied. Echocardiography was performed to assess the type and severity of the disease, tricuspid annular dimension and its 'Z' score. Patients were operated by a modification of the cone repair, with addition of annuloplasty, bidirectional cavopulmonary shunt (BCPS) and right reduction atrioplasty to provide a comprehensive repair. TTA 'Z' score was correlated later with postplication indexed residual RV volume. Results: There was one (4.5%) early and no late postoperative death. There was a significant reduction in tricuspid regurgitation grading (3.40±0.65 to 1.22±0.42, P<0.001). Residual RV volume reduced to 71.96±3.8% of the expected volume and there was a significant negative correlation (rho −0.83) between TTA 'Z' score and indexed residual RV volume. During the follow-up of 20.54±7.62 months, the functional class improved from 2.59±0.7 to 1.34±0.52 (P<0.001). Conclusion: In Ebstein's anomaly, a higher TTA 'Z' score correlates with a lower postplication indexed residual RV volume. Hence, a complete trileaflet repair with offloading of RV by BCPS (when the TTA 'Z' score is >2) is recommended. The short-term outcomes of our technique are promising.

Reparación de la insuficiencia tricuspídea: resultados a largo plazo en 114 pacientes / Repair of tricuspid valve insufficiency: long-term results in 114 patients

Resumen Antecedentes la reparación de la insuficiencia tricuspídea funcional está indicada en casos de insuficiencia cardíaca, generalmente, asociada a enfermedades de las válvulas cardíacas izquierdas y en algunos casos de enfermedad coronaria o cardiopatías congénitas. Objetivo : evaluar los resultados a largo plazo de la reparación tricuspídea en pacientes operados en la región centro sur de Chile. Pacientes y métodos : estudio retrospectivo de registros clínicos y operatorios en 114 pacientes con edad promedio 57.8 (DE 13) años (72 mujeres) sometidos a reparación tricuspídea asociada a otros procedimientos quirúrgicos entre 2009 y 2017. Resultados : la etiología de la insuficiencia tricuspídea fue debida a enfermedad reumática inactiva en 45% y a endocarditis infecciosa en 2.6%. 63% estaban en fibrilación auricular y 75% en capacidad funcional NYHC III. 15.8% tenían cirugía valvular cardíaca previa. El ecocardiograma mostró insuficiencia severa en 56% de los casos y había hipertensión pulmonar severa en 39.5%. La cirugía consistió en la implantación de un anillo semi-rígido en forma concomitante a reemplazo o reparación de lesión valvular mitral, reemplazo valvular aórtico, cierre de comunicación interauricular, cirugía coronaria o resección de tumor intra cardíaco. La mortalidad post operatoria global fue 16%, debido a falla multisistémica en 6%, insuficiencia cardíaca en 5% y hemorragia cerebral en 4.3%. El seguimiento promedio fue 78.8 (DS 7.2) meses. La supervivencia actuarial fue 74% a los 60 y 68% a los 96 meses. Conclusión : La cirugía de reparación de la insuficiencia tricuspídea moderada o severa, asociada a otras enfermedades cardíacas provee una buena recuperación sintomática, con excelente sobrevida alejada.

Abstract Background : Surgery for functional tricuspid valve insufficiency is indicated in cases of congestive heart failure usually associated to left heart valve diseases or as a concomitant surgery for other causes such as congenital or coronary disease. Aim : To assess and report the long-term results of tricuspid valve repair in adult patients in a regional cardiac surgery center in south Chile. Patients and Methods : Retrospective review of clinical and operative records of 114 patients aged 57.8 +/- 13 years (72 women) subjected to tricuspid reparative surgery concomitant with other cardiac procedures between 2009 to 2017. Results : In 45% of cases etiology was due to inactive rheumatic disease and 2.6% was due to endocarditis. 63% presented with atrial fibrillation and 75% were in NYHC CFIII. 15.8% had a previous cardiac valve surgery. Preoperative echocardiography showed severe tricuspid insufficiency in 56% of cases and pulmonary hypertension was severe in 39.5%. In all cases tricuspid repair was performed through the insertion of a semi rigid ring as a concomitant procedure for mitral repair/replacement in most cases, aortic valve replacement, surgical closure of an ASD, CABG surgery and the resection of cardiac tumors. Overall postoperative mortality was 16% due to multi-organic dysfunction in 6%, cardiac failure in 5% and cerebral hemorrhage in 4.3%. Mean long term follow up was 78.8+/- 7.2 months. Actuarial survival was 74% at 60 and 68% at 96 months. Conclusion: Surgical tricuspid valve repair for moderate to severe tricuspid insufficiency isolated or associated to other cardiac diseases provides a good symptomatic recovery, with an excellent long term survival.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC³ Ring

BACKGROUND: We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR). METHODS: From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months. RESULTS: There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p < 0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p < 0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes. CONCLUSION: TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Effect of Patient-Prosthesis Mismatch in Aortic Position on Late-Onset Tricuspid Regurgitation and Clinical Outcomes after Double Valve Replacement

PURPOSE: Significant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR. MATERIALS AND METHODS: Of the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method. RESULTS: Although the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival. CONCLUSION: Aortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.

Valve-Sparing Root Replacement: Aortic Root Remodeling with External Subvalvular Ring Annuloplasty

The original valve-sparing procedures for aortic root aneurysms were remodeling and reimplantation of the aortic root. The remodeling technique provides more physiologic movement of the cusps within 3 reconstructed neo-sinuses, thus preserving root expansibility through the interleaflet triangles. However, the durability of remodeling has been a matter of concern due to the high rate of aortic insufficiency when annular dilation is not addressed. Therefore, a modified approach was developed, combining a physiologic remodeling of the root with a subvalvular annuloplasty. This case report highlights the first case of successful aortic root remodeling with external subvalvular ring annuloplasty in Korea.

Biventricular repair versus uni-ventricular repair for pulmonary atresia with intact ventrical septum: A systematic review / 华中科技大学学报（医学）（英德文版）

The management of pulmonary atresia with intact ventricular septum (PA/IVS) remains controversial. The goal of separating systematic and pulmonary circulation can be achieved by biventricular or uni-ventricular (Fontan or one and a half ventricle repair) strategies. Although outcomes have been improved, these surgical procedures are still associated with high mortality and morbidity. An optimal strategy for definitive repair has yet to be defined. We searched databases for genetically randomized controlled trials (RCTs) comparing biventricular with uni-ventricular repair for patient with PA/IVS. Data extraction and quality assessment were performed following the guidelines of the Cochrane Collaboration. Primary outcome measures were overall survival, and secondary criteria included exercise function, arrhythmia-free survival and treatment-related mortality. A total number of 669 primary citations were screened for relevant studies. Detailed analysis revealed that no RCTs were found to adequately address the research question and no systematic meta-analysis would have been carried out. Nevertheless, several retrospective analyses and case series addressed the question of finding right balance between biventricular and uni-ventricular repair for patient with PA/IVS. In this review, we will discuss the currently available data.

Effect of pretreatment with qishen yiqi dropping pills on right cardiac function of patients undergoing valve replacement / 中国中药杂志

In this study, 120 patients with rheumatic heart disease undergoing valve replacement were randomly divided into the control group and the Qishen group, with 60 cases in each group. Before the operation, the control group was given routine heart and diuretic treatments and placebo of Qishen Yiqi dropping pills for seven days (0.5 g each time, three times a day); While the Qishen group was given Qishen Yiqi dropping pills for seven days (0.5 g each time after meal, three times a day) on the basis of the routine treatments. The right ventricular end-diastolic volume (RVEDV), end-systolic volume (RVESV), stroke volume (SV) and right ventricular ejection fraction (RVEF) were detected after the operation. The results showed that patients in the two groups showed significantly lower right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV) and stroke volume (SV) decreased than that before the operation, but with significantly higher Ejection fraction (RVEF) significantly than that before the operation. However, the Qishen group showed a significantly lower right heart function reduction than the control group, with the statistical significance in the differences (P < 0.05). This indicated that the pretreatment with Qishenyiqi Drop Pills showed a remarkable efficacy in the improvement of right ventricular function after valve replacement.

De Vega Annuloplasty for Functional Tricupsid Regurgitation: Concept of Tricuspid Valve Orifice Index to Optimize Tricuspid Valve Annular Reduction

We evaluated long-term results of De Vega annuloplasty measured by cylindrical sizers for functional tricuspid regurgitation (FTR) and analyzed the impact of measured annular size on the late recurrence of tricuspid valve regurgitation. Between 2001 and 2011, 177 patients (57.9+/-10.5 yr) underwent De Vega annuloplasty for FTR. Three cylindrical sizers (actual diameters of 29.5, 31.5, and 33.5 mm) were used to reproducibly reduce the tricuspid annulus. Long-term outcomes were evaluated and risk factor analyses for the recurrence of FTR > or =3+ were performed. Measured annular diameter indexed by patient's body surface area was included in the analyses as a possible risk factor. Operative mortality occurred in 8 patients (4.5%). Ten-year overall and cardiac death-free survivals were 80.5% and 90.8%, respectively. Five and 10-yr freedom rates from recurrent FTR were 96.5% and 93.1%, respectively. Cox proportional hazard model revealed that higher indexed annular size was the only risk factor for the recurrence of FTR (P=0.006). A minimal P value approach demonstrated that indexed annular diameter of 22.5 mm/m2 was a cut-off value predicting the recurrence of FTR. De Vega annuloplasty for FTR results in low rates of recurrent FTR in the long-term. Tricuspid annulus should be reduced appropriately considering patients' body size to prevent recurrent FTR.

A modified tricuspid valve annuloplasty technique for functional tricuspid regurgitation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Functional tricuspid regurgitation often occurs in patients with concomitant left sided, valve disease. Several types of tricuspid valve annuloplasty have been described, but there is no consensus on the management of functional tricuspid regurgitation. We report a modified annuloplasty technique and compare its efficacy with the conventional Kay technique.</p><p><b>METHODS</b>A retrospective review was made of 60 patients who received tricuspid valve annuloplasty (group A, modified method; group B, Kay technique) and the early and midterm outcomes of modified method and Kay technique were compared.</p><p><b>RESULTS</b>Three patients underwent ring annuloplasty using a semirigid Carpentier-Edwards ring due to failing suture annuloplasty. All patients were completely cured when they left the hospital. The follow-up time was (32 ± 7) months in group A and (30 ± 7) months in group B. After three years, tricuspid regurgitation decreased by more than two grades in 13 patients in group A and 11 in group B. The mean postoperative regurgitation grade in group A was lower than group B at 12, 24 and 36 months but not significantly. Three of 28 patients developed recurrent tricuspid regurgitation in group A and five of 26 patients in group B during the follow-up period (three deaths and three ring annuloplasties excluded). Freedom from recurrent tricuspid regurgitation in group A was higher than that group B at all follow-up points. Postoperative right atrium diameter, right ventricle endodiastolic dimension and tricuspid regurgitation area decreased obviously in both groups. The right ventricle endodiastolic dimension and tricuspid regurgitation area improved more significantly in group A than group B over three years of follow-up,</p><p><b>CONCLUSIONS</b>The modified annuloplasty technique achieved the same outcomes as the conventional Kay annuloplasty over the first three years postoperation. As this modified technique is simple and less expensive, it is another option for correction of functional tricuspid regurgitation.</p>

Eficacia de la plastia de De Vega y la anuloplastia con anillo para el tratamiento de la insuficiencia tricuspídea secundaria a valvulopatía de corazón izquierdo, octubre del 2010 a octubre 2012, Instituto Nacional Cardiovascular, EsSalud / Effectiveness of the plasty of Vega and annuloplasty with ring for the treatment of secondary tricuspid insufficiency to of left heart valve disease, October 2010 to October 2012, National Institute Cardiovascular, EsSalud

Objetivos: Determinar la prevalencia de insuficiencia tricuspídea luego de la plastia de De Vega en comparación con la anuloplastia con anillo. Determinar la morbimortalidad hospitalaria. Metodología: Trabajo prospectivo de cohortes que analiza los resultados postoperatorios inmediatos ya medio plazo (6 meses) de 86 pacientes con valvulopatía mitral y/o aórtica e insuficiencia tricuspídea asociada operados en el INCOR en el periodo de octubre del 2010 a octubre del 2012. Se comparan los resultados de dos técnicas quirúrgicas (anuloplastia de De Vega y anuloplastia con anillo). Resultados: 39 pacientes fueron sometidos a anuloplastia de De Vega y 47 a anuloplastia con anillo protésico. En el primer grupo el 23 por ciento (9 pacientes) presentaron insuficiencia tricuspídea moderada a severa en los primeros 30 días en comparación a 13 por ciento (6 pacientes) (p: 0.2) del grupo de plastia con anillo. A seis meses la insuficiencia tricuspídea moderada a severa fue de 28 por ciento (11) y de 11 por ciento (5) (p: 0.027), respectivamente. La morbimortalidad hospitalaria fue de 18 por ciento en el grupo de De Vega y de 13 por ciento en el otro grupo (p: 0.5). Conclusiones: A seis meses, los pacientes sometidos a plastia de De Vega tienen mayor incidencia de insuficiencia tricuspídea importante en comparación a la anuloplastia con anillo protésico.

Objectives: Determine the prevalence of tricuspid regurgitation after De Vega plasty versus ring annuloplasty. Determine hospital morbidity and mortality. Methodology: Prospective cohort study that analyzes the immediate postoperative outcome and medium-term (6 months) of 86 patients with mitral valve and / or aortic valve disease with tricuspid regurgitation associated, these patients were operated in the "National Institute Cardiovascular, INCOR" from October 2010 to October 2012. We compare the results of two surgical techniques (De Vega annuloplasty and ring annuloplasty). Results: 39 patients underwent De Vega annuloplasty and 47 prosthetic ring annuloplasty. In the first group 23 per cent (9 patients) had moderate to severe tricuspid regurgitation in the first 30 days compared to 13 per cent (6 patients) (p: 0.2) ring plasty group. At six months, moderate to severe tricuspid regurgitation was 28 per cent (11) and 11 per cent (5) (p: 0.027), respectively. The hospital morbidity-mortality was 18 per cent in the De Vega group and 13 per cent in the other group (p: 0.5). Conclusions: At six months, patients underwent De Vega plasty have higher incidence of significant tricuspid regurgitation compared to the prosthetic ring annuloplasty.

Hypertension in a Rural Community in Rivers State; Niger Delta Region of Nigeria: Prevalence and Risk Factors

Background: Hypertension, a known independent and major risk factor for cardiovascular disease which was initially considered to be rare in sub Saharan Africa (SSA), is now a serious endemic threat and an important public health issue. Different studies in SSA have reported higher prevalence of hypertension in urban compared to rural areas. However more recent studies from the rural areas show an increasing pattern in hypertension prevalence. This may be attributed to the rapid 'westernization' of lifestyle in the rural Africa. Only few rural surveys have been conducted in the Nigeria oil-rich Niger Delta region necessitating this study with the aim of determining the hypertension prevalence and risk factors.Methods: This was a rural community-based cross-sectional study involving 500 adults. A questionnaire administered by face-to-face interview was used to assess socio-demographic characteristics of the subjects. Medical history such as prior knowledge of blood pressure status and family history of hypertension were all elicited by the questionnaire. Height and weight measurement were done and body mass indices (BMI) calculated as weight in kilogram divided by the square of height in meters.Results: There were 156 males and 344 females with male to female ratio of 1:2.3. The overall mean age was 41.32±17.0. The mean age for males was 42.84±17.8 and that for females was 40.62±16.6. The prevalence of hypertension in this rural community was 20.2 %. The overall mean systolic blood pressure was 1 2 0.4 6 ± 21.59mmHg (M a l e s123.57±20.41mmHg; females 119.05±22.36 mmHg; p= 0.04) and the mean diastolic blood pressure was 73.86±12.63mmHg (Males 75.52±13.03mmHg; females 73.25±12.3 mmHg; p=0.502). The prevalence was found to be higher in males than females though not statistically significant (Males 20.5%; Females 20.1%; X 0.651; p = 0.72). There was a progressive increase of hypertension prevalence with age. (X for trend = 69.434; p < 0.001). Pearson and Spearman' rho correlation analysis revealed that age, marital status, occupation, educational status and BMI correlated with hypertension in the study subjects while logistic regression analysis showed that BMI and age were the only positive predictors of hypertension in this study .Conclusion: Hypertension and its risk factors, which were initially rare in the rural sub Saharan Africa, is now on the increase in addition to high burden of communicable diseases in this region. The increasingly high 'westernization of lifestyle' may be part of the explanation for this. Hence there is need for an organized and deliberate health campaign and regular screening with adequate management in order to both reduce the incidence of hypertension and to prevent hypertension associated morbidity and mortal

Insuficiencia tricuspídea causada por traumatismo no penetrante de tórax en adolescente de 14 años / Insuficiência tricúspide causada por traumatismo nåo penetrante de tórax em um adolescente de 14 anos / Tricuspid valve regurgitation due to thoracic blunt trauma in a 14 year old adolescent

La insuficiencia tricuspídea como consecuencia de un traumatismo no penetrante de tórax es poco frecuente. Presentamos el caso de una paciente de 14 años con diagnóstico pre quirúrgicode insuficiencia tricuspídea por displasia valvular y de ventrículo derecho en el cual, durante la cirugía, se evidencia la desinserción de la valva anterior tricuspídea sin displasia. Debido a lascaracterísticas de la lesión valvular, se sospecha que su etiología podía ser de origen traumático. Interrogando a la familia, recuerdan un accidente que ocurrió 7 años atrás, en el que la paciente sufrió un fuerte traumatismo no penetrante de tórax...

A insuficiência tricúspide como consequência de um traumatismo não penetrante de tórax é pouco frequente. Apresentamos o caso de uma paciente de 14 anos com diagnóstico pré cirúrgicode insuficiência tricúspide por displasia valvar e de ventrículo direito no qual, durante a cirurgia, evidenciou-se a desinserção da valva anterior tricúspide sem displasia. Devido às característicasda lesão valvar, suspeita-se que sua etiologia pudesse ser de origem traumática. Durante uma entrevista com a familia, foi relatado um acidente ocorrido 7 anos antes, onde a paciente sofreu um forte traumatismo não penetrante de tórax...

Tricuspid insufficiency as a consequence of blunt thoracic trauma is uncommon. We present the case of a 14 year-old patient with preoperative diagnosis of tricuspid insufficiency due to valvularand right ventricle dysplasia where, during the surgery, there is evidence of desinsertion of the anterior leaflet of the tricuspid valve without dysplasia. Because of the characteristics of the valvular injury, its etiology is suspected to be of traumatic origin. The family, when inquired, remembers an accident that occurred 7 years ago, when the patient suffered a blunt thoracic trauma...

Safety of Comprehensive Aortic Root and Valve Repair Surgery: A Retrospective Outcomes Research by National Evidence-Based Health Care Collaborating Agency, Korea

Comprehensive aortic root and valve repair (CARVAR) is a recently introduced surgical technique for aortic valve disease. The National Evidence-based Health Care Collaborating Agency was offered by the ministry of Health and Welfare, Korea to perform a restrospective outcome analysis for this surgical procedure. The aims of this study were to evaluate the safety of patients who underwent CARVAR surgery and to provide a rationale for further prospective randomized study. During the period of March 2007 to November 2009, 397 patients received this procedure and enrolled in this study. Clinical events including major bleeding, endocarditis, re-operation and death were followed-up till March 2010 by medical records. During the follow-up periods, 1-year cumulative incidence of major bleeding, re-operation, endocarditis and death were 3.55, 5.65, 5.05 and 5.33%/year respectively. This study showed that the CARVAR technique is not beneficial, and is indeed even more harmful than conventional valve replacement surgery.

Morbimortalidade em pacientes acima de 75 anos submetidos à cirurgia por estenose valvar aórtica / Morbidity and mortality in patients aged over 75 years undergoing surgery for aortic valve replacement

FUNDAMENTO: A maior longevidade observada atualmente ocasionou aumento do número de idosos que necessitam de intervenções cirúrgicas. A estenose aórtica é uma condição frequente nessa faixa etária. OBJETIVO: Avaliar morbidade e mortalidade hospitalar em pessoas de 75 anos ou mais, que tenham sido submetidas à cirurgia de valvuloplastia, ou de troca valvar por estenose aórtica isolada ou associada a outras lesões. MÉTODOS: Foram estudados 230 casos consecutivos entre jan/2002-dez/2007. Os pacientes tinham 79,5 ± 3,7 anos (75 - 94), sendo que 53,9 por cento eram homens. Na amostra, 68,7 por cento tinham hipertensão arterial, 17,9 por cento tinham fibrilação atrial, 15,9 por cento apresentaram obesidade e 14,4 por cento cirurgia cardíaca prévia. Na cirurgia, 87,4 por cento foram submetidos à colocação de prótese aórtica e 12,6 por cento à valvuloplastia aórtica. RESULTADOS: A mortalidade foi de 13,9 por cento (sendo 9,4 por cento de estenose aórtica isolada x 20,9 por cento com procedimento associado; p = 0,023) e a morbidade foi de 30,0 por cento (sendo 25,2 por cento de estenose aórtica isolada x 37,4 por cento com procedimento associado; p = 0,068). As complicações mais frequentes foram: baixo débito cardíaco (20,2 por cento), disfunção renal (9,7 por cento) e suporte ventilatório prolongado (7,9 por cento). Na análise bivariada, os maiores preditores de mortalidade foram: baixo débito cardíaco (RR 10,1, IC95 por cento: 5,02-20,3), uso do balão intra-aórtico (RR 6,6, IC95 por cento: 3,83-11,4), sepse (RR 6,77, IC95 por cento: 1,66-9,48) e disfunção renal pós-operatória (RR 6,21, IC95 por cento: 3,47-11,1). Quanto à morbidade, foram preditores: disfunção renal pré-operatória (RR 2,22, IC95 por cento: 1,25-3,95), fibrilação atrial (RR 1,74, IC95 por cento: 1,16-2,61) e doença pulmonar obstrutiva crônica (DPOC) (RR 1,93, IC95 por cento: 1,25-2,97). CONCLUSÃO: A cirurgia valvar aórtica em idosos está relacionada à morbimortalidade um pouco ...

BACKGROUND: The greater longevity observed today has caused an increase in the number of elderly who need surgery. Aortic stenosis is a common condition in this age group. OBJECTIVE: To evaluate morbidity and mortality in people aged 75 years or older who have undergone valvuloplasty or valve replacement surgery for aortic stenosis alone or associated with other injuries. METHODS: We studied 230 consecutive cases between Jan/2002-Dec/2007. Patients were 79.5 ± 3.7 years (75 - 94), and 53.9 percent were men. In the sample, 68.7 percent had hypertension, 17.9 percent had atrial fibrillation, 15.9 percent were obese, and 14.4 percent had undergone previous heart surgery. At surgery, 87.4 percent underwent aortic stent placement, and 12.6 percent underwent aortic valvuloplasty. RESULTS: The mortality rate was 13.9 percent (9.4 percent with isolated aortic stenosis versus 20.9 percent with an associated procedure, p = 0.023) and the morbidity rate was 30.0 percent (25.2 percent with aortic stenosis alone versus 37.4 percent with an associated procedure, p = 0.068). The most common complications were: low cardiac output (20.2 percent), renal dysfunction (9.7 percent), and prolonged ventilatory support (7.9 percent). In the bivariate analysis, the main predictors of mortality were low cardiac output (RR 10.1, 95 percent CI: 5.02-20.3), use of intra-aortic balloon (RR 6.6, 95 percent CI: 3.83-11.4), sepsis (RR 6.77, 95 percent: 1.66-9.48) and renal dysfunction after surgery (RR 6.21, 95 percent: 3.47-11.1). As for morbidity, the predictors were: pre-operative renal dysfunction (RR 2.22, 95 percent: 1.25-3.95), atrial fibrillation (RR 1.74, 95 percent: 1.16-2.61), and chronic obstructive pulmonary disease (COPD) (RR 1.93, 95 percent: 1.25-2.97). CONCLUSION: Aortic valve surgery in the elderly is related to a slightly higher mortality rate than in younger patients, and its main risk factors were associated procedures, renal failure, atrial fibrillation, ...