Biological or mechanical prostheses for isolated aortic valve replacement in patients aged 50-65 years: the ANDALVALVE study.

OBJECTIVES: The decision about whether to use a biological or a mechanical prosthesis for aortic valve replacement remains controversial in patients between 50 and 65 years of age and has yet to be addressed in a Mediterranean population. This research aimed to analyse long-term survival and major morbidity rates (30-day mortality, stroke, any prosthetic reoperation and major bleeding) within this population. METHODS: Our multicentre observational retrospective study included all subjects aged 50-65 years who had a primary isolated aortic valve replacement due to severe aortic stenosis at 7 public hospitals from Andalusia (Spain) between 2000 and 2015. Concomitant surgery, reoperations and endocarditis were the exclusion criteria. A total of 1443 patients were enrolled in the study (272 with biological and 1171 with mechanical valves). Multivariate analyses including a 2:1 propensity score matching (506 mechanical and 257 biological prostheses) were conducted. RESULTS: Bioprostheses were implanted in 18.8% (n = 272): 35% were women; the mean EuroSCORE-I was 3%. The mean follow-up was 8.1 ± 4.9 years in a matched sample: 8.8 ± 4.9 years in those receiving a mechanical vs 7.1 ± 4.5 years in those receiving a biological prosthesis (P = 0.001). In the paired sample, the 15-year survival rate was 73% in those who had a biological vs 76% in those who had a mechanical valve [hazard ratio (HR) 0.80, 95% confidence interval (CI) 0.54-1.20; P = 0.159]. No significant differences were observed in patients ≥55 years old (74% of 15-year survival in both groups: HR 0.88, 95% CI 0.56-1.34; P = 0.527). A higher rate of major bleeding was found in patients with a mechanical prosthesis (P = 0.004), whereas reoperation was more frequent among those with a biological prosthesis (P = 0.01). CONCLUSIONS: Long-term survival was comparable in patients above 55 years of age. Mechanical prostheses were associated with more major bleeding and bioprostheses, with more reoperations. A bioprosthesis in patients above 55 years old is a reasonable choice. CLINICAL TRIAL REGISTRATION NUMBER: NCT03239509.

Transcatheter Valve-in-Valve Replacement Through Apicoaortic Conduit for Aortic Bypass Valve Failure.

We report a case of a 69-year-old woman who required an apicoaortic bypass conduit after stenosis of a biological aortic prosthesis valve previously implanted 4 years earlier. The patient was admitted to the emergency department 8 years later with a diagnosis of congestive heart failure. Echocardiography and nuclear magnetic resonance revealed severe regurgitation of the conduit valve. Because the patient had a very high Society of Thoracic Surgeons risk score associated to an acute angle between the aorta artery and the apicoaortic conduit, we decided to perform an antegrade and direct transcatheter valve-in-valve implantation on the apicoaortic valve, with a good result.

Manejo y tratamiento endovascular de rotura traumática de aorta / Management and endovascular treatment of traumatic aortic rupture

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Primary inferior vena cava leiomyosarcoma: reconstruction is not mandatory.

Computed tomography in an 81-year-old woman revealed obstruction of the inferior vena cava by a large primary vascular leiomyosarcoma, and involvement of the right renal vein. She underwent successful en-bloc resection of the tumor, right kidney, hepatic segments IV and VI, and inferior vena cava, without caval reconstruction. A renal vein-to-remaining infrahepatic inferior vena cava saphenous vein graft bypass was performed for left renal venous drainage. The need for vascular reconstruction is not always mandatory.

Transapical aortic valve implantation in bicuspid aortic valves: must be an absolute contraindication?

Transcatheter Aortic Valve Implantation (TAVI) is a new therapeutic option for patients with severe aortic stenosis with unacceptable surgical risk for conventional aortic valve surgery. A Bicuspid Aortic Valve (BAV) is the most common congenital cardiac disorder (1% of the population) and currently is considered exclusion criteria for TAVI, because it predicts an increased risk of adverse aortic events as incomplete sealing, severe paravalvular regurgitation, or dislocation due to more frequent elliptic shape and asymmetric calcifications in BAV annulus. Only few cases have been published in recent literature, so in this case report we illustrate our experience and management of TAVI in a BAV, with excellent outcomes and no late complications at 1 year follow-up. We believe that currently the presence of a BAV might not be considered an absolute contraindication for TAVI, because although there is no sufficient data for assess the safety or efficacy of TAVI in BAV, this case report shows that it could be performed safely in selected patients with unacceptable surgical risk after an extensive preoperative evaluation, avoiding this procedure in patients with bad prognostic factors as huge and heavy calcifications, asymmetric valves, elliptic annulus or small distance from leaflets to coronary ostia. Each case must be individualized, being alert at follow-up because the risk of late complications.

Mega-aorta syndrome development in giant cell arteritis. A same entity?

Giant cell arteritis (GCA) is the most common form of large vessel arteritis. GCA typically involves the branches of the external carotid artery, but is the leading cause of inflammatory aortitis. However, involvement of the aorta often goes undetected. We present a case of an 81-year-old man, with headache and intense chest pain, who was previously given a diagnosis of GCA with a temporal artery biopsy 6 years ago. Owing to the suspicion of acute aortic syndrome, an emergent computed tomography (CT) was performed. CT showed the development of mega-aorta syndrome, with a diameter of 75.2 mm in the ascending aorta, 61.8 mm in the aortic arch, 76.1 mm in the descending thoracic aorta, and 45.1 mm in the abdominal aorta, presenting a chronic type B aortic dissection. Although there are reported cases secondary to Takayasu arteritis, this is the first case reported in the literature of mega-aorta syndrome associated with GCA in a patient previously diagnosed using temporal artery biopsy.

Spontaneous closure of pseudoaneurysm after transapical aortic valve implantation.

Transcatheter aortic valve implantation by an apical approach has been developed as an alternative to conventional aortic valve replacement. Complications with these relatively new procedures are being reported. We report a case of transapical transcatheter aortic valve implantation, in which a pseudoaneurysm at the apex of the left ventricle as a complication of the procedure developed in the patient and was treated without surgery. The defect spontaneously closed.

Mitroaortic valve replacement after aortic transapical approach failure in a patient with essential thrombocytosis.

There is a lack of published information about intraoperative and postoperative course of cardiac surgery in patients with essential thrombocytosis using cardiopulmonary bypass. Both risks of intraoperative thrombosis of extracorporeal conduits or uncontrolled postoperative bleeding are present, but its incidence and treatment are not well known. Here, we present a rare case of a patient with essential thrombocytosis, moderate mitral regurgitation and severe aortic stenosis who had a transapical aortic valve implantation with short-term severe periprosthetic regurgitation, who needed a mitroaortic replacement on cardiopulmonary bypass with no complications.

Video-assisted cardioscopy for removal of primary left ventricular fibroma.

We present a case of a cardiac fibroma affecting the base of the anterior papillary muscle resected under cardiopulmonary bypass with cardioscopy and video-assisted thoracic surgery (VATS) instruments through the mitral valve. The surgical approach and instrumentation of previous case reports are reviewed.

Replacement of A2 and A3 by pericardium due to endocarditis of the anterior leaflet of the mitral valve.

We present a case of acute endocarditis due to enterococcus faecalis involving partially A2 and completely A3 (Carpentier classification) with destruction of the free margin of the mitral valve. Repair was performed by using glutaraldehyde treated porcine pericardium to replace the defect and neochordae of polytetrafluoroethylene sutured to the free margin of the pericardium to achieve competence. Intraoperative and follow-up echocardiogaphies showed no regurgitation.

Aortic valve endocarditis by Capnocytophaga haemolytica.

We report a case of a 51-year-old patient with suspected prosthetic valve endocarditis. Capnocytophaga haemolytica was isolated in blood cultures and the repeated echocardiograms showed growth of vegetations and disruption of the proximal prosthetic valve suture line with progressive aortic regurgitation. The patient underwent a root debridement and replacement with a stentless bioprosthesis.

[Valve repair for bicuspid aortic valve regurgitation: an option?]. / Reparación valvular en la insuficiencia aórtica por válvula bicúspide: una alternativa?

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre.

Reparación valvular en la insuficiencia aórtica por válvula bicúspide: ¿una alternativa? / Valve repair for bicuspid aortic valve regurgitation: an option?

La válvula aórtica bicúspide es la cardiopatía congénita más frecuente. Se asocia tanto a enfermedad valvular como a enfermedad aórtica. La insuficiencia aórtica por válvula aórtica bicúspide es susceptible de corregirse mediante técnicas de reparación quirúrgica, con buenos resultados a corto plazo. Sin embargo, la tasa de recurrencia de insuficiencia aórtica en el seguimiento continúa siendo un problema, en parte motivado por la dilatación aórtica progresiva propia de esta entidad. Presentamos 3 casos distintos de válvula aórtica bicúspide tratados mediante reparación en nuestro centro

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre