Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis.

INTRODUCTION AND OBJECTIVES: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Advanced considerations in survival analysis.

Investigation of survival during the follow-up period is common in cardiovascular research and has intrinsic issues that require precise knowledge, such as survival or censoring. Besides, as the follow-up period lengthens and events other than mortality are studied, the analysis becomes more complex, so Kaplan-Meier analyses or Cox models are not always sufficient. In this primer, we provide the reader with detailed information on the interpretation of the most common survival analyses and delve into methods to analyse competing risks or alternatives to the conventional methods when the proportional hazards assumption is not met.

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.

5-Year haemodynamic performance of three aortic bioprostheses. A randomized clinical trial.

OBJECTIVES: The Carpentier Perimount (CP) Magna Ease, the Crown Phospholipid Reduction Treatment (PRT) and the Trifecta bovine pericardial valves have been widely used worldwide. The primary end point of this study was to compare the haemodynamic performance quantified by in vivo echocardiograms of these 3 aortic prostheses. METHODS: The "BEST-VALVE" (comparison of 3 contemporary cardiac bioprostheses: mid-term valve haemodynamic performance) was a single-centre randomized clinical trial to compare the haemodynamic and clinical outcomes of the aforementioned bioprostheses. The 5-year results are assessed in this manuscript. RESULTS: A total of 154 patients were included. The CP Magna Ease (n = 48, 31.2%), Crown PRT (n = 51, 32.1%) and Trifecta (n = 55, 35.7%) valves were compared. Significant differences were observed among the 3 bioprostheses 5 years after the procedure. The following haemodynamic differences were found between the CP Magna Ease and the Crown PRT bioprostheses [mean aortic gradient: 12.3 mmHg (interquartile range {IQR} 7.8-17.5) for the CP Magna Ease vs 15 mmHg (IQR 10.8-31.9) for the Crown PRT, P < 0.001] and between the CP Magna Ease and the Trifecta prostheses [mean aortic gradient: 12.3 mmHg (IQR 7.8-17.5) for the CP Magna Ease vs 14.7 mmHg (IQR 8.2-55) for the Trifecta, P < 0.001], with a better haemodynamic performance of the CP Magna Ease. The cumulative incidence of severe structural valve degeneration was 9.5% in the Trifecta group at 6 years of follow-up. The 1-, 3- and 5-year survival from all-cause mortality was 91.5%, 83.5% and 74.8%, respectively (log rank P = 0.440). Survival from the composite event at the 1-, 3- and 5-year follow-up was 92.8%, 74.6% and 59%, respectively (log rank P = 0.299). CONCLUSIONS: We detected significant differences between the 3 bioprostheses; the CP Magna Ease had the best haemodynamic performance at the 5-year follow-up.

Cell surface markers for mesenchymal stem cells related to the skeletal system: A scoping review.

Multipotent mesenchymal stromal cells (MSCs) have been described as bone marrow stromal cells, which can form cartilage, bone or hematopoietic supportive stroma. In 2006, the International Society for Cell Therapy (ISCT) established a set of minimal characteristics to define MSCs. According to their criteria, these cells must express CD73, CD90 and CD105 surface markers; however, it is now known they do not represent true stemness epitopes. The objective of the present work was to determine the surface markers for human MSCs associated with skeletal tissue reported in the literature (1994-2021). To this end, we performed a scoping review for hMSCs in axial and appendicular skeleton. Our findings determined the most widely used markers were CD105 (82.9%), CD90 (75.0%) and CD73 (52.0%) for studies performed in vitro as proposed by the ISCT, followed by CD44 (42.1%), CD166 (30.9%), CD29 (27.6%), STRO-1 (17.7%), CD146 (15.1%) and CD271 (7.9%) in bone marrow and cartilage. On the other hand, only 4% of the articles evaluated in situ cell surface markers. Even though most studies use the ISCT criteria, most publications in adult tissues don't evaluate the characteristics that establish a stem cell (self-renewal and differentiation), which will be necessary to distinguish between a stem cell and progenitor populations. Collectively, MSCs require further understanding of their characteristics if they are intended for clinical use.

Co-Management Reduces Mortality in Post-Sternotomy Mediastinitis.

Background: Post-sternotomy mediastinitis (PSM) is one of the most feared complications of cardiac surgery. The impact of a multidisciplinary management approach on this pathology is yet unknown. Patients and Methods: A multidisciplinary approach based on a co-management model (CMM) of care was initiated in January 2018 because of the incorporation of a hospitalist unit on a cardiac surgery department. An observational retrospective cohort study was designed to evaluate the impact of the CMM of care compared to the standard model (SM) of care in patients diagnosed with PSM. Our primary and secondary outcomes were survival time and treatment failure rate (two or more surgical procedures needed to solve PSM or PSM-related death), respectively. Data related to patient death date were collected from the Spanish National Death Index. A multivariable Cox regression model was created using those variables believed to be clinically relevant. Results: Ninety-one patients developed PSM from January 2010 to June 2020. Regarding the pre-operative clinical status, surgical procedure, and PSM severity, both groups had similar baseline characteristics. Patients were followed for a mean of 27.54 ± 30.5 months. A total of 60.3% of the SM group and 11.1% of the CMM group (p < 0.001) died. Treatment failure occurred in 53 patients (72.6%) in the SM group versus 7 (38.6%) in the CMM group (p = 0.007). The CMM independently reduced overall mortality (hazard ratio [HR], 0.11; 95% confidence interval [CI]. 0.01-0.83) and treatment failure rate (HR, 0.01; 95% CI, 0.001-0.183). Gram-positive bacterial infection (HR, 3.73; 95% CI, .6-8.3), and complete osteosynthesis material removal (HR, 0.47; 95% CI, 0.24-0.91) also influenced mortality in our model. Conclusions: A co-management care model reduced overall mortality in patients diagnosed with post-sternotomy mediastinitis.

Genomic characterization of BKC-1-producing Klebsiella pneumoniae strain belonging to high-risk clone sequence type 11 isolated from a river in Brazil.

Carbapenem-resistant Klebsiella pneumoniae is a common cause of healthcare-related infections, and it is widespread in hospitals and diverse environments with potentially serious public health implications. Herein, we have reported the isolation and characterization of an environmental Brazilian Klebsiella carbapenemase (BKC-1)-producing K. pneumoniae strain (IEC1205) isolated in 2018 from a river in the Amazon region, Brazil. Antimicrobial susceptibility of this strain was evaluated by broth microdilution and demonstrated resistance to several antibiotics including ß-lactams, aminoglycosides, fluoroquinolones, and polymyxins. It has an extensively drug-resistant phenotype. Genomic analysis revealed that IEC1205 belonged to sequence type 11, clonal complex 258 and the presence of blaBKC-1 and two other ß-lactamase-encoding genes (blaCTX-M-15 and blaSHV-11). The predicted virulence was associated with biofilm formation-related genes, a type VI secretion system, siderophore production, and type I and II fimbriae formation. We have identified an IncQ1 plasmid, named pIEC1205, harboring blaBKC-1 with high similarity to previously described plasmids carrying blaBKC-1 and blaBKC-2 genes. To our knowledge, this is the first report of an environmental BKC-1-producing K. pneumoniae strain.

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.

[Diagnostic and management of acute aortic syndrome]. / Diagnóstico y manejo del síndrome aórtico agudo.

Acute aortic syndrome includes a group of serious aortic pathologies, with a mortality rate of up to 90% in the first 40 days after the onset of symptoms. Depending on the location of the lesion, the treatment will be medical or surgical which has been shown to improve the prognosis of these patients both in the short- and long-term. Timey diagnosis is essential to increase survival and decrease the rate of related complications; however, due to the low incidence and sometimes non-specific clinical picture, the diagnosis can be delayed or missed, leading to catastrophic consequences for the patients. This article will focus on the diagnostic approach of type A acute aortic syndrome, in addition to offering a brief review regarding the medical and surgical treatment of these pathologies.

El síndrome aórtico agudo incluye un grupo de patologías graves de la aorta, con una mortalidad hasta del 90% en los primeros 40 días tras el inicio de los síntomas. Según la localización de la lesión el tratamiento puede ser médico o quirúrgico, el cual ha demostrado mejorar el pronóstico de estos pacientes tanto a corto como a largo plazo. El diagnóstico oportuno es esencial para incrementar la supervivencia y disminuir la tasa de complicaciones relacionadas; no obstante, debido a la baja incidencia y presentación clínica en ocasiones inespecífica, el diagnóstico puede retrasarse u obviarse, ocasionando consecuencias catastróficas para los pacientes. Este artículo se centrará en el abordaje diagnóstico del síndrome aórtico agudo tipo A, además de ofrecer una breve revisión respecto al tratamiento médico y quirúrgico de estas patologías.

Diagnóstico y manejo del síndrome aórtico agudo / Diagnostic and management of acute aortic syndrom

El síndrome aórtico agudo incluye un grupo de patologías graves de la aorta, con una mortalidad hasta del 90% en los primeros 40 días tras el inicio de los síntomas. Según la localización de la lesión el tratamiento puede ser médico o quirúrgico, el cual ha demostrado mejorar el pronóstico de estos pacientes tanto a corto como a largo plazo. El diagnóstico oportuno es esencial para incrementar la supervivencia y disminuir la tasa de complicaciones relacionadas; no obstante, debido a la baja incidencia y presentación clínica en ocasiones inespecífica, l diagnóstico puede retrasarse u obviarse, ocasionando consecuencias catastróficas para los pacientes. Este artículo se centrará en el abordaje diagnóstico del síndrome aórtico agudo tipo A, además de ofrecer una breve revisión respecto al tratamiento médico y quirúrgico de estas patologías.

Acute aortic syndrome includes a group of serious aortic pathologies, with a mortality rate of up to 90% in the first 40 days after the onset of symptoms. Depending on the location of the lesion, the treatment will be medical or surgical which has been shown to improve the prognosis of these patients both in the short- and long-term. Timey diagnosis is essential to increase survival and decrease the rate of related complications; however, due to the low incidence and sometimes non-specific clinical picture, the diagnosis can be delayed or missed, leading to catastrophic consequences for the patients. This article will focus on the diagnostic approach of type A acute aortic syndrome, in addition to offering a brief review regarding the medical and surgical treatment of these pathologies.

One-Year Hemodynamic Performance of Three Cardiac Aortic Bioprostheses: A Randomized Comparative Clinical Trial.

BACKGROUND: We aimed to compare 1 year the hemodynamic in-vivo performance of three biological aortic prostheses (Carpentier Perimount Magna EaseTM, Crown PRTTM, and TrifectaTM). METHODS: The sample used in this study comes from the "BEST-VALVE" clinical trial, which is a phase IV single-blinded randomized clinical trial with the three above-mentioned prostheses. RESULTS: 154 patients were included. Carpentier Perimount Magna EaseTM (n = 48, 31.2%), Crown PRTTM (n = 51, 32.1%) and TrifectaTM (n = 55, 35.7%). One year after the surgery, the mean aortic gradient and the peak aortic velocity was 17.5 (IQR 11.3-26) and 227.1 (IQR 202.0-268.8) for Carpentier Perimount Magna EaseTM, 21.4 (IQR 14.5-26.7) and 237.8 (IQR 195.9-261.9) for Crown PRTTM, and 13 (IQR 9.6-17.8) and 209.7 (IQR 176.5-241.4) for TrifectaTM, respectively. Pairwise comparisons demonstrated improved mean gradients and maximum velocity of TrifectaTM as compared to Crown PRTTM. Among patients with nominal prosthesis sizes ≤ 21, the mean and peak aortic gradient was higher for Crown PRTTM compared with TrifectaTM, and in patients with an aortic annulus measured with metric Hegar dilators less than or equal to 22 mm. CONCLUSIONS: One year after surgery, the three prostheses presented a different hemodynamic performance, being TrifectaTM superior to Crown PRTTM.

Variablity of Mechanical or Tissue Valve Implantation in Patients Undergoing Surgical Aortic Valve Replacement in Spain: National Retrospective Analysis from 2007 to 2018.

BACKGROUND: There is no robust evidence regarding the types of valves implanted among patients undergoing surgical aortic valve replacement (SAVR) in Spain. METHODS: All cases of patients undergoing SAVR ± coronary artery bypass grafting from January 2007 to December 2018 in the public Spanish National Health System were included. We analyzed the trends of SAVR volume, risk profile and type of implanted valve across time and place. Using multivariable logistic regression, we identified factors associated with biological SAVR. RESULTS: In total, 62,870 episodes of SAVR in 15 Spanish territories were included. In 35,693 (56.8%), a tissue valve was implanted. The annual volume of procedures increased from 107.3/million (2007) to 128.6 (2017). In 2018, it fell to 108.5. Age increased and Charlson's comorbity index worsened throughout the study period. Tissue valve implantation increased in most regions. After adjusting for other covariates, we observed a high variability in aortic valve implantation across different regions, with differences of as much as 20-fold in the use of tissue valves. CONCLUSIONS: Between 2007 and 2018, we detected a significant increase in the use of bioprostheses in patients undergoing SAVR in Spain, and a great variability in the types of valve between the Spanish territories, which was not explained by the different risk profiles of patients.

Psicossociologia com comunidades: abordagens sentipensantes como emergência na América Latina / Psychosociology with Communities: Sentipensantes Approaches as Urgency in Latin America / Psicosociología con comunidades: enfoques sentipensantes como emergencia en América Latina

No campo da Psicossociologia, defende-se a reorientação dos processos interventivos, bem como formulações psicossociológicas sentipensantes em consonância com as demandas da conjuntura atual. Por meio de revisão bibliográfica, o artigo tem por objetivo ensaiar perspectivas teóricas e conceituais a respeito dos percursos latino-americanos feitos por Maritza Montero, Maria Inácia D'Ávila Neto, Ignacio Martín-Baró, Paulo Freire e Orlando Fals Borda. Vislumbramos a proposição de um quadro no qual a Psicossociologia não seria uma ciência "de" comunidades, mas sim "com" comunidades, por se comprometer com a criação de conexões entre o individual-psicológico-singular-subjetivo com o coletivo-social-popular-político, de modo a abarcar as diferentes influências existentes nas interações comunitárias. Portanto, este trabalho se propõe a refletir sobre uma lógica contra-hegemônica e descolonizadora ao caminhar por trilhas suleadoras, sentipensantes e libertadoras. Nesse sentido, reforçamos que uma "Psicossociologia com comunidades" deve se empenhar em fortalecer os encontros e promover confluências, engendrando processos de produção coletiva de conhecimentos contextualizados e críticos sobre as realidades comunitárias.

In the field of Psychosociology, it is advocated the reorientation of interventional processes, as well as psychosociological formulations in line with the demands of the current situation. Through bibliographic review, the article aims to rehearse theoretical and conceptual perspectives on the Latin American paths taken by Maritza Montero, Maria Inácia D'Ávila Neto, Ignacio Martín-Baró, Paulo Freire and Orlando Fals Borda. We envision the proposition of a framework in which Psychosociology would not be a science "of" communities, but "with" communities because it is committed to creating connections between the individual-psychological-singular-subjective with the collective-social-popular-political, in order to encompass the different influences existing in community interactions. Therefore, this work proposes to reflect on a counter-hegemonic and decolonizing logic when walking along suleadoras, sentipensantes and liberating trails. In this sense, we reinforce that a "Psychosociology with communities" must strive to strengthen the meetings and promote confluences, engendering processes of collective production of contextualized and critical knowledge about the community realities.

En el campo de la Psicosociología se aboga por la reorientación de los procesos intervencionistas, así como por formulaciones psicosociológicas acordes con las exigencias de la situación actual. A través de una revisión bibliográfica, el artículo pretende ensayar perspectivas teóricas y conceptuales sobre los caminos latinoamericanos tomados por Maritza Montero, Maria Inácia D'Ávila Neto, Ignacio Martín-Baró, Paulo Freire y Orlando Fals Borda. Visualizamos la propuesta de un marco donde la Psicosociología no sería una ciencia "de" comunidades, sino más bien "con" comunidades porque se compromete a crear conexiones entre lo individual-psicológico-singular-subjetivo con lo colectivo-social-popular-político, con el fin de abarcar las diferentes influencias existentes en las interacciones comunitarias. Por ello, este trabajo propone reflexionar sobre una lógica contrahegemónica y descolonizante al caminar por senderos suleadoras, sentipensantes y liberadores. En este sentido, reforzamos una "Psicosociología con comunidades" debe buscar fortalecer los encuentros y promover confluencias, engendrando procesos de producción colectiva de conocimiento contextualizado y crítico sobre las realidades comunitarias.

Devices for transcatheter mitral valve repair: current technology and a glimpse into the future.

Introduction: Due to a large unmet need for the treatment of mitral regurgitation, transcatheter mitral valve repair devices have emerged in the last decade as an alternative therapeutic option. Given the complexity of this disease, several device systems for transcatheter mitral valve repair have been developed and are categorized according to its mechanism of action; each device has advantages and disadvantages for certain clinical and pathophysiologic characteristics, and in order to improve outcomes, proper patient selection among other key points are fundamental.Areas covered: The purpose of this article is to review the current state-of-the-art technologies available for transcatheter mitral valve repair, patient suitability, outcomes, and future perspectives.Expert opinion: Transcatheter therapy for mitral regurgitation improves outcomes and pushes the boundaries of biomedical technology while maintaining scientific rigor for device development. Surgical and percutaneous procedures should be viewed as complements to treat a wider spectrum of patients affected by this entity. Future directions from multidisciplinary innovation and cooperation will consolidate this therapeutic option.

Reparación del arco aórtico mediante prótesis híbrida y su combinación con TEVAR / Aortic arch repair with elephant trunk and TEVAR combination

Introducción y objetivos: la reparación del arco y aorta torácica descendente (ATD) se asocia a una elevada morbi-mortalidad. Las prótesis híbridas del arco y las endoprótesis torácicas (TEVAR) pueden disminuir sus complicaciones.El objetivo es describir resultados a corto y medio plazo del abordaje híbrido de esta patología.Material y métodos: análisis retrospectivo de pacientes intervenidos entre agosto de 2016 y febrero de 2020 porpatología aneurismática del arco aórtico y ATD mediante una prótesis híbrida y TEVAR en dos tiempos.Resultados: trece pacientes intervenidos, todos por aneurisma sin disección. Inicialmente se empleó una prótesishíbrida con diámetro mediano de 30 mm (29-33) y una longitud de 130 mm en 12 de ellos. Se conservaron los3 TSA en todos los pacientes, con pastilla para tronco braquiocefálico y carótida izquierda y bypass a subclaviaizquierda en el 69 % de ellos.El tiempo mediano hasta el TEVAR fue de 13,5 semanas (6-20), con un éxito técnico del 100 %. Se implantó un solomódulo en 9 casos con una sobredimensión media del 10 % respecto a la trompa de elefante. No hubo ningúncaso de paraplejia, ictus o muerte perioperatoria. El tiempo mediano de ingreso hospitalario fue de 4 días (2-6) y elseguimiento mediano tras el TEVAR de 17 meses (9-25), con una supervivencia del 100 % a 24 meses. Se comprobóuna correcta exclusión del aneurisma en el angio-TC de control en todos los casos y sin objetivarse fugas de altofl ujo durante el seguimiento.Conclusiones: en nuestra experiencia, el TEVAR es una opción segura como segundo tiempo, y ofrece unos exce-lentes resultados a medio plazo en tasa de exclusión del aneurisma.(AU)

Introduction and objectives: aortic arch and descending thoracic aorta repair are associated with a high mor-bidity and mortality. The frozen elephant trunk combined with TEVAR could improve outcomes. The objective isto describe short and midterm results of the hybrid approach in this pathology.Material and methods: retrospective analysis of patients who underwent two-staged intervention with hybridprosthesis and TEVAR for aortic arch and thoracic descending aneurysm between August 2009 and February 2020.Results: thirteen patients were included, all of them secondary to non-dissecting aneurysm. First-stage interventionwith frozen elephant trunk (average prosthesis diameter: 30 mm [29-33] average length: 130 mm). Supraaorticvessel reimplantation was performed most frequently (69 %) with an island technique for innominate artery andleft common carotid artery and a left subclavian artery bypass to the aortic graft.The average time to TEVAR implantation was 13.5 weeks (6-20), with technical success of 100 %. A single devicewas implanted in 9 cases, with 10 % oversizing relative to the hybrid prosthesis. No cases of paraplegia, stroke orperioperative death were observed. The average hospital stay length was 4 days (2-6) and the average follow-upafter TEVAR was 17 months (9-25), survival at 24 months was 100 %. Correct aneurysm exclusion was documentedin all CT controls, with no high-flow endoleaks during follow-up.Conclusions: based on our experience, TEVAR is a safe option as a second-stage intervention for complex thoracicaortic aneurysm pathology, offering excellent mid-term results for aneurysm exclusion.(AU)

Pre-Operative Continued Oral Anticoagulation Impact on Early Outcomes after Transcatheter Aortic Valve Implantation.

Considering that there is a lack of evidence and guideline-based recommendations on the best preoperative oral anticoagulation management (OAC) for transcatheter aortic valve implantation (TAVI), this cohort study aimed to evaluate bleeding, access site complications, and early safety in patients undergoing TAVI on continued OAC therapy vs no-OAC therapy. Three-hundred forty-four patients submitted to a TAVI procedure (66.3% no-OAC vs 33.7% OAC) were consecutively enrolled. Primary endpoint was defined as in-hospital VARC-2 life-threatening or disabling bleeding. Secondary endpoints were in-hospital VARC-2 major vascular complications and VARC-2 early safety at 30 days. Propensity score matching analysis was performed to reduce potential distribution bias, resulting in 2 well-balanced groups (92 patients in each arm). In the overall cohort, mean age, median EuroScore II, and STS-score were 78.7±7.6 years, 2.9% (1.7-5.9), and 2.3% (1.6-3.6), respectively. Despite being older (78 ± 8 vs 80 ± 6, p = 0.004) and having higher STS score (2.1 vs 2.6, p = 0.001), patients on OAC had similar incidence of in-hospital VARC-2 life-threatening or disabling bleeding (1.3% vs. 0.9%, p = 0.711), major vascular complications (4.8% vs 5.2%, p = 0.888), and VARC-2 early safety at 30 days (10.1% vs 12.1%, p = 0.575). No significant differences in the main outcomes were observed when propensity score matching was applied. In conclusion, the management of patients on OAC submitted to a TAVI procedure is challenging and requires balancing the risk of bleeding with the risk of thromboembolic events. The present study suggests that continued OAC was not associated with increased in-hospital VARC-2 life-threatening or disabling bleeding, major vascular complications, and VARC-2 early safety at 30 days.

Tricuspid regurgitation: when is it time for surgery?

Introduction: The interest in tricuspid regurgitation (TR) surgical treatment has grown in the last years, mostly motivated by the trend for early intervention and the development of minimally invasive surgical techniques. Despite this, there is still a lack of evidence regarding when to intervene in functional tricuspid regurgitation outside the context of left-sided valve surgery and when is the best time to approach primary tricuspid regurgitation. Areas covered: Herein, we present the state-of-the-art in tricuspid regurgitation surgical intervention, covering indications, optimum time, surgical options, and outcomes, as well as the role of transcatheter tricuspid valve intervention in the current era. Expert opinion: Current evidence support that the indications and timing of tricuspid valve invasive management should be centered on a range of factors, including patients' characteristics, disease stage, and anatomical considerations. Early intervention, before severe right ventricle dysfunction and pulmonary hypertension, seems to results in better postoperative outcomes. Transcatheter techniques are arising as potential alternatives for inoperable and high-risk patients.

Isolated aortic valve replacement in Spain: national trends in risks, valve types, and mortality from 1998 to 2017.

INTRODUCTION AND OBJECTIVES: To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses. METHODS: We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period. RESULTS: In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P <.001). In-hospital mortality decreased from 7.2% to 3.3% (P <.001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P <.001). CONCLUSIONS: We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced.