Tratamiento de la estenosis aórtica en pacientes mayores de 75 años: visión del cirujano / Treatment of aortic stenosis in patients over 75 years: viewpoint of the surgeon

OBJETIVO: En el presente estudio se pretende demostrar la posibilidad de la cirugía en el tratamiento de la estenosis aórtica en el paciente geriátrico (mayor de 75 años) con resultados y mortalidad asumibles y con posibilidades de mejorar los mismos, haciendo una buena selección y preparación de los enfermos en el preoperatorio. MÉTODO: Para ello se utiliza la experiencia de nuestro Servicio desde 1983 al 2000 y que alcanza hasta 130 pacientes. Se describen los factores de riesgo encontrados, técnica quirúrgica, complicaciones y resultados. RESULTADOS: 130 pacientes intervenidos (62 por ciento mujeres). Prótesis biológica en 122 casos. 18 fallecidos. Ninguna complicación en 60 casos. Complicaciones más frecuentes: fibrilación auricular e infección respiratoria (21 casos cada una) y bajo gasto transitorio (14 casos). CONCLUSIONES: En conclusión, la Cirugía Valvular Aórtica en pacientes mayores de 75 años, va acompañada de una morbi-mortalidad aceptable, permitiendo a estos pacientes una calidad de vida satisfactoria durante largos períodos de tiempo; aunque, por evidentes razones de edad, el pronóstico a largo plazo no sea igual al que se puede encontrar en aquellos pacientes intervenidos en edades más tempranas (AU)

[Guidelines of the Spanish Society of Cardiology on aortic diseases]. / Guías de práctica clínica de la Sociedad Española de Cardiología en enfermedades de la aorta.

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.

Aortic dissection occurring during coronary angioplasty: angiographic and transesophageal echocardiographic findings.

A localized acute aortic dissection was produced in 2 patients, complicating coronary angioplasty. In both cases a coronary dissection provided the entry door, with subsequent retrograde progression of the dissection into the aortic root. After sealing the entry door, both patients could be managed conservatively using transesophageal echocardiography to accurately define the location of the intimal flap and to rule out dissection progression.

Osteogenesis imperfecta and coronary artery surgery. A case report.

A new case of Osteogenesis Imperfecta (OI) suffering ischemic heart disease is reported. The patient was successfully operated on in our Institution and the bibliographic search showed only another case of such an association of diseases successfully treated by surgery. This patient proves that coronary artery surgery procedures are possible when OI complicates the cardiac ischemic syndrome.

[Infectious endocarditis caused by Q fever]. / Endocarditis infecciosa por fiebre Q.

A case of aortic valve endocarditis caused by Coxiella burnetii and operated on with success is reported. The patient is doing well at 18 months follow up. Diagnosis of Q-fever endocarditis was made by high antibodies against phase I Coxiella burnetii antigens titration and by demonstration of aortic valvular vegetations by bidimensional echocardiography. Our patient suffered emergency aortic valve substitution due to acute hemodynamic failure and started a long-term treatment with doxycycline and rifampicin. Some interesting aspects about the diagnosis and treatment of this patient are reviewed because long-term follow-up and serological controls are still rare in the literature.

Predictors, mechanisms and outcome of severe mitral regurgitation complicating percutaneous mitral valvotomy with the Inoue balloon.

During 241 consecutive percutaneous mitral valvotomy (PMV) procedures performed with the Inoue balloon, 16 patients (6.6%) developed severe mitral regurgitation (MR). Baseline clinical, echocardiographic (Doppler mitral valve area and Wilkins' score) and hemodynamic data were not different from those of patients without this complication. Severe MR occurred during the first inflation in 7 patients and after several stepwise inflations in 9. Although maximal balloon size was similar in both groups, unusual indentations and subvalvular inflations were more frequently observed in patients who developed severe MR. Early mitral valve replacement was required in 6 patients. All of them had a leaflet rupture either along the midportion (2 patients), along a commissure (4 patients), or both. Commissural calcium was present in 5 valves and 5 also had severe subvalvular involvement that had been underestimated by echocardiography. Of the 10 nonsurgically treated patients, 4 had chordal rupture by echocardiographic criteria, whereas in the remaining 6 the precise mechanism of MR could not be determined. During follow-up (11.4 +/- 4 months, range 1 to 30), 1 patient required surgery for symptoms and the remaining 9 were symptomatically improved and free of left ventricular dilatation. In conclusion, severe MR complicated 6.6% of PMV procedures with the Inoue balloon, and its mechanism was leaflet or chordal rupture. Although one third of the patients required early mitral surgery, most of the remaining obtained midterm symptomatic benefit.

[Coronary angioplasty: experience at the University Hospital of Madrid]. / Angioplastia coronaria: experiencia en el Hospital Universitario de Madrid.

The results of 963 consecutive coronary angioplasties, with 1.135 lesions attempted in 816 patients, were prospectively analyzed. Initial angiographic success (residual stenosis less than 50%) was achieved in 1.017 lesions (89.6%), and final success was obtained in 838/963 procedures (87%). Major complications included: emergency surgery in 4 cases (0.4%), acute myocardial infarction in 28 (2.9%), and death during hospitalization in nine (0.9%). Surgical stand-by was required only for cases with vital risk should the attempted vessel occlude. This criteria was present in 230 (23.8%) angioplasties. Coronary angioplasty was performed during the diagnostic procedure in 300 (31.1%) case, with final success in 264 (88%) of them. A exercise test was achieved before the procedure in 419 (50%) successful angioplasties and in 246 (58.7%) of them it was abnormal because of angina (with or without ST depression). After procedure, exercise could be performed in 780 cases (93%), and the result remained unchanged in only 44 (5.6%) (p less than 0.01). At discharge 780 (93%) patients with final success considered themselves clinically improved. In our experience, coronary angioplasty is a good myocardial revascularization technique, with high success, low rate of major complications, and that provides a good clinical outcome. Surgical stand-by may be unnecessary in prost of angioplasty procedures if patients selection is carefully done, also, this approach makes it possible to perform angioplasty at time of diagnostic catheterization.

Annuloaortic ectasia and adult polycystic kidney. A frequent association.

The association of annuloaortic ectasia and polycystic kidney in 18 consecutive patients who had intravenous pyelograms was 22 percent (4/18). Due to this high association rate, some type of work-up to study the kidney anatomy should be performed in every case of annuloaortic ectasia. For the same reasons, patients with adult polycystic kidney should have a careful cardiovascular evaluation.

Compound grafts of xenopericardium and Dacron fabric for repair or replacement of great vessels: a method to avoid interstitial and suture hole bleeding.

Compound grafts constructed by wrapping pericardial xenografts around fabric grafts were used for replacement or repair of the great vessels. After cardiopulmonary bypass (CPB), bleeding through the compound graft is nil. Nine patients had the intrathoracic aorta replaced with a compound graft, and eight patients had patch repair of the ascending aorta or the right ventricular outflow tract. Bleeding in all patients was minimal because the nonporous nature of the xenopericardium avoids interstitial and suture hole hemorrhage until normal hemostasis is obtained.

Prevention of thromboembolism using aspirin after mitral valve replacement with porcine bioprosthesis.

The thromboembolic rate of 768 patients who were treated only with aspirin after mitral valve replacement or mitral plus aortic valve replacement with porcine bioprostheses was evaluated. We analyzed the thromboembolic rate for the whole series and for subgroups of patients categorized by atrial fibrillation, giant left atrium, left atrial thrombosis, and dosage of aspirin (1 gm daily or 0.5 gm every 48 hours). The total embolic rate was 1.4% (11/768). No patient in sinus rhythm had an embolic event. The embolic rate for patients in atrial fibrillation was 1.9% (11/583). There were no embolic events in 31 patients with a giant atrium. An embolic event occurred in 1 of 42 patients with atrial thrombosis (2.4%). Patients treated with 1 gm of aspirin daily had a 3% embolic rate (9/295) while the incidence was 0.4% (2/473) in those treated with 0.5 gm every 48 hours (p less than 0.01). Administration of aspirin after mitral valve replacement with a bioprosthesis is a very effective treatment for prevention of thromboembolism. In our experience, this treatment provides protection equal to or better than that offered by oral anticoagulants for patients in atrial fibrillation as well as for patients with a giant atrium or atrial thrombosis at operation. The dosage and timing of aspirin administration may markedly affect the result of this type of treatment. Oral anticoagulation with coumarin derivatives may not be appropriate after mitral valve replacement with a bioprosthesis, and platelet antiaggregates should be used for this purpose in the future.

Pregnancy and mechanical valve prostheses: a high-risk situation for the mother and the fetus.

Thirty-eight women with mechanical valve prostheses had a total of 47 pregnancies. All patients were on oral anticoagulants before pregnancy. A high incidence of complications was seen in both the mothers and the fetuses. The rate of spontaneous abortion was 23.4% (11/47), and 2 of the 36 newborns had chondrodysplasia punctata. Three of the women (7.9%) had acute valvular thrombosis; 1 died after replacement of the thrombosed valve. Thus, the overall mortality for the series was 2.6%. More complications were observed in the fetuses and infants of women treated with oral anticoagulants during pregnancy than in women treated with heparin. However, the mothers had more complications with heparin anticoagulation. Neither heparin nor oral anticoagulants clearly proved superior as the anticoagulation regimen of choice for pregnant women with mechanical valves. Counseling before conception occurs and avoidance of pregnancy are recommended for women with mechanical valve prostheses because of the high risk of serious or fatal complications in the mother and fetus. Use of tissue valves in women of childbearing age who desire to have children also seems advisable, even with the possibility of having to undergo another operation as a result of degeneration of the valve tissue.

Pregnancy in 20 patients with bioprosthetic valve replacement.

We studied twenty women who became pregnant after porcine bioprosthetic valve replacement. Six patients had aortic valve, seven mitral, and seven aortic plus mitral valve replacement. All women were treated with aspirin (1 g daily or 500 mg every 48 hours) during pregnancy, delivery, and the postdelivery period. Thirteen patients experienced atrial fibrillation. There were 27 pregnancies with three ending in abortion. Twenty five normal babies were delivered. There was no maternal mortality or morbidity from thromboembolism or hemorrhage. Comparison of the pregnancy course of these women and the general population shows no difference with respect to fetal or maternal morbidity and mortality. Pregnant women with bioprosthetic valve replacement treated with aspirin had normal pregnancies without the risk of thromboembolism. Fetal and perinatal morbidity and mortality was also within normal limits.

Diagnosis and treatment of subacute free wall ventricular rupture after infarction.

Ventricular rupture is usually a sudden, lethal complication after acute myocardial infarction (MI). Some patients, however, may survive several hours after ventricular rupture, and there is time for surgical repair if the diagnosis is made quickly. In 1980 and 1981, 7 patients underwent operation for ventricular rupture at our institution. Bedside hemodynamic studies with a Swan-Ganz catheter confirmed the diagnosis of pericardial tamponade. Urgent operation with cardiopulmonary bypass was performed. Control of hemorrhage was obtained by covering the ventricular tear and the surrounding infarcted myocardium with a wide Teflon patch. Four patients are alive and well 2, 3, 4, and 10 months after operation. Clinically, free wall ventricular rupture should be suspected when any patient recovering from an acute MI experiences chest pain and cardiovascular collapse. Bedside hemodynamic monitoring will confirm the diagnosis of cardiac tamponade, and urgent operation will save some of these patients.