Overexpression of scavenger receptor and infiltration of macrophage in epicardial adipose tissue of patients with ischemic heart disease and diabetes.

BACKGROUND: Oxidized low-density lipoproteins and scavenger receptors (SRs) play an important role in the formation and development of atherosclerotic plaques. However, little is known about their presence in epicardial adipose tissue (EAT). The objective of the study was to evaluate the mRNA expression of different SRs in EAT of patients with ischemic heart disease (IHD), stratifying by diabetes status and its association with clinical and biochemical variables. METHODS: We analyzed the mRNA expression of SRs (LOX-1, MSR1, CXCL16, CD36 and CL-P1) and macrophage markers (CD68, CD11c and CD206) in EAT from 45 patients with IHD (23 with type 2 diabetes mellitus (T2DM) and 22 without T2DM) and 23 controls without IHD or T2DM. RESULTS: LOX-1, CL-P1, CD68 and CD11c mRNA expression were significantly higher in diabetic patients with IHD when compared with those without T2DM and control patients. MSR1, CXCL16, CD36 and CD206 showed no significant differences. In IHD patients, LOX-1 (OR 2.9; 95% CI 1.6-6.7; P = 0.019) and CD68 mRNA expression (OR 1.7; 95% CI 0.98-4.5; P = 0.049) were identified as independent risk factors associated with T2DM. Glucose and glycated hemoglobin were also shown to be risk factors. CONCLUSIONS: SRs mRNA expression is found in EAT. LOX-1 and CD68 and were higher in IHD patients with T2DM and were identified as a cardiovascular risk factor of T2DM. This study suggests the importance of EAT in coronary atherosclerosis among patients with T2DM.

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.

Rationale and design of a multicentre, prospective, randomised, controlled clinical trial to evaluate the efficacy of the adipose graft transposition procedure in patients with a myocardial scar: the AGTP II trial.

INTRODUCTION: Cardiac adipose tissue is a source of progenitor cells with regenerative capacity. Studies in rodents demonstrated that the intramyocardial delivery of cells derived from this tissue improves cardiac function after myocardial infarction (MI). We developed a new reparative approach for damaged myocardium that integrates the regenerative properties of cardiac adipose tissue with tissue engineering. In the adipose graft transposition procedure (AGTP), we dissect a vascularised flap of autologous pericardial adipose tissue and position it over the myocardial scarred area. Following encouraging results in acute and chronic MI porcine models, we performed the clinical trial (NCT01473433, AdiFLAP trial) to evaluate safety in patients with chronic MI undergoing coronary artery bypass graft. The good safety profile and trends in efficacy warranted a larger trial. STUDY DESIGN: The AGTP II trial (NCT02798276) is an investigator initiated, prospective, randomised, controlled, multicentre study to assess the efficacy of the AGTP in 108 patients with non-revascularisable MI. Patients will be assigned to standard clinical practice or the AGTP. The primary endpoint is change in necrotic mass ratio by gadolinium enhancement at 91 and 365 days. Secondary endpoints include improvement in regional contractibility by MRI at 91 and 365 days; changes in functional MRI parameters (left ventricular ejection fraction, left and right ventricular geometric remodelling) at 91 and 365 days; levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) at 7, 91 and 365 days; appearance of arrhythmias from 24 hour Holter monitoring at 24 hours, and at 91 and 365 days; all cause death or re-hospitalisation at 365 days; and cardiovascular death or re-hospitalisation at 365 days. ETHICS AND DISSEMINATION: The institutional review board approved the trial which will comply with the Declaration of Helsinki. All patients will provide informed consent. It may offer a novel, effective and technically simple technique for patients with no other therapeutic options. The results will be submitted to indexed medical journals and national and international meetings. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02798276, pre-results.

Abordaje mínimamente invasivo en cirugía valvular y del septo interauricular / Minimally invasive approach for valvular surgery and atrial septal defect

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Acceso aórtico directo para implante transcatéter de la válvula aórtica autoexpandible CoreValve ®: serie de dos casos / Direct transaortic access for transcatheter aortic valve implantations with the self-expanding CoreValve ® prosthesis: a series of 2 cases

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Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction.

INTRODUCTION AND OBJECTIVES: At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction. METHODS: Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval [CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38; 95% CI, 1.40-80.0; P=.020) and coronary artery disease (OR=2.09; 95% CI, 1.26-51.0; P=.027). RESULTS: During the mean follow-up period of 42.59+/-40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was a low postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction (P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients. CONCLUSIONS: Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class.

Predictores de mortalidad y recuperación funcional a largo plazo en el reemplazo valvular por estenosis aórtica severa con disfunción ventricular / Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction

Introducción y objetivos. El tratamiento quirúrgico de la estenosis aórtica severa es el único efectivo recomendado actualmente para esta patología, pero el riesgo quirúrgico aumenta con la disfunción ventricular izquierda. Nuestro objetivo fue identificar predictores de mortalidad y mejoría funcional en el postoperatorio y a largo plazo tras reemplazo valvular en pacientes con estenosis aórtica y disfunción ventricular severa. Métodos. Entre 1996 y 2008, 635 pacientes con estenosis aórtica severa fueron intervenidos, 82 con fracción de eyección < 40%, con mortalidad postoperatoria precoz del 19,5%. Identificamos como predictores independientes de mortalidad postoperatoria precoz el sexo femenino (OR = 2,60; IC del 95%, 2,20-89; p = 0,004), la regurgitación mitral no severa (OR = 2,38; IC del 95%,1,40-80; p = 0,020) y las lesiones coronarias (OR = 2,09;IC del 95%, 1,26-51; p = 0,027).Resultados. Tras seguimiento medio de 42,59 ± 40,83meses, la mortalidad global fue del 18,8% y la cardiovascular, del 11,3%. Sólo el bajo gasto cardiaco postoperatorio(OR = 4,40; IC del 95%, 1,20-15,50; p = 0,02)se relacionó con mayor mortalidad en el seguimiento. El70,5% presentó mejoría precoz de la función ventricular, siendo predictores de ausencia de mejoría el infarto previo(p = 0,04), las lesiones coronarias no revascularizadas (p = 0,04) y un gradiente aórtico reducido (p = 0,02). El93,4% mejoró su grado funcional significativamente durante el seguimiento. Conclusiones. Pese a la considerable mortalidad postoperatoria precoz de los pacientes con estenosis aórtica y disfunción ventricular izquierda, a largo plazo se observa una supervivencia elevada junto a mejora de la función ventricular y del grado funcional (AU)

Introduction and objectives. At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction. Methods. Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval[CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38;95% CI, 1.40-80.0; P=.020) and coronary artery disease(OR=2.09; 95% CI, 1.26-51.0; P=.027).Results. During the mean follow-up period of42.59±40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was allow postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction(P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients. Conclusions. Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class (AU)

[Influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis]. / Influencia del sexo en el pronóstico perioperatorio de pacientes sometidos a sustitución valvular por estenosis aórtica severa.

INTRODUCTION AND OBJECTIVES: The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis. METHODS: This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007. RESULTS: Women (44% of patients) were older than men (70.3+/-7.9 years vs. 66.8+/-9.8 years; P< .001), had a smaller body surface area (1.68+/-0.15 m(2) vs. 1.83+/-0.16 m(2); P< .001), more often had arterial hypertension (73% vs. 49%; P< .001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P< .001), and less often had coronary artery disease (19.1% vs. 31.8%; P< .001) and severe ventricular dysfunction (7.9% vs. 17.4%; P< .001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119). CONCLUSIONS: Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality.

Influencia del sexo en el pronóstico perioperatorio de pacientes sometidos a sustitución valvular por estenosis aórtica severa / Influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis

Introducción y objetivos. La influencia pronóstica del sexo de los pacientes sometidos a sustitución valvular aórtica por estenosis severa tiene un papel controvertido, y algunos estudios le atribuyen un papel relevante como marcador de riesgo independiente. El objetivo del estudio es valorar la influencia pronóstica perioperatoria del sexo de los pacientes sometidos a sustitución valvular por estenosis aórtica severa. Métodos. Estudio retrospectivo en el que se analizó una cohorte de 577 pacientes sometidos a cirugía de reemplazo valvular aórtico por estenosis aórtica entre 1996 y abril de 2007. Resultados. Las mujeres (44%) tenían mayor edad (70,3 ± 7,9 frente a 66,8 ± 9,8 años; p < 0,001), menos superficie corporal (1,68 ± 0,15 frente a 1,83 ± 0,16 m2; p < 0,001), más hipertensión arterial (el 73 frente al 49%; p < 0,001), diabetes mellitus (el 33,5 frente al 24,5%; p = 0,001) e hipertrofia ventricular (el 89,1 frente al 83,1%; p < 0,001), menos enfermedad coronaria (el 19,1 frente al 31,8%; p < 0,001) y menos disfunción ventricular severa (el 7,9 frente al 17,4%; p < 0,001). A pesar de esto, las mujeres tuvieron más infarto agudo de miocardio perioperatorio (el 3,9 frente al 0,9%; p = 0,016), bajo gasto en el postoperatorio (el 30,3 frente al 22,3%; p = 0,016) y mortalidad perioperatoria que los varones (el 13 frente al 7,4%; p = 0,019). El sexo femenino no se mostró, al ajustar por los diferentes factores de confusión, como factor independiente relacionado con la mortalidad (odds ratio = 2,4; intervalo de confianza del 95%, 0,79-7,26; p = 0,119). Conclusiones. La mortalidad perioperatoria de las mujeres con estenosis aórtica severa sometidas a sustitución valvular es alta. Al ajustar por potenciales factores de confusión, especialmente superficie corporal, el sexo femenino no se comporta como factor independiente de mortalidad (AU)

Introduction and objectives. The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis. Methods. This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007. Results. Women (44% of patients) were older than men (70.3±7.9 years vs. 66.8±9.8 years; P<.001), had a smaller body surface area (1.68±0.15 m2 vs. 1.83±0.16 m2; P<.001), more often had arterial hypertension (73% vs. 49%; P<.001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P<.001), and less often had coronary artery disease (19.1% vs. 31.8%; P<.001) and severe ventricular dysfunction (7.9% vs. 17.4%; P<.001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119). Conclusions. Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality (AU)

Severe stenosis of anastomoses by using the symmetry aortic connector system.

The St. Jude Medical Symmetry Aortic Connector System was developed to create the proximal vein graft anastomoses in coronary artery bypass grafting. We describe three symptomatic patients with severe stenosis of the proximal anastomosis several months after using the Symmetry aortic connector system. Intravascular ultrasound study showed anastomotic neointimal hyperplasia.