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)

Neointimal hyperplasia associated with the use of u-clip.

The U-Clip (Coalescent Surgical, Sunnydale, CA USA) allows the surgeon to create an interrupted anastomosis in the same amount of time that is required for a continuous anastomosis with the elimination of knotting. Its use is indicated especially in minimally invasive surgery. We describe a case of a patient in which the proximal anastomosis was performed by interrupted suture with Coalescent U-Clip anastomotic device. Six months later, he presented with stenosis of the anastomosis, and intravascular ultrasound showed anastomotic neointimal hyperplasia.

Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm.

OBJECTIVES: To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. METHODS: We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. RESULTS: This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. CONCLUSIONS: AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

Incidence, associated factors and evolution of non-severe functional mitral regurgitation in patients with severe aortic stenosis undergoing aortic valve replacement.

INTRODUCTION: In order to improve the prognosis, repair of severe mitral regurgitation should be undertaken at the same time as aortic valve replacement in patients with severe aortic valve stenosis. However, mitral regurgitation may be secondary to pressure overload or ventricular dysfunction and improve after surgery. AIM: To assess the incidence of non-severe functional mitral regurgitation before and after isolated aortic valve replacement and determine its influence on the postoperative course. METHODS: The clinical and surgical characteristics were compared in a cohort of 577 consecutive patients who underwent isolated aortic valve replacement. RESULTS: The mean age was 68.4+/-9.2 years (44% women). Non-severe functional mitral valve regurgitation was detected prior to surgery in 26.5% of the patients. These patients were older (p=0.009), more often had ventricular dysfunction (p=0.005) and pulmonary hypertension (0.002), and had been admitted more frequently for heart failure (0.002), with fewer of them conserving sinus rhythm (p<0.001). Additionally, the pre-surgery existence of mitral regurgitation was associated with greater morbidity and mortality (10.5% vs 5.6%; p=0.025). The mitral regurgitation disappeared or improved prior to hospital discharge in 56.2% and 15.6%, respectively. Independent factors predicting this improvement were the presence of coronary lesions (OR 3.7, p=0.038), and the absence of diabetes (OR 0.28, p=0.011) and pulmonary hypertension (0.33, p=0.046). CONCLUSIONS: The presence of intermediate degree mitral regurgitation in patients undergoing isolated aortic valve replacement increases morbidity and mortality. However, a high percentage of those who do survive experience disappearance or improvement of the mitral regurgitation.

[Absence of a relationship between surgical volume and mortality in cardiac surgery units in Spain]. / No hay relación entre el volumen quirúrgico y la mortalidad en los servicios de cirugía cardiaca en España.

INTRODUCTION AND OBJECTIVES: The relationship between the annual number of cardiac procedures at a particular center (i.e., volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and risk-adjusted mortality. METHODS: This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality. RESULTS: Overall mortality was 7.7% (95% confidence interval, 7.0%-8.4%). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the two centers with highest and lowest mortality rates, respectively, the correlations were -0.464, -0.420 and -0.267, respectively. CONCLUSIONS: No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality.

No hay relación entre el volumen quirúrgico y la mortalidad en los servicios de cirugía cardiaca en España / Absence of a relationship between surgical volume and mortality in cardiac surgery units in Spain

Introducción y objetivos. La relación entre el número de intervenciones cardiacas anuales (volumen) de un centro y sus resultados es controvertido. Varios estudios occidentales hallan una relación inversa volumen/mortalidad. Analizamos el número de intervenciones de algunos centros cardioquirúrgicos nacionales y su mortalidad bruta y ajustada a riesgo. Métodos. Estudio observacional prospectivo de 6.054 pacientes intervenidos en 16 hospitales, correspondientes al 34% del total de la actividad cardioquirúrgica que se realizó en España durante el año 2004. Se analizaron los factores de riesgo y los resultados de cada paciente intervenido en los centros participantes. Los datos de cada centro fueron verificados por auditoría independiente. Se estimó el riesgo quirúrgico de cada paciente intervenido por los métodos de Parsonnet y EuroSCORE, con objeto de evaluar la mortalidad ajustada a riesgo. Resultados. La mortalidad total fue del 7,7% (intervalo de confianza del 95%, 7%-8,4%). El índice de mortalidad ajustada a riesgo fue 0,81 por el método de Parsonnet y 1,12 por EuroSCORE. La correlación entre número de cirugías de un centro y mortalidad por el método de Pearson fue 0,065 para la mortalidad bruta, 0,092 para la mortalidad ajustada a riesgo por Parsonnet y 0,111 para la mortalidad ajustada por EuroSCORE. Descartando los centros con mortalidades más alta y más baja, los resultados fueron ­0,464, ­0,420 y ­0,267 respectivamente. Conclusiones. En España no hay relación estadísticamente significativa entre el número de intervenciones cardiacas de un centro y su mortalidad hospitalaria

Introduction and objectives. The relationship between the annual number of cardiac procedures at a particular center (i.e., volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and risk-adjusted mortality. Methods. This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality. Results. Overall mortality was 7.7% (95% confidence interval, 7.0%­8.4%). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the two centers with highest and lowest mortality rates, respectively, the correlations were ­0.464, ­0.420 and ­0.267, respectively. Conclusions. No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality

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.

Mixoma de gran tamaño en la aurícula derecha / Huge Myxoma in the Right Atrium

Describimos el caso de un paciente en el que la ecocardiografía bidimensional, realizada en estudio por colestasis disociada, demostró la existencia de una gran masa en la aurícula derecha que prolapsaba en ventrículo el derecho. Se realizó ecocardiografía transesofágica intraoperatoria para delimitar las dimensiones y características de la masa con lo que se descartó la afectación de estructuras asociadas. El paciente fue intervenido bajo circulación extracorpórea, extirpándose una gran masa de 12 × 5 cm, sin ninguna complicación posterior. El estudio histológico demostró que se trataba de un mixoma. El interés del caso se centra en el diagnóstico tras la sospecha del médico por el patrón de colestasis disociada e ingurgitación yugular y la resección quirúrgica, que evitó posibles complicaciones embólicas que por el tamaño de la masa pudieron ser fatales (AU)