Sobrevida y libertad de reoperación en pacientes sometidos a tratamiento endovascular de enfermedades de la aorta / Reoperation-free survival in patients subjected to endovascular treatment of diseases of the aorta

Resumen Introducción: El manejo endovascular para patologías de la aorta ha aumentado como opción para pacientes de alto riesgo quirúrgico de cirugía convencional abierta. Los resultados a corto plazo para mortalidad, libertad de enfermedad y reintervención, evidencian resultados favorables respecto a la cirugía abierta, pero a mediano (1-12 meses) y largo plazo (>1 año) no existen resultados en nuestro medio. Métodos: Estudio de cohorte bidireccional, en el cual se realizó el segmento retrospectivo en pacientes sometidos a manejo endovascular con prótesis aórtica y el segmento prospectivo en el seguimiento de los pacientes. Resultados: Se identificaron 194 pacientes entre abril de 2002 y diciembre de 2015 sometidos a tratamiento endovascular, que cumplían con los criterios de inclusión. El seguimiento se completó en el 82,2%. 92 casos (56.8%) de aorta abdominal con un seguimiento de 4,9 años (RIC 2,5-8,9. La sobrevida calculada fue 92% al año, 86% 2 años y 66.4% a los 5 años. El periodo libre de enfermedad fue 88.7% al año, 86.4% 2 años y 78.5% a los 10 años y 13 pacientes requirieron reintervención. 67 casos de aorta torácica con un seguimiento de 5,3 años (RIC 2,9-10.2), la sobrevida calculada 94% al año, 90.7% 2 años y 75.2% a los 5 años. El periodo libre de enfermedad fue 88.7% al año, 86.4% 2 años y 78.5% a los 10 años y 9 pacientes requirieron reintervención. Conclusiones: Los resultados obtenidos son favorables e incentivan para continuar ofreciendo el abordaje endovascular ya que la supervivencia y la libertad de reoperación se encuentran de acuerdo con lo reportado en la literatura.

Abstract Introduction: The endovascular management for diseases of the aorta has increased as an option for patients of high risk for conventional open surgery. The short-term mortality, disease-free and reoperation results, show favourable outcomes compared to open surgery, but there are no results available in this country for the medium (1-12 months) and long-term (>1 year). Methods: A bi-directional cohort study, in which the retrospective segment was conducted on patients subjected to endovascular management with an aortic replacement, and the prospective segment on the follow-up of the patients. Results: A total of 194 patients, subjected to endovascular treatment and met the inclusion criteria, were identified between April 2002 and December 2015. The follow-up was completed in 82.2% of cases. There were 92 (56.8%) cases of abdominal aorta with a mean follow-up of 4.9 years (95% range; 2.5-8.9). The calculated survival was 92% at one year, 86% at 2 years, and 66.4% at 5 years. The period free of disease was 88.7% at one year, 86.4% at 2 years, and 78.5% at 10 years, with 13 patients requiring re-operation. There were 67 cases of thoracic aorta, with a mean follow-up of 5.3 years (95% range; 2.9-10.2). The calculated survival was 94% at one year, 90.7% at 2 years, and 75.2% at 5 years. The period free of disease was 88.7% at one year, 86.4% at 2 years, and 78.5% at 10 years, and 9 patients required re-operation. Conclusions: The results obtained are favourable and are encouraging to continue offering the endovascular approach since the re-operation survival is similar to that reported in the literature.

Wide Dissection and Intercostal Vessel Division Allows for Repair of Hypoplastic Aortic Arch Through Thoracotomy.

BACKGROUND: The approach to coarctation of the aorta with hypoplastic aortic arch is controversial. We evaluated the outcomes in patients with coarctation of the aorta with or without hypoplastic aortic arch operated through a posterior left lateral thoracotomy. METHODS: A retrospective cohort of patients with aortic coarctation, who underwent repair between January 2009 and October 2017, was analyzed. Preoperative, postoperative, and echocardiographic characteristics were reviewed. Statistical analysis examined survival, freedom from reintervention, and freedom from recoarctation. RESULTS: In nine years, 389 patients who underwent surgical treatment for coarctation of the aorta were identified; after exclusion criteria and complete echocardiographic reports, 143 patients were analyzed, of which 29 patients had hypoplastic aortic arch. The modification in the extended end-to-end anastomosis technique was a wide dissection and mobilization of the descending aorta that was achieved due to the ligation and division of 3 to 5 intercostal vessels. In both groups, patients were close to one month of age and had a median weight of 3.6 and 3.4 kg for hypoplastic and nonhypoplastic arch, respectively. In postoperative events, there was no statistically significant difference between the groups ( P = .57 for renal failure, P = .057 for transient, nonpermanent neurologic events, P = .496 for sepsis), as for intensive care unit ( P = .502) and total in-hospital stay ( P = .929). There was one case of postoperative mortality in each group and both were associated with noncardiac comorbidities. Regarding survival (log-rank = 0.060), freedom from reintervention (log-rank = 0.073), and freedom from recoarctation (log-rank = 0.568), there was no statistically significant difference between the groups. CONCLUSION: We believe that it is the modified technique that allowed greater mobilization of the aorta and successful repair of hypoplastic arch through thoracotomy, without an increase in paraplegia or other adverse outcomes.

Mitral valve repair, how to make volume not matter; techniques, tendencies, and outcomes, a single center experience.

BACKGROUND: Recent evidence has showed us that quality of mitral valve repair is strongly related to volume. However, this study shows how low-volume centers can achieve results in mitral valve repair surgery comparable to those reported by referral centers. It compares outcomes of mitral valve repair using resection versus noresection techniques, tendencies, and rates of repair. METHODS: Between 2004 and 2017, 200 patients underwent mitral valve repair for degenerative mitral valve disease at Fundación Cardioinfantil-Institute of Cardiology. Fifty-eight (29%) patients underwent resection and 142 (71%) noresection. RESULTS: Follow-up was 94% complete, mean follow-up time was 2.3 years. There was no 30-day mortality. Five patients required mitral valve replacement after an average of 5.3 years (Resection = 2; Noresection = 3). Freedom from severe mitral regurgitation was 98% at 6.6 years of follow-up for the noresection group, and 92.5% at 7 years for the resection group (log rank: 0.888). At last follow-up, two patients died of cardiovascular disease related to mitral valve, 181 patients (86%) showed no or grade I mitral regurgitation. Patients with previous myocardial infarction had increased risk of recurrent mitral regurgitation (p = 0,030). Within four years, we inverted the proportion of mitral valve replacement and repair, and in 2016 we achieved a mitral valve repair rate of 96%. CONCLUSION: This study suggests that resection and noresection techniques are safe and effective. Recurrence of severe mitral regurgitation and need for mitral valve replacement are rare. We show that low-volume centers can achieve results comparable to those reported worldwide by establishing a mitral valve repair team. We encourage hospitals to follow this model of mitral valve repair program to decrease the proportion of mitral valve replacement, while increasing mitral valve repair.

Identification of clinically relevant phenotypes in patients with Ebstein anomaly.

BACKGROUND: Ebstein anomaly (EA) is a heterogeneous congenital heart defect (CHD), frequently accompanied by diverse cardiac and extracardiac comorbidities, resulting in a wide range of clinical outcomes. HYPOTHESIS: Phenotypic characterization of EA patients has the potential to identify variables that influence prognosis and subgroups with distinct contributing factors. METHODS: A comprehensive cross-sectional phenotypic characterization of 147 EA patients from one of the main referral institutions for CHD in Colombia was carried out. The most prevalent comorbidities and distinct subgroups within the patient cohort were identified through cluster analysis. RESULTS: The most prevalent cardiac comorbidities identified were atrial septal defect (61%), Wolff-Parkinson-White syndrome (WPW; 27%), and right ventricular outflow tract obstruction (25%). Cluster analysis showed that patients can be classified into 2 distinct subgroups with defined phenotypes that determine disease severity and survival. Patients in cluster 1 represented a particularly homogeneous subgroup with a milder spectrum of disease, including only patients with WPW and/or supraventricular tachycardia (SVT). Cluster 2 included patients with more diverse cardiovascular comorbidities. CONCLUSIONS: This study represents one of the largest phenotypic characterizations of EA patients reported. The data show that EA is a heterogeneous disease, very frequently associated with cardiovascular and noncardiovascular comorbidities. Patients with WPW and SVT represent a homogeneous subgroup that presents with a less severe spectrum of disease and better survival when adequately managed. This should be considered when searching for genetic causes of EA and in the clinical setting.