Frailty, disability and comorbidity: different domains lead to different effects after surgical aortic valve replacement in elderly patients.

OBJECTIVES: Frailty syndrome predicts adverse outcomes after surgical aortic valve replacement. However, disability or comorbidity is frequently associated with preoperative frailty evaluation. The effects of these domains on early and late outcomes were analysed. METHODS: A prospective study including patients aged ≥75 years with symptomatic severe aortic stenosis who received aortic valve replacement with or without coronary artery bypass grafting was conducted. We used the Cardiovascular Health Study Frailty Phenotype to assess frailty, the Lawton-Brody index to define disability and the Charlson comorbidity index (CCI) to evaluate comorbidity. RESULTS: Frailty was identified in 57 (31%), dependence in 18 (9.9%) and advanced comorbidity (CCI ≥ 4) in 67 (36.6%) of the 183 enrolled patients. Operative mortality (1.6%), transfusion rate and duration of stay increased in patients with CCI ≥4 (P < 0.005). There was a non-significant trend for these adverse outcomes among the frail patients. Follow-up was achieved in all patients (median/interquartile range 869/699-1099 days). Kaplan-Meier univariable analysis showed a reduced survival rate for frail and dependent patients and for those with multiple comorbidities (P < 0.05). According to multivariable analysis, frailty and comorbidity were independent risk factors for 1-year mortality, while disability and comorbidity, but not frailty, were risk factors for 3-year mortality (P < 0.05). CONCLUSIONS: Surgical aortic valve replacement in patients aged ≥75 years is a safe procedure with low mortality rates. Operative outcomes are mainly affected by comorbidities. The main influence of survival occurs throughout the first year, and an improved functional status prevents any progression towards disabilities, which could potentially benefit long-term outcomes. CLINICAL TRIAL REGISTRATION NUMBER: NCT02745314.

Quick spontaneous remodelling of thrombosed false lumen in acute type-A aortic dissection.

Natural history of acute Stanford type A aortic dissection (AAAD) implies the need of emergent surgical treatment in the vast majority of cases. Nevertheless, conservative treatment has been described to yield acceptable outcomes, when compared to surgery, in selected high risk cases of thrombosed false lumen. We report a significant quick remodelling of the false lumen occurred in an 85-year-old female 6 days after conservative treatment.

Use of self-expanding venous cannula in tricuspid reoperation.

Significant tricuspid regurgitation requiring surgical correction is associated with poor survival in patients undergoing tricuspid valve reoperations. Right chamber dilatation increases the risk of injury during resternotomy. The novel technique of peripheral cannulation using an expandable venous cannula for cardiopulmonary bypass can help to reduce the risk of complications and associated morbidity, thus enhancing the short-term outcomes.

Leaflet tear in a Trifecta aortic bioprosthesis 34 months after implantation.

Bioprosthetic valves are used in aortic valve replacement to avoid lifelong anticoagulation. Bovine pericardial valves have excellent haemodynamics and equivalent freedom from reoperation compared with a porcine bioprosthesis [ 1]. However, early failure (parastent post-cusp tear) can take place due to mechanical stress. We report an acute structural failure on a Trifecta pericardial valve (St Jude Medical, Inc.) explanted after 34 months from a 71-year old woman.

Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry.

OBJECTIVES: This study sought to evaluate the main baseline and procedural characteristics, management, and clinical outcomes of patients from a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) who suffered coronary obstruction (CO). BACKGROUND: Very little data exist on CO following TAVI. METHODS: This multicenter registry included 44 patients who suffered symptomatic CO following TAVI of 6,688 patients (0.66%). Pre-TAVI computed tomography data was available in 28 CO patients and in a control group of 345 patients (comparisons were performed including all patients and a cohort matched 1:1 by age, sex, previous coronary artery bypass graft, transcatheter valve type, and size). RESULTS: Baseline and procedural variables associated with CO were older age (p < 0.001), female sex (p < 0.001), no previous coronary artery bypass graft (p = 0.043), the use of a balloon-expandable valve (p = 0.023), and previous surgical aortic bioprosthesis (p = 0.045). The left coronary artery was the most commonly involved (88.6%). The mean left coronary artery ostia height and sinus of Valsalva diameters were lower in patients with obstruction than in control subjects (10.6 ± 2.1 mm vs. 13.4 ± 2.1 mm, p < 0.001; 28.1 ± 3.8 mm vs. 31.9 ± 4.1 mm, p < 0.001). Differences between groups remained significant after the case-matched analysis (p < 0.001 for coronary height; p = 0.01 for sinus of Valsalva diameter). Most patients presented with persistent severe hypotension (68.2%) and electrocardiographic changes (56.8%). Percutaneous coronary intervention was attempted in 75% of the cases and was successful in 81.8%. Thirty-day mortality was 40.9%. After a median follow-up of 12 (2 to 18) months, the cumulative mortality rate was 45.5%, and there were no cases of stent thrombosis or reintervention. CONCLUSIONS: Symptomatic CO following TAVI was a rare but life-threatening complication that occurred more frequently in women, in patients receiving a balloon-expandable valve, and in those with a previous surgical bioprosthesis. Lower-lying coronary ostium and shallow sinus of Valsalva were associated anatomic factors, and despite successful treatment, acute and late mortality remained very high, highlighting the importance of anticipating and preventing the occurrence of this complication.

Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.

This study was conducted to compare the clinical outcomes of drug-eluting stents (DESs) with those of standard bypass surgery for the treatment of patients with left main lesions in a single-center experience. From January 2000 to October 2005, a total of 96 patients with significant unprotected left main disease were treated with DES implantation, and 245 with bypass surgery. Baseline features, such as Euroscore, were similar between groups, except for diabetes and hypertension, which were more frequent in the surgical group. The combination of death, Q-wave myocardial infarction, stroke, and repeated revascularization (major adverse cardiac and cerebrovascular events [MACCEs]) at 30 days occurred in 2.1% after DES implant and 9.0% after surgery (p=0.03). At 1 year, DES-treated patients more frequently needed repeat revascularization (5.2% vs 0.8%; p=0.02), although combined MACCE rates were similar (10.4% for DES, 11.4% for surgery; p=0.50). Moreover, after a mean follow-up of 1.3+/-0.8 and 3.2+/-1.6 years for the DES and surgical groups, there were no significant differences in MACCEs, respectively. In conclusion, in our experience, percutaneous treatment of patients with unprotected left main disease with DESs provided similar clinical results compared with surgical revascularization at a midterm follow-up.

[Congenital apical left ventricular aneurysm]. / Aneurisma congénito apical ventricular izquierdo.

Congenital ventricular aneurysm is an infrequently occurring disease entity that usually affects the left ventricle. Its etiopathology is unknown. Clinical presentation is variable, and the condition is potentially lethal in some cases. Various imaging techniques are useful in diagnosis and enable the condition to be differentiated from congenital left diverticulum. We present a patient with a calcified congenital ventricular aneurysm who presented with supraventricular and ventricular arrhythmias and who was treated by surgical resection.

Aneurisma congénito apical ventricular izquierdo / Congenital apical left ventricular aneurysm

El aneurisma ventricular congénito es una entidad infrecuente que generalmente se localiza en el ventrículo izquierdo y cuya etiopatogenia es desconocida. Su presentación clínica es muy variable, pero hay casos potencialmente letales. Varias técnicas de imagen cardíaca pueden ser útiles para su diagnóstico y permiten diferenciarlo de los divertículos ventriculares congénitos, con los que en ocasiones se confunden. Presentamos el caso de un aneurisma ventricular congénito calcificado que cursó con arritmias supraventriculares y ventriculares, y que requirió resección quirúrgica

Congenital ventricular aneurysm is an infrequently occurring disease entity that usually affects the left ventricle. Its etiopathology is unknown. Clinical presentation is variable, and the condition is potentially lethal in some cases. Various imaging techniques are useful in diagnosis and enable the condition to be differentiated from congenital left diverticulum. We present a patient with a calcified congenital ventricular aneurysm who presented with supraventricular and ventricular arrhythmias and who was treated by surgical resection

[Percutaneous coronary intervention for iatrogenic occlusion of the circumflex artery after mitral anuloplasty]. / Intervencionismo coronario en la oclusión iatrogénica de circunfleja tras anuloplastia mitral.

We describe a patient with obstruction of the dominant circumflex artery after surgical repair of the mitral valve, repaired successfully with percutaneous coronary intervention during the immediate postoperative period. We discuss the etiology, prevention and management of this complication with special emphasis on percutaneous intervention.

Intervencionismo coronario en la oclusión iatrogénica de circunfleja tras anuloplastia mitral / Percutaneous coronary intervention for iatrogenic occlusion of the circumflex artery after mitral anuloplasty

Describimos el caso de un paciente con obstrucción de la arteria circunfleja dominante tras una cirugía de reparación mitral, resuelta con éxito mediante intervencionismo coronario percutáneo realizado en el postoperatorio inmediato. Se discute la etiopatogenia con vistas a la prevención de esta complicación y su manejo, con especial énfasis en el intervencionismo coronario percutáneo (AU)

Comprehensive experience with the Ross operation in Spain.

OBJECTIVE: Although the first pulmonary autograft operations were performed in Spain in 1991, this procedure has gained substantial interest and has been consolidated since 1997. The establishment of the Spanish Registry of the Ross Operation pretends to evaluate the results of this option in aortic valve disease patients in our setting. METHODS: In a yearly fashion, the cardiac surgery departments in Spain currently performing this intervention send data from new patients or follow-ups to the reference center. Preoperative, intraoperative and postoperative data are included in the registry, with special attention to morbidity, mortality, autograft and homograft dysfunction and need for reintervention. RESULTS: Since February 1991 to May 2002, 169 patients have been treated with this technique. The most prevalent aortic disease was regurgitation (72; 42.59%), congenital being the most frequent etiology (108; 63.9%). Four (2.36%) patients required intraoperative aortic counterpulsation. Operative mortality was 2.36% (n=4). Follow-up is 98.7% complete, with an average of 36.08+/-31.09 months (range 1-135), 84 patients (49.7%) were followed for more than 2 years. The autograft remains competent or with trivial to mild regurgitation in 161 patients (95.6%), presenting two (1.18%) with severe regurgitation. The homograft was normal or with mild stenosis in 159 patients (94.07%), presenting five (2.95%) with severe stenosis. Three (1.77%) required reintervention (surgical or interventional) on the right ventricular outflow tract and four (2.36%) required autograft replacement for a mechanical prosthesis. Actuarial survival is 95.99+/-1.65% at 36 months, remaining 92.44+/-2.55% free from reintervention in the same period. CONCLUSIONS: The Ross operation is an increasingly popular surgical option in Spain, and although the number of patients and length of follow-up are still limited, initial results are at least as good as those reported internationally. It is important to continue a close follow-up of these patients to assess the long-term function of auto and homograft. With the available data, we believe that this therapeutic approach is a valid option for selected groups of patients with surgical aortic valve disease in Spain.