Efficacy of losartan vs. atenolol for the prevention of aortic dilation in Marfan syndrome: a randomized clinical trial.

AIMS: To determine the efficacy of losartan vs. atenolol in aortic dilation progression in Marfan syndrome (MFS) patients. METHODS AND RESULTS: A phase IIIb, randomized, parallel, double-blind study was conducted in 140 MFS patients, age range: 5-60 years, with maximum aortic diameter <45 mm who received losartan (n = 70) or atenolol (n = 70). Doses were raised to a maximum of 1.4 mg/kg/day or 100 mg/day. The primary end-point was the change in aortic root and ascending aorta maximum diameter indexed by body surface area on magnetic resonance imaging after 36 months of treatment. No serious drug-related adverse effects were observed. Five patients presented aortic events during a follow-up (one in the losartan and four in the atenolol groups, P = 0.366). After 3 years of follow-up, aortic root diameter increased significantly in both groups: 1.1 mm (95% CI 0.6-1.6) in the losartan and 1.4 mm (95% CI 0.9-1.9) in the atenolol group, with aortic dilatation progression being similar in both groups: absolute difference between losartan and atenolol -0.3 mm (95% CI -1.1 to 0.4, P = 0.382) and indexed by BSA -0.5 mm/m2 (95% CI -1.2 to 0.1, P = 0.092). Similarly, no significant differences were found in indexed ascending aorta diameter changes between the losartan and atenolol groups: -0.3 mm/m2 (95% CI -0.8 to 0.3, P = 0.326). CONCLUSION: Among patients with MFS, the use of losartan compared with atenolol did not result in significant differences in the progression of aortic root and ascending aorta diameters over 3 years of follow-up.

Preservación de la válvula aórtica bicúspide asociada a aneurismas de la raíz de aorta y aorta ascendente / Preservation of the bicuspid aortic valve associated with aneurysms of the aortic root and ascending aorta

Introducción y objetivos. Cuando la válvula aórtica bicúspide se asocia a dilatación de la aorta, la reparación quirúrgica precisa actuar sobre todos los componentes de la raíz de aorta. Revisamos nuestra experiencia en esta cirugía. Métodos. Se realizó un estudio observacional descriptivo y retrospectivo con el objetivo de analizar la morbilidad y la mortalidad de estas técnicas y valorar la durabilidad a medio plazo de la válvula aórtica. Se incluyó a todos los pacientes con válvula aórtica bicúspide y dilatación de la aorta intervenidos en nuestro centro entre 1999 y 2011 con alguna técnica de preservación valvular. Resultados. Se intervino a 151 pacientes. En 51 se empleó alguna técnica de preservación valvular. La media de edad era 51 ± 12 años y el 92% eran varones. En el 69% la insuficiencia aórtica era menor de grado II y los velos aórticos presentaban poca degeneración estructural. En 32 pacientes se realizó reimplante valvular. No hubo mortalidad hospitalaria. Con una mediana de seguimiento de 36 [intervalo intercuartílico, 18-45] meses, ningún paciente ha fallecido o ha requerido reintervención y todos los pacientes están libres de insuficiencia aórtica mayor de grado II . Conclusiones. La cirugía de preservación de la válvula aórtica bicúspide asociada a dilatación de la aorta muestra unos resultados a corto y medio plazo excelentes en válvulas seleccionadas. La estabilización de todos los componentes de la raíz de aorta mejora la durabilidad de la válvula, y las técnicas propuestas se muestran reproducibles y estables a medio plazo (AU)

Introduction and objectives: When the bicuspid aortic valve is associated with dilatation of the aorta, surgical repair requires correction of all the components of the aortic root. Here, we review our experience in this type of surgery. Methods: A descriptive and retrospective observational study was carried out to analyze morbidity and mortality in valve-sparing techniques and evaluate the medium-term durability of the aortic valve. We included all patients with a bicuspid aortic valve and dilatation of the aorta who underwent surgery with a valve-sparing technique in our center between 1999 and 2011. Results: A total of 151 patients underwent surgery. A valve-sparing technique was used in 51 patients. The mean (standard deviation) age of the patients was 51 (12) years and 92% were men. In 69% of the patients, aortic insufficiency was less than grade II and the aortic cusps showed little structural degeneration. Valve reimplantation was performed in 32 patients. There was no hospital mortality. With a median follow-up of 36 months (interquartile range, 18-45 months), none of the patients died or required reoperation, and all patients were free of aortic insufficiency greater than grade II. Conclusions: Valve-preserving surgery in bicuspid aortic valves associated with dilatation of the aorta shows excellent short- and medium-term results in selected valves. The stabilization of all of the components of the aortic root improves the durability of the valve, and the techniques proposed are reproducible and stable in the medium-term (AU)

Should aortic valve reimplantation be offered to patients with a large aorto-ventricular junction?

OBJECTIVES: Large aortic root aneurysms might increase leaflet stress and compromise aortic valve durability after the reimplantation technique. We analysed the impact of the preoperative aorto-ventricular junction (AVJ) diameter on the durability of the valve. METHODS: Between March 2004 and January 2012, 150 patients underwent the David operation on the aortic root. We identified 47 patients with a preoperative AVJ >28 mm (Group A) and 103 patients with a diameter ≤ 28 mm (Group B). The mean follow-up was 44 ± 27 months. Both groups were compared regarding mortality, freedom from moderate or severe aortic valve regurgitation and freedom from reoperation. RESULTS: Early mortality was 1.3%. Actuarial survival at 1, 3 and 5 years was 97 ± 2, 94 ± 3 and 94 ± 3% for Group A, and 99 ± 1, 97 ± 1 and 94 ± 3% for Group B, respectively (P = 0.3). Two patients in Group B were reoperated for severe aortic regurgitation (AR). Actuarial freedom from reoperation at 1, 3 and 5 years was 100% for Group A, and 98 ± 1, 98 ± 1 and 96 ± 2% for Group B, respectively (P = 0.3). During the follow-up, 6 patients (3 in each group) developed AR ≥ Grade II. Therefore, actuarial freedom from AR grade II or greater at 1.3 and 5 years was 97 ± 2, 94 ± 4 and 87 ± 7% for Group A, and 99 ± 1, 97 ± 1 and 95 ± 2% for Group B (P = 0.3). CONCLUSIONS: The reimplantation technique shows excellent results. Medium-term stability of the aortic valve repair was not influenced by the preoperative aorto-ventricular junction diameter.

Preservation of the bicuspid aortic valve associated with aneurysms of the aortic root and ascending aorta.

INTRODUCTION AND OBJECTIVES: When the bicuspid aortic valve is associated with dilatation of the aorta, surgical repair requires correction of all the components of the aortic root. Here, we review our experience in this type of surgery. METHODS: A descriptive and retrospective observational study was carried out to analyze morbidity and mortality in valve-sparing techniques and evaluate the medium-term durability of the aortic valve. We included all patients with a bicuspid aortic valve and dilatation of the aorta who underwent surgery with a valve-sparing technique in our center between 1999 and 2011. RESULTS: A total of 151 patients underwent surgery. A valve-sparing technique was used in 51 patients. The mean (standard deviation) age of the patients was 51 (12) years and 92% were men. In 69% of the patients, aortic insufficiency was less than grade II and the aortic cusps showed little structural degeneration. Valve reimplantation was performed in 32 patients. There was no hospital mortality. With a median follow-up of 36 months (interquartile range, 18-45 months), none of the patients died or required reoperation, and all patients were free of aortic insufficiency greater than grade II. CONCLUSIONS: Valve-preserving surgery in bicuspid aortic valves associated with dilatation of the aorta shows excellent short- and medium-term results in selected valves. The stabilization of all of the components of the aortic root improves the durability of the valve, and the techniques proposed are reproducible and stable in the medium-term.

Cirugía de preservación valvular en 120 pacientes con aneurismas de la raíz aórtica / Aortic valve sparing in 120 patients with aortic root aneurysms

Introducción y objetivos. Existen varias técnicas para tratar de preservar la válvula aórtica en los aneurismas de la raíz aórtica. Presentamos nuestra experiencia con la técnica del reimplante valvular aórtico en 120 pacientes. Métodos. Desde marzo de 2004 hasta octubre de 2010, se ha realizado la técnica de David en 120 pacientes con aneurismas de la raíz de aorta; 51 tenían síndrome de Marfan, con una media de edad de 31±12 años. El diámetro aórtico medio a nivel de los senos de Valsalva fue de 51±5mm y el 16% tenía una insuficiencia aórtica moderada/severa. En los 69 pacientes restantes, la media de edad era 56±14 años, el diámetro aórtico medio, 53±7mm y el 66% tenía una insuficiencia aórtica moderada/severa. En 14 pacientes la válvula aórtica era bicúspide. Resultados. La mortalidad hospitalaria fue del 1,7%. Con un seguimiento medio de 37±21 meses, la supervivencia a los 5 años es del 94±3%, y el 96% presenta insuficiencia aórtica de grado ≤ II (el 87% de los pacientes con insuficiencia aórtica ausente o de grado I). Un paciente ha sido reoperado por presentar insuficiencia aórtica severa. No ha habido endocarditis o eventos cerebrovasculares, y el 96% está libre de tratamiento anticoagulante. Conclusiones. La técnica de reimplante de la válvula aórtica ofrece unos resultados excelentes. Elimina las complicaciones asociadas a las prótesis valvulares, por lo que debe considerarse el tratamiento de elección para los aneurismas de la raíz de aorta en pacientes jóvenes (AU)

Introduction and objectives. Several aortic valve sparing techniques have been described for the treatment of aortic root aneurysms. We report our experience using the reimplantation technique in 120 patients. Methods. Between March 2004 and October 2010, 120 patients with aortic root aneurysms underwent David operations. Of these, 51 were diagnosed with Marfan syndrome. Mean patient age was 31±12 years. The mean diameter of the sinuses of Valsalva was 51±5mm and moderate/severe aortic regurgitation was present in 16% of these patients. In the other 69 patients mean age was 56±14 years, the mean diameter of the sinuses of Valsalva was 53±7mm and moderate/severe aortic regurgitation was present in 66%. A bicuspid aortic valve was presented in 14 cases. Results. Hospital mortality was 1.7%. Mean follow-up was 37±21 months; 94% of the patients survived and 96% had an aortic regurgitation below grade II during 5 years of follow-up. One patient required re-operation because of severe aortic regurgitation. No endocarditis or thromboembolic complications have been documented, and 96% of the patients did not receive any anticoagulation therapy. Conclusions. Short- and mid-term results with the reimplantation technique for aortic root aneurysms are excellent. This technique prevents the need for chronic anticoagulation treatment as well as the complications arising from mechanical prostheses, and it should be the treatment of choice for young patients (AU)

[Aortic valve sparing in 120 patients with aortic root aneurysms]. / Cirugía de preservación valvular en 120 pacientes con aneurismas de la raíz aórtica.

INTRODUCTION AND OBJECTIVES: Several aortic valve sparing techniques have been described for the treatment of aortic root aneurysms. We report our experience using the reimplantation technique in 120 patients. METHODS: Between March 2004 and October 2010, 120 patients with aortic root aneurysms underwent David operations. Of these, 51 were diagnosed with Marfan syndrome. Mean patient age was 31 ± 12 years. The mean diameter of the sinuses of Valsalva was 51 ± 5 mm and moderate/severe aortic regurgitation was present in 16% of these patients. In the other 69 patients mean age was 56 ± 14 years, the mean diameter of the sinuses of Valsalva was 53 ± 7 mm and moderate/severe aortic regurgitation was present in 66%. A bicuspid aortic valve was presented in 14 cases. RESULTS: Hospital mortality was 1.7%. Mean follow-up was 37 ± 21 months; 94% of the patients survived and 96% had an aortic regurgitation below grade II during 5 years of follow-up. One patient required re-operation because of severe aortic regurgitation. No endocarditis or thromboembolic complications have been documented, and 96% of the patients did not receive any anticoagulation therapy. CONCLUSIONS: Short- and mid-term results with the reimplantation technique for aortic root aneurysms are excellent. This technique prevents the need for chronic anticoagulation treatment as well as the complications arising from mechanical prostheses, and it should be the treatment of choice for young patients.

Aortic valve-sparing in 37 patients with Marfan syndrome: midterm results with David operation.

BACKGROUND: We reviewed our experience with aortic valve-sparing operations in Marfan syndrome during last 5 years. METHODS: Between March 2004 and June 2009, 94 patients with aortic root aneurysms underwent valve-sparing operations. Of these, 37 (68% male) were diagnosed with Marfan syndrome, according to the Ghent diagnostic criteria. Mean age was 30 +/- 10 years (range, 11 to 59 years). Moderate/severe aortic regurgitation was present in 13%, and the mean diameter of the Valsalva sinuses was 50 +/- 4 mm (range, 42 to 62 mm). The David V modification was performed in the last 28 patients. Additional procedures were mitral valve repair in 6, tricuspid valve repair in 3, closure of septal atrial defect in 2, and closure of a patent foramen ovale in 13. Mean follow-up was 27 +/- 16 months (range, 1 to 61 months). RESULTS: There were no in-hospital deaths and no major adverse outcomes. One patient required implantation of a mechanical prosthesis during the same procedure because of moderate aortic regurgitation. One late death occurred. No patients required reoperation. In the last follow-up, 23 patients did not have aortic regurgitation, 12 had grade I, and 1 had grade II. No thromboembolic complications have been documented, and 97% of the patients are free from anticoagulation. CONCLUSIONS: Short-term and midterm results with the reimplantation technique for aortic root aneurysms in Marfan patients are excellent. If long-term results are similar, this technique could be the treatment of choice for these patients.

Staphylococcus aureus poststernotomy mediastinitis: description of two distinct acquisition pathways with different potential preventive approaches.

OBJECTIVE: Determining the acquisition routes of infection is crucial to designing specific preventive approaches against Staphylococcus aureus poststernotomy mediastinitis. METHODS: From 2002 to 2004, a nasal sample was obtained from patients before cardiac surgery. We collected clinical and microbiologic data of all episodes of S aureus poststernotomy mediastinitis. A case-control study (3:1) was performed to confirm the role of previous preoperative nasal colonization by S aureus as a risk factor for S aureus poststernotomy mediastinitis. Pulsed field gel electrophoresis molecular analysis of nasal and surgical site S aureus isolates was performed to analyze their relatedness in each patient with poststernotomy mediastinitis and with other patients of the study cohort. RESULTS: S aureus nasal cultures were positive in 228 (15.9%) of 1432 patients: methicillin-susceptible S aureus in 222 (15.5%) and meticillin-resistant S aureus in 6 (0.4%). S aureus poststernotomy mediastinitis was diagnosed in 17 (1.2%) of 1432 patients: 9 (3.95%) of 228 in colonized patients versus 8 (0.66%) of 1204 in noncolonized patients (P < .0001). Seven of 9 patients (1.2%) with methicillin-susceptible S aureus had an identical isolate by pulsed field gel electrophoresis in preoperative nasal and surgical-site cultures, but no clonal relatedness was shown among the isolates from these 9 patients. None of the 8 patients with methicillin-resistant S aureus poststernotomy mediastinitis had an identical isolate by pulsed field gel electrophoresis in preoperative nasal and surgical-site cultures, and the same clone of methicillin-resistant S aureus was responsible for all these cases. CONCLUSIONS: Endogenous [corrected] nasal colonization often precedes methicillin-resistant S aureus poststernotomy mediastinitis, which suggests that preoperative [corrected] decontamination is adequate for preventing methicillin-susceptible [corrected] S aureus poststernotomy mediastinitis, whereas hospital infection control measures seem to be the major factor for preventing methicillin-resistant S aureus poststernotomy mediastinitis.

[Aortic valve preservation in Marfan syndrome. Initial experience]. / Experiencia inicial con la preservación de la válvula aórtica en el síndrome de Marfan.

INTRODUCTION AND OBJECTIVES: Preservation of the aortic valve using the technique described by David has been shown to be as effective as the Bentall-De Bono procedure. It avoids both the need for long-term anticoagulation and the complications associated with mechanical prostheses. We report our initial experience using this technique in patients with Marfan syndrome. METHODS: Between April 2004 and April 2006, we used the David reimplantation technique in 40 patients with an aortic root aneurysm. Eighteen patients had Marfan syndrome. Their median age was 29 years (13-55 years). Echocardiography showed that the median diameter of the aortic sinus was 53 mm (46-59 mm). RESULTS: In 17 patients, aortic valve preservation was possible. No patient died during hospitalization and there were no significant complications. On echocardiography at discharge, no patient had greater than grade-II aortic regurgitation. During a median follow-up period of 8 months (1-24 months), one patient died due to rupture of an abdominal aneurysm. The others are all in New York Heart Association class I. CONCLUSIONS: Preservation of the aortic valve by means of valve reimplantation produced excellent results. It avoided both the thromboembolic and hemorrhagic complications associated with prostheses and the need for long-term anticoagulation. If reimplanted valves continue to function adequately over the long term, this technique should become the treatment of choice for aneurysms of the ascending aorta in patients with Marfan syndrome.

Experiencia inicial con la preservación de la válvula aórtica en el síndrome de Marfan / Aortic valve preservation in Marfan syndrome. Initial experience

Introducción y objetivos. La preservación de la válvula aórtica nativa descrita por David ha demostrado ser igual de eficaz que la técnica de Bentall-Bono, pero además evita la anticoagulación crónica y las complicaciones de las prótesis mecánicas. Presentamos nuestra experiencia inicial con esta técnica en pacientes con síndrome de Marfan. Métodos. Desde abril de 2004 hasta abril de 2006 se ha realizado la técnica de David en 40 pacientes con aneurisma de raíz de aorta. Dieciocho pacientes tenían síndrome de Marfan, con una mediana de edad de 29 años (intervalo, 13-55 años). En el estudio ecocardiográfico, la mediana del diámetro de los senos de Valsalva fue de 53 mm (intervalo, 46-59 mm). Resultados. En 17 pacientes se pudo preservar la válvula aórtica. No hubo mortalidad hospitalaria ni ninguna complicación reseñable. En el estudio ecocardiográfico previo al alta ningún paciente mostró una insuficiencia aórtica mayor de grado II. La mediana de seguimiento es de 8 meses (intervalo, 1-24 meses) y se ha producido una muerte por rotura de un aneurisma abdominal. El resto de los pacientes están en clase funcional I. Conclusiones. La preservación de la válvula aórtica mediante reimplante valvular ha mostrado unos resultados excelentes. Evita las complicaciones tromboembólicas y hemorrágicas derivadas de las prótesis y de la anticoagulación crónica. Si la válvula aórtica reimplantada mantiene una funcionalidad adecuada a largo plazo, debería convertirse en la técnica de elección en la cirugía de los aneurismas de aorta ascendente en el síndrome de Marfan (AU)

Introduction and objectives. Preservation of the aortic valve using the technique described by David has been shown to be as effective as the Bentall-De Bono procedure. It avoids both the need for long-term anticoagulation and the complications associated with mechanical prostheses. We report our initial experience using this technique in patients with Marfan syndrome. Methods. Between April 2004 and April 2006, we used the David reimplantation technique in 40 patients with an aortic root aneurysm. Eighteen patients had Marfan syndrome. Their median age was 29 years (13-55 years). Echocardiography showed that the median diameter of the aortic sinus was 53 mm (46-59 mm). Results. In 17 patients, aortic valve preservation was possible. No patient died during hospitalization and there were no significant complications. On echocardiography at discharge, no patient had greater than grade-II aortic regurgitation. During a median follow-up period of 8 months (1-24 months), one patient died due to rupture of an abdominal aneurysm. The others are all in New York Heart Association class I. Conclusions. Preservation of the aortic valve by means of valve reimplantation produced excellent results. It avoided both the thromboembolic and hemorrhagic complications associated with prostheses and the need for long-term anticoagulation. If reimplanted valves continue to function adequately over the long term, this technique should become the treatment of choice for aneurysms of the ascending aorta in patients with Marfan syndrome (AU)

Activation of peroxisome proliferator-activated receptor-alpha and -gamma in auricular tissue from heart failure patients.

OBJECTIVE: Peroxisome proliferator-activated receptors (PPARs), key transcriptional regulators of lipid and energy metabolism in cardiomyocytes, have recently been proposed to modulate cardiovascular pathophysiological responses in experimental models. However, there is little information about the functional activity of PPARs in human heart failure. AIMS: To investigate PPAR-alpha and -gamma expression and activity, and the association with ET-1 production and fibrosis, in cardiac biopsies from patients with end-stage heart failure due to ischemic cardiomyopathy (ICM) in comparison and from non-failing donor hearts. All samples were obtained during cardiac transplantation. METHODS AND RESULTS: Morphological analysis (by Masson trichrome and image analysis) did not detect fibrosis in the left atrium from non-failing donors (NFLA) or from ICM patients (FLA). However, left ventricles from failing hearts (FLV) contained a greater number of fibrotic areas (NFLA: 3.21+/-1.15, FLA: 1.63+/-0.83, FLV: 14.5+/-3.45%; n = 9, P<0.05). By RT-PCR, preproET-1 expression was similar in the non-failing and failing atrium but was significantly higher in the ventricles from failing hearts (NFLA: 1.00+/-0.06, FLA: 1.08+/-0.11, FLV: 1.74+/-0.19; n = 9, P<0.05). PPAR-alpha and PPAP-gamma mRNA (by RT-PCR) and protein (by Western blot) levels were higher in the ventricles from failing hearts compared with the atrium from failing and non-failing hearts. Electrophoretic mobility shift assays showed that PPAR-alpha and PPAP-gamma were not activated in the ventricles (NFLA: 1.00+/-0.11, FLA: 1.89+/-0.24, FLV: 0.95+/-0.07; n = 9, P<0.05). CONCLUSIONS: These data suggest that PPAR-alpha and PPAP-gamma are selectively activated in the atria from ICM patients and might be functionally important in the maintenance of atrial morphology.

Comparative evaluation of small-size Sorin Slimline and St. Jude HP heart valve prostheses.

BACKGROUND: The Sorin Slimline aortic valve prosthesis, a modification of the Sorin Bicarbon valve with increased internal orifice diameter and geometric orifice area, may show improved hemodynamic performance when compared with other previous prosthesis, but so far no comparison study has been reported. METHODS: Between May 1999 and March 2002, 80 patients (31 to 81 years of age; mean, 65 years) with a small aortic annulus were randomized to undergo aortic valve replacement with either the Sorin Slimline (n = 40) or St. Jude High Performance (n = 40) valve prosthesis. Clinical and echocardiographic Doppler follow-up was performed at 3 to 4 weeks, and 6 and 12 months postoperatively. RESULTS: One patient died of non-valve-related causes 9 months after operation. Mean and peak pressure gradients at 6 and 12 months in the Sorin Slimline valve were lower than in the St. Jude High Performance valve for both size 19 and 21 mm. Effective orifice area and effective orifice area index were not significantly different. There was a significant (p = 0.0001) reduction in left ventricular mass and left ventricular mass index between preoperative measurements and at 12 months after surgery for both valves, but there was no difference (p = 0.27) between the Sorin Slimline and St. Jude High Performance valve prosthesis at any other follow-up period. Clinical results showed similarly good results with both valves. CONCLUSIONS: No clinically significant difference in the hemodynamics of both valves was appreciated; patients with a Sorin Slimline valve exhibited statistically significantly lower pressure gradients, but the small differences in effective orifice area and effective orifice area index did not reach significance. A significant left ventricular mass regression was observed with both valve models. Both prostheses provided a satisfactory clinical outcome.

Left ventricular-coronary sinus/right ventricular fistula late after mitral valve replacement.

Development of an intracardiac fistula is a rare complication after mitral valve replacement. In the literature we have found six cases of left ventricular-coronary sinus fistula and another one of left ventricular-coronary sinus and right atrial fistula. We report the history and course of a patient in whom a left ventricular-coronary sinus and right ventricular fistula developed late after mitral valve replacement. The current study examines this type of intracardiac shunt, and presents our report on a left ventricular-coronary sinus and right ventricular fistula complication.

Impact of diltiazem administration and cyclosporine levels on the incidence of acute rejection in heart transplant patients.

To identify the clinical factors associated with acute rejection (AR) in the first year after heart transplantation (HT), we analysed 112 patients. All patients received OKT3 and standard triple-drug therapy. We analysed the following variables to determine their relationship with AR: age and gender, panel-reactive antibodies, HLA-DR mismatch, use of Sandimmune vs Neoral, diltiazem administration, and cyclosporine levels in week 2 and months 1, 2, and 3 after HT. Fifty-two patients had no AR and 49 had at least one episode. The variables independently associated with absence of AR were diltiazem administration (odds ratio 0.306, confidence limit 0.102-0.921) and cyclosporine level in the first month after HT (odds ratio 0.996, confidence limit 0.992-0.999). Furthermore, a cyclosporine level greater than 362 ng/ml in the first month predicted the absence of AR. In conclusion, a cyclosporine level greater than 362 ng/ml and diltiazem administration in the first month after HT reduce AR during the first year. Both cyclosporine level and diltiazem show a large and independent protective effect.

Reason for discrepancies in identifying myocardial viability by thallium-201 redistribution, magnetic resonance imaging, and dobutamine echocardiography.

Dobutamine echocardiography (DE), magnetic resonance imaging (MRI), and thallium redistribution (TS) are used to assess cardiac viability. However, these modalities sometimes yield contradictory results. Our aim was to establish the degrees of agreement among DE, MRI, and TS in identifying myocardial viability and to analyze the minimum critical mass of live (viable) cells required for each test to identify viability. A prospective study was done in which DE, MRI, and TS were consecutively performed in 10 ischemic patients scheduled for heart transplantation. The explanted heart was analyzed to quantify the amount of live cells per segment. The pathologic data were compared with the test results to analyze the minimum mass of viable cells required by each technique to identify viability. Mean age was 58 +/- 8 years (8 men). The mean ejection fraction was 0.27 +/- 0.04. Seven patients had severe cardiac failure (New York Heart Association functional class IV) and 6 patients had refractory angina. A total of 150 cardiac segments were analyzed. Among the 150 segments, 107 (71.3%) showed some degree of myocardial necrosis. Mean total area, mean fatty area, and mean necrotic area per segment were 2.53 +/- 0.7, 0.13 +/- 0.2, and 0.55+/-0.5 cm(2), respectively. As expected, a higher amount of necrotic tissue was found in nonviable segments. From the 150 segments, DE identified 90 as viable and 60 as nonviable. These data were similar to that of MRI (98 viable and 52 nonviable). A higher proportion of viable segments was found by TS (117 viable vs 33 nonviable). The concordance between DE and TS was only moderate (kappa 0.49). The agreement between MRI and TS also showed moderate concordance (kappa 0.56). The highest agreement was found between DE and MRI (kappa 0.73). Thus, discrepancies in assessing viability by DE, MRI, and TS may be due to differences in the minimum critical mass of live myocytes required by each technique to diagnose viability. Thallium requires a lesser amount of live tissue than DE or MRI to detect viability; also, its maximum diagnostic efficiency is obtained with lesser amounts of live tissue on each segment. These considerations should be taken into account when these diagnostic tests are used for the detection of viability before revascularization procedures.

Paravalvular leak and other events in silzone-coated mechanical heart valves: a report from AVERT.

BACKGROUND: The Artificial Valve Endocarditis Reduction Trial (AVERT) was designed to compare endocarditis rates in Silzone versus conventional valves. Recruitment ended January 21, 2000, because of higher rates of paravalvular leakage in patients receiving the Silzone prosthesis. The present analysis determined late event rates that might be used in the management of approximately 36,000 patients who have received the Silzone prosthesis. METHODS: A total of 807 patients in 19 centers in North America and Europe were randomized. Mean age was 61+/-11 years; 41% were women. Operations included aortic valve replacement in 59%, mitral valve replacement in 32%, and aortic and mitral valve replacements in 9%; 41% had concomitant operations (26% coronary artery bypass grafting). RESULTS: Major paravalvular leakage (followed by repair, explant, or mortality) occurred in 18 of 403 patients receiving Silzone valves and 4 of 404 patients without Silzone valves (2-year event-free rates: 91.1% versus 98.9% conventional, p < 0.003). Similarly, 2-year freedom from any explant was lower in the Silzone arm (19 versus 2 events; 90.1% versus 99.4%, p = 0.0002). Rates of mortality and stroke were similar during follow-up. CONCLUSIONS: Continued follow-up of AVERT supports the conclusion that the Silzone prosthesis has increased risk of paravalvular leakage requiring reoperation. Overall survival is similar in the two groups.

Assessment of cardiac viability by thallium 201 redistribution and dobutamine echocardiography.

OBJECTIVE: Dobutamine echocardiography and thalium 201 are useful in the assessment of myocardial viability, but both techniques frequently yield conflicting results. The objective of this study was to determine the minimum mass of viable myocardium that each test could detect and compare the agreement of dobutamine echocardiography and thallium 201 to detect viability. METHODS: Dobutamine echocardiography and thallium 201 were performed in 10 patients scheduled for cardiac transplantation. In each patient, 15 segments were studied. After transplantation these segments were analyzed by the pathologist measuring by a computer system the total area of each segment, the necrotic + fatty mass, and area (%) of viable myocytes per segment. The percentage of viable tissue was estimated ([Total mass - (Necrotic + Fatty tissue)]/Total mass x 100) on each segment, which was compared with the result (viable or not viable) obtained by echocardiography or thallium 201. RESULTS: Dobutamine echocardiography defined 90 segments (60%) as viable versus 117 (78%) in thallium (kappa 0.49, 95% CI 0.36-0.63). The minimum percent of viable tissue per segment defined as viable by thallium was 43% versus 49% by echocardiography. With use of thallium, the highest accuracy of the test to detect viability was when the percent of necrotic tissue of the segment analyzed was 40% (positive and negative likelihood ratio 2.2 and 3.6, respectively). By use of echocardiography, the highest accuracy of the test was observed when the percent of necrotic tissue of the segment analyzed was 31% (positive and negative likelihood ratio 5.5 and 7.7, respectively). CONCLUSION: The discrepant results of dobutamine echocardiography and thallium 201 are due to differences in the minimum mass of live myocytes required by each technique to detect viability.

Incidencia y comportamiento dinámico del contraste ecocardiográfico espontáneo y del trombo auricular en el corazón trasplantado / Incidence and Dynamic Nature of Spontaneous Echocardiographic Contrast and Atrial Thrombi in Heart Transplantation

Introducción. La técnica de Lower y Shumway en el trasplante cardíaco produce importantes alteraciones en la anatomía y función auricular incrementando el riesgo de trombosis. Este estudio analiza la prevalencia y la evolución del contraste ecocardiográfico espontáneo, del trombo auricular y de los fenómenos embólicos. Pacientes y método. Se han analizado 52 pacientes trasplantados mediante ecocardiografía transtorácica y transesofágica y se ha efectuado un estudio hemodinámico a los 15 días y al año del trasplante. Resultados. Se encontró contraste ecocardiográfico espontáneo en 27 pacientes (52 por ciento) y trombos auriculares en 10 (19,2 por ciento), en nueve acompañados de contraste ecocardiográfico espontáneo. Un total de 6 trombos auriculares aparecieron a los 15 días y cuatro lo hicieron al año de evolución (todos ellos con contraste ecocardiográfico espontáneo en el estudio inicial). En el análisis multivariante, el tamaño auricular fue el único factor predictor independiente en la formación de contraste ecocardiográfico espontáneo (OR = 1,27; IC del 95 por ciento, 1,09-1,54) y un importante predictor en la génesis del trombo auricular (OR = 1,19; IC del 95 por ciento, 1,04-1,42). Así mismo, el principal predictor de la trombosis auricular fue la presencia de contraste ecocardiográfico espontáneo (OR = 116; IC del 95 por ciento, 8,4-999). El perfil hemodinámico no predijo la presencia de contraste ecocardiográfico espontáneo ni de trombo auricular. La incidencia global de embolias fue del 4 por ciento. Conclusiones. La incidencia de trombo auricular es del 19,2 por ciento y la de contraste ecocardiográfico espontáneo del 52 por ciento. El gran tamaño auricular y/o el contraste ecocardiográfico espontáneo incrementan el riesgo de trombosis auricular. Se recomienda efectuar ecocardiogramas transesofágicos periódicos tras el trasplante, dado el carácter dinámico de la formación del contraste ecocardiográfico espontáneo y del trombo auricular (AU)

Cirugía de reconstrucción del cuerpo fribroso intervalvular en la endocarditis infecciosa activa / Surgical Reconstruction of Fibrous Body Destruction in Active Infective Endocarditis

Introducción y objetivos. La cirugía en la endocarditis infecciosa activa, con múltiples abscesos y destrucción del cuerpo fibroso intervalvular, presenta la mayor morbimortalidad en una enfermedad de muy alto riesgo quirúrgico. Como alternativa a la cirugía convencional presentamos nuestra experiencia con una técnica novedosa más radical, cuya base es la resección completa de todas las estructuras afectadas y reconstrucción posterior con pericardio. Métodos. Seis pacientes intervenidos en los dos últimos años con endocarditis infecciosa activa y abscesos paravalvulares que destruían la unión mitroaórtica (en cinco la infección asentaba sobre prótesis). La sepsis persistente a pesar de tratamiento antibiótico adecuado fue la indicación quirúrgica en 5 pacientes, y la insuficiencia cardíaca en un paciente. Tras una amplia resección de los abscesos de la unión mitroaórtica se reconstruyó el cuerpo fibroso con pericardio bovino fijado en glutaraldehído. Resultados. No hubo mortalidad hospitalaria. La mediana de los tiempos de circulación extracorpórea y de clampaje fue de 198 y 174 min. Un paciente desarrolló bloqueo auriculoventricular completo requiriendo implantación de marcapasos definitivo. En todos se realizó control ecocardiográfico previo al alta, no observándose dehiscencias en el parche ni fugas paravalvulares. Con un seguimiento medio de 15 meses no se han producido muertes tardías, recidivas ni complicaciones mayores. Conclusiones. La resección de la unión mitroaórtica y de los abscesos perivalvulares, y la posterior reconstrucción con pericardio bovino, es una técnica factible y radical, ya que se reseca toda la zona afectada por la infección, con lo que evitarían la recidiva y las fugas perivalvulares (AU)

Resultados precoces de la ventriculectomía parcial izquierda (operación de batista) / Early results with partial left ventriculectomy (the Batista operation)

Introducción y objetivos. La escasez de donantes así como la morbimortalidad asociada al trasplante han motivado el planteamiento de otras opciones quirúrgicas para la miocardiopatía dilatada en fase terminal. Entre ellas se encuentra la ventriculectomía parcial izquierda, que implica la reducción del diámetro y la masa ventricular. Presentamos en este trabajo la experiencia inicial (no limitada a la alternativa al trasplante) y los resultados inmediatos de esta técnica en nuestro centro. Métodos. Hemos intervenido a 6 pacientes con miocardiopatía dilatada: cuatro de etiología idiopática y con motivos de exclusión para trasplante cardíaco y dos de origen valvular. Se practicó resección de la pared lateral de ventrículo izquierdo entre los músculos papilares y cierre directo con sutura continua, asociándose anuloplastia mitral en 5 casos, tricuspídea en uno y sustitución valvular aórtica en los dos últimos. Resultados. Dos pacientes precisaron balón de contrapulsación; uno falleció por shock cardiogénico refractario y el otro a los 15 días tras episodios de arritmia ventricular. Los estudios ecocardiográficos intraoperatorios pusieron de manifiesto una reducción significativa del diámetro diastólico (de 8,7 a 6,8 cm; p = 0,02) y de la insuficiencia mitral, con una mejoría en la fracción de eyección (del 17 al 27 por ciento; p = 0,09) mantenidos en el ecocardiograma previo al alta. Conclusiones. La técnica es reproducible y adecuada como posibilidad terapéutica en la insuficiencia cardíaca en fase terminal. Quedan por precisar el grupo y tipo de paciente ideal, el manejo perioperatorio y el soporte a largo plazo (AU)