Coronary Bypass in an Adolescent With Systemic Lupus Erythematosus and Acute Coronary Syndrome.

A 12-year-old female with active pediatric juvenile systemic lupus erythematosus presented to the emergency department because of episodes of oppressive central thoracic pain associated with pallor, sweating, and muscle weakness that persisted for >30 minutes. During the last episode, the electrocardiogram revealed alterations in cardiac repolarization coincident with progressive troponin T elevation. An angio computed tomography revealed a 20 mm long complete segmental obstruction of the proximal anterior descending artery that was confirmed by angiography. Because this extensive occlusion did not permit a noninvasive procedure, an off-pump coronary bypass of the internal mammary artery to the anterior descending artery was performed without complication. Six months after the procedure, myocardial function was good. To our knowledge, this is the first case report of an adolescent girl with acute coronary syndrome complicating juvenile systemic lupus erythematosus that was treated with a surgical procedure.

Isolated aortic valve replacement in Spain: national trends in risks, valve types, and mortality from 1998 to 2017.

INTRODUCTION AND OBJECTIVES: To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses. METHODS: We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period. RESULTS: In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P <.001). In-hospital mortality decreased from 7.2% to 3.3% (P <.001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P <.001). CONCLUSIONS: We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced.

Pulmonary regurgitation after repaired tetralogy of Fallot: surgical versus percutaneous treatment.

Pulmonary regurgitation is the most important sequellae after correction of Tetralogy of Fallot and has a considerable impact over the right ventricle. Surgery has demonstrated low early mortality after pulmonary valve replacement and good long-term outcomes, remaining nowadays the gold standard treatment of pulmonary regurgitation in rTOF patients. Nevertheless, transcatheter pulmonary valve implantation has emerged as a new, safe and efficient alternative to surgical valve replacement. In this review article, we try to evaluate and compare both techniques to find out which is the best therapeutic option in this patients.

La insuficiencia aórtica en las asistencias ventriculares mecánicas de larga duración y flujo continuo: reto diagnóstico y terapéutico / Aortic regurgitation in continuous flow left ventricular assist devices for long-term use: a diagnostic and therapeutic challenge

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Sarcoma sinovial pericárdico primario: un reto clínico / Primary pericardial synovial sarcoma. A clinical challenge

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Ascending aorta reinterventions.

Ascending aorta reinterventions present a challenge for surgeons as the technical difficulties of the procedure and the complex strategic approach can complicate successful treatment. These patients should be treated by surgical teams with ample experience in aortic diseases as they can be at high risk of mortality. The number of interventions on the ascending aorta and aortic arch and the use of biological conducts (lung autograft, homograft, etc.) have increased in recent years; therefore, the number of reinterventions can also be expected to increase, representing 10% of aortic surgical procedures. This article reviews the current status of ascending aorta reinterventions, analyzing the principal aspects of indication and surgical strategy, as well as the results published in the largest studies.

Systolic flow displacement using 3D magnetic resonance imaging in an experimental model of ascending aorta aneurysm: impact of rheological factors.

OBJECTIVES: The impact of systolic flow displacement on the development and progression of ascending aorta dilatation in aortic valve disease is a matter of controversy. Our objective was to study the association between rheological stimuli and development of aortic dilatation in a large animal model of supravalvular aortic stenosis and eccentric flow. METHODS: Twenty-four pigs weighing 10-14 kg were randomly allocated (ratio 2:1) to either restrictive ascending aortic banding or sham operation. Aortic diameter and systolic flow displacement were assessed by three-dimensional phase-contrast magnetic resonance imaging at 6 and 18 weeks after surgery. Twenty pigs (n = 14, banded vs n = 6, sham) completed full imaging protocol and were included in the analysis. After the last follow-up, a subset of 14 animals was sacrificed for histological analysis. RESULTS: All banded animals developed significant progressive aortic dilatation both at 6 and 18 weeks, compared with sham-operated pigs: 34.3 ± 4.8 vs 21.4 ± 2.7 mm at 6 weeks (P < 0.001); and 50.0 ± 8.4 vs 38.0 ± 8.3 mm at 18 weeks (P = 0.002). The peak gradient at 6 weeks showed a trend to positively correlate with aortic diameter at 18 weeks (R = 0.50, P = 0.06), whereas the systolic flow displacement at 6 weeks correlated better with aortic diameter at 18 weeks (R = 0.59, P = 0.02). The aortic wall thickness was significantly decreased in the anterior aortic section in banded, compared with sham-operated, pigs (1.5 ± 0.4 vs 2.0 ± 0.1 mm, respectively; P = 0.03). In addition, banded pigs showed a higher degree of cystic medial necrosis and elastin fibre fragmentation, compared with sham-operated animals. CONCLUSIONS: In this preclinical model of supravalvular aortic stenosis and eccentric flow, we found that systolic flow displacement at earlier stages is positively correlated with the degree of aortic dilatation during follow-up as assessed by three-dimensional phase-contrast magnetic resonance imaging. If our findings are confirmed in further studies, this imaging parameter might be useful to identify those subjects with aortic valve disease who are at risk of developing aortic dilatation at a later stage.

Validation of EuroSCORE II on a single-centre 3800 patient cohort.

OBJECTIVES: To compare and validate the new European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with EuroSCORE at our institution. METHODS: The logistic EuroSCORE and EuroSCORE II were calculated on the entire patient cohort undergoing major cardiac surgery at our centre between January 2005 and December 2010. The goodness of fit was compared by means of the Hosmer-Lemeshow (HL) chi-squared test and the area under the curve (AUC) of the receiver operating characteristic curves of both scales applied to the same sample of patients. These analyses were repeated and stratified by the type of surgery. RESULTS: Mortality of 5.66% was observed, with estimated mortalities according to logistic EuroSCORE and EuroSCORE II of 9 and 4.46%, respectively. The AUC for EuroSCORE (0.82, 95% confidence interval [CI] 0.79-0.85) was lower than that for EuroSCORE II (0.85, 95% CI 0.83-0.87) without the differences being statistically significant (P = 0.056). Both scales showed a good discriminative capacity for all the pathologies subgroups. The two scales showed poor calibration in the sample: EuroSCORE (χ(2) = 39.3, P(HL) < 0.001) and EuroSCORE II (χ(2) = 86.69, P(HL) < 0.001). The calibration of EuroSCORE was poor in the groups of patients undergoing coronary (P(HL) = 0.01), valve (P(HL) = 0.01) and combined coronary valve surgery (P(HL) = 0.012); and that of EuroSCORE II in the group of coronary (P(HL) = 0.001) and valve surgery (P(HL) < 0.001) patients. CONCLUSIONS: EuroSCORE II demonstrated good discriminative capacity and poor calibration in the patients undergoing major cardiac surgery at our centre.

Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stent.

OBJECTIVE: An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery. METHODS: A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Cox's proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events. RESULTS: A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08-48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29-5.756] and MACEs (HR 2.784, 95% CI 1.962-3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319-6.21) and MACEs (HR 2.89, 95% CI 2.008-4.158). CONCLUSIONS: Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main complex coronary disease.

OBJECTIVE: The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events. METHODS: All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders. RESULTS: A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively). CONCLUSIONS: SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.

Clinical outcomes with off-pump coronary surgery after angioplasty with stent.

INTRODUCTION AND OBJECTIVES: The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. METHODS: Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization). RESULTS: In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34). CONCLUSIONS: In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Resultados de la cirugía coronaria sin circulación extracopórea tras angioplastia con stent / Clinical outcomes with off-pump coronary surgery after angioplasty with stent

Introducción y objetivos. Evaluar el impacto de la implantación de stents coronarios previa a la cirugía de revascularización miocárdica en los resultados postoperatorios de ésta. Métodos. Desde enero de 2005 hasta abril de 2008, se evaluó retrospectivamente el impacto de la implantación de stents coronarios previa a la cirugía coronaria sin circulación extracorpórea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 días o ingreso hospitalario postoperatorios). Resultados. Se sometió a 796 pacientes consecutivos a revascularización miocárdica quirúrgica; 116 (14,6%) portaban algún stent coronario en el momento de la cirugía. Los grupos con stent y sin stent tenían un perfil de riesgo similar (EuroSCORE). En el análisis multivariable, ajustando el riesgo por las variables de confusión detectadas (fracción de eyección del ventrículo izquierdo preoperatoria < 40%, estado crítico preoperatorio, edad, antecedentes de accidente cerebrovascular agudo, infarto miocárdico agudo previo reciente, número de vasos coronarios enfermos, revascularización quirúrgica incompleta y conversión a circulación extracorpórea) se detectó que el ser portador de stent se asociaba de forma significativa a un mayor riesgo de infarto miocárdico postoperatorio (RR = 3,13; intervalo de confianza [IC] del 95%, 1,75-5,96), mortalidad cardiaca hospitalaria (RR = 4,62; IC del 95%, 1,76-12,11) y mortalidad hospitalaria por todas las causas (RR = 3,65; IC del 95%, 1,6-8,34). Conclusiones. En nuestra experiencia, la implantación previa de stents coronarios se asocia a un mayor riesgo de infarto miocárdico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugía coronaria (AU)

Introduction and Objectives. The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. Methods. Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (ie, at 30 days or during postoperative hospitalization). Results. In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (ie, EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (ie, preoperative left ventricular ejection fraction <40 critical preoperative state age history of cerebrovascular accident recent acute myocardial infarction number diseased coronary vessels incomplete revascularization and on-pump conversion showed that the presence a stent was significantly associated with increased risks postoperative relative risk rr="3.65;" 95 confidence interval ci 1 75-5 96 in-hospital cardiac mortality 76-12 11 all-cause 60-8 34 conclusions in our experience artery implantation prior to surgery period inhospital (AU)

Short-term and mid-term follow-up of sutureless surgery for postinfarction subacute free wall rupture.

We report our short-term and mid-term results with sutureless repair of postinfarction subacute left ventricular free wall rupture (LVFWR). For this purpose, we evaluated the short-term and mid-term postoperative results assessed by clinical examination and echocardiography of all patients who underwent surgery for subacute LVFWR between January 2004 and January 2009. Twenty-one patients were operated. Direct suture repair of LVFWR was carried out in only one patient. In all other cases we used a pericardial patch with biological glue. Early mortality was 19% (n=4). The median duration of follow-up was 17.3 months (interquartile range, 5-38.7), with a 13-month survival of 76%. Follow-up echocardiography showed no constriction associated with the rupture zone in any patient. According to our early experience, sutureless LVFWR repair is safe, effective and reproducible, and offers acceptable morbidity and mortality during follow-up.