Patients with aortic stenosis referred for TAVI: treatment decision, in-hospital outcome and determinants of survival.

AIMS: To assess treatment decision and outcome in patients referred for transcatheter aortic valve implantation (TAVI) in addition to predictive factors of mortality after TAVI. METHODS: Three-centre prospective observational study including 358 patients. Endpoints were defined according to the Valve Academic Research Consortium. RESULTS: Of the 358 patients referred for TAVI, TAVI was performed in 235 patients (65%), surgical aortic valve replacement (AVR) in 24 (7%) and medical therapy (MT) in 99 (28%). Reasons to decline TAVI in favour of AVR/MT were patient preference (29%), peripheral vascular disease (15%) and non-severe aortic stenosis (11%). The logistic EuroSCORE was significantly higher in patients who underwent TAVI and MT in comparison with those undergoing AVR (19 vs. 10%, p = 0.007). At 30 days, all-cause mortality and the combined safety endpoint were 9 and 24% after TAVI and 8 and 25% after AVR, respectively. All-cause mortality was significantly lower in the TAVI group compared with the MT group at 6 months, 1 year and 2 years (12% vs. 22%, 21% vs. 33% and 31% vs. 55%, respectively, p < 0.001). Multivariable analysis revealed that blood transfusion (HR: 1.19; 95% CI: 1.05-1.33), pre-existing renal failure (HR: 1.18; 95% CI: 1.06-1.33) and STS score (HR: 1.06; 95% CI: 1.02-1.10) were independent predictors of mortality at a median of 10 (IQR: 3-23) months after TAVI. CONCLUSIONS: Approximately two-thirds of the patients referred for TAVI receive this treatment with gratifying short- and long-term survival. Another 7% underwent AVR. Prognosis is poor in patients who do not receive valve replacement therapy.

Neurocisticercosis en niños costarricenses: experiencia clínica e importancia de la vigilancia epidemiológica / Neurocysticercosis in Costa Rica children: clinical experience and the importance of epidemiological surveillance

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Endovascular treatment of aortic dissections and thoracic aortic aneurysms.

Diseases of the thoracic aorta pose a significant challenge to the surgeon because of the complexity of the disease and the characteristics of the patient population. Frequent comorbidities and increasing age account for mortality rates between 5% and 20% for surgical repair of descending thoracic aortic aneurysms and in excess of 50% for Stanford type B aortic dissections, when complicated by preoperative end-organ ischemia. Endovascular techniques of fenestration, stenting, and stent-grafting have emerged as viable alternatives to conventional surgery in these patients. The authors review their experience using endovascular stent-grafts in the treatment of 103 patients with descending thoracic aortic aneurysms and 19 patients with acute aortic dissections. Fenestration and stenting are also addressed as adjuvant therapies in the treatment of complicated aortic dissections. Actuarial survival for aneurysms was 81% +/- 5% at 1 year and 73% +/- 5% at 2 years. Stent-grafting for acute aortic dissections achieved instant relief of symptoms in 71% of cases with an early procedural mortality of 16%, and endovascular revascularization of ischemic beds was achieved in 93% +/- 4% of cases of peripheral or visceral ischemia. The authors' experience supports the use of endovascular techniques in the treatment of thoracic aortic pathologic conditions. Longer follow-up and results of ongoing trials that use newer devices will help define the indications for their future use.

Retinoic acid suppresses intimal hyperplasia and prevents vessel remodeling following arterial injury.

Vitamin A and its derivatives (retinoids) are capable of inhibiting vascular smooth muscle cell proliferation in vitro. The present study examines the effect of two retinoids, all-trans retinoic acid and 13-cis retinoic acid, on intimal hyperplasia following arterial injury. After receiving varying doses of all-trans retinoic acid or 13-cis retinoic acid, 78 male Sprague-Dawley rats underwent standard balloon catheter denudation of the left common carotid artery. Morphometric analysis and immunohistochemistry for proliferating cell nuclear antigen was performed at early and late time points. Intimal/medial ratios were reduced in a dose-dependent fashion for animals treated with all-trans retinoic acid (P = 0.001) and 13-cis retinoic acid (P = 0.004). Proliferating cell nuclear antigen labeling indices were reduced after treatment with all-trans retinoic acid and 13-cis retinoic acid at early time points post-injury. At a dose of 10 mg/kg, both all-trans retinoic acid and 13-cis retinoic acid inhibited vessel remodeling as measured by increases in luminal diameter (P < 0.05) and external elastic lamina (P < 0.05). Retinoids are an attractive clinical option for the treatment of restenosis following angioplasty and arterial surgery.

"Bow-tie" mitral valve repair: an adjuvant technique for ischemic mitral regurgitation.

BACKGROUND: Current techniques of mitral valve repair rely on decreasing valve area to increase leaflet apposition, but fail to address subvalvular dysfunction. A novel repair has been introduced with partial left ventriculectomy, which apposes the anterior leaflet to a corresponding point on the posterior leaflet creating a double-orifice valve, with reported adequate control of mitral regurgitation. METHODS: We started to use the "bow-tie" repair as an adjunct to posterior ring annuloplasty in cases in which mitral regurgitation was not adequately controlled by decreasing mitral valve area (n = 6), or when placement of an annuloplasty ring was impractical (n = 4). Mean follow-up was 336 days (range, 82 to 551 days) with no postoperative deaths. RESULTS: Mitral regurgitation decreased from 3.6+/-0.5 to 0.8+/-0.4 (p < 0.0001), with a concomitant increase in ejection fraction from 33%+/-13% to 45%+/-11% (p = 0.0156) before hospital discharge. Mitral valve area, measured by pressure half-time, decreased from a mean of 2.5+/-0.3 to 2.1+/-0.3 cm2, with a mean transvalvular gradient of 4.5+/-2.0 mm Hg. In patients whose mitral valve was repaired using the bow-tie alone, mitral regurgitation was reduced from 4+, to a trace to 1+. Postoperatively, mitral valve area increased from 1.9 to 2.5 cm2 during exercise, further supporting the concept that this technique preserves mitral valve annular function. CONCLUSIONS: These observations suggest that the bow-tie repair may offer advantages over conventional techniques of mitral valve repair and should be considered as an adjunct, especially in patients with impaired left ventricular function.

Implantable left ventricular assist devices provide an excellent outpatient bridge to transplantation and recovery.

OBJECTIVES: Our recent experience with outpatient left ventricular assist device (LVAD) support is presented to demonstrate the possibilities and limitations of long-term outpatient mechanical circulatory assistance. BACKGROUND: The experience with inpatient LVAD support as a bridge to transplantation has proved the efficacy of such therapy in improving circulatory hemodynamic status, restoring normal end-organ function and facilitating patient rehabilitation. With miniaturization of the power supplies and controllers, such mechanical circulatory support can now be accomplished in an outpatient setting. METHODS: Between March 1993 and February 1997, 32 patients (26 male, 6 female, mean [+/-SEM] age 49 +/- 15 years) underwent implantation of the ThermoCardiosystems (TCI) Heartmate vented electric (VE) LVAD. The VE LVAD is powered by batteries worn on shoulder holsters and is operated by a belt-mounted system controller, allowing unrestricted patient ambulation and hospital discharge. RESULTS: Mean duration of support was 122 +/- 26 days (range 3 to 605), with a survival rate to transplantation or explantation of 78%. Nineteen patients were discharged from the hospital on mean postoperative day 41 +/- 4 (range 17 to 68), for an outpatient support time of 108 +/- 30 days (range 2 to 466). Four patients underwent early transplantation and could not participate in the discharge program, and three patients currently await discharge. The complication rate was not statistically different from that encountered in our previous 52 patients with a pneumatic LVAD. CONCLUSIONS: Outpatient LVAD support is safe and provides improved quality of life for patients awaiting transplantation. Wearable and totally implantable LVADs should be studied as permanent treatment options for patients who are not candidates for heart transplantation.

Mechanical unloading with a miniature in-line axial flow pump as an alternative to cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) causes a well described systemic inflammatory response. To avoid these potential detrimental effects, coronary artery bypass grafting (CABG) has been attempted off CPB on the beating heart. With the use of a left ventricular (LV) assist device during CABG, the heart can be made flaccid with beta-blockade, and the systemic circulation can continue to be supported. The hemodynamic and hematologic consequences of left heart bypass with a miniature axial flow pump were studied in a sheep CABG model. The pump weighs 45 g and was connected to standard venous and arterial cannulas. Left sided inflow and brachiocephalic outflow were employed. A pump speed of 14,000 rpm resulted in a flow of 5.63 +/- 0.18 L/min and provided 75% of the LV output during a 2 hr pump run. This resulted in complete capture of the aortic pressure tracing (mean 56.3 mmHg) with a 15.5 mmHg augmentation in the esmolol depressed ventricle. Reductions in LV end diastolic pressure and LV end systolic pressure resulted in a 66% reduction in LV external work under baseline conditions and an 83% reduction in the beta-blocked ventricle. Myocardial oxygen demand was reduced 16% after axial flow unloading in the esmolol depressed condition. Right ventricular pressures, pulmonary artery flow, LV filling, and oxygenation were adequate in the esmolol depressed animal and remained unchanged throughout the experiment. No changes in hematocrit, total bilirubin, lactate dehydrogenase, or plasma free hemoglobin were detected after 2 hr of assist. Axial flow left heart bypass results in acceptable hemodynamics with no hemolysis and may provide an alternative to CPB during CABG.

Improved results for postcardiotomy cardiogenic shock with the use of implantable left ventricular assist devices.

BACKGROUND: Over the past decade, the use of mechanical circulatory support in patients with postcardiotomy cardiogenic shock has resulted in hospital discharge rates of 25% to 40%. In an attempt to improve patient survival, we initiated a program of early insertion of an implantable Thermocardiosystems Incorporated Heartmate left ventricular assist device in patients who have circulatory failure after having undergone high-risk cardiac operations. METHODS: Between April 1993 and February 1997, 12 patients underwent insertion of an implantable left ventricular assist device for postcardiotomy cardiogenic shock after coronary artery bypass grafting. Indications for insertion included postoperative cardiogenic shock (7 patients), postoperative cardiac arrest (3 patients), and failure to wean from cardiopulmonary bypass (2 patients). RESULTS: The median time to device insertion was 3.5 days. The mean duration of left ventricular assist device support was 103 +/- 19 days (range, 2 to 225 days). Nine of 11 patients (82%) survived to undergo either transplantation (8 patients) or explantation (1 patient), with successful hospital discharge of all 9 patients. The major complication was device-related infection (42%). A single thromboembolism occurred in a patient with an infection. CONCLUSIONS: Long-term outcome after postcardiotomy cardiogenic shock is improved substantially with the use of an implantable left ventricular assist device early in the postoperative course. Access to such a device is an important consideration before undertaking a high-risk cardiac operation, and early implantation of the device is a critical factor in ensuring long-term survival.