La degeneración real de la prótesis aórtica Mitroflow: análisis con riesgos competitivos / Real structural valve deterioration of the mitroflow aortic prosthesis: competing risk analysis

Introducción y objetivos: La prótesis aórtica Mitroflow es una válvula de pericardio bovino especialmente diseñada para aumentar el área valvular. Hay controversia en relación con su patrón de degeneración estructural valvular (DEV). El objetivo es conocer la incidencia acumulada de DEV, los factores que influyen en su aparición y su impacto sobre la mortalidad. Métodos: Se siguió a 1.028 pacientes clínica y ecocardiográficamente. Puesto que se trata de una población cardiópata y anciana, se realizó un análisis de riesgos competitivos. Resultados: El porcentaje de DEV a los 5 años fue 4,22% (IC95%, 2,96-5,81) y a los 8 años 15,77% (IC95%, 12,46-19,43). La incidencia fue superior para las válvulas de tamaños pequeños (19 y 21 mm). A los 5 años llegó al 6,43% (IC95%, 4,48-8,84) y a los 8 años al 20,06% (IC95%, 15,53-25,01). El desajuste paciente-prótesis (DPP) grave influyó en la incidencia de DEV (sHR = 3,53; IC95%, 2,20-5,66; p < 0,001). Sin embargo, el DPP moderado no tuvo ningún impacto. La presencia de DEV fue el mayor predictor de mortalidad (HR = 4,59; IC95%, 2,91-7,22; p < 0,001). Conclusiones: Utilizando una definición basada en el aumento del gradiente transprotésico, la incidencia de DEV de la prótesis Mitroflow es superior a la indicada por otras series, especialmente para las de tamaños pequeños (19 y 21 mm) o en pacientes con DPP grave. Aumenta exponencialmente a partir del quinto año y desde que se diagnostica aumenta por 4,5 el riesgo de muerte (AU)

Introduction and objectives: The Mitroflow aortic prosthesis is a bovine pericardial bioprosthesis specially designed to increase the valve area in relation to its size. There is controversy regarding the pattern of structural valve deterioration (SVD). Our aim was to determine the cumulative incidence of SVD, risk factors influencing its occurrence, and its impact on mortality. Methods: A total of 1028 patients were clinically and echocardiographically followed up. Because the study population was elderly and had heart disease, we used a competing risk analysis. Results: The percentage of patients with SVD at 5 years was 4.22% (95%CI, 2.96-5.81) and was 15.77% at 8 years (95%CI, 12.46-19.43). The incidence was higher for small valves (19 mm and 21 mm) reaching 6.43% at 5 years (95%CI, 4.48-8.84) and 20.06% at 8 years (95%CI, 15.53-25.01). Severe patient-prosthesis mismatch (PPM) influenced the incidence of SVD (sHR, 3.53; 95%CI, 2.20-5.66; P < .001) but moderate PPM had no impact. The most powerful predictor of mortality was the presence of SVD (HR, 4.59; 95%CI, 2.91-7.22; P < .001). Conclusions: This study used a definition based on the increase in the transprosthetic gradient and found a higher incidence of SVD of the Mitroflow prosthesis than that reported by other series, especially for sizes 19 mm and 21 mm and in patients with severe PPM. The incidence of SVD increased exponentially from the fifth year after implantation and its occurrence led to a 4.5-fold increase in the risk of death (AU)

Real Structural Valve Deterioration of the Mitroflow Aortic Prosthesis: Competing Risk Analysis.

INTRODUCTION AND OBJECTIVES: The Mitroflow aortic prosthesis is a bovine pericardial bioprosthesis specially designed to increase the valve area in relation to its size. There is controversy regarding the pattern of structural valve deterioration (SVD). Our aim was to determine the cumulative incidence of SVD, risk factors influencing its occurrence, and its impact on mortality. METHODS: A total of 1028 patients were clinically and echocardiographically followed up. Because the study population was elderly and had heart disease, we used a competing risk analysis. RESULTS: The percentage of patients with SVD at 5 years was 4.22% (95%CI, 2.96-5.81) and was 15.77% at 8 years (95%CI, 12.46-19.43). The incidence was higher for small valves (19mm and 21mm) reaching 6.43% at 5 years (95%CI, 4.48-8.84) and 20.06% at 8 years (95%CI, 15.53-25.01). Severe patient-prosthesis mismatch (PPM) influenced the incidence of SVD (sHR, 3.53; 95%CI, 2.20-5.66; P < .001) but moderate PPM had no impact. The most powerful predictor of mortality was the presence of SVD (HR, 4.59; 95%CI, 2.91-7.22; P < .001). CONCLUSIONS: This study used a definition based on the increase in the transprosthetic gradient and found a higher incidence of SVD of the Mitroflow prosthesis than that reported by other series, especially for sizes 19mm and 21mm and in patients with severe PPM. The incidence of SVD increased exponentially from the fifth year after implantation and its occurrence led to a 4.5-fold increase in the risk of death.

Insuficiente control de parámetros lipídicos en pacientes con enfermedad coronaria: un problema por resolver / Insufficient lipid control in patients with coronary artery disease: An unresolved problem

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Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center.

INTRODUCTION: Primary cardiac tumors are rare entities with an autopsy frequency ranging between 0.001% and 0.3%. Our objective was to review 32 years of experience from a Spanish tertiary surgical center. METHOD: We collected data on 73 patients with a histopathological diagnosis of a primary cardiac tumor in a retrospective analysis from 1979 to 2012. Tissue samples were obtained either at surgery or from necropsy and subsequently divided into benign and malignant groups. RESULTS: Benign neoplasms accounted for 84.9% of cases. The average age at diagnosis was 61 years, and tumors were twice as frequent among women. It was an incidental finding in one quarter of patients. In symptomatic patients, the typical presentation was of cardioembolic stroke or of congestive symptoms. Myxoma (93.5%) was the most common diagnosis, typically affecting the left atrium (74.2%). Surgical resection was curative for 95% of these patients. Malignant tumors represented 15.1% of cases with an average age at diagnosis of 50 years. Over 90% of these patients were symptomatic at presentation with the cardinal symptom being heart failure. Undifferentiated sarcoma was the most frequent malignant tumor (36.4%). Less than 20% of patients were alive 1 year after diagnosis despite the treatment. CONCLUSIONS: In our study, primary cardiac tumors were insidious. The most common was left atrial myxoma in which surgical resection was considered curative. Undifferentiated sarcoma was the most frequent malignant tumor. Malignant neoplasms carried a worse prognosis with unsuccessful total excision and the presence of metastatic disease being markers of an adverse outcome.

Left ventricle non-compaction cardiomyopathy: Different clinical scenarios and magnetic resonance imaging findings / Miocardiopatía no compactada: diferentes escenarios clínicos y hallazgos en cardiorresonancia magnética

Left ventricle non-compaction cardiomyopathy is currently considered as a well-defined individual entity. However, it includes a broad spectrum of clinical, radiological and pathophysiological findings. In this review we describe 3 different scenarios of this entity: an isolated case with severe left ventricle dysfunction, an "associated" case in a patient with previous atrial septum defect and pulmonary stenosis and finally, as a finding in a patient with a transient cerebrovascular ischemic attack. In the 2 last cases, both asymptomatic, morphological criteria of left ventricle non-compaction were found but, ventricular function was normal and cardiac-MRI showed no late gadolinium hyperenhancement. Periodical follow-up and familial screening were recommended. Natural history and prognosis factors of this disease are still not well known. Further and longer series of patients with this diagnosis are needed to completely define radiological criteria, clinical presentation and evolution.

La miocardiopatía no compactada está considerada actualmente como una entidad independiente y bien definida. Sin embargo, presenta un espectro amplio de hallazgos clínicos, radiológicos y fisiopatológicos. En la presente revisión describimos 3 escenarios clínicos diferentes de dicha entidad: un caso con disfunción ventricular severa, un caso como entidad «asociada¼ a una cardiopatía congènita en un pacientes con un defecto del septo interauricular previo y estenosis pulmonar, y finalmente, como un hallazgo casual en un paciente con un accidente cerebrovascular transitorio. En estos 2 últimos casos se encontraron criterios morfológicos de miocardiopatía no compactada con función ventricular normal y sin presencia de realce tardío de gadolinio en el estudio de cardio-RM. En todos ellos se recomendó estudio familiar. La historia natural y el pronóstico de esta anatomía patológica no son todavía del todo conocidos. Series mayores y seguimiento más largos son necesarios para definir completamente los criterios radiológicos, la presentación clínica y la evolución de esta fascinante entidad.

Left ventricle non-compaction cardiomyopathy: different clinical scenarios and magnetic resonance imaging findings.

Left ventricle non-compaction cardiomyopathy is currently considered as a well-defined individual entity. However, it includes a broad spectrum of clinical, radiological and pathophysiological findings. In this review we describe 3 different scenarios of this entity: an isolated case with severe left ventricle dysfunction, an "associated" case in a patient with previous atrial septum defect and pulmonary stenosis and finally, as a finding in a patient with a transient cerebrovascular ischemic attack. In the 2 last cases, both asymptomatic, morphological criteria of left ventricle non-compaction were found but, ventricular function was normal and cardiac-MRI showed no late gadolinium hyperenhancement. Periodical follow-up and familial screening were recommended. Natural history and prognosis factors of this disease are still not well known. Further and longer series of patients with this diagnosis are needed to completely define radiological criteria, clinical presentation and evolution.

Management and risk factors for mortality in very elderly patients with acute myocardial infarction.

AIM: Elderly patients often remain underrepresented in clinical trials. The aim of our study was to analyze the treatment, clinical outcome and risk factors for mortality in patients aged ≥85 years with ST-segment elevation myocardial infarction (STEMI). METHODS: From 2005-2011, 102 patients aged ≥85 years with STEMI admitted to a coronary care unit were retrospectively reviewed. Clinical data, treatment and outcome were recorded. Reperfusion strategy and its influence in hospital morbidity and mortality were evaluated. Morbidity was defined as the presence of heart failure (Killip-Kimball >1), arrhythmias, mechanical complications, stroke or major bleeding. Risk factors for mortality were assessed by multivariate analysis. RESULTS: The mean age was 87.5±2.5 years (range 85-96). Therapeutic strategy on admission was: primary-angioplasty (PCI) for 33 patients (32.3%) fibrinolysis for 30 patients (29.4%) and conservative treatment for 35 patients (34.3%). In the four remaining patients, rescue angioplasty was required. A total of 29 patients (28.4%) died, and morbidity was seen in 63 patients (61.7%). The morbidity and mortality rates in the conservative treatment group (77.1% and 48.5%) were higher than that found in the reperfusion strategy group (primary-PCI and fibrinolysis; 53.7% and 17.9%; P=0.02 and P=0.002, respectively). Regarding mortality, the univariate analysis showed that heart failure on admission (P=0.0001) and previous coronary artery disease (P=0.01) were prognostic variables. Only heart failure was an independent risk factor for mortality (odds ratio=3.64, 95% CI 0.78-21.87, P<0.0001). CONCLUSIONS: Mortality and morbidity in very elderly patients with STEMI are very high, especially in those not receiving reperfusion therapies. Heart failure on admission was an independent risk factor for hospital mortality.

Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST: ¿hay más de un mundo real? / Invasive treatment of non-ST-segment elevation acute coronary syndrome: is there more than one real world?

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