Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study.

BACKGROUND: The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. METHODS: A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. RESULTS: Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. CONCLUSION: In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Progressive right ventricular failure is not explained by myocardial ischemia in a pig model of right ventricular pressure overload.

BACKGROUND: Current concepts of acute pulmonary embolism suggest that right ventricular (RV) dilatation and failure are the consequence of pressure overload-induced RV hypoperfusion and ischemia. METHODS: Sixteen human-sized hybrid pigs were instrumented for the measurement of RV and aortic pressure, aortic and right coronary artery blood flow (RCA BF), RV oxygen consumption (RV MVO(2)) and RV free wall segment length. The pulmonary artery was constricted (PAC) to increase RV peak pressure acutely 2.5-fold (from 27+/-2 to 64+/-3 mmHg, n=9), and the constriction was maintained for 6h. RESULTS: At 10 min after PAC, a RV work index (RVWI, RV pressure-segment length loops) was increased 2.3-fold, indicating an initial RV adaptation to increased afterload. At 1h, 3h and 6h after PAC, however, RVWI decreased progressively towards control levels, while RCA BF and RV MVO(2) continued to increase. The arterial-coronary venous pH difference did not increase throughout the protocol. Arterial troponin T concentration increased from 0.08+/-0.03 to 0.80+/-0.20ng/ml at 6h after PAC. None of the parameters changed in control animals (n=7). CONCLUSION: We conclude that in our model RV failure during PAC develops in spite of increased coronary blood flow and MVO(2). Thus, mechanisms different from ischemia may contribute to progressive RV failure after pulmonary embolism.

Valoración del riesgo de la cirugía mitral combinada con la revascularización miocárdica / Risk assessment of combined mitral valve and coronary artery surgery

Introducción y objetivos. Identificar los factores que afectan precoz y tardíamente en el resultado de esta cirugía combinada, considerada de alto riesgo. Pacientes y método. Entre 1984 y 1997 fueron operados 264 pacientes (edad media 63 ñ 7,3 años) con cirugía valvular mitral (199 pacientes, 75 por ciento remplazo valvular, 25 por ciento reconstrucción) en combinación con revascularización miocárdica (media 2,4 ñ 1,3 bypass). El seguimiento medio fue de 69 ñ 42 meses, con un cumplimiento del 98,3 por ciento. Resultados. La mortalidad hospitalaria fue del 10,6 por ciento (28/264). La cirugía de urgencia en pacientes con etiología mitral isquémica, la reducción moderada a severa de la función ventricular izquierda y la edad avanzada (> 60 años) se asociaron de manera independiente con la mortalidad hospitalaria (p < 0,05). La etiologia isquémica de la patología mitral (cirugía programada y de urgencia), el grado de severidad de la insuficiencia mitral y la clase IV de la NYHA se asociaron con la mortalidad hospitalaria solamente en el análisis estadístico univariante. La supervivencia actuarial fue del 86, 69 y 48 por ciento a 1, 5, y 10 años, respectivamente. La clase preoperatoria de la NYHA fue la única variable independiente relacionada con la supervivencia total. El 85 por ciento de los supervivientes se encontraban postoperatoriamente en clases I o II de la NYHA. Conclusiones. La cirugía mitral combinada con revascularización miocárdica está asociada con una alta mortalidad hospitalaria. Factores de riesgo independientes de la mortalidad hospitalaria son la cirugía de urgencia en pacientes con etiología mitral isquémica, la función ventricular izquierda reducida y la edad vanzada. La mortalidad total se encuentra influida, de manera independiente, por la clase funcional IV preoperatoria de la NYHA (AU)