Improved Hypertension Risk Assessment with Photoplethysmographic Recordings Combining Deep Learning and Calibration.

Hypertension, a primary risk factor for various cardiovascular diseases, is a global health concern. Early identification and effective management of hypertensive individuals are vital for reducing associated health risks. This study explores the potential of deep learning (DL) techniques, specifically GoogLeNet, ResNet-18, and ResNet-50, for discriminating between normotensive (NTS) and hypertensive (HTS) individuals using photoplethysmographic (PPG) recordings. The research assesses the impact of calibration at different time intervals between measurements, considering intervals less than 1 h, 1-6 h, 6-24 h, and over 24 h. Results indicate that calibration is most effective when measurements are closely spaced, with an accuracy exceeding 90% in all the DL strategies tested. For calibration intervals below 1 h, ResNet-18 achieved the highest accuracy (93.32%), sensitivity (84.09%), specificity (97.30%), and F1-score (88.36%). As the time interval between calibration and test measurements increased, classification performance gradually declined. For intervals exceeding 6 h, accuracy dropped below 81% but with all models maintaining accuracy above 71% even for intervals above 24 h. This study provides valuable insights into the feasibility of using DL for hypertension risk assessment, particularly through PPG recordings. It demonstrates that closely spaced calibration measurements can lead to highly accurate classification, emphasizing the potential for real-time applications. These findings may pave the way for advanced, non-invasive, and continuous blood pressure monitoring methods that are both efficient and reliable.

Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study.

BACKGROUND: Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. METHODS: We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. RESULTS: A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. CONCLUSIONS: Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.

Novel Entropy-Based Metrics for Long-Term Atrial Fibrillation Recurrence Prediction Following Surgical Ablation: Insights from Preoperative Electrocardiographic Analysis.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia often treated concomitantly with other cardiac interventions through the Cox-Maze procedure. This highly invasive intervention is still linked to a long-term recurrence rate of approximately 35% in permanent AF patients. The aim of this study is to preoperatively predict long-term AF recurrence post-surgery through the analysis of atrial activity (AA) organization from non-invasive electrocardiographic (ECG) recordings. A dataset comprising ECGs from 53 patients with permanent AF who had undergone Cox-Maze concomitant surgery was analyzed. The AA was extracted from the lead V1 of these recordings and then characterized using novel predictors, such as the mean and standard deviation of the relative wavelet energy (RWEm and RWEs) across different scales, and an entropy-based metric that computes the stationary wavelet entropy variability (SWEnV). The individual predictors exhibited limited predictive capabilities to anticipate the outcome of the procedure, with the SWEnV yielding a classification accuracy (Acc) of 68.07%. However, the assessment of the RWEs for the seventh scale (RWEs7), which encompassed frequencies associated with the AA, stood out as the most promising individual predictor, with sensitivity (Se) and specificity (Sp) values of 80.83% and 67.09%, respectively, and an Acc of almost 75%. Diverse multivariate decision tree-based models were constructed for prediction, giving priority to simplicity in the interpretation of the forecasting methodology. In fact, the combination of the SWEnV and RWEs7 consistently outperformed the individual predictors and excelled in predicting post-surgery outcomes one year after the Cox-Maze procedure, with Se, Sp, and Acc values of approximately 80%, thus surpassing the results of previous studies based on anatomical predictors associated with atrial function or clinical data. These findings emphasize the crucial role of preoperative patient-specific ECG signal analysis in tailoring post-surgical care, enhancing clinical decision making, and improving long-term clinical outcomes.

A Novel Signal Restoration Method of Noisy Photoplethysmograms for Uninterrupted Health Monitoring.

Health-tracking from photoplethysmography (PPG) signals is significantly hindered by motion artifacts (MAs). Although many algorithms exist to detect MAs, the corrupted signal often remains unexploited. This work introduces a novel method able to reconstruct noisy PPGs and facilitate uninterrupted health monitoring. The algorithm starts with spectral-based MA detection, followed by signal reconstruction by using the morphological and heart-rate variability information from the clean segments adjacent to noise. The algorithm was tested on (a) 30 noisy PPGs of a maximum 20 s noise duration and (b) 28 originally clean PPGs, after noise addition (2-120 s) (1) with and (2) without cancellation of the corresponding clean segment. Sampling frequency was 250 Hz after resampling. Noise detection was evaluated by means of accuracy, sensitivity, and specificity. For the evaluation of signal reconstruction, the heart-rate (HR) was compared via Pearson correlation (PC) and absolute error (a) between ECGs and reconstructed PPGs and (b) between original and reconstructed PPGs. Bland-Altman (BA) analysis for the differences in HR estimation on original and reconstructed segments of (b) was also performed. Noise detection accuracy was 90.91% for (a) and 99.38-100% for (b). For the PPG reconstruction, HR showed 99.31% correlation in (a) and >90% for all noise lengths in (b). Mean absolute error was 1.59 bpm for (a) and 1.26-1.82 bpm for (b). BA analysis indicated that, in most cases, 90% or more of the recordings fall within the confidence interval, regardless of the noise length. Optimal performance is achieved even for signals of noise up to 2 min, allowing for the utilization and further analysis of recordings that would otherwise be discarded. Thereby, the algorithm can be implemented in monitoring devices, assisting in uninterrupted health-tracking.

Practical Considerations for the Application of Nonlinear Indices Characterizing the Atrial Substrate in Atrial Fibrillation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and in response to increasing clinical demand, a variety of signals and indices have been utilized for its analysis, which include complex fractionated atrial electrograms (CFAEs). New methodologies have been developed to characterize the atrial substrate, along with straightforward classification models to discriminate between paroxysmal and persistent AF (ParAF vs. PerAF). Yet, most previous works have missed the mark for the assessment of CFAE signal quality, as well as for studying their stability over time and between different recording locations. As a consequence, an atrial substrate assessment may be unreliable or inaccurate. The objectives of this work are, on the one hand, to make use of a reduced set of nonlinear indices that have been applied to CFAEs recorded from ParAF and PerAF patients to assess intra-recording and intra-patient stability and, on the other hand, to generate a simple classification model to discriminate between them. The dominant frequency (DF), AF cycle length, sample entropy (SE), and determinism (DET) of the Recurrence Quantification Analysis are the analyzed indices, along with the coefficient of variation (CV) which is utilized to indicate the corresponding alterations. The analysis of the intra-recording stability revealed that discarding noisy or artifacted CFAE segments provoked a significant variation in the CV(%) in any segment length for the DET and SE, with deeper decreases for longer segments. The intra-patient stability provided large variations in the CV(%) for the DET and even larger for the SE at any segment length. To discern ParAF versus PerAF, correlation matrix filters and Random Forests were employed, respectively, to remove redundant information and to rank the variables by relevance, while coarse tree models were built, optimally combining high-ranked indices, and tested with leave-one-out cross-validation. The best classification performance combined the SE and DF, with an accuracy (Acc) of 88.3%, to discriminate ParAF versus PerAF, while the highest single Acc was provided by the DET, reaching 82.2%. This work has demonstrated that due to the high variability of CFAEs data averaging from one recording place or among different recording places, as is traditionally made, it may lead to an unfair oversimplification of the CFAE-based atrial substrate characterization. Furthermore, a careful selection of reduced sets of features input to simple classification models is helpful to accurately discern the CFAEs of ParAF versus PerAF.

An Efficient Hybrid Methodology for Local Activation Waves Detection under Complex Fractionated Atrial Electrograms of Atrial Fibrillation.

Local activation waves (LAWs) detection in complex fractionated atrial electrograms (CFAEs) during catheter ablation (CA) of atrial fibrillation (AF), the commonest cardiac arrhythmia, is a complicated task due to their extreme variability and heterogeneity in amplitude and morphology. There are few published works on reliable LAWs detectors, which are efficient for regular or low fractionated bipolar electrograms (EGMs) but lack satisfactory results when CFAEs are analyzed. The aim of the present work is the development of a novel optimized method for LAWs detection in CFAEs in order to assist cardiac mapping and catheter ablation (CA) guidance. The database consists of 119 bipolar EGMs classified by AF types according to Wells' classification. The proposed method introduces an alternative Botteron's preprocessing technique targeting the slow and small-ampitude activations. The lower band-pass filter cut-off frequency is modified to 20 Hz, and a hyperbolic tangent function is applied over CFAEs. Detection is firstly performed through an amplitude-based threshold and an escalating cycle-length (CL) analysis. Activation time is calculated at each LAW's barycenter. Analysis is applied in five-second overlapping segments. LAWs were manually annotated by two experts and compared with algorithm-annotated LAWs. AF types I and II showed 100% accuracy and sensitivity. AF type III showed 92.77% accuracy and 95.30% sensitivity. The results of this study highlight the efficiency of the developed method in precisely detecting LAWs in CFAEs. Hence, it could be implemented on real-time mapping devices and used during CA, providing robust detection results regardless of the fractionation degree of the analyzed recordings.

The Relevance of Heart Rate Fluctuation When Evaluating Atrial Substrate Electrical Features in Catheter Ablation of Paroxysmal Atrial Fibrillation.

Coronary sinus (CS) catheterization is critical during catheter ablation (CA) of atrial fibrillation (AF). However, the association of CS electrical activity with atrial substrate modification has been barely investigated and mostly limited to analyses during AF. In sinus rhythm (SR), atrial substrate modification is principally assessed at a global level through P-wave analysis. Cross-correlating CS electrograms (EGMs) and P-waves' features could potentiate the understanding of AF mechanisms. Five-minute surface lead II and bipolar CS recordings before, during, and after CA were acquired from 40 paroxysmal AF patients. Features related to duration, amplitude, and heart-rate variability of atrial activations were evaluated. Heart-rate adjustment (HRA) was applied. Correlations between each P-wave and CS local activation wave (LAW) feature were computed with cross-quadratic sample entropy (CQSE), Pearson correlation (PC), and linear regression (LR) with 10-fold cross-validation. The effect of CA between different ablation steps was compared with PC. Linear correlations: poor to mediocre before HRA for analysis at each P-wave/LAW (PC: max. +18.36%, p = 0.0017, LR: max. +5.33%, p = 0.0002) and comparison between two ablation steps (max. +54.07%, p = 0.0205). HRA significantly enhanced these relationships, especially in duration (P-wave/LAW: +43.82% to +69.91%, p < 0.0001 for PC and +18.97% to +47.25%, p < 0.0001 for LR, CA effect: +53.90% to +85.72%, p < 0.0210). CQSE reported negligent correlations (0.6−1.2). Direct analysis of CS features is unreliable to evaluate atrial substrate modification due to CA. HRA substantially solves this problem, potentiating correlation with P-wave features. Hence, its application is highly recommended.

Risk Factors for Postoperative Pacemaker Implantation After Rapid Deployment Aortic Valve Replacement: Results from the RADAR Registry.

INTRODUCTION: Rapid deployment aortic valve replacement has been recently introduced in clinical practice. Different studies have reported a significant reduction in surgical times with excellent hemodynamic profiles and short-term results. However, an increase in permanent pacemaker requirements compared with conventional aortic valve replacement has been described. Nevertheless, risk factors for postoperative pacemaker implantation are not well known. The aim of this study is to report our early outcomes with rapid deployment aortic valve replacement within the RADAR Registry, especially focusing on risk factors for postoperative pacemaker implantation. METHODS: Between April 2012 and January 2016, 164 patients undergoing isolated or combined aortic valve replacement with Edwards INTUITY Elite (Edwards Lifesciences, Irvine, CA, USA) were included in the RADAR Registry. Pre-, intra- and postoperative clinical data results and complications were recorded, especially focusing on risk factors for the development of postoperative complete or high-grade AV block requiring pacemaker implantation. Patients were followed up for up to 1 year with evaluation of clinical and echocardiographic outcomes. RESULTS: A total of 164 consecutive patients were included in this study, where 128 patients (78.05%) had an isolated aortic valve replacement (group 1) and 36 (21.95%) a concomitant procedure (group 2). The surgical approach was ministernotomy in 61 patients (37.20%) and median sternotomy in 100 patients (60.98%). Complications with valve implantation were observed in three patients. Postoperative complete or high-degree AV block requiring a permanent pacemaker implantation developed in ten patients (6.9%). Seven patients died in-hospital (4.27%). No significant differences between groups were found in terms of stroke, postoperative infection, mortality, atrial fibrillation and postoperative atrioventricular block. Seven patients presented acute renal impairment (5.51%) in group 1 versus seven patients (20%) in group 2 (p = 0.007). In multivariate analysis, low weight and preoperative arrhythmia (atrial fibrillation, bifascicular block, left bundle branch block) emerged as risk factors for postoperative AV block requiring a pacer. In median follow-up of 1 year, seven (4.27%) patients died, and no cases of structural valve deterioration or endocarditis were observed. Significant patient-prosthesis mismatch was found in seven (4.27%) patients. CONCLUSION: Initial experience with rapid deployment aortic valve replacement in the RADAR Registry demonstrates low rates of implantation complications and good perioperative and 1-year clinical and echocardiographic outcomes. Incidence of postoperative AV block requiring a pacer correlated with low weight and preoperative arrythmias (atrial fibrillation, bifascicular block and left bundle branch block). Avoidance of oversizing and careful consideration of implantation of this technology in patients with pre-existing arrythmias could minimize the risk for postoperative pacemaker implantation.

Splitting the P-Wave: Improved Evaluation of Left Atrial Substrate Modification after Pulmonary Vein Isolation of Paroxysmal Atrial Fibrillation.

Atrial substrate modification after pulmonary vein isolation (PVI) of paroxysmal atrial fibrillation (pAF) can be assessed non-invasively by analyzing P-wave duration in the electrocardiogram (ECG). However, whether right (RA) and left atrium (LA) contribute equally to this phenomenon remains unknown. The present study splits fundamental P-wave features to investigate the different RA and LA contributions to P-wave duration. Recordings of 29 pAF patients undergoing first-ever PVI were acquired before and after PVI. P-wave features were calculated: P-wave duration (PWD), duration of the first (PWDon-peak) and second (PWDpeak-off) P-wave halves, estimating RA and LA conduction, respectively. P-wave onset (PWon-R) or offset (PWoff-R) to R-peak interval, measuring combined atrial/atrioventricular and single atrioventricular conduction, respectively. Heart-rate fluctuation was corrected by scaling. Pre- and post-PVI results were compared with Mann-Whitney U-test. PWD was correlated with the remaining features. Only PWD (non-scaling: Δ=-9.84%, p=0.0085, scaling: Δ=-17.96%, p=0.0442) and PWDpeak-off (non-scaling: Δ=-22.03%, p=0.0250, scaling: Δ=-27.77%, p=0.0268) were decreased. Correlation of all features with PWD was significant before/after PVI (p<0.0001), showing the highest value between PWD and PWon-R (ρmax=0.855). PWD correlated more with PWDon-peak (ρ= 0.540-0.805) than PWDpeak-off (ρ= 0.419-0.710). PWD shortening after PVI of pAF stems mainly from the second half of the P-wave. Therefore, noninvasive estimation of LA conduction time is critical for the study of atrial substrate modification after PVI and should be addressed by splitting the P-wave in order to achieve improved estimations.

Short-Time Estimation of Fractionation in Atrial Fibrillation with Coarse-Grained Correlation Dimension for Mapping the Atrial Substrate.

Atrial fibrillation (AF) is currently the most common cardiac arrhythmia, with catheter ablation (CA) of the pulmonary veins (PV) being its first line therapy. Ablation of complex fractionated atrial electrograms (CFAEs) outside the PVs has demonstrated improved long-term results, but their identification requires a reliable electrogram (EGM) fractionation estimator. This study proposes a technique aimed to assist CA procedures under real-time settings. The method has been tested on three groups of recordings: Group 1 consisted of 24 highly representative EGMs, eight of each belonging to a different AF Type. Group 2 contained the entire dataset of 119 EGMs, whereas Group 3 contained 20 pseudo-real EGMs of the special Type IV AF. Coarse-grained correlation dimension (CGCD) was computed at epochs of 1 s duration, obtaining a classification accuracy of 100% in Group 1 and 84.0-85.7% in Group 2, using 10-fold cross-validation. The receiver operating characteristics (ROC) analysis for highly fractionated EGMs, showed 100% specificity and sensitivity in Group 1 and 87.5% specificity and 93.6% sensitivity in Group 2. In addition, 100% of the pseudo-real EGMs were correctly identified as Type IV AF. This method can consistently express the fractionation level of AF EGMs and provides better performance than previous works. Its ability to compute fractionation in short-time can agilely detect sudden changes of AF Types and could be used for mapping the atrial substrate, thus assisting CA procedures under real-time settings for atrial substrate modification.

Quantitative Transthoracic Echocardiography of the Response to Dobutamine in Cardiac Surgery Patients With Low Cardiac Output Syndrome.

OBJECTIVE: To quantify the acute effects of dobutamine in postoperative low cardiac output syndrome (LCOS) using transthoracic echocardiographic, hemodynamic, and blood biomarker monitoring and to assess its association with clinical outcomes. DESIGN: Observational prospective study. SETTING: Single university hospital. PARTICIPANTS: Patients undergoing elective cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Echocardiographic parameters, hemodynamic data, and plasma biomarkers were obtained before and early after inotrope initiation. The diagnostic value of transthoracic echocardiographic parameters and their association with clinical outcome were evaluated. Thirty-eight LCOS patients and 12 control patients were included. The left ventricular outflow tract velocity time integral was significantly lower in LCOS patients (11.75 v 19.08 cm; p < 0.001) and showed a marked improvement after dobutamine administration (∼37% increase). Dobutamine improved left and right ventricular function, increased mean arterial pressure and urine output, and lowered lactate levels. The duration of dobutamine support, but not in-hospital mortality, was associated with echocardiographic estimates of cardiac performance early after dobutamine initiation. CONCLUSIONS: Early transthoracic echocardiographic assessment and the acute response to inotropic therapy may provide rapid and highly valuable information in the diagnostic workup and risk evaluation of patients with suspected LCOS after cardiac surgery.

Utilidad del quirófano híbrido en la extracción de dispositivos implantables: experiencia inicial de un centro / Utility of the hybrid operating room for lead extraction: initial experience in a single center

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Electrocardiographic Spectral Features for Long-Term Outcome Prognosis of Atrial Fibrillation Catheter Ablation.

Atrial fibrillation (AF) is the most common arrhythmia in routine clinical practice. Despite many years of research, its mechanisms still are not well understood, thus reducing the effectiveness of AF treatments. Nowadays, pulmonary vein isolation by catheter ablation is the treatment of choice for AF resistant either to pharmacological or electrical cardioversion. However, given that long-term recurrences are common, an appropriate patient selection before the procedure is of paramount relevance in the improvement of AF catheter ablation outcome. The present work studies how several spectral features of the atrial activity (AA) from a single lead of the surface electrocardiogram (ECG) can become potential pre-ablation predictors of long-term (>2 months) sinus rhythm maintenance. Among all the analyzed spectral features, results indicated that the most significant single predictor of paroxysmal AF ablation treatment outcome was related to the amplitude of the first harmonic of the dominant frequency, providing sensitivity (Se), specificity (Sp) and accuracy (Ac) values of 90%, 42.86 and 77.78%, respectively. On the other hand, the AA harmonic structure was the most significant single predictor for persistent AF, with Se, Sp and Ac values of 100%, 54.55 and 77.27%, respectively. A logistic regression analysis, mainly based on spectral amplitudes as well as on the harmonic structure of the AA, provided a higher predictive ability both for paroxysmal AF (Se = 100%, Sp = 57.14% and Ac = 88.89%) and persistent AF (Se = 90.91%, Sp = 72.73 and Ac = 81.82%). In conclusion, the study of key AA spectral features from the surface ECG can provide a significant preoperative prognosis of AF catheter ablation outcome at long-term follow-up.

mRNA PGC-1α levels in blood samples reliably correlates with its myocardial expression: study in patients undergoing cardiac surgery.

OBJECTIVE: Peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) is a transcriptional coactivator that has been proposed to play a protective role in mouse models of cardiac ischemia and heart failure, suggesting that PGC-1α could be relevant as a prognostic marker. Our previous studies showed that the estimation of peripheral mRNA PGC-1α expression was feasible and that its induction correlated with the extent of myocardial necrosis and left ventricular remodeling in patients with myocardial infarction. In this study, we sought to determine if the myocardial and peripheral expressions of PGC-1α are well correlated and to analyze the variability of PGC-1α expression depending on the prevalence of some metabolic disorders. METHODS: This was a cohort of 35 consecutive stable heart failure patients with severe aortic stenosis who underwent an elective aortic valve replacement surgery. mRNA PGC-1α expression was simultaneously determined from myocardial biopsy specimens and blood samples obtained during surgery by quantitative PCR, and a correlation between samples was made using the Kappa index. Patients were divided into two groups according to the detection of baseline expression levels of PGC-1α in blood samples, and comparisons between both groups were made by chi-square test or unpaired Student's t-test as appropriate. RESULTS: Based on myocardial biopsies, we found that mRNA PGC-1α expression in blood samples showed a statistically significant correlation with myocardial expression (Kappa index 0.66, p<0.001). The presence of higher systemic PGC-1α expression was associated with a greater expression of some target genes such as silent information regulator 2 homolog-1 (x-fold expression in blood samples: 4.43±5.22 vs. 1.09±0.14, p=0.044) and better antioxidant status in these patients (concentration of Trolox: 0.40±0.05 vs. 0.34±0.65, p=0.006). CONCLUSIONS: Most patients with higher peripheral expression also had increased myocardial expression, so we conclude that the non-invasive estimation of mRNA PGC-1α expression from blood samples provides a good approach of the constitutive status of the mitochondrial protection system regulated by PGC-1α and that this could be used as prognostic indicator in cardiovascular disease.

Is off-pump technique a safer procedure for coronary revascularization? A propensity score analysis of 20 years of experience.

OBJECTIVES: We aim to describe our experience in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass by comparing intraoperative and postoperative outcomes. METHODS: From January 1993 to June 2013, 3097 patients underwent consecutive emergency and scheduled CABG surgery. A total of 1770 patients underwent on-pump CABG (ONCABG) and 1327 off-pump CABG (OPCABG). A propensity score matching was performed to identify appropriate matched-pair patients; univariable and multivariable logistic regression analyses were performed to assess significant predictors of hospital and 30-day morbidity and mortality composite end-points. Morbidity composite end-point was defined as any renal, pulmonary, cardiovascular and neurological complication that occurred during hospital stay. We collected all-cause mortality data during the study period. RESULTS: We identified 1004 patients in each group. There were no significant differences in thirty day mortality, 2.8 vs 3.8%, in OPCABG and ONCABG, respectively (P = 0.21). Cardiovascular, neurological, respiratory and renal complications were more frequent in the ONCABG group: 13.9 vs 8.7% (P < 0.001), 3.9 vs 2.2% (P = 0.03), 13.5 vs 7.5% (P < 0.001), 7.1 vs 5.3% (P = 0.095), respectively. The long-term all-cause mortality rate was 12.3 vs 12.9% in the OPCABG versus ONCABG group (P = 0.42), respectively. In both uni- and multivariable analysis preoperative renal failure, chronic obstructive pulmonary disease and ONCABG were independent predictors of mortality and morbidity composite end-points. CONCLUSIONS: OPCABG is associated with less postoperative morbimortality and shorter hospital and intensive care unit length of stay. ONCABG resulted as an independent predictor of morbidity and mortality composite end-point. No statistically significant differences were observed in long-term all-cause mortality between groups.

Preoperative study of the surface ECG for the prognosis of atrial fibrillation maze surgery outcome at discharge.

The Cox-maze surgery is an effective procedure for terminating atrial fibrillation (AF) in patients requiring open-heart surgery associated with another heart disease. After the intervention, regardless of the patient's rhythm, all are treated with oral anticoagulants and antiarrhythmic drugs prior to discharge. Furthermore, patients maintaining AF before discharge could also be treated with electrical cardioversion (ECV). In view of this, a preoperative prognosis of the patient's rhythm at discharge would be helpful for optimizing drug therapy planning as well as for advancing ECV therapy. This work analyzes 30 preoperative electrocardiograms (ECGs) from patients suffering from AF in order to predict the Cox-maze surgery outcome at discharge. Two different characteristics of the AF pattern have been studied. On the one hand, the atrial activity (AA) organization, which provides information about the number of propagating wavelets in the atria, was investigated. AA organization has been successfully used in previous studies related to spontaneous reversion of paroxysmal AF and to the outcome of ECV. To assess organization, the dominant atrial frequency (DAF) and sample entropy (SampEn) have been computed. On the other hand, the second characteristic studied was the fibrillatory wave (f-wave) amplitude, which has been demonstrated to be a valuable indicator of the Cox-maze surgery outcome in previous studies. Moreover, this parameter has been obtained through a new methodology, based on computing the f-wave average power (fWP). Finally, all the computed indices were combined in a decision tree in order to improve prediction capability. Results for the DAF yielded a sensitivity (Se), a specificity (Sp) and an accuracy (Acc) of 61.54%, 82.35% and 73.33%, respectively. For SampEn the values were 69.23%, 76.00% and 73.33%, respectively, and for fWP they were 92.31%, 82.35% and 86.67%, respectively. Finally, the decision tree combining the three parameters analyzed improved the preoperative prognosis of the Cox-maze outcome with values of Se, Sp and Acc of 100%, 82.35% and 90%, respectively. As a consequence, the analysis of parameters related to the f-wave pattern, extracted from the preoperative ECG, has provided a considerable ability to predict the outcome of AF Cox-maze surgery at discharge.

Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique.

OBJECTIVES: Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'. METHODS: Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. RESULTS: All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR. CONCLUSIONS: MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.

Cirugía mínimamente invasiva para el recambio valvular aórtico. Una técnica segura y útil más allá de lo estético / Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits

Introducción y objetivos. El objetivo es comparar resultados clínicos intrahospitalarios entre pacientes sometidos a recambio valvular aórtico aislado por abordaje mínimamente invasivo frente a esternotomía estándar. Métodos. Se incluyó a 615 pacientes sometidos a recambio valvular aórtico entre 2005 y 2012, 532 mediante abordaje estándar (grupo E) y 83 mediante miniesternotomía en «J» (grupo M). Resultados. No se encontraron diferencias significativas en cuanto a edad (69,27 ± 9,31 frente a 69,40 ± 10,24 años) y EuroSCORE logístico (6,27 ± 2,91 frente a 5,64 ± 2,17) entre los grupos E y M. Tampoco en la incidencia de diabetes mellitus, hipercolesterolemia, hipertensión arterial y enfermedad pulmonar obstructiva crónica o el tamaño de válvulas implantadas (grupo E frente a grupo M, 21,94 ± 2,04 y 21,79 ± 2,01 mm). Sí las hubo en los tiempos de circulación extracorpórea y de pinzamiento aórtico, mayores en el grupo E: 102,90 ± 41,68 frente a 81,37 ± 25,41 min (p < 0,001) y 77,31 ± 29,20 frente a 63,45 ± 17,71 min (p < 0,001) respectivamente. La mortalidad del grupo E fue del 4,88% (26). En el grupo M no hubo muertes (p < 0,05). No hubo diferencia en las complicaciones hemodinámicas, neurológicas, renales, infecciosas o de herida. Los días de estancia en unidad de cuidados intensivos y de estancia hospitalaria fueron más en el grupo E: 4,17 ± 5,23 frente a 3,22 ± 2,01 días (p = 0,045) y 9,58 ± 7,66 frente a 7,27 ± 3,83 días (p < 0,001). En el grupo E hubo más complicaciones respiratorias postoperatorias, 42 (8,0%) frente a 1 (1,2%) (p < 0,05). Conclusiones. El abordaje mínimamente invasivo presenta resultados al menos equiparables al estándar en cuanto a morbimortalidad y tiempos quirúrgicos, y en nuestra serie ha permitido disminuir significativamente la estancia hospitalaria. Dado que el estudio es retrospectivo, creemos que se debe confirmar estos hallazgos en estudios prospectivos aleatorizado(AU)

Introduction and objectives. The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. Methods. Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). Results. No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. Conclusions. In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results(AU)

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score.

OBJECTIVES: To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery. METHOD: A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump). RESULTS: Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG. CONCLUSIONS: PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.