Prognostic implications of fibrosis in low risk aortic stenosis patients.

INTRODUCTION AND OBJECTIVES: Among patients with aortic stenosis (AS), interstitial fibrosis has been associated with progression to heart failure and is a marker of poorer prognosis. We aimed to assess the impact of myocardial fibrosis on clinical events after aortic valve replacement (AVR) in low risk, severe AS. METHODS: We prospectively followed 56 severe AS patients with ejection fraction >40%, who underwent AVR with simultaneous myocardial biopsies and collagen volume fraction (CVF) determination. Baseline and follow-up echocardiographic parameters were assessed. Outcomes were all-cause death and the combined endpoint of all-cause death or non-fatal cardiovascular hospitalization. RESULTS: Patients were predominantly women (67.9%) and mean age was 66±12 years. At follow-up, there was a significant decrease in transaortic gradients and wall stress, as well as regression in indexed LV mass. Patients who suffered a fatal event or the combined endpoint had a higher degree of fibrosis (27.1±20.7% vs. 15.4±11.8%, p=0.035; 24.0±18.2% vs. 15.3±12.0%, p=0.038, respectively). Patients with CVF≥15.4% had higher rates of all-cause death (37.5% vs. 97.0%, p=0.001) and lower survival free of the combined endpoint of all-cause death or non-fatal cardiovascular hospitalization (0% vs. 91.2%, p<0.001). CVF was the only independent predictor of all-cause death (hazard ratio (HR) 1.88; 95% confidence interval (CI): 1.08-3.29 for each 10% increase; p=0.026) and all-cause death or cardiovascular hospitalization (HR 1.73; 95% CI: 1.03-2.911 for each 10% increase; p=0.038). CONCLUSIONS: In low risk AS patients, higher levels of fibrosis are independent predictors of all-cause death and the composite of all-cause death or non-fatal cardiovascular hospitalization. Further advances in anti-fibrotic therapies in AS are needed.

Infective aortitis after self-expanding transcatheter valve implantation: a case report of a new reality for cardiac surgeons.

A 62-year-old female patient was admitted to hospital care due to an ischaemic stroke and fever of unknown origin, 6 months after a transfemoral aortic valve implantation for symptomatic aortic stenosis. Further study resulted in the diagnosis of infective aortitis, and clinical course deemed prosthesis explantation necessary. In this case report, we describe the technique used to explant the partially endothelized aortic valve and review the alternatives found in literature for safe prosthesis removal.

Hemodynamic and clinical performance of Solo stentless bioprosthetic aortic valves.

OBJECTIVE: To report the hemodynamic profile and short- and medium-term outcomes of Freedom Solo and Solo Smart stentless aortic valves implanted at our center. METHODS: Between 2009 and 2015, all patients undergoing aortic valve replacement using Solo stentless valves at our center were enrolled. Clinical and echocardiographic follow-up was carried out six months postoperatively. Survival and major events, including structural valve deterioration and non-structural valve dysfunction, endocarditis, reoperation and stroke, were assessed through medical records or telephone interview with the referring cardiologist up to November 2015 (mean and maximum follow-up 39±22 and 78 months, respectively). RESULTS: Patients' (n=345) mean age was 72±8 years, 52% were female and median euroSCORE II was 2.7 (1.5-4.7). There was no intraoperative mortality and in-hospital mortality was 2.6%. Postoperatively, mean transvalvular gradient was 11.9±4.5 mmHg and effective orifice area was 1.9±0.5 cm2. Patient-prosthesis mismatch occurred in 14% but was severe in only one patient. Cumulative survival at six years was 72%. Six patients were reoperated: three due to endocarditis, two for structural prosthesis deterioration and one because of periprosthetic fistula. Five patients suffered stroke, three had medically-treated endocarditis and one had structural valve deterioration but was not considered suitable for reoperation. None of the remainder had structural valve deterioration or non-structural valve dysfunction. CONCLUSIONS: Solo stentless aortic valves are safe to implant, with promising clinical outcomes in short- and medium-term assessment. Moreover, they show an excellent hemodynamic performance: low transvalvular gradients, large effective orifice areas and low incidence of patient-prosthesis mismatch.

Load independent impairment of reverse remodeling after valve replacement in hypertensive aortic stenosis patients.

BACKGROUND: We evaluated the impact of hypertension on the left ventricular mass regression in aortic stenosis after aortic valve replacement. METHODS: We prospectively studied 135 patients with severe aortic stenosis at baseline and 1 year after surgery. In 32 patients we analyzed myocardial gene expression of collagen types I and III, connective tissue growth factor, transforming growth factor-ß1, metalloproteinase-2 and its tissue inhibitor and compared its levels vs controls. RESULTS: Seventy-six patients (56.3%) had a history of hypertension. Hypertensive patients were older, had higher Euroscore-II and NYHA class, with no differences in stenosis severity. At 1 year follow-up there was a median decrease of mass index of 14.2% (P25-75: -4.3%-30.4%; p<0.001). Mass regression was significantly higher in patients without hypertension, with a median decrease of 25.9% (P25-75: 12.0%-38.7%) vs 5.4% (P25-75: -12.5%-20.1%; p=0.001), despite similar increase in effective orifice area and no differences in valvuloarterial impedance. After 1 year, higher baseline left ventricular mass index (p=0.005) and the absence of hypertension (p=0.002) or diabetes (p=0.041) were the only independent predictors of mass regression higher than the median. Comparing with controls, aortic stenosis patients had an increased expression of collagen types I and III, but only hypertensive patients had higher relative expression of collagen type I vs III. In hypertensive patients TIMP2 expression was up-regulated and correlated with higher baseline left ventricular mass index (r=0.61; p=0.020). CONCLUSIONS: In aortic stenosis, hypertension impairs mass regression one year after valve replacement, independently of total afterload. Differences in the expression of extracellular matrix remodeling genes might contribute to this finding.

[Acute coronary syndrome as clinical presentation of cardiac paraganglioma]. / Síndrome coronário agudo como manifestação de paraganglioma cardíaco.

We present the case of a 60-year-old woman with a non secretor cardiac paraganglioma diagnosed in the setting of an acute coronary syndrome. The tumor was supplied by a huge branch of the circumflex artery and we admit flow steal as the cause of myocardial ischemia. Complete resection was feasible under cardiopulmonary bypass and the patient was discharged on the 9th postoperative day.