Ali Alswies

Short- and mid-term results for aortic valve replacement in octogenarians

Population over 80 years who require surgery for degenerative aortic stenosis has largely increased in the past decades. We have compared short- and mid-term results for conventional aortic valve replacement (AVR) for calcific-degenerative aortic stenosis in older and younger than 80 years operated at our institution between April 2004 and December 2008. Predictors of mortality and major adverse cardio and cerebrovascular events (MACCEs) on the postoperative and follow-up period were determined through multivariable analysis. Four hundred and fifty-one patients were included in the study. Ninety-four (20.8%) were >or=80. Previous cardiac surgery [odds ratio (OR)=4.08, P=0.047], renal failure (OR=6.75, P<0.001), concomitant coronary artery bypass grafting (CABG) (OR=2.57, P=0.034), female sex (OR=2.49, P=0.047), and severe pulmonary hypertension (OR=3.68, P=0.024) were independent predictors of in-hospital mortality. In the follow-up, age >or=80 years [Hazard ratio (HR)=2.44, P=0.02], high blood pressure (HBP) (HR=5.2, P=0.025) and peripheral arterial disease (PAD) (HR=5.1, P<0.001) were independent predictors for late mortality. Only PAD (HR=3.55, P=0.014) and HBP (HR=8.24, P=0.04) were independent predictors for late cardiac mortality. Renal failure (OR=2.57, P=0.005), severe pulmonary hypertension (OR=3.49, P=0.005) and concomitant CABG (OR=2.49, P=0.002) were independent predictors for postoperative MACCEs. Diabetes mellitus (HR=2.03, P=0.033) and PAD (HR=2.3, P=0.041) were independent predictors for MACCEs in the follow-up. According to these data, we can conclude that conventional open AVR for degenerative aortic stenosis grants good early- and mid-term outcomes in octogenarians in our experience.

SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main complex coronary disease

OBJECTIVE The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events. METHODS All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders. RESULTS A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively). CONCLUSIONS SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.

Short-term and mid-term follow-up of sutureless surgery for postinfarction subacute free wall rupture

We report our short-term and mid-term results with sutureless repair of postinfarction subacute left ventricular free wall rupture (LVFWR). For this purpose, we evaluated the short-term and mid-term postoperative results assessed by clinical examination and echocardiography of all patients who underwent surgery for subacute LVFWR between January 2004 and January 2009. Twenty-one patients were operated. Direct suture repair of LVFWR was carried out in only one patient. In all other cases we used a pericardial patch with biological glue. Early mortality was 19% (n=4). The median duration of follow-up was 17.3 months (interquartile range, 5-38.7), with a 13-month survival of 76%. Follow-up echocardiography showed no constriction associated with the rupture zone in any patient. According to our early experience, sutureless LVFWR repair is safe, effective and reproducible, and offers acceptable morbidity and mortality during follow-up.

Validación del EuroSCORE II: ¿funciona en nuestro medio?

a b s t r a c t Objectives: Validate the new EuroSCORE (ESII) risk model in terms of discriminative and calibration power and compare this results with the classic EuroSCORE (ES).We also compare our data distribution with the ESII database. Methods: A 4166 patient population operated during a 7 year period was analyzed. The model was then tested on the validation data set for calibration (by comparing the observed and predicted mortality) and for discrimination (using the area under the ROC curve). Results: The predicted mortality by the ESII was higher than the ES: 9.1(SD: 10.4) vs 3.46 (SD: 4.3): p<0.001. The Hosmer-Lemeshow test showed a poor calibration for both models: ES (x 2 =26.6, p=<0.001),ESII (x 2 =58.19, p<0.0001). Areas under ROC curves were 0.75 (IC95% 0.72-0.78) for ES and 0.78 (IC95% 0.75-0.81) for ESII (p<0.233). Conclusions: The new EuroSCORE II risk model has a predicted mortality lower than EuroSCORE and a good predictive value in terms of calibration and poor discrimination. A non significant better discrimination power was observer in the ESII. The distribution of some variables was different between our data and ESII.

Seguimiento ecocardiográfico a medio plazo de las alteraciones de la función sistólica y diastólica del ventrículo izquierdo tras rotura subaguda tratada quirúrgicamente

El papel de las revistas nacionales europeas en la formacion medica Peter Millsa, Adam Timmisb, Kurt Huberc, Hugo Ectord, Patrizio Lancellottic, Izet Masicc, Mario Ivanusac, Loizos Antoniadesc, Michael Aschermannc, Jorgen Videvaekc, Aleksandras Lauceviciusc, Pirjo Mustonenc, Jean-Yves Artigouc, Panos Vardase, Christodoulos Stefanadisc, Massimo Chiarielloc, Leonardo Bolognesec, Guiseppe Ambrosiof, Ernst E. van der Wallc, Piotr Kulakowskig, Fausto J. Pintoh, Eduard Apetreic, Rafael G. Oganovc, Gabriel Kamenskyc, Thomas F. Luscherc, Rene Lerchc, Habib Haoualac, Vedat Sansoyc, Valentin Shumakovc, Carlos Daniel Tajeri, Chu-Pak Laui, Manlio Marquezi, Rungroj Krittayaphongi, Kaduo Araii y Fernando Alfonsoj

Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stent

OBJECTIVE An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery. METHODS A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Coxs proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events. RESULTS A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08-48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29-5.756] and MACEs (HR 2.784, 95% CI 1.962-3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319-6.21) and MACEs (HR 2.89, 95% CI 2.008-4.158). CONCLUSIONS Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

Resultados de la cirugía coronaria sin circulación extracopórea tras angioplastia con stent

Introduccion y objetivos. Evaluar el impacto de la implantacion de stents coronarios previa a la cirugia de revascularizacion miocardica en los resultados postoperatorios de esta. Metodos. Desde enero de 2005 hasta abril de 2008, se evaluo retrospectivamente el impacto de la implantacion de stents coronarios previa a la cirugia coronaria sin circulacion extracorporea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 dias o ingreso hospitalario postoperatorios). Resultados. Se sometio a 796 pacientes consecutivos a revascularizacion miocardica quirurgica; 116 (14,6%) portaban algun stent coronario en el momento de la cirugia. Los grupos con stent y sin stent tenian un perfil de riesgo similar (EuroSCORE). En el analisis multivariable, ajustando el riesgo por las variables de confusion detectadas (fraccion de eyeccion del ventriculo izquierdo preoperatoria < 40%, estado critico preoperatorio, edad, antecedentes de accidente cerebrovascular agudo, infarto miocardico agudo previo reciente, numero de vasos coronarios enfermos, revascularizacion quirurgica incompleta y conversion a circulacion extracorporea) se detecto que el ser portador de stent se asociaba de forma significativa a un mayor riesgo de infarto miocardico postoperatorio (RR = 3,13; intervalo de confianza [IC] del 95%, 1,75-5,96), mortalidad cardiaca hospitalaria (RR = 4,62; IC del 95%, 1,76-12,11) y mortalidad hospitalaria por todas las causas (RR = 3,65; IC del 95%, 1,6-8,34). Conclusiones. En nuestra experiencia, la implantacion previa de stents coronarios se asocia a un mayor riesgo de infarto miocardico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugia coronaria.

Clinical Outcomes With Off-Pump Coronary Surgery After Angioplasty With Stent

INTRODUCTION AND OBJECTIVES The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. METHODS Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization). RESULTS In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34). CONCLUSIONS In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Off-Pump to On-Pump Emergency Conversion: Incidence, Risk Factors, and Impact on Short- and Long-Term Results.

Emergency conversion to on‐pump during off‐pump coronary artery bypass surgery (CABG) increases morbidity and mortality. We analyze its risk factors and impact on short‐ and long‐term outcomes.

314. Extracción de dispositivos intracardíacos en pacientes sometidos previamente a procedimientos de cardiología intervencionista

Objetivos Descripcion de una cohorte de pacientes sometidos a la implantacion de algun dispositivo intracardiaco percutaneo (DCIP) que finalmente fueron intervenidos quirurgicamente por disfuncion de los mismos. Material y metodos Se analizo de forma retrospectiva toda la cohorte de pacientes sometidos a extraccion de DCIP intervenidos en nuestro centro. Se describe la muestra de pacientes y se resumen los resultados quirurgicos. Resultados Desde julio de 2007 – julio de 2011, 25 pacientes intervenidos tras haberse sometido al implante de algun DCIP; 18 mujeres. Edad mediana: 64 anos (rango 26–90). EuroSCORE logistico preimplante de DCIP 6% interquartile range (IQR) (4–9%) y prequirurgico 10% IQR (8–14%). En 8 se implanto Amplatzer para cierre de CIA: 5 quedaron con shunt residual importante; 2 libres en auricula derecha (AD); 1 en ventriculo derecho (VD); 1 implante de Amplatzer para cierre de comunicacion interventricular (CIV) postinfarto agudo de miocardio (post-IAM) con fracaso terapeutico y perforacion de VD. En 8 se implanto un Amplatzer para cierre de leak protesico mitral y 2 aorticos, quedando todos incompetentes; 1 implante de Mitraclip con desagarro del aparato subvalvular e insuficiencia mitral (IM) grave; 5 casos de implante de protesis aorticas transapicales (TAVI) transfemoral con 3 desgarros ventriculares y 2 migraciones de la protesis hacia ventriculo y aorta ascendente. En todos se extrajo el dispositivo y se procedio a sustitucion valvular, cierre de defecto y/o contencion de rotura ventricular. Cuatro pacientes fallecieron. Conclusiones La extraccion de DCIP se esta convirtiendo en una indicacion frecuente de cirugia cardiaca. El riesgo quirurgico aumenta ostensiblemente en la cirugia de retirada de DCIP. Es necesario definir con mas precision esta nueva poblacion de pacientes asi como conocer sus resultados operatorios.