Ana Mendez

Long term outcome of mechanical valve prosthesis in the pulmonary position

OBJECTIVES Assessment of the long term outcome of mechanical valve prosthesis at pulmonary position in a population of grown-up congenital heart disease patients from a tertiary referral center. METHODS From 1977 to 2007, 22 consecutive patients underwent a total of 25 pulmonary valve replacements with mechanical prosthesis. The most frequent underlying cardiac condition was tetralogy of Fallot (n=16, 64%) and the mean age at the time of pulmonary valve replacement was 32 ± 11 years (range 14-50 years). RESULTS The postoperative mortality rate was 4% (n=1) with no late deaths documented after a mean follow-up of 7.6 ± 7.6 years (range 0.29-24 years). No major bleeding episodes occurred. Three patients presented with valve thrombosis in the setting of long term anticoagulation withdrawal and required valve re-replacement. Two of these patients, both with poor right ventricular function and overt clinical signs of right heart failure at the time of valve re-replacement, experienced further episodes of thrombosis despite correct anticoagulation. All episodes resolved with thrombolysis. After addition of antiplatelet treatment in one case and anticoagulation self-control, in the other, no further thrombosis has been documented. CONCLUSIONS Mechanical valve prosthesis may be an alternative to tissue valve prosthesis in patients with congenital heart disease requiring pulmonary valve replacement. Optimal anticoagulation is crucial and additional antiplatelet treatment should be considered. Our data also suggest that patients with severe right ventricular dysfunction and congestive heart failure might be at particular risk for valve thrombosis.

Differential clinical characteristics and prognosis of intraventricular conduction defects in patients with chronic heart failure

Intraventricular conduction defects (IVCDs) can impair prognosis of heart failure (HF), but their specific impact is not well established. This study aimed to analyse the clinical profile and outcomes of HF patients with LBBB, right bundle branch block (RBBB), left anterior fascicular block (LAFB), and no IVCDs.

Prognostic Value of Body Mass Index and Waist Circumference in Patients With Chronic Heart Failure (Spanish REDINSCOR Registry)

INTRODUCTION AND OBJECTIVES To analyze the association between higher body mass index and waist circumference, and the prognostic values of both indicators in total and cardiac mortality in patients with chronic heart failure. METHODS The study included 2254 patients who were followed up for 4 years. Obesity was classified as a body mass index ≥30 and overweight as a body mass index of 25.0-29.9. Central obesity was defined as waist circumference ≥88 cm for women and ≥102cm for men. Independent predictors of total and cardiac mortality were assessed in a multivariate Cox model adjusted for confounding variables. RESULTS Obesity was present in 35% of patients, overweight in 43%, and central obesity in 60%. Body mass index and waist circumference were independent predictors of lower total mortality: hazard ratio=0.84 (P<.001) and hazard ratio=0.97 (P=.01), respectively, and lower cardiac death (body mass index, hazard ratio=0.84, P<.001; waist circumference, hazard ratio=0.97, P=.01). The interaction between body mass index and waist circumference (hazard ratio=1.001, P<.01) showed that the protective effect of body mass index was lost in patients with a waist circumference >120cm. CONCLUSIONS Mortality was significantly lower in patients with a high body mass index and waist circumference. The results also showed that this protection was lost when these indicators over a certain limit.

Prognostic value of increased carbohydrate antigen in patients with heart failure.

AIM To study the prognostic value of carbohydrate antigen 125 (CA125) and whether it adds prognostic information to N-terminal pro-brain natriuretic peptide (NT-proBNP) in stable heart failure (HF) patients. METHODS The predictive value of CA125 was retrospectively assessed in 156 patients with stable HF remitted to the outpatient HF unit for monitoring from 2009 to 2011. Patients were included in the study if they had a previous documented episode of HF and received HF treatment. CA125 and NT-proBNP concentrations were measured. The independent association between NT-proBNP or CA125 and mortality was assessed with Cox regression analysis, and their combined predictive ability was tested by the integrated discrimination improvement (IDI) index. RESULTS The mean age of the 156 patients was 72 ± 12 years. During follow-up (17 ± 8 mo), 27 patients died, 1 received an urgent heart transplantation and 106 required hospitalization for HF. Higher CA125 values were correlated with outcomes: 58 ± 85 KU/L if hospitalized vs 34 ± 61 KU/L if not (P < 0.05), and 94 ± 121 KU/L in those who died or needed urgent heart transplantation vs 45 ± 78 KU/L in survivors (P < 0.01). After adjusting for propensity scores, the highest risk was observed when both biomarkers were elevated vs not elevated (HR = 8.95, 95%CI: 3.11-25.73; P < 0.001) and intermediate when only NT-proBNP was elevated vs not elevated (HR = 4.15, 95%CI: 1.41-12.24; P < 0.01). Moreover, when CA125 was added to the clinical model with NT-proBNP, a 4% (P < 0.05) improvement in the IDI was found. CONCLUSION CA125 > 60 KU/L identified patients in stable HF with poor survival. Circulating CA125 level adds prognostic value to NT-proBNP level in predicting HF outcomes.

Percutaneous closure of iatrogenic aortopulmonary fistula using the Amplatzer Septal Occluder.

Percutaneous treatment of stenotic lesions in the pulmonary artery system has been shown to be a valid and effective intervention, in both adults and children. The development of an iatrogenic aortopulmonary fistula after pulmonary angioplasty is a rare complication described by several authors who have chosen different devices for percutaneous closure of the lesion. The present letter discusses this uncommon lesion and considers the percutaneous treatment options. A 13-day-old boy diagnosed with transposition of the great arteries underwent an arterial switch operation and a Lecompte maneuver. In the operating room, he was diagnosed with a coronary anatomy consisting of an intramural left coronary artery, from which the left anterior descending artery and the right coronary artery originated. There was an independent filiform circumflex artery. To correct the defect, a 3.5-mm PTFE tube was placed between the ascending aorta and the left coronary artery. The postoperative outcome was satisfactory, and the patient was discharged 14 days after the procedure. In subsequent follow-up, the patient was found to have supravalvular pulmonary stenosis with an echocardiographic gradient of 62 mmHg. A cardiac catheterization procedure was performed when the patient was 1 year old. A stenosis gradient of 52 mmHg was detected, along with right ventricular pressures that were 66% of systemic pressures and stenosis at the origin of the right pulmonary artery (gradient, 18 mmHg). Percutaneous angioplasty of the pulmonary artery and origin of the right pulmonary artery was performed with a balloon catheter measuring 15 30 mm and 10 20 mm, respectively, using an 8-Fr introducer sheath. Disappearance of the gradient in the branch was confirmed and the gradient in the main artery decreased to 16 mmHg. There was also a mild tear in the intimal layer at the origin of the right pulmonary artery. However, magnetic resonance imaging showed the integrity of the wall of the main artery and branch. The patient was asymptomatic for the next 4 years until signs of congestive heart failure developed. Echocardiography revealed a progressive increase in the size of the left heart chambers, along with continuous flow at the origin of the right pulmonary branch and retrograde flow in the descending aorta. Because an aortopulmonary window secondary to angioplasty was suspected when the patient was 5.5 years old and weighed 22 kg, cardiac catheterization and transesophageal echocardiography were performed. An 8-mm fistula was observed between the ascending aorta and the origin of the right pulmonary artery. The mean aortic and pulmonary pressures were 65 mmHg and 28 mmHg, respectively, with a QP/QS ratio of 2.3 and a suprapulmonary gradient of 15 mmHg and 8 mmHg at the origin of the right pulmonary branch. The atrial fistula was closed in a percutaneous procedure using a 9-mm Amplatzer Septal Occluder device, chosen in view of the size of the lesion. The defect was probed from an aortic approach with a 4-Fr distal needle catheter and 0.014’’ hydrophilic guidewire. Once in the pulmonary lumen, an arteriovenous loop was created by capturing the guidewire with a 10-mm loop catheter, allowing the guidewire to leave via the femoral vein. Once the guidewire was in place, the distal needle catheter was advanced to place a more supportive guidewire (0.035’’), over which the sheaf was placed (Amplatzer 7 Fr Delivery System) and the device was deployed using the pulmonary approach. The procedure was a success; there were no incidents or need for repositioning (Figure 1 and Figure 2). After closure, a residual shunt through the device was observed (QP/ QS = 1.5), without increasing either the pulmonary gradient or affecting the ascending aorta. The shunt could be detected in echocardiographic studies for 1 month. In addition, there was mild hemolysis that disappeared 6 days after the intervention without requiring any treatment. The patient was asymptomatic on the 5th day after the procedure. After 28 months of follow-up, there have been no new complications. Percutaneous treatment of stenotic lesions of the pulmonary artery branch has been accepted as an effective and valid option. There are isolated reports of patients with an iatrogenic shunt between the aorta and the pulmonary artery, especially in patients who have undergone an arterial switch, as was the case in our patient. The etiopathogenesis has been attributed to the widely reported adherence between the aorta and pulmonary artery on performing the Lecompte maneuver in arterial switching. The progressive development of symptoms of heart failure due to the iatrogenic window is due to the progressive increase in the size of the lesion, as explained by Vida et al and as occurred in our patient. When percutaneous closure is performed, care should be taken when choosing the device so as not to affect normal pulmonary valve function, to ensure sufficient coronary perfusion, and to keep obstruction of the lumen of both arteries to a minimum. Drugeluting stents have been used during the closure procedure. These are indicated in lesions close to pulmonary branching, as another device would lead to protrusion into the lumen of the pulmonary arteries. Amplatzer Duct Occluder II devices and Amplatzer Septal Occluder devices have also been used, above all for small lesions. The reason for our choice was the better profile

Apical Muscular Ventricular Septal Defects: Surgical Strategy Using Three-Dimensional Printed Model

To evaluate the utility of a three-dimensional printed model (3D-model) for surgical decision planning in a complex case of multiple ventricular septal defect (VSD) (so-called Swiss-cheese septum). A 3 month-old-girl with diagnosis of multiple apical VSDs in the trabecular septum, perimembranous VSD, and atrial septal defect that resulted in congestive heart failure was referred for surgical intervention. Due to inconclusive understanding of the total number, openings and locations of the apical VSDs, there were concerns regarding the best surgical approach. Using computed tomography images, a 3D-model was fabricated by fused deposition modeling of polyurethane filament. The 3D model helped identifying the total number of VSD, their origins and exits as well as the minimum number of septal bands to resect, the optimal patch size and morphology to completely close all VSDs without reducing significantly the RV cavity. The procedure was successfully replicated in the patient by right atrial approach, resulting in good RV cavity size, function and no residual VSDs evaluated by transesophageal echocardiography. Direct evaluation of the 3D printed replica anatomy and surgical simulation may help optimizing surgical approach, patch size and location and therefore it might reduce complications and residual defects.

Tricuspid valve replacement with mechanical prostheses: Short and long-term outcomes

Tricuspid valve replacement has been associated with high mortality and poor long‐term outcomes. We report the preoperative risk factors associated with short and long‐term outcomes following tricuspid valve replacement with mechanical prostheses.