Antonio García-Valentín

Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures

OBJECTIVE This study analyzes the anatomic structure of the mitral and tricuspid annuli, their relationship with the coronary arteries and veins, and how this anatomic distribution may affect atrial ablation with bipolar radiofrequency clamps, the only technology that ensures transmurality. METHODS Nine explanted fresh human hearts were studied, two of them with left coronary dominance. Two types of bipolar radiofrequency clamps were positioned to reach the mitral and tricuspid annuli, and relationships within the atrioventricular junction were analyzed, including coronary sinus and coronary arteries. RESULTS In all hearts studied, the coronary arteries and veins within the adipose tissue of the right or left atrioventricular groove lay in the atrial side, 3 to 18 mm away from the mitral or tricuspid annuli. When the bipolar radiofrequency clamp was closed toward the mitral annulus, the coronary sinus was always included between the jaws, and in left coronary-dominant hearts, the circumflex artery was also included. Nevertheless, the clamp never reached the annulus owing to the increase in thickness of the adipose tissue around the groove and the ventricular mass, leaving 5 to 10 mm of atrial myocardium free from the radiofrequency electrodes. In the right atrium, clamp placement toward the tricuspid annulus excluding the right coronary left 8 to 18 mm of atrial muscle free from the bipolar electrodes. CONCLUSIONS Bipolar radiofrequency clamps are not sufficient to complete a Cox maze IV procedure. Moreover, they may compromise coronary arteries in patients with left coronary dominance. Lines to the atrioventricular annuli need to be completed with the cut-and-sew technique or with alternative monopolar energy devices.

Validation and quality measurements for EuroSCORE and EuroSCORE II in the Spanish cardiac surgical population: a prospective, multicentre study

OBJECTIVES Since its development in the late 1990s, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been the predictive model of choice for estimating mortality after cardiac surgery. As outcomes from cardiac surgery improved, the EuroSCORE showed a loss of calibration, and a revised version of the model was developed, EuroSCORE II. The objectives of this study were to examine the validity of both scores in the Spanish population, and to depict the performance of both models on a funnel plot. METHODS A prospective multicentre study was performed, with requests to participate sent to all centres in Spain. Participating centres reported the EuroSCORE, EuroSCORE II and the actual mortality of each patient. Incomplete data were requested to get a zero incidence of lost data. Calibration of models was evaluated with the Hosmer-Lemeshow goodness-of-fit test, and discrimination with the areas under the receiver operating characteristic (ROC) curve. A funnel plot was constructed using mortality data from the 2010 European Registry, to represent risk-adjusted mortality. RESULTS Twenty Spanish centres participated in the study; 4034 patients undergoing cardiac surgery between 1 October 2012 and 31 March 2013 were collected. Prevalence of risk factors was analysed. The observed mortality rate was 6.5%. The mean additive EuroSCORE was 6.5. The mean expected mortality rate was 9.8% for the logistic EuroSCORE, and 5.7% for EuroSCORE II. Areas under the ROC curves were EuroSCORE: 0.77 [95% confidence interval (CI): 0.75-0.80], EuroSCORE II: 0.79 (95% CI: 0.76-0.82). Results for the goodness-of-fit test were EuroSCORE: 33.02 (P < 0.001), EuroSCORE II: 38.98 (P < 0.001). Risk-adjusted mortality is far beyond the lower bound of the CI if EuroSCORE is used as the reference model, and is between the confidence limits, but near to the upper bound when EuroSCORE II is used. CONCLUSIONS Spanish cardiac surgical patients have a high-risk profile. Areas under the ROC curve show good discrimination for both models. Predicted mortality using EuroSCORE II more closely matches actual mortality than that predicted by the original EuroSCORE. Both models show statistically significant differences from the actual mortality rate, with EuroSCORE overpredicting and EuroSCORE II underpredicting mortality. The funnel plot illustrates risk-adjusted mortality clearly out of boundaries when EuroSCORE is used, and near underprediction when the reference is EuroSCORE II.

Miniplegia versus blood cardioplegia in elective aortic valve replacement: a prospective randomised, non - inferiority controlled trial

Antegrade intermittent 4:1 blood cardioplegia with Buckberg solution is widely used in elective aortic valve replacement. Use of miniplegia could simplify myocardial protection in this setting.

Endocarditis trombótica no bacteriana (Libman-Sacks)

Mujer de 47 anos ingresada en 2002 por ictus. Se diagnostico masa valvular aortica. Se intervino realizandose exeresis de trombo no bacteriano (Fig 1a, b). Durante el estudio de trombofilia fue diagnosticada de sindrome antifosfolipido primario (SAP), inciandose anticoagulacion. Hasta la fecha, ha padecido multiples accidentes cerebrovasculares, isquemicos y hemorragicos. Esta en dialisis peritoneal con probable origen en SAP. SAP es un trastorno autoinmune caracterizado por fenomenos tromboticos iterativos y alargamiento de tiempos de coagulacion. La cirugia cardiaca conlleva morbimortalidad por tromboembolias, suponiendo un reto en el manejo de la circulacion extracorporea. Las complicaciones tromboembolicas son frecuentes durante el seguimiento.

Reply to Nezic.

We are deeply thankful for the comments by Nezic [1] regarding our recent contribution [2]. An overall analysis of the results was performed for different reasons. First, the expected size was smaller than what was finally reached; so we initially considered that the statistical power would not be enough for subgroup analyses. Second, EuroSCORE II was designed to precisely predict overall mortality [3]. It was our goal to test its performance in our environment, aiming at approving its utilization in routine practice. Collaborating units accepted these rules for the project and although the number of patients collected exceeded the initial expectations, we decided not to change the original project design. We have already contacted the EuroSCORE II team in order to analyse the differences in the prevalence of risk factors between Spanish and developmental groups. Subgroup analyses probably lay in the limit of methodological correctness, and it is our intention to publish them incorporating those data. Regarding the requests of Nezic, coronary patients represented 25.4% (n = 1024), a relatively low percentage when compared with other registries. Thirty-four patients (3.3%) died in this group. The logistic EuroSCORE was 5.4% and EuroSCORE II 3.2%, the latter being close to the actual mortality. Discrimination was similar for both models (0.80 and 0.82, respectively), although with a higher confidence interval due to the smaller size. One thousand six hundred and ten patients (39.9%) underwent single non-coronary surgery, but none of the models is discriminative for aortic or mitral surgery. One hundred and eight patients died (6.7%), for an expected mortality rate of 10.0% by the logistic EuroSCORE and 4.5% by EuroSCORE II, setting the observed mortality at a midpoint between them and probably showing miscalibration of both models. Discrimination was also good (0.75 and 0.78, respectively), with also higher confidence intervals. Other combinations such as aortic or combined surgery require a more difficult analysis by the methodology used for data recruitment, and are intended to be shown in the forthcoming study. The funnel plot showed a non-significant trend towards underestimation, which became significant in the observed/expected ratio calculated by Nezic. This fact may be related to the level of significance used in each test. The funnel plot was constructed following the Spiegelhalter methodology [4] employing a 99% confidence interval, which is the most common in previous studies [5], whereas the calculations by Nezic were made with a 95% confidence interval. This small difference in the level of significance can transform the trend we described in a statistically significant difference, sometimes depending on only one postoperative death in the whole group. The message is that a degree of underestimation in EuroSCORE II must be taken into consideration when analysing surgical results, at least in our country. Finally, we must admit that the introduction statement may be confusing. We meant that the result of applying a predictive model to one specific patient is the individual likelihood of the expected result to happen in that patient. Overall results and quality studies are referred to group analysis and are not related to individual prognosis.

119. Reparación quirúrgica de la salida anómala del tronco de la coronaria izquierda desde el seno coronario derecho

Objetivos presentamos una reconstruccion quirurgica de la salida y el trayecto anomalo de la arteria coronaria izquierda desde el seno coronario derecho. Material y metodos se presenta el caso de un varon joven que debuto con una fibrilacion ventricular durante el ejercicio fisico. La coronariografia invasiva evidencio la salida anomala de la coronaria izquierda en el seno coronario derecho. La coronariografia no invasiva mediante tomografia computarizada multidetector (TCMD) mostro el origen acodado de la coronaria izquierda en el seno coronario derecho y un trayecto intramural aortico en intima relacion con la arteria pulmonar. La correccion quirurgica consistio en ampliar la raiz aortica con parche de pericardio heterologo creando un infundibulo hacia la salida de la coronaria izquierda, unroofing del trayecto intramural de la coronaria, y reposicionamiento de la comisura de la valvula aortica a la derecha del nuevo ostium. Resultados el postoperatorio transcurrio sin incidencias. El TCMD postoperatorio demostro la reconstruccion anatomica de la salida de la coronaria izquierda, sin acodamiento ni interferencia con la arteria pulmonar. A los 6 meses de seguimiento, se realizo ergometria que mostro capacidad funcional normal sin isquemia residual. Tras 3 anos de segui-miento el paciente se encuentra asintomatico. Conclusiones el origen anomalo de las coronarias es una alteracion congenita rara asociada a muerte subita. Cuando existe un trayecto intramural, el unroofing es la tecnica mas empleada. La TCMD es util para la planificacion preoperatoria, permitiendo individualizar la reconstruccion quirurgica, y para evaluar en el postoperatorio el resultado anatomico.

118. Explante de electrodos endocárdicos con el sistema cook-evolution®. Experiencia inicial

Objetivos el sistema Cook-Evolution ® es un dispositivo mecanico disenado para la extraccion de electrodos endocavitarios cardiacos retenidos. Se trata de una vaina con un mecanismo de cuchillas giratorias en uno de sus extremos que permite liberar las adherencias que se forman entre el endocardio y el electrodo. En el presente estudio analizamos nuestra experiencia inicial con este dispositivo. Material y metodos se incluyeron todos los pacientes a quienes les fue explantado uno o mas electrodos endocardicos con este sistema entre junio de 2009 – enero de 2012. El sistema fue utilizado en todos aquellos pacientes con indicacion de explante de los electrodos en los que estos no pudieron ser extraidos mediante traccion simple. La intervencion fue llevada a cabo en todos los casos con anestesia local y sedacion. Resultados se estudiaron 34 pacientes (25 varones, 9 mujeres, edad media 68 anos) a los que se explantaron un total de 48 electrodos (14 auriculares, 19 ventriculares, 10 desfibriladores automaticos implantables, 3 VDD y 2 en seno coronario) implantados por puncion de vena subclavia en todos los casos (derecha en 5 pacientes, izquierda en 29 pacientes). El tiempo medio transcurrido desde su implantacion fue de 93 meses. La extraccion fue completa en 41 (85%) de los electrodos. No hubo mortalidad asociada al procedimiento y 3 pacientes presentaron complicaciones (hematoma de herida, absceso de herida y hematoma mediastinico autolimitado). Conclusiones en nuestra experiencia, el sistema Cook-Evolution ® parece ser una herramienta eficaz y segura para la extraccion de electrodos endocardicos.

Reparación valvular mitral en un caso de endocarditis de Libman-Sacks

La endocarditis de Libman-Sacks es una forma de endocarditis no bacteriana asociada a los pacientes con lupus eritematoso sistemico (LES). Aunque con frecuencia cursa de forma asintomatica, en ocasiones es causa de insuficiencia cardiaca grave. Presentamos un caso de reparacion valvular mitral en una paciente aquejada de esta infrecuente entidad, que debuto clinicamente con un edema agudo de pulmon secundario a insuficiencia mitral masiva. La reparacion valvular mitral puede ser un procedimiento eficaz y seguro, que permite evitar el riesgo adicional asociado al uso de protesis valvulares en estos pacientes con riesgo trombotico elevado.

Aneurisma del seno de Valsalva derecho

Varon de 60 anos con antecedente de hipertension arterial, diagnosticado incidentalmente de aneurisma del seno de Valsalva derecho de 7 cm con insuficiencia aortica ligera. Bajo circulacion extracorporea y pinzamiento aortico se reseca el aneurisma y se reconstruye el defecto con un parche de protesis Dacron Hemashield Platinum® (Maquet, Rastatt, Alemania), reimplantando el ostium coronario derecho y realizando derivacion aortocoronaria a primera marginal con vena safena (hallazgo en cateterismo preoperatorio). La ecocardiografia intraoperatoria objetivo insuficiencia aortica trivial residual. Como complicacion postoperatoria presento ictus en el territorio de la cerebral media izquierda, con restitutio ad integrum.

Post-infarction left ventricular false aneurysm.

For reprint information contact: C.A. Mestres, MD Tel: 34 93 227 5515 Fax: 34 93 227 5749 Email: cmestres@clinic.ub.es Cardiovascular Surgery Department, Hospital Clinic, University of Barcelona, C/Villarroel, 170; Barcelona (E-08036), Spain. ASIAN CARDIOVASCULAR & THORACIC ANNALS 512 2008, VOL. 16, NO. 6 Figure 1. Coronary angiography suggests false left ventricular aneurysm during ventriculography.