Carlos-A. Mestres

Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1).

OBJECTIVES Assessment of long-term results of immunodeficiency virus type-1 (HIV-1)-infected patients undergoing cardiac surgery. METHODS Retrospective analysis of profile and outcomes of 31 HIV-1-infected patients (35 operations, 1985-2002). RESULTS Twenty-seven males and four females (mean age 34.67) in three groups: acute infective endocarditis (AIE) 21 (67.74%), coronary (CAD) 5 (16.13%) and non-infective valvular disease (NIVD) 5 (16.13%). HIV factors: drug addiction (23-74.19%), homosexuality (5-16.12%), heterosexuality (3-9.67%), hemodialysis (1-3.22%). HIV stage: A (17), B (2), C (2) in AIE; A (2), B (3) in CAD and A (3), C (2) in NIVD. Mean preoperative CD4 count was 278 cells/microL (12<200 cells/microL, 38.7%). The most frequent pathogens: S. aureus (52.38%), S. viridans (23.8%), Candida (19.04%). Native valve involved in 22 cases (78.33%) and prostheses in 8 (26.67%); 8.57% were operated in 1980-1985, 14.28% in 1986-1990, 22.85% in 1991-1995 and 54.28% in 1996-2002 with 16 elective (48.17%), 17 urgent (45.71%) and two emergencies (5.71%); mean aortic clamping and cardiopulmonary bypass time 78.9 and 107.47 min. Hospital mortality was 22.58 and 28.57% in AIE. No CAD patient died. Nine patients (37.5%) died between 2 and 171 months (mean 54.5). Mortality was 50% in AIE. CD4 count increased from 185.33 to 396.55 cells/microL (P=0.43) in nine patients on antiretrovirals. Fifteen-year actuarial survival is 58.16% overall and 48.01% for AIE. CONCLUSIONS There is an increase in HIV-1-infected patients requiring cardiac surgery, a decrease in AIE, however NIVD and CAD increasingly seen. Cardiac surgery did not blunt CD4 response induced by antiretrovirals. The late cause of death were not AIDS-related events.

Delayed sternal closure for life-threatening complications in cardiac operations: An update

Over a 7-year-period, 25 patients had delayed sternal closure after open heart operations out of 34 patients whose sternum was not closed. The indications were extreme cardiac dilatation and uncontrollable mediastinal hemorrhage. This represented a 1.79% incidence in the overall open heart surgical experience at our unit. Sternal closure was performed at a mean of 2.64 days after the initial operation. Eighteen patients (52.9%) left the hospital alive and well, representing a 72% survival rate among patients undergoing delayed sternal closure. No mediastinal or fatal infection developed and only 1 patient had late superficial wound infection after delayed sternal closure. We conclude that delayed sternal closure is an effective method to treat severe complications after cardiac operations.

Specialist valve clinics: recommendations from the British Heart Valve Society working group on improving quality in the delivery of care for patients with heart valve disease

The population prevalence of moderate or severe valve disease in industrialised countries is as high as 13% in those aged 75 years or older.1 Undetected valve disease leads to premature death1 but valve surgery, when indicated, can prolong life.2 Access to medical care in industrialised countries is usually good, but limitations exist3 and better ways of organising care are needed.4 A working group was therefore convened by the British Heart Valve Society with representatives of all interested national bodies and a panel of invited international commentators. The aim was to produce recommendations to improve the detection, conservative management and interventional treatment of valve disease. This paper focusses on conservative management and proposes recommendations for overcoming limitations in care by means of a specialist valve clinic. The initial management of patients with valve disease is usually conservative and meticulous follow-up is then vital. However, accepted management guidelines are not followed adequately.5–7 Furthermore, the application of accepted guidelines requires specialist experience especially in determining whether a patient is genuinely asymptomatic. Most patients with valve disease are still cared for by general cardiologists or general physicians who may be less skilled than a valve disease specialist in making a diagnostic formulation. Furthermore, it is likely that advances in practice are more slowly assimilated by a generalist than by a cardiologist who undertakes specialist continuing education. As a result, patients are often referred for surgery too late. In the EuroHeart Survey,6 approximately one half of patients were in New York Heart Association class III or IV at the time of valve surgery. At least one third of elderly patients with severe aortic stenosis are not referred for surgery at all even when clinically indicated.8 Developing a percutaneous valve programme leads to increased rates of conventional surgery suggesting …

Management of persistent tricuspid endocarditis with transplantation of cryopreserved mitral homografts

Transplantation of the human mitral valve in the tricuspid position for intractable infective endocarditis has been successfully performed in three young patients who were addicted to drugs. The maximum follow-up is 20 months. The rationale and historical basis for using this approach in the surgical treatment of patients with right-sided infective endocarditis is discussed and the appropriate literature reviewed. Because the technical aspects have been previously reported, this article can be considered an argument to renew past interest in atrioventricular valve replacement with fully biologic tissue of human origin.

The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience

OBJECTIVES Providing effective treatment for complicated type B aortic dissection (AD) with concomitant pathologies of the aortic arch or ascending aorta is challenging, especially if the aortic anatomy is contraindicated for thoracic endovascular aortic repair (TEVAR). We present the early results of a multicentre study using the frozen elephant trunk (FET) technique for type B AD. METHODS From January 2005 to March 2013, data from 465 patients who had undergone treatment with the FET technique were collected in the database of the International E-vita Open Registry. From this cohort, 57 patients who had a primary indication for surgery for type B AD were included in the present study. Their mean age was 58±12 years, and 72% had a chronic dissection. All operations were performed in circulatory arrest and bilateral antegrade cerebral perfusion. Computed aortic imaging was performed for false lumen (FL) evaluation during the follow-up. RESULTS The in-hospital mortality rate was 14% (8/57). Stroke and spinal cord injury occurred in 6 (10%) and 2 patients (4%), respectively. The rate of immediate FL thrombosis at the level of the stent graft was 75% (40/53) and increased to 97% (41/42) during the follow-up period (23±19 months). Distally, at the level of the abdominal aorta, the FL remained patent in 50% (21/42) of patients. The 1- and 3-year survival was 81 and 75%, respectively. CONCLUSION The FET technique is a feasible therapeutic option for complicated type B AD with involvement of the aortic arch if TEVAR is contraindicated. In contrast to conventional aortic surgery via a lateral thoracotomy, the FET procedure can provide simultaneous treatment of the ascending aorta and aortic arch.

Large-caliber cryopreserved arterial allografts in vascular reconstructive operations: Early experience

Between October 1992 and June 1994, 16 patients (mean age, 55.6 years) underwent vascular reconstruction using cryopreserved arterial allografts. Aortoiliac aneurysms, vascular infections, and trauma accounted for the majority of case diagnoses. Twenty allografts were implanted. Two patients died in the hospital (12.5%) and 1 patient died 9 months after the operation. Early patency rate on angiography is 92.9%. Follow-up averages 8.2 months. Large-caliber cryopreserved arterial vascular allografts seem to provide satisfactory clinical results.

Video-assisted cardioscopy for removal of primary left ventricular myxoma.

Left ventricular myxoma is a rare benign cardiac tumor. Surgical excision is the treatment of choice and completeness of removal is mandatory to avoid late recurrence. A case is presented in which aortic transvalvular video-assisted cardioscopy was used to facilitate removal.

One-stage repair in complex multisegmental thoracic aneurysmal disease: results of a multicentre study †

OBJECTIVES Patients with thoracic aneurysmal disease involving the arch and the descending or thoracoabdominal aorta may require more than one surgical intervention. The results of one-stage repair using a hybrid stent-graft in the frozen elephant trunk manner are presented. METHODS Between January 2005 and March 2012, 113 (age 67 ± 10 years) of 358 registered patients in the International E-Vita Open Registry were operated on for combined arch and descending and thoracoabdominal aortic aneurysm. Thirty-one (27%) patients had a previous cardiothoracic, abdominal aortic surgery or endovascular repair. The E-Vita Open hybrid stent-graft was used in all cases. Postoperatively and during the follow-up (100%), aortic image examinations were performed. RESULTS Combined arch replacement and antegrade stent-grafting distally (graft diameter 34 ± 4 mm) were performed under selective cerebral perfusion (72 ± 27 min) and hypothermic visceral ischaemia (65 ± 27 min). Postoperatively, aneurysm exclusion was completely and partially achieved in 80% and 20%, respectively. In-hospital mortality and survival rate after 5 years were 12% (13 of 113) and 78%, respectively. Latest aortic imaging demonstrated 93% complete aneurysm exclusion. Freedom from secondary endovascular intervention and open surgery were 88 and 90%, respectively. CONCLUSIONS In multisegmental thoracic aneurysmal disease, combined arch replacement with distal repair by a hybrid stent-graft enables one-stage treatment with acceptable mortality. Aneurysm exclusion by the stent-graft seems to be primarily curative and allows easier access for distal open or endovascular reintervention.

Cirugía Cardiovascular en España en los años 2009–2010. Registro de intervenciones de la Sociedad Española de Cirugía Torácica-Cardiovascular (SECTCV)

El Registro de Intervenciones de la Sociedad Espanola de Cirugia Toracica-Cardiovascular (SECTCV) de 2006-2008 lo integran datos de 52, 49 y 49 hospitales. Se realizaron 29.000 intervenciones/ano, media 585 intervenciones/centro. Dieciocho mil fueron intervenciones mayores bajo circulacion extracorporea (CEC), revascularizacion miocardica sin CEC o cirugia congenita sin CEC; media 372 intervenciones/hospital. Por tipos: valvular 40,6%, coronaria aislada 28,5%, combinada 9,5%, cirugia de la aorta 6%, congenita 10%, miscelanea 4%. Los procedimientos valvulares estan estabilizados, con ligero aumento de los aorticos; su mortalidad se incrementa 4% al asociarse a revascularizacion miocardica. Se realizaron 3.700 sustituciones valvulares aorticas aisladas, 1.600 mitrales y 60 tricuspideas. Se implantaron 10.500 protesis valvulares/ano, con un incremento de 1.000 en 3 anos, por las biologicas aorticas y anillos valvulares. Con mas de 5.000 casos de revascularizacion miocardica aislada, la mortalidad fue 4% con CEC y 3,7% sin CEC. Media 2,9 y 2,4 injertos/paciente. Procedimientos sobre la aorta ascendente 1.200/ano, con predominio sobre la raiz. Se intervinieron 1.700 pacientes por cardiopatias congenitas; 1.300 procedimientos abiertos, uno de cada tres menores de 1 ano y 400 cerrados. Se realizaron 276 trasplantes cardiacos en adultos, con mortalidad hospitalaria 18%. Se implantaron 5.000 marcapasos (1.400 cambios de generador), detectandose un descenso de 5%/ano, 450 implantaciones de desfibriladores y 150 cambios de generador. Se intervinieron 3.500 pacientes de cirugia vascular periferica, con 300 aneurismas aorticos y 600 intervenciones de cirugia arterial directa, 90 casos de troncos supraaorticos. Se analizan las intervenciones por cirujano y residente/ano y las reclamaciones judiciales.

Long-term Patency of Polytetrafluoroethylene Vascular Grafts in Coronary Artery Surgery

Patients undergoing coronary revascularization may not have suitable autologous vessels for coronary artery grafting and therefore may need vascular prostheses. We present a case report of a patient undergoing coronary artery bypass with polytetrafluoroethylene vascular grafts. Follow-up has been 53 months, and the grafts remain patent.