Eduardo Bernabeu

Acute aortic and mitral valve regurgitation following blunt chest trauma.

Traumatic rupture of intracardiac structures is an uncommon phenomenon although there are a number of reports with regards to rupture of the tricuspid, mitral and aortic valves. We report the case of a 25-year-old patient who presented with acute aortic and mitral valve regurgitation of traumatic origin. Both lesions were seen separated by 2 weeks. Pathophysiology is reviewed. The combination of both aortic and mitral lesions following blunt chest trauma is almost exceptional.

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.

Capillary Supply to the Sinus Node in Subjects with Long-Term Atrial Fibrillation

BACKGROUND Atrial ischemia, and sinus node ischemia in particular, may be involved in the pathogenesis of atrial fibrillation. In this study we compared the sinus node blood capillary content in normal hearts in sinus rhythm and in pathologic hearts with chronic atrial fibrillation and we analyzed the ultrastructural features of such capillaries. METHODS Sinus node biopsy specimens were obtained from 16 patients in chronic atrial fibrillation undergoing open heart surgery. Control sinus node specimens of normal hearts were obtained at autopsy from 7 subjects. Specimens were processed for immunohistochemical, light microscopy and transmission electron microscopy analysis and compared grossly and with morphometric techniques. RESULTS The proportion of sinus node tissue corresponding to capillaries, defined as blood vessel density (or BVD), was estimated as 1.06 +/- 1.47% for the atrial fibrillation group versus 2.12 +/- 2.0% for controls (p < 0001). Internal capillary diameter averaged 21.6 microm in the atrial fibrillation group and 24.2 microm in controls (p = 0.175), whereas external diameter averaged 32.2 microm in the atrial fibrillation group and 38.9 microm in controls (p = 0.052). Ultrastructural analysis demonstrated scarce and interrupted myoendocardial bridges and abnormal deposits of elastic fibers under the endothelial basal membrane at the level of precapillary sphincters and metaarterioles of atrial fibrillation specimens. CONCLUSIONS There is a significant reduction in the amount of capillaries in the sinus node of hearts in chronic atrial fibrillation. Our findings would support a potential association between sinus node tissue ischemia and chronic atrial fibrillation.

Aortic valve calcium scoring is a predictor of paravalvular aortic regurgitation after transcatheter aortic valve implantation

Degenerative aortic stenosis is the most common native valve disorder in the ageing population of industrialized nations. Surgical aortic valve replacement has excellent clinical outcomes but there is an increasing number of patients with severe aortic stenosis who are not considered surgical candidates because of significant co-morbidity. Transcatheter aortic valve implantation (TAVI) has been established as a clinically accepted minimally invasive therapeutic option for selected high-risk patients with symptomatic aortic valve stenosis (1-4). The Edwards SAPIENTM prosthes i s (Edwards Lifescience, Irvine, USA) which can be deployed via both transfemoral and transapical routes, and the CoreValve Revalving System® (CoreValve Inc., Irvine, California) which is inserted only via a transfemoral approach, represent the currently used transcatheter aortic valves. The technical feasibility has been shown for both approaches (5,6) and when successful, transcatheter aortic valve replacement results in marked hemodynamic and clinical improvements (7,8). However, despite a clear benefit of survival and improvement in symptoms (1,2), TAVI is also associated with post-implantation paravavular aortic regurgitation (PAR) in up to 60% of patients (3). In contrast with surgery, TAVI does not involve excision of the diseased native valve. The metal stent of the implanted device leads to compression of native valve cusps and associated calcification against the aortic annulus and aortic wall. The precise mechanism behind this phenomenon remains unclear. PAR may be related to the specific anatomy of the annulus and aortic root, as well as to the amount and distribution of leaflet and annular calcification (9). Although efforts have been made to reduce this incidence significantly (10,11), PAR still necessitates additional interventions in a considerable number of patients and its presence is known to confer a higher mortality rate amongst patients undergoing TAVI procedures (12). This has led to guarded acceptance of TAVI in patients others than those in high-risk or inoperable patient populations. Therefore, careful patient selection is of fundamental importance to avoid intraoperative complications. Excessive calcification of the aortic valve cusps may result in haemodynamically relevant PAR (10), further sustaining pressure overload, which is poorly tolerated by these patients. As a result, several imaging methods have been routinely used for procedure planning and proper device selection (9,13-20). The size of the aortic annulus is commonly assessed by transoesophageal echocardiography (TEE) (9), and multidetector row computed tomography (MDCT) (14,15). MDCT has increased its role because it not only enables the evaluation of the distances from the annulus to the coronary ostia, but also allows accurate detection, localization and quantification of aortic valve calcification and calcification of the entire aorta (14-22). It has been demonstrated that the amount of aortic valve calcium is associated with unfavorable prognosis (23). Recent studies using MDCT have focused on the role of aortic valve calcium (AVC) and its relation to post TAVI AR (17-22). We are providing a video presentation entitled “Aortic valve calcium scoring is a predictor of paravalvular aortic regurgitation after transcatheter aortic valve implantation” (Video 1). Aortic valve calcium scoring is a predictor of paravalvular aortic regurgitation after transcatheter aortic valve implantation

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.

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.