Francisco Nistal

Comparison of Doppler-determined elevated pulmonary arterial pressure with pressure measured at cardiac catheterization

This study assesses use of pulsed Doppler echocardiography to measure pulmonary artery (PA) pressure. PA flow at the right ventricular (RV) outflow tract was analyzed in 51 patients. Attention was focused on PA flow morphologic pattern, RV systolic intervals, time to peak flow and acceleration time index. Correlation was made with PA pressure and total pulmonary resistance. Three morphologic patterns of PA flow were found: type I indicates normal PA pressure (sensitivity 85%, specificity 100%) and types II and III indicate PA hypertension (sensitivity 100%, specificity 85%). The RV preejection/RV ejection ratio, time to peak flow and acceleration time index show a good correlation coefficient improved when a logarithmic function was applied. The best correlation was achieved with time to peak flow (r = -0.77 with PA pressure, r = -0.79 with total pulmonary resistance), and especially with acceleration time index (r = -0.84 with PA pressure, r = -0.87 with total pulmonary resistance). Analysis of pulmonary flow is a reliable new tool for evaluating PA pressure and is even better for evaluating total pulmonary resistance. Acceleration time index is the parameter that correlates best with these 2 variables.

Degeneration in porcine bioprosthetic cardiac valves: Incidence of primary tissue failures among 938 bioprostheses at risk

From June 1974 through December 1980, 938 porcine xenografts were inserted in 794 selected patients who survived surgery and who were considered at risk for primary tissue valve failure. Sixty-three instances of primary tissue valve degeneration occurred in 59 of the 794 patients. In patients operated on 9 years ago, 29% of the valves implanted in the mitral position (5 of 17) and 27% in the aortic position (3 of 11) failed. These percentages decreased to 18% (14 of 80) and 20% (11 of 54) for those implanted in 1975, 8% (6 of 73) and 14% (7 of 51) for those implanted in 1976, 9% (6 of 68) and 5% (4 of 76) for 1977, and 4% (3 of 79) and 3% (2 of 63) for 1978. The average interval between valve placement and explantation or death was 56 months (range 10 to 98) for valves in the mitral position and 68 months (range 12 to 92) for valves in the aortic position. The rate of valve survival without degeneration was 98 +/- 1% at 4 years, 96 +/- 2% at 5 years, 90 +/- 3% at 6 years, 87 +/- 4% at 7 years and 76 +/- 7% at 8 and 9 years. Until 1978, 4 valves failed, 8 failed in 1979 to 1980, 12 in 1981, 25 in 1982, and 14 have already failed from January to May 1983. Our figures show a progressive increase in valve degeneration with the passing of time. No leveling of this failure rate has so far been observed.

Comparative study of primary tissue valve failure between lonescu-shiley pericardial and Hancock porcine valves in the aortic position

From August 1977 to June 1981, 221 patients received a Hancock porcine valve and 133 an Ionescu-Shiley bovine (I-S) pericardial valve as aortic valve substitutes. No special selection or randomization was used and no patient with either of these types of valves was excluded. Preoperative data show no differences between the groups influencing the appearance of primary tissue failure. Hospital survivors were followed until June 1984 and those with an uneventful history at least 36 months. Patients who died late postoperatively or who underwent reoperation for causes other than primary dysfunction were considered at risk until death or reoperation. Primary tissue failure occurred in 8 patients in the I-S group from 36 to 70 months postoperatively and in 6 patients of the Hancock group from 24 to 83 months. Linearized rates of primary failure were 0.61 valves per 100 patient-years for the Hancock and 1.70 valves per 100 patient-years for the I-S group. Mean age of patients with failing valves was 38 years (range 25 to 55) for Hancock valves and 39 years (range 15 to 62) for I-S valves. Actuarial analysis shows a lower rate of primary dysfunction in the Hancock group since the fourth year, which is statistically significant in the sixth and seventh years (96.5 +/- 1.5% vs 79.6 +/- 7.6% in the sixth year and 93.1 +/- 3.6 vs 79.6 +/- 7.6% in the seventh year). Microscopically, calcium and collagen degeneration were consistently associated and present on failing bioprostheses.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of primary tissue valve failure in porcine bioprosthetic heart valves

This report provides retrospective follow-up data on 324 consecutive patients who received a Hancock-I porcine valve in the aortic or the mitral position, or in both positions, between June, 1974, and December, 1976. This analysis included 319 valves (193 mitral, 126 aortic) available for study of the incidence of primary tissue valve failure after 10 to 12.5 years of follow-up. Of the 319 prostheses at risk, 114 instances of primary tissue valve failure occurred. Seventy-three of the failed valves were in the mitral position, and 41 were in the aortic position. The calculated actuarial probability of freedom from primary tissue valve failure was 52 +/- 5% for the mitral and 58 +/- 6% for the aortic prostheses at 12.5 years of follow-up. For patients older than 40 years at the time of operation, the rate of freedom from primary failure was 68 +/- 8% and 55 +/- 6% for aortic and mitral prostheses, respectively, at 12.5 years. Comparison of both actuarial curves disclosed no meaningful difference. However, a tendency toward greater failure rate was observed in the mitral prosthesis group.

Comparative study of primary tissue failure between porcine (Hancock and Carpentier-Edwards) and bovine pericardial (Ionescu-Shiley) bioprostheses in the aortic position at five- to nine-year follow-up.

Retrospective follow-up data on 458 consecutive patients who received a Hancock, Carpentier-Edwards (C-E) or Ionescu-Shiley (I-S) bioprosthesis in the aortic valve position between April 1978 and December 1981 are reviewed. A total of 461 valves (184 Hancock, 131 C-E and 146 I-S) were available for study of the incidence of primary tissue valve failure after 5 to 9 years of follow-up. Cumulative follow-up was 1,016 patient-years for patients with Hancock valve, 688 for the C-E and 767 for the I-S group. Of the 397 prostheses at risk (154 Hancock, 120 C-E and 123 I-S), 36 instances of primary tissue valve failure occurred (12 Hancock, 7 C-E and 17 I-S). On an actuarial basis, the calculated probability of freedom from primary tissue valve failure was 88 +/- 4% for the Hancock group, 87 +/- 6% for the C-E and 51 +/- 17% for the I-S at 9 years. The linear incidence of tissue valve failure was 1.2 failing valves per 100 patient-years for the Hancock group, 1 for the C-E and 2.2 for the I-S. In a cohort of patients older than 40 years of age at the time of valve replacement, the rate of freedom from primary failure was 98 +/- 1%, 87 +/- 9% and 44 +/- 22% for the Hancock, C-E and I-S groups, respectively, at 9 years. Comparison of actuarial curves disclosed a meaningful difference between the pericardial valve and the Hancock and C-E porcine bioprostheses at 9-year follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Spanish Acute Aortic Syndrome Study (RESA). Better Diagnosis Is Not Reflected in Reduced Mortality

INTRODUCTION AND OBJECTIVES Because acute aortic syndrome (AAS) is associated with high mortality, early diagnosis and treatment are vital. The aim of the Spanish Acute Aortic Syndrome Study (RESA) was to investigate the effectiveness of current treatment of AAS in a broad range of tertiary care hospitals in Spain. METHODS Between January 2005 and December 2007, 24 tertiary care hospitals reported data on 519 patients with AAS (78% male, mean age 61 +/- 13 years, range 20-92 years): 357 had type-A AAS and 162 had type B. RESULTS The time delay between symptom onset and diagnosis was <24 hours in 67% of cases and >72 hours in 11%. Some 80% of patients with type-A AAS were treated surgically. The interval between diagnosis and surgery was <24 hours in 90% of cases. In patients with type-B AAS, 34% received invasive treatment: 11% had surgery and 23% underwent endovascular procedures. Mortality during hospitalization in patients with type-A disease was 33% in those treated surgically and 71% in those treated medically. Mortality in patients with type-B disease was 17% with medical treatment, 27% with endovascular treatment and 50% with surgical treatment. CONCLUSIONS Despite significant advances in the diagnosis of AAS, in-hospital mortality remains high. The findings of this study are representative of a broad range of unselected patients undergoing treatment for the disease and support the need for continuing improvements in therapeutic approaches to AAS.

Primary Tissue Valve Degeneration in Glutaraldehyde-Preserved Porcine Bioprostheses: Hancock I Versus Carpentier-Edwards at 4- to 7-Years' Follow-up

In the 32-month period between April, 1978, and December, 1980, 292 patients, divided into two equal groups, received a glutaraldehyde porcine bioprosthesis--either Hancock or Carpentier-Edwards (CE)--as mitral valve substitute. Every patient receiving a mitral porcine xenograft during that time was included in the study. The type of bioprosthesis was always selected by the surgeon and not randomly. Preoperative clinical characteristics, associated surgical procedures, valve implantation sizes, and follow-up data showed no relevant differences between the two groups. There were three instances of primary tissue failure in the Hancock group and six in the CE (linearized rates of 0.49 and 0.97 events percentage of patient/years, respectively). Mean duration of explanted valves and microscopic findings were similar in both groups. Primary tissue failure was more frequent in patients under 40 years of age in both groups, although differences were not statistically significant. A marginally significant trend toward greater incidence of tissue failure in patients of 40 years of age and older was seen in the CE group when compared with the Hancock group. Actuarial survival of the bioprostheses free from primary tissue failure was 6.5 years of 95 +/- 3% (mean +/- standard error) for Hancock and 84 +/- 9% for CE (p = NS). No significant difference in terms of durability has been found between the two most popular glutaraldehyde porcine bioprostheses, although the behavior of the CE in patients older than 40 years should be reassessed in a study with a larger number of patients and a longer follow-up period.

Long-term performance of porcine heart valve bioprostheses.

To assess the results after long-term implantation of porcine bioprosthetic heart valves, 320 patients with 381 valves were retrospectively reviewed. This group included all patients receiving one such xenograft in the mitral or aortic position (or both) in our institution between June 1974 and December 1976. The patients had a follow-up of 9-11.5 years. Actuarial patient survival rats (hospital mortality excluded) were 85%-90% at 6 years and 68%-79% at 11.5 years. Thromboembolic episodes did not show any significant clustering over the first weeks or months, in fact, they appeared at a constant rate. Actuarial rates of freedom from thromboembolism were greater than 90% for aortic patients at 11.5 years and greater than 80% for mitral and mitroaortic patients at 11.5 years. The linearized rate of anticoagulant-related haemorrhage for the whole group of patients was 0.4 events/100 patient years with a related mortality of 0.2 events/100 patient years. Prosthetic valve endocarditis and paravalvular leak appeared at linearized rates of 0.6 (0.1 of related mortality) and 0.4 (0.1 of related mortality) events/100 patient years. Primary tissue valve failure constituted the most prevalent complication (82 cases) in the long term but did not significantly worsen patient survival. Actuarial rates of freedom from primary tissue failure were 91% +/- 2% at 6, and 40% +/- 14% at 11.5 years for mitral valves, and 95% +/- 4% at 6 and 64% +/- 6% at 11.5 years for aortic valves.(ABSTRACT TRUNCATED AT 250 WORDS)

Current Surgical Treatment of Calcified Aortic Stenosis

Currently, aortic stenosis is the main indication for cardiac surgery in western countries. With the aim of describing the clinical and surgical characteristics and the short-term outcome of current surgical treatment, we carried out a retrospective study of 238 patients (mean age 71 years, 43% female) who underwent surgery during 2002-2003. Of these, 73% had a EuroSCORE >6. Surgical procedures included isolated aortic valve replacement in 61%, ascending aorta surgery in 14%, coronary artery by-pass grafting in 21%, and mitral surgery in 4%. The in-hospital mortality rate in the 30 days after surgery was 7.1%. Multivariate analysis, adjusted for age, sex and left ventricular ejection fraction, showed that only concomitant coronary artery by-pass grafting was significantly associated with in-hospital mortality (odds ratio=4; P=.019). Factors associated with mortality at 18 months were: previous neurological disease (hazard ratio [HR]=3.25; P=.017), prosthesis diameter <21 mm (HR=2.86; P=.018), and coronary artery by-pass grafting (HR=2.35; P=.05).

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

Background: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. Methods: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22–92), 443 type A (70.4%) and 186 type B (29.6%). Results: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th–75th percentiles, 2.7–15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1–3, 2.5–11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. Conclusion: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.