Gerardo Soca

Two cases of pulmonary homograft replacement for isolated pulmonary valve endocarditis.

Isolated pulmonary endocarditis is rare. Two cases that required surgical treatment are reported: a 35-year-old woman with predisposing factors for right-sided endocarditis who presented with complete heart block; and a healthy 65-year-old man with no predisposing factors who was admitted with septic shock. Both patients presented with septic shock and pulmonary septic emboli requiring urgent surgical treatment. Surgical correction using pulmonary homograft was done, with immediate postoperative recovery. The current literature of isolated pulmonary endocarditis is also reviewed.

First-degree relatives of bicuspid aortic valve patients with normal aortic dimensions do not carry an increased risk of aortic dilatation

Bicuspid aortic valve (BAV) is the most common congenital cardiac diseasewith an estimated incidence in the North American population of 1–2% [1]. Patients with BAV have a lifetime risk of 22–25% of surgery due to aortic valve disease and/or ascending aorta dilatation [1]. This has encouraged cardiac surgeons to be more aggressive in considering replacement of the ascending aorta at a lower diameter (50 mm) than in tricuspid aortic valve (TAV) patients (55 mm) [2]. Recent studies have questioned this kind of “paradigm” [3,4]. First-degree relatives (FDR) of BAV individuals are at an increased risk of inheriting a BAV (9%), or any congenital cardiac disease (31%) [5]. Recently, Biner et al. have shown that 32% of FDRs of BAV patients have dilated aorta [6]. Based on these data, guidelines recommend as class IC, echocardiographic evaluation of all FDR of patients with BAV in search of aortic dilatation and/or BAV [2]. In Biner et al.s study, BAV patients from whom FDRs were contacted had normal and pathological aorta. We hypothesized that FDRs of BAV patients with normal aortic diameter share a similar risk of aortic dilatation as FDRs of TAV patients. Patients with BAV and TAV who underwent isolated aortic valve replacement and had normal aortic dimensions were identified from the database. FDRs of these patients were contacted by phone to participate in this study. The study complies with the Declaration of Helsinki. Informed consent was obtained and the ethical review board approved the study. Echocardiographic evaluation was done entirely at the echocardiography laboratory of the Department of Cardiology of the University Hospital (Hospital de Clinicas). A single observer supervised by an expert blinded to anthropometric and clinical data of participants performed the measurements. Aortic dimensions (annulus, root, sino-tubular junction, ascending aorta) were obtained during end systole and indexed to body surface area of patients. In order to calculate the sample size needed to find differences between both groups, we used published data obtained from a sample of North American individuals [6]. Based on these data our sample size calculation estimated a total of 20 individuals per group. Continuous data were presented as mean ± standard deviation (SD) and categorical variables as percentage. Continuous variables were compared using independent t test. For comparison of categorical data among the study groups, the Fisher exact test was used. Analysis was performed using the statistical software program SPSS version 18. The significance level was set at p b 0.05. Body surface area was significantly greater in FDR of TAV patients than in BAV patients (p = 0.006). This was mainly due to a higher weight (p = 0.006) (Table 1). All evaluated patients had a normal functioning tricuspid aortic valve. No differences were found at either of the aortic segments between both groups (Fig. 1). There is no evidence regarding the risk of aortopathy in tricuspid FDR of BAV individuals with normal aortic dimensions. The only published report in the matter, documents that aortic root dilation is highly prevalent (32%) in tricuspid FDRs of BAV patients [6]. In this study [6], FDRs were derived from BAV patients in whom 53% had a dilated aorta. Our results show that FDRs of BAV and TAV patients with

Is patient–prosthesis mismatch a predictor of survival or a surrogate marker of co-morbidities in cardiac surgery?☆

BACKGROUND Patient-prosthesis mismatch (PPM) has ignited much debate and no definite conclusions have been drawn on the outcome of these patients. Therefore, additional large studies with long-term follow-up are required to help the cardiologist and surgeon outline the best therapeutic strategy for patients with high risk for PPM. METHODS Patients who underwent aortic valve replacement (AVR) from 2000 to 2013 were identified. Baseline and operative data was extracted and indexed effective orifice area calculated for each patient. The presence of PPM was defined in those patients with an iEOA ≤ 0.85 cm(2)/m(2). Regression analyses were performed to determine the association of PPM with operative mortality, post-operative complications and survival. Predictors for PPM were evaluated based on clinical and operative data. RESULTS From 2023 patients who underwent AVR, PPM was present in 64.6%. These patients had increased age, more coronary artery bypass procedures, increased risk of diabetes, hypertension, higher creatinine values and higher Euroscore. Age, body surface area, prosthesis type and size were found to be predictors of mismatch. Operative mortality (8.1% vs 5.7%, p = 0.05), stroke (3.9% vs 2.4, p = 0.02) and acute kidney injury (47.6% vs 35.1%, p =< 0 .001) were more frequent in patients with PPM and mean 10-year survival was reduced (6.6 years, 95% CI: 6.3-6.8 vs 7.3, 95% CI: 6.9-7.2, p < 0.001). After adjusting for confounders, PPM was not found to be associated to either adverse outcome or survival. CONCLUSIONS Patients with PPM have worse operative mortality, post-operative complications and survival mainly due to the fact that they represent a higher risk population based on age and co-morbidities.

CABG and Preoperative use of Beta-Blockers in Patients with Stable Angina are Associated with Better Cardiovascular Survival

Objective In contrast to unstable angina, optimal therapy in patients with stable angina is debated. Our aim was to evaluate the outcomes of patients with stable angina scheduled for isolated coronary artery bypass grafts and the effect of preoperative use of beta-blockers. Overall and cardiovascular survivals were our primary outcome. Operative mortality and postoperative complications along with subgroup analysis of diabetic patients were our secondary outcomes. Methods Retrospective evaluation of patients with stable angina scheduled for isolated coronary artery bypass grafts was included. Pre- and postoperative variables were extracted from the institution database. Survival was obtained from the National Registry. Results We included 282 patients with stable angina, with a mean age of 65.6±9.5 years. 26.6% were female and 38.7% had diabetes. Three-vessel disease was present in 76.6% of patients. Previous beta-blocker treatment was evident in 69.9% of patients. 10-year overall survival in the whole population was 60.5% (95% confidence interval [CI]: 50.3-70.7%). Operative mortality during the study period was 3.5%. Patients with preoperative use of beta-blocker therapy had better overall survival (9.0 years, 95%CI: 8.6-9.5) than those without treatment (7.9 years, 95%CI: 7.1-8.8 years; P=0.048). Predictors for overall survival were: hypertension, diabetes, and age. Predictors for cardiovascular survival in diabetic patients were: beta-blocker use, gender, and age. Conclusion Coronary artery bypass grafts surgery in patients with stable angina carries low operative mortality, postoperative complications, and excellent long-term cardiovascular survival. The preoperative use of beta-blockers in diabetic patients is associated with better cardiovascular survival after coronary artery bypass grafts.

Do Flow and Pulsatility Index within the Accepted Ranges Predict Long-Term Outcomes after Coronary Artery Bypass Grafting?

Background Transit-time flow measurement (TTFM) is the gold standard for intraoperative detection of graft failure. Several reports show that TTFM and distal coronary bed quality (DCBQ) may also be useful for midterm detection of graft failure. Nonetheless, there are no data regarding their predictive role on long-term outcomes. Methods Patients with three-vessel disease who underwent isolated coronary artery bypass grafting (CABG) in 2006 and received at least one graft to the left anterior descending artery (LAD) or to the first obtuse marginal (OM1) or posterior descending artery (PDA) were included. Baseline characteristics, mean graft flow, pulsatility index, and subjective impression of DCBQ for each coronary territory were collected. Long-term cardiovascular (CV) and overall survival, operative mortality, and new percutaneous coronary intervention (PCI) were evaluated. Results A total of 177 patients underwent isolated CABG. The OM1 was grafted in 131 patients, the LAD in 169 patients, and the PDA in 100 patients. Neither DQCB nor TTFM were predictors for new PCI. Independent predictors for overall survival were age, previous acute myocardial infarction (AMI), and DQCB of OM1 (odds ratio [OR] = 2.97; 95% confidence interval [CI]: 1.15-7.71). Age, previous AMI, and DCBQ of OM1 (OR = 2.5; 95% CI: 1.39-4.81) were independent predictors for CV survival. Conclusions TTFM on patients with functioning grafts does not predict long-term survival or performance of new PCI. Subjective evaluation of distal coronary bed, especially of the OM1, has a strong impact on long-term outcomes.

Early surgery after angiography in patients scheduled for valve replacement.

Background There are limited data regarding the risks of cardiac surgery early after coronary angiography in patients scheduled for isolated aortic and/or mitral valve replacement. Our aim was to evaluate the risk of early surgery after coronary angiography in these patients. Methods We retrospectively analyzed data of 1044 patients who underwent isolated aortic and/or mitral valve replacement from 2006 to 2014. Baseline, operative, and postoperative variables were collected. The patients were divided into 3 groups based on the interval between coronary angiography and surgery: ≤3 days (n = 216), 4–7 days (n = 109), and ≥8 days (n = 719). We evaluated hospital mortality and postoperative acute kidney injury. Subgroup analysis was performed according to preoperative creatinine clearance. Results Postoperative creatinine clearance was lower in patients who underwent surgery ≤3 days after coronary angiography (63.57 ± 38.52 mL min−1) compared to ≥8 days after coronary angiography (74.56 ± 54.25 mL min−1, p = 0.015). Patients who underwent surgery ≤3 days after coronary angiography had higher hospital mortality when preoperative creatinine clearance was ≤60 mL min−1 (12% vs. 4% for creatinine clearance ≤and >60 mL min−1, respectively; p = 0.039). Predictors of hospital mortality were New York Heart Association class and postoperative creatinine clearance. Conclusion Hospital mortality was higher in patients with decreased preoperative renal function who underwent surgery within the first 3 days after coronary angiography. Delaying surgery in this subgroup of patients could be a good strategy.

Aortic assessment of bicuspid aortic valve patients and their first-degree relatives

Background Bicuspid aortic valve patients have an increased risk of aortic dilatation. A deficit of nitric oxide synthase has been proposed as the causative factor. No correlation between flow-mediated dilation and aortic diameter has been performed in patients with bicuspid aortic valves and normal aortic diameters. Being a hereditary disease, we compared echocardiographic features and endothelial function in these patients and their first-degree relatives. Methods Comprehensive physical examinations, routine laboratory tests, transthoracic echocardiography, and measurements of endothelium-dependent and non-dependent flow-mediated vasodilatation were performed in 18 bicuspid aortic valve patients (14 type 1 and 4 type 2) and 19 of their first-degree relatives. Results The first-degree relatives were younger (36.7 ± 18.8 vs. 50.5 ± 13.9 years, p = 0.019) with higher ejection fractions (64.6% ± 1.7% vs. 58.4% ± 9.5%, p = 0.015). Aortic diameters indexed to body surface area were similar in both groups, the except the tubular aorta which was larger in bicuspid aortic valve patients (19.3 ± 2.7 vs. 17.4 ± 2.2 mm·m−2, p = 0.033). Flow-dependent vasodilation was similar in both groups. A significant inverse correlation was found between non-flow-dependent vasodilation and aortic root diameter in patients with bicuspid aortic valve (R = −0.57, p = 0.05). Conclusions Bicuspid aortic valve patients without aortopathy have larger ascending aortic diameters than their first-degree relatives. Endothelial function is similar in both groups, and there is no correlation with ascending aorta diameter. Nonetheless, an inverse correlation exists between non-endothelial-dependent dilation and aortic root diameter in bicuspid aortic valve patients.

Dilatación de la raíz aórtica en pacientes con válvula bicúspide tras la sustitución valvular aórtica

Background: Bicuspid aortic valve (BAV) has been closely correlated with aortic pathology. BAV patients have a high probability of being operated along their lifetime for aortic disease. Progression of aortic dilatation after aortic valve replacement (AVR) has not being definitely assessed. Methods: A total of 23 BAV with aortic diameter ≤ 45mm patients were followed for a mean of 8 years after AVR. Echocardiographic measurement of the aortic root and tubular aorta was done after a mean of 6 and 8 years post-operatively. Predictors for dilatation were estimated. Results: Paired comparison of aortic root diameter between 6 (34.6±7.4 mm) and 8 years (37.6±7.7 mm) of follow-up showed that its dimension increased significantly (p<0.023) while no differences were found with the tubular aorta. Dilatation was seen mainly in smokers, family history and dyslipemic patients. Univariate predictors for aortic root dilatation were: family history of BAV or aortic pathology, prosthesis size and body surface area (BSA). Multivariate regression evidenced only BSA (beta coefficient 11.5) and family history (beta coefficient 4.5) as significant predictors. Conclusion: Aortic root continues to dilate after AVR in BAV patients. Higher BSA and family history of aortic pathology were found as strong predictors of aortic root dilatation. These patients should be closely followed after AVR.

Cardiac denervation procedure to treat refractory angina in a patient with Churg–Strauss syndrome and non-obstructive coronary lesions

Cardiac involvement in Churg-Strauss syndrome is common and represents the main cause of mortality. We report the case of a patient with Churg-Strauss vasculitis, mitral regurgitation with left ventricular dysfunction, paroxysmal atrial fibrillation and refractory angina with non-significant coronary lesions. Cardiac denervation was proposed as an associated procedure to treat angina. The total removal of peri-adventitial and adventitial tissue around the superior vena cava, ascending aorta and main pulmonary trunk was performed. After 3 months of follow-up, the patient was angina-free and could resume his normal lifestyle.