José E. Rodríguez

Transapical off-pump aortic valve-in-a-valve implantation in two elderly patients with a degenerated porcine bioprosthesis.

Re-operative heart-valve replacement is a high-risk procedure and even more so in elderly patients. Another option in high-risk patients with a degenerated aortic xenograft is the implant of a second aortic bioprosthesis using a transcatheter approach. We report two cases of patients with a severely degenerated porcine aortic bioprosthesis who were successfully treated by a transapical valve-in-a-valve implantation.

Early recurrence is a predictor of late failure in surgical ablation of atrial fibrillation

We sought to determine if early recurrence of atrial fibrillation (AF) after surgical ablation is a risk factor of late failure. Between February 2004 to May 2009, 106 patients underwent surgical ablation of concomitant permanent AF with radiofrequency. Operations primarily consisted of valve surgery in 85% of patients. Hospital mortality was 2.8% (n = 3). The median follow-up was 37 months (interquartile rank 12-77), and was complete in 99% of patients. Freedom from AF was 82%, 76% and 68% at one, two and three years, respectively. Patients with early recurrence of AF had less prevalence of sinus rhythm in late follow-up (P < 0.001). Multivariate Cox regression analysis showed that AF duration [hazard ratio (HR) 1.014, 95% CI 1.009-1.020, P < 0.001] and early recurrence of AF (HR 3.45, 95% CI 1.50-7.95, P = 0.004) were independent risk factors for failure. In conclusion, in our series, early recurrence of AF after surgical ablation is a strong predictor of late failure.

Ascending Aorta and Aortic Root Reoperations: Are Outcomes Worse Than First Time Surgery?

BACKGROUND The aim of this study was to analyze surgery and survival data in the midterm after aortic root and (or) ascending aorta reoperations and compare these results with those obtained after first time surgery. METHODS Over a 6-year period, 365 patients underwent an aortic root and (or) ascending aorta surgery procedure at our center. Mean patient age was 63.1 + or - 25.5 years; 27.1% were women. Fifty-eight patients had had prior ascending aorta and (or) aortic valve surgery (group I) and the remaining 307 patients were assigned to an initial surgery group (II). The reoperative procedures were Bentall in 45 (77.6%), ascending aorta and valve replacement in 8 (13.8%), and ascending aorta replacement in 5 (8.6%). RESULTS The reoperation group showed a worse preoperative risk profile indicated by a higher logistic European system for cardiac operative risk evaluation: group I (26.9) versus group II (9.9) (p < 0.0001). Hospital mortality was 7 of 58 (12.1%) in group I and 21 of 207 (6.8%) in group II (p = 0.18; relative risk 1.9 [0.8 to 4.6]). After adjusting for the different variables, reoperation could not be identified as an independent predictor of postoperative morbidity. Survival rates (including in-hospital mortality) were lower in group I at one year (77.9 + or - 1.11% vs 91.9 + or - 0.3%) and at 3 years (75.3 + or - 0.11% vs 88.9 + or - 0.03% [log-rank p = 0.005]). In the multivariate analysis, reoperation (p = 0.01; hazard ratio 2.6 [1.2 to 5.3]) was a determining factor for survival once corrected for variables predicting mortality during follow-up. CONCLUSIONS Reoperations on the ascending aorta and aortic root showed acceptable morbidity and mortality. Their midterm survival was lower than for patients not requiring a repeat operation.

Delayed dislocation of a transapically implanted aortic bioprosthesis

Trans-apical aortic bioprosthesis implantation is currently evaluated as an alternative technique in high-risk patients. We report the case of a delayed upward displacement of a prosthesis after this procedure. It is hypothesised that the asymmetric calcification of the native valve and the presence of a mitral prosthesis caused the dislocation.

Can estimated glomerular filtration rate improve the EuroSCORE

Several studies have shown that the glomerular filtration rate is a strong predictor of mortality following cardiac surgery. This study was designed to identify the estimated glomerular filtration rate using the MDRD-4 equation as an independent predictive variable of mortality and to determine whether the inclusion of this variable could improve the discriminating power of the EuroSCORE. Data from 2014 consecutive patients who underwent cardiac surgery over a 3-year period were analysed. Mean glomerular filtration rate was 68.4+/-22.7 ml/min per 1.73 m(2); 704 patients (35%) showed a rate <or=60 ml/min/1.73 m(2). An estimated glomerular filtration rate <or=60 ml/min/1.73 m(2) was found to be an independent predictor of mortality adjusted for age, sex and EuroSCORE (P<0.001, OR 2.4, 95% CI 1.6-3.4). The discriminating power of the EuroSCORE improved when this variable was included: area under the ROC curve for EuroSCORE plus estimated glomerular filtration rate was 0.77 (0.73-0.81) compared to 0.75 (0.71-0.80) for the additive EuroSCORE (z=2.55, P<0.05) and 0.75 (0.71-0.80) for the logistic EuroSCORE (z=2.45, P<0.05). The estimated glomerular filtration rate using the MDRD-4 equation is an independent predictive factor of perioperative mortality in cardiac surgery. The inclusion of this variable could improve the discriminatory capacity of the EuroSCORE.

Resultados precoces de la ventriculectomía parcial izquierda (operación de Batista)

Introduccion y objetivos La escasez de donantes asi como la morbimortalidad asociada al trasplante han motivado el planteamiento de otras opciones quirurgicas para la miocardiopatia dilatada en fase terminal. Entre ellas se encuentra la ventriculectomia parcial izquierda, que implica la reduccion del diametro y la masa ventricular. Presentamos en este trabajo la experiencia inicial (no limitada a la alternativa al trasplante) y los resultados inmediatos de esta tecnica en nuestro centro. Metodos Hemos intervenido a 6 pacientes con miocardiopatia dilatada: cuatro de etiologia idiopatica y con motivos de exclusion para trasplante cardiaco y dos de origen valvular. Se practico reseccion de la pared lateral de ventriculo izquierdo entre los musculos papilares y cierre directo con sutura continua, asociandose anuloplastia mitral en 5 casos, tricuspidea en uno y sustitucion valvular aortica en los dos ultimos. Resultados Dos pacientes precisaron balon de contrapulsacion; uno fallecio por shock cardiogenico refractario y el otro a los 15 dias tras episodios de arritmia ventricular. Los estudios ecocardiograficos intraoperatorios pusieron de manifiesto una reduccion significativa del diametro diastolico (de 8,7 a 6,8 cm; p = 0,02) y de la insuficiencia mitral, con una mejoria en la fraccion de eyeccion (del 17 al 27%; p = 0,09) mantenidos en el ecocardiograma previo al alta. Conclusiones La tecnica es reproducible y adecuada como posibilidad terapeutica en la insuficiencia cardiaca en fase terminal. Quedan por precisar el grupo y tipo de paciente ideal, el manejo perioperatorio y el soporte a largo plazo.

Giant Right Atrial Dilation and Left Atrial Calcification

A65-year-old woman, with a history of rheumatic valvulopathy and mitral-aortic replacement surgery in 1983, was referred to our center by her cardiologist. She presented with severe tricuspid regurgitation and was sent to us to be considered for valvular surgery. At the point of admittance to the center, the patient had signs of right heart failure and cachexia, and she had a lower left sternal border pansystolic murmur. The electrocardiogram showed atrial fibrillation and right bundle branch block. A chest roent-

Right intra-atrial catheter insertion at the end stage of peripheral vascular access for dialysis.

The number of patients with end-stage renal failure requiring dialysis keeps increasing every year. Many of these patients also suffer from peripheral arterial disease. We report the case of a middle age woman receiving dialysis who had undergone amputation of both lower limbs and suffered multiple deep venous thrombosis. Therefore, peripheral accesses for venous dialysis were not available. A catheter had to be implanted right into the right atrium.

314. Extracción de dispositivos intracardíacos en pacientes sometidos previamente a procedimientos de cardiología intervencionista

Objetivos Descripcion de una cohorte de pacientes sometidos a la implantacion de algun dispositivo intracardiaco percutaneo (DCIP) que finalmente fueron intervenidos quirurgicamente por disfuncion de los mismos. Material y metodos Se analizo de forma retrospectiva toda la cohorte de pacientes sometidos a extraccion de DCIP intervenidos en nuestro centro. Se describe la muestra de pacientes y se resumen los resultados quirurgicos. Resultados Desde julio de 2007 – julio de 2011, 25 pacientes intervenidos tras haberse sometido al implante de algun DCIP; 18 mujeres. Edad mediana: 64 anos (rango 26–90). EuroSCORE logistico preimplante de DCIP 6% interquartile range (IQR) (4–9%) y prequirurgico 10% IQR (8–14%). En 8 se implanto Amplatzer para cierre de CIA: 5 quedaron con shunt residual importante; 2 libres en auricula derecha (AD); 1 en ventriculo derecho (VD); 1 implante de Amplatzer para cierre de comunicacion interventricular (CIV) postinfarto agudo de miocardio (post-IAM) con fracaso terapeutico y perforacion de VD. En 8 se implanto un Amplatzer para cierre de leak protesico mitral y 2 aorticos, quedando todos incompetentes; 1 implante de Mitraclip con desagarro del aparato subvalvular e insuficiencia mitral (IM) grave; 5 casos de implante de protesis aorticas transapicales (TAVI) transfemoral con 3 desgarros ventriculares y 2 migraciones de la protesis hacia ventriculo y aorta ascendente. En todos se extrajo el dispositivo y se procedio a sustitucion valvular, cierre de defecto y/o contencion de rotura ventricular. Cuatro pacientes fallecieron. Conclusiones La extraccion de DCIP se esta convirtiendo en una indicacion frecuente de cirugia cardiaca. El riesgo quirurgico aumenta ostensiblemente en la cirugia de retirada de DCIP. Es necesario definir con mas precision esta nueva poblacion de pacientes asi como conocer sus resultados operatorios.

Tricuspid Valve Stenosis Due to a Pacemaker Lead

the maximum gradient was 11 mm Hg, mean gradient 7.7 mm Hg, and the area was 0.76 cm2 (Figure 1). During surgery, we found a highly unstructured tricuspid valve with severe stenosis due to fusion of the commissures and thickening of the subvalvular apparatus (Figure 2A). The lead was embedded in one of the tricuspid leaflets (Figure 2B), and therefore, any attempt at repair was impossible. Valve replacement with a 25-mm Carpentier Perimount bioprosthesis (Figure 3) was decided upon, based on the patient’s history of thromboembolism and the low thrombogenic profile of this type of prosthesis. She was discharged at 7 days following the procedure, at which time echocardiographic study showed a normally functioning prosthesis.