José M. Herrera-Noreña

Utilidad de la escala INTERMACS para estratificar el pronóstico tras el trasplante cardiaco urgente

INTRODUCTION AND OBJECTIVES Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). METHODS Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. RESULTS Patients at the INTERMACS 1 level (n=31) more frequently had ischemic heart disease (P=.03) and post-cardiothomy shock (P=.02) than patients at the INTERMACS 2 (n=55) and INTERMACS 3-4 (n=25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P=.001), a higher frequency of use of mechanical ventilation (P<.001), intraaortic balloon (P=.002) and ventricular assist devices (P=.002), and a higher frequency of preoperative infection (P=.015). The INTERMACS 1 group also presented higher central venous pressure (P=.02), AST (P=.002), ALT (P=.006) and serum creatinine (P<.001), and lower hemoglobin (P=.008) and creatinine clearance (P=.001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P=.03) and postoperative need for renal replacement therapy (P=.004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P=.023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p=0.013; HR 6.8, IC 95% 1.2-39.1). CONCLUSIONS Our results suggest that the INTERMACS scale may be a useful tool to stratify postoperative prognosis after urgent HT.

Predictors of outcome and different management of aortobronchial and aortoesophageal fistulas

OBJECTIVE Aortoesophageal and aortobronchial fistulas are uncommon but life-threatening conditions. The present study aimed to identify potential differences in outcomes, depending on the etiology, type, and management of the fistulas, and to determine mortality predictors. METHODS We retrospectively reviewed a series of 26 consecutive patients with thoracic aorta fistulas admitted to our institution from 1998 to 2013 (18 aortobronchial, 7 aortoesophageal, and 1 combined fistula). RESULTS The mean age was 61.5 ± 13.4 years, with 22 men. Management was thoracic endovascular aortic repair (TEVAR) in 8, open repair in 7, and conservative in 11. The TEVAR and nonoperative patients were significantly older and presented with more comorbidities. Shock developed in 15 patients and sepsis in 9. The most common radiologic findings were intramural hematoma (65.4%), pseudoaneurysm (53.8%), and bronchial compression (46.20%). Active contrast extravasation (23.1%) and ectopic gas (19.2%) were associated with a worse prognosis. In-hospital mortality was 100% in the conservative group, 37.5% in the TEVAR group, and 14.3% in the open repair group (P = .04). Septic shock was the most common cause of death. The risk factors for in-hospital mortality were hemodynamic instability on admission (P = .02), sepsis (P = .04), and conservative management (P < .001). The overall long-term survival in surgical patients at 1 and 5 years was 66% and 58.7%, respectively. Infectious and malignant etiologies resulted in the worst prognosis. CONCLUSIONS The outcomes are ultimately conditioned by the etiology of the fistula. Both open and endovascular management of aortic fistulas can prevent death by exsanguination; however, patients remain at high risk of infectious complications. Failure to treat the underlying cause will result in poor midterm outcomes.

Minimal traumatic aortic injuries: meaning and natural history

OBJECTIVE Minimal aortic injuries (MAIs) are being recognized more frequently due to the increasing use of high-resolution diagnostic techniques. The objective of this case series review was to report the clinical and radiological characteristics and outcomes of a series of patients with MAI. METHODS From January 2000 to December 2011, 54 major blunt trauma patients were admitted to our institution with traumatic aortic injuries. Nine of them presented with MAI, whereas the remaining 45 patients suffered a significant aortic injury (SAI). RESULTS MAIs accounted for 17% of the overall traumatic aortic injuries in our series. Major trauma patients with MAI and SAI were similar regarding the presence of severe associated non-aortic injuries and the expected mortality calculated by injury severity score, revised trauma score and trauma injury severity score. There were no statistically significant differences in in-hospital mortality between MAI (22.2%) and SAI (30.2%). No death in the MAI group was aortic related, whereas five deaths in the SAI group were caused by an aortic complication. The survival of MAI patients was 77.8% at 1 and 5 years. There was no late mortality among MAI patients. The survival of SAI patients was 69.7% at 1 year and 63.6% at 5 and 10 years. None of the seven surviving patients with MAI presented a progression of the aortic injury. In six patients, the intimal tear completely healed in imaging controls, whereas one patient developed a small saccular pseudoaneurysm. CONCLUSIONS Blunt traumas presenting MAI are as severe as traumas that associate SAI and present similar in-hospital mortality. In contrast to SAI traumas, in-hospital mortality due to MAI is not usually related to the aortic injury, so these injuries are more amenable to a conservative management. It is mandatory to perform a close imaging surveillance to detect early any potential adverse evolution of an MAI. Nevertheless, a balance must be struck between a close serial imaging surveillance and the potentially detrimental effects of obtaining high-resolution additional images.

Venous thromboembolism in heart transplant recipients: Incidence, recurrence and predisposing factors

BACKGROUND A high frequency of venous thromboembolism (VTE) has been observed after lung, kidney, and liver transplantation. However, data about the incidence of this complication among heart transplant (HT) recipients are lacking. METHODS We analyzed the incidence, recurrence, and predisposing factors of VTE in a single-center cohort of 635 patients who underwent HT from April 1991 to April 2013. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were considered as VTE episodes. RESULTS During a median post-transplant follow-up of 8.4 years, 62 VTE episodes occurred in 54 patients (8.5%). Incidence rates of VTE, DVT, and PE were, respectively, 12.7 (95% confidence interval [CI], 9.7-16.3), 8.4 (95% CI, 6.0-11.4), and 7.0 (95% CI 4.8-9.7) episodes per 1,000 patient-years. Incidence rates of VTE during the first post-transplant year and beyond were, respectively, 45.1 (95% CI, 28.9-67.1) and 8.7 (95% CI 6.2-11.2) episodes per 1,000 patient-years. The incidence rate of VTE recurrence after a first VTE episode was 30.5 (95% CI, 13.2-60.2) episodes per 1,000 patient-years. By means of multivariable Cox regression, chronic renal dysfunction, older age, obesity, and the use of mammalian target of rapamycin inhibitors were identified as independent risk factors for VTE among HT recipients. CONCLUSIONS VTE is a frequent complication after HT, mainly during the first post-operative year. In view of a high recurrence rate, long-term anti-coagulation should be considered in HT recipients who experience a first VTE episode.

Late graft failure in heart transplant recipients: incidence, risk factors and clinical outcomes.

To analyse the incidence, risk factors and clinical outcomes of late graft failure after heart transplantation.

The CarboMedics supra-annular Top Hat valve improves long-term left ventricular mass regression

OBJECTIVE The present study aimed to identify potential differences in hemodynamic performance between the supra-annular CarboMedics Top Hat valve and the intra-annular CarboMedics standard valve in terms of the long-term left ventricular mass reduction and transvalvular gradients. METHODS We retrospectively reviewed a series of 186 consecutive patients who had undergone aortic valve replacement with a small size mechanical prosthesis at our institution from 2003 to 2013, receiving either a CarboMedics Top Hat valve (53 patients, valve size, 21 mm in 52.8% and 23 mm in 47.2%) or a CarboMedics standard prosthesis (133 patients, valve size, 19 mm in 14.3% and 21 mm in 85.7%). RESULTS The in-hospital mortality was 9.4% and 11.3% in the Top Hat and standard groups, respectively (P = .71). The mean percentage of left ventricular mass reduction was greater in the Top Hat group (33% ± 15.8% vs 20.1% ± 16.6%, P < .001). The mean postoperative peak aortic gradient was lower in the Top Hat group (19.9 ± 8.9 vs 29.6 ± 8.6 mm Hg; P < .001). Spearman analysis showed a positive correlation between the indexed effective orifice area and the percentage of left ventricular mass reduction (Rho = +0.65, P = .02). The survival in the Top Hat group was 79.7% and 71.7% at 5 and 10 years, respectively. In the standard group, survival was 66.8% and 61.5% at 5 and 10 years, respectively (log-rank test, 0.19). Cox regression demonstrated severe myocardial hypertrophy (hazard ratio, 2.559; 95% confidence interval, 1.095-5.981) as one of the independent predictors of survival. CONCLUSIONS The Top Hat valve surpasses hemodynamically the intra-annular valve. We suggest the supra-annular Top Hat prosthesis can be especially recommended for patients with a small aortic root and severe myocardial hypertrophy.

Prognostic Value of the Nutritional Risk Index in Heart Transplant Recipients

INTRODUCTION AND OBJECTIVES To study the prognostic impact of preoperative nutritional status, as assessed through the nutritional risk index (NRI), on postoperative outcomes after heart transplantation (HT). METHODS We conducted a retrospective, single-center study of 574 patients who underwent HT from 1991 to 2014. Preoperative NRI was calculated as 1.519 × serum albumin (g/L) + 41.7 × (body weight [kg] / ideal body weight [kg]). The association between preoperative NRI and postoperative outcomes was analyzed by means of multivariable logistic regression and multivariable Cox regression. RESULTS Mean NRI before HT was 100.9 ± 9.9. According to this parameter, the prevalence of severe nutritional risk (NRI < 83.5), moderate nutritional risk (83.5 ≤ NRI < 97.5), and mild nutritional risk (97.5 ≤ NRI < 100) was 5%, 22%, and 10%, respectively. One year post-transplant mortality rates in these 4 categories were 18.2%, 25.3%, 7.9% and 10.2% (P < .001), respectively. The NRI was independently associated with a lower risk of postoperative infection (adjusted OR, 0.97; 95%CI, 0.95-1.00; P = .027) and prolonged postoperative ventilator support (adjusted OR, 0.96; 95%CI, 0.94-0.98; P = .001). Patients at moderate or severe nutritional risk had significantly higher 1-year post-HT mortality (adjusted HR, 1.55; 95%CI, 1.22-1.97; P < .001). CONCLUSIONS Malnourished patients have a higher risk of postoperative complications and mortality after HT. Preoperative NRI determination may help to identify HT candidates who might benefit from nutritional intervention.

Long‐Term Outcomes and Durability of the Mitroflow Aortic Bioprosthesis

This study aims to determine the incidence and causes of structural valve deterioration (SVD) among all models of Mitroflow bioprostheses (A12/LX/DL), as well as to define their long‐term clinical and hemodynamic performance.

Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction

Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve‐in‐valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses.

Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows

OBJECTIVES The objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy. METHODS From January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores. RESULTS All but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, P = 0.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1 year, 68.2%, 80.8% and 79.4% at 5 years and 63.9%, 72.7% and 79.4% at 10 years, respectively (log-rank = 0.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; P = 0.021], Trauma Injury Severity Score >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011). CONCLUSIONS Minimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage.