José M. Mesa

Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation☆

OBJECTIVES We sought to determine the prevalence and rate of progression of left ventricular outflow tract obstruction (LVOTO) and aortic regurgitation (AR) in adults with discrete subaortic stenosis (DSS). BACKGROUND Discrete subaortic stenosis is an uncommon form of LVOTO, with rapid hemodynamic progression in children, but the prevalence and rate of progression in adults have not been studied so far. METHODS The prevalence of DSS was determined in 2,057 consecutive adults diagnosed with congenital heart disease (CHD). The relationship between LVOTO on Doppler echocardiography and patient age was analyzed. Sequential changes in LVOTO and AR were determined for patients with two or more Doppler echocardiograms obtained with at least a two-year interval. RESULTS A total of 134 adults (mean age 31 +/- 17 years) were diagnosed with DSS. The prevalence was 6.5% for all adults with CHD. Sixty patients (44%) had other associated CHD. The mean age of 29 patients who had undergone an operation for DSS during their adult life (56 +/- 15 years) was significantly higher than that of 64 patients (27 +/- 13 years) who had not required a surgical intervention (p < 0.0001). A significant relationship between LVOTO and patient age (r = 0.61, p < 0.0001) was found: 21 +/- 16 mm Hg in patients <25 years old, 51 +/- 47 mm Hg for those between 25 and 50 years old, and 78 +/- 36 mm Hg for those >50 years old. The LVOTO increased from 39.2 +/- 28 to 46.8 +/- 34 mm Hg (p = 0.01) during a mean follow-up of 4.8 +/- 1.8 years in 25 patients. The slope of the change in LVOTO was 2.25 +/- 4.7 mm Hg per year of follow-up. Aortic regurgitation was detected by color Doppler imaging in 109 patients (81%), but it was hemodynamically significant in <20%. An increase in the mean degree of AR over time was not significant (baseline: 1.3 +/- 0.8; follow-up: 1.5 +/- 0.9; p = 0.096). CONCLUSIONS The prevalence of DSS is increasing in adults due to the greater number of repaired CHDs that develop into evolutive DSS. In contrast to infants and children, adults with DSS show a slow rate of LVOTO progression. Aortic regurgitation is a common but usually mild and nonprogressive consequence. The current indications for surgical intervention should be revised.

Predisposing conditions for atrial fibrillation in atrial septal defect with and without operative closure

The aims of this study were to determine the prevalence and predisposing conditions for atrial fibrillation (AF) in adults with atrial septal defect (ASD) and to evaluate the influence of age at surgical repair. The study population consisted of 286 adults with ASD (mean age 39.5 +/- 19 years). All patients had >or = 1 follow-up visit and a Doppler echocardiographic study. One hundred ninety-two of the patients underwent surgical closure 1 to 34 years before the study. Analyzed variables were entered into univariate (Mann-Whitney U) and multivariate (stepwise logistic regression) models to assess independent predictors for AF. The prevalence of AF was similar in surgically treated patients (15.6%) and in the nonsurgical group (13.8%) (p = 0.69). Multivariate analysis showed that current age (RR 1.9 per each decade of age, 95% confidence interval [CI] 1.3 to 2.7, p = 0.001), mitral regurgitation (RR 3.0 per each degree of regurgitation, 95% CI 1.6 to 5.8, p = 0.001), left atrial enlargement (RR 2.8 per each 10 mm increase in size, 95% CI 1.5 to 5.2, p = 0.001), and tricuspid regurgitation (RR 1.9 per each degree of regurgitation, 95% CI 1.0 to 3.7, p = 0.04) were independent predictors of AF; however, gender, anatomic type, defect size, Qp:Qs, pulmonary artery pressure, right ventricular dimension, left ventricular shortening fraction, and prior surgical repair were not related to late AF development. In the surgical group, age >25 years at the time of surgery was the only predictor for AF independent of age at the time of the study (p = 0.02).

Bioprosthetic mitral valve thrombosis: Clinical profile, transesophageal echocardiographic features, and follow-up after anticoagulant therapy

Cardiac bioprosthetic valve thrombosis is frequently found on pathologic examination, but preoperative diagnosis is rarely performed. Four hundred six patients with mitral porcine xenograft bioprostheses were examined by transthoracic echocardiography. Transesophageal echocardiography (TEE) was performed in 161 of the patients, with clinical or echocardiographic criteria of prosthetic malfunction. Fairly homogeneous and echodense masses, attached to the ventricular surface of the mitral bioprosthetic cusps, were detected by TEE in 15 patients. Only 10 patients, in whom diagnosis of bioprosthetic thrombosis was confirmed, are included in this study. After TEE, two patients underwent prosthetic replacement and eight patients received anticoagulants. A new TEE was performed 85.6 +/- 29.8 days after anticoagulation in these eight patients. Clinical follow-up was continued for 13.6 +/- 8.6 months, and one additional patient underwent surgery during the follow-up. Pathologic examination of removed grafts (three cases) identified these masses as being thrombotic tissue. TEE examination after therapeutic anticoagulation demonstrated complete disappearance of the echogenic masses on bioprosthetic cusps and normal mobility of all leaflets in six cases. In the other two cases, cusp masses were notably reduced, but partially restrictive mobility of affected leaflets persisted, suggesting incomplete resolution of thrombi. Mitral valve prosthetic mean gradient decreased from 11.8 +/- 4.5 to 7.6 +/- 3.7 mm Hg (p < 0.001), and mitral valve area increased from 1.13 +/- 0.3 to 1.72 +/- 0.6 cm2 (p < 0.001). Long-term symptomatic improvement after anticoagulation was obtained in seven patients. Thus this study shows that mitral bioprosthetic thrombosis is a relatively frequent cause of valve dysfunction, TEE is useful for detecting thrombus in relation to mitral bioprosthetic valves, and oral anticoagulation is effective in resolving thrombosis on bioprostheses.

Immediate and Mid-term Clinical Course After Percutaneous Closure of Paravalvular Leakage

INTRODUCTION AND OBJECTIVES Percutaneous closure of paravalvular leakage is an alternative to surgery in high-risk patients, but its use has been limited by a lack of specific devices. More appropriate devices-like the Amplatzer Vascular Plug III-have recently been developed, but information about their efficacy and safety is still scarce. The objective of the present study was to assess the mid-term results of paravalvular leakage closure with this device. METHODS We analyzed the clinical and echocardiographic course both in-hospital and mid-term (13 [9] months) in a series of 20 consecutive patients (age, 68 years; logistic EuroSCORE, 29) with paravalvular leakage and attempted percutaneous closure. RESULTS Closure was attempted for 23 leaks (17 mitral and 6 aortic) during 22 procedures in 20 patients. Implantation was successful in 87% of the leaks and the procedure was successful in 83%-with success being defined as a reduction in regurgitation of ≥ 1 degree. Survival at 1 year was 64.7% and survival free of the composite event of death/surgery was 58.8%. The degree of residual regurgitation was not associated with mortality but was associated with functional status. Survivors showed significant improvement in functional class. CONCLUSIONS Percutaneous closure of leakage with the Amplatzer Vascular Plug III is safe and efficient in the mid-term. However, mortality among high-risk patients is high independently of the degree of residual regurgitation, indicating that these procedures are performed when heart disease has reached an advanced stage.

Cirugía cardíaca en pacientes octogenarios: Factores predictores de mortalidad y evaluación de la supervivencia y la calidad de vida a largo plazo

Fundamento y objetivo Debido al aumento de la esperanza de vida en los paises occidentales, el numero de octogenarios con enfermedades cardiacas susceptibles de tratamiento quirurgico se ha incrementado considerablemente. El objetivo del presente estudio ha sido identificar los factores predictores de mortalidad y determinar la supervivencia y la calidad de vida a largo plazo de los octogenarios a quienes se realiza cirugia cardiaca. Pacientes y metodo En los ultimos 26 anos se ha intervenido en nuestro centro a un total de 150 pacientes de 80 anos o mas, con una media (desviacion estandar) de edad de 82,7 (2,5) anos. Analizamos las variables cinicas y epidemiologicas incluidas en el euroSCORE (European System for Cardiac Operative Risk Evaluation), la mortalidad hospitalaria, la supervivencia a largo plazo y la calidad de vida despues de la cirugia cardiaca. Resultados La mortalidad hospitalaria fue del 30,1%, con una estancia media de 16,5 dias (intervalo intercuartilico, 13-27). La cirugia emergente, la reparacion de una rotura cardiaca, la clase funcional IV de la New York Heart Association, la insuficiencia renal cronica y la presencia de un infarto de miocardio previo fueron predictores independientes de la mortalidad hospitalaria. El seguimiento medio fue de 72,2 (9,9) meses, con tasas de supervivencia del 87,3 y del 57% a 1 y 5 anos, respectivamente. La calidad de vida en los 53 que continuan con vida en la actualidad es significativamente mejor que la que presentaban antes de la cirugia, con una mejoria de la clase funcional desde 2,52 a 1,48. La mayoria de los supervivientes (97,7%) se sienten satisfechos con su calidad de vida actual. Conclusiones La cirugia cardiaca en octogenarios se asocia con un aumento de la mortalidad y de la estancia media hospitalarias. Nuestros resultados apoyan el hecho de que en una poblacion seleccionada de pacientes ancianos la cirugia cardiaca puede llevarse a cabo con aceptables resultados y buena calidad de vida a largo plazo.

Clinical and prognostic implications of atrial fibrillation in patients undergoing transcatheter aortic valve implantation

AIM To study a cohort of consecutive patients undergoing transcatheter aortic valve implantation (TAVI) and compare the outcomes of atrial fibrillation (AF) patients vs patients in sinus rhythm (SR). METHODS All consecutive patients undergoing TAVI in our hospital were included. The AF group comprised patients in AF at the time of TAVI or with history of AF, and were compared with the SR group. Procedural, echocardiographic and follow-up variables were compared. Likewise, the CHA(2)DS(2)-VASC stroke risk score and HAS-BLED bleeding risk score and antithrombotic treatment at discharge in AF patients were compared with that in SR patients. RESULTS From a total of 34 patients undergoing TAVI, 17 (50%) were allocated to the AF group, of whom 15 (88%) were under chronic oral anticoagulation. Patients in the AF group were similar to those in the SR group except for a trend (P = 0.07) for a higher logistic EuroSCORE (28% vs 19%), and a higher prevalence of hypertension (82% vs 53%) and chronic renal failure (17% vs 0%). Risk of both stroke and bleeding was high in the AF group (mean CHA(2)DS(2)-VASC 4.3, mean HAS-BLED 2.9). In the AF group, treatment at discharge included chronic oral anticoagulation in all except one case, and in association with an antiplatelet drug in 57% of patients. During a mean follow-up of 11 mo (maximum 32), there were only two strokes, none of them during the peri-procedural period: one in the AF group at 30 mo and one in the SR group at 3 mo. There were no statistical differences in procedural success, and clinical outcome (survival at 1 year 81% vs 74% in AF and SR groups, respectively, P = NS). CONCLUSION Patients in AF undergoing TAVI show a trend to a higher surgical risk. However, in our cohort, patients in AF did not have a higher stroke rate compared to the SR group, and the prognosis was similar in both groups.

Sarcoma primario de arteria pulmonar: diagnóstico mediante ecocardiograma transtorácico y transesofágico

El sarcoma primario de arteria pulmonar es un tumor maligno infrecuente y de dificil diagnostico antes de la autopsia o la cirugia. Presentamos el caso de una paciente con sarcoma de arteria pulmonar diagnosticado mediante ecocardiograma transtoracico y transesofagico que fue tratado quirurgicamente.

Long-term Follow-up After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

INTRODUCTION AND OBJECTIVES Transcatheter aortic valve implantation is used as an alternative to surgical valve replacement in patients with severe aortic stenosis who are considered high-surgical-risk or inoperable. Two of the main areas of uncertainty in this field are valve durability and long-term survival. METHODS This prospective single-center registry study from a tertiary hospital included all consecutive patients who underwent percutaneous aortic valve implantation between 2008 and 2012. Clinical follow-up lasted a minimum of 2.5 years and a maximum of 6.5 years. Valve Academic Research Consortium-2 definitions were used. RESULTS Seventy-nine patients were included, with an immediate success rate of 94.9%. The median survival was 47.6 months (95% confidence intervals, 37.4-57.9 months), ie, 4 years. One quarter of deaths occurred in the first month, and most were of cardiovascular cause. After the first month, most deaths were due to noncardiovascular causes. The mean values of valve gradients did not increase during follow-up. The cumulative rate of prosthetic valve dysfunction was 15.3%, with no cases of repeat valve replacement. CONCLUSIONS Half of the patients with aortic stenosis who underwent transcatheter aortic valve implantation were alive 4 years after the procedure. There was a 15.3% prosthetic valve dysfunction rate in cumulative follow-up, with no cases of repeat valve replacement.

Effectiveness of balloon percutaneous valvuloplasty for stenotic bioprosthetic valves in different positions

Abstract Percutaneous balloon valvuloplasty has been used as treatment for native valvular stenosis in the mitral, aortic, pulmonary and tricuspid positions. 1–4 It has also been used as palliative therapy for stenotic bioprosthetic valves. 5–8 In this study we present the immediate results and midterm follow up of percutaneous balloon valvuloplasty of 5 bioprosthetic valves in different positions.

Cierre quirúrgico de la comunicación interauricular antes o después de los 25 años de edad. Comparación con la evolución natural en pacientes no operados

Introduccion El cierre quirurgico de la comunicacion interauricular (CIA) antes de los 25 anos de edad disminuye las complicaciones durante la vida adulta, pero las consecuencias de la intervencion en pacientes mayores de 25 anos siguen siendo motivo de controversia. Metodos Para comparar los efectos de la cirugia precoz y/o tardia con la evolucion natural se ha estudiado, de forma retrospectiva, a 280 adultos (edad media 40 ± 18 anos) con CIA no restrictiva. Ciento dos pacientes (grupo 1) habian sido operados antes de los 25 anos, 90 (grupo 2) habian sido operados despues de los 25 anos y 88 (grupo 3) no habian sido operados previamente. Se comparo la presion pulmonar sistolica, el tamano del ventriculo derecho y la auricula izquierda, el grado de insuficiencia mitral y tricuspide, la funcion sistolica del ventriculo izquierdo y la prevalencia de fibrilacion auricular. Resultados No habia diferencia en la funcion sistolica del ventriculo izquierdo o en el grado de insuficiencia mitral entre los tres grupos. Comparado con el grupo 2, el grupo 1 tenia menores presion sistolica pulmonar (p Conclusiones El cierre quirurgico de la CIA despues de los 25 anos no previene el deterioro hemodinamico o el desarrollo de arritmias auriculares, por lo que se deberia concentrar esfuerzos en corregir el defecto antes de la edad adulta.