Juan Sierra

Early calcification of the aortic Mitroflow pericardial bioprosthesis in the elderly

BACKGROUND We report our experience in the elderly with aortic valve replacement using the Mitroflow A12 pericardial bioprosthesis. METHODS From January 1993 to January 2006, 491 patients over the age of 70 years received an aortic Mitroflow A12 bioprosthesis implantation. Concomitant procedures included coronary artery bypass grafting in 20% of patients. All patients had routine postoperative Echo-Doppler studies at discharge, one month and a mean of 11.1 months after surgery and annually thereafter. RESULTS Twenty (4%) patients underwent a second aortic valve replacement due to bioprosthetic valve dysfunction (Group 2). Calcified stenosis was the most common finding at reoperation (98%). Median time to valve reoperation was 76 months. Of patients requiring reoperation, median age at first and second implantation was 73 (70-78) and 79 (76-83) years, respectively. For all patients, freedom from structural valve dysfunction (SVD) was 95+/-3% at 5 years and 55.8+/-2% at 10 years. Bioprosthetic valve deterioration was identified in 27 patients (Group 1). Median age of these patients at first operation and at diagnosis of deterioration by echo was 75 (70-84) and 77 (70-82) years, respectively. The median interval between operation and detection of bioprosthesis valve deterioration was 46 months. Among the total patient population, freedom from bioprosthetic deterioration was 85.7+/-2% at 5 years and 33.5+/-4% at 10 years. CONCLUSION The Mitroflow A12 pericardial bioprosthesis provides less than optimal performance in elderly patients.

Preoperative statin treatment reduces systemic inflammatory response and myocardial damage in cardiac surgery

OBJECTIVE To determine if preoperative statin treatment is associated with a reduction in systemic inflammatory response (SIR) and myocardial damage markers following cardiac surgery with cardiopulmonary bypass (CPB). METHODS We study a prospective cohort of 138 patients who underwent coronary and valvular surgery with CPB. We differentiate two study groups: patients with (group A, n=72) or without (group B, n=66) statins. Plasma levels of pro-inflammatory interleukins (tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-2R), creatine phosphokinase (CPK), CPK-MB and troponin I were measured before and 1, 6, 24 and >72 h after surgery. RESULTS The baseline, operative and postoperative morbidity and mortality characteristics were similar for both the groups. Group A had significantly lower postoperative levels of IL-6 than group B at 6h (68.8+/-5 pg ml(-1) vs 108.9+/-108 pg ml(-1), p=0.01), 24h (71.7+/-7 pg ml(-1) vs 110.4+/-106 pg ml(-1), p=0.01) and before hospital discharge (21.6+/-12 pg ml(-1) vs 32.8+/-27 pg ml(-1), p=0.005), as well as significantly lower average IL-6 levels in the first 24h following surgery (71.8+/-5 pgml(-1) vs 112.8+/-82 pg ml(-1), p=0.002). The postoperative CPK-MB at 24h (19.7+/-23 ng ml(-1) vs 33.1+/-32 ng ml(-1), p=0.02) and troponin I levels at the end of the intervention (2.2+/-2.2 ng ml(-1) vs 3.3+/-3.1 ng ml(-1), p=0.03) and at 24h (4.1+/-3.5 ng ml(-1) vs 6.6+/-8 ng ml(-1), p=0.04) were also significantly lower in the group treated with statins prior to surgery. CONCLUSIONS Preoperative treatment with statins is associated with a lower biochemical parameters of SIR and myocardial damage following cardiac surgery with CPB, regardless of it being coronary bypass grafting (CABG) or valvular surgery.

Minimally Invasive Surgical Implantation of Left Ventricular Epicardial Leads for Ventricular Resynchronization Using Video-Assisted Thoracoscopy

BACKGROUND AND OBJECTIVES Cardiac resynchronization via left ventricular or biventricular pacing is an option for selected patients with ventricular systolic dysfunction and widened QRS complex. Stimulation through a coronary vein is the technique of choice for left ventricular pacing, but this approach results in a failure rate of approximately 8%. We describe our initial experience with minimally invasive surgical implantation of left ventricular epicardial leads using video-assisted thoracoscopy. PATIENTS AND METHOD A total of 14 patients with congestive heart failure, NYHA functional class 3.2 (0.6) and mean ejection fraction 22.9 (6.8)% were included in this study. Left bundle branch block, QRS complex >140 ms and abnormal septal motion were observed in all cases. Epicardial leads were implanted on the left ventricular free wall under general anesthesia using video-assisted thoracoscopic surgery. RESULTS Lead implantation was successful in 13 patients. Conversion to a small thoracotomy was necessary in one patient. All patients were extubated in the operating room. None of the patients died during their hospital stay. Follow-up showed reversal of ventricular asynchrony and significant improvement in ejection fraction and functional class. CONCLUSIONS Minimally invasive surgery for ventricular resynchronization using video-assisted thoracoscopy in selected patients is a safe procedure that makes it possible to choose the best site for lead implantation and provides adequate short- and medium-term stimulation.

Evaluación de una PCR multiplex en tiempo real para la detección de patógenos en el tejido valvular de pacientes con endocarditis

Un nuevo test multiplex basado en una reaccion en cadena de polimerasa en tiempo real LightCycler Septi- Fast® permite la identificacion de 25 especies bacterianas y fungicas directamente desde la sangre. El test SeptiFast® ha sido utilizado para el diagnostico etiologico rapido de la endocarditis infecciosa, pero no ha sido ensayado directamente sobre las vegetaciones cardiacas de pacientes intervenidos por endocarditis infecciosa. Se realizo un estudio prospectivo para analizar 15 muestras de tejido valvular con endocarditis infecciosa activa utilizando SeptiFast® y comparando su sensibilidad con el hemocultivo, el cultivo del tejido valvular y el SeptiFast® en sangre. La sensibilidad del SeptiFast® del tejido valvular fue del 100%, confirmo el diagnostico obtenido mediante hemocultivo en 13 casos y proporciono el diagnostico etiologico en 2 casos con hemocultivo negativo. La sensibilidad de SeptiFast en el tejido valvular fue superior al cultivo convencional de las vegetaciones y al SeptiFast en sangre.

Evaluation of a Multiplex Real-Time PCR Assay for Detecting Pathogens in Cardiac Valve Tissue in Patients With Endocarditis

With a novel real-time multiplex polymerase chain reaction test, the LightCycler SeptiFast® test, 25 bacterial and fungal species can be identified directly in blood. The SeptiFast® test has been used for rapid etiologic diagnosis in infectious endocarditis using blood samples but has not been evaluated directly on cardiac vegetations in patients being treated for infectious endocarditis. We prospectively analyzed 15 samples of heart valve tissue with active infectious endocarditis using the SeptiFast® test and compared the tests sensitivity with that of blood culture, valve tissue culture, and the SeptiFast® test in blood. The sensitivity of the SeptiFast test in heart valve tissue was 100%. The test results confirmed the diagnosis obtained using blood culture in 13 cases and identified the pathogen in 2 cases where blood culture tested negative. The sensitivity of the SeptiFast® test in heart valve tissue was greater than that obtained with conventional culture of vegetations or with the SeptiFast test in blood.

Thromboembolism in patients with pericardial valves in the absence of chronic anticoagulation : 12 years' experience

Between January 1977 and January 1989, 465 pericardial bioprostheses were implanted in 424 patients. The mean age of patients was 59.1 years (range 16-81 y.) At the time of surgery, 68% of the patients suffered from chronic atrial fibrillation. Mitral valve replacement was performed in 167 patients, aortic valve replacement in 216, multiple replacement in 40 (36 mitral and aortic, 3 mitral and tricuspid, and 1 mitral, aortic and tricuspid), and 1 pulmonary valve replacement. The different types of pericardial valve used were: Ionescu-Shiley 408, Mitral Medical 23, Bioflo 30, and Hancock 4. Hospital mortality was 10.1% with an attrition rate of 1.8 episodes per 100 patients/year. The 12-year actuarial survival rate was 65.1%. No patient underwent long-term anticoagulant treatment. The first 144 patients undergoing mitral and multiple valve replacements received temporary anticoagulation for the first 8 weeks after surgery. There was no valve thrombosis observed. Altogether 19 thromboembolic events (6 early and 13 late) were clinically documented. One patient died after an embolic event. The linearized rates of thromboembolism were 1.64 episodes per 100 patients/year for mitral and multiple valve replacements and 0.33 episodes per 100 patients/year for aortic valve replacement, with an overall rate of 1.0 episodes per 100 patients/year. Excluding early thromboembolism, the linearized rate was 1.02 episodes per 100 patients/year overall. The actuarial freedom from embolism was 92.4% overall, 88.2% for the mitral and multiple valve replacement group, and 97.6% for the aortic valve replacement group at a maximum follow-up of 12 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential Association of S100A9, an Inflammatory Marker, and p53, a Cell Cycle Marker, Expression with Epicardial Adipocyte Size in Patients with Cardiovascular Disease

ABSTRACTS100A9 (calgranulin B) has inflammatory and oxidative stress properties and was found to be associated with atherosclerosis and obesity. One of the proteins that can regulate S100A9 transcription is p53, which is involved in cell cycle, apoptosis and adipogenesis. Thus, it triggers adipocyte enlargement and finally obesity. Because epicardial adipose tissue (EAT) volume and thickness is related to coronary artery disease (CAD), we studied the gene expression of this pathway in patients with cardiovascular disease and its association with obesity. Adipocytes and stromal cells from EAT and subcutaneous adipose tissue (SAT) from 48 patients who underwent coronary artery bypass graft and/or valve replacement were obtained after collagenase digestion and differential centrifugation. The expression levels of the involved genes on adipogenesis and cell cycle like fatty acid-binding protein (FABP) 4, retinol-binding protein (RBP)4, p53 and S100A9 were determined by real-time polymerase chain reaction (PCR). Adipocyte diameter was measured by optical microscopy. We found that epicardial adipocytes expressed significantly lower levels of adipogenic genes (FABP4 and RBP4) and cell cycle-related genes (S100A9 and p53) than subcutaneous adipocytes. However, in obese patients, upregulation of adipogenic and cell cycle-related genes in subcutaneous and epicardial adipocytes, respectively, was observed. The enlargement of adipocyte size was related to FABP4, S100A9 and p53 expression levels in stromal cells. But only the p53 association was maintained in epicardial stromal cells from obese patients (p = 0.003). The expression of p53, but not S100A9, in epicardial stromal cells is related to adipocyte enlargement in obese patients with cardiovascular disease. These findings suggest new mechanisms for understanding the relationship between epicardial fat thickness, obesity and cardiovascular disease.

Transvenous right ventricular pacing in a patient with tricuspid mechanical prosthesis

We report a patient in whom permanent endocardial pacing was accomplished by passage of the electrode through a mechanical tricuspid valve. Echocardiography study showed a minimal tricuspid regurgitation.

Mitral annuloplasty ring detachment in real-time three-dimensional echocardiography

A 64-year-old man was referred to our institution for the surgical repair of a severe mitral regurgitation (MR). A valve repair with the placement of a 27-mm Carpentier– Edwards Classic mitral annuloplasty ring and left anterior descending coronary artery revascularization with the saphenous vein was performed. The etiology of MR was considered to be of type I according to the Carpentier classification with annular dilatation. The patient presented with heart failure due to severe MR 2 months after mitral valve repair. Two-dimensional transesophageal color Doppler showed severe mitral regurgitation (Fig. 1a) and it revealed that the mitral regurgitation was due to the displacement of the mitral annuloplasty ring (Fig. 1b, red arrow). Real-time three-dimensional (3D) transesophageal color Doppler revealed detachment of the mitral annuloplasty ring along the ring over half of its circumference (Fig. 1c, d, asterisks). A surgical intervention was performed. The location and extent of the dehiscence viewed on the real-time 3D transesophageal color Doppler correlated highly with the intraoperative findings, which consisted mainly of annuloplasty ring displacement relative to the native mitral annulus (Fig. 2, asterisks). Bad placement of the sutures within the annulus fibrosus was the cause of ring dehiscence. A mitral valve prosthesis was implanted and the patient’s postoperative course was uneventful. The pathologic findings of the resected mitral valve showed no signs of infection. The evaluation of mitral valve pathology is one of the most challenging clinical applications of real-time 3D echocardiography [1, 2] and this is particularly true for realtime 3D transesophageal color Doppler. The surgical exploration was considered as the ‘‘gold standard’’ [3] and, in this case, real-time 3D transesophageal color Doppler demonstrated better correlation with the pathology involved compared to two-dimensional echocardiography.