Miguel Such

Left ventricular outflow tract obstruction with mitral mechanical prosthesis

Left ventricular outflow tract obstruction after mitral valve replacement may occur when the native mitral apparatus is preserved intact. Although it has usually been reported using bioprostheses, we present one case using a low-profile mechanical prosthesis. The reduction of left ventricular dimensions and valvular redundancy contributed to this complication. We obtained definitive relief of left ventricular outflow tract obstruction by transaortic exposure and partial resection of the obstructing tissue with the help of video-assisted cardioscopy.

Influence of Sex on Perioperative Outcomes in Patients Undergoing Valve Replacement for Severe Aortic Stenosis

INTRODUCTION AND OBJECTIVES The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis. METHODS This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007. RESULTS Women (44% of patients) were older than men (70.3+/-7.9 years vs. 66.8+/-9.8 years; P< .001), had a smaller body surface area (1.68+/-0.15 m(2) vs. 1.83+/-0.16 m(2); P< .001), more often had arterial hypertension (73% vs. 49%; P< .001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P< .001), and less often had coronary artery disease (19.1% vs. 31.8%; P< .001) and severe ventricular dysfunction (7.9% vs. 17.4%; P< .001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119). CONCLUSIONS Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality.

Long-Term Predictors of Mortality and Functional Recovery After Aortic Valve Replacement for Severe Aortic Stenosis With Left Ventricular Dysfunction

INTRODUCTION AND OBJECTIVES At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction. METHODS Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval [CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38; 95% CI, 1.40-80.0; P=.020) and coronary artery disease (OR=2.09; 95% CI, 1.26-51.0; P=.027). RESULTS During the mean follow-up period of 42.59+/-40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was a low postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction (P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients. CONCLUSIONS Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class.

Short- and Long-term Outcomes of Surgery for Severe Tricuspid Regurgitation

INTRODUCTION AND OBJECTIVES There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation. The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. METHODS Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. RESULTS A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty (P=.04). CONCLUSIONS Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.

Coronary Bypass Grafting to a “Full-Metal Jacket” Left Anterior Descending Artery

An increasing number of patients are being referred for coronary artery bypass grafting (CABG) after several previous percutaneous coronary interventions. We report a 70-year-old woman with a history of hypertension, diabetes, and chronic ischemic heart disease, who had undergone several previous percutaneous procedures and multiple stenting of the left anterior descending artery (LAD). She was admitted with unstable angina. Coronary angiogram revealed a proximally occluded LAD covered with multiple patent stents extending to its distal portion (Fig 1, arrows). After a failed attempt at angioplasty, she was referred for urgent CABG.

Expression of Sterol Regulatory Element-Binding Proteins in epicardial adipose tissue in patients with coronary artery disease and diabetes mellitus: preliminary study

Objectives: Sterol regulatory element-binding proteins (SREBP) genes are crucial in lipid biosynthesis and cardiovascular homeostasis. Their expression in epicardial adipose tissue (EAT) and their influence in the development of coronary artery disease (CAD) and type-2 diabetes mellitus remain to be determined. The aim of our study was to evaluate the expression of SREBP genes in EAT in patients with CAD according to diabetes status and its association with clinical and biochemical data. Methods: SREBP-1 and SREBP-2 mRNA expression levels were measured in EAT from 49 patients with CAD (26 with diabetes) and 23 controls without CAD or diabetes. Results: Both SREBPs mRNA expression were significantly higher in patients with CAD and diabetes (p<0.001) and were identified as independent cardiovascular risk factor for coronary artery disease in patients with type-2 diabetes (SREBP-1: OR 1.7, 95%CI 1.1-2.5, p=0.02; SREBP-2: OR 1.6, 95%CI 1.2-3, p=0.02) and were independently associated with the presence of multivessel CAD, left main and anterior descending artery stenosis, and higher total and LDL cholesterol levels, and lower HDL cholesterol levels, in patients with CAD and diabetes. Conclusions: SREBP genes are expressed in EAT and were higher in CAD patients with diabetes than those patients without CAD or diabetes. SREBP expression was associated as cardiovascular risk factor for the severity of CAD and the poor lipid control. In this preliminary study we suggest the importance of EAT in the lipid metabolism and cardiovascular homeostasis for coronary atherosclerosis of patients with diabetes and highlight a future novel therapeutic target.

Delayed mitral regurgitation following transmyocardial revascularization with CO2 laser

Transmyocardial laser revascularization is a controversial surgery for the treatment of advanced coronary disease aimed at improving myocardial perfusion and palliating the level of angina, with promising clinical results and low risks [1±3]. It is not an alternative to direct procedures, as the de®nitive mode of action has not been established yet [1,4]. In-hospital mitral regurgitation (MR) has been described [2], but a delayed clinical presentation has never been reported. We found a post-discharge MR possibly linked to this procedure. The objective of this letter is to draw attention to this rare circumstance. A 59-year-old woman was diagnosed of coronary artery disease and treated with percutaneous angioplasty to the LCx artery. Three years later the angina recurred. The treadmill exercise-tolerance testing was positive and the thallium-201 scintigraphy revealed reversible defects in the anterior, septal and lateral walls. The cardiac catheterization showed an occluded LAD artery, a vessel smaller than 1 mm diameter, with poor distal bed only visible through collateral ̄ow. The LCx was not restenotic, while the RCA looked ectasic without stenosis. The ventricular function was normal, and the mitral valve, competent. Symptoms were attributed to the evidenced ischemic areas. CABG to the LAD was rejected due to the disfavourable anatomy, and transmyocardial laser revascularization with CO2 was performed using transesophageal echocardiographic monitoring, drilling 29 effective channels in the anterior and lateral walls. The patient was discharged on the seventh postoperative day. She needed readmission 1 month later because of sudden pulmonary edema without angina. A systolic murmur was then detected and the echocardiography made a severe MR evident due to a broken chordae, together with normal ventricular motion, non-dilated mitral annulus and non-enlarged left atrium. As the clinical course was acute and very badly tolerated, an emergency intervention became necessary. A ruptured mitral chordae was detected intraoperatively whereas the papillary muscle was intact (Fig. 1). Mitral replacement was performed in an attempt to correct the problem ef®ciently and to reduce the myocardial ischemic time. A Carbomedics 25-mm mechanical prosthesis (Carbomedics Inc, Austin, TX) was implanted keeping the native valve in place. From that moment onwards, the patient was asymptomatic after 10 months of follow-up. Few data have been reported about potential risks or predictor factors of cardiac events after transmyocardial laser revascularization [3]. Accidental laserhit on valvular structures is remote because laser lacks enough power to drill a channel to such distal targets or it is very small, about 1 mm, to be relevant [5]. In our case, differing from other cases reported, MR appeared after discharge. NeverEuropean Journal of Cardio-thoracic Surgery 18 (2000) 498±499

Aortitis as a Rare Cause of Aortic Aneurysm and Valve Regurgitation: Is Repair Precluded?

Aortitis is an infrequent cause of aortic root dilatation and aortic valve regurgitation. Valve-sparing procedures have been proposed, but there is not clear evidence of which is the treatment of choice. We report the case of a 38-year-old pregnant lady with a diagnosis of idiopathic aortitis associated with aortic root aneurysm and severe aortic valve regurgitation.

Venous Collector in a Case of Partial Anomalous Pulmonary Venous Drainage.

e report on a 43-year-old woman with partial Wanomalous pulmonary venous drainage (PAPVD) diagnosed by cardiac magnetic resonance imaging. Echocardiography did not show an interatrial septal defect. Computed tomography angiography confirmed the presence of PAPVD of the superior and medium lobar veins into the right atrium (RA). Next to this connection was a lateral venous collector connecting the RA to the left atrium (LA) (Fig 1: red arrows show the venous collector and blue arrows show the pulmonary veins).