Oscar Gil

Midterm Clinical and Echocardiographic Results With Patch Glue Repair of Left Ventricular Free Wall Rupture

Background—Left ventricular free wall rupture (LVFWR) is a dramatic complication after myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with an epicardial patch without cardiopulmonary bypass. Methods—From February 1993 to May 2001, 17 patients underwent surgery for LVFWR. The mean age±SD of 12 males and 5 females was 68±10 years. All patients presented for emergency surgery with cardiac tamponade confirmed on echocardiography. After opening the chest and identification of the site of rupture, a Goretex patch was fashioned and applied with enbucrilate surgical glue. Results—Effective control of bleeding was achieved in all cases. There were no on-table deaths. The operative (30 day) mortality was 23.5% (4/17). One death occurred because of patch failure, two because of cardiogenic shock, and one from pneumonia. On follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two further deaths occurred, one from myocardial infarction and another of undetermined etiology. Echocardiography did not reveal any evidence of restriction to left ventricular free wall motion. Conclusions—Patch glue repair is expedient, simple and effective; with no adverse effects on mid-term ventricular dynamics. In view of superior published results to infarctectomy and repair with extra corporeal circulation, it should be considered to be the initial procedure of choice for the surgical repair of LVFWR.

Stroke after coronary artery bypass grafting: Preoperative predictive accuracies of CHADS2 and CHA2DS2VASc stroke risk stratification schemes

OBJECTIVE Neurologic events after coronary artery bypass grafting are an infrequent but devastating complication. This study analyzed the preoperative predictive abilities of the CHADS(2) and CHA(2)DS(2)VASc stroke scores in patients undergoing isolated coronary artery bypass grafting. METHODS Included in the study were 2910 patients who underwent isolated coronary artery bypass grafting during a 19-year period. CHADS(2) and CHA(2)DS(2)VASc scores were computed for all patients, and outcomes were evaluated in terms of perioperative stroke and compared with 2 specific models for predicting surgical coronary artery bypass grafting stroke (Northern New England Cardiovascular Disease Study Group and Multicenter Study of Perioperative Ischemia Research Group). Perioperative stroke discrimination was quantified by computing the area under the receiver operating characteristic curve. RESULTS Overall, 62 (2.1%) had perioperative strokes. Areas under the curve were 0.71 (95% confidence interval, 0.64-0.78) for CHADS(2), 0.72 (95% confidence interval, 0.65-0.79) for CHA(2)DS(2)VASc, 0.69 (95% confidence interval, 0.61-0.76) for Northern New England Cardiovascular Disease Study Group, and 0.73 (95% confidence interval, 0.67-0.80) for Multicenter Study of Perioperative Ischemia Research Group scores. Northern New England Cardiovascular Disease Study Group and CHA(2)DS(2)VASc scores were better at discriminating patients with particularly low or high risk of stroke. CONCLUSIONS CHADS(2) and CHA(2)DS(2)VASc scores predicted perioperative coronary artery bypass grafting strokes with discriminatory abilities similar to those of specific predictive surgical coronary artery bypass grafting stroke models. All schemes tested showed similar limitations in discriminating patients with high postoperative stroke risk, with a high proportion being classified as having intermediate stroke risk.

Tendencias en cirugía coronaria: cambios en el perfil del paciente quirúrgico

Introduccion y objetivos. En los ultimos anos se ha producido un aumento del riesgo en los pacientes en los que se realiza una derivacion coronaria. La mayor edad y comorbilidad son las causas involucradas con mas frecuencia. Se ha realizado un estudio retrospectivo para constatar este nuevo perfil y valorar su impacto. Pacientes y metodo. Se ha analizado la tendencia de riesgo de 1.360 pacientes en los que se realizo una derivacion coronaria consecutivamente entre 1993 y 2001 en nuestro centro. Se han considerado 3 cohortes historicas: en los anos 1993-1996, 1997-1999 y 2000-2001. Se ha estudiado la morbimortalidad y sus principales factores asociados mediante un analisis de regresion logistica. Se ha valorado la influencia de nuevas tecnicas, como la revascularizacion con injertos arteriales o la cirugia sin circulacion extracorporea. Resultados. Se ha constatado un riesgo quirurgico creciente: mayor edad, mayor frecuencia de morbilidad asociada y peor funcion ventricular. El EuroSCORE ha ratificado esta tendencia (el 2,0, el 4,0 y el 4,2% de mortalidad estimada en las cohortes respectivas; p < 0,001). Pese a ello, la mortalidad ajustada al riesgo ha descendido (el 3,7, el 2,7 y el 1,5%; p < 0,05) y la morbimortalidad global se ha mantenido (el 16,7, el 16,4 y el 13,8%; p = 0,39). El empleo de injertos arteriales y la cirugia sin circulacion extracorporea han mostrado una tendencia hacia una menor morbimortalidad hospitalaria. Conclusiones. Ha empeorado el riesgo quirurgico de los pacientes coronarios debido a una mayor edad y comorbilidad. Pese a ello, no se ha producido un aumento de la mortalidad ajustada al riesgo. El probable efecto beneficioso de la cirugia sin circulacion extracorporea y el empleo de injertos arteriales debe ser corroborado por futuros estudios.

Factors for development of late significant tricuspid regurgitation after mitral valve replacement: the impact of subvalvular preservation

OBJECTIVE Development of late significant tricuspid regurgitation (TR) after successful mitral valve replacement (MVR) is not infrequent. The impact of different aetiologies or diverse surgical procedures has not been adequately investigated. We studied the influence of subvalvular preservation techniques during MVR on the incidence of late TR. METHODS A total of 801 patients with grade ≤ 2+/4+ preoperative TR underwent MVR without associated tricuspid procedures from January 1994 to August 2008. In 595 patients, only posterior mitral leaflet preservation was performed (group A). In the remaining 206 patients, both anterior and posterior leaflets were retained (group B). Postoperative development of significant TR was defined as a TR increase by more than one grade from preoperative or final TR grade ≥ 3+/4+ at follow-up. RESULTS The global incidence of postoperative significant TR was 8.6%, with higher incidence in females (9.4% vs 6.7%, p=0.12), rheumatic disease (9.7% vs 6.5%, p=0.07), patients with previous AF (11.8% vs 3.8%, p<0.001) and, especially, in group A (10.8% vs 2.4%, p<0.001). The Maze procedure was protective in patients with AF (the incidence with and without associated Maze was 6.7% vs 13.2%, p=0.04). Preoperative left-atrial diameters were higher in patients with postoperative development of TR (56 ± 9 mm vs 51 ± 12 mm, p=0.01). Group A (p=0.04) and preoperative atrial fibrillation (p=0.001) were significant predictors of late postoperative TR. Late functional TR decreased free survival from chronic heart failure. CONCLUSIONS Several clinical and operative factors are associated with the development of significant TR after MVR. Although early surgical intervention for TR may be recommended in selected patients, complete subvalvular preservation of the mitral valve and routine surgical ablation of atrial fibrillation can significantly reduce its incidence.

Mitral Valve Replacement in Rheumatic Patients: Effects of Chordal Preservation

BACKGROUND Subvalvular preservation is beneficial in patients undergoing mitral valve replacement, especially in degenerative mitral regurgitation. Its feasibility and benefit is less evident in rheumatic disease. Our aim was to study the impact of preservation techniques in rheumatic patients and determine risk factors for mortality. METHODS Five hundred sixty-six rheumatic patients undergoing mitral valve replacement between 1996 and 2006 have been included. One hundred fifty-six patients had complete excision of the subvalvular apparatus (group 1), 248 had preservation of the posterior leaflet (group 2), and 162 had total chordal preservation (group 3). Echocardiography was performed preoperatively, at discharge, at 1 year, and at late follow-up. RESULTS Reduction of ventricular volume was greater in groups 2 and 3, especially if previous mitral regurgitation or mixed disease were present. In mitral stenosis, valve resection caused postoperative increase of volume. Ventricular ejection and pulmonary hypertension had better outcome with valve preservation. Valve resection was associated with late mortality (hazard ratio, 2.64; p < 0.05), and complete chordal preservation was protective (hazard ratio, 0.31; p = 0.13). Actuarial survival (130 months) was better in group 3: 77.18% +/- 0.04%, 85.38% +/- 0.03%, and 93.22% +/- 0.02%, respectively (p < 0.01 group 1 versus group 3). Group 1 exhibited more low cardiac output syndrome (p < 0.01) and more patients in New York Heart Association functional class III and IV at last follow-up: 17.8% versus 3.9% and 2.0% (p < 0.001). CONCLUSIONS Complete chordal preservation is possible in a large percentage of rheumatic patients. Greater decrease of ventricular volume is obtained for mitral regurgitation. In mitral stenosis, subvalvular preservation may avoid postoperative ventricular dilatation. Consequently, ventricular ejection, pulmonary hypertension, and clinical outcomes may improve with time.

Atrial Remodeling After Mitral Valve Surgery in Patients with Permanent Atrial Fibrillation

Abstract  Background: Mitral valve pathology is frequently associated with auricular dilatation and atrial fibrillation. Mitral surgery allows an immediate surgical auricular remodeling and besides in those cases in which sinus rhythm is reached, it is followed by a late remodeling. The aim of this study is to investigate the process of postoperative auricular remodeling in patients with permanent atrial fibrillation undergoing mitral surgery. Methods: In a prospective randomized trial, 50 patients with permanent atrial fibrillation and dilated left atrium, submitted to surgical mitral repair, were divided into two groups: Group I contained 25 patients with left auricular reduction and mitral surgery, and Group II contained 25 patients with isolated valve surgery. Both groups were considered homogeneous in the preoperative assessment. Results: After a mean follow‐up of 31 months, 46% of patients included in Group I versus 18% of patients included in Group II restarted sinus rhythm (p = 0.06). An auricular remodeling with size regression occurred in those patients who recovered from sinus rhythm, worthy of remark in Group II (–10.8% of left auricular volume reduction in Group I compared to –21.5% in Group II; p < 0.05). A new atrial enlargement took place in those patients who remained with atrial fibrillation (+16.8% left auricular volume in Group I vs. +8.4% in Group II; p < 0.05). Conclusions: Mitral surgery produces an atrial postoperative volume that decrease especially when reduction techniques are employed. Late left atrial remodeling depended on the type of atrial rhythm and postoperative surgical volume.

Recambio valvular aórtico en pacientes mayores de 70 años: determinantes de mortalidad temprana

Introduction and objectives. There is controversy regarding the risk factors associated with early death in geriatric patients undergoing aortic valve replacement. We analyzed the risks in these patients and established an accurate model for predicting in-hospital mortality. Patients and method. Univariate and multivariate analyses were made of the risk factors associated with early death in a group of 129 patients older than 70 years who underwent aortic valve replacement (May 1994-June 2001). The variables obtained by multivariate logistic regression were combined to produce an equation for the prediction of early death. The equation was tested using a receiver operating characteristic curve. Results. Univariate analysis identified four factors related to early death: NYHA III-IV (p 1.90 m 2 , 20% for < 1.40 m 2 ). The estimated mortality with the predictive model was 7.06%, which was similar to the observed mortality of 7.80% (area under the ROC curve 0.87) and better than estimates obtained with the EuroSCORE (6.5%; area under the ROC curve 0.56). Conclusions. Risk factors associated with early death after aortic valve replacement in geriatric patients include functional status, aortic regurgitation, and small body surface area. Our model based on these factors accurately predicted operative mortality in our patients. Gender, prosthesis size, and pump time were not identified as risk factors.

Trends in Coronary Artery Bypass Surgery: Changing Type of Surgical Patient

Introduction and objectives. In the last few years, the percentage of high-risk patients proceeding to coronary artery bypass surgery has increased. The most common risk factors are older age and the presence of comorbid complaints. We carried out a retrospective study to confirm this new risk profile and to evaluate its impact on surgical results. Patients and method. We analyzed the changing risk profile of 1360 patients who underwent coronary artery bypass surgery in our hospital between 1993 and 2001, divided into three historical cohorts: 1993-1996, 19971999, and 2000-2001. The main factors associated with morbidity and mortality were analyzed by logistic regression analysis. The introduction of new operative techniques, such as off-pump surgery and arterial grafting, was also evaluated. Results. The patients’ risk profile worsened over time: patients were older, comorbid complaints were more common, and ventricular function was poorer. EuroSCORE figures reflected this trend: estimated mortality in the three historical cohorts was 2.0%, 4.0%, and 4.2%, respectively (P<.001). However, risk-adjusted mortality, at 3.7%, 2.7%, and 1.5%, respectively, decreased (P<.05), and combined overall morbidity and mortality remained stable, at 16.7%, 16.4%, and 13.8%, respectively (P<.39). There was a nonsignificant tendency for arterial grafting and off-pump surgery to reduce in-hospital morbidity and mortality. Conclusions. The risk profile of patients undergoing surgery has worsened as their mean age has increased and as comorbid complaints have become more prevalent. However, there has been no simultaneous increase in risk-adjusted mortality. The potential benefits of new surgical advances such as off-pump surgery and multiple arterial grafting must be corroborated by future studies.

Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits.

INTRODUCTION AND OBJECTIVES The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. METHODS Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). RESULTS No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. CONCLUSIONS In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.

The Folding Leaflet: A Simple Method for Neochordal Repair

We present a simple technique for facilitating accurate polytetrafluoroethylene chordal height adjustment in surgical repair of myxomatous mitral valve disease. This approach is based on the annulus as the reference level. The artificial chordae are first fixed to the corresponding papillary muscle. Each chordal pair is then attached to the free edge of the prolapsed leaflet, and subsequently, the leaflet edge is also attached to the adjacent annulus by temporary fixing sutures. As a result, the leaflet is gently folded. Finally, the polytetrafluoroethylene suture is knotted during proper apposition of the free edge of the leaflet to the annulus.