Parwis B. Rahmanian

Early and late outcome of cardiac surgery in patients with liver cirrhosis

Liver cirrhosis is a major risk factor in general surgery. Few studies have reported on the outcome of cardiac surgery in these patients. Herein we report our recent experience in this high‐risk patient population according to the Child‐Turcotte‐Pugh classification and Model for End‐Stage Liver Disease (MELD) score. Between January 1998 and December 2004, 27 patients (mean age 58 ± 10 yr, 20 male) with cirrhosis who underwent cardiac surgery were identified. Patients were in Child‐Turcotte‐Pugh class A (n = 10), B (n = 11), and C (n = 6) and mean MELD score was 14.2 ± 4.2. Operative mortality was 26% (n = 7). Stratified mortality according to Child‐Turcotte‐Pugh class was 11%, 18%, and 67% for class A, B, and C, respectively. No mortality occurred in patients who had revascularization without the use of cardiopulmonary bypass (n = 5). The 1‐yr survival was 80%, 45%, and 16% for Child‐Turcotte‐Pugh class A, B, and C, respectively (P = 0.02). Major postoperative complications occurred in 22%, 56%, and 100% for Child‐Turcotte‐Pugh class A, B, and C, respectively. Child‐Turcotte‐Pugh classification was a better predictor of hospital mortality (P = 0.02) compared to MELD score (P = 0.065). In conclusion, our results suggest that cardiac surgery can be performed safely in patients with Child‐Turcotte‐Pugh class A and selected patients with class B. Operative mortality remains high in class C patients. Careful patient selection is critical in order to improve surgical outcome in patients with cirrhosis. Liver Transpl, 2007.

Current concepts in mitral valve repair for degenerative disease

The term degenerative mitral valve disease encompasses a broad spectrum of conditions in which dysplastic or infiltrative changes in tissue morphology cause elongation or rupture of the mitral valve chordae producing leaflet prolapse and/or mitral annular dilatation resulting in mitral regurgitation. Conditions responsible for degenerative mitral disease include Barlow’s disease, fibroelastic deficiency, and Marfan’s syndrome. Mitral valve prolapse is a common condition affecting up to 3% of the population. Although benign in most patients, mitral valve prolapse is now recognized as an important cause of cardiovascular mortality and morbidity. This review focuses on the pathophysiologic basis of degenerative mitral valve disease, its surgical management, and outcomes following surgical repair.

Anuloplastia remodeladora mediante un anillo específico para la reparación de la regurgitación mitral isquémica de tipo IIIb

Introduccion y objetivos El mecanismo mas frecuente de regurgitacion mitral isquemica es la restriccion de movimiento de los velos en sistole (tipo IIIb de Carpentier). La anuloplastia es la tecnica mas aceptada para su reparacion. El nuevo anillo protesico Carpentier-Mc-Carthy-Adams IMR Etlogix® fue disenado para tratar cada una de las peculiaridades de esta entidad, principalmente la dilatacion anular asimetrica. En este estudio revisamos las bases de creacion del anillo y describimos nuestra experiencia clinica inicial. Metodos Se intervino a 40 pacientes (edad, 68 ± 10 anos) de regurgitacion mitral isquemica de tipo IIIb (grados 3+/4+) mediante el nuevo anillo protesico entre diciembre de 2003 y junio de 2005. Los procedimientos asociados fueron la revascularizacion coronaria (n = 27 [68%]), la valvuloplastia tricuspidea (n = 10 [25%]) y la tecnica modificada de Maze (n = 9 [22%]). La estimacion del riesgo quirurgico por EuroSCORE fue del 17% ± 11%. Resultados La mortalidad hospitalaria fue del 2,5% (n = 1). La morbilidad postoperatoria incluyo 1 caso de accidente cerebrovascular (2,5%), 1 caso de insuficiencia renal (2,5%) y 4 casos de insuficiencia respiratoria (10%). El estudio ecocardiografico previo al alta hospitalaria revelo la ausencia de regurgitacion mitral en 36 pacientes (92%) y regurgitacion de grado leve en 3 (8%). Se obtuvo el seguimiento ecocardiografico a largo plazo de 36 pacientes (92%; intervalo de seguimiento, 15-34 meses), y se objetivo una tasa de recurrencia (grado ≥ 2+) del 3% (n = 1). Conclusiones El anillo de Carpentier-McCarthy-Adams IMR Etlogix® corrige de manera efectiva la regurgitacion mitral isquemica de tipo IIIb. La nueva conformacion tridimensional asimetrica afronta las caracteristicas anatomopatologicas de este tipo de disfuncion y puede aportar excelentes resultados a largo plazo.

Quadruple valve surgery in carcinoid heart disease.

Abstractu2002 We describe a 42‐year‐old male with primary carcinoid tumor of the ileum, secondary liver metastases, and subsequent severe carcinoid heart disease with quadruple valve involvement. The patient underwent tricuspid and pulmonic bioprosthetic valve replacement, mitral and aortic valve reconstruction. Transthoracic echocardiography at 25 months showed competent mitral and aortic valves with only mild regurgitation. Valve reconstruction is rarely performed in patients with carcinoid heart disease. However, in selected cases it is a valuable alternative technique with good mid‐term outcome.

Remodeling Annuloplasty Using a Prosthetic Ring Designed for Correcting Type-IIIb Ischemic Mitral Regurgitation

INTRODUCTION AND OBJECTIVESnThe most common mechanism underlying ischemic mitral regurgitation is restricted leaflet motion during systole (Carpentiers type IIIb). Annuloplasty is the preferred technique for surgical repair. The new Carpentier-McCarthy-Adams IMR Etlogix prosthetic annuloplasty ring was designed specifically to address the particular peculiarities of this condition, principally asymmetric annular dilatation. The aims of this study were to review the rationale underlying the creation of the ring and to report our early clinical experience.nnnMETHODSnThe study included 40 patients with type-IIIb ischemic mitral regurgitation (grade 3+/4+) who underwent mitral value reconstruction using the new prosthetic ring between December 2003 and June 2005. Their mean age was 68+/-10 years. Concomitant procedures included coronary artery bypass grafting (n=27, 68%), tricuspid valvuloplasty (n=10, 25%), and a modified Maze procedure (n=9, 22%). The mean predicted EuroSCORE mortality for surgery was 17+/-11%.nnnRESULTSnIn-hospital mortality was 2.5% (n=1). Major postoperative morbidities included one case of stroke (2.5%), one renal failure (2.5%), and four respiratory failures (10%). Predischarge echocardiography revealed no mitral regurgitation in 36 patients (92%) and mild regurgitation in three (8%). Long-term follow-up echocardiography was carried out in 36 patients (92%) after 15-34 months, and showed that the rate of recurrence of (grade >/=2+) mitral regurgitation was 3% (n=1).nnnCONCLUSIONSnThe Carpentier-McCarthy-Adams IMR Etlogix(R) annuloplasty ring was effective in correcting type-IIIb ischemic mitral regurgitation. Its novel three-dimensional asymmetric shape is designed to deal with the anatomical and pathological characteristics of the condition and its use may, therefore, result in an excellent long-term outcome.

Cardiovascular Surgery in Patients With HIV: Epidemiology, Current Indications, and Long-Term Outcome

INTRODUCTION AND OBJECTIVESnThe new highly active antiretroviral therapies used for the treatment of patients with human immunodeficiency virus (HIV) infection have dramatically modified the natural history of the disease. Although these therapies may themselves have adverse cardiovascular side-effects, their use has also resulted in seropositive patients surviving long enough to be exposed to the same risk factors as the general population. As a consequence, referrals for cardiovascular surgery have increased.nnnMETHODSnWe carried out a retrospective analysis of 39 consecutive HIV patients who underwent cardiovascular surgery between January 1998 and December 2006.nnnRESULTSnThe patients mean age was 49+/-10 years and 77% (n=30) were male. The CD4-lymphocyte count was <500 cells/microl in 56% of patients (n=22). The main indications for surgery were endocarditis (n=18, 46%), coronary artery disease (n=12, 31%), and aortic disease (n=5, 13%). The in-hospital mortality rate was 5% (n=2). Postoperative complications included systemic infection (n=2, 5%), stroke (n=1, 3%), kidney failure (n=1, 3%) and respiratory failure (n=5, 13%). Repeat surgery for bleeding was necessary in 2 patients (5%). There were no postoperative complications in 29 patients (72%). After a clinical follow-up period of 8.2 years, the long-term mortality rate was 10.8% (4/37), giving survival rates at 1, 3 and 5 years of 91%, 86% and 81% respectively.nnnCONCLUSIONSnCardiovascular surgery can be performed with complete safety in HIV patients, and with promising results. This study indicates that, currently, long-term survival in this particular group of patients is potentially greater than 80%.

Cirugía cardiovascular en pacientes con VIH: epidemiología, indicaciones actuales y resultados a largo plazo

Introduccion y objetivos Las nuevas terapias antirretrovirales de gran actividad (TARGA) para el tratamiento del virus de la inmunodeficiencia humana (VIH), aunque no exentas de efectos cardiovasculares adversos, han modificado espectacularmente la historia natural de la enfermedad, con lo que se expone a los pacientes seropositivos a factores de riesgo propios de la poblacion general y se incrementa la necesidad de cirugia cardiovascular. Metodos Se estudio retrospectivamente a 39 pacientes con VIH que se sometieron a cirugia cardiovascular de manera consecutiva entre enero de 1998 y diciembre de 2006. Resultados La media de edad fue de 49xa0±xa010 anos, y el 77% de los pacientes (nxa0=xa030) eran varones. Los linfocitos CD4 eran Conclusiones La cirugia cardiovascular puede llevarse a cabo de manera totalmente segura en pacientes con VIH, y se obtienen prometedores resultados. Este estudio ha reflejado que actualmente la supervivencia a largo plazo en este particular grupo de pacientes seria superior al 80%.