Rafael García Fuster

Left ventricular mass index in aortic valve surgery: a new index for early valve replacement?

OBJECTIVE Increased left ventricular mass index has been associated with higher mortality. We analyze the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement. METHODS Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index in 614 patients who underwent aortic valve replacement between June 1993 and November 2001. Left ventricular mass index was considered increased if higher than the value of the superior decile (277 g/m(2) in males and 251 in females). RESULTS Mean left ventricular mass index was: 178+/-111 g/m(2), and increased index was considered in 9.9% of patients. Postoperative complications (low cardiac output syndrome, respiratory failure, arrhythmias, pneumonia and mediastinitis), median length of hospital stay: 12 days (6-57) versus 11 days (5-51), and in-hospital mortality (11.4, 3.2%, P<0.01) were higher in patients with increased left ventricular mass index. Multivariable analysis identified increased left ventricular mass index (odds ratio: 5.6; 95% confidence interval: 1.2-25.0; P=0.02) and other three variables: age (P=0.04), history of chronic renal failure (P=0.03) and cardiopulmonary bypass time (P=0.004), as independent predictors of early mortality. CONCLUSIONS Increased left ventricular mass index is associated with an in-hospital adverse outcome and a significantly higher in-hospital mortality in patients undergoing aortic valve replacement. Outcomes in asymptomatic patients could be improved before a clinically significant increase in left ventricular mass index. Further studies should be performed to determine the usefulness of this index in selecting patients for earlier aortic valve replacement.

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.

Auriculectomía parcial izquierda en el tratamiento de la fibrilación auricular por valvulopatía mitral

Background. Atrial fibrillation is frequently observed under conditions associated with atrial dilatation. Atrial size is a factor related to the genesis and maintenance of atrial fibrillation. Predictive parameters of persistence of atrial fibrillation after maze procedure are atrial size and long duration of atrial fibrillation. The aim of this study was to investigate the effects of surgical left atrial reduction in chronic atrial fibrillation by mitral valvulopathy. Patients and method. Nineteen patients with chronic atrial fibrillation and dilated left atrium undergoing mitral valve procedures were included in this prospective study: group I with left atrial reduction (10 patients) and group II including control (9 patients). Both groups were with similar preoperative characteristics. Results. At the mean follow-up of 12 months, all the patients in group II had chronic atrial fibrillation, and 7 patients in group I showed in atrial rhythm (p < 0.003). The patients in whom atrial fibrillation continued after surgery showed left atrial area of 33.8 ± 12.3 cm 2 and a volume of 98.5 ± 53.9 ml; and the patients with normal rhythm had a left atrial area of 24.5 ± 5.3 cm 2 and a volume 60.3 ± 21.2 ml. Conclusions. Preliminary results indicate that surgical left atrial reduction in patients with chronic atrial fibrillation may be a mechanism implicated in the elimination of arrhythmia after surgery.

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.

Ablación de la fibrilación auricular permanente en la cirugía cardíaca. Resultados a corto y medio plazo

Introduccion y objetivos Actualmente la ablacion quirurgica de la fibrilacion auricular (FA) es un procedimiento simple que puede realizarse en la mayoria de los pacientes durante la cirugia cardiaca. Diferentes fuentes de energia para la ablacion permiten crear con facilidad las lineas de ablacion en las auriculas. Presentamos nuestra experiencia durante los ultimos 3 anos. Pacientes y metodo En 93 pacientes con diferentes afecciones quirurgicas cardiacas y FA permanente (> 3 meses) se asocio la ablacion quirurgica de la arritmia. La antiguedad media de la FA fue de 6 anos (rango, 0,3-24). El tamano preoperatorio por ecocardiografia (ECO) de la auricula izquierda (AI) fue de 51,7 ± 8,8 mm (rango, 35-77). Resultados La mortalidad hospitalaria fue de 5 pacientes (5,3%). Tras un seguimiento medio de 10 meses, el 16,1% de los pacientes siguen en FA permanente y el 83,8% han recuperado y mantenido el ritmo sinusal; 3 pacientes necesitaron la implantacion de un marcapasos definitivo. Analizando el resultado en los 82 pacientes con un seguimiento mayor de 6 meses, la prevalencia del ritmo sinusal fue del 84,1%. Se evidencio funcion contractil biauricular (ecocardiografica) en el 50% de los pacientes. Las complicaciones mayores relacionadas con el procedimiento de la ablacion fueron del 3,5%: 1 leak perivalvular al segundo mes postoperatorio, 1 espasmo de la arteria circunfleja y 1 fistula auriculoesofagica. Conclusiones La ablacion quirurgica de la FA permanente puede realizarse de forma simple, con baja morbimortalidad quirurgica, con recuperacion del ritmo sinusal en la mayoria de los pacientes. La incidencia de arritmias en el postoperatorio inicial es el principal problema del procedimiento.

Ventajas de la revascularización miocárdica sin circulación extracorpórea en pacientes de riesgo

Introduction and objectives. Myocardial revascularization without cardiopulmonary bypass has been shown to reduce operative morbi-mortality. We report our recent experience with this novel technique in order to evaluate its theoretical advantages in comparison with conventional surgery. Patients and methods. This retrospective analysis included 547 consecutive patients undergoing isolated myocardial revascularization from December 1997 through November 2000. One hundred twenty-one offpump patients were compared to 426 undergoing cardiopulmonary bypass. Logistic regression analysis was performed to find predictors of mortality, transfusion, postoperative atrial fibrillation and length of hospital stay. Results. Off-pump patients were at greater risk: they were older, with a lower ejection fraction and a higher prevalence of unstable angina, heart failure and associated comorbidity. Off-pump surgery reduced transfusions (1 ± 1 vs 1,9 ± 2 blood units; p < 0.0001) and postoperative hospital stays (8.9 ± 5 vs 11,3 ± 7 days; p < 0.001). The off-pump group showed a trend toward reduced morbidity but the technique did not decrease hospital mortality. Cardiopulmonary bypass was an independent predictor of blood transfusion and longer hospital stay. Short-term follow-up revealed no significant differences in recurring angina or patency rates. Conclusions. Off-pump coronary bypass surgery is a good option in high-risk patients because it reduces the incidence of perioperative transfusion and the length of hospitalization. Furthermore, it showed a trend toward reduced morbidity. Mortality was not significantly higher in spite of the higher risk of the patients. Long-term longitudinal follow-up is mandatory to assess the true effectiveness of this technique.

Ablación quirúgica de la fibrilación auricular con radiofrecuencia biauricular epicárdico-endocárdica: experiencia inicial

Background. Atrial fibrillation is frequent in surgical patients with cardiac valvulopathies. Radiofrequency energy applied by means of surgical probes permits the reproduction of atriotomies described in the maze surgical procedure for the ablation of atrial fibrillation in a fast, safe and efficient way. This study presents our initial experience in treatment of chronic atrial fibrillation through radiofrequency performed in patients with surgical cardiac valvulopathies. Patients and method. From June to November 2000, 10 patients, with surgical indications of valvulopathy, were intraoperatively treated through radiofrequency for its atrial fibrillation. Ablations were performed in the right auricle from the epicardium before starting extracorporeal circulation, and in the left auricle from the endocardium, while under circulation. Radiofrequency was applied through a surgical multielectrode probe. Results. Eight patients (80%) presented some type of postoperative arrhythmia, with relapse of paroxysmal fibrillation in 3 patients and flutter in another one. At discharge, none of the patients presented relapse of chronic atrial fibrillation. There was no in-hospital mortality. After a mean follow-up of 3 months (range, 1-6), 8 patients (80%) have recovered and maintained sinus rhythm. Only one patient has re-established echocardiographic biatrial contraction. Conclusions. Intraoperative radiofrequency has allowed us to perform the auricular lesions, in both auricles, in a simple way, with an initial effectiveness of 80%. Epicardial ablation of the right auricle was simple and safe. Although no patient presented relapse of chronic atrial fibrillation at hospital discharge, postoperative arrhythmias have continued to be the main postsurgical problem.

Comments on the ESC guidelines on the management of valvular heart disease (version 2012). A report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology.

A task force was formed consisting of experts from different fields. Members of the task force were proposed by the SEC Clinical Cardiology, Cardiac Catheterization, and Cardiac Imaging sections and by the SECTCV (Spanish Society of Thoracic and Cardiovascular Surgery). The Task Force was coordinated by 2 representatives of the CGPC. The guidelines were divided into blocks and sent to members of the Task Force, who analyzed the most novel and important aspects in terms of clinical practice. They also gave their opinion on the methodology used, possible areas of conflict, and limitations with regard to other guidelines. In addition, they were asked to describe the implications for actual practice in the Spanish setting. The information received was used to produce a first draft of the document, which the original committee evaluated before referring it to a second group of 11 reviewers also proposed by sections of the SEC and the SECTCV. All authors and reviewers were asked to disclose any conflicts of interest, details of which are provided at the end of the article.