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Resumen Introduccion y objetivos A fin de entender la evolucion de la sustitucion convencional de la valvula aortica (SVAo) en Espana, se llevo a cabo un analisis nacional para investigar, entre 1998 y 2017: a) el volumen de procedimientos; b) perfil de riesgo de los pacientes; c) mortalidad hospitalaria, y d) tipo de protesis aortica utilizada. Metodos Se incluyeron todos los episodios de pacientes sometidos a SVAo del Conjunto Minimo Basico de Datos (Ministerio de Sanidad, Consumo y Bienestar Social de Espana) entre enero de 1998 y diciembre de 2017. La duracion del estudio se dividio en 4 periodos de 5 anos. Se analizaron las tendencias en numero de intervenciones, comorbilidades y mortalidad hospitalaria. Mediante analisis multivariante, se identificaron los factores asociados con la mortalidad hospitalaria y el tipo de protesis utilizada. Se compararon los indices de mortalidad ajustada por el riesgo en el periodo de estudio. Resultados En el periodo de estudio, se sometieron a SVAo 73.668 pacientes. El numero de SVAo/ano aumento desde 16.363 entre 1998 y 2002 a 22.685 entre 2013 y 2017. Se incremento la prevalencia de todas las comorbilidades salvo las de infarto de miocardio e ingreso urgente. El indice de Charlson empeoro entre el primer (1998-2002) y el cuarto (2013-2017) periodo: 2,3 ± 1,4 frente a 3,6 ± 1,7 (p Conclusiones Se detecto un aumento del volumen anual de SVAo en Espana, con un empeoramiento del perfil de riesgo y mas pacientes con bioprotesis. Se observo una reduccion muy relevante de la mortalidad hospitalaria.

Resumen: El presente registro aporta los datos correspondientes a la actividad de cirugía cardiovascular realizada en España durante el año 2019. Se trata del trigésimo primer año en el que, desde la recién renombrada Sociedad Española de Cirugía Cardiovascular y Endovascular, se procede a la comunicación de los datos de la actividad en el territorio nacional. Por primera vez en los últimos 15 años, se rompe una tendencia creciente de participación de centros y baja el número de participantes. Se trata de un registro anónimo y voluntario de datos agregados en el que han colaborado 57 hospitales, transfiriendo sus datos al registro nacional, por los 62 centros que comunicaron su actividad durante el año 2018.El presente registro recoge un total de 33.660 cirugías. Se realizaron 21.525 procedimientos de cirugía cardiaca mayor (19.657 de cirugía cardiaca adquirida y 1.868 de cirugía cardiaca mayor congénita). De estos procedimientos, 19.221 se efectuaron con circulación extracorpórea (CEC).Como en registros previos, tanto la cirugía cardiaca congénita como el trasplante cardiaco disponen de su propio registro.La cirugía cardiaca mayor de patología adquirida se reparte de la siguiente manera: la cirugía univalvular aislada fue la más frecuente, una vez más, con 8.607 casos, seguida de la cirugía coronaria con 4.734 casos (3.415 con CEC y 1.443 sin CEC). Se registraron 2.315 procedimientos sobre la aorta y 1.983 casos de cirugía combinada. También se reflejan, en el presente informe, datos de implante de prótesis transcatéter, cirugía vascular periférica e implante de dispositivos de electroestimulación.Por primera vez en la serie histórica del registro, el número de implantes valvulares aórticos aislados es inferior al documentado en el registro cardiológico, pudiendo así afirmar que se implantan más prótesis transcatéter que «puramente» quirúrgicas, según los datos disponibles en 2019.Por último, se informa de diversos datos de distribución geográfica de la actividad quirúrgica a nivel nacional. Abstract: The Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) reports the results of the 2019 registry of the surgical activity in our country. This year represents the 31th consecutive year in which this report is published. The participation in this registry is anonymous and voluntary, and it is based on the analysis of the information gathered from 57 centers with activity in cardiovascular surgery in our country, and the confidentiality of the individual data of each center is warranted. For the first time, in the last 15 years, a tendency is broken and fewer hospitals have communicated their activity. In certain cases, estimations have to be calculated in order to make comparisons possible. The registry reports the global activity in our country, the observed mortality and the estimated mortality risk, stratified in different types of procedures.The global cardiac surgical activity in our country remains stable, with an observed mortality that is adequately adjusted to the estimated surgical risk.During 2019, a total of 33,660 procedures of cardiovascular surgery were performed. Major heart surgery was performed in 21,525 cases, among which 19,657 procedures of adult cardiac surgery and 1,868 procedures of congenital cardiac surgery. Out of those, 19,221 procedures were performed under extracorporeal circulation (CEC). Congenital and transplant registries are specifically analysed in their corresponding reports.Among the 19,720 procedures of acquired major cardiac surgery, isolated valve surgery was predominant (8,607 procedures), followed by coronary by-pass surgery (4,734), aorta surgery (2,315) and combined coronary-valvular surgery (1,983). Vascular surgery and transcatheter activity are also reported.The information derived from this national registry allows to know the state-of-the-art of the surgical specialty in our country, through the knowledge of the surgical activity, the risk profile and the observed results, which is a keystone for an adequate evaluation of the quality of the health care that we deliver to the patients affected with cardiovascular pathologies. Risk adjusted mortality seems adequately adjusted, though important local differences are observed.

IntroductionEstimation of peri-procedural risk in patients with tricuspid regurgitation (TR) undergoing isolated tricuspid valve surgery (ITVS) is of paramount importance. The TRI-SCORE is a new surgical risk scale specifically developed for this purpose, which ranged from 0 to 12 points and included eight parameters: right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate MethodsA retrospective observational study was performed in four centres, including consecutive adult patients undergoing ITVS for TR between 2005 and 2022. The TRI-SCORE and the traditional risk scores used in cardiac surgery (Logistic EuroScore (Log-ES) and EuroScore-II (ES-II)) were applied for each patient, and discrimination and calibration of the three scores were evaluated in the entire cohort.ResultsA total of 252 patients were included. The mean age was 61.5±11.2 years, 164 (65.1%) patients were female, and TR mechanism was functional in 160 (63.5%) patients. The observed in-hospital mortality was 10.3%. The estimated mortality by the Log-ES, ES-II and TRI-SCORE was 8.7±7.3%, 4.7±5.3% and 11.0±16.6%, respectively. Patients with a TRI-SCORE ≤4 and >4 had an in-hospital mortality of 1.3% and 25.0%, p=0.001, respectively. The discriminatory capacity of the TRI-SCORE had a C-statistic of 0.87 (0.81–0.92), which was significantly higher than both the Log-ES (0.65 (0.54–0.75)) and ES-II (0.67 (0.58–0.79)), p=0.001 (for both comparisons).ConclusionThis external validation of the TRI-SCORE demonstrated good performance to predict in-hospital mortality in patients undergoing ITVS, which was significantly better than the Log-ES and ES-II, which underestimated the observed mortality. These results support the widespread use of this score as a clinical tool.

Resumen: Introducción y objetivos: La ablación de la fibrilación auricular (FA) por toracoscopia o totally thoracoscopic maze (TT-MAZE) es un tratamiento quirúrgico eficaz cuya indicación, en nuestro país, es marginal. El objetivo es resumir nuestra experiencia en el tratamiento de la fibrilación auricular aislada mediante TT-MAZE. Material y método: Se incluyó a todos los pacientes intervenidos de TT-MAZE entre junio del 2018 y mayo del 2020. Analizamos las características de la serie, las complicaciones asociadas y la supervivencia libre de fibrilación auricular. Resultados: Se incluyó a 26 pacientes. La mediana de edad fue de 64,5 años (IQR 52-69) y el 84,6% (n = 22) eran varones. El 46,2% (n = 12) presentaba una fibrilación auricular persistente, el 34,6% (n = 9) paroxística y el 19,2% (n = 5) persistente de larga duración. La mediana de duración de la FA era de 4 años (IRQ 2-10). A 15 pacientes (57,7%) se les habían realizado ablaciones percutáneas previas y a 6 (23,1%), ablación del istmo cavotricuspídeo. No hubo conversiones a esternotomía media, sangrados ni otras complicaciones mayores.La supervivencia libre de fibrilación auricular a los 6 meses fue del 95,45% y al año del 90,43%. El 54,55% de los pacientes estaban libres de anticoagulación a los 6 meses. Conclusiones: La TT-MAZE es una estrategia eficaz para el tratamiento de la fibrilación auricular sintomática, con una elevada tasa de éxito y una limitada incidencia de complicaciones. Abstract: Introduction and objectives: Ablation of auricular fibrillation (AF) by thoracoscopy or totally thoracoscopic maze (TT-MAZE) is an effective surgical treatment whose indication, in our country, is marginal. The objetive is to summarize our experience in the treatment of isolated auricular fibrillation using TT-MAZE. Material and method: All patients who underwent a TT-MAZE between June 2018 and May 2020 were included. We analyzed the characteristics of the series, the associated complications, and survival free of auricular fibrillation. Results: 26 patients were included. The median age was 64.5 years (IQR 52-69) and 84.6% (n = 22) were male. 46.2% (n = 12) had persistent AF, 34.6% (n = 9) paroxysmal, and 19.2% (n = 5) persistent long-term. The median duration of auricular fibrillation was 4 years (IRQ 2-10). Fifteen patients (57.7%) had undergone previous percutaneous ablations and 6 (23.1%) had ablation of the cavotricuspid isthmus. There were no conversions to median sternotomy, bleeding, or other major complications.Atrial fibrillation-free survival at 6 months was 95.45% and at one year 90.43%. 54.55% of the patients were free of anticoagulation at 6 months. Conclusions: TT-MAZE is an effective strategy for the treatment of symptomatic auricular fibrillation, with a high success rate and a limited incidence of complications.

Resumen: Introducción y objetivos: La revascularización coronaria de la arteria descendente anterior (DA) mediante derivación aortocoronaria mínimamente invasiva (MIDCAB) mantiene los beneficios del uso de la arteria mamaria interna izquierda y evita las complicaciones asociadas a la esternotomía media y a la circulación extracorpórea. El objetivo es presentar nuestra experiencia inicial en el MIDCAB. Material y método: Se incluyeron todos los pacientes intervenidos mediante MIDCAB de marzo 2019 a junio del 2020. En todos los pacientes se realizó un puente coronario de arteria mamaria interna izquierda a la descendente anterior mediante minitoracotomía anterolateral izquierda sin circulación extracorpórea. Resultados: Se intervinieron 22 pacientes. La mediana de edad era de 70 años (IQR 63-77) y el 90,9% (n = 20) eran varones. En dos pacientes con estenosis aórtica severa se realizó simultáneamente implante de una prótesis aórtica transcatéter por vía transapical y en ocho (36,4%) pacientes se realizó un procedimiento híbrido con revascularización percutánea al resto de lesiones. No hubo mortalidad hospitalaria, infarto agudo de miocardio, accidente cerebrovascular, ni fracaso renal agudo postoperatorio. La mediana de estancia hospitalaria fue de cuatro días (IQR 3-5). Conclusiones: El MIDCAB es una técnica segura y eficaz para la revascularización coronaria en el territorio de la descendente anterior que combina las ventajas de un abordaje mínimamente invasivo sin circulación extracorpórea y el uso de la arteria mamaria interna izquierda para la realización de un puente coronario. Summary: Introduction and objectives: Coronary revascularization of the anterior descending artery (DA) using MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) maintains the benefits of the use of the left internal mammary artery (AMII) and avoids the complications associated with middle sternotomy and extracorporeal circulation. The objective is to present our initial experience at MIDCAB. Material and method: All patients who underwent MIDCAB from March 2019 to June 2020 were included. In all patients, a left internal mammary artery bypass was performed to the anterior descending artery using a left anterolateral minithoracotomy without extracorporeal circulation. Results: 22 patients. The median age was 70 years (IQR 63-77) and 90.9% (n = 20) were male. Transapical aortic valve implantation was performed simultaneously in two patients with severe aortic stenosis and in 8 (36.4%) patients a hybrid procedure with percutaneous coronay intervention was performed for the rest of the lesions. There were no hospital mortality, miocardial infarction, stroke, or postoperative acute renal failure. The median hospital stay was 4 days (IQR 3-5). Conclusions: MIDCAB is a safe and effective technique for coronary revascularization in the left anterior descending coronary artery that combines the advantages of a minimally invasive approach without extracorporeal circulation and the use of the left internal mammary artery bypass.

Resumen: Introducción: Actualmente existe controversia respecto a los beneficios y riesgos de la revascularización coronaria con injertos arteriales múltiples. Objetivos: Analizar la supervivencia a medio plazo entre pacientes sometidos a cirugía coronaria aislada sin circulación extracorpórea (CEC) según recibiesen, o no, más de un injerto arterial. Evaluar el objetivo primario en una muestra ajustada mediante puntuación de propensión. Material y métodos: Revisión retrospectiva de pacientes sometidos a cirugía coronaria sin CEC entre 2005 y 2017. Con el propósito de limitar sesgos, se realizó un análisis de supervivencia tras ajustar la muestra mediante puntuación de propensión (1:1; nearest neighbor) y un análisis de riesgos proporcionados de Cox para identificar variables asociadas al evento primario. Resultados: Se incluyeron 1.875 pacientes. En la cohorte total, los pacientes con solo un injerto arterial presentaron edad media más avanzada (70,3 vs 60,4 años; p

Resumen Introduccion y objetivos El mixoma es el tumor benigno intracardiaco mas frecuente, constituyendo el 50-65% de los mismos. El objetivo es presentar nuestra experiencia en su tratamiento quirurgico y analizar los resultados a corto y largo plazo. Material y metodos Se recogieron retrospectivamente todos los pacientes sometidos a cirugia para extirpacion de mixoma cardiaco, con diagnostico histopatologico confirmado, desde 2003 al 2019. Se realiza descripcion de la serie y un analisis de la supervivencia. Resultados Del total de 41 pacientes, el 80,5% (n = 33) eran mujeres con una mediana de edad de 59,3 anos (IQR 50,6-71,0). El sintoma mas frecuente era la disnea (39,0%), seguido de las palpitaciones (12,2%) y el sincope (12,2%). El 14,6% (n = 6) empezo con un evento embolico. El diametro medio del tumor era de 3,7 cm (DE 1,3). El 92,6% (n = 38) se localizaba en la auricula izquierda (37 en el septo interauricular y uno en la valvula mitral), el 4,9% (n = 2) en la auricula derecha y el 2,4% (n = 1) en ambas auriculas. Un paciente tuvo que ser reoperado por sangrado excesivo, un paciente presento un ACV permanente y 4 pacientes fibrilacion auricular posquirurgica. No hubo mortalidad hospitalaria. Mediana de seguimiento: 8,1 anos (IQR 3,8-13). La supervivencia al ano, 5 y 10 anos fue del 97,5%, 94,6% y 88,2%, respectivamente. Sin recidivas tumorales durante el seguimiento. Conclusiones La reseccion quirurgica es el tratamiento de eleccion en el mixoma cardiaco, con escasa morbimortalidad y excelentes resultados a corto y largo plazo.

Background: We aimed to compare 1 year the hemodynamic in-vivo performance of three biological aortic prostheses (Carpentier Perimount Magna EaseTM, Crown PRTTM, and TrifectaTM). Methods: The sample used in this study comes from the “BEST-VALVE” clinical trial, which is a phase IV single-blinded randomized clinical trial with the three above-mentioned prostheses. Results: 154 patients were included. Carpentier Perimount Magna EaseTM (n = 48, 31.2%), Crown PRTTM (n = 51, 32.1%) and TrifectaTM (n = 55, 35.7%). One year after the surgery, the mean aortic gradient and the peak aortic velocity was 17.5 (IQR 11.3–26) and 227.1 (IQR 202.0–268.8) for Carpentier Perimount Magna EaseTM, 21.4 (IQR 14.5–26.7) and 237.8 (IQR 195.9–261.9) for Crown PRTTM, and 13 (IQR 9.6–17.8) and 209.7 (IQR 176.5–241.4) for TrifectaTM, respectively. Pairwise comparisons demonstrated improved mean gradients and maximum velocity of TrifectaTM as compared to Crown PRTTM. Among patients with nominal prosthesis sizes ≤ 21, the mean and peak aortic gradient was higher for Crown PRTTM compared with TrifectaTM, and in patients with an aortic annulus measured with metric Hegar dilators less than or equal to 22 mm. Conclusions: One year after surgery, the three prostheses presented a different hemodynamic performance, being TrifectaTM superior to Crown PRTTM.

A 67-year-old man with severe mitral regurgitation and paroxysmal atrial fibrillation was admitted to our institution for surgical repair. The procedure was carried out off-pump. We first performed a totally thoracoscopic maze box lesion set with epicardial transmural radiofrequency, and clipped the left atrial appendage. The mitral valve prolapse was repaired by implanting three transapical neochordae. Six months later, the patient was in sinus rhythm with minimal residual mitral regurgitation on echocardiography. This novel approach is less invasive than the standard surgical correction and should ensure a faster recovery with similar safety and efficacy in selected cases.

Resumen: Introducción y objetivos: La pericarditis constrictiva es una enfermedad poco frecuente, con una elevada morbimortalidad, cuyo tratamiento es la pericardiectomía quirúrgica. El objetivo es presentar nuestra experiencia y analizar los resultados a corto y largo plazo. Métodos: Se incluyeron todos los pacientes intervenidos de pericardiectomía por pericarditis constrictiva desde enero de 2003 hasta febrero de 2018. Se describe la serie y se analizan los resultados a corto y largo plazo y los factores de riesgo de mortalidad. Resultados: Cincuenta y tres pacientes, con edad media de 60,5 años (±10,3). El 71,7% eran varones. La etiología más frecuente fue la idiopática (52,8%), seguida de la infecciosa/inflamatoria (28,3%) y la poscardiotomía (11,3%). El 62,3% presentaba una NYHA III-IV en el preoperatorio. La mortalidad hospitalaria fue del 11,3% (n = 6). Sin recidivas en el seguimiento. Mediana de seguimiento 64,9 meses (IQR 3,1-131,2). Supervivencia al año, a los 5 y a los 8 años del 86,4%, 81,6% y 75,1%. La NYHA IV fue el único factor independiente de mortalidad a largo plazo en el análisis multivariante. Conclusiones: La pericardiectomía es el tratamiento de elección en la pericarditis constricitiva. Aunque se trata de un procedimiento con elevada morbimortalidad, puede disminuirse significativamente si la indicación de la cirugía es precoz, antes de la aparición de síntomas refractarios. Además, una técnica quirúrgica agresiva previene la recidiva en el seguimiento a largo plazo. Abstract: Introduction and objectives: Constrictive pericarditis is a rare disease with a high morbidity and mortality. His treatment is the surgical pericardiectomy. The aim of this study is to present our experience and analyze the short and long-term outcomes. Methods: All patients who were underwent to a subtotal pericardiectomy for constrictive pericarditis from january 2003 to february 2018 were included. A description of the serie was made, short and long-term outcomes and mortality risk factors were analyzed. Results: A total of 53 patients were underwent to a subtotal pericardiectomy. The mean age was 60.5 years (±10.3). The 71.7% were males. The most frequent etiology was idiopathic (52.8%), followed by infectious/inflammatory (28.3%) and postcardiotomy (11.3%). A 62.3% of the patients had NYHA functional class III-IV preoperatively. In-hospital mortality rate was 11.3% (n = 6). There were no recurrences in follow-up. Median postoperative follow-up was 64.9 months (IQR 3.1 – 131.2). One, 5 and 10 years survival rates were 86.4%, 81.6% and 75.1%, respectively. NHYA functional class IV was the only independent factor of risk of long-term mortality. Conclusions: Pericardiectomy is the surgical technique of choice for the treatment of constrictive pericarditis. Although it is a procedure with high morbidity and mortality, it can be significantly reduced if the indication for surgery is early, before the appearance of refractory symptoms. In addition, an aggressive surgical technique prevents recurrence in long-term follow-up. Palabras clave: Pericardiectomía, Constricción pericárdica, Efusión pericárdica, Pericarditis, Pericardio, Keywords: Pericardiectomy, Pericardial constriction, Pericardial effusion, Pericarditis, Pericardium

Resumen: Introducción: La ateromatosis coronaria difusa actualmente es un reto para el cirujano cardiaco. La endarterectomía coronaria es un procedimiento útil para el tratamiento de esta enfermedad en conjunto con la cirugía de revascularización. Actualmente existe poca evidencia del impacto de la endarterectomía coronaria en la supervivencia a largo plazo de la cirugía de revascularización miocárdica. Objetivos: Analizar y comparar supervivencia y eventos adversos cardiovasculares mayores de la endarterectomía en la cirugía coronaria a corto y largo plazo. Material y métodos: Revisión retrospectiva de los pacientes sometidos a cirugía coronaria aislada, comparando endarterecomías vs revascularización aislada. Comparación de supervivencia a largo plazo en la cohorte total y análisis de riesgos proporcionados de Cox para la supervivencia. Comparación de eventos adversos cardiovasculares en una muestra ajustada mediante propensity score. Resultados: Media de seguimiento: 5,9 años (±3,9). Ciento siete pacientes sometidos a endarterectomía y 1.936 a revascularización aislada, a 10 años. La supervivencia fue del 62% y del 70% (p = 0,044) para el grupo de endarterectomía y revascularización aislada, respectivamente. La endarterectomía fue un factor de riesgo independiente para mortalidad (HR: 1,6; IC 95%: 1,1-2,3). En la muestra ajustada observamos una mayor incidencia de eventos adversos cardiovasculares perioperatorios (23,8% vs 10,4%; p

IntroductionSpain is one of the countries with the lowest rates of revascularisation and highest ratio of percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG).ObjectivesTo investigate the changes and trends in the two revascularisation procedures between 1998 and 2017 in Spain.DesignRetrospective cohort study. Analysis of in-hospital outcomes.SettingMinimum basic data set from the Spanish National Department of Health: mandatory database collecting information of patients who are attended in the Spanish public National Health System.Participants603 976 patients who underwent isolated CABG or PCI in the Spanish National Health System. The study period was divided in four 5-year intervals. Patients with acute myocardial infarction on admission were excluded.Primary and secondary outcomesWe investigated the volume of procedures nationwide, the changes of the risk profile of patients and in-hospital mortality of both techniques.ResultsWe observed a 2.2-fold increase in the rate of any type of myocardial revascularisation per million inhabitants-year: 357 (1998) to 776 (2017). 93 682 (15.5%) had a coronary surgery. PCI to CABG ratio rose from 2.2 (1998–2002) to 8.1 (2013–2017). Charlson’s index increased by 0.8 for CABG and 1 for PCI. The median annual volume of PCI/hospital augmented from 136 to 232, while the volume of CABG was reduced from 137 to 74. In the two decades, we detected a significant reduction of CABG in-hospital mortality (6.5% vs 2.6%, pConclusionWe detected a significant increase in the volume of revascularisations (particularly PCI) in Spain. Risk-adjusted in-hospital mortality was significantly reduced.

Resumen: Introducción y objetivos: La pandemia de COVID-19 causada por infección del virus SARS-CoV-2 ha puesto en una situación de sobrecarga grave al sistema sanitario español. Como consecuencia se ha visto afectada la atención de las enfermedades cardiovasculares. Queremos cuantificar a nivel estatal el impacto de la pandemia en el número de las intervenciones quirúrgicas, para poder planificar la nueva normalidad pospandemia. Métodos: A instancias de la Sociedad Española de Cirugía Cardiovascular y Endovascular se envió una encuesta telemática anónima de 10 preguntas a todos los jefes de servicio de España. El período de estudio fue entre el 1 de enero de 2020 y el 30 de septiembre de 2020 (9 meses), y como período control las mismas fechas del año 2019. Resultados: Se recibieron los datos de 32 centros hospitalarios. Un 22% del total de cirujanos cardiovasculares se contagiaron de COVID-19, siendo la media de 1,3 ± 1,5 adjuntos infectados/centro. Hubo fallecidos en lista de espera en el 46% de los centros, con una media de 1,5 ± 3,6 pacientes/centro. Hubo un descenso global del 13% en el número de cirugías (43 menos de media/centro respecto a 2019), desde una mediana de 300 (230-444) en 2019 y de 253 (172-389) en 2020 (p = 0,03) con un incremento del 12% (+7 pacientes/centro, p = 0,68) en las listas de espera. Conclusiones: Existió un descenso global de cirugías del 13% respecto a 2019, con un incremento del 12% en las listas de espera. El 22% de los cirujanos se contagiaron de COVID-19. Abstract: Introduction and objectives: The COVID-19 pandemic caused by the infection of the SARS-CoV-2 virus has put the Spanish health system in a situation of serious overload. As a consequence, the care of cardiovascular diseases has been affected. We want to quantify at the Spanish level the impact that the pandemic has on the number of surgical interventions, in order to be able to plan for the new post-pandemic normality. Methods: At the request of the Spanish Cardiovascular National Society, an anonymous telematic survey of 10 questions was sent to all Heads of Service in Spain. The study period was between January 1 and September 30, 2020 (9 months), and as a control period the same dates in 2019. Results: Data were received from 32 Hospital Centers. The 22% of all cardiovascular surgeons were infected with COVID-19, with an average of 1.3±1.5 infected surgeons/center. There were deaths on the waiting list in 46% of the centers, with a mean of 1.5±3.6 patients/center. There was a global decrease of 13% in the number of surgeries (43 less than average/center compared to 2019, p=0.03), from 300 (230-444) in 2019 to 253 (172-389) in 2020 (p=0.03), with an increase of 12% (+7 patients/center, p=0.68) on the waiting lists. Conclusions: There was a global decrease in surgeries of 13% compared to 2019, with a 12% increase in waiting lists. 22% of surgeons were infected with COVID-19.

Introduction and objectives: To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses. Methods: We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period. Results: In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P < .001). In-hospital mortality decreased from 7.2% to 3.3% (P < .001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P < .001). Conclusions: We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced. (C) 2020 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Long-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population.This was a multicenter observational study including all patients aged between 50 and 65 years who underwent an aortic valve replacement because of severe isolated aortic stenosis between the years 2000 and 2018. A total of 5215 patients from 27 Spanish hospitals were registered with a follow-up of 15 years. Multivariable analyses, including a 2:1 propensity score matching (1822 Mech and 911 Bio) and competing risks analyses were applied.Bio prostheses were implanted in 19% of patients (n = 992). No significant differences were observed between matched groups in long-term survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.88-1.47; P = .33). Stroke rates were higher for Mech prostheses, but not significant (HR, 0.72; 95% CI, 0.50-1.03; P = .07). Finally, higher rates of major bleeding were found in the Mech group (HR, 0.65; 95% CI, 0.49-0.87; P = .004), whereas reoperation was more frequent among the Bio group (HR, 3.04; 95% CI, 1.80-5.14; P .001). Bio prostheses increased from 13% in the period from 2000 to 2008 to 24% in 2009 to 2018.Long-term survival was comparable among groups in patients between 50 and 65 years of age. Mech prostheses were associated with a higher risk of major bleeding, whereas Bio prostheses entailed higher reoperation rates. Bio prostheses seem a reasonable choice for patients between 50 and 65 years in Spain.

Resumen: Introducción: Actualmente existe una gran controversia sobre el uso de prótesis biológicas o mecánicas en posición aórtica para pacientes de mediana edad. Objetivos: Analizar la supervivencia a largo plazo de los pacientes entre 50 y 69 años según el tipo de prótesis implantada. Métodos y materiales: Revisión retrospectiva de pacientes con sustitución valvular aórtica convencional, con o sin revascularización miocárdica con edad entre 50 y 69 años. Análisis y comparación de supervivencia. Predictores del evento primario mediante análisis de riesgos proporcionales de Cox. Análisis con muestra ajustada mediante propensity score. Resultados: Media de seguimiento 5,3 años (±3,7). Doscientos noventa (52,5%) recibieron prótesis biológica y 262 (44,4%) una mecánica. Supervivencia a 7 años de 85 vs. 88% (p = 0,26) respectivamente. No identificamos el tipo de prótesis como factor predictor o de riesgo para el evento primario (HR1,5; 95% CI: 0,91-2,6). Supervivencia en la muestra ajustada: 86 vs. 90%(= 0,89) respectivamente. Conclusiones: Tanto en la cohorte total como en la ajustada, no existen diferencias significativas en la supervivencia a largo plazo según el tipo de prótesis utilizada. Abstract: Introduction: There continues to be controversy on the use of biological or mechanical prosthesis for aortic valve replacement in the middle aged population. Objectives: To analyse and compare long-term survival in patients aged from 50-69 years, according to the type of valve replacement. Methods and materials: A retrospective review was conducted on of patients aged 50-69 years with aortic valve replacement, with or without adjunct coronary artery surgery. The long-term survival was analysed and compared. A proportional hazard risks model was also performed for the primary outcome. This primary outcome was then analysed in a propensity score-matched cohort. Results: The mean follow-up was 5.3 years (±3.7). A total of 290 (52.5%) patients received a bioprosthesis, and 262 (44%) a mechanical one. The 7- year survival was 85 vs. 88% (P = .26), respectively. Valve replacement type was not associated with the primary outcome (HR1,5; 95%CI: 0.91-2.6). Survival on the adjusted cohort was 86% vs. 90% (P = .89), respectively. Conclusions: In the total cohort studied, as well as in the adjusted cohort, there was no difference in long-term survival between middle aged patients with a biological or mechanical aortic valve. Palabras clave: Sustitución valvular aórtica, Prótesis biológica, Prótesis mecánica, Edad media, Keywords: Aortic valve replacement, Surgical aortic valve replacement, Mechanical prosthesis, Biologic prosthesis, Middle aged

Resumen: Introducción y objetivos: Las prótesis híbridas combinan una prótesis vascular convencional con un stent graft de nitinol, facilitando el abordaje simultáneo de la aorta ascendente, cayado y descendente proximal. Presentamos nuestra experiencia en el tratamiento de la patología compleja de la aorta torácica. Métodos: Un total de 27 pacientes intervenidos con prótesis híbridas E-vita (n = 27) o Thoraflex (n = 1) desde octubre de 2013. Se realiza descripción de la serie y análisis de los resultados. Resultados: Edad media: 64,1 años (DE: 14,5). Varones: n = 21 (75%); 17 aneurismas (60,7%), 5 disecciones agudas (17,9%), 5 crónicas, una aortitis. EuroSCORE logístico medio: 20,2 (DE: 11,5). Cirugía previa: n = 5 (17,9%). Tiempos de circulación extracorpórea, isquemia, parada circulatoria y perfusión cerebral anterógrada: 184,7 min (DE: 52,6), 109,4 min (DE: 46,3), 50,6 min (DE: 19,6), y 75,7 min (DE: 32). Perfusión cerebral bilateral: n = 19 (67,9%). Temperatura media: 22,6 °C (DE: 3,5). Zona anastomosis distal: Z1 (n = 3; 10,7%), Z2 (n = 18; 64,3%) y Z3 (n = 7; 25%). Implante troncos supraaórticos: pastilla (n = 8; 28,6%), pastilla + bypass (n = 13; 46,3%) e injerto trifurcado (n = 7; 25%). Segundo tiempo programado en aorta distal: n = 12 (10 endovascular, una cirugía abierta y una combinada). Mortalidad hospitalaria: n = 3 (10,7%). Ictus permanente: n = 2 (7,1%). Reoperación por hemorragia: n = 2 (7,1%). Seguimiento medio: 16,6 meses (DE: 18). Supervivencia al año: 89,3%. Mortalidad en el seguimiento: n = 3 (2 de causa cardiovascular). Conclusiones: Las prótesis híbridas simplifican el tratamiento de la patología compleja de la aorta torácica, permitiendo con frecuencia resolverla en un solo tiempo o bien facilitando el segundo, sea quirúrgico o endovascular. Abstract: Introduction and objectives: The hybrid prostheses combine a conventional vascular prosthesis with a nitinol stented portion to facilitate the simultaneous approach of the ascending aorta, aortic arch, and proximal descending aorta. Experience in the treatment of this complex thoracic aorta pathology is presented. Methods: A total of 28 patients underwent surgery using the E-vita prosthesis (n = 27) or Thoraflex prosthesis (n = 1) from October 2013. The experience and the medium-term results are presented. Results: The patient variables included: mean age: 64.1 years (SD: 14.5). Men: n = 21 (75%). 17 aneurysms (60.7%), 5 acute aortic dissections (17.9%), 5 chronic dissections, 1 aortitis. Mean EuroSCORE logistic 20.2 (SD: 11.5). Prior cardiac surgery: n = 5 (17.9%). Mean cardiopulmonary bypass time, aortic cross clamp time, circulatory arrest time and selective antegrade cerebral perfusion: 184.7 min (SD: 52.6), 109.4 min (SD: 46.3), 50.6 min (SD: 19.6), and 75.7 min (SD: 32). Bilateral antegrade selective cerebral perfusion: n = 19 (67.9%). Temperature: 22.6 °C (SD: 3.5). Distal anastomosis zone: Z1 (n = 3, 10.7%), Z2 (n = 18, 64.3%), and Z3 (n = 7, 25%). Supra-aortic vessels re-implantation: En bloc (n = 8, 28.6%), En bloc + bypass (n = 13, 46.3%), and trifurcated graft (n = 7, 25%). Second-stage distal aortic intervention: n = 12 (10 endovascular, 1 open surgery, 1 combined). In-hospital mortality: n = 3 (10.7%). Permanent stroke: n = 2 (7.1%). Re-exploration due to bleeding: n = 2 (7.1%). Mean follow-up: 16.6 months (SD: 18). 1-year survival: 89.3%. Mortality during follow-up: n = 3 (2 cardiovascular). Conclusions: Hybrid prostheses simplify the treatment of complex pathology of the thoracic aorta, often being able to resolve it in a single stage, or facilitating an open or endovascular second stage. Palabras clave: Patología compleja aorta torácica, Prótesis híbridas, Trompa de elefante congelada, Keywords: Complex thoracic aortic disease, Hybrid prosthesis, Frozen elephant trunk

Resumen: La endocarditis protésica tras el implante de una prótesis aórtica transcatéter es una complicación poco frecuente que se asocia a una elevada mortalidad. Presentamos el caso de un varón de 63 años con antecedentes de implante de una prótesis aórtica transcatéter por vía transfemoral (29 mm Edwards SapienTM) quien, 4 meses tras el procedimiento, ingresa en nuestro centro por endocarditis protésica por Staphylococcus epidermidis. El ecocardiograma preoperatorio mostraba una vegetación gigante que ocupaba parte del tracto de salida del ventrículo izquierdo y la raíz aórtica, provocando una estenosis aórtica severa. Además, presentaba una insuficiencia mitral severa que no se trató en un primer procedimiento. Se explantó la prótesis infectada y se implantaron una prótesis aórtica y mitral. Abstract: Infective prosthetic valve endocarditis after a transcatheter aortic valve implantation (TAVI) is a rare complication with a high mortality rate. We report the case of a 63-years-old man with a previous history of a transfemoral transcatheter aortic valve implantation (29 mm Edwards SapienTM). Four months after the procedure, the patient was admitted to our Institution with aortic prosthetic valve endocarditis by Staphylococcus Epidermidis. The preoperative echocardiography demostrated a massive vegetation that occupied most of the left ventricle outflow tract and the aortic root resulting in a severe aortic stenosis. Besides, the echocardiogram showed a severe mitral regurgitation that was left undertreated when her transcatheter procedure was originally performed. The infected prosthesis was explanted and mitral and aortic tissue valves were implanted. Palabras clave: Endocarditis, Endocarditis protésica precoz, Prótesis valvular aórtica transcatéter, Keywords: Endocarditis, Early prostethic valve endocarditis, Transcatheter aortic valve implantation

Background: There is no robust evidence regarding the types of valves implanted among patients undergoing surgical aortic valve replacement (SAVR) in Spain. Methods: All cases of patients undergoing SAVR ± coronary artery bypass grafting from January 2007 to December 2018 in the public Spanish National Health System were included. We analyzed the trends of SAVR volume, risk profile and type of implanted valve across time and place. Using multivariable logistic regression, we identified factors associated with biological SAVR. Results: In total, 62,870 episodes of SAVR in 15 Spanish territories were included. In 35,693 (56.8%), a tissue valve was implanted. The annual volume of procedures increased from 107.3/million (2007) to 128.6 (2017). In 2018, it fell to 108.5. Age increased and Charlson’s comorbity index worsened throughout the study period. Tissue valve implantation increased in most regions. After adjusting for other covariates, we observed a high variability in aortic valve implantation across different regions, with differences of as much as 20-fold in the use of tissue valves. Conclusions: Between 2007 and 2018, we detected a significant increase in the use of bioprostheses in patients undergoing SAVR in Spain, and a great variability in the types of valve between the Spanish territories, which was not explained by the different risk profiles of patients.

Resumen El ensayo clinico Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) ha marcado un hito en la historia de la revascularizacion miocardica. El analisis del objetivo primario demostro que la cirugia era capaz de reducir el riesgo de eventos cardiovasculares mayores frente al intervencionismo coronario con stents recubiertos en pacientes con enfermedad multivaso o del tronco coronario. Sin embargo, la interpretacion de los analisis de subgrupos y eventos secundarios ha servido para justificar la revascularizacion con stents recubiertos en grupos seleccionados de enfermos. Las conclusiones de SYNTAX han tenido un gran y discutido impacto en las guias de revascularizacion miocardica europeas y en la practica clinica diaria, forzando nuevas indicaciones, fomentando la reunion del Heart Team y poniendo a nuestro alcance nuevas herramientas como SYNTAX score. Los cirujanos cardiacos y cardiologos hemos asumido todos estos cambios sin apenas critica. Pero, ?cuanta verdad irrefutable hay en SYNTAX?

ObjectiveThe incidence of aortitis in patients with thoracic aortic diseases is not well established. The aim of this study was to analyse the frequency and clinical course of patients with aortitis in a surgical series.Methods320 consecutive patients with ascending aorta/aortic arch aneurysm or acute aortic syndrome who underwent surgery from 2012 to 2017 in a single tertiary referral hospital were retrospectively reviewed. Epidemiological data, clinical course and variables related to diagnosis, treatment and follow-up were collected from patients with histologically proven aortitis.ResultsFrom 320 examined aortic samples, 279 (87.2%) thoracic aneurysms and 41 acute aortic syndromes (12.8%), 9 (2.8%) were aortitis: 3 cases of Takayasu’s arteritis, 3 of IgG4-related aortitis, 2 of giant cell, and 1 classified as idiopathic. Median age at surgery was 53.4 (51–69.2) years and six cases were female. Seven patients presented with non-specific symptoms and the diagnosis was made at pathology. Surgery was elective in eight patients and emergent in one case of IgG4-related aortitis. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) was performed for disease extension study and as a monitoring technique during the follow-up of five patients, with just one case performed presurgically. All the patients with IgG4-related disease showed extrathoracic aortic involvement. There were no deaths, neither in-hospital nor during the 1.7 years of median follow-up.ConclusionsIn surgically treated thoracic aorta pathology, the frequency of aortitis is low; IgG4-related disease is among the most common aetiologies with a frequency similar to other types of aortitis, such as Takayasu’s and giant cell arteritis, and clinical manifestations are non-specific making presurgical diagnosis difficult. 18F-FDG PET/CT allows a better assessment of disease extension and therapeutic response. Surgery can be successfully performed and corticosteroid therapy ensures a good mid-term follow-up.

OBJECTIVES We investigated the impact of acute kidney failure after a heart valve procedure among patients with or without chronic kidney disease (CKD). METHODS All patients who had undergone a surgical valve procedure between 2005 and 2017 at our institution were divided into 2 groups depending on whether they had previous history of CKD (estimated glomerular filtration rate