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Surgery for left-sided infective endocarditis (IE) has been demonstrated to improve patients’ survival rates but information about quality of life (QoL) after surgery is scarce. The aim of this study was to assess the postoperative outcomes and QoL after surgery for IE patients compared to patients undergoing cardiac surgery for non-IE indications. Adult patients with definite acute left-sided IE were matched 1:1 to patients who underwent cardiac surgery for non-endocarditic purposes from 2014 to 2019. QoL was assessed using the SF-36 survey at the last follow-up. A total of 105 patients were matched. The IE group had higher rates of preoperative stroke (21% vs. 7.6%, p = 0.005) and higher stages of NYHA class (p < 0.001), EuroSCORE II (12.3 vs. 3.0, p < 0.001) and blood cell count abnormalities (p < 0.001). The IE group had higher incidence of low cardiac output syndrome (13.3% vs. 4.8%, p = 0.029), dialysis (10.5% vs 1.0%, p = 0.007) and prolonged mechanical ventilation (16.2% vs. 2.9%, p = 0.002) after surgery. At the last follow-up, subcomponents of the SF-36 QoL survey were not different between the groups. Patients who underwent cardiac surgery for IE demonstrated a higher risk profile with a higher rate of postoperative complications. Once recovered from the acute phase of the disease, the reported QoL at follow-up was comparable to that of matched cardiac patients operated for non-IE purposes.

Background Heart transplant (HT) remains the last treatment option for patients with non-obstructive hypertrophic cardiomyopathy (HCM) who develop end-stage heart failure (HF). Early identification of patients who may require a HT in the future is crucial in order to advise them, establish the appropriate follow-up and determine the appropriate time to include them in the waiting list. Objectives Our study sought to find predictive factors related with requiring HT during follow-up in patients with HCM. Methods Consecutive patients with HCM referred to a HCM monographic clinic from 2018 to 2020 (HCM controls) and transplanted patients due to HCM in the same tertiary HT hospital since 2003 (cases) were included. Baseline (on the date of HCM diagnosis) and longitudinal data regarding clinical, genetic, ECG and echocardiographic variables were retrospectively evaluated. Follow-up was registered from HCM diagnosis to HT (in cases) or last medical check up (controls). Results A total of 157 patients (24 HCM-HT cases and 133 HCM controls) were included (45±19 yo; 57% male). At the time of MCH diagnosis (Table), cases were significantly younger than controls, were more frequently symptomatic and showed significantly higher BNP levels and more advanced diastolic dysfunction (larger left atrium, higher E/A ratio and lower e'); also, HCM-HT reported more family history and had higher proportion of pathogenic mutations (being MYH7 the most frequently involved). Left ventricular (LV) systolic function was slightly reduced in HCM-HT cases. In contrast, HCM controls were more frequently diagnosed by casual findings or family screening and had more LV outflow tract obstruction at first medical evaluation. LV maximal wall thickness (MWT) did not differ between groups. During a median follow-up since HCM diagnosis of 6.2 years (median follow-up of 8.9 and 7.1 years in cases and controls, respectively), HCM-HT cases presented a higher incidence of sustained ventricular tachycardia or ICD therapy (HR=4.0; CI95%:1.6–10.0 p=0.03) and HF admissions (HR=3.9; CI95%:1.8–8.1 p Conclusions The presence of symptoms in a young non-obstructive HCM patient, along with family history and a pathogenic mutation, should advice clinicians a closer follow-up and early transfer to a HT referral center, especially if associated with diastolic dysfunction and high BNP values. Funding Acknowledgement Type of funding sources: None. Table 1

Trasplante combinado de corazón e hígado; Cardiomiopatía Trasplantament combinat de fetge i cor; Cardiomiopatia Combined heart-liver transplant; Cardiomyopathy Background Uhl's anomaly is an extremely rare congenital heart defect characterized by absence of the right ventricle myocardium and preserved left ventricular myocardium. Although the disease has a poor prognosis and is generally fatal in the perinatal period, some patients may reach adulthood. Methods We describe a case of Uhl's anomaly complicated with heart failure and decompensated cardiac cirrhosis in a 42-year-old man treated by combined heart-liver transplant. Results The patient underwent heart transplant using the bicaval technique followed by subsequent liver transplant with the piggyback technique without venovenous bypass. Total ischemia time was 108 minutes for the heart and 360 and 25 minutes of cold and warm ischemia, respectively, for the liver. No intraoperative complications occurred. The patient was discharged without severe complications on postoperative day 22. Pathologic examination of the organs reported advanced cirrhosis of the liver and severe dilated myocardiopathy of right ventricle with absence of myocardium and a normal left ventricle. Twenty-seven months after the transplant the patient has been free from hospital admissions, with normal function of both transplanted organs. Conclusions We report the first successful combined heart-liver transplant for Uhl's anomaly indication in an adult patient. Despite of the insufficient knowledge of natural history of this exceptional disease, we successfully apply the management principles of other end-stage right heart disorders complicated with liver failure.

Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. Methods: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. Results: We identified 52 patients. Mean age was 71.8 ± 4.9 years, 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. Conclusion: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Heparin-induced thrombocytopaenia (HIT) complicates the management of patients in need for mechanical circulatory support awaiting heart transplantation. The limited available treatment options are fraught with complications and limitations in their applicability. We report on the combined use of therapeutic plasma exchange therapy and intravenous immunoglobulin, used in 3 consecutive heparin-induced thrombocytopaenia-positive patients on temporary mechanical circulatory support awaiting urgent heart transplant. This combined approach allowed us to use heparin safely.

Objective: Surgical repair remains the standard treatment for severe mitral regurgitation (MR) due to mitral prolapse. Minimally-invasive mitral valve surgery (MIMVS) has been increasingly performe...

Pulmonary embolism and concomitant floating aortic thrombus are a rare and potentially life-threatening association. Several therapeutic options are available and best management can be controversial when these conditions coexist. We describe a case of a 79-year-old woman presented with massive pulmonary embolism and simultaneous floating thrombus in the ascending aorta. She underwent concomitant ascending aortic replacement and surgical pulmonary embolectomy with an uneventful postoperative recovery. Open surgical repair is a one stage repair approach that may offer the most efficient treatment to allow survival.

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.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH) are two subtypes of pulmonary hypertension (PH). Endothelial dysfunction is believed the main cause of the hyperproliferative and antiapoptotic phenotype in PH characterized by increased glycolysis in PAH. It is unknown whether PAH and CTEPH share the same metabolic abnormalities. The aim of our study is to perform a systematic metabolic comparison of endothelial cells (ECs) derived from PAH and CTEPH patients. Methods: ECs from human pulmonary artery endothelial cells HPAECs (n=3), CTEPH (n=7) and PAH (n=6) were expanded until the same passage. Metabolic targets were analysed by qRT-PCR and Western Blot. Viability and migration were studied using MTT and wound healing assay. Supernatants were assessed by BGEM Test Cards. All values are shown as mean±SD. The analysis was performed using one-way ANOVA (p Results: Gene and protein expression of key glycolytic enzymes were significantly upregulated in PAH-ECs compared to CTEPH-ECs and HPAECs. Mitochondrial enzymes, pentose phosphate pathway and glutamine metabolism-related enzymes were upregulated in PAH-ECs compared to the CTEPH-ECs and HPAECs. Both PAH and CTEPH-ECs showed significant higher viability compared to HPAECs. Acidification of the supernatant was detected in both patients’ lines. Statistical higher glucose and lower lactate concentration in the supernatant were shown in HPAECs compared to patient cell lines. Conclusion: PAH-ECs were found to be metabolically different than CTEPH-ECs indicating distinct pathogenic mechanisms in the development of the two PH subtypes. This creates the opportunity to specifically target the distinct metabolic abnormalities in both diseases.

For the first time, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery have joined forces to develop consensus guidelines for the management of atrial fibrillation (AF). One of the main issues is the integrated care of patients with AF, with emphasis on multidisciplinary teams of general physicians, cardiologists, stroke specialists and surgeons, together with the patient's involvement for better management of AF. These guidelines also help in the detection of risk factors and concomitant cardiovascular diseases, stroke prevention therapies, including anticoagulation and antiplatelet therapies after acute coronary episodes, major haemorrhages or strokes. In the field of ablation, surgery plays an important role as concomitant with other surgical procedures, and it should be considered in symptomatic patients with the highest level of evidence. Asymptomatic patients with mitral insufficiency should also be considered for combined mitral and AF surgery if they have new-onset AF. In patients with stand-alone AF, recommendations for minimally invasive ablation have an increased level of recommendation and should be considered as the same level as catheter ablation in patients with persistent or long-standing persistent AF or with paroxysmal AF who fail catheter ablation. Surgical occlusion or exclusion of the left atrial appendage may be considered for stroke prevention in patients with AF about to have surgery. Nevertheless, not enough is known to avoid long-term anticoagulation in patients at risk of stroke even if the left atrial appendage has been excluded. These Guidelines provide a full spectrum of recommendations on the management of patients with AF including prevention, treatment and complications based on the latest published evidence.

Early degeneration of tricuspid bioprostheses is a rare, but extremely serious, complication. Several mechanisms have been described, both for surgically implanted and transcatheter bioprosthesis. We report a case of early degeneration of tricuspid porcine bioprosthesis and a subsequent transcatheter valve-in-valve bovine prosthesis due to severe fibrosis with leaflet retraction in a patient with restrictive cardiomyopathy who finally underwent orthotopic heart transplantation.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by non-resolution of thrombi that obstruct main pulmonary arteries and secondary cause vascular remodeling of the pulmonary vasculature. Endothelial cells (EC) lining the vascular wall are an important component in vascular disease development. We speculated that metabolic dysregulation of EC contribute to cellular changes that promote vascular remodeling in CTEPH. Methods: This study used endothelial cells (EC-CTEPH, n=12) isolated from specimen extracted at pulmonary endarterectomy. Expression levels of metabolic enzymes were studied at mRNA and protein level by RT-PCR and western blot, respectively. Glucose consumption and lactate production was measured in the supernatant overlying EC-CTEPH and HPAE using BGEM test cards. Results: EC-CTEPH showed significantly lower mRNA levels of all glycolytic enzymes analyzed compared to HPAE. Additionally, protein levels of HK2, PFKFB3 and LDH-A were reduced in EC-CTEPH compared to HPAE. Transcript levels of PDK1, inhibitor of PDHA1, and GLUD1, involved in glutamine metabolism, were also downregulated. Fatty acid and pentose phosphate metabolism did not present significant differences between EC-CTEPH and HPAE. A lower glycolytic flux in EC-CTEPH, when compared to HPAE, was observed in terms of glucose consumption and lactate production. Conclusion: Our results showed that EC in human CTEPH present a reduced glycolytic metabolism compared to healthy EC. TCA and glutamine metabolism were also downregulated in EC-CTEPH. Other metabolic pathways such as FAO and PPP did not show a compensatory upregulation. More studies need to be performed to determine the role of our findings in EC-CTEPH pathogenesis.

PURPOSE OF REVIEW Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. RECENT FINDINGS non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. SUMMARY considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions.

Resumen Introduccion Analizar las indicaciones, acciones y resultados de las operaciones realizadas en la Unidad de Cuidados Intensivos (UCI) de Cirugia Cardiovascular. Metodos Analisis retrospectivo de pacientes adultos consecutivos intervenidos en la Unidad de Cuidados Intensivos (UCI). Se incluyeron todas las intervenciones practicadas. Se realizo estadistica descriptiva. Resultados Entre 2008 y 2013 se intervinieron 3379 pacientes adultos consecutivos. Se practicaron en la UCI 124 intervenciones en 109 pacientes, 70 hombres (64,2%) y 39 mujeres (35,8%) con un promedio de edad de 61,6 anos (12-80). Ello ha representado un 3,2%. Durante el mismo periodo de tiempo, se intervinieron en quirofano 185 pacientes por taponamiento cardiaco/hemorragia postoperatoria (5,5%). Las intervenciones previas fueron por cardiopatia valvular (34,9%), patologia aortica (22,9%), cardiopatia isquemica (15,6%), valvular/isquemica (12%), valvular/de la aorta (11%) y miscelanea (3,6%). Las indicaciones de intervencion fueron hemorragia persistente 54 (43,5%), taponamiento cardiaco 41 (33%), bajo gasto cardiaco 13 (10,5%), parada cardiaca/arritmias 8 (6,5%), insuficiencia respiratoria 6 (4,8%) e isquemia de extremidades 2 (1,7%). Las intervenciones fueron: exploracion mediastinica 73 (58,9%), colocacion/retirada de ECMO 17 (13,7%), cierre esternal 16 (12,9%), resucitacion abierta 9 (7,3%), drenaje subxifoideo 7 (5,6%) y embolectomia femoral 2 (1,6%). La mortalidad fue 33%. Hubo un caso de mediastinitis (0,9%), sin diferencias con la tasa de infecciones profundas en pacientes no intervenidos en UCI. Conclusiones La intervencion en UCI es una alternativa segura y de rescate en subgrupos especificos de pacientes. no incrementa el riesgo de infeccion, evita el transporte de pacientes inestables y permite ahorrar tiempo en la decision quirurgica postoperatoria.

Objective To analyse the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. Methods Retrospective analysis of consecutive non-selected adult patients operated in the ICU, with descriptive statistics. All operations performed were included. Results Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients 70 male (64.2%) and 39 female (35.8%), with a mean age of 61.6 years (12–80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/cardiac tamponade in the operating room. Previous interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischaemic heart disease (15.6%), combined valvular/ischaemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were: persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischaemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxiphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis 0.9%, with no difference from patients operated in the regular operating room. Conclusions Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

Long-term real-world outcomes are critical to support medical decisions about using biological (B) or mechanical (M) prostheses for aortic valve replacement (AVR), particularly in patients aged between 50 and 65 years. This study aims to provide new evidence from a large national database on long

Both stroke prevention and rhythm control therapy of atrial fibrillation (AF) have been shaped by interdisciplinary teams of surgeons and cardiologists. This chapter describes the roles of the AF Heart Team in supporting difficult management decisions in AF patients in need of advanced stroke prevention or rhythm control therapy options. It delineates the organizational structure of such AF Heart Teams and provides an outline of their potential role within integrated AF management.

Background: Treatment of severe aortic valve stenosis (SAVS) is a hot topic due to improved life expectancy of general population, improvement of diagnostic tools, and consequent increased number of patients requiring aortic valve surgery. Traditional aortic valve replacement and recent transcatheter aortic prosthesis implantation have reported comparable or non-inferior mortality in randomised controlled trials (RCTs). However, RCTs have the limitation of the predefined inclusion/exclusion criteria, and cannot completely reflect the ‘real clinical world’. Recently sutureless prostheses, often implanted via minimally invasive approaches, have been reported as an alternative strategy. However, their definitive impact on clinical results is not yet completely evaluated because of the limited sample size of patients population of most of published studies, based on monocentric patients series. Methods: The aim of this prospective multicentre registry including all patients referred for aortic valve surgery and treated with all available techniques is to obtain a ‘real-world’ scenario of the clinical results arising from current surgical options. Results: The research protocol enrollment phase is ongoing. Therefore we have not yet results to publish. When available, the research findings deriving from E-AVR registry will be presented in the scientific community in international congresses and published in peer review international journals in the fields of cardiac surgery and cardiology. Conclusions: This multicenter, prospective, European registry has been designed with the aim to cast light on a lot of controversial issues, particularly those regarding the impact of patient baseline risk factors as well as treatment methods for SAVR, with or without coronary artery bypass grafting (CABG), on the prognosis after treatment. We believe that the information derived from this registry can provide deep knowledge on the causes that lead to adverse outcomes after SAVR, to avoid them, and finally to identify the best treatment option for SAVS for each patient.

ResumenIntroducción y objetivosEl Grupo de Trabajo en Reparación Valvular de la Sociedad Española de Cirugía Torácica y Cardiovascular presenta el tercer Registro anual de actividad en cirugía reparadora de las válvulas mitral, aórtica y tricúspide realizadas en España en el año 2013.MétodosLos datos se obtuvieron mediante encuesta por vía web. La participación fue voluntaria. Se contabiliza el número de intervenciones valvulares (reparaciones y recambios). Se detallan las reparaciones valvulares mitrales por etiologías. Se reporta la mortalidad. Se realiza una comparación de resultados de la cirugía valvular con años anteriores.ResultadosSe ofrecen datos de 25 centros (48% de la actividad quirúrgica del país). El volumen de reparación valvular global sigue incrementándose. La actuación sobre la válvula mitral degenerativa es mayoritariamente reparadora (61,7%). El 46% de todas las válvulas mitrales fueron reparadas. En la válvula aórtica esta técnica es todavía incipiente (2,7%). La etiología degenerativa sigue siendo la más habitual en caso de reparación valvular mitral; no obstante, en nuestro país la etiología reumática no acaba de desaparecer, siendo causa de gran cantidad de implantes protésicos. La mortalidad en la reparación fue del 1,5%±1,9, frente al 5,3%±3,5 en caso del recambio, aunque la comorbilidad asociada a los grupos fue también claramente diferente (Euroscore de 6,0±3,0 frente a 8,9±2,4).ConclusionesEl porcentaje de pacientes que se benefician de las técnicas de reparación valvular sigue aumentando, con unos resultados satisfactorios en términos de mortalidad.AbstractIntroduction and objectivesThe Spanish Society of Thoracic and Cardiovascular Surgery Valve Repair Working Group presents the third annual activity report in reconstructive surgery of the mitral, aortic and tricuspid valves performed in Spain in 2013.MethodsData were obtained using a web-based survey for which participation was voluntary. The number of valvular interventions (repairs and replacements) were recorded. Mitral valve repair surgery was reported by aetiology. Mortality was also reported. A comparison was made with the results of valve surgery performed in previous years.ResultsThe data from 25 centres (48% of the surgical activity in the country) are shown. The overall volume of valve repair continues to increase. Almost half (46%) of all mitral valves were repaired. Repair was most common (61.7%) intervention on degenerative mitral valves. Aortic valve repair technique is still developing (2.7% of overall valve surgery). Degenerative aetiology remains the most common in the case of mitral valve repair, however in Spain, rheumatic aetiology has still not disappeared, being the cause of many prosthetic implants. Overall repair mortality was 1.5%±1.9 versus 3.5±5.3% in the case of replacement. Nevertheless, the comorbidity associated with the two groups was also clearly different (EuroSCORE repair 6.0±3.0 vs. replacement 8.9±/2.4).ConclusionsThe percentage of patients who benefit from valve repair techniques continues to rise, with satisfactory results in terms of mortality.

OBJECTIVES: Recurrent mitral regurgitation is a significant problem after mitral valve repair in patients with functional valve disease. We report the safety and feasibility of a novel adjustable mitral annuloplasty device that permits downsizing of the anterior–posterior diameter late after initial surgery. METHODS: In this multicentre, non-randomized, observational register, patients with moderate or severe mitral regurgitation undergoing surgical mitral valve repair with the MiCardia EnCorSQ™ Mitral Valve Repair system were evaluated. Patient characteristics, operative specifications and results as well as postoperative follow-up were collected for all five centres. RESULTS: Ninety-four patients with a median age of 71 (64–75) years (EuroSCORE II 6.7 ± 6.3; 66% male, 48% ischaemic MR, 37% dilated cardiomyopathy and 15% degenerative disease) were included. Operative mortality was 1% and the 1-year survival was 93%. Ring adjustment was attempted in 12 patients at a mean interval of 9 ± 6 months after surgery. In three of these attempts, a technical failure occurred. In 1 patient, mitral regurgitation was reduced two grades, in 2 patients mitral regurgitation was reduced one grade and in 6 patients, mitral regurgitation did not change significantly. The mean grade of mitral regurgitation changed from 2.9 ± 0.9 to 2.1 ± 0.7 (P= 0.02). Five patients were reoperated after 11 ± 9 months (Ring dehiscence: 2; failed adjustment: 3). CONCLUSION: We conclude that this device may provide an additional treatment option in patients with functional mitral regurgitation, who are at risk for reoperation due to recurrent mitral regurgitation. Clinical results in this complex disease were ambiguous and patient selection seems to be a crucial step for this device. Further trials are required to estimate the clinical value of this therapeutic concept.

The goal of all clinical guidelines is to assist patients and practitioners in making healthcare decisions. However, clinical guidelines have been questioned about their quality, transparency and independence. Based on the revision of manuals by other scientific cardiothoracic organizations, this document provides instructions for the development of European Association for Cardio-Thoracic Surgery (EACTS) clinical guidelines and other types of evidence-based documents. Four key areas have been addressed: (i) selection of taskforce members and transparency of relations with the industry, (ii) methods for critical appraisal of medical evidence, (iii) rules for writing recommendations and (iv) review process. It is hoped that, by adopting this methodology, clinical guidelines produced by the EACTS will be well balanced, objective and, importantly, trusted by physicians and patients who benefit from their implementation.

Resumen Introduccion La endarterectomia pulmonar (EP) es el tratamiento de eleccion para la hipertension pulmonar tromboembolica cronica (HPTEC). El objetivo del estudio fue analizar nuestra experiencia en el tratamiento medico (TM) y quirurgico de la HPTEC. Metodos Se evaluaron 80 pacientes diagnosticados de HPTEC en el periodo enero 2000-julio 2012. En 32 casos se realizo EP, el resto recibio TM. Se analizaron: clase funcional (CF), distancia recorrida en seis minutos (PM6M) y hemodinamica pulmonar. Se analizo la mortalidad segun el tratamiento y el periodo. Resultados Los pacientes del grupo EP eran mas jovenes, mayoritariamente hombres y recorrieron mayor distancia en la PM6M. No hubo diferencias hemodinamicas ni de CF al diagnostico. Al ano del tratamiento, el 100% del grupo EP y el 41% del grupo TM estaban en CF I-II. Al seguimiento, el grupo EP presento mayor incremento en la PM6M y mayor reduccion de la PAPm y la RVP que en el grupo TM (p Conclusiones La EP proporciona buenos resultados clinicos, hemodinamicos y de supervivencia en los pacientes que superan satisfactoriamente el postoperatorio inmediato. Tras un periodo de aprendizaje, la mortalidad perioperatoria actual en nuestro centro es superponible a los estandares internacionales.

It has been 21 years since the first description of the maze procedure by James Cox.1 At that time the hypothesis of multiple independent wavelets propagating randomly through both atria was the most accepted dominant atrial fibrillation (AF) mechanism; there was no knowledge of the importance of focal triggers within the pulmonary veins, the influence of different local activation rates, frequency gradients, the autonomic nervous system, or genetics in the genesis of AF. The Cox maze procedure was designed basically with two aims: to reconduct the electrical impulse into dead-end paths, and to avoid its rotation on round structures like the mitral and tricuspid annuli, both venae cavae and atrial appendages. Interestingly, it still is the most successful therapy for controlling AF, with over 90% of sinus rhythm (SR) recovery in patients with lone AF,2 but the aggressiveness of the original procedure limited its implementation by most surgeons. The introduction in the last decade of surgical devices with different energies to produce scars less aggressively has expanded the use of this therapy remarkably, basically in the field of AF concomitant to other surgical pathology. With this new technology, a maze procedure can be performed with no increase in operative risk,3 and the efficacy is comparable with the cut-and-sew technique.4 Moreover, in patients with a successful concomitant Cox maze procedure versus patients with heart surgery alone, recent data indicate better long term survival,5 reduced incidence of stroke,6 and better ventricular function.7 The last consensus statement of the International Society of Minimally Invasive Cardiothoracic Surgery in 2009 recommended concomitant surgical ablation in patients with persistent and longstanding persistent AF undergoing cardiac surgery to increase the incidence of SR at short and long term follow-up (class I, level A), to improve ejection fraction and exercise tolerance (class …

Rationale: Hyperproliferative phenotype of CTEPH patient9s cells obtained from pulmonary endarterectomy (PEA) specimens may suggest mitochondrial involvement in CTEPH etiopathogenesis. We aimed to develop an in vitro model of CTEPH using patient-derived cell lines and to assess potential mitochondrial disturbances. Methods: Endothelial cells isolated from specimens obtained at PEA, had a cobblestone morphology, endothelial phenotype and functionality (tubule formation, proliferation and migration).We also measured: i)mitochondrial membrane potential, mitochondrial content and apoptosis/necrosis ii) mitochondrial dynamics by flow cytometry and confocal microscopy. Results: Isolated cells maintained a cobblestone morphology and stained positive for endothelial markers. They showed a hyperproliferative phenotype when compared with control human pulmonary artery endothelial cell lines (HPAE): number of Ki67 + cells (50.33±13.4 vs 32.5±9.5; p Conclusions: This study provides a novel endothelial cell line from PEA material. Cells show a hyperproliferative and apoptotic resistance phenotype with trends towards mitochondrial inactivation and apoptotic resistance. This could suggest a potential etiopathogenic basis for CTEPH. Funded by SEPAR, SOCAP, BIOTRACK-Postdoc Programme and PFIS ISCIII.

El tratamiento de las arritmias evoluciona con rapidez, y con ello las indicaciones. La ablación con catéter, en los laboratorios de electrofisiología, tiene una gran eficacia y baja morbilidad, siendo actualmente la cirugía una alternativa poco frecuente excepto en la fibrilación auricular. La ablación quirúrgica, en procedimientos asociados o con técnicas mínimamente invasivas, se realiza en numerosos centros, en especial de la fibrilación auricular. Las diversas alternativas terapéuticas deben indicarse de forma gradual atendiendo a su efectividad, invasividad y tipo de arritmia. No son excluyentes entre sí, pues a menudo se combinan en el mismo paciente. El tratamiento exige conocer las actuales indicaciones, aunque siempre ha de ser individualizado según la presentación clínica y experiencia de los grupos medicoquirúrgicos.The treatment of arrhythmias progresses rapidly and thus the clinical indications. Catheter ablation in the laboratory of electrophysiology has high efficacy and low morbidity; surgery is rarely an option except in atrial fibrillation. Ablation surgery, in procedures associated or with minimally invasive techniques, is widely performed, especially with regards atrial fibrillation. Various types of treatments are listed in a gradual manner according to their effectiveness, invasiveness, and the type of arrhythmia. These are not mutually exclusive, often combined in the same patient. The treatment requires knowledge of current indications, although it must always be individualized according to clinical presentation and experience of medical-surgical groups.

La cirugía de la aorta intratorácica sigue siendo un reto quirúrgico. La disección aguda y los aneurismas del cayado aórtico y la aorta toracoab-dominal tienen riesgos relacionados con la presentación clínica y la técnica quirúrgica, la cual exige tiempos prolongados y la necesidad de modificar temporalmente la circulación cerebral y medular. El tratamiento del arco aórtico exige con frecuencia un abordaje en dos tiempos con las ventajas e inconvenientes que ello representa. La introducción en clínica de endoprótesis integradas que persiguen el tratamiento simultáneo en un solo tiempo de la aorta intratorácica puede representar un cambio conceptual en ciertas situaciones, como la disección aguda de aorta. La acumulación de experiencia clínica y el análisis cuidadoso de los datos disponibles pueden aportar información crítica en un futuro no lejano.Surgery of the intrathoracic aorta continues to be a surgical challenge. Acute dissection and arch and thoracoabdominal aneurysms do have intrinsic risks related with the clinical presentation and surgical technique, which entails prolonged surgical times and the need to temporarily modify the cerebral and spinal circulation. The treatment of the aortic arch usual requires a two-stage procedure with the advantages and disadvantages of both. the introduction in clinical practice of integrated stent-grafts is an attempt to offer a single-stage treatment of the intrathoracic aorta and may represent a conceptual challenge in some situations like acute aortic dissection. the accumulation of clinical experience and a careful analysis of available data can provide critical information in the near future.

La fibrilación auricular es el trastorno del ritmo cardíaco más frecuente. Durante años, su tratamiento se vio limitado casi exclusivamente al control farmacológico de la frecuencia cardíaca y a la prevención de eventos tromboembólicos con fármacos anticoagulantes. Debido a los recientes avances en el campo de la electrofisiología cardíaca y al desarrollo tecnológico, el abordaje terapéutico de esta arritmia se contempla hoy en día desde una perspectiva mucho más intervencionista que antaño. Recientemente, técnicas de cirugía videoasistida de última generación han comenzado a ser aplicadas en el tratamiento de la fibrilación auricular aislada con dos modalidades de abordaje: la cirugía mediante miniincisiones (minitoracotomía) y la cirugía toracoscópica propiamente dicha. En este artículo describiremos y comentaremos estas formas de tratamiento quirúrgico de la fibrilación auricular.Atrial fibrillation is the most frequent of all heart rhythm disturbances. For many years, its treatment was reduced to pharmacological heart rate control and to prevention of thromboembolic events with oral anticoagulant agents. Recent advances in the knowledge and understanding of cardiac electrophysiology and the development of new and improved surgical technologies have led to a more invasive therapeutic approach to isolated atrial fibrillation. In recent times, new generation of video-assisted, minimally invasive surgical techniques have been introduced for the surgical treatment of this arrhythmia, with two different approaches: surgery with miniincisions (minithoracotomy) and thoracoscopic surgery. These two procedures will be described and discussed in this article.

Objective: To mechanically test the intact cardiac structure to determine the sequence of contraction within the myocardial mass to try to explain ejection and suction. Methods: In 24 pigs (30–85kg), segment shortening at the site of sonomicrometer crystals was continuously recorded. The ECG evaluated rhythm, and Millar pressure transducers measured intraventricular pressure and dP/dt. Results: Study of segment shortening defined a sequence of contraction within the myocardial mass, starting at the free wall of the right ventricle and on the endocardial side of the antero-septal wall of the left. Crystal location defined underlying contractile trajectory; transverse in right ventricle followed by basal posterior left ventricle, and from the endocardial anterior wall to the posterior apical segment and finally to the epicardial side of the anterior wall. Mean shortening fraction averaged 18±3%, with endocardial exceeding epicardial shortening by 5±1%. Epicardial segment crystal displacement followed endocardial shortening by 82±23ms in the anterior wall, and finished 92±33ms after endocardial shortening stopped, time frame that matches the interval of fast drop of ventricular pressure and the start of suction. Conclusions: Crystal shortening fraction sequence followed the rope-like myocardial band model to contradict traditional thinking, with two starting points of excitation–contraction, the right anterior free wall of the right ventricle, and the endocardial side of the anterior wall. Active suction may be due to active shortening of the epicardial fibers of the anterior wall, because relaxation was not detected when both mitral and aortic valves were closed during the interval previously termed ‘isovolumetric relaxation’.

Background Normal functioning mechanical heart valve prostheses are designed to have a certain degree of intrinsic structural regurgitation as a washout mechanism to avoid prosthetic thrombosis. However, intrinsic regurgitation leads to blood cell trauma and hemolysis. Information on hemolysis associated with mechanical bileaflet prostheses is scarce. This study evaluated factors influencing hemolysis in 197 Bicarbon mechanical bileaflet prostheses implanted in 164 patients. Methods Serial office interviews, laboratory studies, and echocardiography evaluations were done in the surviving patients. An assay for measuring lactate dehydrogenase activity was developed, and the presence and severity of subclinical hemolysis was determined using reported criteria and analyzed at 1 and 2 years. Results Hospital mortality was 5.5%. Follow-up was 98.1% complete. No patient had clinically significant or severe subclinical hemolysis. Serum lactate dehydrogenase levels were significantly higher when a paravalvular leak was documented (282 ± 85 U/L versus 242 ± 64 U/L; p = 0.0026). Subclinical hemolysis was significantly more frequent after mitral valve ( p = 0.001) and double valve replacement ( p = 0.001) than after aortic valve replacement, and was unrelated to prosthetic size or to geometric area index, even in those cases with effective orifice area index equal to or less than 0.85 cm 2 /m 2 ( p = 0.298). Conclusions Mild subclinical hemolysis is frequently associated with normal functioning Bicarbon heart valves. Subclinical hemolysis was significantly influenced by valve position but not by valve size or effective orifice area index and remained stable through time. The magnitude of hemolysis in Bicarbon prostheses compared favorably with that reported for other bileaflet heart valve prostheses.

Objective: The systolic and diastolic effects of myocardial stunning were studied to evaluate the contributions of the endocardial and epicardial segments of the ventricular myocardial band, and determine if preconditioning by Na + —H + exchange (NHE) inhibition effected poststunning dysfunction. Methods: Thirteen Yorkshire—Duroc pigs (27.3—38.2 kg) underwent 15 min of mid-LAD clamping. Seven had no protective measures and six were pretreated with IV Cariporide 5 mg/kg 15 min before ischemia. Sonomicrometer crystals evaluated systolic dysfunction (impaired regional shortening) and diastolic dysfunction (contraction extending into early diastole). Results: Before ischemia, contraction started first on the endocardial side followed 82 � 23 ms later by the subepicardium. Endocardial shortening stopped first, coinciding with negative dP/dt onset, while epicardial shortening phase persisted for 92 � 33 ms more during occurrence of rapid LVP descent and development of peak negative dP/dt. Ischemia produced paradoxical bulging of both segments. Sixty minutes after ischemia systolic segment shortening recovered 36 � 24% of baseline values without pretreatment, compared to 75.8 � 15% with Cariporide (p < 0.05). Global ejection force (maximum dP/dt) fell 32 � 20% in the unprotected group, but was maintained by Cariporide pretreatment. Diastolic dysfunction always showed continued endocardial contraction into early diastole (occupying 38 � 16% of diastole in untreated hearts), whereas Cariporide treatment reduced this dysfunction to 5 � 10% (p < 0.05). Persistent diastolic dysfunction raised left ventricle end diastolic pressure (LVEDP) 4 mmHg in untreated hearts, whereas Cariporide returned LVEDP to normal. Less elevation of creatine kinase MB (CK-MB) and conjugated dienes followed Cariporide pretreatment. Conclusions: Temporary LAD ischemia alters the normal sequential pattern of contraction responsible for ejection and suction by (a) reducing systolic contractile force, and (b) prolonging endocardial contraction into early diastole to disrupt the normal endocardial—epicardial sequence responsible for ventricular suction. NHE inhibition before ischemia limits postischemic systolic and diastolic dysfunction by re-establishing the expected shortening sequences within the ventricular myocardial band model.

The effects of pretreatment with cariporide (HOE 642 Aventis Pharma, Strasbourg-Cedex, France), a Na+-H+ exchanger (NHE) blocker, were studied in a cerebral ischemia-reperfusion model of hypothermic arrest.Fifteen Yorkshire-Duroc pigs (37.1 +/- 4.2 kg) underwent femoral-jugular bypass and 90 minutes of deep hypothermic circulatory arrest at 19 degrees C. Ten animals were untreated, whereas 5 received 5 mg/kg of intravenous cariporide before cooling. After rewarming and off cardiopulmonary bypass, the pigs were weaned from anesthesia and followed for 24 hours. A standardized neurologic scoring system assessed brain functional recovery. Biochemical markers were used to analyze cellular injury. Control studies without circulatory arrest were done in 2 animals that underwent similar cooling and rewarming.Neurologic recovery was rapid and complete in the nonischemic controls and in all pretreated animals. Conversely, at 24 hours, all untreated pigs exhibited a cloudy or stuporous level of consciousness, abnormal positioning, and with only one exception, could not sit or stand. The gradation of neurologic score (evaluating central nervous system, motor and sensory functions, respiration condition, level of consciousness, and behavior) was 0 +/- 0 (0 = normal, 500 = brain death) in the treated group, compared with 124 +/- 59 in the untreated animals. Biochemical analysis showed every variable of whole-body injury (including conjugated dienes (p0.05), serum aspartate amino transferase (p0.01), creatine kinase p0.001) and endothelin-1 (p0.001) to be higher in the untreated group.NHE function alters experimental brain ischemia-reperfusion damage. These observations imply that NHE inhibition therapy before ischemia may improve neurologic protection in adult and infant patients undergoing cerebral ischemia during procedures that use hypothermic circulatory arrest.

The need for arterial grafts in coronary surgery to complement autologous vessels has generated interest in cryopreservation of small diameter allografts. We evaluated functional and histologic changes occurring in cryopreserved allografts 3 months after porcine femoral artery transplants.Twenty recipient and 15 donor pigs included a control group of 16 fresh and 12 cryopreserved nonimplant arteries were used. Fresh (n=5) and cryopreserved (n=5) autografts were implanted to assess cryopreservation effects in the absence of rejection. Fresh allografts with or without treatment with cyclosporine (CsA) (n=6 of 8) and cryopreserved allografts with or without treatment with CsA (n=6 of 10) were performed to study the antigenicity of cryopreserved allografts. Arteries were stained with hematoxylin and eosin, Masson's trichrome, and orcein for morphometric analyses and immunostained to identify endothelial cells, smooth muscle cells, T lymphocytes, and macrophages.Among nonimplant arteries, cryopreservation reduced alpha-actin expression and increased the luminal area. All implanted autografts were patent. Cryopreserved autografts showed reduced alpha-actin expression and developed intimal hyperplasia compared to fresh autografts. Treatment with CsA improved the patency of fresh allografts from 0% to 83% (P.01) and of cryopreserved allografts from 40% to 100% (P.05). Cryopreserved allografts showed substantial intimal hyperplasia, and fresh allografts had more T lymphocyte infiltration in the intimal layer with aneurysmal dilatation.Cryopreservation reduces the deposition of inflammatory cells and prevents the thrombosis or aneurysmal lesions observed in fresh allografts. Therefore, cryopreservation modifies the antigenicity of vascular allografts.

ObjectivesWe evaluated the protective effects of retrograde coronary sinus perfusion to offset potential systolic and diastolic dysfunction (myocardial stunning) after temporary regional ischemia needed for off-pump coronary artery bypass grafting.MethodsTwenty Yorkshire-Duroc pigs (31.8 ± 3.9 kg) underwent 15 minutes of mid-left anterior descending coronary artery ischemia in the beating heart. In 8 pigs, no protective measures were used. In 12 pigs, an aorta-coronary sinus shunt (with conventional cannulas) allowed retrograde perfusion during temporary ischemia; in 6 of these pigs, no leakage to the right atrium was ensured. Regional endocardial contraction was measured with sonomicrometer crystals. Systolic dysfunction (impaired regional shortening), diastolic dysfunction (contraction extending into early diastole), and coronary sinus nitric oxide and endothelin-1 levels were recorded.ResultsBefore ischemia, contraction did not extend into the diastolic interval. During ischemia, paradoxic bulging occurred in all hearts except in the occlusive coronary sinus shunt group (16% ± 6% of baseline, P < .01). Sixty minutes after ischemia, systolic segment shortening recovered 36% ± 24% without retrograde perfusion versus 56% ± 20% and 61% ± 14% with coronary sinus shunting (P < .05). Diastolic dysfunction (as percentage of diastolic time in contraction) was 38% ± 16% in the nontreated group versus 22% ± 22% and 9% ± 9% (P < .05) after shunting and occlusive shunting, respectively. This correlated with a left ventricular end-diastolic pressure increase of 4 mm Hg in the ischemic group versus no change in the retrograde perfusion groups. Nitric oxide decreased 15% without shunting and increased 8% after occlusive coronary sinus shunting (P < .05).ConclusionsRetrograde coronary sinus perfusion during simulated off-pump coronary revascularization diminishes systolic and diastolic dysfunction. An aortic-coronary sinus shunt is a rapid, recognized approach that can improve myocardial muscle and endothelial safety during off-pump coronary artery bypass grafting.

Objectives:Thirty minutes of unprotected ischemia produced a jeopardized heart that was treated with a blood cardioplegic solution containing the natural erythrocyte and protein buffers. Cardioplegic pH was changed to 7.7 (buffered) or 7.2 (nonbuffered), and this was tested alone and after pretreatment with Na+-H+ exchange blockade (cariporide) to define their protective effects.MethodsTwenty-four Yorkshire-Duroc pigs (27-34.5 kg) underwent 30 minutes of normothermic global ischemia, followed by 30 minutes of aortic clamping during protection with buffered (n = 12) or nonbuffered (n = 12) glutamate-aspartate–enriched blood cardioplegic solution. Twelve hearts (6 buffered and 6 nonbuffered) were pretreated with intravenous cariporide (5 mg/kg) 15 minutes before ischemia.ResultsSevere and comparable left ventricle dysfunction followed buffered or nonbuffered cardioplegia: Preload recruitable stroke work recovered to 56% ± 21% and 45% ± 20% of baseline levels; creatine kinase MB, conjugated dienes, and myeloperoxidase activity markedly increased; moderate myocardial edema occurred; and endothelin-1 increased 2-fold more than baseline values. Cariporide pretreatment caused a similar return of preload recruitable stroke work to 86% ± 9% and 90% ± 6% after buffered or nonbuffered cardioplegia (P < .05 vs nonpretreated groups), allowed only minor creatine kinase MB and conjugated diene changes, and reduced endothelin-1 release 3-fold compared with hearts without sodium-hydrogen exchange blockage.ConclusionsThe severe ischemia-reperfusion injury of 30 minutes of normothermic ischemia is not altered by an acidic or alkalotic pH cardioplegic solution. Correction of damage is achieved by adding Na+-H+ exchange blocker therapy before treatment with buffered and nonbuffered solutions; thus, sodium-hydrogen exchange inhibition plays a more vital role in recovery than pH management.

Mitral disease is known to be associated to atrial fibrillation (AF) for decades. The most common association is with mitral stenosis, which produces an important dilatation and fibrosis of the left atrium due to volume overload. Interestingly, in young patients with mitral disease, sinus rhythm is maintained even with a very enlarged left atrium, but when AF starts, it is to stay in what is was called chronic AF and nowadays persistent and after one year, long-standing AF.

Las declaraciones de conflicto de intereses de los expertos participantes en el desarrollo de esta guía están disponibles en la página web de la esc: http://www.escardio.org/guidelines.

Early detection of right ventricular (RV) involvement in chronic pulmonary hypertension (PH) is essential due to prognostic implications. T1 mapping by cardiac magnetic resonance (CMR) has emerged as a noninvasive technique for extracellular volume fraction (ECV) quantification. We assessed the association of myocardial native T1 time and equilibrium contrast ECV (Eq-ECV) at the RV insertion points with pulmonary hemodynamics and RV performance in an experimental model of chronic PH. Right heart catheterization followed by immediate CMR was performed on 38 pigs with chronic PH (generated by surgical pulmonary vein banding) and 6 sham-operated controls. Native T1 and Eq-ECV values at the RV insertion points were both significantly higher in banded animals than in controls and showed significant correlation with pulmonary hemodynamics, RV arterial coupling, and RV performance. Eq-ECV values also increased before overt RV systolic dysfunction, offering potential for the early detection of myocardial involvement in chronic PH. Sin financiación 7.815 JCR (2015) Q1, 6/124 Cardiac and cardiovascular system, 1/124 Radiology, nueclear medicine and medicine imaging UEM