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Fundamentos y objetivo La enfermedad coronaria puede actuar como factor de riesgo cognitivo. Se ha estudiado en pacientes programados para cirugia coronaria la presencia de deterioro cognitivo leve disejecutivo. Pacientes y metodo Se ha evaluado en 35 pacientes la funcion ejecutiva (Trail Making Test). Se clasificaron en grupos con rendimiento normal o con deterioro, estudiandose su relacion con otras variables (Mann-Whitney, ji al cuadrado y analisis de regresion multiple). Resultados El grupo con deterioro disejecutivo (n = 7; 20%) presento mayor grado de angina (odds ratio [OR] 1,4, intervalo de confianza del 95% [IC 95%] 1,1-2,6; p = 0,04), enfermedad de 3 vasos (OR 1,3, IC 95% 1,08-3,6; p = 0,04) e indice de masa corporal (OR 1,56, IC 95% 1,16-3,65; p = 0,03), y menor presion arterial diastolica (OR 1,56, IC 95% 1,2-2,98; p = 0,02), hemoglobina (OR 2,03, IC 95% 1,18-4,05; p = 0,02) y hematocrito (OR 2,45, IC 95% 1,67-3,99; p < 0,001); estas variables resultaron significativas del rendimiento en el test como variable dependiente (R2 = 0,62). Conclusiones Se muestra una importante prevalencia de deterioro cognitivo leve disejecutivo asociado a factores de riesgo cardiovascular. Se recomienda realizar una valoracion cognitiva prequirurgica y un seguimiento posterior por las posibles complicaciones neurologicas posquirurgicas.

Recently, percutaneous aortic valve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValve aortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under local anesthesia and guided by angiography. The prosthesis was implanted successfully in all patients, although a second prosthesis was required in one case because the first was positioned too high. There were no major complications. After a mean follow-up of 7 months (SD, 4.7), all patients remained asymptomatic.

Resumen El implante valvular aortico percutaneo ha surgido recientemente como alternativa terapeutica para pacientes con estenosis aortica severa sintomatica y alto riesgo quirurgico. Se presenta la experiencia inicial en el tratamiento de la disfuncion de la bioprotesis aortica mediante el implante percutaneo de protesis aortica CoreValve en 4 pacientes, tanto con estenosis como con insuficiencia aortica, y se analiza los resultados hospitalarios y a medio plazo. El procedimiento se realizo con anestesia local y guiado por angiografia. Se implantaron con exito en todos los casos, si bien uno preciso una segunda protesis por posicionamiento alto de la primera. No hubo complicaciones mayores. Tras un seguimiento medio de 7 ± 4,7 meses, todos los pacientes se encuentran asintomaticos.

Introduccion y objetivos El tratamiento quirurgico de la estenosis aortica severa es el unico efectivo recomendado actualmente para esta patologia, pero el riesgo quirurgico aumenta con la disfuncion ventricular izquierda. Nuestro objetivo fue identificar predictores de mortalidad y mejoria funcional en el postoperatorio y a largo plazo tras reemplazo valvular en pacientes con estenosis aortica y disfuncion ventricular severa. Metodos Entre 1996 y 2008, 635 pacientes con estenosis aortica severa fueron intervenidos, 82 con fraccion de eyeccion Resultados Tras seguimiento medio de 42,59 ± 40,83 meses, la mortalidad global fue del 18,8% y la cardiovascular, del 11,3%. Solo el bajo gasto cardiaco postoperatorio (OR = 4,40; IC del 95%, 1,20-15,50; p = 0,02) se relaciono con mayor mortalidad en el seguimiento. El 70,5% presento mejoria precoz de la funcion ventricular, siendo predictores de ausencia de mejoria el infarto previo (p = 0,04), las lesiones coronarias no revascularizadas (p = 0,04) y un gradiente aortico reducido (p = 0,02). El 93,4% mejoro su grado funcional significativamente durante el seguimiento. Conclusiones Pese a la considerable mortalidad postoperatoria precoz de los pacientes con estenosis aortica y disfuncion ventricular izquierda, a largo plazo se observa una supervivencia elevada junto a mejora de la funcion ventricular y del grado funcional.

Introduccion y objetivos. La estrategia de revascularizacion en el paciente diabetico con enfermedad multivaso en la era actual de los stents farmacoactivos es controvertida. Metodos. Comparamos a 270 pacientes diabeticos consecutivos (2000-2004) con enfermedad multivaso (al menos 2 vasos con estenosis > 70% de novo y afeccion de la descendente anterior proximal) a los que se practico cirugia de revascularizacion coronaria (n = 142) o se implanto stents farmacoactivos (rapamicina/paclitaxel) (n = 128) mediante analisis de regresion logistica multivariable con propensity score. Analizamos los resultados clinicos (eventos cardiacos y cerebrovasculares mayores): muerte, infarto no fatal, ictus y necesidad de revascularizacion a 24 meses. Resultados. Los pacientes que recibieron stents farmacoactivos tuvieron mayor edad (67,5 ± 7 frente a 65,3 ± 8 anos; p = 0,05) y mas infarto previo (el 49,2 frente al 28,2%; p < 0,01), aunque no hubo diferencias en la presencia de disfuncion ventricular significativa (? 45%): el 32,4 frente al 28,1%. En los pacientes quirurgicos, la anatomia coronaria fue mas compleja: score SYNTAX (25,9 ± 7 frente a 18,5 ± 6; p < 0,001) y la calidad de la revascularizacion fue superior (revascularizacion anatomica completa, el 52,8 frente al 28,1%; p < 0,01). La incidencia total del evento combinado fue del 18,7% en el grupo quirurgico y el 21,8% en el grupo percutaneo (odds ratio [OR] ajustada = 0,93; intervalo de confianza [IC] del 95%, 0,47-1,86). El evento combinado de muerte, infarto e ictus fue del 15,8% en el grupo quirurgico, frente al 12,9% en el grupo de stent farmacoactivo (OR ajustada = 1,19; IC del 95%, 0,72-1,88). Los pacientes quirurgicos tuvieron menor necesidad de revascularizacion (el 4,3 frente al 12,1%; OR ajustada = 0,42; IC del 95%, 0,16-1,14; p = 0,09). Conclusiones. En una poblacion no seleccionada de diabeticos multivaso, la ventaja de la cirugia de revascularizacion coronaria se centro en reducir las revascularizaciones. No encontramos diferencias en muerte, infarto o ictus.

Introduccion y objetivos La influencia pronostica del sexo de los pacientes sometidos a sustitucion valvular aortica por estenosis severa tiene un papel controvertido, y algunos estudios le atribuyen un papel relevante como marcador de riesgo independiente. El objetivo del estudio es valorar la influencia pronostica perioperatoria del sexo de los pacientes sometidos a sustitucion valvular por estenosis aortica severa. Metodos Estudio retrospectivo en el que se analizo una cohorte de 577 pacientes sometidos a cirugia de reemplazo valvular aortico por estenosis aortica entre 1996 y abril de 2007. Resultados Las mujeres (44%) tenian mayor edad (70,3 ± 7,9 frente a 66,8 ± 9,8 anos; p Conclusiones La mortalidad perioperatoria de las mujeres con estenosis aortica severa sometidas a sustitucion valvular es alta. Al ajustar por potenciales factores de confusion, especialmente superficie corporal, el sexo femenino no se comporta como factor independiente de mortalidad.

The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis.This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007.Women (44% of patients) were older than men (70.3+/-7.9 years vs. 66.8+/-9.8 years; P.001), had a smaller body surface area (1.68+/-0.15 m(2) vs. 1.83+/-0.16 m(2); P.001), more often had arterial hypertension (73% vs. 49%; P.001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P.001), and less often had coronary artery disease (19.1% vs. 31.8%; P.001) and severe ventricular dysfunction (7.9% vs. 17.4%; P.001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119).Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality.

Introduccion y objetivos. La relacion entre el numero de intervenciones cardiacas anuales (volumen) de un centro y sus resultados es controvertido. Varios estudios occidentales hallan una relacion inversa volumen/mortalidad. Analizamos el numero de intervenciones de algunos centros cardioquirurgicos nacionales y su mortalidad bruta y ajustada a riesgo. Metodos Estudio observacional prospectivo de 6.054 pacientes intervenidos en 16 hospitales, correspondientes al 34% del total de la actividad cardioquirurgica que se realizo en Espana durante el ano 2004. Se analizaron los factores de riesgo y los resultados de cada paciente intervenido en los centros participantes. Los datos de cada centro fueron verificados por auditoria independiente. Se estimo el riesgo quirurgico de cada paciente intervenido por los metodos de Parsonnet y EuroSCORE, con objeto de evaluar la mortalidad ajustada a riesgo. Resultados La mortalidad total fue del 7,7% (intervalo de confianza del 95%, 7%-8,4%). El indice de mortalidad ajustada a riesgo fue 0,81 por el metodo de Parsonnet y 1,12 por EuroSCORE. La correlacion entre numero de cirugias de un centro y mortalidad por el metodo de Pearson fue 0,065 para la mortalidad bruta, 0,092 para la mortalidad ajustada a riesgo por Parsonnet y 0,111 para la mortalidad ajustada por EuroSCORE. Descartando los centros con mortalidades mas alta y mas baja, los resultados fueron –0,464, –0,420 y –0,267 respectivamente. Conclusiones En Espana no hay relacion estadisticamente significativa entre el numero de intervenciones cardiacas de un centro y su mortalidad hospitalaria.

Introduction and objectives. The relationship between the annual number of cardiac procedures at a particular center (ie, volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and riskadjusted mortality. Methods. This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality. Results. Overall mortality was 7.7% (95% confidence interval, 7.0-8.4). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the 2 centers with highest and lowest mortality rates, respectively, the correlations were ‐0.464, ‐0.420, and ‐0.267, respectively. Conclusions. No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality.

Introduccion y objetivos Durante la cirugia cardiaca se produce una isquemia miocardica transitoria que implica el desarrollo de fenomenos de estres oxidativo con liberacion de radicales libres. El dano resultante puede ser menor si se obvia el bypass aortopulmonar. Se estudia el sistema antioxidante del glutation como medida indirecta del dano oxidativo asociado con la cirugia cardiaca. Se analiza la influencia del empleo de circulacion extracorporea. Pacientes y metodo Se incluye a 19 pacientes en los que se realizo cirugia cardiaca, 9 de ellos con bomba (47,4%). De cada paciente se extrajeron muestras sanguineas en diferentes momentos (intraoperatorios y postoperatorios) y en ellas se cuantificaron el glutation (total, oxidado y reducido) plasmatico e intraeritrocitario y se determino la actividad enzimatica implicada (glutation-peroxidasa, glutation-reductasa y glutation-transferasa). Resultados El glutation total disminuyo mas en los pacientes operados con circulacion extracorporea. Tambien se redujo el glutation oxidado plasmatico e intraeritrocitario, lo que expresa una defensa antioxidante ineficaz, mientras que en los casos sin bomba esta tendencia fue creciente. No hubo diferencias significativas en la actividad enzimatica entre ambos grupos. Conclusiones En nuestra serie, los pacientes intervenidos sin circulacion extracorporea mostraron un mejor perfil antioxidante en relacion con el sistema del glutation. Esto puede traducirse en que la cirugia cardiaca sin bomba resulta menos agresiva para el miocardio.

Valvular heart disease associated with the use of anorectic agents is a recently described clinical entity. We report the case of a 46-year-old woman with severe regurgitation of the mitral, aortic and tricuspid valves who had been taking fenfluramine and dexfenfluramine for two years. Surgical treatment was required with replacement of three valve by mechanical prostheses. The previous history of treatment with anorectic agents, the echocardiographic morphology of the injured valves and the macroscopic and histopathologic findings strongly suggested an association between the anorectic agents and the valvular disease of the patient.

Coronary disease has been associated with cognitive disorders. We studied the presence of dysexecutive mild cognitive impairment in patients scheduled for coronary surgery.The executive function of 35 patients was evaluated (Trail Making Test). They were classified into 2 groups: normal performance or cognitive impairment, and we assessed the relationship with others variables (Mann-Whitney, chi-square and multiple regression analysis).The dysexecutive cognitive impairment group (n=7; 20%) showed greater degree of angina (odds ratio [OR] 1.4, 95% confidence interval [95% CI] 1.1-2.6; P=.04), 3-vessels coronary artery disease (OR 1.3, 95% CI 1.08-3.6; P=.04) and body mass index (OR 1.56, 95% CI 1.16-3.65; P=.03) and lower diastolic blood pressure (OR 1.56, 95% CI 1.2-2.98; P=.02), hemoglobin (OR 2.03, 95% CI 1.18-4.05; P=.02) and hematocrit (OR 2.45, 95% CI 1.67-3.99; P.001); these variables proved to be significant in the test performance considered as a dependent variable (R(2)=0.62).We found a significant prevalence of dysexecutive mild cognitive impairment, which was associated with cardiovascular risk factors. We recommend assessment and monitoring of cognitive performance for probable neurological complications after cardiac surgery.

The St. Jude Medical Symmetry Aortic Connector System was developed to create the proximal vein graft anastomoses in coronary artery bypass grafting. We describe three symptomatic patients with severe stenosis of the proximal anastomosis several months after using the Symmetry aortic connector system. Intravascular ultrasound study showed anastomotic neointimal hyperplasia.

Desde la introduccion de las protesis percutaneas en la practica clinica y de los procedimientos valve in valve se pueden tratar de forma no quirurgica las disfunciones de protesis biologicas aorticas. Analizamos nuestros datos para ver si se justificaria rebajar mas la edad de implantacion de protesis biologicas (60–65 anos) con el planteamiento: primer procedimiento en edad joven, segundo (primera reintervencion) en edad intermedia, con bajo riesgo y tercero percutaneo. En los ultimos 10 anos hemos reoperado 28 pacientes con protesis aorticas previas (disfuncion de protesis biologicas, trombosis protesicas mecanicas o leaks periprotesicos) habiendo fallecido uno, lo que significa una mortalidad del 3,6%. Se excluyen del analisis los pacientes reintervenidos por endocarditis (al no tener relacion dicha patologia con tener previamente implantada una protesis biologica vs mecanica) y los pacientes con otra cirugia previa asociada. Dado el bajo riesgo que representa una primera reintervencion, especialmente a edad relativamente joven, creemos recomendable expandir la edad en la que se implantan protesis biologicas en posicion aortica y dificil de justificar la implantacion de protesis mecanicas en dicha posicion, salvo en pacientes muy jovenes en los que la reparacion valvular o el procedimiento de Ross no sean posibles.

La reparacion es la tecnica de eleccion en la cirugia de la insuficiencia mitral. Se reserva basicamente para los pacientes con patologia degenerativa o funcional, siendo pocos los casos en los que valvulas reumaticas pueden ser reparadas. Presentamos nuestra corta experiencia en cirugia reparadora compleja de la valvula mitral reumatica insuficiente. De las 102 reparaciones mitrales efectuadas en nuestro servicio en los ultimos 4 anos solo cuatro se hicieron en valvulas reumaticas. En dos ocasiones se amplio el velo anterior con parche de pericardio, en otra papilotomias extensas, y en la ultima se despegaron los velos mitrales que estaban fusionados en mas del 50% de su linea de coaptacion y se reseco el aparato subvalvular del papilar posterior que se sustituyo por neocuerdas. Siempre se asocio anuloplastia con anillo semirrigido, en tres casos ablacion de la fibrilacion auricular y en uno cirugia reductora de la auricula izquierda. No ha habido mortalidad. Un caso se reconvirtio en quirofano a sustitucion valvular por mal resultado y otro se reopero antes del alta por rotura de una neocuerda con prolapso residual, consiguiendo ser reparada. Al alta las valvulas presentaban gradientes medios de 2 mmHg y regurgitacion nula en dos casos y trivial en uno. En el seguimiento (6–28 meses) las valvulas han permanecido estables y los pacientes siguen en ritmo sinusal. La reparacion de la insuficiencia mitral de origen reumatico, aun siendo poco frecuente y tecnicamente compleja, es factible en casos seleccionados, con aceptables resultados.

La valvula aortica insuficiente puede ser reparada en muchos casos, lo que ofrece al paciente la ventaja de evitar las morbimortalidad asociada a portar una protesis. Comenzamos en noviembre de 2008 un programa de reparacion de la valvula aortica. Hemos intervenido a 59 pacientes. En 41 casos la valvulopatia se asociaba a dilatacion de la aorta ascendente. La regurgitacion preoperatoria era de 3,4/4 (0–4); 15 valvulas bicuspides. En 41 casos se asocio cirugia sobre la aorta ascendente (17 procedimientos de David, 14 de Yacoub y 10 sustituciones de la aorta supracoronariana), en 5 cirugia mitral o coronaria, en otro caso una estenosis pulmonar y una comunicacion interventricular (CIV) y en los 18 restantes se realizo reparacion valvular aislada. No ha habido mortalidad hospitalaria, aunque un paciente sufrio un accidente cerebrovascular (ACV) con secuelas graves. En 3 pacientes hubo que reconvertir a protesis. La regurgitacion postoperatoria media al alta fue de 0,6/4. En el seguimiento (1–38 meses), un paciente se reopero por endocarditis, ningun paciente ha precisado ser reintervenido por insuficiencia aortica, estando libres de regurgitacion grado III-IV el 97% de los pacientes. Creemos que la cirugia reparadora de la valvula aortica es factible en nuestro medio, con buenos resultados.

Las valvulas bicuspides degeneran de forma mas frecuente y precoz que las normales. En muchas el modo de disfuncion es regurgitacion, acompanada frecuentemente de dilatacion de aorta ascendente. En nuestra unidad de valvula bicuspide se siguen 215 individuos, remitiendose a cirugia 17 pacientes. Los 17 varones, con edad media de 49 anos (33–68), regurgitacion media 3,8/4, volumen telediastolico medio 68 mm y fraccion de eyeccion media 60% (31–71%). Ocho presentaban dilatacion significativa de raiz aortica y uno dilatacion aislada de aorta tubular; en los otros 8 la aorta era normal o levemente dilatada. Se realizaron 8 reparaciones aisladas, una asociada anuloplastia mitral sobrerreductora y sustitucion de aorta tubular y 8 con sustitucion de aorta ascendente mediante tecnica de Yacoub. Quince reparaciones fueron satisfactorias y en 2 se implanto finalmente una protesis. Ningun Yacoub hubo de ser reconvertido. La regurgitacion residual fue 0/4 en 12 pacientes y 1/4 en 3, y el gradiente pico medio 12 mmHg. El volumen telediastolico se redujo siempre significativamente. El unico factor predictor de fracaso fue la fecha de cirugia. La valvula bicuspide insuficiente se puede reparar en un alto porcentaje de casos librando al paciente de la morbimortalidad asociada al uso de protesis valvulares.

Presentamos el video de un paciente al que se le sustituyo la aorta ascendente preservando su valvula aortica nativa mediante tecnica de Yacoub. Se trata de un paciente de 54 anos en grado funcional II, con valvula aortica bicuspide tipo A con fusion parcial, rafe muy calcificado y comisuras a unos 130°. Presentaba regurgitacion aortica grave, dilatacion leve de ventriculo izquierdo y fraccion de eyeccion conservada. Los diametros aorticos eran los siguientes: anillo 23 mm, senos de Valsalva 43 mm, union sinotubular 42 mm y aorta tubular 54 mm. Se realizo reseccion completa del rafe con reconstruccion del velo conjunto y sustitucion de la aorta ascendente con preservacion de la valvula segun tecnica de Yacoub realineando las comisuras a 180°. El resultado quirurgico fue satisfactorio, con valvula con regurgitacion residual grado I al alta y sin gradiente significativo.

The U-Clip (Coalescent Surgical, Sunnydale, CA USA) allows the surgeon to create an interrupted anastomosis in the same amount of time that is required for a continuous anastomosis with the elimination of knotting. Its use is indicated especially in minimally invasive surgery. We describe a case of a patient in which the proximal anastomosis was performed by interrupted suture with Coalescent U-Clip anastomotic device. Six months later, he presented with stenosis of the anastomosis, and intravascular ultrasound showed anastomotic neointimal hyperplasia.

Describimos el caso de un paciente en el que la ecocardiografia bidimensional, realizada en estudio por colestasis disociada, demostro la existencia de una gran masa en la auricula derecha que prolapsaba en ventriculo el derecho. Se realizo ecocardiografia transesofagica intraoperatoria para delimitar las dimensiones y caracteristicas de la masa con lo que se descarto la afectacion de estructuras asociadas. El paciente fue intervenido bajo circulacion extracorporea, extirpandose una gran masa de 12 × 5 cm, sin ninguna complicacion posterior. El estudio histologico demostro que se trataba de un mixoma. El interes del caso se centra en el diagnostico tras la sospecha del medico por el patron de colestasis disociada e ingurgitacion yugular y la reseccion quirurgica, que evito posibles complicaciones embolicas que por el tamano de la masa pudieron ser fatales.

Recently, percutaneous aortic valve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValve aortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under local anesthesia and guided by angiography. The prosthesis was implanted successfully in all patients, although a second prosthesis was required in one case because the first was positioned too high. There were no major complications. After a mean follow-up of 7 months (SD, 4.7), all patients remained asymptomatic.

At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction.Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval [CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38; 95% CI, 1.40-80.0; P=.020) and coronary artery disease (OR=2.09; 95% CI, 1.26-51.0; P=.027).During the mean follow-up period of 42.59+/-40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was a low postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction (P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients.Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class.

Analizar los resultados de la cirugía de revascularización coronaria de nuestro servicio y cómo la cirugía sin bomba ha modificado nuestra estrategia quirúrgica y los resultados hospitalarios de morbimortalidad. Material y métodos: Es un estudio de revisión retrospectivo. Desde enero de 1996 hasta diciembre de 2009 se han intervenido un total de 1.802 pacientes de cirugía coronaria aislada, con edad media de 63,4 ± 9,3, de los cuales 661 (36,6%) con circulación extracorpórea (CEC) y 1.141 (63,3%) sin CEC. Hemos analizado la curva evolutiva del número de pacientes intervenidos con CEC frente a aquellos sin CEC, los factores de riesgo, tipo de enfermedad coronaria, situación clínica previa, actuación quirúrgica, morbilidad y mortalidad hospitalaria. Resultados: El porcentaje de cirugía sin CEC ha ido aumentando progresivamente hasta alcanzar el año pasado el 89%. El incremento de la cirugía sin CEC se ha asociado a un descenso de la mortalidad hospitalaria global. La cirugía sin bomba ha reducido de forma significativa (p < 0,05) la mortalidad hospitalaria cuando se compara con el grupo intervenido con CEC (7,5 vs 2,3%). Esta reducción es más evidente en los grupos de alto riesgo. Asimismo, hemos encontrado un descenso de la morbilidad postoperatoria con p significativa (p < 0,05) en bajo gasto, infarto agudo de miocardio (IAM) perioperatorio, ventilación prolongada y reoperación por sangrado. El número de anastomosis distales se ha reducido desde 3 hasta 2,7, aunque ha aumentado el número de injertos arteriales. Conclusiones: En la experiencia de nuestra institución, la cirugía sin bomba ha supuesto una mejora significativa de la morbimortalidad hospitalaria. La cirugía coronaria sin CEC se puede extender a la casi totalidad de los pacientes.

Objectives To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. Methods We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. Results This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. Conclusions AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

INTRODUÇÃO: A prevalência de estenose aórtica grave vem crescendo em decorrência do aumento da expectativa de vida. Alguns pacientes não se beneficiam do tratamento cirúrgico por causa das comorbidades associadas. Apresentamos os resultados de nossa experiência no tratamento percutâneo da estenose aórtica. MÉTODO: Estudo prospectivo, realizado entre abril de 2008 e fevereiro de 2009, em que 31 pacientes consecutivos com estenose aórtica grave sintomática e que apresentavam alto risco cirúrgico foram tratados com a prótese aórtica CoreValve. Todos os procedimentos foram realizados com anestesia local. Em 29 casos a via de acesso foi a artéria femoral, com introdutor 18 F, a punção femoral foi fechada com Prostar 10 F, e em 2 pacientes a artéria subclávia esquerda foi a via de acesso. RESULTADOS: A média de idade foi de 77,8 ± 8,9 anos e o EuroSCORE logístico médio foi de 17,5 ± 12,6%. O sucesso do implante foi de 100%. O gradiente de pico a pico após o implante desapareceu. Nenhum paciente apresentou insuficiência aórtica residual > grau 2 de Sellers. A mortalidade aos 30 dias foi de 3,2%. Foram necessários marca-passos definitivos em 31% dos pacientes. Depois de acompanhamento médio de 154 ± 90 dias, foram registrados 4 óbitos (1 morte súbita e 3 por causas não-cardíacas). CONCLUSÕES: O implante percutâneo da prótese aórtica Core-Valve como tratamento alternativo da estenose aórtica grave em pacientes com alto risco cirúrgico é factível e seguro, com elevada taxa de êxito no procedimento e porcentual de complicações abaixo do esperado em função do risco cirúrgico estimado com o EuroSCORE. BACKGROUND: The prevalence of severe aortic stenosis is increasing with the rise in life expectancy. Some patients cannot undergo surgical treatment of aortic stenosis due to associated disorders. We present the results of our experience with the percutaneous treatment of aortic stenosis as an alternative to surgery in high-risk patients. METHODS: This prospective cohort study included 31 consecutive high surgical risk patients with severe and symptomatic aortic stenosis treated with a CoreValve aortic prosthesis from April 2008 to February 2009. All the procedures were undertaken with local anesthesia. In 29 patients we used a femoral artery access, with an 18 F introducer, closing the femoral puncture with a 10 F Prostar, and in two patients the access was via the left subclavian artery. RESULTS: The mean age of the patients was 77.8 ± 8.9 years and the mean logistic EuroSCORE was 17.5 ± 12.6%. The implant was successful in 100% of cases. The peak-to-peak gradient after the implant disappeared. No patient had residual aortic insufficiency Sellers' grade > 2. One-month mortality was 3.2%. A definitive pacemaker was required in 31% of the patients. After a mean follow-up of 154 ± 90 days there were four deaths (1 sudden death and 3 for non-cardiac causes). CONCLUSIONS: Percutaneous implantation of the CoreValve aortic prosthesis as an alternative treatment for severe aortic stenosis in high surgical risk patients is feasible and safe, with a high success rate for the procedure and a percentage of complications below the expected for the surgical risk, as estimated by the EuroSCORE.

Since the introduction of drug-eluting stents, the optimum revascularization strategy in diabetic patients with multivessel coronary disease has remained controversial.This study used multivariate logistic regression analysis and propensity score matching to compare results in 270 consecutive diabetic patients (2000-2004) with multivessel disease (or =2 vessels with a70% de novo stenosis involving the proximal left anterior descending coronary artery) who underwent either coronary artery bypass grafting (CABG; n=142) or implantation of a drug-eluting stent (DES; i.e. rapamycin or paclitaxel; n=128). The following clinical outcomes (i.e. major adverse cardiac or cerebrovascular events [MACCEs]) were assessed: death, nonfatal myocardial infarction (MI), stroke and repeat revascularization at 2 years.Patients who received DESs were older (67.5+/-7 years vs. 65.3+/-8 years; P=.05) and more often had a previous MI (49.2% vs. 28.2%; P.01), but no more often had a depressed left ventricular ejection fractionor =45% (32.4% vs. 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9+/-7 vs. 18.5+/-6; P.001) and the quality of revascularization was better (i.e. anatomically complete revascularization: 52.8% vs. 28.1%; P.01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] = 0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR = 1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs. 12.1%; adjusted OR = 0.42; 95% CI, 0.16-1.14; P=.09).In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke.

The relationship between the annual number of cardiac procedures at a particular center (i.e., volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and risk-adjusted mortality.This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality.Overall mortality was 7.7% (95% confidence interval, 7.0%-8.4%). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the two centers with highest and lowest mortality rates, respectively, the correlations were -0.464, -0.420 and -0.267, respectively.No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality.

Introduction: In order to improve the prognosis, repair of severe mitral regurgitation should be undertaken at the same time as aortic valve replacement in patients with severe aortic valve stenosis. However, mitral regurgitation may be secondary to pressure overload or ventricular dysfunction and improve after surgery. Aim: To assess the incidence of non-severe functional mitral regurgitation before and after isolated aortic valve replacement and determine its influence on the postoperative course. Methods: The clinical and surgical characteristics were compared in a cohort of 577 consecutive patients who underwent isolated aortic valve replacement. Results: The mean age was 68.4 9.2 years (44% women). Non-severe functional mitral valve regurgitation was detected prior to surgery in 26.5% of the patients. These patients were older (p = 0.009), more often had ventricular dysfunction (p = 0.005) and pulmonary hypertension (0.002), and had been admitted more frequently for heart failure (0.002), with fewer of them conserving sinus rhythm (p < 0.001). Additionally, the pre-surgery existence of mitral regurgitation was associated with greater morbidity and mortality (10.5% vs 5.6%; p = 0.025). The mitral regurgitation disappeared or improved prior to hospital discharge in 56.2% and 15.6%, respectively. Independent factors predicting this improvement were the presence of coronary lesions (OR 3.7, p = 0.038), and the absence of diabetes (OR 0.28, p = 0.011) and pulmonary hypertension (0.33, p = 0.046). Conclusions: The presence of intermediate degree mitral regurgitation in patients undergoing isolated aortic valve replacement increases morbidity and mortality. However, a high percentage of those who do survive experience disappearance or improvement of the mitral regurgitation. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Introduction and objectives The transient myocardial ischemia that occurs during cardiac surgery leads to oxidative stress and the production of free radicals. The resulting damage can be reduced if cardiopulmonary bypass is avoided. We obtained indirect measures of the oxidative damage occurring during cardiac surgery by monitoring the glutathione system and we studied the influence of cardiopulmonary bypass. Patients and method The study included 19 patients undergoing cardiac surgery. Cardiopulmonary bypass was used in 9 (47.4%). Blood samples were obtained from each patient at different times during and after surgery. Total, oxidized and reduced glutathione levels were measured, as was the activity of related enzymes (i.e., glutathione peroxidase, glutathione reductase, and glutathione transferase). Results The total glutathione level decreased more in patients in whom cardiopulmonary bypass had been used. In addition, the oxidized glutathione level was reduced in these patients, which suggests that antioxidant defense was not fully effective. In contrast, the oxidized glutathione level tended to increase in patients in whom cardiopulmonary bypass had not been used. There was no significant difference in enzymatic activity between the two groups. Conclusions In this study, patients who underwent off-pump cardiac surgery had a better antioxidant profile. The implication could be that cardiac surgery without cardiopulmonary bypass has a less damaging effect on ischemic myocardium.

Left ventricular outflow tract obstruction after mitral valve replacement may occur when the native mitral apparatus is preserved intact. Although it has usually been reported using bioprostheses, we present one case using a low-profile mechanical prosthesis. The reduction of left ventricular dimensions and valvular redundancy contributed to this complication. We obtained definitive relief of left ventricular outflow tract obstruction by transaortic exposure and partial resection of the obstructing tissue with the help of video-assisted cardioscopy.

Between August 1987 and November 1988, combined mitral and aortic balloon valvuloplasty was performed in 10 patients (mean age 42 ± 9 years), all of whom had symptomatic mitral and aortic stenosis, the procedure was performed using a transarterial approach with a multiballoon catheter and an exteriorized intracardiac long guidewire circuit. The procedure could be considered successful in 9 patients where significant increases in the mean mitral (0.97 ± 0.19 to 1.80 ± 0.26 cm 2 ) and aortic (0.63 ± 0.18 to 1.15 ± 0.32 cm 2 ) areas were achieved. Severe mitral regurgitation that required surgery developed in 1 patient in the following 24 hours. Femoral vascular surgery was necessary in 1 patient. Mid-term follow-up was available in 8 patients for a period averaging 8 ± 3 months. The 9 patients in whom the procedure was successful showed persistent clinical improvement in functional class- Doppler echocardiography showed 2 cases of aortk restenosis and none of mitral restenosis. Combined mitral and aortic balloon valvuloplasty could be a valid alternative treatment in selected patients with both mitral and aortic rheumatic stenosis. Further experience and longterm hemodynamic follow-up are necessary to define the role of this mode of treatment.

Balloon valvuloplasty was used in the operating room on 7 patients to visually assess the valvular changes induced by inflation of a balloon catheter. All patients had typical pulmonary valve stenosis and an associated cardiac condition which necessitated surgery. Of 23 fused commissures present, 21 were successfully opened with a single balloon inflation. In 2 patients, damage to the leaflets was observed. In 1 patient there was partial detachment and in the other a small tear was noted at the margin of one leaflet. These intraoperative results may be similar to the results obtained with percutaneous balloon valvuloplasty.