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OBJECTIVES: To compare and validate the new European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with EuroSCORE at our institution. METHODS: The logistic EuroSCORE and EuroSCORE II were calculated on the entire patient cohort undergoing major cardiac surgery at our centre between January 2005 and December 2010. The goodness of fit was compared by means of the Hosmer–Lemeshow (HL) chi-squared test and the area under the curve (AUC) of the receiver operating characteristic curves of both scales applied to the same sample of patients. These analyses were repeated and stratified by the type of surgery. RESULTS: Mortality of 5.66% was observed, with estimated mortalities according to logistic EuroSCORE and EuroSCORE II of 9 and 4.46%, respectively. The AUC for EuroSCORE (0.82, 95% confidence interval [CI] 0.79–0.85) was lower than that for EuroSCORE II (0.85, 95% CI 0.83–0.87) without the differences being statistically significant (P= 0.056). Both scales showed a good discriminative capacity for all the pathologies subgroups. The two scales showed poor calibration in the sample: EuroSCORE (χ 2 = 39.3, PHL< 0.001) and EuroSCORE II (χ 2 = 86.69, PHL< 0.001). The calibration of EuroSCORE was poor in the groups of patients undergoing coronary (PHL =0.01), valve (PHL= 0.01) and combined coronary valve surgery (PHL = 0.012); and that of EuroSCORE II in the group of coronary (PHL = 0.001) and valve surgery (PHL< 0.001) patients. CONCLUSIONS: EuroSCORE II demonstrated good discriminative capacity and poor calibration in the patients undergoing major cardiac surgery at our centre.

OBJECTIVE: An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery. METHODS: A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Cox’s proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events. RESULTS: A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08–48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29–5.756] and MACEs (HR 2.784, 95% CI 1.962–3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319–6.21) and MACEs (HR 2.89, 95% CI 2.008–4.158). CONCLUSIONS: Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting.Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization).In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34).In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Introduccion y objetivos Evaluar el impacto de la implantacion de stents coronarios previa a la cirugia de revascularizacion miocardica en los resultados postoperatorios de esta. Metodos Desde enero de 2005 hasta abril de 2008, se evaluo retrospectivamente el impacto de la implantacion de stents coronarios previa a la cirugia coronaria sin circulacion extracorporea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 dias o ingreso hospitalario postoperatorios). Resultados Se sometio a 796 pacientes consecutivos a revascularizacion miocardica quirurgica; 116 (14,6%) portaban algun stent coronario en el momento de la cirugia. Los grupos con stent y sin stent tenian un perfil de riesgo similar (EuroSCORE). En el analisis multivariable, ajustando el riesgo por las variables de confusion detectadas (fraccion de eyeccion del ventriculo izquierdo preoperatoria Conclusiones En nuestra experiencia, la implantacion previa de stents coronarios se asocia a un mayor riesgo de infarto miocardico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugia coronaria.

La enfermedad cardiovascular en general y la cardiopatia isquemica en particular constituyen una importante fuente de morbimortalidad en la mujer. La sintomatologia mas atipica, la baja percepcion del riesgo por parte de las mujeres, la menor precision diagnostica de las pruebas no invasivas y la menor utilizacion de la coronariografia dificultan el diagnostico de la cardiopatia isquemica en la mujer. La mujer con cardiopatia isquemica, tanto en el contexto de la angina estable e inestable como del infarto sin onda Q o con elevacion del segmento ST, se beneficia tanto como el varon de la revascularizacion percutanea o quirurgica, aunque la tasa de complicaciones hemorragicas y la mortalidad periprocedimiento son algo mas elevadas en la mujer; sin embargo, se observa una tendencia hacia una reduccion en las diferencias en los ultimos anos. Tanto los stents farmacoactivos como la revascularizacion arterial sin circulacion extracorporea aportan beneficios similares en varones y mujeres. El estricto control de los factores de riesgo es imprescindible tras cualquier procedimiento de revascularizacion. La seleccion del metodo de revascularizacion mas adecuado en cada paciente dependera de la edad, la comorbilidad, el tipo, el numero y la localizacion de las lesiones coronarias, la funcion ventricular y las preferencias del paciente, entre otros factores. Hoy dia, un numero considerable de pacientes puede ser revascularizado por ambas tecnicas. Por ello es imprescindible la discusion conjunta de casos y la estrecha colaboracion de cardiologos intervencionistas y cirujanos, que lleve a la toma conjunta de decisiones terapeuticas que puedan ser convenientemente evaluadas y modificadas.

Cardiovascular disease and, in particular, ischemic heart disease are major causes of morbidity and mortality in women. Diagnosis of ischemic heart disease in women is made more difficult by the occurrence of atypical symptoms, a perception that the risk is low, the limited accuracy of non-invasive tests, and underuse of coronary angiography. Women with ischemic heart disease, with either stable or unstable angina or non-Q wave or ST-elevation myocardial infarction, benefit as much as men from percutaneous or surgical revascularization. However, hemorrhagic complications occur more often in women and periprocedural mortality is slightly higher with both techniques, though the sex difference has tended to decrease in recent years. Moreover, drug-eluting stents, arterial revascularization, and off-pump procedures are equally beneficial to men and women. Nevertheless, strict control of risk factors is essential following any revascularization procedure. Selecting which of the 2 revascularization procedures is more appropriate depends on the patient's age and comorbid conditions, the number, location and type of coronary lesions, ventricular function, and the patient's preferences, among other factors. Nowadays, a significant number of patients can be revascularized using either technique. Therefore, open discussion of each case and close collaboration between interventional cardiologists and surgeons are essential so that joint decisions about the most appropriate treatment can be made in a consistent manner.

We read with interest the article by Farooq et al, “Quantification of Incomplete Revascularization and Its Association With Five-Year Mortality in the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) Trial: Validation of the Residual SYNTAX Score,”1 in which the authors investigated the effect on long-term outcomes of the randomized patients receiving percutaneous coronary intervention in the SYNTAX study according to the SYNTAX score (SS) of the residual coronary lesions once subjects had been revascularized (residual SS). They concluded that a residual SS >8 was associated with increasing adverse long-term clinical outcomes, including mortality. On the other hand, residual SS ≤8 was associated with long-term mortality comparable …

Population over 80 years who require surgery for degenerative aortic stenosis has largely increased in the past decades. We have compared short- and mid-term results for conventional aortic valve replacement (AVR) for calcific-degenerative aortic stenosis in older and younger than 80 years operated at our institution between April 2004 and December 2008. Predictors of mortality and major adverse cardio and cerebrovascular events (MACCEs) on the postoperative and follow-up period were determined through multivariable analysis. Four hundred and fifty-one patients were included in the study. Ninety-four (20.8%) were ≥80. Previous cardiac surgery wodds ratio (OR=4.08, P=0.047), renal failure (OR=6.75, P

Pregnant women with a mechanical heart prosthesis are at a higher risk of thromboembolic complications. The optimal anticoagulation strategy in this setting remains unclear. When prosthesis thrombosis happens and cardiac surgery must be performed, the risk of fetal mortality is high. Special attention must be paid to improve the placental perfusion during cardiopulmonary bypass (CPB) in order to improve fetal outcomes. A 31-year-old woman, nine weeks pregnant, was admitted to our institution due to a mitral mechanical prosthesis thrombosis. She had been receiving low molecular weight heparin (LMWH) since pregnancy was detected. She underwent a mitral valve replacement with CPB at 34 degrees C and a short cardiac arrest time. Both mother and fetus survived. We briefly review the different anticoagulation options during pregnancy and perfusion strategies on CPB to improve fetal outcomes.

An 83-year-old patient underwent a transapical aortic valve implantation at our institution. Four months later, she was readmitted to our institution because of fever and heart failure. A prosthetic aortic valve endocarditis was diagnosed. Because of the high surgical risk, surgery was refused and the patient died shortly after the diagnosis. We briefly discuss the implications of this finding in the prevention of infective endocarditis after transcatheter aortic valve implantation.

Varon de 77 anos, portador de protesis mitral y aortica mecanicas desde 1993, diagnosticado, a raiz de una cuadro de disnea y anemia, de fuga periprotesica mitral. Considerado de alto riesgo operatorio (debido a su edad, hipertension pulmonar grave, insuficiencia renal cronica y cirugia cardiaca previa) se desestimo una reintervencion quirurgica en su centro de referencia y se lo remitio al servicio de cardiologia de nuestro hospital para valorar un cierre percutaneo. Mediante ecocardiografia 3D se objetivo una insuficiencia mitral (IM) periprotesica grave (fig. 1, flechas). Se implantaron tres dispositivos de cierre percutaneo Amplatzer (fig. 2, asteriscos), lo que redujo el grado de IM a moderado (fig. 2, flechas). Dos meses despues, el paciente reingreso por insuficiencia cardiaca y anemia hemolitica. Se evidencio una nueva IM grave por incremento de las fugas periprotesicas residuales posteriores al cierre percutaneo. Dado el deterioro progresivo del paciente (edema de pulmon, bajo gasto, anuria), se opto por una cirugia urgente para extraerle los dispositivos percutaneos (fig. 3, flechas) y sustituir la protesis mitral por una nueva. Aunque el postoperatorio inmediato transcurrio sin incidencias (protesis normofuncionante en ecocardiografia transesofagica), el paciente fallecio al octavo dia por una isquemia intestinal aguda. El tratamiento de eleccion de la fuga periprotesica valvular cardiaca es la sustitucion quirurgica de la protesis. El cierre percutaneo no esta exento de morbimortalidad y los resultados con frecuencia son suboptimos, por lo que solo debe plantearse en pacientes con un riesgo quirurgico prohibitivo, tras la valoracion conjunta por parte de cirujanos y cardiologos. Figura 1.

ObjectiveThe SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events.MethodsAll patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders.ResultsA total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5–76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33–37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P