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Objective To analyse the relationship between the degree of frailty and the risk of presenting poor short-term outcomes. Methods observational cohort study of the population ≥ 70 years of age undergoing elective and high-priority major cardiac surgery at our hospital. A total of 232 consecutive patients were enrolled in Salamanca University Hospital from October 2017-December 2019 This cohort study of 232 patients prospectively compared the results of the FRAIL questionnaire and the Fried Phenotype Criteria (FPC) and retrospectively adapted these tools based on the characteristics and confounding factors found in our sample. The individual items comprising the multi-item scales were then independently analysed using logistic regressions. Results Frailty was associated with increased mortality, although the differences were not significant. Standardizing the FPC improved its ability to identify frail patients (p = 0.027). Scores with both original tools were associated with a prolonged postoperative stay (p ≤ 0.05). Additionally, a positive result on the FRAIL questionnaire was associated with a higher number of complications (p = 0.025). In our study, the predictive capacity emerged from specific items: grip strength, gait speed, illness, and resistance. We united these items with the severity of pulmonary hypertension to create a specific frailty scale for cardiac surgery, and the scores were significantly associated with a combined endpoint, containing death, prolonged stay, and/or presenting ≥ 3 complications (p = 0.011). Conclusions The results indicated that frailty determined by either of the original tools was associated with worse results after cardiac surgery. Likewise, milder degrees of frailty, which we call pre-frailty, can also anticipate poor outcomes, in some cases. Standardization of the FPC improved its predictive capacity. In our study, we designed a tool for cardiovascular patients that is predictive of poor postoperative outcomes. Adapting frailty tools is necessary to avoid confusion with cardiovascular disease.

Resumen: Introducción y objetivos: El grupo de Trabajo en Reparación Valvular de la Sociedad Española de Cirugía Torácica y Cardiovascular presenta el registro anual de actividad en cirugía reparadora de la válvula mitral, aórtica y tricúspide realizada en España en los años 2016 y 2017. Métodos: La recogida de datos se realizó a través de un cuestionario online, de forma retrospectiva, voluntaria, anónima y no auditada. Se detallan parámetros en cuanto al tipo de cirugía, etiología, mortalidad y riesgo quirúrgico de cada una de las válvulas. Resultados: Se obtuvieron datos de 27 centros, con 6.751 y 7.634 intervenciones registradas en 2016 y 2017, respectivamente. La cirugía mitral reparadora supone el 35%, y 30% de las válvulas mitrales intervenidas. El porcentaje de cirugía reparadora aórtica (4,5%) se mantiene como en años anteriores. La cirugía valvular tricúspide aumenta un 26% en el 2017 respecto al año anterior, manteniendo una tasa de reparación estable del 88%, mayoritariamente con el uso de anillos protésicos. Respecto a la cirugía mitral miniinvasiva, se aprecia una disminución de los centros y del número de cirugías: de 14 centros con 109 cirugías en 2016 a 9 centros con 83 cirugías en 2017. La cirugía miniinvasiva aórtica se sitúa en un 15% en 2016 y un 13% en 2017. Conclusiones: Existe una disminución considerable de los centros participantes y consiguientemente del número de cirugías. La actividad reparadora mitral está establecida en la mayoría de los grupos, aunque con unas tasas de reparación bajas. Se observa una estabilización en la tasa de reparación valvular tricúspide. La cirugía miniinvasiva mitral disminuye mientras que la aórtica aumenta respecto a años anteriores. Abstract: Introduction and objectives: The Working Group on Valve Repair of the Spanish Society of Thoracic and Cardiovascular Surgery presents the annual report on reconstructive valve surgery of the mitral, aortic and tricuspid valves performed in Spain during 2016-2017. Methods: The data was gathered using an online form, in a retrospective, voluntary, anonymous and non-audited way. Different parameters regarding etiology, type of surgery, mortality and risk scores were collected. Results: Data was collected from 27 centers with 6.751 and 7.634 recorded interventions in 2017 and 2017, respectively. Mitral repair surgery accounts for 35% and 30% of all mitral valve operated. The percentage of aortic valve sparing interventions was 4,5%, similar to previous years. Tricuspid surgery has increased 26% in 2017 in relation to 2106, confirming a stable repair rate of 88%, mainly with a wide use of prosthetic rings. Regarding mini-invasive mitral surgery, a decrease in centers and number of surgeries is observed (14 centers reporting 109 surgeries in 2106 to 9 centers with 83 surgeries in 2017). Mini-invasive aortic surgery means a 15% in 2016 and 13% in 2017. Conclusions: It has been observed a decrease in the number of participating centers and therefore of the number of surgeries. Mitral valve repair is a established option in our country, although with very low repair rates. Tricuspid valve repair surgery has stabilized in the last years. Mini-invasive mitral surgery has decreased while aortic mini-invasive has increased. Palabras clave: Registro, Reparación valvular, Sustitución valvular, Válvula mitral, Válvula aórtica, Válvula tricúspide, Keywords: Registry, Valve repair, Valve replacement, Mitral valve, Aortic valve, Tricuspid valve

A patient with advanced rheumatic heart valve disease underwent aortic and mitral valve replacement with tricuspid ring annuloplasty. There was an anomalous left circumflex coronary artery (LCCA) arising from the right coronary artery (RCA) running along the anterior surface of an enlarged right ventricle (RV). During the immediate postoperative course, signs of inferior and lateral myocardial ischemia developed. An emergent coronary angiography revealed LCCA entrapment. An additional suture placed in the RV outflow tract used to optimize exposition of the aortic root during the aortotomy was determined to be the origin of the coronary entrapment. No similar case of LCCA occlusion has previously been reported. This is a description of successful management of this complication.

We report on the case of spontaneous rupture of an On-X-pure pyrolytic carbon mechanical valve prosthesis implanted seven years earlier, in a mitral position, at our hospital. The patient was admitted with valvular dysfunction and acute pulmonary edema requiring emergency surgery (prosthesis replacement); the absence of a leaflet was confirmed intraoperatively. The patient presented severe respiratory failure, which prolonged the postoperative period. A CT scan showed that the migrated leaflet was located in the aortic bifurcation with no apparent arterial lesion. Four months later, once the patient had recovered, laparotomy and aortotomy were performed in order to retrieve the leaflet, which was found to have become included (neoendothelized) in the aortic wall without compromising the latter's integrity or obstructing the blood flow. A subsequent CT scan confirmed the persistence of the leaflet in its initial position. The literature review highlights two singular facts: 1) this is the second published case of the escape of a leaflet from an On-X prosthesis (the first patient died); 2) this is the first case in which a laparotomy was performed to retrieve the leaflet but finally a decision was made to leave it in situ. Seven months later, the patient remained asymptomatic.

Resumen Introduccion y objetivos El numero de pacientes ancianos con insuficiencia cardiaca terminal ha crecido espectacularmente. Considerando que el numero de trasplantes cardiacos se ha estancado, se requiere una alternativa terapeutica. Desde hace poco se estan aplicando como terapia de destino (TD) dispositivos de asistencia ventricular izquierda (DAVI). Asumiendo que los pacientes de mas edad tienen mayor riesgo quirurgico, es presumible que la cirugia menos invasiva (CMI) para el DAVI contribuya a mejorar los resultados operatorios en pacientes en TD. Metodos Se realizo un estudio prospectivo con un seguimiento de 2 anos de 46 pacientes en TD (edad mayor de 60 anos) consecutivos a los que se trato con DAVI (HVAD, HeartWare) en nuestra institucion entre 2011 y 2013. Se formaron 2 grupos segun el metodo quirurgico de implante: CMI (n = 20) o cirugia convencional (n = 26). Resultados A pesar de que no se hallaron diferencias estadisticas significativas respecto a la supervivencia a 2 anos, si se observo una tendencia a mayor supervivencia en el grupo CMI (el 85,0 frente al 69,2%; p = 0,302). Asimismo, los pacientes del grupo de CMI presentaron menor incidencia de hemorragias tras la cirugia (0 frente al 26,9%; p Conclusiones Los datos indican que los pacientes sometidos a CMI para implante de DAVI como TD muestran tras la cirugia menor incidencia de hemorragias, menor necesidad de apoyo con inotropicos y una tendencia a menor mortalidad que los pacientes operados de manera convencional.

The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients.We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26).There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P.05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P.05).Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.

Acute aortic dissection (AAD) is a life-threating condition considered one of the most catastrophic pathologies affecting the aorta and nowadays its management represents a clinical challenge. The most common presentation of AAD is chest and/or back pain. Factors such as age, male, gender, and aortic wall structural abnormalities are main risk factors implied in the development of aortic dissection.

Resumen Introduccion y objetivos El grupo de Trabajo de en Reparacion Valvular de la Sociedad Espanola de Cirugia Toracica y Cardiovascular presenta el quinto registro anual de actividad en cirugia reparadora de la valvulas mitral, aortica y tricuspide realizada en Espana en el ano 2015. Material y metodos La recogida de datos se realizo a traves de cuestionario on-line, de forma retrospectiva, voluntaria, anonima y no auditada. Se detallan parametros en cuanto al tipo de cirugia, etiologia, mortalidad y riesgo quirurgico, tanto en el grupo global con en pacientes electivos. Resultados Se obtuvieron datos de 31 centros, con 9.112 intervenciones reportadas. La cirugia mitral reparadora supone el 29,6% de las valvulas mitrales intervenidas, con una amplia diferencia relativa a la etiologia del proceso, asi como muy diferente perfil de riesgo. La tasa de cirugia reparadora aortica continua en ascenso respecto a la sustitucion valvular, aunque con gran variacion intergrupos. La cirugia valvular tricuspide es mayoritariamente reparadora con uso de anillos con un numero estable en el tiempo de reemplazos valvulares. Conclusiones La actividad reparadora mitral esta establecida en la mayoria de los grupos, siendo muy dependiente de etiologia. Se observa un incremento en la tasa de reparacion valvular aortica y permanece estabilizada la actividad sobre la valvula tricuspide.

ResumenObjetivosDurante los últimos años el número de pacientes de avanzada edad que presentan insuficiencia cardíaca congestiva se ha incrementado de manera dramática. En el contexto del estancamiento global del trasplante cardíaco nace la necesidad de una terapia definitiva alternativa para estos pacientes. Recientemente, los dispositivos de asistencia ventricular izquierda (DAVI) han experimentado un auge, sobrepasando incluso el número de pacientes trasplantados mundialmente. El desarrollo tecnológico de los nuevos dispositivos y el surgimiento de nuevas técnicas quirúrgicas derivados de la cirugía cardíaca mínimamente invasiva han formado parte de este desarrollo. El propósito del presente estudio fue revisar la primera serie de implantes de DAVI mínimamente invasivo en pacientes septuagenarios.MétodosEl diseño del ensayo clínico es monocéntrico prospectivo. Se incluyó a todos los pacientes mayores o iguales a 70 años que requirieron un implante de DAVI (HVAD, HeartWare Inc.) como terapia de destino durante los años 2013 y 2015 en la Medizinische Hochschule Hannover. El seguimiento concluyó luego de 2 años. Todos los pacientes fueron operados por una técnica mínimamente invasiva compuesta por una miniesternotomía en «J» y una toracotomía lateral izquierda.ResultadosUn total de 14 pacientes fueron incluidos (edad 71,8±1,5 años, 100% hombres, miocardiopatía isquémica 64,3%). El 50% de los casos correspondía a una reoperación, un 7,1% recibió soporte mecánico circulatorio previo. Todos los pacientes fueron operados utilizando circulación extracorpórea (CEC) (tiempo medio de CEC 51±8min). El tiempo promedio de permanencia en la Unidad de Cuidados Intensivos fue de 6,4±5,2 días. Eventos adversos en el transcurso postoperatorio temprano fueron: reintervención quirúrgica por sangrado 7,1%, falla ventricular derecha 14,3% y diálisis 14,3%. Los niveles de supervivencia fueron: 30 días: 85,7%, un año: 78,6%, y 2 años: 70,7%.ConclusionesNuestros resultados iniciales demuestran que el implante mínimamente invasivo de DAVI puede ser realizado de manera eficaz, segura y con buenos resultados en pacientes septuagenarios terapia de destino. Los bajos niveles de eventos adversos durante el seguimiento por 2 años demuestran que la terapia de destino puede ser realizada incluso en pacientes septuagenarios.AbstractObjectivesThe number of elderly patients suffering from congestive heart failure has increased dramatically in recent years. In the context of global stagnation of heart transplantation, comes the need for an alternative definitive therapy for these patients. Recently left ventricular assist devices (LVAD) have increased significantly, surpassing even the number of transplants worldwide. The technological development of new devices and the emergence of new surgical techniques arising from minimally invasive cardiac surgery have been part of this development. The purpose of this study was to review the first series of minimally invasive LVAD implants in septuagenarian patients.MethodsA prospective single-centre clinical trial was conducted on all patients greater than or equal to 70 years that required an LVAD implant (HVAD, HeartWare Inc.) as destination therapy for the years 2013 to 2015 in the Medizinische Hochschule Clinic in Hannover. The monitoring ended after two years. All patients were operated by a minimally invasive technique consisting of a “J” mini-sternotomy and a left lateral thoracotomy.ResultsA total of 14 patients were included (age 71.8 ± 1.5 years, all (100%) males, and 64.3% with ischaemic heart disease). It was a second operation for 50% of the cases, and 7.1% received a prior mechanical circulatory assist device (MCAD). All patients were operated on using extracorporeal circulation (ECC) for a mean time of 51 ± 8 min). The mean length of stay in ICU was 6.4 ± 5.2 days. Adverse events during the early post-operative period included, surgical re-intervention due to bleeding (7.1%), right ventricular failure (14.3%), and dialysis (14.3%). Survival rates were: 30 days: 85.7% 1 year: 78.6% 2 years: 70.7%.ConclusionsThe initial results show that minimally invasive implantation of LVAD can be performed effectively, safely, and with good results in septuagenarian patients as destination therapy. There were low levels of adverse events during a two year follow-up, showing that destination therapy can be performed even in patients in their seventies.

Herein we present the case of an 82 year-old patient undergoing cardiac surgery for mitral valve replacement. Fifteen years earlier, the patient had undergone surgery to replace his aortic valve, so that it was now a cardiac reoperation. Through sternotomy, and release of pericardial adherences, there was an accidental opening of a small portion of the peritoneum, proceeding to repair with simple suture. Postoperatively, the presence of pneumoperitoneum alarmed about the possibility of an intra-abdominal complication but it was subsequently discarded with recent surgical process. Through this article we review what the pneumoperitoneum consist, its causes and management, as well as highlighting possible etiologies sometimes not considered as a recent cardiac surgery, simply because the patient in found in different contexts and we do not think about those possibilities.

A patient was submitted to mitral valve replacement and tricuspid ring annuloplasty. During immediate postoperative course, signs of inferior myocardial ischemia appeared. Acute entrapment of the right coronary artery due to tricuspid ring sutures was confirmed by coronary angiography. The patient was reoperated and a right coronary bypass graft was successfully performed. Tricuspid procedures have shown to be effective and secure with a low rate of complication. Few cases of right coronary artery occlusion have been described and the majority not treated. Exceptional cases of right coronary occlusion related to tricuspid ring annuloplasty have been reported with a favorable outcome, as the case described herein.

Resumen Los puntos de Campbell de Morgan, o angiomas seniles, son la forma mas frecuente de todos los tipos de angiomas que existen. Tambien denominados puntos rubi, hemangiomas cereza o cherry angiomas, son un motivo de consulta altamente frecuente en la practica clinica. De origen vascular, consisten en unas pequenas lesiones rojizas puntiformes cutaneas de pequeno tamano y naturaleza benigna. De aparicion espontanea predominantemente, existe un cierto caracter hereditario en su aparicion. Su tratamiento es simple y efectivo, aunque requiere tecnicas dermatologicas especificas para lograr su resolucion.

Dilatation of the ascending aorta (AA) is a common finding in patients with aortic valve disease. The clinical practice guidelines recommend replacing the AA whenever the diameter exceeds 45 mm. However, no consensus has been reached regarding the approach when the aorta is only moderately dilated. Although the risk in aorta replacement is generally low, it may be higher when associated with other complex surgical procedures or it is carried out in elderly patients or patients with significant comorbidity. This would justify the use of alternative surgical techniques, which reduce surgical risk and guarantee a durable correction of the aortic pathology. Conservative treatment of aneurysms of the AA via wrapping with different synthetic materials has been implemented for many years. The most commonly used technical variant is wrapping the dilated aorta with a vascular prosthesis with a predetermined diameter. When this technique is adequately applied, it immediately reduces the diameter of the AA and, to a lesser degree, the diameter of the aortic root and arch, while at the same time it reinforces the weak aortic wall. These effects lead to a drop-in wall shear stress and in the risk of aortic dissection and rupture, and persist over time. Although the low elasticity of the external support causes significant changes in the histologic structure of the aortic wall, mainly atrophy and alterations typical of a foreign body-induced reaction, this does not seem to involve a higher risk of complications. In some selected patients, this technique may be used in cases other than post-stenotic aortopathy, and also in aortas with a larger diameter.

A 52-year-old male patient, who underwent mitral replacement with a mechanical prosthesis as a child, sustained a cardiac arrest which was successfully resuscitated. Further investigation showed prosthesis malfunction with significant regurgitation in the context of multi-organ failure. In such a life-threatening condition, veno-arterial extracorporeal membrane oxygenation was considered as a rescue procedure to achieve optimisation of clinical status to allow definitive surgical treatment. An unusual complete fracture of the prosthesis was subsequently identified as the cause of acute dysfunction. Keywords: VA-ECMO, Mitral, Prosthesis, Dysfunction, Cardiogenic shock

Background The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II has been recently introduced to improve mortality prediction in cardiac surgery. We compare the predictive ability of the new EuroSCORE II with that of the original logistic EuroSCORE and we made an evaluation of a sample of our population submitted to major cardiac surgery in the context of a Mediterranean country. Materials and Methods Predicted and observed mortality were recorded in 1,200 consecutive patients undergoing major cardiac surgery at our institution with both logistic EuroSCORE and EuroSCORE II. Patients were grouped according to type of surgery: isolated valvular ( n = 538), isolated coronary ( n = 322), combined ( n = 192), and miscellaneous ( n = 148). Predictive capacity of both scales was compared for overall population and for each group in terms of calibration and discrimination using the observed by expected mortality rate, Hosmer–Lemeshow test, and C-statistic. Results Overall mortality was 6.8%, whereas that predicted by logistic EuroSCORE and EuroSCORE II was 9.7 and 3.7%, respectively. Mortality in our population was higher than mortality expected according to the original EuroSCORE II database. For all groups included in our population, logistic EuroSCORE overestimated mortality and EuroSCORE II underestimated the outcome even more. However, EuroSCORE II showed better calibration than logistic EuroSCORE for overall, valvular, and combined surgery. In contrast, logistic EuroSCORE demonstrated better calibration for coronary surgery. Discrimination capacity was good for both risk scores, but it was superior for logistic EuroSCORE than for EuroSCORE II in all considered subgroups unless combined surgery. Conclusion Mortality in our population was higher than the mortality that would have been expected by the new EuroSCORE II analysis. Although EuroSCORE II has good calibration and discrimination capacity, both are worse than those demonstrated by logistic EuroSCORE. Forthcoming evaluations are necessary when the new model will be widely used.

La disfuncion de la valvula tricuspide (VT) es frecuente en los pacientes con enfermedad de otras valvulas y otras afecciones cardiacas. La insuficiencia tricuspidea (IT) es habitual entre los pacientes con valvulopatias izquierdas, especialmente cuando hay hipertension pulmonar; mas de un 30% de los candidatos a cirugia mitral tienen IT moderada o grave. En la mayoria de los casos se trata de un hecho funcional, consecuencia del remodelado del ventriculo derecho (VD). Mas raramente la propia VT resulta afectada por diferentes procesos que alteran su morfologia y comprometen su funcion. A pesar de que se tolera bien durante anos, la IT tiene evidente repercusion clinica; en pacientes con valvulopatias izquierdas, la IT moderada o grave reduce la supervivencia, limita la capacidad de ejercicio y condiciona peor clase funcional. A pesar de la elevada prevalencia de esta afeccion valvular, la VT ha merecido poca atencion en la literatura medica en nuestro pais. En el articulo publicado en REVISTA ESPANOLA DE CARDIOLOGIA, RodriguezCapitan et al presentan los resultados de mas de una decada de tratamiento de esta valvulopatia. Los autores analizan la epidemiologia y los resultados clinicos y funcionales de la cirugia de la IT grave relacionandolos con el tipo de procedimiento quirurgico practicado.

Internal mammary artery (IMA) and radial artery (RA) are the 2 main arterial conduits used in coronary artery bypass grafting (CABG). The aim of this study was to analyze in vitro the vasoreactive properties in both vessels and to investigate the effects of pravastatin incubation on vascular function. IMA and RA rings obtained from patients undergoing CABG were studied in organ baths. We examined the contractile responses to phenylephrine and U46619 and the relaxation to acetylcholine (ACh) and sodium nitroprusside. In another series of experiments, the vascular reactivity and the superoxide anion production were studied after incubation with pravastatin. The effect of mevalonic acid on such responses was also assessed. Our results show that RA significantly evoked greater tension in response to vasoconstrictor agents and higher relaxation to ACh than IMA. In contrast, relaxation induced by sodium nitroprusside was not significantly different. Incubation with pravastatin reduced the contractile response to U46619 and improved the endothelium-dependent relaxation to ACh in both arteries. Whereas the effect of pravastatin on response to U46619 was completely abolished by coincubation with mevalonic acid, only a partial inhibition on ACh relaxation was observed. In conclusion, in vitro incubation with pravastatin enhanced endothelial function in IMA and RA. This suggests that postoperative (may include intraoperative) administration of statins could improve the endothelial function of arterial grafts in patients undergoing CABG.

ResuménLa cirugía cardiovascular (CCV) es una especialidad de la medicina que se ocupa de los trastornos y enfermedades del sistema cardiocirculatorio que requieren una terapéutica quirúrgica. El presente documento está dedicado a los aspectos definitorios de la especialidad y a los organizativos de la actividad profesional incluyendo la acreditación y homologación. se define asimismo la sociedad profesional, la sociedad Española de Cirugía Torácica-Cardiovascular (SECTCV) en sus aspectos relacionados con la profesión, con la formación continuada así como la comunicación en el seno y fuera de la misma al igual que la necesidad y existencia de la fundación Cirugía y Corazón (FCC). También se focaliza en la actividad en CCV y los requerimientos estructurales mínimos para llevar a cabo el componente de intervención de la CCV. Por último, se confirman las recomendaciones para su práctica y se presentan los requerimientos de calidad y del programa docente de la especialidad. Este documento de la junta directiva de la SECTCV y asesores externos de la misma confirma la realidad de la especialidad y sus contenidos como señas de identidad inalienables.AbstractCardiovascular surgery (CVS) is a branch of medicine related to the diseases of the cardio-circulatory system requiring surgical treatment. this current document is dedicated to all aspects defining the specialty and the organization of the professional activity including accreditation and credentialing. The professional society, the spanish society of thoracic-Cardiovascular surgery (SECTCV) is also defined and insights on its professional, continuing education and communication given as well as the background for the Cirugía y Corazón foundation. Attention is also given to the activity in CVS and the core requirements for practice. The recommendations for practice and quality requirements and the postgraduate teaching programme are also presented. This document of the Council of the SECTCV and its external advisors confirms the reality of the specialty and its contents as sound signs of identity.

Objective: Clinical outcomes of patients undergoing aortic valve replacement may be influenced by the presence of residual gradients and patient—prosthesis mismatch. The aim of this study was to compare hemodynamic performance and clinical outcomes at 5 years after prospectively randomized porcine versus bovine aortic valve replacement. We also aimed to determine the effects of valve hemodynamics on left ventricular (LV) mass regression.Methods: A total of 108 patients undergoing aortic valve replacement were randomized to receive either theMedtronicMosaic(MM)porcine(n = 54)ortheEdwardsPerimountMagna(EPM)bovinepericardialprosthesis(n = 54).Clinicaloutcomes,mean gradients,effectiveorificeareaandLVmassregressionwereevaluatedat1and5 yearsaftersurgery. Follow-upechocardiogramswereperformed on 106 (98%) and 87 (92%) patients, respectively. Results: Preoperative characteristics were similar between groups. Mean aortic annulus diameter and mean implant size were comparable in both groups. At 1 and 5 years, mean transprosthetic gradients were lower in the EPM group: EPM 10.3 3.4 mmHg versus MM 16.3 7.6 mmHg (p < 0.0001) and EPM 9.6 3.5 mmHg versus MM 16.8 8.7 mmHg (p < 0.0001), respectively. Similarly, indexed effective orifice areas (IEOA) at 1 and 5 years were significantly greater in the EPM group: EPM 1.10 0.22 cm 2 m 2 versus MM 0.96 0.22 cm 2 m 2 (p < 0.004) and EPM 1.02 0.25 cm 2 m 2 versus MM 0.76 0.19 cm 2 m 2 (p < 0.0001), respectively. At 5 years, the incidence of patient—prosthesis mismatch (IEOA 0.85 cm 2 m 2 ) was significantly lower in the EPM group: EPM 22.9% vs MM 73.9% (p < 0.0001). Such differences were similar when analysis was stratified by surgically measured annular size and implant valve size. During thefirst year after surgery, both groups demonstrated similar regression of LV mass index(MM26.3 43 g m 2 vs EPM30.1 36 g m 2 ;p = 0.8); however, at 5 years, regression of LV mass index was significantly greater in the EPM group: (EPM 47.4 35 g m 2 vs 4.4 36 g m 2 ; p < 0.0001). Five-year survival was 79.6 4.1% in the MM group and 94.4 2.2% in the EPM group (p = 0.03). Conclusions: At 5 years, the EPM valve was significantly superior to the MM prosthesis with regard to hemodynamic performance, incidence of patient—prosthesis mismatch and regression of LV mass index. The hemodynamic superiority of the EPM prostheses in comparison to MM-prostheses demonstrated at 1 year, increased significantly over time. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Introduccion y objetivos La edad de los pacientes sometidos a cirugia cardiaca se ha incrementado en los ultimos anos. Pretendemos conocer los resultados a medio plazo de la cirugia en octogenarios, comparandolos con los de otros ancianos de menos edad. Metodos Analizamos la mortalidad precoz, la incidencia de complicaciones postoperatorias, la supervivencia a medio plazo y los factores asociados a estas de 589 ancianos consecutivos sometidos a cirugia: 140 octogenarios entre 80 y 87 anos (grupo I) y 449 entre 75 y 70 anos (grupo II). Resultados Ambos grupos fueron homogeneos. No hubo diferencias en la mortalidad (I, 10%; II, 10,9%) e incidencia de complicaciones postoperatorias (I, 22%; II, 30%). La cirugia de emergencia, la combinada y la hipertension pulmonar se asociaron de manera independiente a la mortalidad y al desarrollo de complicaciones mayores. La supervivencia a 5 anos fue del 79% (I) y el 65% (II) (p = 0,832) y la supervivencia libre de evento cardiaco fue del 75% (I) y el 64% (II) respectivamente (p = 0,959). El 97% de los pacientes de ambos grupos se encontraban en clase funcional I-II. El EuroSCORE aditivo y la fibrilacion auricular preoperatoria se asociaron a una mayor mortalidad en el seguimiento. Ser octogenario no fue predictor (hazard ratio = 0,78; intervalo de confianza del 95%, 0,51-1,21; p = 0,373). Conclusiones La cirugia cardiaca en octogenarios seleccionados ofrece resultados similares a los de otros ancianos mas jovenes, con una buena supervivencia y calidad de vida a medio plazo. La hipertension pulmonar, la cirugia de emergencia y la combinada conllevan un riesgo elevado en estos pacientes.

Introduction and objectives. The age of patients undergoing cardiac surgery has increased in recent years. Our aims were to investigate the medium-term clinical outcomes of surgery in octogenarians and to compare them with outcomes in other elderly individuals of a less advanced age. Methods. We investigated early mortality, the incidence of postoperative complications, medium-term survival and factors associated with these parameters in 589 consecutive elderly patients undergoing surgery: 140 were octogenarians aged 80-87 years (group I) while 449 were aged between 75 and 79 years (group II). Results. The 2 groups were similar. There was no difference in mortality (10.0% in group I vs 10.9% in group II) or in the incidence of postoperative complications (22% in group I vs 30% in group II). Emergency surgery, combined surgery, and pulmonary hypertension were all independent predictors of mortality and of major postoperative complications. The 5-year survival rate was 79% in group I and 65% in group II (P=.832) and the cardiac event-free survival rate was 75% in group I and 64% in group II (P=.959). Overall, 97% of patients in both groups were in functional class I or II. The additive EuroSCORE and preoperative atrial fibrillation were both associated with increased mortality during follow-up. Being an octogenarian was not a predictor (hazard ratio=0.78; 95% confidence interval, 0.51-1.21; P=.373). Conclusions. In selected octogenarians, cardiac surgery gives similar results to those obtained in other elderly individuals of a less advanced age. The mediumterm survival rate and quality of life are good. Pulmonary hypertension, emergency surgery and combined surgery all increased risk in these patients.

A patient who underwent previous implantation of a mitral valve replacement with a Bjork-Shiley Delrin (BSD) mitral valve prosthesis during infancy was admitted to our institution 43 years later after an episode of syncope and cardiac arrest. Under extreme hemodynamic instability, a mitral valve prosthetic dysfunction causing massive mitral regurgitation was identified. The patient underwent an emergent cardiac operation, and a complete disc fracture with partial disc migration was found. Exceptional cases of mechanical prosthetic heart valve fracture exist. We report the first case of complete transversal disc rupture of a BSD mitral valve prosthesis after the longest period of implantation ever reported in that position.

A 56-year-old female patient was transferred due to the presence of a left supraclavicular pulsatile mass. Further work-up was performed to confirm diagnosis. Angiography and computed tomography were also performed. The anatomy of the thoracic aorta suggested an unknown and untreated aortic coarctation. A second aortic narrowing was identified at the aortic arch, a result of elongation of the aorta. Endovascular approach was not possible, due to complexity of the aortic anatomy, and tortuosity. Open surgical repair was successfully performed. A primary coarctation-related isthmus aneurysm is an exceptional finding in adults, and is a life-threatening condition when diagnosis is delayed. Management and treatment are controversial and challenging.

Recent studies have suggested that endogenous vasopressin (AVP) acts as a spasmogen during coronary artery bypass grafting (CABG). Given that AVP could induce vasospasm in the grafted vessel, we assessed the release of this peptide during and after CABG, and explored ways of counteracting its contractile effect on the internal mammary artery (IMA).Plasma levels of AVP were determined by radioimmunoassay in 16 patients before, during and after CABG. Using isometric force recording techniques, we also investigated the mechanisms involved in the contractile effect of AVP in ring preparations of IMA specimens taken from 95 patients.Plasma AVP levels peaked after the start of cardiopulmonary bypass (CPB) and correlated well with serum osmolality (Pearson's r=0.9490; P0.0001; n=16). An inverse correlation was observed between plasma AVP levels recorded at this stage and the maximal contraction induced in vitro by AVP in vascular rings from the same patients (Pearson's r=-0.6968; P0.01; n=16). No change in the AVP response was produced by endothelium removal, exposure to the NO precursor (3 x 10(-4)M L-arginine), inhibition of nitric oxide (NO) synthase (3 x 10(-5) M L-NAME) or soluble guanylate cyclase (3 x 10(-6) M 1H-[1,2,4]oxadiazol [4,3,-alpha]quinoxalin-1-one (ODQ)), removal of the superoxide anion (100 U/ml superoxide dismutase (SOD) plus 1200 U/ml catalase) or hydroxyl radical (10(-4) M deferoxamine), or specific alpha1 - (10(-6) M prazosin) or endothelin (10(-5) M bosentan) receptor antagonism. In contrast, adenylate cyclase activation (3 x 10(-8) M forskolin) reduced the contractile response to AVP, while prostanoid synthesis (3 x 10(-6) M indomethacin) inhibition and blockade of Ca2+ -activated potassium channels (KCa) (10(-3) M tetraethylammonium (TEA)) enhanced AVP contraction. Age, gender and smoking also modified the AVP response.Our findings suggest a role for AVP as a modulator of vascular tone in human IMA. The effect of AVP is dependent on prostanoids and Ca2+ -activated K+ channels, so its dysfunction in pathophysiological cardiovascular processes could mean that AVP, among other factors, produces vasospasm in IMA grafts.