Asunto(s)
Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Prolapso de la Válvula Mitral , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/efectos adversos , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/cirugía , Prolapso , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Resultado del TratamientoRESUMEN
There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Válvula Mitral , Inteligencia Artificial , Cateterismo Cardíaco , Humanos , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Valor Predictivo de las PruebasRESUMEN
Primary or secondary tricuspid regurgitation (TR) represents an important health care burden and challenge which has often been neglected or undertreated in the past. The expansion and reinforcement of the indications for tricuspid valve (TV) intervention in the 2017 editions of the guidelines as well as the introduction of transcatheter tricuspid valve intervention (TTVI) has considerably increased the attention of the community on the TV and the volume of TV interventions in the past years. Depending on the anatomic target, TTVI can be categorized as the following: 1) direct or indirect tricuspid restrictive annuloplasty; 2) direct (edge-to-edge repair) or indirect (coaptation device) restoration of leaflet coaptation; 3) heterotopic tricuspid valve implantation; and 4) transcatheter tricuspid valve replacement. Multimodality imaging has crucial role for the following: 1) patient selection for TTVI and procedure planning; 2) guiding and monitoring the procedure; and 3) assessing and following over time the results of the procedure. The key points for pre-procedural imaging are: 1) accurate quantitation of TR severity; 2) proper identification of the mechanism(s) responsible for the TR; and 3) quantitation of RV dysfunction and pulmonary arterial hypertension. This imaging work-up is essential to select the right type of intervention for the right patient and TV. Transesophageal echocardiography and fluoroscopy imaging is also key for guiding the TTVI procedures and fusion between these 2 modalities may further enhance the quality of procedure guiding.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Válvula Tricúspide , Humanos , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
OBJECTIVE: The preoperative ejection fraction (EF) and left ventricular (LV) end-systolic dimension are known predictors of postoperative LV dysfunction after mitral valve repair. We investigated the effect of a preoperative history of atrial fibrillation and moderate pulmonary hypertension (defined as pulmonary artery systolic pressure >50 mm Hg) on early postoperative LV dysfunction. METHODS: From 2003 to 2010, 632 patients who had undergone successful mitral valve repair surgery for degenerative disease were included in the present study. The preoperative and postoperative echocardiographic data and postoperative outcomes were collected retrospectively. We analyzed the demographic, hemodynamic, and echocardiographic parameters to assess the predictors of early postoperative LV dysfunction, defined as an LVEF <50%. RESULTS: The mean age of the cohort was 57 ± 13 years. All patients had less than mild mitral regurgitation on postoperative echocardiography. After mitral valve repair, a significant decrease in the LVEF (60% ± 8% to 54% ± 9%), LV end-systolic diameter (36 ± 7 mm to 33 ± 7 mm), and LV end-diastolic dimension (56 ± 8 mm to 48 ± 7 mm) was observed at early postoperative echocardiography (P < .001). On multivariate regression analysis, preoperative atrial fibrillation, pulmonary hypertension, and LV end-systolic dimension were independent predictors of the postoperative LVEF (P = .035 and P < .001, respectively). Preoperative atrial fibrillation (odds ratio, 1.97; 95% confidence interval, 1.28-3.02; P = .002) and pulmonary artery systolic pressure >50 mm Hg (odds ratio, 1.82; 95% confidence interval, 1.11-2.97; P = .017) increased the risk of postoperative LV dysfunction by almost twofold. CONCLUSIONS: In addition to the established predictors of postoperative LV dysfunction, the presence of preoperative pulmonary hypertension and a history of atrial fibrillation in patients undergoing mitral valve repair surgery increased the risk of early postoperative LV dysfunction by almost twofold.
Asunto(s)
Fibrilación Atrial/complicaciones , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Hipertensión Pulmonar/complicaciones , Válvula Mitral/cirugía , Procedimientos de Cirugía Plástica/efectos adversos , Disfunción Ventricular Izquierda/etiología , Función Ventricular Izquierda , Adulto , Anciano , Presión Arterial , Fibrilación Atrial/diagnóstico , Distribución de Chi-Cuadrado , Femenino , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/fisiopatología , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/fisiopatología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Válvula Mitral/fisiopatología , Análisis Multivariante , Oportunidad Relativa , Arteria Pulmonar/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
Median sternotomy has unquestionably evolved over recent decades. Modern sternotomy involves a 7-8 cm lower midline skin incision, tunneling of the subcutaneous tissues with subsequent creation of myocutaneous flaps, full sternotomy, and standard cardiopulmonary bypass techniques with central cannulation. In experienced centers, modern sternotomy may achieve all the goals of minimally invasive surgery, including excellent cosmesis, excellent postoperative pain control, low rates of bleeding and transfusion (our re-exploration rate for bleeding is <1%), and the ability to perform any reconstructive technique that would be used in a standard sternotomy, with very high repair rates (our most recent series documented a repair rate exceeding 99% in an all-comers population of degenerative disease regardless of complexity).
Asunto(s)
Cardiomiopatías/complicaciones , Cardiomiopatías/diagnóstico , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Ecocardiografía Transesofágica , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Músculos Papilares , Enfermedad Aguda , Anciano , Angina de Pecho/etiología , Bioprótesis , Angiografía Coronaria , Puente de Arteria Coronaria , Oclusión Coronaria/complicaciones , Stents Liberadores de Fármacos , Disnea/etiología , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Rotura Espontánea , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Quadricuspid aortic valve (QAV) is a rare congenital anomaly of the aortic valve. We describe transplanting a donor heart with a QAV with successful mid-term outcome.
Asunto(s)
Válvula Aórtica/anomalías , Cardiopatías/cirugía , Trasplante de Corazón/métodos , Donantes de Tejidos , Anciano , Válvula Aórtica/diagnóstico por imagen , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
OBJECTIVES: Recently, the initial therapy for refractory cardiogenic shock has largely been based on use of short-term mechanical devices with later conversion to durable options. The premise is that such patients cannot tolerate cardiopulmonary bypass and the extended surgery needed for implantable left ventricular assist device (LVAD) placement. We have adopted an alternative strategy to implant long-term LVADs as the initial device therapy in such patients. METHODS: Over a 3 year period, we used implantable LVADs (Jarvik 2000, one; Ventrassist, one; Heartmate XVE, two; and Heartmate II, nine) in 13 patients (11 men and two women; mean age 54 years) with postmyocardial infarction shock without prior use of a short-term LVAD. The median time interval from myocardial infarction to LVAD implantation was 3.5 days. Eight patients were on a ventilator, two had unknown neurological status and four had suffered cardiac arrest in the preceding 24 h. Two had prior coronary artery bypass graft. Nine had received dual antiplatelet therapy postmyocardial infarction. The mean laboratory value of creatinine was 1.5 mg/dl, alanine aminotransferase 748 U/l, international normalized ratio 1.5 and lactate 3.2 mmol/l. One procedure was carried out off pump; for the others, the mean cardiopulmonary bypass time was 72 min. Right ventricular assist devices were used in two cases and were later explanted. RESULTS: One patient died of progressive multiorgan failure. All others survived to hospital discharge. There were no re-explorations for bleeding or major infectious complications; two patients had perioperative stroke. The median duration of mechanical ventilation, intensive care unit stay and hospital stay was 3, 9 and 18 days, respectively. At 1 year, of the 12 survivors, eight have since had heart transplant, one patient underwent device explant, two remained alive on support and one died 7 months post-LVAD. CONCLUSIONS: Our data challenge the notion that patients in refractory cardiogenic shock are too ill to tolerate immediate placement of implantable LVADs. Despite the surgical challenges, a one-stop implantable LVAD approach for cardiogenic shock is feasible and may offer unique advantages over the bridge-to-bridge approach because it avoids the incremental costs, hospitalization and morbidity associated with repeated interventions.
Asunto(s)
Corazón Auxiliar , Infarto del Miocardio/cirugía , Choque Cardiogénico/cirugía , Procedimientos Quirúrgicos Cardíacos/instrumentación , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Implantación de Prótesis/instrumentación , Resultado del TratamientoAsunto(s)
Cardiomiopatía Dilatada/cirugía , Trasplante de Corazón , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Obtención de Tejidos y Órganos , Adulto , Procedimientos Quirúrgicos Cardíacos , Contraindicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/prevención & control , Resultado del Tratamiento , Listas de EsperaRESUMEN
Although both heart transplantation and left ventricular assist device therapy have enjoyed clinical success in the treatment of patients with end-stage heart disease, newer left ventricular assist devices currently undergoing testing are likely to have a tremendous impact on the management of these patients. Smaller, more durable devices with improved safety profiles will allow for longer duration of therapy and make biventricular support more feasible, obviating the need for the total artificial heart. In this article we review the historical aspects of both forms of therapy and highlight the current use of left ventricular assist device therapy on patients awaiting heart transplantation.
Asunto(s)
Trasplante de Corazón/métodos , Ventrículos Cardíacos , Corazón Auxiliar , Trasplante de Corazón/historia , Trasplante de Corazón/instrumentación , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Inmunosupresores/uso terapéuticoRESUMEN
OBJECTIVE: To evaluate the effectiveness and outcomes of an intraoperative and postoperative algorithm for managing systolic anterior motion (SAM) after mitral valve repair (MVRr). METHODS: All consecutive patients who underwent MVRr for degenerative disease from January 2002 to June 2011 were included, with the data collected retrospectively. Patients who underwent MVRr for primary SAM were excluded from the study. Patients who developed SAM after the repair were systematically treated according to the algorithm. The intraoperative algorithm first involved medical management techniques, followed by surgical correction for significant SAM (mild or greater mitral regurgitation, left ventricular outflow tract gradient > 50 mm Hg). The postoperative algorithm focused on medical management and symptoms to guide the treatment decisions. RESULTS: The overall in-hospital incidence of SAM was 6.6% (52/785). In 41 patients, SAM was identified in the operating room, and in 11 patients, it was found postoperatively on the predischarge echocardiogram. Of the 41 patients with intraoperative SAM, 35 (85.4%) had resolution with medical management and 6 (14.6%) required surgical repeat repair while in the operating room. No patient required mitral valve replacement for persistent SAM. Postoperatively, 11 new cases were identified, and 7 cases of resolved intraoperative SAM recurred. These postoperative cases of SAM were managed according to the postoperative SAM algorithm. At last follow-up, 17 (94.4%) of 18 patients had resolution of SAM and 1 (5.6%) patient had mild SAM (less than mild mitral regurgitation, peak left ventricular outflow tract gradient < 50 mm Hg) and were asymptomatic. No patients with postoperative SAM required reoperation after their initial surgery. The median echocardiographic follow-up was 1.3 years. During follow-up, 1 early death (noncardiac) and 2 late deaths (1 noncardiac, 1 of unknown etiology) occurred. CONCLUSIONS: SAM is a relatively frequent complication after MVRr and can occur intraoperatively or postoperatively. A systematic approach addressing perioperative SAM after MVRr yields excellent mid-term results.
Asunto(s)
Algoritmos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Prolapso de la Válvula Mitral/terapia , Válvula Mitral/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/terapia , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/etiología , Prolapso de la Válvula Mitral/fisiopatología , Ciudad de Nueva York , Cuidados Posoperatorios , Reoperación , Estudios Retrospectivos , Sístole , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/terapiaRESUMEN
Controversy exists regarding the indication and method of repair of functional tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. Whereas the American College of Cardiology/American Heart Association guidelines recommend tricuspid repair in the setting of severe TR, tricuspid repair is advised for less than severe TR in the setting of annular dilation or pulmonary hypertension. Although multiple repair strategies exist, the use of a ring annuloplasty (semirigid remodeling rings vs flexible bands) is the preferred method of therapy to avoid short- and long-term recurrence of TR. The new Tri-Ad Adams annuloplasty ring combines elements of semirigid and flexible bands that will not only allow for annular remodeling in the region of the right ventricular free wall but also potentially reduce injury to the conduction system with its flexible and "open" ends. In this article, we discuss the rational for an aggressive approach to functional tricuspid regurgitation, and show our initial clinical experience with the Tri-Ad Adams annuloplasty ring.
Asunto(s)
Anuloplastia de la Válvula Cardíaca/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Humanos , Selección de Paciente , Guías de Práctica Clínica como Asunto , Diseño de Prótesis , Recurrencia , Resultado del TratamientoRESUMEN
Carcinoid tumors are neuroendocrine tumors with an unpredictable clinical behavior. In the setting of hepatic metastases, the release of bioactive amines from the tumor into the systemic circulation results in carcinoid syndrome: a constellation of clinical symptoms, among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most frequent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe endocardial fibrotic reaction that leads to progressive valve thickening and retraction. Imaging studies commonly reveal severe right-sided valve disease, with fixed leaflets or cusps in a semiopen position. The replacement of the right-sided valves, including the patch enlargement of the right ventricular outflow tract, is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend toward improved surgical outcomes has triggered a more liberal referral for valve replacement during the past decade.
Asunto(s)
Cardiopatía Carcinoide/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Válvula Pulmonar/cirugía , Válvula Tricúspide/cirugía , Bioprótesis , Cardiopatía Carcinoide/patología , Fibrosis , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Humanos , Diseño de Prótesis , Válvula Pulmonar/patología , Resultado del Tratamiento , Válvula Tricúspide/patologíaRESUMEN
Severe pulmonary embolism often leads to right ventricular failure after surgical embolectomy secondary to ischaemia reperfusion injury and acute lung injury (ALI). Acute right ventricular dysfunction is traditionally treated with inotropes and vasopressors to maintain cardiac output and coronary perfusion as well as selective pulmonary vasodilators to provide right ventricular afterload reduction. We report the first case of utilisation of methylene (MB) in a patient with acute right ventricular failure and vasoplegic shock after surgical pulmonary embolectomy.
Asunto(s)
Embolectomía , Inhibidores Enzimáticos/administración & dosificación , Azul de Metileno/administración & dosificación , Vasoplejía/tratamiento farmacológico , Disfunción Ventricular Derecha/tratamiento farmacológico , Anciano , Quimioterapia Adyuvante/métodos , Humanos , Masculino , Embolia Pulmonar/cirugía , Vasoplejía/etiología , Disfunción Ventricular Derecha/etiologíaAsunto(s)
Disección Aórtica/diagnóstico por imagen , Rotura Cardíaca/diagnóstico por imagen , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Prolapso de la Válvula Mitral/diagnóstico por imagen , Disección Aórtica/etiología , Atrios Cardíacos/diagnóstico por imagen , Rotura Cardíaca/etiología , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Prolapso de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , UltrasonografíaRESUMEN
The efficacy of vein grafts used in coronary and peripheral artery bypass is limited by excessive hyperplasia and fibrosis that occur early after engraftment. In the present study, we sought to determine whether low-dose spironolactone alleviates maladaptive vein graft arterialization and alters intimal reaction to coronary artery stenting. Yorkshire pigs were randomized to treatment with oral spironolactone 25 mg daily or placebo. All animals underwent right carotid artery interposition grafting using a segment of external jugular vein and, 5 days later, underwent angiography of carotid and coronary arteries. At that time, a bare metal stent was placed in the left anterior descending artery and balloon angioplasty was performed on the circumflex coronary artery. Repeat carotid and coronary angiograms were performed before euthanasia and graft excision at 30 days. Angiography revealed that venous grafts of spironolactone-treated animals had lumen diameters twice the size of controls at 5 days, a finding that persisted at 30 days. However, neointima and total vessel wall areas also were 2- to 3-fold greater in spironolactone-treated animals, and there were no differences in vessel wall layer thicknesses or collagen and elastin densities. In the coronary circulation, there were no differences between treatment groups in any vessel wall parameters in either stented or unstented vessels. Taken together, these observations suggest that low-dose spironolactone may exert a novel protective effect on remodeling in venous arterial grafts that does not depend on the reduction of hyperplastic changes but may involve dilatation of the vessel wall.
Asunto(s)
Angioplastia Coronaria con Balón , Arterias Carótidas/cirugía , Venas Yugulares/trasplante , Espironolactona/uso terapéutico , Bloqueadores del Receptor Tipo 1 de Angiotensina II/farmacología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Animales , Arterias Carótidas/diagnóstico por imagen , Angiografía Coronaria , Vasos Coronarios/patología , Stents , PorcinosRESUMEN
BACKGROUND: Patients aged 90 years and older represent a rapidly growing subset of the population, many of whom are functionally limited by cardiovascular disease. Clinical decision making about cardiac surgical intervention in nonagenarians is hindered by a paucity of data examining survival outcomes in this population. METHODS: A consecutive series of nonagenarians who underwent cardiac operations between 1995 and 2004 were retrospectively reviewed. Data collection included baseline preoperative clinical status, intraoperative characteristics, and perioperative course. Area under the Kaplan-Meier survival estimate method was used to calculate mean survival. RESULTS: Cardiac surgical procedures were done in 49 patients (51% male); their mean age was 91.9 years (range, 90 to 97 years). Operative mortality was 8% (n = 4). Multivariate Cox proportional hazards models found preoperative chronic renal insufficiency (hazard ratio [HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p = 0.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00; p = 0.033) were independently associated with death. Overall mean survival was 5.1 +/- 0.5 years (median, 5.2 years). Quality of life outcomes were similar to that of two related norm-based populations based on age and disease process. CONCLUSIONS: Cardiac surgical procedures can be performed safely and with therapeutic benefit in carefully selected nonagenarians. We consider physiologic indicators, social factors, and patient preferences to be the main determinants in the patient selection process. Our results support the need for more proactive intervention in symptomatic nonagenarian patients as it relates to earlier consideration of elective, rather than emergency cardiac operations.