RESUMEN
OBJECTIVE: Patients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. METHODS: From 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. RESULTS: The prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). CONCLUSIONS: Preoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/epidemiología , Complicaciones Posoperatorias/epidemiología , Anciano , Aorta/cirugía , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tratamientos Conservadores del Órgano/efectos adversos , Tratamientos Conservadores del Órgano/mortalidad , Reoperación/mortalidad , Estudios RetrospectivosRESUMEN
The development of aortic insufficiency (AI) is known to be associated with prolonged left ventricular assist device (LVAD) support, but its overall significance with regards to long-term outcomes is unclear. This uncertainty translates to a lack of consensus regarding the management of AI in this patient population-an increasingly pertinent question as more patients are placed on LVAD support as destination therapy. A retrospective review of a single, high-volume institution was performed to assess outcomes in patients who received a HeartMate II or HeartWare (LVAD) between 2008 and 2018. Patients were stratified by AI severity at 6 months, and those with LVAD support of less than 6 months were excluded. The primary endpoint was 2 year mortality, and secondary endpoints were right heart failure and functional exercise capacity. At 6 month follow-up 111, 92, and 18 patients had no (0), mild (1), and moderate (2) AI, respectively. Moderate AI was a significant predictor of 2 year mortality in a multivariable model (p = 0.024). Functional exercise capacity (measured by 6 minute walk test) and incidence of right heart failure at 1 year were not significantly different between groups (P = 0.1421; P = 0.2189). In conclusion, moderate AI at 6 months post-LVAD implant is associated with worse long-term mortality. More aggressive management strategies targeting AI development in long-term LVAD patients may be warranted.
Asunto(s)
Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia Cardíaca/mortalidad , Corazón Auxiliar/efectos adversos , Insuficiencia de la Válvula Aórtica/mortalidad , Femenino , Insuficiencia Cardíaca/terapia , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.
Asunto(s)
Insuficiencia de la Válvula Aórtica/etiología , Endocarditis Bacteriana/complicaciones , Enfermedad Aguda , Insuficiencia de la Válvula Aórtica/mortalidad , Ecocardiografía , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
La insuficiencia aórtica aguda (IAOA) por endocarditis infecciosa (EI) es grave y generalmente requiere tratamiento quirúrgico. Se compararon los pacientes con IAOA grave por EI e insuficiencia cardíaca (IC) en clase funcional I-II NYHA (G1) con los pacientes en clase funcional III-IV (G2) en relación a características clínicas, ecocardiográficas, microbiológicas y evolución hospitalaria y se evaluaron los predictores de mortalidad, en un centro de alta complejidad. Desde 06/92 a 07/16, de 439 pacientes con EI, 86 presentaron IAOA: (G1, 39: 45.4% y G2, 47: 54.7%). El G1 presentó mayor EI protésica (43.6% vs. 17.0%; p < 0.01). Los 47 casos G2 presentaban disnea vs. 12 (30.8%) G1 (p < 0.0001). No hubo diferencias en cuanto a las características clínicas, ecocardiográficas y microbiológicas. El tratamiento quirúrgico fue principalmente por extensión de la infección y/disfunción valvular en el G1 y por IC en el G2. La mortalidad hospitalaria fue del 15.4% vs. 27.7% (G1 y G2 respectivamente, p NS). Fueron predictores en el análisis multivariado: la infección intrahospitalaria (p 0.001), los hemocultivos negativos (p 0.004) y la presencia de IC clase funcional III-IV (p 0.039).Una quinta parte de los pacientes con EI presentaron IAOA. Aquellos con IC grave requirieron tratamiento quirúrgico de emergencia y con IC con clase funcional I-II requirieron cirugía por extensión de la infección y/o disfunción valvular. La mortalidad quirúrgica y hospitalaria continúan siendo elevadas en ambos grupos y fueron predictores de mortalidad hospitalaria: la infección intrahospitalaria, los hemocultivos negativos y la IC avanzada.
Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Insuficiencia de la Válvula Aórtica/etiología , Endocarditis Bacteriana/complicaciones , Insuficiencia de la Válvula Aórtica/mortalidad , Ecocardiografía , Enfermedad Aguda , Estudios Prospectivos , Mortalidad Hospitalaria , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidadRESUMEN
OBJECTIVES:: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS:: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS:: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION:: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.
Asunto(s)
Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Tempo Operativo , Tratamientos Conservadores del Órgano , Procedimientos de Cirugía Plástica/métodos , Reoperación , Adulto , Anciano , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/cirugía , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Reoperación/estadística & datos numéricos , Reimplantación/métodos , Reimplantación/mortalidad , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Tempo Operativo , Tratamientos Conservadores del Órgano , Procedimientos de Cirugía Plástica/métodos , Reoperación , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/cirugía , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Reoperación/estadística & datos numéricos , Reimplantación/métodos , Reimplantación/mortalidad , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Due to late complications associated with the use of conventional prosthetic heart valves, several centers have advocated aortic valve repair and/or valve sparing aortic root replacement for patients with aortic valve insufficiency, in order to enhance late survival and minimize adverse postoperative events. METHODS: From March/2012 thru March 2015, 37 patients consecutively underwent conservative operations of the aortic valve and/or aortic root. Mean age was 48±16 years and 81% were males. The aortic valve was bicuspid in 54% and tricuspid in the remaining. All were operated with the aid of intraoperative transesophageal echocardiography. Surgical techniques consisted of replacing the aortic root with a Dacron graft whenever it was dilated or aneurysmatic, using either the remodeling or the reimplantation technique, besides correcting leaflet prolapse when present. Patients were sequentially evaluated with clinical and echocardiographic studies and mean follow-up time was 16±5 months. RESULTS: Thirty-day mortality was 2.7%. In addition there were two late deaths, with late survival being 85% (CI 95% - 68%-95%) at two years. Two patients were reoperated due to primary structural valve failure. Freedom from reoperation or from primary structural valve failure was 90% (CI 95% - 66%-97%) and 91% (CI 95% - 69%-97%) at 2 years, respectively. During clinical follow-up up to 3 years, there were no cases of thromboembolism, hemorrhage or endocarditis. CONCLUSIONS: Although this represents an initial series, these data demonstrates that aortic valve repair and/or valve sparing aortic root surgery can be performed with satisfactory immediate and short-term results.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/anomalías , Enfermedades de las Válvulas Cardíacas/cirugía , Adulto , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Enfermedad de la Válvula Aórtica Bicúspide , Supervivencia sin Enfermedad , Ecocardiografía Transesofágica/métodos , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Análisis de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
Abstract Background: Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair. Objectives: To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure. Methods: This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure. Results: The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08). Conclusion: Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk.
Resumo Fundamento: Regurgitação ou escape paravalvar é uma complicação grave e incomum associada ao implante de prótese valvar. Estudos mostram incidência de 3% a 6% com repercussão hemodinâmica. Existem poucos estudos na literatura que comparam as abordagens cirúrgica e percutânea para sua correção. Objetivos: Comparar as abordagens cirúrgica e percutânea de correção da regurgitação paravalvar quanto a desfechos clínicos durante a internação e após 1 ano do procedimento. Métodos: Este é um estudo retrospectivo, descritivo e observacional, que incluiu 35 pacientes com escape paravalvar acompanhados no Instituto Dante Pazzanese de Cardiologia entre janeiro de 2011 e dezembro de 2013 e que necessitaram de correção. Os pacientes foram divididos de acordo com o tratamento estabelecido e acompanhados por um período 1 ano após o procedimento. Resultados: O grupo submetido ao tratamento percutâneo foi considerado como de maior risco para complicações por apresentar pacientes mais idosos, com maior prevalência de diabetes, maior quantidade de cirurgias valvares prévias e menor valor médio de clearance de creatinina. Durante a evolução intra-hospitalar, observou-se grande número de complicações nos dois grupos (74,3% dos casos), sem diferença estatística nos desfechos analisados. Após 1 ano, o grupo percutâneo teve maior número de reintervenções (8,7% vs. 20%, p = 0,57) e mortalidade maior (0% vs. 20%, p = 0,08). Uma alta incidência de escape residual mitral foi verificada após procedimento percutâneo (8,7% vs. 50%, p = 0,08). Conclusão: A cirurgia é o tratamento de escolha da regurgitação paravalvar. A abordagem percutânea pode ser uma alternativa para os pacientes com risco cirúrgico elevado.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/etiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Intervención Coronaria Percutánea/métodos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/etiología , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/mortalidad , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/mortalidad , Reoperación , Factores de Tiempo , Bioprótesis/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Ecocardiografía Transesofágica , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Oclusión Terapéutica/métodos , Oclusión Terapéutica/mortalidad , Intervención Coronaria Percutánea/mortalidad , Hospitalización , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/mortalidadRESUMEN
BACKGROUND: Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair. OBJECTIVES: To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure. METHODS: This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure. RESULTS: The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08). CONCLUSION: Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk.
Asunto(s)
Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugía , Intervención Coronaria Percutánea/métodos , Oclusión Terapéutica/métodos , Adulto , Anciano , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/mortalidad , Bioprótesis/efectos adversos , Ecocardiografía Transesofágica , Femenino , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/mortalidad , Intervención Coronaria Percutánea/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Oclusión Terapéutica/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Introducción: La Insuficiencia Aórtica (IA) excepcionalmente es susceptible de reparación. Una de estas excepciones es la Válvula Aórtica Bicúspide (VAB). Objetivo: Analizar nuestros resultados de la reparación de la VAB insuficiente. Método: Se revisó la Base de Datos para el período enero 1994 a Julio 2014. Se identificaron 29 pacientes y se revisaron las fichas clínicas y protocolos operatorios. La supervivencia se certificó en el Registro Civil e Identificación de Chile. Resultados: Todos los pacientes fueron hombres. La edad promedio fue 39,4 años (19- 61 años). Cinco pacientes presentaban una endocarditis. El ecocardiograma preoperatorio demostró IA severa en 25 casos (86%) y moderada en 4. El diámetro sis-tólico fue 44 ± 7,1 mm y el diastólico 67,8 ± 6,7 mm. La fracción de acortamiento fue 35,96 ± 5,54%. En todos los casos la VAB presentaba fusión del velo coronariano izquierdo y derecho con rafe medio; en 3, el rafe era incompleto produciéndose un cleft. En 23 casos (79%) la IA era secundaria a prolapso del velo fusionado, en 3 a perforación de velo, en 1 a un cleft y en 2 a perforación y cleft. En 23 casos (79%) se efectuó una resección triangular y en 16 (55%) se complementó con una anuloplastía. En 3 se cerró una perforación y en otros 3 se efectuó un cierre primario de cleft. En 10 casos se realizó un procedimiento asociado. En todos los casos se realizó un ecocardiograma transesofágico intra-operato-rio. En 35% no hubo insuficiencia aórtica residual y en 65% esta fue mínima o leve. No hubo mortalidad operatoria. El seguimiento se completó en el 100%. Dos pacientes (7%) fallecieron por causas no cardiacas. Siete (24%) fueron re-operados, en promedio a los 7,14 años. La media de supervivencia fue 19,3 años (IC95% 17,6-21) y la supervivencia libre de re-operación 15,8 años (IC95% 13-18,7), a 20,6 años de seguimiento. El ecocardiograma efectuado en promedio a los 4,9 años demostró una reducción del diámetro sistólico de 6,15 ± 7,2 mm (p<0,05), del diastólico de 11,26 ± 8,7 mm (p<0,05) y de la fracción de acortamiento de 1,12 ± 5,57% (p<0,33). De los 22 pacientes no reoperados, 9 no tenían IA, en 6 esta era leve (1+) y en 3 leve a moderada (2+); 4 pacientes tenían una estenosis aórtica leve. Conclusión: La reparación quirúrgica de la válvula aortica bicúspide insuficiente tiene baja mortalidad peri-operatoria y excelente supervivencia alejada. Si bien el 24% de los pacientes requirió una re-operación, esta fue tardía en la mayoría de los casos.
Background: Aortic insufficiency (AI) is rarely amenable to surgical repair. One of the exceptions to that statement is the bicuspid aortic valve Aim: to analyze our results in the repair of a regur-gitant bicuspid aortic valve Method: A review of the cardiac surgery data base in the period January 1994 to July 2014 allowed the identification of 29 patients with AI and a bicuspid aortic valve submitted to surgical repair. The data from the clinical record and the surgical report was analyzed. Survival was established from the National Identification Service. Results: all patients were males. Mean age was 39.4 years (range 19-61). Five patients had infective endocarditis. Preoperative echocardiography revealed severe AI in 25 patients (86%) and moderate AI in 4. Left ventricular diastolic and systolic diameters were 67,8 ± 6,7 and 44 ± 7,1 mm, respectively. All patients presented fusion of the left and right leaflets with mid rafhe, and 3 patients had an incomplete rafhe with a cleft. AI was caused by prolapsed fu-sioned leaflet in 23 patients, leaflet perforation in 3, cleft in one and perforation plus cleft in 2 patients. Triangular resection was performed in 23 (79%) and complemented by annuloplasty in 16 (55%) patients. Three patients underwent closure of a perforation and 3 a repair of the cleft. An additional surgical procedure was performed in 10 patients. All patients underwent intra-operative TEE. 35% had no residual AI and 65% had minimal or mild AI. There was no surgical mortality. Follow up was completed in all patients. Two patients (7%) died from non cardiac causes. Seven patients (24%) had to be re-operated on, a mean of 7.1 years after the initial surgery. Mean survival rate was 19.3 (95% CI 17.6-21), and mean survival free from re-operation was 15.8 years (95%CI 13-18.7) at 20.6 years of follow up. Echo-cardiogram performed at a mean of 4.9 years after surgery showed a reduction of LV systolic diameter of 6,15 ± 7,2 mm (p<0,05), LV diastolic diameter of 11,26 ± 8,7 mm (p<0,05) and fractional shortening of 1,12 ± 5,57% (p<0,33). In the group of 22 patients who did not have a re-operation, AI was absent in 9, mild in 6 and moderate in 3; 4 patients had mild aortic stenosis. Conclusion: Surgical repair of the regurgitant bicuspid aortic valve has low peri-operative mortality rate and excellent late survival. Reoperation, required in 24% of patients, occurred late after the initial operation in most cases.
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Humanos , Masculino , Adulto , Persona de Mediana Edad , Adulto Joven , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Procedimientos de Cirugía Plástica/métodos , Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Ecocardiografía , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: This study evaluates the early and midterm results of decellularized aortic valve allografts (DAVA) as an aortic valve replacement. METHODS: Between October 2005 and February 2010, 41 patients, 28 of whom were male, with a median age of 34 years (range, 0.1 to 71), had aortic valve replacement with DAVA. Decellularization was obtained with a 0.1% sodium dodecyl sulfate solution. Postoperative evaluation was performed with serial echocardiograms, magnetic resonance imaging, and multislice computed tomography studies to evaluate valve hemodynamics, allograft conduit dimensions, and calcification scores. RESULTS: There were 3 early deaths and 1 late death, with a mean follow-up of 19 months (range, 1 to 53). There was 1 reoperation due to a failed mitral valve repair. By echocardiography in all patients, the median immediate postoperative peak gradient was 7 mm Hg (range, 1 to 26 mm Hg), and at last follow-up it was 4 mm Hg (range, 1 to 16 mm Hg); valvular regurgitation was graded as none or trivial in all but 1 patient, who had a regurgitation graded as mild to moderate. By magnetic resonance imaging (n = 4), mean root dimensions were stable at the annulus (24 mm), sinus of Valsalva (33 mm), and sinotubular junction (28 mm). By computed tomography (n = 22), there was only discrete conduit calcification (median calcium score 63 Hounsfield units [HU]; range, 0 to 894 HU) to 3 years of follow-up. Conduit biopsy in the patient who underwent reoperation demonstrated well-preserved wall structure, absence of calcification, and limited in vivo host repopulation. CONCLUSIONS: The early and midterm results with DAVA demonstrated stable structural integrity, low rate of calcification, and adequate hemodynamics. Although longer periods of observation are necessary, DAVA appears to be a promising alternative for aortic valve replacement in selected patients.
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Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/trasplante , Velocidad del Flujo Sanguíneo/fisiología , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Anciano , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Biopsia , Brasil/epidemiología , Niño , Preescolar , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Trasplante Homólogo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: This study aims to verify the applicability of Ambler's risk score to patients who have undergone implantation of bovine pericardial bioprosthesis at the Instituto de Cardiologia do RGS/FCU. This study also aims to quantify the risk factors. METHODS: Retrospective study with 703 patients who had undergone implantation of bovine pericardial bioprosthesis between 1991 and 2005 at the Instituto de Cardiologia do RS. Aortic implant occurred in 392 patients, mitral in 250 and combined in 61. Primary outcome was hospital mortality. Characteristics used to estimate risk were: gender, age, body mass index (BMI), NYHA functional class, left ventricular ejection fraction, valvular lesions, systemic arterial hypertension, diabetes mellitus, renal function, cardiac rhythm, previous cardiac operations, and surgical priority. Univariate and multivariate logistic regression was used to quantify preponderant risk factors by the odds-ratio (OR). RESULTS: The mortality rate was 14.3%, which was higher than the estimated mortality rate (3%, according to Ambler's mean score of 6, (p<0.01)). Patients who died presented a mean score of 8.26, which was higher than the survivors' average score of 5.68. Characteristics of increased risk were emergency surgery (OR=10.87), dialysis (OR=6.10), and age higher than 80 years (OR=6.10). Our sample indicates an area under the ROC curve of 72.9% (accepted value > 70%). CONCLUSION: The mortality predicted in Ambler's score was not reproduced in the observed results. However, the ROC curve provides evidence that this model is applicable. Preponderant risk factors were individualizated.
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Insuficiencia de la Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Modelos Teóricos , Pericardio , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Animales , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Brasil/epidemiología , Bovinos , Diálisis/efectos adversos , Tratamiento de Urgencia/efectos adversos , Métodos Epidemiológicos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Valores de Referencia , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the long-term results of the Ross procedure in the treatment of aortic valve disease. METHODS: Between July 1995 and May 2006, a total of 165 patients (131 males, 34 females; mean age 39 +/- 13 years) underwent the Ross procedure using the freestanding root technique. Both, clinical and echocardiographic follow ups were conducted, with valve-associated events (death, endocarditis, thromboembolism, reoperation, valvular dysfunction) being analyzed using Kaplan-Meier curves. Log-rank tests, chi-square tests and the Cox model were used for variable analysis. RESULTS: The mean preoperative left ventricular ejection fraction was 55 +/- 12%. Surgery was indicated for aortic stenosis (54%) or aortic insufficiency (46%). The aortic valve was bicuspid in 125 patients, while in four patients surgery was indicated in the setting of active infective endocarditis, and in six for prosthetic dysfunction. The in-hospital mortality was 2.5% (n = 4). Survival at one and 10 years was 97% (95% CI, 93-99) and 94.8% (95% CI, 89-98), respectively. Freedom from endocarditis at 10 years was 95% (95% CI, 84-98), and from valve-related events was 95% (95% CI, 90-98) and 88% (95% CI, 75-94) at one and 10 years, respectively. Four patients required reoperation (one case of recurrent mitral regurgitation after previous mitral valve repair; three cases of autograft dysfunction and disease of other valves). Based on this experience, and during the follow up period, the presence of aortic regurgitation as a baseline aortic lesion was not associated with any need for reoperation. CONCLUSION: As a surgical technique, the Ross procedure has a low event rate at 10 years after surgery, and may be considered a valid alternative for the treatment of aortic valve disease.
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Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Complicaciones Posoperatorias/diagnóstico por imagen , Válvula Pulmonar/trasplante , Adolescente , Adulto , Anciano , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Recurrencia , Reoperación , Ultrasonografía , Adulto JovenRESUMEN
OBJETIVO: O estudo objetiva verificar aplicabilidade do escore de Ambler para pacientes que receberam implante bioprótese de pericárdio bovino no Instituto de Cardiologia do RGS/FUC e quantificar os fatores de risco. MÉTODOS: Estudo retrospectivo com 703 pacientes submetidos ao implante de bioprótese de pericárdio bovino entre 1991 e 2005, no Instituto de Cardiologia do RS. Em 392 pacientes, ocorreu implante aórtico, em 250, mitral e, em 61, combinado. Desfecho primário foi mortalidade hospitalar. As características estimativas do risco foram: idade, sexo, IMC, classe funcional (NYHA), fração de ejeção ventricular esquerda (FE), lesão valvar, hipertensão arterial sistêmica, diabete melito, função renal, ritmo cardíaco, cirurgia cardíaca prévia, revascularização miocárdica e/ou plastia tricúspide concomitante, caráter cirúrgico. Utilizada regressão logística uni e multivariada para quantificar fatores de risco preponderantes, pelo odds ratio (OR). RESULTADOS: A mortalidade observada foi de 14,3%, superior à prevista de valor 3% para escore médio 6 de Ambler, (p<0,01). Pacientes falecidos mostraram escore médio 8,26, superior ao dos sobreviventes, de 5,68. Características de maior risco foram cirurgia emergencial (OR=10,87), diálise (OR=6,10) e idade > 80 anos (OR=6,10). A área sob curva ROC para nossa amostra foi calculada em 72,9% (aceitável > 70%). CONCLUSÃO: A mortalidade prevista no escore de Ambler não é reproduzida no resultado observado, mas a curva ROC evidenciou que o modelo é aplicável. Fatores de risco preponderantes foram individualizados.
OBJETIVES: This study aims to verify the applicability of Ambler's risk score to patients who have undergone implantation of bovine pericardial bioprosthesis at the Instituto de Cardiologia do RGS/FCU. This study also aims to quantify the risk factors. METHODS: Retrospective study with 703 patients who had undergone implantation of bovine pericardial bioprosthesis between 1991 and 2005 at the Instituto de Cardiologia do RS. Aortic implant occurred in 392 patients, mitral in 250 and combined in 61. Primary outcome was hospital mortality. Characteristics used to estimate risk were: gender, age, body mass index (BMI), NYHA functional class, left ventricular ejection fraction, valvular lesions, systemic arterial hypertension, diabetes mellitus, renal function, cardiac rhythm, previous cardiac operations, and surgical priority. Univariate and multivariate logistic regression was used to quantify preponderant risk factors by the odds-ratio (OR). RESULTS: The mortality rate was 14.3%, which was higher than the estimated mortality rate (3%, according to Ambler's mean score of 6, (p<0.01)). Patients who died presented a mean score of 8.26, which was higher than the survivors' average score of 5.68. Characteristics of increased risk were emergency surgery (OR=10.87), dialysis (OR=6.10), and age higher than 80 years (OR=6.10). Our sample indicates an area under the ROC curve of 72.9% (accepted value > 70%). CONCLUSION: The mortality predicted in Ambler's score was not reproduced in the observed results. However, the ROC curve provides evidence that this model is applicable. Preponderant risk factors were individualizated.
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Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Animales , Bovinos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Insuficiencia de la Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Modelos Teóricos , Pericardio , Factores de Edad , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Brasil/epidemiología , Diálisis/efectos adversos , Métodos Epidemiológicos , Tratamiento de Urgencia/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Valores de Referencia , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: This study was designed to assess the feasibility and the long-term results of a symptom-based strategy of aortic valve replacement in a Brazilian population with predominant rheumatic etiology. BACKGROUND: Optimal criteria for valve replacement in aortic regurgitation (AR) are still not entirely clear. The appearance of symptoms is an indication for surgery, but may be associated with myocardial damage. Although cardiac imaging data have provided a safer guide for such decisions, the use of symptom-based surgical indication has not been validated and might conceivably be better in populations with predominant rheumatic etiology and younger age. METHODS: Echocardiography and rest-exercise radionuclide ventriculography were performed in 75 patients with severe AR, age 28 +/- 9 years, over a period of 10 +/- 0.69 years. Thirty-seven patients developed symptoms and underwent aortic valve replacement surgery within six months. Thirty-eight patients remained asymptomatic and were managed medically. RESULTS: Survival was 100% in asymptomatic patients and 82% in symptomatic. Surgical treatment caused marked ventricular remodeling, with ventricular diameter involution and an improvement of rest-exercise ejection fraction percent variation. Multivariate analysis showed that the probability of developing symptoms within 10 years was 58% for a patient with a left ventricular end-diastolic diameter > or =70 mm and 76% for a patient with left ventricular end-systolic (LVESD) > or =50 mm. Logistic regression identified LVESD and age as the most predictive and specific, but not sensitive, indicators of symptom development. CONCLUSIONS: Application of a standardized therapeutic strategy to patients with severe AR and predominant rheumatic etiology resulted in 90.6% survival after 10 years of follow-up.
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Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/terapia , Implantación de Prótesis de Válvulas Cardíacas , Hipertrofia Ventricular Izquierda/etiología , Disfunción Ventricular Izquierda/etiología , Adulto , Insuficiencia de la Válvula Aórtica/complicaciones , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/cirugía , Enfermedad Crónica , Ecocardiografía , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico , Hipertrofia Ventricular Izquierda/terapia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Ventriculografía con Radionúclidos , Índice de Severidad de la Enfermedad , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/terapiaAsunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Disfunción Ventricular Izquierda/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Enfermedad Crónica , Humanos , Factores Desencadenantes , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiologíaAsunto(s)
Humanos , Disfunción Ventricular Izquierda/fisiopatología , Insuficiencia de la Válvula Aórtica/cirugía , Factores Desencadenantes , Enfermedad Crónica , Función Ventricular Izquierda/fisiología , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Volumen Sistólico/fisiologíaRESUMEN
Com o objetivo de avaliar os resultados clínicos e ecocardiográficos tardios obtidos com a correçäo da insuficiência aórtica decorrente da dissecçäo crônica da aorta proximal, foram estudados 48 pacientes consecutivos operados entre janeiro de 1980 e dezembro de 1989, separados em 2 grupos de 24 pacientes cada. Grupo A - pacientes nos quais a valva aórtica foi preservada pela "resuspensäo comissural"; Grupo B - pacientes nos quais a valva aórtica foi substituída. Na avaliaçäo ecocardiográfica pré-operatória, os pacientes do Grupo B apresentavam grau de insuficiência aórtica, diâmetros ventriculares (sistólico e diastólico) e da aorta ascendente significativamente maiores do que os do Grupo A (p=0,03), sendo comparáveis nos demais parâmetros. A mortalidade hospitalar foi 12,5 por cento no Grupo A e de 4,17 por cento no Grupo B e a sobrevida aos 7 anos, respectivamente, 75,75 por cento + ou -9,82 por cento e 82,72 por cento + ou - 7,87 por cento (NS). A avaliaçäo clínica mostrou que, no pós-operatório, houve melhora significativa (p<0,001) e semelhante dos parâmetros dos dois grupos. A comparaçäo ecocardiográfica pré e pós-operatória tardia mostrou, da mesma forma, reduçäo importante dos diâmetros sistólico e diastólico do ventrículo esquerdo e no diâmetro da aorta (p<0,05), mantendo-se inalteradas as fraçöes de encurtamento e de ejeçäo ventriculares nos pacientes dos dois grupos. Nos pacientes do Grupo A, entretanto, houve persistência de insuficiência aórtica residual (p=0,03). Os autores concluem que, com as duas técnicas empregadas, o tratamento cirúrgico da dissecçäo da aorta ascendente com insuficiência aórtica associada permite sobrevida imediata e tardia satisfatórias e nítida melhora funcional. Nos pacientes do Grupo A, a insuficiência aórtica residual detectada à ecocardiografia näo produziu sintomas ou repercussäo hemodinâmica tardios e, desta forma, preconizam a preservaçäo da valva, sempre que tecnicamente possível.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Aneurisma de la Aorta/mortalidad , Disección Aórtica/mortalidad , Aorta/anatomía & histología , Enfermedad Crónica , Ecocardiografía , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica , Periodo Posoperatorio , Volumen Sistólico , Tasa de Supervivencia , Función Ventricular IzquierdaRESUMEN
Se estudiaron 18 pacientes que se sometieron a reemplazo valvular aórtico con diagnóstico de insuficiencia aórtica crónica. Se realizaron tres estudios ecocardiográficoss antes y después de la operación. Dos pacientes fallecieron tardíamente (11.1 por ciento). Para poder determinar el pronóstico a largo plazo no fueron de utilidad la clase funcional, el grado de cardiomegalia, la hipertrofia ventricular izquierda en el electrocardiograma ni la presión arterial. De los aspectos ecocardiográficos el diámetro sistólico final del ventrículo izquierdo mayor de 55 mm sí fue útil para la valoración postoperatoria. Sin embargo, cabe considerar que cuando los pacientes sobrepasan los 55 mm el daño miocárdico es importante y, en ocasiones, no susceptible de mejoría después de la operación. Por lo tanto, se recomienda operar a los pacientes con insuficiencia aórtica crónica que rebasan los 50 mm de diámetro sistólico final del ventrículo izquierdo, independientemente de la sintomatología