Impacto de la disfunción ventricular izquierda en el paciente intervenido de estenosis valvular aórtica moderada-grave

Objetivo: El objetivo de este estudio es analizar el efecto de la disfunción ventricular izquierda grave en la mortalidad de la cirugía de estenosis valvular aórtica aislada o combinada con cirugía coronaria en el Hospital Universitario Son Espases. Métodos: Se incluyeron 666 pacientes intervenidos desde noviembre del 2002 hasta diciembre del 2009 en nuestro centro. Los pacientes se clasificaron en dos grupos según su fracción de eyección (FE): ≤35% y >35%. Se excluyeron los pacientes con insuficiencia valvular aórtica severa asociada y/o los intervenidos de cualquier otra valvulopatía. El seguimiento se realizó hasta el 31 de diciembre del 2011. El análisis del efecto de la disfunción ventricular grave en la mortalidad a medio plazo se realizó mediante curvas de supervivencia y un análisis de regresión de Cox ajustado por factores de confusión. Resultados: El 42,49% (n = 283) eran mujeres. La mediana de edad fue de 71,42 años (62,82 – 80,02) y la del Euroscore logístico 5,82 (3,74 - 9,15). La mortalidad bruta hospitalaria observada fue del 2,1% (n = 14). La mediana del tiempo seguimiento fue de 4,6 años, muy similar en ambos grupos. El análisis de regresión de Cox mostró una asociación entre disfunción ventricular izquierda severa y mortalidad a medio plazo (HR 2,55, IC 95% 1,36 - 4,76). Conclusiones: La disfunción ventricular izquierda grave es un factor de riesgo independiente asociado con una mayor mortalidad a medio plazo en pacientes intervenidos de estenosis aórtica aislada o combinada con cirugía coronaria. Palabras clave: Estenosis de la válvula aórtica, mortalidad, disfunción ventricular, procedimientos quirúrgicos cardíacos, válvula aórticaObjective: The objective of this study was to analyze the impact of severe left ventricular dysfunction on mortality after aortic valve replacement with and without combined coronary artery bypass graft surgery in Son Espases University Hospital. Methods: We included 666 patients undergoing aortic valve replacement from November 2000 through December 2009. Patients were clasified in two groups according to the ejection fraction (EF): ≤35% and >35%. Patients with associated severe aortic valve insufficiency or undergoing another surgical valve procedure were excluded. Mortality following discharge was calculated from data on patient life status at December 31, 2011. The effect of severe left ventricular dysfunction on mid-term mortality was analyzed with Kaplan-Meyer survival estimates and a risk-adjusted Cox proportional regression model. Results: The proportion of female sex was 42,49% (n = 283). Median age was 71,42 years (62,82 – 80,02) and median logistic Euroscore was 5,82 (3,74 – 9,15). Observed in-hospital mortality was 2,1% (n = 14). Median time of follow-up was 4,6 years, very similar in both groups. Cox regression analysis showed an association between severe left ventricular dysfunction and mid-term mortality (HR 2,55, CI 95% 1,36 - 4,76). Conclusions: Severe left ventricular dysfunction is associated with a higher mid-term mortality in patients undergoing aortic valve replacement with and without combined coronary surgery, aortic valve. Keywords: Aortic Valve Stenosis, Mortality, Ventricular Dysfunction, Cardiac Surgical Procedures, aortic valv

Impact of left ventricular dysfunction on early and late outcomes in patients undergoing concomitant aortic valve replacement and coronary artery bypass graft surgery

Background: An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with left ventricular (LV) dysfunction. The aim of this study was to evaluate the early outcomes and late survival of patients with different degrees of LV function undergoing concomitant AVR and CABG. Methods: Between June 2001 and December 2009, patients undergoing concomitant AVR-CABG were identified from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program. Demographic, operative data and post-operative outcomes were compared between patients with normal (> 60%), moderately impaired (30-60%), and severely impaired (< 30%) estimated LV ejection fraction (LVEF). Independent risk factors for short-and long-term mortality were identified using binary logistic and Cox regression, respectively. Results: AVR-CABG was performed in 2,563 patients with a mean follow up of 36 months (range 0-106). 144 (5.6%) had severely impaired LVEF, 983 (38.3%) had moderately impaired LVEF while the remaining 1377 (53.7%) had normal LVEF. The 30-day mortality in patients with severely impaired, moderately impaired and normal LVEF was 9.0%, 4.3% and 2.9%, respectively. This was significant on univariate (p < 0.001) but not multivariate analysis (p = NS). Severely impaired, moderately impaired and normal LVEF patients experienced 5-year survivals of 63.7%, 77.1% and 82.5%, respectively. Severely impaired LVEF was an independent multivariable predictor of late mortality (HR 1.71; 95% CI 1.22-2.40; p = 0.002). Conclusions: Patients with severely impaired LVEF experience worse outcomes. However, in the era of modern surgery, this alone should not predicate exclusion, given the established benefits of surgery in this high-risk group. © 2013 Via Medica

Medicina Balear 2015, vol. 30, n. 1

Medicina Balear, òrgan de la Reial Acadèmia de Medicina de les Illes Balears, publica en català, castellà o anglès treballs originals, articles de revisió, cartes al director i altres escrits d'interès relacionats amb les ciències de la salut i presta particular atenció als treballs que tinguin per àmbit les Illes Balears i altres territoris de la conca mediterrània occidental. La revista sotmet els manuscrits a la revisió anònima per al menys dos experts externs (peer review

The relationship between aortic stiffness, health related quality of life and post-operative organs recovery (cardiac, renal and cognitive) following aortic valve replacement

Background: Aortic stiffness as measured by pulse wave velocity (PWV) is a predictor of cardiovascular disease and other outcomes in different diseased and healthy populations, independent of traditional risk factors. The relationships between PWV measurement, global functional outcome and injury to the brain, kidney, and heart have never been examined in cardiac surgery patients. Objective: The objective of this project was to assess the relationship between aortic stiffness and health related quality of life (QoL), cognitive function, acute kidney injury (AKI), and cardiac function in patients undergoing aortic valve replacement (AVR). Methods: Aortic PWV, QoL, cognitive function, left ventricular (LV) function and NYHA class were assessed pre- and post-operatively (409 ± 159 days). The brain injury biomarker, N-methyl-D-aspartate receptor antibody (NR2Ab), was measured pre-operatively only. The biomarker of myocardial strain, B-type natriuretic peptide (BNP), and the novel AKI biomarker, neutrophil gelatinase-associated lipocalin (NGAL), were measured pre-operatively, and at 3 h and 18-24 h post-CPB. Results: Fifty-six patients (16 females; mean age, 71 ± 8.4 years) were included in this study, of which 50 (89%) patients attended the follow-up visit. No relationship was found between the degree of aortic stenosis (AS) and PWV, and AVR had no effect on aortic stiffness post-operatively. QoL and NYHA class significantly improved, while cognitive function did not deteriorate after AVR. High PWV is independently related to poorer QoL, cognitive function levels and NYHA class both pre- and post-operatively. PWV was not related to LV function, BNP or NGAL levels, but it was independently related to the level of NR2Ab. PWV did not correlate with AKI which was developed in 30% of the cases. Early post-operative plasma level of NGAL is the earliest predictive marker of post-operative AKI and the need for early medical renal intervention. Pre-operative BNP level was significantly and negatively correlated with pre-operative LV function, AS (valve area), and NYHA class in the post-operative follow-up period. Conclusion: In AVR patients, PWV is independently related to global functional status, cognitive function and brain injury biomarkers, but is not related to AKI or myocardial strain.Open Acces