V01 345. Implante de prótesis aórtica transcatéter por vía transaórtica: una alternativa de abordaje a las vías convencionales

Objetivosel implante de prótesis valvulares aórticas por vía transcatéter es una opción terapéutica reconocida en pacientes de alto riesgo quirúrgico. Nuestro objetivo es mostrar una vía de abordaje alternativa para su implante en algunos pacientes no candidatos para las vías usuales de acceso vascular periférico (femoral/subclavia) o transapical.Material y métodospresentamos el caso de un varón de 74 años con estenosis aórtica grave, CF IV y fracción de eyección del ventrículo izquierdo (FEVI) gravemente deprimida. Antecedentes de neoplasia de colon, diabetes mellitus tipo 2, enfermedad vascular periférica grave, cardiopatía isquémica crónica con revascularización percutánea mediante stents convencionales y neumonectomía derecha por carcinoma de pulmón. EuroSCORE logístico: 42,57%. Ecocardiograma: válvula aórtica trivalva (gradiente máximo 76, medio 51mmHg, área: 0,6cm2;, anillo: 24mm). Angiotomografía computarizada (angio-TC): grave ateromatosis ilíaca bilateral, desplazamiento importante del ápex cardíaco hacia la línea media y de la aorta ascendente hacia el hemitórax derecho. Cateterismo: ateromatosis grave de subclavia izquierda y estenosis grave de subclavia derecha, no reestenosis intra-stents.Se somete a implante de prótesis aórtica Core-Valve autoexpandible número 29 vía transaórtica (aorta ascendente) bajo visión directa a través de minitoracotomía anterior derecha por segundo espacio intercostal.Resultadosel paciente es extubado en 6h. Ecocardiograma de control: prótesis con apertura conservada e insuficiencia aórtica ligera-moderada. Ritmo sinusal estable.Conclusionesaunque la vía transaórtica mediante cirugía mínimamente invasiva está aún poco utilizada, en pacientes con alto riesgo para cirugía convencional puede ser una opción factible y segura para el implante de prótesis transcatéter en las que no sea posible el abordaje habitual

Revascularización miocárdica en la población femenina

Introducción y objetivos: Realizamos estudio de los factores que influyen en los resultados de la revascularización miocárdica quirúrgica en la población femenina. Pacientes y método: Analizamos retrospectivamente los factores de riesgo preoperatorios asociados a morbi-mortalidad hospitalaria en 128 pacientes intervenidas entre enero de 2000 y septiembre de 2004. Resultados: La edad media fue 69.19 ± 9.05 años, las patologías asociadas más frecuentes fueron dislipemia, HTA e IAM. Presentaron angina inestable 63.28% pacientes, teniendo lesión del TCI (42.96%), permaneciendo en clase funcional (NYHA) III-IV 23.43%. El riesgo preoperatorio medio (EuroSCORE) fue 5.57; realizando 12 cirugías urgentes; anastomosando una media de 2.57 injertos. La mortalidad hospitalaria fue 5.4% en cirugía programada, 7% global. Fueron factores de riesgo de mortalidad en análisis univariante (p < 0.05): grado funcional (NYHA) III-IV, FEVI < 50%, cirugía urgente y edad superior a 67 años. Fueron factores de riesgo de mortalidad en análisis multivariante (p < 0.05): edad superior a 67 años, grado funcional (NYHA) y realización de cirugía urgente. Se complicaron 25.2%. Se realizó seguimiento en el 90.8% de los supervivientes, seguimiento medio 17.11 ± 14.94 meses, estando 115 pacientes asintomáticos para angor. El factor de riesgo de angina en seguimiento en análisis univariante (p < 0.05) fue no usar AMI como injerto anastomosado a la descendente anterior. Conclusiones. La urgencia, edad superior a 67 años y deterioro de clase funcional son factores de riesgo directamente relacionados con mortalidad en este grupo. El uso de injertos arteriales está asociado a la disminución de recurrencia de angor en el seguimiento

Surgery for atrial fibrillation in patients with mitral valve disease: results at five years from the International Registry of Atrial Fibrillation Surgery

ObjectivesWe sought to assess the clinical and survival benefit of atrial fibrillation surgery in patients submitted to mitral valve surgery after stabilization of postoperative rhythm at 1 year.MethodsOne thousand seven hundred twenty-three patients were enrolled. Patients with follow-up of longer than 1 year (n = 972) were divided into 3 groups according to surface electrocardiographic rhythm during follow-up visits: stable sinus rhythm, stable atrial fibrillation, and intermittent rhythms. Adverse cardiac event incidence and predictors of long-term outcome were compared among the 3 groups.ResultsIn-hospital mortality was 2.6%. Risk factors for mortality were the cut-and-sew technique (odds ratio, 8.92; 95% confidence interval, 1.71–46.50; P = .009) and isolated left atrial procedure (odds ratio, 0.16; 95% confidence interval, 0.04–0.56; P = .004). At 1 year, 63.4% patients were in stable sinus rhythm. Stable sinus rhythm was found to be associated with early and late survival (P = .01, log-rank analysis). Multivariate binary logistic regression analysis found that left atrial dimension (odds ratio, 0.97; 95% confidence interval, 0.96–0.99; P = .005) and concomitant coronary revascularization (odds ratio, 0.48; 95% confidence interval, 0.25–0.92; P = .027) were independent predictors of stable sinus rhythm at 1 year after surgical intervention. At 48 months' follow-up, predictors for stable sinus rhythm were biatrial surgical approach and absence of preoperative permanent atrial fibrillation (odds ratio, 3.56; 95% confidence interval, 1.62–7.83; P < .002). Left atrial size (each millimeter) has a borderline statistical significance (odds ratio, 0.97; 95% confidence interval, 0.93–1.00; P = .065). Thromboembolic events were found to be associated with absence of stable sinus rhythm (P = .010, log-rank analysis).ConclusionsThe achievement of stable sinus rhythm is a predictor of better survival and lower incidence of thromboembolic events. Predictors of stable sinus rhythm were smaller dimensions of the left atrium, biatrial approach, absence of preoperative permanent atrial fibrillation, and absence of concomitant coronary artery bypass grafting

Mortality reduction by post-dilution online-haemodiafiltration : A cause-specific analysis

Background. From an individual participant data (IPD) meta-analysis from four randomized controlled trials comparing haemodialysis (HD) with post-dilution online-haemodiafiltration (ol-HDF), previously it appeared that HDF decreases all-cause mortality by 14% (95% confidence interval 25; 1) and fatal cardiovascular disease (CVD) by 23% (39; 3). Significant differences were not found for fatal infections and sudden death. So far, it is unclear, however, whether the reduced mortality risk of HDF is only due to a decrease in CVD events and if so, which CVD in particular is prevented, if compared with HD. Methods. The IPD base was used for the present study. Hazard ratios and 95% confidence intervals for cause-specific mortality overall and in thirds of the convection volume were calculated using the Cox proportional hazard regression models. Annualized mortality and numbers needed to treat (NNT) were calculated as well. Results. Besides 554 patients dying from CVD, fatal infections and sudden death, 215 participants died from 'other causes', such as withdrawal from treatment and malignancies. In this group, the mortality risk was comparable between HD and ol-HDF patients, both overall and in thirds of the convection volume. Subdivision of CVD mortality in fatal cardiac, non-cardiac and unclassified CVD showed that ol-HDF was only associated with a lower risk of cardiac casualties [0.64 (0.61; 0.90)]. Annual mortality rates also suggest that the reduction in CVD death is mainly due to a decrease in cardiac fatalities, including both ischaemic heart disease and congestion. Overall, 32 and 75 patients, respectively, need to be treated by high-volume HDF (HV-HDF) to prevent one all-cause and one CVD death, respectively, per year. Conclusion. The beneficial effect of ol-HDF on all-cause and CVD mortality appears to be mainly due to a reduction in fatal cardiac events, including ischaemic heart disease as well as congestion. In HV-HDF, the NNT to prevent one CVD death is 75 per year

Mortality reduction by post-dilution online-haemodiafiltration : A cause-specific analysis

Background. From an individual participant data (IPD) meta-analysis from four randomized controlled trials comparing haemodialysis (HD) with post-dilution online-haemodiafiltration (ol-HDF), previously it appeared that HDF decreases all-cause mortality by 14% (95% confidence interval 25; 1) and fatal cardiovascular disease (CVD) by 23% (39; 3). Significant differences were not found for fatal infections and sudden death. So far, it is unclear, however, whether the reduced mortality risk of HDF is only due to a decrease in CVD events and if so, which CVD in particular is prevented, if compared with HD. Methods. The IPD base was used for the present study. Hazard ratios and 95% confidence intervals for cause-specific mortality overall and in thirds of the convection volume were calculated using the Cox proportional hazard regression models. Annualized mortality and numbers needed to treat (NNT) were calculated as well. Results. Besides 554 patients dying from CVD, fatal infections and sudden death, 215 participants died from 'other causes', such as withdrawal from treatment and malignancies. In this group, the mortality risk was comparable between HD and ol-HDF patients, both overall and in thirds of the convection volume. Subdivision of CVD mortality in fatal cardiac, non-cardiac and unclassified CVD showed that ol-HDF was only associated with a lower risk of cardiac casualties [0.64 (0.61; 0.90)]. Annual mortality rates also suggest that the reduction in CVD death is mainly due to a decrease in cardiac fatalities, including both ischaemic heart disease and congestion. Overall, 32 and 75 patients, respectively, need to be treated by high-volume HDF (HV-HDF) to prevent one all-cause and one CVD death, respectively, per year. Conclusion. The beneficial effect of ol-HDF on all-cause and CVD mortality appears to be mainly due to a reduction in fatal cardiac events, including ischaemic heart disease as well as congestion. In HV-HDF, the NNT to prevent one CVD death is 75 per year