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Background Aortic stenosis is one of the most prevalent valve diseases but is rarely accompanied by tricuspid regurgitation. Our objective was to analyse the impact of tricuspid regurgitation severity and its surgical treatment on prognosis of patients undergoing aortic valve replacement. Methods Retrospective cohort study including all patients presenting with aortic stenosis with some degree of tricuspid regurgitation between 2001 and 2018. Patients were divided into groups according to the degree of tricuspid regurgitation. Results From a sample of 8,080 patients with aortic stenosis, 143 (1,8%) presented with more than trace tricuspid regurgitation. Among patients with mild, moderate, or severe tricuspid regurgitation, we observed no differences in 30-day (15,1 vs 14,8 vs 8,7%;p=0,727), 12-month (51,2 vs 56 vs 55%;p=0,892) or 5-year (64 vs 73,3 vs 66,7%;p=0,798) survival. Aortic valve replacement plus tricuspid annuloplasty, when compared with aortic valve replacement only was associated with longer ICU stay (9 vs 3 days;p=0,043) but not higher 30-day (0 vs 15,5%;p=0,112), 12-month (38,5 vs 54,3%;p=0,278) or 5-year mortality (57,1 vs 67.1%;p=0,594). Only history of liver disease and postoperative major morbidity were independent predictors of survival 30 days, 12 months and 5 years after surgery. Conclusions Severity of tricuspid regurgitation in patients with aortic stenosis was not associated with increased mortality. Tricuspid annuloplasty did not improve survival in this subset of patients but was associated with increased postoperative morbidity.

Predictive factors of significant functional tricuspid regurgitation (FTR) are not completely understood. We investigated sex-related differences in predictors of FTR progression.Clinical and echocardiographic variables were recorded in a prospective single-centre observational cohort of 251 consecutive stable patients with FTR. Multivariable logistic regression analyses stratified by sex were performed to identify predictors of significant FTR.The mean age of the whole cohort was 72.2±11.4 years, and 133 (53%) patients were women. Females tended to have a higher prevalence of significant FTR (22.6% vs 13.6%; p=0.066). Women were also older than men (mean age 74.4 vs 69.6 years; p0.001), with more frequent history of arterial hypertension, worse New York Heart Association functional class, higher E/e' quotient, and higher left ventricular ejection fraction. The independent predictors of significant FTR in women were atrial fibrillation (AF) (odds ratio [OR] 10.8, 95% confidence interval [CI] 2.9-40.7; p0.001), indexed tricuspid diameter annulus (OR 1.24, 95% CI 1.04-1.47; p=0.017), and pulmonary artery systolic pressure (PASP) (OR 1.09, 95% CI 1.04-1.15; p=0.001). The independent predictors of outcome in men were indexed tricuspid tenting height (OR 2.71, 95% CI 1.20-6.11; p=0.016), indexed tricuspid diameter annulus (OR 1.98, 95% CI 1.26-3.09; p=0.003), and PASP (OR 1.08, 95% CI 1.01-1.16; p=0.021).The presence of AF and longer indexed tenting height convey a greater risk of significant FTR in females and males, respectively. These findings suggest the existence of different physiopathological mechanisms involved in the progression of FTR in both sexes.

Resumen Introduccion y objetivos En endocarditis infecciosa (EI), la decision quirurgica es dificil. Un alto porcentaje de pacientes con indicacion quirurgica no son intervenidos. El objetivo fue evaluar el pronostico a corto y largo plazo de los pacientes con indicacion quirurgica, comparando los que se sometieron a cirugia con los que no lo hicieron. Metodos Se incluyeron 271 pacientes con EI izquierda e indicacion quirurgica tratados en el centro desde 2003 a 2018. Ochenta y tres pacientes (31%) no fueron finalmente operados. El objetivo primario fue la mortalidad a 60 dias y el secundario desde el dia 61 a los 3 anos de seguimiento. Se realizo regresion de Cox multivariable y emparejamiento por puntuacion de propension. Resultados A los 60 dias, 40 (21,3%) pacientes operados y 53 (63,9%) pacientes no intervenidos fallecieron (p Conclusiones Dos tercios de los pacientes con indicacion quirurgica no intervenidos fallecieron antes de 60 dias. Entre los supervivientes, la mortalidad a largo plazo depende mas de factores relacionados con comorbilidad previa que del tratamiento recibido durante el ingreso.

Evidence regarding any association of HDL-particle (HDL-P) derangements and HDL-cholesterol content with cardiovascular (CV) death in chronic heart failure (HF) is lacking. To investigate the prognostic value of HDL-P size (HDL-Sz) and the number of cholesterol molecules per HDL-P for CV death in HF patients. Outpatient chronic HF patients were enrolled. Baseline HDL-P number, subfractions and HDL-Sz were measured using 1H-NMR spectroscopy. The HDL-C/P ratio was calculated as HDL-cholesterol over HDL-P. Endpoint was CV death, with non-CV death as the competing event. 422 patients were included and followed-up during a median of 4.1 (0–8) years. CV death occurred in 120 (30.5%) patients. Mean HDL-Sz was higher in CV dead as compared with survivors (8.39 nm vs. 8.31 nm, p

Background Left ventricular ejection fraction (LVEF) trajectories and functional recovery with current heart failure (HF) management is increasingly recognized. Type 2 diabetes mellitus (T2D) leads to a worse prognosis in HF patients. However, it is unknown whether T2D interferes with LVEF trajectories. The aim of this study was to prospectively assess very long-term (up to 15 years) LVEF trajectories in patients with and without T2D and underlying HF. Methods Ambulatory patients admitted to a multidisciplinary HF clinic were prospectively evaluated by scheduled two-dimensional echocardiography at baseline, 1 year, and then every 2 years afterwards, up to 15 years. Statistical analyses of LVEF change with time were performed using the linear mixed effects (LME) models, and locally weighted error sum of squares (Loess) curves were plotted. Results Of the 1921 patients, 461 diabetic and 699 non-diabetic patients with LVEF Conclusions LVEF trajectories in T2D patients with depressed systolic function showed a pronounced inverted U shape with a marked decline after 9 years. Diabetic cardiomyopathy may underlie the functional decline observed.

BACKGROUND Long-term trajectories of left ventricular ejection fraction (LVEF) in heart failure (HF) are incompletely characterized. OBJECTIVES This study sought to examine LVEF trajectories in HF with reduced LVEF (

Resumen Objetivo La introduccion de las nuevas protesis aorticas sin sutura ha supuesto una alternativa para el tratamiento quirurgico de la estenosis aortica severa. Presentamos la experiencia de nuestro grupo tras el inicio de un programa con protesis Perceval S (Livanova, Saluggia, Italia). Pacientes y metodos Entre marzo de 2012 y octubre de 2016 se implanto la protesis Perceval S en 262 pacientes (edad media: 77,97 ± 6,12 anos; 56,49% de mujeres). En 176 casos (67,18%) se realizo sustitucion valvular aortica aislada, con miniesternotomia en un 36,9%. El seguimiento clinico y ecocardiografico se realizo al alta, a los 6 meses y anualmente. Resultados La mortalidad esperada fue del 14,19 ± 1,31% (Euroscore log I ) y del 7,47 ± 1,11% (Euroscore log II ). La mortalidad observada fue del 4,23%. Hubo complicaciones neurologicas en 2 pacientes (0,94%), y fuga periprotesica moderada al alta en 2 pacientes. El seguimiento medio fue de 26 ± 6,2 meses. La mortalidad en el seguimiento fue del 1,9% (4 pacientes); estabilidad de las fugas grado II en el seguimiento; gradiente medio de 10,2 mmHg. El 95% de los pacientes se encontraban en grado funcional I - II . Conclusiones El inicio de un programa de implante de protesis sin sutura Perceval S ha permitido intervenir a pacientes de alto riesgo con buenos resultados y baja morbilidad. La protesis ha demostrado ser muy versatil, tener un excelente comportamiento hemodinamico y favorecer la cirugia de minimo acceso.

Long-term trajectories of left ventricular ejection fraction (LVEF) in heart failure (HF) patients with preserved EF (HFpEF) remain unclear. Our objective was to assess long-term longitudinal trajectories in consecutive HFpEF patients and the prognostic impact of LVEF dynamic changes over time.Consecutive ambulatory HFpEF patients admitted to a multidisciplinary HF Unit were prospectively evaluated by 2-dimensional echocardiography at baseline and at 1, 3, 5, 7, 9, and 11 years of follow-up. Exclusion criteria were patients having a previous known LVEF50%, patients undergoing only 1 echocardiogram study, and those with a diagnosis of dilated, noncompaction, alcoholic, or toxic cardiomyopathy. One hundred twenty-six patients (age, 71±13 years; 63% women) were included. The main pathogeneses were valvular disease (36%) and hypertension (28%). Atrial fibrillation was present in 67 patients (53%). The mean number of echocardiographies performed was 3±1.2 per patient. Locally weighted error sum of squares curves showed a smooth decrease of LVEF during the 11-year follow-up that was statistically significant in linear mixed-effects modeling ( P=0.01). Ischemic patients showed a higher decrease than nonischemics. The great majority (88.9%) of patients remained in the HFpEF category during follow-up; 9.5% evolved toward HF with midrange LVEF, and only 1.6% dropped to HF with reduced LVEF. No significant relationship was found between LVEF dynamics in the immediate preceding period and mortality.LVEF remained ≥50% in the majority of patients with HFpEF for ≤11 years. Only 1.6% of patients evolved to HF with reduced LVEF. Dynamic LVEF changes were not associated with mortality.

Background: In asymptomatic severe aortic stenosis (ASAS), treatment decisions are made on an individual basis, and case management presents a clinical conundrum.Methods: We prospectively phenotyped consecutive patients with ASAS using echocardiography, exercise echocardiography, cardiac MRI and biomarkers (NT-proBNP, high-sensitivity troponin T (hs-TnT) and ST2) (n=58). The primary endpoint was a composite of cardiovascular death, new-onset symptoms, cardiac hospitalization, guideline-driven indication for valve replacement and cardiovascular death at 12months.Results: During the first year, 46.6% patients met primary endpoint. In multivariable analysis, aortic regurgitation 2 (p=0.01) and hs-TnT (p=0.007) were the only independent predictors of the primary endpoint. The best cutoff value was identified as hs-TnT >10ng/L, which was associated with a approximate to 10-fold greater risk of the primary endpoint (HR, 9.62; 95% CI, 2.27-40.8; p=0.002). A baseline predictive model including age, sex and variables showing p10ng/L was associated with high risk of events within 12months. Including hs-TnT in routine ASAS management markedly improved prediction metrics.

ResumenIntroducción y objetivosLa reparación mitral es adecuada cuando en el control ecocardiográfico poscirculación extracorpórea no hay insuficiencia mitral residual o es ligera. Poco se conoce de la evolución clínica y ecocardiográfica de esta insuficiencia mitral ligera residual. El objetivo del estudio era valorar la evolución clínica y ecocardiográfica de los enfermos según la presencia o no de insuficiencia mitral residual ligera poscirugía.MétodosEstudio prospectivo de pacientes con reparación mitral por regurgitación mitral severa degenerativa operados durante el período comprendido entre 2002–2010.ResultadosFueron intervenidos 105 pacientes con afectación de 1 o 2 segmentos según la clasificación de Carpentier (edad media 67±12 años, hombres 61%). En 102 casos (97,1%), la reparación mitral fue adecuada, y en 3 (2,9%) no, sustituyéndose la válvula. La mortalidad hospitalaria fue del 2,9% (EuroSCORE logístico 5±5,5%). En el ecocardiograma transesofágico en quirófano, de los 102 pacientes reparados satisfactoriamente, 69 no presentaban insuficiencia mitral residual (grupo A) y 33 presentaban una regurgitación leve (grupo B). Durante el seguimiento [mediana 37 meses (1–105)], la evolución clínica fue correcta, aunque los pacientes del grupo B evolucionaron peor desde el punto de vista ecocardiográfico por recidiva más precoz de la insuficiencia mitral.ConclusionesLa reparación valvular mitral se ha mostrado como una técnica segura y eficaz. La ausencia de insuficiencia mitral al final de la reparación determina una mejor evolución con mínima recidiva durante un seguimiento a medio plazo.AbstractIntroduction and objectivesA successful mitral valve repair is considered when no or mild residual regurgitation is determined in the echocardiography after weaning from cardiopulmonary bypass. Little is known about the clinical and echocardiographic outcome, in the medium term, of the patients with mild residual regurgitation post-repair. The aim of this study was to evaluate the clinical and echocardiographic outcome depending on the presence or absence of mild residual regurgitation after weaning from cardiopulmonary bypassMethodsA prospective study was conducted on patients with severe degenerative mitral regurgitation, who underwent mitral valve repair in our hospital during the period 2002–2010.ResultsMitral valve repair was performed on 105 patients (66%males, mean age 67±12 years-old) with prolapse of 1 or 2 scallops/segments according to the Carpentier classification. In three patients the repair was not adequate and the valve was replaced. The successful repair rate was 97.1%. After weaning from cardiopulmonary bypass, 69 patients had no residual regurgitation (group A), and in 33 it was mild (group B). The postoperative mortality was 2.9% (logistic EuroSCORE 5±5.5%). During a median follow-up period of 37 months (1–105) both groups had improved their clinical condition, but group B patients suffered an earlier II or III mitral regurgitation recurrence.ConclusionsMitral valve repair proved to be a safe and effective technique. Absence of mitral regurgitation post-repair determines a better outcome with minimal recurrence in the medium term.

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p

Introducción y objetivosLa reparación mitral es el tratamiento de elección de la insuficiencia mitral grave degenerativa por prolapso. El objetivo del estudio es analizar los resultados a medio plazo de la cirugía reparadora mitral.MétodosEstudio prospectivo de pacientes con insuficiencia mitral grave degenerativa, por prolapso de uno o dos segmentos valvulares en los que se realizó cirugía reparadora mitral en nuestro centro (2002–2008). Se practicó valoración clínica y ecocardiográfica precirugía, en la intervención y en el seguimiento.ResultadosSe intervinieron 100 pacientes (edad media 65±12 años, hombres 66%). El estudio ecocardiográfico prequirúrgico nos permitió una correcta identificación de los segmentos valvulares afectos en el 96,3% de los casos. La mortalidad quirúrgica fue del 0% y la postoperatoria del 4%. Durante el seguimiento (mediana 31 meses [1–93) hubo una tasa de pacientes libres de reintervención del 98% al año y del 96% a los 5 años. La supervivencia actuarial fue del 94% al año y del 92% a los 5 años. Ningún paciente operado en CF I-II requirió reintervención, siendo la mortalidad hospitalaria y durante el seguimiento de cero.ConclusionesLa reparación valvular mitral se ha mostrado como una técnica segura y eficaz. Un equipo multidisciplinario permite la correcta identificación de pacientes candidatos y la aplicación de las técnicas quirúrgicas adecuadas. A la espera de un mayor seguimiento, los resultados son satisfactorios.Introduction and objectivesValve repair is the procedure of choice for severe mitral regurgitation due to leaflet prolapse. The aim of this study is to analyze the mid-term results of mitral valve repair.MethodsWe performed a prospective study including patients with severe degenerative mitral regurgitation due to leaflet prolapse (one or two segments) who underwent mitral valve repair during the study period (2002–2008) in our hospital. Clinical and echocardiographic evaluation was performed before surgery, intraoperatively and during the follow-up.ResultsMitral valve repair was performed in 100 patients (mean age 65±12 years-old, 66% males). The accuracy of preoperative echocardio-graphic identification of the prolapsed segments/ scallops was 96.3%. Intraoperative mortality was 0% and hospital mortality 4%. Median follow-up period was 31 months (1–93). Freedom from reoperation at 1 year and 5 years was 98 and 96%. The actuarial survival rate at 1 year and 5 years was 94 and 92%. No patient operated on in NYHA class I-II required a reoperation, being both inhospital and follow-up mortality zero in that group of patients.ConclusionsMitral valve repair proved to be a safe and effective technique. A multidisciplinary team allows a correct patient’s selection and the application of the right surgical technique. Awaiting for longer follow-up results are satisfactory.

Introduccion y objetivo Los marcapasos temporales (MT) permiten el tratamiento urgente de pacientes con bradiarritmias severas. Se los utiliza en las situaciones urgentes y con frecuencia en ancianos con estado general deteriorado, inestabilidad hemodinamica y escasa colaboracion. El objetivo es revisar los MT implantados en nuestro centro en los ultimos 6 anos y analizar sus indicaciones, incidencia y tipo de complicaciones. Pacientes y metodo Se han analizado las variables clinicas significativas, la indicacion, la via de acceso, el seguimiento, las complicaciones y los dias de mantenimiento del MT. Resultados Se implanto un total de 568 MT y se pudo revisar 530 casos (edad, 74,8 ± 11 anos). Las indicaciones para su implantacion fueron: bloqueo auriculoventricular sintomatico (51%) y profilactico por recambio de generador (14,7%), bloqueo en la fase aguda del infarto (12,6%), bradiarritmia por intoxicacion medicamentosa (12,2%), enfermedad del nodo sinusal (7,5%) e intervalo QT largo o taquicardia ventricular (2,5%). Se colocaron por la vena femoral en el 99% de los casos. La duracion del MT fue de 4,2 dias (rango, 1-31 dias). Requirieron un marcapasos definitivo 369 pacientes (69,6%). En cuanto a las complicaciones, se produjo el fallecimiento de 34 pacientes (6,4%), aunque solo en 3 fue atribuible al MT. En 98 pacientes (18,5%) se observaron otras complicaciones severas, entre ellas, disfuncion del MT en 48 pacientes (9%) por movilizacion del electrocateter. Conclusiones Los MT se emplean con frecuencia en ancianos con bradiarritmia extrema y, en ocasiones, infarto agudo de miocardio. Las complicaciones graves son frecuentes (22%) y se puede producir desde un hematoma femoral hasta un taponamiento cardiaco o incluso la muerte (6%). En un 9% de los casos, el electrodo debe ser recolocado por fallo del sensado o de la captura ventricular.

Introduction. Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood. Aim. To evaluate the incidence of DIG and determine risk factors and associated morbimortality. Patients and method. One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity ≥ 2.5 m/s. Results. Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, P

Ectopic thyroid tissue is a rare congenital anomaly that results from multiple events during development. The ectopic thyroid may lie in several human organs including the tongue and mediastinum. It is rarely seen as an intracardiac mass. We report the case of a patient with an intracardiac mass diagnosed by echocardiography. The pathology of the mass was compatible with ectopic thyroid tissue with no signs of malignancy.

Introduction and objective. Temporary pacemakers (TP) are used in the emergency treatment of patients with severe bradyarrhythmia. They are often used in emergency situations and for older patients in poor general condition who are hemodynamically unstable and uncooperative. The aim of this study was to review and analyze the indications, incidence, and type of complications associated with TP implanted in our center during a 6-year period. Patients and method. We analyzed significant clinical variables, indication, route of insertion, follow-up, complications, and duration of temporary pacing. Results. A total of 568 TP were implanted, and 530 cases were available for review (mean age 74.8 [11] years). The main indications were symptomatic complete AV block (51%), prophylaxis for replacement with a definitive pacemaker (14.7%), blockage in the acute phase of myocardial infarction (12.6%), bradyarrhythmia due to drug intoxication (12.2%), symptomatic sick sinus syndrome (7.5%), and long QT interval or ventricular tachycardia (2.5%). The route of insertion was via the femoral vein in 99% of the cases. The duration of TP use was 4.2 days (range, 1 to 31 days). A total of 369 patients (69.6%) required a permanent pacemaker. Complications: 34 patients died (6.4%), but only 3 deaths were attributable to TP implantation. Other severe complications were seen in 98 patients (18.5%). Malfunction of the TP occurred in 48 patients (9%) because of electrode displacement. Conclusions. Temporary pacemakers are used in older patients with extreme bradyarrhythmia and occasionally with acute myocardial infarction. Serious complications are not uncommon (22% of all patients), and can range from femoral hematoma to cardiac tamponade and even death (6%). In 9% of the patients the electrode needed to be repositioned because of failure of sensing or loss of ventricular capture.

Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood.Aim. To evaluate the incidence of DIG)and determine risk factors and associated morbimortality.One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity/= 2.5 m/s.Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, p0.001; left end-systolic ventricular diameter (LESVD) 21 vs. 29 mm, p0.001); left ventricular mass index (165 vs. 193 g/m(2), p0.05); mean aortic valve gradient (68 vs. 59 mmHg, p0.01),; ejection fraction (73 vs. 61%, p0.001). No significant differences were found with respect to ventricular wall thicknesses (septal 16.3 vs. 15.7; posterior 14.37 vs. 14.62), the presence of aortic insufficiency, or other postoperative factors (anemia, inotropic agents, etc.).DIG after aortic valve replacement to treat severe stenosis is not unusual (15%). DIG is usually found at a midventricular location, close to the septum. In patients with postoperative DIG the most common associated factors were small LEDVD, high ejection fractions and ratios of intraventricular septal to posterior wall ratios, high valve gradients and small left ventricular masses. Preoperative echocardiography can identify patients with a higher risk of developing DIG after aortic valve replacement.

Left atrial wall haematoma is a very uncommon entity, associated mainly to cardiac surgery, interventional procedures, or trauma. Spontaneous cases are supposed to be associated with left atrial wall pathology. We present a case of a 53-year-old male who was admitted for prolonged chest pain, with transthoracic and transesophagic echocardiography documentation of a left atrial mass in close proximity to a mitral annular calcification. Tissue characterization with cardiac magnetic resonance suggested the aetiology of the mass, which was confirmed histologically.