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Background: We aimed to compare 1 year the hemodynamic in-vivo performance of three biological aortic prostheses (Carpentier Perimount Magna EaseTM, Crown PRTTM, and TrifectaTM). Methods: The sample used in this study comes from the “BEST-VALVE” clinical trial, which is a phase IV single-blinded randomized clinical trial with the three above-mentioned prostheses. Results: 154 patients were included. Carpentier Perimount Magna EaseTM (n = 48, 31.2%), Crown PRTTM (n = 51, 32.1%) and TrifectaTM (n = 55, 35.7%). One year after the surgery, the mean aortic gradient and the peak aortic velocity was 17.5 (IQR 11.3–26) and 227.1 (IQR 202.0–268.8) for Carpentier Perimount Magna EaseTM, 21.4 (IQR 14.5–26.7) and 237.8 (IQR 195.9–261.9) for Crown PRTTM, and 13 (IQR 9.6–17.8) and 209.7 (IQR 176.5–241.4) for TrifectaTM, respectively. Pairwise comparisons demonstrated improved mean gradients and maximum velocity of TrifectaTM as compared to Crown PRTTM. Among patients with nominal prosthesis sizes ≤ 21, the mean and peak aortic gradient was higher for Crown PRTTM compared with TrifectaTM, and in patients with an aortic annulus measured with metric Hegar dilators less than or equal to 22 mm. Conclusions: One year after surgery, the three prostheses presented a different hemodynamic performance, being TrifectaTM superior to Crown PRTTM.

OBJECTIVES: The impact of systolic flow displacement on the development and progression of ascending aorta dilatation in aortic valve disease is a matter of controversy. Our objective was to study the association between rheological stimuli and development of aortic dilatation in a large animal model of supravalvular aortic stenosis and eccentric flow. METHODS: Twenty-four pigs weighing 10-14 kg were randomly allocated (ratio 2:1) to either restrictive ascending aortic banding or sham operation. Aortic diameter and systolic flow displacement were assessed by three-dimensional phase-contrast magnetic resonance imaging at 6 and 18 weeks after surgery. Twenty pigs (n = 14, banded vs n = 6, sham) completed full imaging protocol and were included in the analysis. After the last follow-up, a subset of 14 animals was sacrificed for histological analysis. RESULTS: All banded animals developed significant progressive aortic dilatation both at 6 and 18 weeks, compared with sham-operated pigs: 34.3 ± 4.8 vs 21.4 ± 2.7 mm at 6 weeks (P < 0.001); and 50.0 ± 8.4 vs 38.0 ± 8.3 mm at 18 weeks (P = 0.002). The peak gradient at 6 weeks showed a trend to positively correlate with aortic diameter at 18 weeks (R = 0.50, P = 0.06), whereas the systolic flow displacement at 6 weeks correlated better with aortic diameter at 18 weeks (R = 0.59, P = 0.02). The aortic wall thickness was significantly decreased in the anterior aortic section in banded, compared with sham-operated, pigs (1.5 ± 0.4 vs 2.0 ± 0.1 mm, respectively; P = 0.03). In addition, banded pigs showed a higher degree of cystic medial necrosis and elastin fibre fragmentation, compared with sham-operated animals. CONCLUSIONS: In this preclinical model of supravalvular aortic stenosis and eccentric flow, we found that systolic flow displacement at earlier stages is positively correlated with the degree of aortic dilatation during follow-up as assessed by three-dimensional phase-contrast magnetic resonance imaging. If our findings are confirmed in further studies, this imaging parameter might be useful to identify those subjects with aortic valve disease who are at risk of developing aortic dilatation at a later stage.

BACKGROUND AND AIM OF THE STUDY The replacement of a failed composite valve graft is technically more demanding and is associated with increased morbidity and mortality. We present our technique and outcomes for reoperations for composite graft failures. METHODS Between September 2011 and June 2017, 14 patients underwent a redo composite graft replacement. Twelve patients (85.7%) were male, and mean age was 58.4 years ± 12 standard deviation (SD). One patient had two previous root replacements. Indications for reoperation were endocarditis (8), aortic pseudoaneurysm (3), and aortic prosthesis thrombosis (3). Mean logistic EuroSCORE and EuroSCORE II were 30.8% and 14.7%, respectively. RESULTS A mechanical composite graft was used in 12 patients and biological composite grafts were used in two patients. Hospital mortality was 14.3% (n = 2). One patient (7.1%) required reoperation for bleeding, One patient (7.1%) had mechanical ventilation >24 h, and four patients (28.6%) required implantation of a permanent pacemaker. Median intensive care unit and hospital stays were 3 days (interquartile range [IQR] 1-5) and 10 days (IQR 6.5-38.5). One patient experienced recurrent prosthetic valve endocarditis 14 months after operation. On follow-up, 11 of 12 survivors were in New York Heart Association class I or II. Survival at 3 years was 85.7% ± 9.4% SD. CONCLUSIONS Composite valve graft replacement can be performed with acceptable morbidity and mortality with good mid-term survival.

Background and aim of the study Emergency conversion to on-pump during off-pump coronary artery bypass surgery (CABG) increases morbidity and mortality. We analyze its risk factors and impact on short- and long-term outcomes. Methods All patients undergoing isolated CABG between 2006 and 2012 were included. Postoperative and midterm mortality and the combined event (death, myocardial infarction, cerebrovascular accident, and repeat revascularization) were compared between patients with and without conversion. Multivariate analysis and propensity score matching were performed. Results A total of 1268 patients were operated off pump and 37 patients required an emergency conversion. Postoperative death and combined event were more frequent among patients who were converted (31.6% vs. 3.31%, p

Resumen Introduccion La arteriosclerosis coronaria se ha relacionado con la deplecion y la alteracion funcional de las celulas progenitoras endoteliales (EPC). Nos propusimos determinar el numero de celulas CD34 + /KDR + y CD34 + /CD144 + en pacientes sometidos a revascularizacion miocardica quirurgica, comparados con pacientes operados de recambio valvular, asi como el efecto de su plasma sobre EPC cultivadas de donantes sanos. Metodos El numero de CD34 + /KDR + y CD34 + /CD144 + se determino por citometria de flujo. Las EPC cultivadas se obtuvieron de residuos leucoplaquetarios transfusionales. La apoptosis se midio por fragmentacion de ADN. La expresion de CD34 y CD144 se determino por Western blot. Resultados Encontramos un menor numero de CD34 + /CD144 + en pacientes revascularizados comparados con los de recambio valvular, pero en ambos casos fue un numero mayor que el hallado en sujetos sanos. El plasma de pacientes revascularizados tuvo un efecto antiapoptotico sobre EPC de sujetos sanos (al dia 7 de aislamiento), y este efecto fue inhibido por los bloqueadores de la via del TGF-beta1 SIS3 y SB-431542. Previo a ello, en el dia 4, el plasma de los pacientes revascularizados aumento la expresion in vitro de CD34 y CD1144. Conclusion El plasma de los pacientes revascularizados es antiapoptotico y aumenta la expresion de CD34 y CD144 en EPC de donantes sanos. Por lo tanto, el numero suboptimo de CD34 + /CD144 + que se observa in vivo sugiere un defecto en su liberacion de la medula osea.

We sought to determine if early recurrence of atrial fibrillation (AF) after surgical ablation is a risk factor of late failure. Between February 2004 to May 2009, 106 patients underwent surgical ablation of concomitant permanent AF with radiofrequency. Operations primarily consisted of valve surgery in 85% of patients. Hospital mortality was 2.8% (n = 3). The median follow-up was 37 months (interquartile rank 12-77), and was complete in 99% of patients. Freedom from AF was 82%, 76% and 68% at one, two and three years, respectively. Patients with early recurrence of AF had less prevalence of sinus rhythm in late follow-up (P < 0.001). Multivariate Cox regression analysis showed that AF duration [hazard ratio (HR) 1.014, 95% CI 1.009-1.020, P < 0.001] and early recurrence of AF (HR 3.45, 95% CI 1.50-7.95, P = 0.004) were independent risk factors for failure. In conclusion, in our series, early recurrence of AF after surgical ablation is a strong predictor of late failure.

Inflammation is a common feature in cardiovascular diseases, including diabetes mellitus. In addition to the well-known inflammatory role of cyclo-oxygenase-2 (COX-2), this protein has also been implicated in apoptosis resistance in tumour cells. Vascular smooth muscle cells (VSMC) from diabetic patients are also resistant to apoptosis because of an increased abundance of B cell lymphoma 2 protein (BCL2). In this work, we investigated whether overproduction of COX-2 was involved in the resistance to apoptosis in VSMC from diabetic patients. VSMC were obtained from internal mammary arteries from patients who had undergone coronary artery bypass graft surgery. Apoptosis was measured by DNA fragmentation, BCL2 degradation and cytochrome c release. Apoptosis induced by C-reactive protein in cells from non-diabetic patients was mediated by COX-2. VSMC from diabetic patients showed higher basal levels of COX-2 compared with those from non-diabetic patients. Transfection of VSMC from non-diabetic patients with a plasmid containing COX-2 (also known as PTGS2) increased basal production of COX-2 and BCL2 and mimicked the resistance to apoptosis that occurs in diabetic patients. We also found a significant correlation (R = 0.846, p = 0.016) between COX-2 and BCL2 production in arterial rings from diabetic patients measured by confocal microscopy. However, inhibition of COX-2 production by small interfering RNA proved unable to reverse BCL2 production in diabetic VSMC. These results suggest a link between inflammation (COX-2) and apoptosis resistance (BCL2) in the arteries of diabetic patients. This relationship is not causative and the common production of these two proteins may be co-regulated by shared regulatory elements in diabetes.

Resumen Introduccion La disfuncion endotelial es un importante mediador de la mayor morbimortalidad cardiovascular de los pacientes diabeticos. Las celulas progenitoras endoteliales (EPC) parecen poseer defectos funcionales en estos pacientes. La pioglitazona aumenta el numero y funcion de las EPC y disminuye la mortalidad cardiovascular en la poblacion diabetica. Objetivos Determinar la capacidad de adhesion de EPC cultivadas sobre arterias de pacientes diabeticos y no diabeticos, asi como evaluar los efectos de la glucosa y la pioglitazona sobre estos parametros. Material y metodos Las EPC se aislaron de celulas mononucleares a partir de la capa leucoplaquetaria de sangre de donantes y se cultivaron sobre fibronectina en medio microvascular. La adhesion se midio marcando las celulas con 111 In-oxina y pasandolas ex vivo sobre una camara de flujo con arterias mamarias internas remanentes de cirugia cardiaca. La expresion de la proteina CXCR-4 se determino por citometria de flujo. Resultados Se observo una mayor adhesion de las EPC sobre las arterias de pacientes diabeticos. Esta adhesion disminuyo al incubar las celulas con glucosa a 15 mM. La co-incubacion con pioglitazona 1 μM restauro la capacidad adhesiva de las EPC. La glucosa a 15 mM disminuyo la expresion de CXCR-4 en las EPC cultivadas, en cambio, la pioglitazona a 1 μM fue capaz de aumentarla. Conclusion Pese a que las arterias de pacientes diabeticos tienen una mayor capacidad de reclutar EPC, la hiperglucemia disminuye las propiedades adhesivas de estas celulas.

We report our short-term and mid-term results with sutureless repair of postinfarction subacute left ventricular free wall rupture (LVFWR). For this purpose, we evaluated the short-term and mid-term postoperative results assessed by clinical examination and echocardiography of all patients who underwent surgery for subacute LVFWR between January 2004 and January 2009. Twenty-one patients were operated. Direct suture repair of LVFWR was carried out in only one patient. In all other cases we used a pericardial patch with biological glue. Early mortality was 19% (n=4). The median duration of follow-up was 17.3 months (interquartile range, 5-38.7), with a 13-month survival of 76%. Follow-up echocardiography showed no constriction associated with the rupture zone in any patient. According to our early experience, sutureless LVFWR repair is safe, effective and reproducible, and offers acceptable morbidity and mortality during follow-up.

Introduccion y objetivos. La relacion entre el numero de intervenciones cardiacas anuales (volumen) de un centro y sus resultados es controvertido. Varios estudios occidentales hallan una relacion inversa volumen/mortalidad. Analizamos el numero de intervenciones de algunos centros cardioquirurgicos nacionales y su mortalidad bruta y ajustada a riesgo. Metodos Estudio observacional prospectivo de 6.054 pacientes intervenidos en 16 hospitales, correspondientes al 34% del total de la actividad cardioquirurgica que se realizo en Espana durante el ano 2004. Se analizaron los factores de riesgo y los resultados de cada paciente intervenido en los centros participantes. Los datos de cada centro fueron verificados por auditoria independiente. Se estimo el riesgo quirurgico de cada paciente intervenido por los metodos de Parsonnet y EuroSCORE, con objeto de evaluar la mortalidad ajustada a riesgo. Resultados La mortalidad total fue del 7,7% (intervalo de confianza del 95%, 7%-8,4%). El indice de mortalidad ajustada a riesgo fue 0,81 por el metodo de Parsonnet y 1,12 por EuroSCORE. La correlacion entre numero de cirugias de un centro y mortalidad por el metodo de Pearson fue 0,065 para la mortalidad bruta, 0,092 para la mortalidad ajustada a riesgo por Parsonnet y 0,111 para la mortalidad ajustada por EuroSCORE. Descartando los centros con mortalidades mas alta y mas baja, los resultados fueron –0,464, –0,420 y –0,267 respectivamente. Conclusiones En Espana no hay relacion estadisticamente significativa entre el numero de intervenciones cardiacas de un centro y su mortalidad hospitalaria.

Introduction and objectives. The relationship between the annual number of cardiac procedures at a particular center (ie, volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and riskadjusted mortality. Methods. This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality. Results. Overall mortality was 7.7% (95% confidence interval, 7.0-8.4). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the 2 centers with highest and lowest mortality rates, respectively, the correlations were ‐0.464, ‐0.420, and ‐0.267, respectively. Conclusions. No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality.

Presentamos el caso de un varón de 57 años que, en el seno de un meningioma microcítico, padece una tromboembolia pulmonar masiva aguda con inestabilidad hemodinámica. Dado el riesgo de hemorragia por el tumor craneal, se contraindica la terapia fibrinolítica y se procede a practicar embolectomía pulmonar. Ésta se realiza bajo anestesia general, con canulación convencional y bajo hipotermia moderada. Se extrae émbolo en el tronco de la arteria pulmonar y con catéter de Fogarty se extraen émbolos en ramas lobares y segmentarias. Discutimos la asociación de enfermedad tromboembólica con determinadas neoplasias y el tratamiento de la tromboembolia pulmonarThe case of a 57-year-old male, suffering from a microcitic meningioma, who presented with an acute massive pulmonary embolism and hemodynamic instability is presented. Given the risk of haemorrhages because of intracraneal tumor, fibrinolytic therapy was contraindicated and pulmonary embolectomy performed under general anesthesia, with conventional cannulation and moderate hypothermia. An embolus was removed from the pulmonary artery trunk and several emboli from lobar and segmental branches using a Fogarty catheter. The association between thromboembolic pathology and some tumours and the treatment of pulmonary emboli is discussed.

Introduccion El objetivo de este trabajo fue estudiar la expresion de ciclooxigenasa 2 (COX-2) en arterias y celulas de musculo liso vascular provenientes de pacientes diabeticos y no diabeticos, asi como su induccion tras incubar celulas de pacientes no diabeticos con un preparado de trigliceridos. Material y metodos Se utilizaron segmentos de arterias mamarias internas usadas en cirugia de revascularizacion coronaria, y se procedio a homogeneizarlos, fijarlos o cultivarlos para obtener celulas de musculo liso vascular. La expresion de COX-2 se analizo por Western blot y microscopia confocal. Para inducir in vitro la expresion de COX-2, se incubaron las celulas de pacientes no diabeticos con Intralipid ® . Resultados Todas las medidas indicaron una mayor expresion de COX-2 tanto en arterias como en celulas de pacientes diabeticos. La expresion de COX-2 se correlaciono con el indice EuroSCORE, como indice pronostico de mortalidad precoz y de complicaciones mayores en la cirugia coronaria, menos favorable. Asimismo, la expresion de COX-2 se incremento de forma significativa con concentraciones crecientes de Intralipid ® . Conclusiones La expresion de COX-2 en arterias mamarias internas se relaciona con la diabetes mellitus y un indice EuroSCORE mas desfavorable. Tambien es posible aumentar la expresion de COX-2 incubando las celulas de pacientes no diabeticos con trigliceridos, lo que refuerza la asociacion entre hipertrigliceridemia, diabetes tipo 2, inflamacion vascular y un peor pronostico clinico.

An emerging body of evidence suggests that vascular remodeling in diabetic patients involves a perturbation of the balance between cell proliferation and cell death. Our aim was to study whether arteries and vascular smooth muscle cells (VSMCs) isolated from diabetic patients exhibit resistance to apoptosis induced by several stimuli. Internal mammary arteries (IMAs) were obtained from patients who had undergone coronary artery bypass graft surgery. Arteries from diabetic patients showed increasing levels of Bcl-2 expression in the media layer, measured by immunofluorescence and by Western blotting. Human IMA VSMCs from diabetic patients showed resistance to apoptosis, measured as DNA fragmentation and caspase-3 activation, induced by C-reactive protein (CRP) and other stimuli, such as hydrogen peroxide and 7β-hydroxycholesterol. The diabetic cells also exhibited overexpression of Bcl-2. Knockdown of Bcl-2 expression with Bcl-2 siRNA in cells from diabetic patients reversed the resistance to induced apoptosis. Consistent with the above, we found that pretreatment of nondiabetic VSMCs with high glucose abolished the degradation of Bcl-2 induced by CRP. Moreover, cell proliferation was increased in diabetic compared with nondiabetic cells. This differential effect was potentiated by glucose. We conclude that the data provide strong evidence that arterial remodeling in diabetic patients results from a combination of decreased apoptosis and increased proliferation.

Objetivos reducir la incidencia de infeccion del sitio quirurgico (ISQ) en pacientes sometidos a cirugia cardiaca (CC), mediante un protocolo de prevencion, para mejorar el pronostico tras una nueva estrategia diagnostica y terapeutica. Material y metodos analisis de la incidencia de ISQ en nuestro centro mediante un equipo multidisciplinario. Implantacion de medidas pre, intra y postoperatorias. Evaluacion tras 6 meses de implantacion y comparacion con datos historicos del centro. Variables analizadas: porcentaje de cumplimiento, tipo de profilaxis antibioticas y momento de administracion, control de glucemia, incidencia de ISQ (criterios de Centers for Disease Control [CDC]), entre otras. Analisis descriptivo y comparacion con la serie historica del centro. Resultados se intervinieron 376 pacientes entre mayo-no-viembre de 2011; 149 (39,6%) cumplimentaron completamente la lista de comprobacion. Rasurado correcto 68,4%, aplicacion de la mupirocina nasal 89,9%, hexetidina 86%, aseo con clorhexidina 86,5%. Correcta eleccion del antibiotico segun protocolo, 100% correcta, correcto momento de administracion 87%. Control glucemia 78,5%, uso correcto de corse 80,1%; 49% llegaron a la unidad de cuidados intensivos (UCI) en normotermia. Porcentaje ISQ 8 (2,1%), 2 casos ISQ superficial y 6 (1,59%) mediastinitis. Mortalidad hospitalaria 1 (0,26%). Conclusion tras 6 meses de aplicacion del protocolo se observa una reduccion del 41% de la tasa de mediastinitis en CC y de la mortalidad con respecto a la previa. Mejorar la tasa de cumplimiento de la lista de comprobacion nos permitira identificar areas de mejora para conseguir ISQ proxima a 0, para lo cual es fundamental una actuacion multidisciplinaria.

El factor de crecimiento transformante β (TGFß1) es una citocina antiinflamatoria de la cual se desconoce el papel de la edad en este contexto. Nuestro objetivo fue medir la señalización de TGF-β1 como fosforilación de p27 serina-10 en células de músculo liso vascular y arterias mamarias internas, provenientes de pacientes con diferentes edades. Material y métodos: Se reclutaron pacientes de cirugía abdominal para cultivo de células de músculo liso vascular. La proliferación y la apoptosis se midieron con kits enzymelinked immunosorbent assay (ELISA) (n = 5). Se reclutaron 169 pacientes de cirugía de revascularización miocárdica para análisis sérico de TGF-β1 mediante kit de ELISA. La fosforilación de serina se midió por Western blot de lisado celular (n = 5) o de arteria entera (n = 3). Resultados: Se observó una menor proliferación y una mayor apoptosis en células de músculo liso vascular provenientes de pacientes mayores de 65 años (p

Objetivos Validar la nueva escala EuroSCORE II (EII) en terminos de calibracion y capacidad discriminatoria, asi como comparar estos resultados con el EuroSCORE logistico clasico (ES). Material y metodos Se analizo una poblacion de 4.166 pacientes intervenidos durante un periodo de 7 anos. Se estudio, tanto para el ES como EII, la discriminacion mediante curvas ROC y la calibracion mediante el test de Hosmer-Lemeshow para los distintos terciles. Resultados La puntuacion media del ES fue superior a la del EII (9,1 ± 10,4 vs 3,46 ± 4,3; p Conclusiones El nuevo sistema de estratificacion de riesgo EII obtiene una mortalidad esperada inferior al ES y tiene un valor predictivo adecuado en terminos de calibracion y capacidad de discriminacion. Se observa una tendencia a una mejor capacidad discriminatoria respecto al ES, aunque dicho hallazgo no muestra significacion estadistica. ES EII Global (n = 4.166) 0,75 (0,72–0,78) 0,78 (0,75–0,81) Coronario (n = 1.202) 0,79 (0,71–0,86) 0,80 (0,74–0,86) Valvular (n = 1.678) 0,73 (0,68–0,77) 0,76 (0,71–0,8) Mixto (n = 293) 0,78 (0,70–0,86) 0,80 (0,73–0,87) Aorta (n = 411) 0,70 (0,62–0,79) 0,72 (0,63–0,81) Otras (n = 582) 0,73 (0,61–0,84) 0,85 (0,75–0,94)

Background Cardiovascular disease has been linked to endothelial progenitor cell (EPC) depletion and functional impairment in atherosclerosis and aortic stenosis. EPCs may play a pivotal role in vascular grafting. However, the EPC depletion in coronary artery bypass grafting (CABG) patients has not been compared to coronary artery disease-free valvular replacement patients with aortic stenosis. Methods We aimed to assess the basal number of CD34+/KDR+ and CD34+/CD144+ cells in CABG patients, compared to aortic stenosis valvular replacement patients. 100 patients (51 CABG and 49 valvular surgery ones) were included in the present study. All CABG or valvular patients had angiographic demonstration of the presence or the absence of coronary artery disease, respectively. Numbers of CD34+/KDR+ and CD34+/CD144+ were assessed by flow cytometry of pre-surgical blood samples. Results We found a lower number of CD34+/CD144+ cells in CABG patients compared to valvular patients (0.21 ± 0.03% vs. 0.47 ± 0.08%), and this difference remained statistically significant after the P was adjusted for multiple comparisons (P = 0.01428). Both groups had more EPCs than healthy controls. Conclusions Pre-surgical CD34+/CD144+ numbers are decreased in CABG patients, compared to valvular patients with absence of coronary disease., This work was supported by FISS (Health Research Fund, PI080920) and Red Tematica de Investigacion Cardiovascular RECAVA (RD06/0014/1007, RD06/0014/1027), both from the Instituto de Salud Carlos III (ISCIII). We are grateful to Fernando Ortego and all the nurses and doctors from the Cardiac Surgery service, Hospital Clinico San Carlos, for their technical assistance. We acknowledge support from Centro de Microscopía y Citometría (Universidad Complutense) and the Regional Blood Transfusion Centre, Madrid.

Population over 80 years who require surgery for degenerative aortic stenosis has largely increased in the past decades. We have compared short- and mid-term results for conventional aortic valve replacement (AVR) for calcific-degenerative aortic stenosis in older and younger than 80 years operated at our institution between April 2004 and December 2008. Predictors of mortality and major adverse cardio and cerebrovascular events (MACCEs) on the postoperative and follow-up period were determined through multivariable analysis. Four hundred and fifty-one patients were included in the study. Ninety-four (20.8%) were ≥80. Previous cardiac surgery wodds ratio (OR=4.08, P=0.047), renal failure (OR=6.75, P

Pregnant women with a mechanical heart prosthesis are at a higher risk of thromboembolic complications. The optimal anticoagulation strategy in this setting remains unclear. When prosthesis thrombosis happens and cardiac surgery must be performed, the risk of fetal mortality is high. Special attention must be paid to improve the placental perfusion during cardiopulmonary bypass (CPB) in order to improve fetal outcomes. A 31-year-old woman, nine weeks pregnant, was admitted to our institution due to a mitral mechanical prosthesis thrombosis. She had been receiving low molecular weight heparin (LMWH) since pregnancy was detected. She underwent a mitral valve replacement with CPB at 34 degrees C and a short cardiac arrest time. Both mother and fetus survived. We briefly review the different anticoagulation options during pregnancy and perfusion strategies on CPB to improve fetal outcomes.

A 62-year-old man was accepted to our institution because of hypereosinophilia, severe tricuspid regurgitation and isolated right restrictive myocardiopathy, with thrombi inside the right atrium and ventricle. Based on the diagnosis of hypereosinophilic syndrome plus eosinophilic myocarditis, the patient underwent a tricuspid valve repair and endomyocardiectomy. We briefly discuss hypereosinophilic syndrome myocardiopathy, and its management.

The relationship between the annual number of cardiac procedures at a particular center (i.e., volume) and surgical outcome is controversial. Several studies in western countries indicate that there is an inverse relationship between surgical volume and mortality. We studied the number of procedures carried out at several cardiac surgery units in Spain and their relationship to overall and risk-adjusted mortality.This prospective observational study carried out in 6054 patients undergoing cardiac surgery at 16 hospitals represents 34% of all cardiac surgery performed in Spain during 2004. Data on risk factors and outcomes for each patient treated at participating institutions were analyzed. Data from each center were checked by an external referee. Surgical risk was evaluated for each patient using the Parsonnet and EuroSCORE methods, with the aim of determining risk-adjusted mortality.Overall mortality was 7.7% (95% confidence interval, 7.0%-8.4%). The risk-adjusted mortality index was calculated to be 0.81 using the Parsonnet method, and 1.12 using EuroSCORE. The Pearson correlation coefficient for the relationship between the number of procedures carried out at a center and mortality was 0.065 for overall mortality, 0.092 for risk-adjusted mortality (Parsonnet method), and 0.111 for risk-adjusted mortality (EuroSCORE method). After discarding data from the two centers with highest and lowest mortality rates, respectively, the correlations were -0.464, -0.420 and -0.267, respectively.No statistically significant relationship was found between the number of cardiac procedures carried out at a particular center in Spain and inhospital mortality.

Mujer de 36 años con malformaciones en primer dedo y eminencia tenar desde la infancia. Seis meses antes, estando asintomática, presentó fibrilación auricular, siendo diagnosticada de comunicación interauricular ostium secundum de 2 × 2cm, que producía un cortocircuito Qp/Qs 2:1. La exploración muestra hipoplasia bilateral de la eminencia tenar y primer dedo (Fig. 1), con ausencia de flujo, por eco-Doppler, en tercio distal de ambas arterias radiales. La radiología objetiva hipoplasia ósea del primer metacarpiano y ambas falanges del primer dedo (Fig. 2). Se intervino cerrándose la comunicación con sutura directa, siendo dada de alta a los 5 días.A 36-year-old female patient with bilateral thenar eminence and thumb malformations since childhood. Six months earlier she presented with a bout of atrial fibrillation. The diagnosis of a 2 × 2cm secundum type atrial septal defect with a Qp/Qs 2:1 shunt was performed. Physical examination showed a bilateral thenar and thumb hypoplasia (Fig. 1) with no echo- Doppler flow in the distal third of both radial arteries. Plain X-ray showed bilateral hypoplasia of the thenar bones and phalanges (Fig. 2). Direct suture closure of the atrial septal defect was successfully performed and the patient was discharged on the fifth postoperative day.

Objective: This study sought to evaluate the prognostic significance of the presence of DNA of Chlamydia pneumoniae in the coronary atherosclerotic lesions of patients with unstable angina. Background: C. pneumoniae has been implicated in the pathogenesis of coronary artery disease by serological and pathological studies, but whether antichlamydial antibodies and the presence of this pathogen in the coronary atherosclerotic tissue are related to prognosis in unstable angina remains unclear. Methods: A total 76 coronary specimens from 45 patients with unstable angina undergoing bypass surgery were subjected to nested polymerase chain reaction (PCR) for C. pneumoniae . Antichlamydial immunoglobulin G (IgG), A (IgA) and M (IgM) were also examined by an enzyme immunoassay. Patients were followed during a 2-year period to determine the incidence of adverse cardiovascular events. Results: DNA of C. pneumoniae was detected in 57 (75%) of 76 atherosclerotic lesions: 39 patients showed a positive PCR result in at least one plaque. Of the 45 patients, 44 (97.7%) showed a positive serological result: IgG was positive in 39 (86.6%) patients, IgM in five (11.1%) patients and IgA in 42 (93.3%). Clinical characteristics and serologic results were similarly distributed in patients with and without infected lesions at enrollment. At least one adverse event occurred in 21 (46.6%) of the 45 patients at 2 years: death in nine (20%), recurrent angina in 12 (26.6%), revascularization in six (13.3%) and myocardial infarction in two (4.4%) patients. The composite endpoint of death, myocardial infarction, recurrent angina and revascularization at 2-year follow-up did not differ according to the PCR or serologic results. Conclusions: The presence of C. pneumoniae in coronary atherosclerotic plaques of patients with unstable angina undergoing coronary bypass grafting does not have prognostic significance. In addition, serology does not allow us to differentiate those patients with plaque infection by C. pneumoniae and also does not provide any prognostic information in these patients.

Endothelial progenitor cell (EPC) dysfunction is an important mediator of vascular disease in diabetes. We aimed to elucidate the mechanism of adhesion of EPC to diabetic and non-diabetic arteries and to study the effect of the anti-diabetic drug pioglitazone. Peripheral blood mononuclear cells were isolated from healthy donors. Human internal mammary arteries (HIMA) were isolated from patients who underwent coronary artery bypass surgery. EPC were labelled with 111In-oxine and perfused to HIMA in a perfusion chamber. Stromal derived factor-1 (SDF-1) and cyclooxygenase-2 (COX-2) were assessed by immunohistochemical analysis. CXCR-4 expression was assessed by flow cytometry. Adhesion of EPC was increased in HIMA from diabetic patients and was reduced after preincubation with 15 mM glucose for 72 h. EPC adhesion and CXCR-4 expression were inversely correlated. COX-2 and SDF-1 immunostaining in HIMA were positively correlated. Pioglitazone (1 microM) increased the adhesion of EPC to HIMA and the expression of CXCR-4 in EPC. Therefore, EPC-recruiting capability is increased in diabetic arteries, although EPC adhesion is notably impaired by high glucose concentrations. Interestingly, pioglitazone treatment enhances EPC adhesiveness.

Mujer de 59 años, que presentaba accidentes cerebrovasculares de repetición, de posible origen cardioembólico. Al realizar el estudio cardiológico, en el ecocardiograma transesofágico se detectó una masa de 7–8mm dependiente de la valva anterior mitral, que ocasionaba una insuficiencia mitral leve (Fig. 1). Fue intervenida bajo circulación extracorpórea, por vía transeptal anterior auricular, extirpándose dicha masa y la base de implantación, cerrando el defecto de la valva mitral con puntos sueltos (Fig. 2). El postoperatorio fue normal, siendo dada de alta a los 7 días. La anatomía patológica demostró que se trataba de un fibroelastoma papilar.A 59-year-old female, with past history of recurrent ischemic cerebrovascular accidents. Transesophageal echocardiography showed a 7–8mm mass arising from the anterior leaflet of the mitral valve with trivial mitral insufficiency (Fig. 1). The patient was operated through a trans-right atrial septal incision. The mass was excised and the anterior leaflet of the mitral valve repaired (Fig. 2). The histological examination confirmed papillary fibroelastoma. The patient was discharged on the seventh postoperative day.

Background Transforming growth factor beta (TGF-β1) is a pleiotropic cytokine, which is deregulated in atherosclerosis; however the role of age in this process is unknown. We aimed to assess whether TGF-β1 signaling is affected by age. Methods Vascular smooth muscle cells (VSMC) were obtained from patients undergoing abdominal surgery. Levels of TGF-β1 were measured by ELISA in sera from 169 patients undergoing coronary artery bypass grafting (CABG). The p27 expression was determined by Western blot from internal mammary arteries (IMA) obtained from CABG patients (n = 13). In VSMC from these patients undergoing abdominal surgery, secretion of TGF-β1 was determined by ELISA of cell-conditioned media. Results In VSMC from aged patients we observed a lower TGF-β1 secretion, measured as TGF-β1 concentration in cell conditioned medium (p p = 0.0195). Conclusions VSMC from aged patients showed a higher degree of cellular senescence and it was associated to a lower TGF-β1 secretion and signaling.

Background Inflammation is a common feature in the majority of cardiovascular disease, including Diabetes Mellitus (DM). Levels of pro-inflammatory markers have been found in increasing levels in serum from diabetic patients (DP). Moreover, levels of Cyclooxygenase-2 (COX-2) are increased in coronary arteries from DP. Methods Through a cross-sectional design, patients who underwent CABG were recruited. Vascular smooth muscle cells (VSMC) were cultured and COX-2 was measured by western blot. Biochemical and clinical data were collected from the medical record and by blood testing. COX-2 expression was analyzed in internal mammary artery cross-sections by confocal microscopy. Eventually, PGI2 and PGE2 were assessed from VSMC conditioned media by ELISA. Results Only a high glucose concentration, but a physiological concentration of triglycerides exposure of cultured human VSMC derived from non-diabetic patients increased COX-2 expression. Diabetic patients showed increasing serum levels of glucose, Hb1ac and triglycerides. The bivariate analysis of the variables showed that triglycerides was positively correlated with the expression of COX-2 in internal mammary arteries from patients (r2 = 0.214, P Conclusions We conclude that is not the glucose blood levels but the triglicerydes leves what increases the expression of COX-2 in arteries from DP.