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Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomized trials. The QUALITY-AVR trial is a single-blind, single-center, independent, randomized clinical trial comparing ministernotomy to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients were randomized in a 1:1 computational fashion. The primary endpoint was a difference between intervention groups of ≥0.10 points in change from baseline quality of life Questionnaire EuroQOL-index, measured at 1, 6, or 12 months. Secondary endpoints were differences in change from other baseline EuroQOL-index utilities, cardiac surgery-specific satisfaction questionnaire (SATISCORE), a combined safety endpoint of 4 major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events, and acute renal failure), bleeding through drains within the first 24 hours, intubation time, and other minor endpoints. Clinical follow-up was scheduled at baseline, 1, 6, and 12 months after randomization. Change from baseline mean difference EQ-5D-index was +0.20 points (95% confidence interval 0.10–0.30, P

Background: Currently, studies are underway to determine whether coronary stent implantation with percutaneous transluminal coronary angioplasty before a coronary artery bypass graft (CABG) influences the prognosis of surgery. This study aimed to assess the need for future revascularisation or all-cause mortality as a composite endpoint after CABG surgery among patients with previous stent implantation. Methods: A retrospective, non-randomised study was performed on 721 patients who underwent CABGin our centre between 2012 and 2017. This single-centre study compared two groups: 1) the previous stent group, patients with previous stent implantation (n=144), and 2) the non-previous stent group, patients without previous stent implantation (n=577). Results: After a median follow-up of 36 months, the previous stent group presented a decreased combined event-free survival at 1, 3 and 5 years compared with the non-previous stent group (67.4, 43.5 and 23.0% vs. 91.0, 80.3 and 63.0%, respectively; p Conclusions: Patients with percutaneous coronary intervention before CABG present higher comorbidities and clinical events during follow-up than those who do not undergo stenting.

Background: Isolated tricuspid valve surgery is a rarely performed procedure and traditionally is associated with a bad prognosis, although its clinical outcomes still are little known. The aim of this study was to assess the short- and long-term clinical outcomes obtained at our center after isolated tricuspid valve surgery as treatment for severe tricuspid regurgitation. Methods: This retrospective study included 71 consecutive patients with severe tricuspid regurgitation who underwent isolated tricuspid valve surgery between December 1996 and December 2017. Perioperative and long-term mortality, tricuspid valve reoperation, and functional class were analyzed after follow up. Results: Regarding surgery, 7% of patients received a De Vega annuloplasty, 14.1% an annuloplasty ring, 11.3% a mechanical prosthesis, and 67.6% a biological prosthesis. Perioperative mortality was 12.7% and no variable was shown to be predictive of this event. After a median follow up of 45.5 months, long-term mortality was 36.6%, and the multivariate analysis identified atrial fibrillation as the only predictor (Hazard Ratio 3.014, 95% confidence interval 1.06-8.566; P = 0.038). At the end of follow up, 63.6% of survivors had functional class I. Conclusions: Isolated tricuspid valve surgery was infrequent in our center. Perioperative mortality was high, as was long-term mortality. However, a high percentage of survivors were barely symptomatic after follow up.

Resumen: Introducción: La minitoracotomía anterior derecha es un abordaje alternativo a la esternotomía media para tratar dolencias mitrales, tricúspides y defectos interauriculares. Además de evitar las complicaciones asociadas a la esternotomía, este abordaje aporta ventajas estéticas y una recuperación precoz. Métodos: Realizamos un estudio observacional retrospectivo de toda nuestra serie de 106 pacientes intervenidos con una minitoracotomía anterior derecha entre enero de 2013 y junio de 2019. En los primeros 55 casos el procedimiento se realizó con visión directa y desde octubre de 2017 la cirugía fue videoasistida. Comparamos los datos perioperatorios de ambos grupos. Resultados: Los procedimientos fueron: 46 reparaciones mitrales, 30 recambios mitrales, 15 recambios tricúspides y 15 cierres de comunicaciones interauriculares. Dieciocho pacientes tenían cirugía cardíaca previa. El EuroSCORE I medio fue de 6,08. La mortalidad hospitalaria fue del 0,9% (un paciente). La reconversión a esternotomía se realizó en 6 pacientes. El tiempo medio de pinzamiento aórtico y circulación extracorpórea fue de 88 ± 27 y 137 ± 36 min, respectivamente. La estancia media hospitalaria fue de 5,8 ± 1,9 días. El 78% de los pacientes no recibió transfusión de hematíes. Cuando se compararon los resultados perioperatorios de los primeros 55 pacientes con el grupo de cirugía videoasistida (51 pacientes), la estancia hospitalaria y la transfusión de hematíes mejoró significativamente en el grupo videoasistido. Conclusiones: La minitoracotomía anterior derecha es una alternativa segura a la esternotomía, al menos con los mismos estándares de calidad y morbimortalidad postoperatoria. La introducción de una torre videotoracoscópica y la experiencia mejoraron los resultados iniciales. Abstract: Introduction: The right anterior mini-thoracotomy is an alternative approach to medial sternotomy to treat mitral pathology, tricuspid valve, and atrial septal defect. In addition to avoiding complications associated with sternotomy, this approach provides cosmetic advantages and early recovery. Methods: A retrospective observational study was performed on the entire series of 106 patients operated using a right anterior mini-thoracotomy between January 2013 and June 2019. In the first 55 cases the procedure was performed with direct vision, and from October 2017 the surgery was video-assisted. A comparison is made of the perioperative data of both groups. Results: The procedures performed were: 46 mitral repairs, 30 mitral replacements, 15 tricuspid replacements, and 15 atrial septal defect closures. Eighteen patients had previous cardiac surgery. The mean EuroSCORE I was 6.08. Hospital mortality was 0.9% (one patient). Conversion to sternotomy was performed in 6 patients. The mean aortic clamping time and bypass time was 88 ± 27 and 137 ± 36 minutes, respectively. The mean hospital stay was 5.8 ± 1.9 days. Only 22% of patients received a red blood cell transfusion. When the perioperative results of the first 55 patients were compared with the group in which video-assisted surgery was performed (51 patients), hospital stay and red blood cell transfusion improved significantly in the video-assisted group. Conclusions: The right anterior mini-thoracotomy is a safe alternative to sternotomy with at least the same standards of quality and postoperative morbidity and mortality. The introduction of a thoracoscopic camera and experience, improved the initial results. Palabras clave: Cirugía cardiaca, Minitoracotomía, Reparación mitral, Cirugía videoasistida, Visión directa, Keywords: Cardiac Surgery, Mini-thoracotomy, Mitral repair, Video-assisted surgery, Direct vision

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Resumen: Introducción y objetivos: ESPAMACS es el registro de asistencia circulatoria y respiratoria de la SECTCV. Empezó su funcionamiento en 2013, como evolución del anterior registro del Grupo de Trabajo de Asistencia Circulatoria. El objetivo del presente trabajo es presentar un resumen de la actividad realizada en los 2 últimos años. Métodos: ESPAMACS es un registro voluntario. Se ha hecho una revisión retrospectiva de todos los dispositivos registrados en ESPAMACS en el período 2017-2018. Resultados: En este período de tiempo se incluyeron en ESPAMACS 35 implantes de larga duración y 378 implantes de corta duración (303 membranas de oxigenación extracorpórea, 30 asistencias biventriculares, 41 asistencias ventriculares izquierdas y 5 asistencias ventriculares derechas).La supervivencia hospitalaria de los dispositivos de larga duración fue del 80%. Los dispositivos de corta duración presentan supervivencias que oscilan entre el 25% y el 60% según el dispositivo. Conclusiones: El implante de dispositivos de larga duración ha experimentado un ligero aumento respecto a años previos. Se ha registrado un gran número de implantes de membrana de oxigenación extracorpórea con múltiples indicaciones. Los resultados son similares a los de años previos. Abstract: Introduction and objectives: ESPAMACS is the SECTCV's registry for circulatory and respiratory support. It started functioning on 2013 as an evolution of the prior registry from the Grupo de Trabajo de Asistencia Circulatoria. The objective of the current manuscript is presenting a summary of the activity registered. Methods: ESPAMACS is a voluntary registry. Authors have performed a retrospective review of all devices registered between 2017 and 2018. Results: Between 2017-2018, 35 long-term support devices were registered. A number of 378 short-term devices were included in the registry during the same period (303 extracorporeal membrane oxygenation, 30 biventricular assist device, 41 left ventricular assist device y 5 right ventricular assist device).Hospital survival for long-term devices was 80%. Short-term devices present lower rates of survival that varies between 25 and 60%. Conclusions: Long-term devices show a steady increase from previous years. There is a significant increase in the extracorporeal membrane oxygenation implant, for multiple indications. Despite this growing in the number of implants, results remain similar to previous years. Palabras clave: Registro, Asistencia ventricular, Membrana de oxigenación extracorpórea, Corta duración, Larga duración, Keywords: Registry, Ventricular assist device, Extracorporeal membrane oxygenation, Short-term, Long-term

Resumen: La cirugía cardiovascular es la especialidad médica que se ocupa de la prevención, diagnóstico y tratamiento quirúrgico de los trastornos y enfermedades del sistema cardiocirculatorio. Los continuos y rápidos avances en el diagnóstico y tratamiento de las enfermedades cardiovasculares justifican la necesidad de llevar a cabo una actualización de los principales aspectos definitorios y organizativos de la especialidad, relacionados con la profesión (de la práctica, calidad asistencial), con el programa docente de la especialidad, la formación continuada de los cirujanos, los procesos de acreditación desde la Sociedad Española de Cirugía Torácica-Cardiovascular, entre otros.Este documento, elaborado por expertos de la cirugía cardiovascular, representa la opinión de la Sociedad Española de Cirugía Torácica-Cardiovascular y actualiza los principales aspectos de la especialidad en nuestro país. Abstract: Cardiovascular surgery is the medical specialty that deals with the prevention, diagnosis, and surgical treatment of disorders and diseases of the circulatory system. The continuous and rapid advances in the diagnosis and treatment of cardiovascular diseases justify the need to update the main, defining, and organisational aspects of the specialty, related to the profession (its practice, quality care), aspects on the teaching program of the specialty, the continuing education program of the surgeons, the processes of accreditation from the Spanish Society of Thoracic-Cardiovascular Surgery, etc.This document, prepared by experts in cardiovascular surgery, represents the opinion of the Spanish Society of Thoracic-Cardiovascular surgery and updates the main aspects of the specialty in our country. Palabras clave: Cirugía cardiovascular, Cirugía cardíaca, Cirugía torácica, Cirugía vascular, Recomendaciones, Keywords: Cardiovascular surgery, Cardiac surgery, Thoracic surgery, Vascular surgery, Recommendations

Objectives To investigate long term survival (15 years) and major morbidity in patients aged 50–65 years undergoing primary isolated aortic valve replacement with bioprosthetic or mechanical valves. Methods A single center retrospective analytical study of all patients aged 50–65 years with severe aortic stenosis who underwent surgery between 2000 and 2015 was performed (n = 200). Two groups, mechanical (n = 117) and biological (n = 83) were obtained. Propensity score matching was performed for analysis. Primary outcome was survival, secondary outcome was major adverse cardiovascular complications (30-day mortality, stroke, any prosthesis-related reoperation and major bleeding). Results Mean age was 60 ± 4 years, 33% female, mean follow up was 8.2 ± 3 years (range 0–17 years). Matched overall survival was similar between groups, 65% at 15 years [Log Rank p = 0.71, hazard ratio 0.87 (95% CI, 0.41–1.82)]. After matching, mechanical prosthesis presented a trend toward of more major adverse cardiovascular complications (30% versus 15%, p = 0.07) with more major bleedings (15% versus 6.3%, p = 0.06), stroke 11% versus 7.6% (p = 0.44), and cardiac-related rehospitalization (33.7% versus 21.5%, p = 0.06). Reoperation was nonsignificant between groups (2.5% mechanical versus 6.3% bioprosthesis, with only 2 cases of structural valve degeneration). Follow up mean transprosthetic gradients were higher in the mechanical group (18 ± 6 versus 15 ± 7 mmHg, p = 0.01). Conclusions Among propensity matched patients there were no differences in survival between groups at 15 years. The mechanical prosthesis presented a trend toward twofold more major adverse cardiovascular complications specially due to major bleeding. Studies with larger sample sizes are needed to confirm these results.

Background During the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes. Methods/design The QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy (“J” shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria. Discussion The QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical “gold standard” for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled. Trial registration ClinicalTrials.gov, NCT02726087. Registered on 13 March 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2486-x) contains supplementary material, which is available to authorized users.

Resumen Introduccion La valvula aortica bicuspide (VAB) es la malformacion cardiaca congenita mas frecuente. Se asocia a un mayor riesgo de complicaciones cardiovasculares, entre las que se incluye la endocarditis infecciosa (EI). Metodos Estudio observacional, unicentrico de cohorte, que incluye de forma prospectiva a todos los pacientes ingresados por EI entre 1996 y 2014. Se analizan datos epidemiologicos, clinicos, microbiologicos, ecocardiograficos, complicaciones durante la hospitalizacion, necesidad quirurgica, mortalidad intrahospitalaria y seguimiento a un ano. Se excluyen los casos con endocarditis sobre valvulas protesicas o en otras localizaciones, y aquellos de cuya valvula aortica no se tienen datos certeros acerca de su morfologia. Se ha realizado un analisis estadistico comparativo entre VAB y tricuspide (VAT). Resultados De un total de 328 casos con EI, 118 (35,67%) fueron sobre valvula aortica. Tenian VAB 18 (16,22%). Los casos con VAB eran mas jovenes que los portadores de VAT (51 ± 19,06 vs. 60,83 ± 15,73 anos, p = 0,021) y tenian menos comorbilidad (indice de Charlson 0,67 ± 0,77 vs. 1,44 ± 1,64, p = 0,03). En el grupo con VAB observamos tendencia a EI causada por Staphylococcus spp. (38,9 vs. 21,5%, p = 0,137). Con diferencia estadistica, hubo mas complicaciones perivalvulares entre los casos con VAB (55,6% vs. 16,1%, p = 0,001) predominando los abscesos (38,9 vs. 16,1%, p = 0,047). Ser portador de VAB fue el unico factor predictor de las mismas (OR 7,87, IC del 95%, 2,38-26,64, p = 0,001). Los pacientes con VAB se operaron mas (83,3 vs. 44,1%, p = 0,004) y la mortalidad durante el ingreso hospitalario fue menor, aunque no alcanzo significacion estadistica (5,6 vs. 25,8%, p = 0,069). La supervivencia a un ano fue significativamente superior en el grupo de VAB (93,8 vs 69,3%, p = 0,048). Conclusiones Los pacientes con EI sobre VAB son jovenes, con poca comorbilidad asociada. Tienen frecuentemente complicaciones perivalvulares por lo que requieren cirugia precoz. La mortalidad intrahospitalaria comparada con EI sobre VAT es menor y la supervivencia a un ano es significativamente mayor.

Resumen Presentamos el caso de una paciente de 44 anos, con insuficiencia mitral severa por prolapso de P2. Realizamos una reparacion mitral mediante reseccion cuadrangular y anuloplastia con anillo, a traves de auriculotomia izquierda en surco. La paciente se extuba a las 6 h, presentando buena hemodinamica sin aminas. Se realiza ecocardiograma a las 24 h confirmando el buen resultado de la cirugia. Se intenta retirar el cateter de Swan-Ganz sin exito, por lo que se decide reintervencion. En el quirofano se intenta retirar el cateter de manera directa comprobandose que se encuentra firmemente fijado. Se decide entrar en bypass y sin isquemia se realiza una auriculotomia derecha comprobando que se encuentra incluido en la sutura de cierre de la auriculotomia izquierda. Cortamos el cateter a nivel de la sutura y, con la ayuda de un gancho de nervio, se consigue movilizar y retirar el mismo. No fue necesario rehacer la sutura de la auriculotomia, por lo que se consiguio evitar el pinzamiento aortico. La paciente se volvio a extubar a las 4 h, siguiendo un curso postoperatorio satisfactorio y siendo dada de alta a los 5 dias.

ResumenEl envejecimiento de la población ha aumentado el número de cirugías sobre la válvula aórtica. Durante los últimos 20años la técnica quirúrgica ha evolucionado hacia una menor agresión corporal, apareciendo nuevos tipos de cirugía aórtica mínimamente invasiva (CMIAo). De todas estas técnicas, la hemiesternotomía superior (HES), o miniesternotomía, se ha convertido en la más utilizada, seguida por la minitoracotomía anterior derecha (MTA). Ambas, comparadas con la cirugía convencional, han demostrado una recuperación más rápida, mejor resultado cosmético, menor estancia hospitalaria y en UCI, mejor función respiratoria, menor pérdida de sangre y transfusiones, e incluso menor mortalidad precoz y tardía. A pesar de estos avances, su uso no se ha extendido definitivamente debido a un incremento en los tiempos de isquemia y de circulación extracorpórea (CEC) necesarios en estos procedimientos más complejos. La aparición de las prótesis sin sutura «Sutureless» de nueva generación puede solventar este contratiempo al reducir hasta en un 43% los tiempos de isquemia y CEC, y permitir que la CMIAo se expanda y sea una alternativa real a las válvulas transcatéter (TAVI) en los pacientes de alto riesgo operables. A pesar de que son recomendables ensayos clínicos prospectivos aleatorizados para confirmar estos datos, existe suficiente evidencia disponible como para considerar la CMIAo (sobre todo la HES) como el gold standard actual para la sustitución valvular aórtica aislada.AbstractThe aging of the population has led to an increase in the number of surgeries on the aortic valve. During the past 20years the surgical technique has progressed to less aggressive techniques, with new types of minimally invasive aortic valve surgery (MIAVR) emerging. Of these techniques, the upper hemi-sternotomy (UHS) or mini-sternotomy has become the most commonly used, followed by the right anterior thoracotomy (RAT). Compared with conventional surgery, both have shown a faster recovery, better cosmetic results, shorter hospital and ICU stay, better respiratory function, reduced blood loss and transfusions, as well as lower early and late mortality. Despite these advances, their use has not been definitively extended, due to an increase in the ischaemia and cardiopulmonary bypass (CPB) times needed in these more complex procedures. The emergence of new generation sutureless prosthesis can overcome this setback by reducing the ischemic and CPB by up to 43%, and allows MIAVR to expand and become a real alternative to the transcatheter valves (TAVI) in high risk operable patients. Although prospective randomised controlled trials are required to confirm these data, there is sufficient available evidence to consider MIAVR (especially UHS) as the current reference method for isolated aortic valve replacement.

Objectives Bicuspid aortic valve (BAV) is the most prevalent congenital cardiac malformation, frequently associated with aortic dilatation (AD). The molecular mechanisms involved in AD and its aetiological link with BAV formation are poorly understood. Altered fibrillin-1 (FBN1) and metalloprotease-2, -9 (MMP2,9) protein activities have been suggested to be involved in BAV aortopathy. In addition, FBN2 participates in embryonic valve formation, but its possible involvement in BAV-associated AD has never been explored. In this report, we evaluate the expression levels of MMP2,9 and FBN1,2 in the ascending aorta of patients with normal or dilated aortas and with tricuspid aortic valve (TAV) or BAV, using appropriate tissue-specific reference genes. Methods Gene expression was quantified by real-time quantitative polymerase chain reaction in 52 patients, using one or three reference genes previously validated in the same patient population. Results FBN2 expression was significantly increased in the aortas of patients with BAV compared with individuals with TAV (0.178 ± 0.042 vs 0.096 ± 0.021, P = 0.015), whereas differences in FBN1 did not reach statistical significance (1.946 ± 0.228 vs 1.430 ± 0.114, P = 0.090). When four groups of samples were considered, FBN2 expression was significantly higher in patients with BAV and AD compared with patients with TAV and AD (0.164 ± 0.035 vs 0.074 ± 0.027, P = 0.040). No significant differences were found when FBN1/FBN2 ratio, and MMP2 and MMP9 expression levels were analysed. No linear relationship between aortic diameter and gene expression levels were found. Conclusions BAV patients have an increased FBN (especially FBN2) gene expression level in the ascending aorta, irrespective of dilatation, whereas MMP expression does not change significantly. These results add a new piece of information to the pathophysiology of BAV disease and point to FBN2 as a new molecular player.

ResumenFundamentoLa cirugía valvular aórtica aislada mínimamente invasiva mediante miniesternotomía superior se está generalizando debido a ventajas respecto a la cirugía convencional. Analizamos los resultados a 2 años en nuestro centro tras la implementación de la técnica en noviembre del 2013.MétodosEstudio observacional analítico retrospectivo de 92 pacientes consecutivos intervenidos de sustitución valvular aórtica aislada por estenosis aórtica severa, desde noviembre del 2013. Se obtuvieron 2 grupos (grupo miniesternotomía y grupo convencional) de 40 pacientes mediante puntuación de propensión para su comparación (objetivo primario compuesto de 6 complicaciones cardíacas y cerebrovasculares mayores, y secundarios como tiempos de circulación extracorpórea e isquemia, tiempo intubación, sangrado en 24h, transfusiones y supervivencia).ResultadosLa mediana de los tiempos de circulación extracorpórea e isquemia fueron 15 y 10 min más largos en el grupo miniesternotomía (89 [75-110] y 74 [64-90] vs. convencional 65 [55-73] y 55 [47-63] min, respectivamente, p

ResumenLa enfermedad degenerativa de la válvula aórtica es cada vez más frecuente en nuestro medio. El tratamiento quirúrgico clásico consiste en la sustitución de la válvula por algún tipo de injerto mecánico o biológico. La reparación valvular, aunque no sea una opción posible en todos los pacientes, ofrece ventajas en cuanto a morbimortalidad, ofreciendo resultados duraderos a medio y largo plazo.En el presente artículo intentaremos establecer una guía de ayuda para decidir si la válvula –y el paciente– a los que nos enfrentamos pueden y deben repararse o no.AbstractAortic valve degnerative disease is increasingly prevalent in our environment. The stablished surgical treatment for this disease is valve replacement with a biological or mechanical substitute. Valve repair, although not always feasible, is superior to replacement in terms of morbidity and mortality with good medium and long term durabilities.This paper pretends to be an aid guide for those starting with aortic valve repair, to help them evaluate both the valve and the patient in order to decide what to do: repair or to replace.

The aim of our study was to assess the outcomes of surgical treatment for severe tricuspid regurgitation according to whether cardiac surgery had been performed before the tricuspid valve intervention. Between 1996 and 2013, 201 consecutive patients with severe tricuspid regurgitation underwent tricuspid surgery at our center. Patients were classified according to whether or not they had undergone previous cardiac surgery, which 33% of the sample had. Perioperative as well as long-term morbidity and mortality were analyzed. Mean patient age was 62.3 years. 32.8% underwent suture annuloplasty, 41.3% underwent ring annuloplasty, 15.4% received a bioprosthesis, and 10.4% received a mechanical prosthesis. There were no significant differences in perioperative mortality between the group that had not undergone previous cardiac surgery and the group that had (12.7% vs. 17.9%, respectively; p = 0.32). The long-term mortality rate (median follow-up time: 53 months) was 43.3%. Long-term survival curves showed no significant differences between the two groups (p = 0.884), and previous cardiac surgery was not a predictive factor for long-term mortality (hazard ratio = 1.211; p = 0.521). In a series of patients who underwent tricuspid valve surgery, no significant differences were observed in perioperative mortality or in long-term survival according to whether or not subjects had undergone previous cardiac surgery.

ResumenLas prótesis sin sutura representan una nueva alternativa en el tratamiento quirúrgico de la estenosis aórtica severa. En el siguiente artículo intentamos resumir las características fundamentales de cada una de ellas y la bibliografía más importante publicada hasta ahora con el fin de hacer una revisión rápida de estas prótesis para poder orientar su uso.AbstractThe sutureless prosthesis represent a new alternative in the surgical treatment of severe aortic stenosis. In the following article we try to summarize the main features of each of them and the most important literature published so far in order to make a quick review of these prostheses to guide their use.

[Objective] To simplify and optimize the ability of EuroSCORE I and II to predict early mortality after surgery for infective endocarditis (IE)., [Methods] Multicentre retrospective study (n = 775). Simplified scores, eliminating irrelevant variables, and new specific scores, adding specific IE variables, were created. The performance of the original, recalibrated and specific EuroSCOREs was assessed by Brier score, C-statistic and calibration plot in bootstrap samples. The Net Reclassification Index was quantified., [Results] Recalibrated scores including age, previous cardiac surgery, critical preoperative state, New York Heart Association >I, and emergent surgery (EuroSCORE I and II); renal failure and pulmonary hypertension (EuroSCORE I); and urgent surgery (EuroSCORE II) performed better than the original EuroSCOREs (Brier original and recalibrated: EuroSCORE I: 0.1770 and 0.1667; EuroSCORE II: 0.2307 and 0.1680). Performance improved with the addition of fistula, staphylococci and mitral location (EuroSCORE I and II) (Brier specific: EuroSCORE I 0.1587, EuroSCORE II 0.1592). Discrimination improved in specific models (C-statistic original, recalibrated and specific: EuroSCORE I: 0.7340, 0.7471 and 0.7728; EuroSCORE II: 0.7442, 0.7423 and 0.7700). Calibration improved in both EuroSCORE I models (intercept 0.295, slope 0.829 (original); intercept –0.094, slope 0.888 (recalibrated); intercept –0.059, slope 0.925 (specific)) but only in specific EuroSCORE II model (intercept 2.554, slope 1.114 (original); intercept –0.260, slope 0.703 (recalibrated); intercept –0.053, slope 0.930 (specific)). Net Reclassification Index was 5.1% and 20.3% for the specific EuroSCORE I and II., [Conclusions] The use of simplified EuroSCORE I and EuroSCORE II models in IE with the addition of specific variables may lead to simpler and more accurate models., This work was supported by the Ministerio de Economía y Competitividad, Instituto de Salud Carlos III—co-financed by European Development Regional Fund A way to achieve Europe ERDF, Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015); Catalan Society of Cardiology (Grant Orion Pharma); and Spanish Society of Cardiology.

ResumenIntroduccion y objetivos La mortalidad por endocarditis infecciosa izquierda continua siendo muy elevada. El objetivo de este estudio es valorar el impacto en la mortalidad precoz de la endocarditis infecciosa izquierda de una estrategia de alerta multidisciplinaria (AMULTEI, basada en la alerta clinica, ecocardiografica y microbiologica) iniciada en 2008 en un centro hospitalario de tercer nivel. Metodos Estudio de cohortes que compara nuestra serie historica (1996-2007) con la serie de pacientes de 2008-2011 diagnosticada de endocarditis izquierda (AMULTEI). Resultados La cohorte AMULTEI incluye a 72 pacientes, frente a los 155 de la cohorte historica. Los pacientes AMULTEI presentaron significativamente mas edad (62,5 frente a 57,9 anos en la cohorte historica; p = 0,047) y mas comorbilidad (indice de Charlson, 3,33 frente a 2,58 en la cohorte historica; p = 0,023). Se observo una tendencia a mas etiologia enterococica (el 20,8% del grupo AMULTEI frente al 11,6% de la cohorte historica; p = 0,067). Se realizo cirugia sin demora durante el ingreso hospitalario mas frecuentemente (el 48,6 frente al 23,2%; p

Introduction and Objectives Mortality from left-sided infective endocarditis remains very high. The aim of this study was to assess the impact of a multidisciplinary alert strategy (AMULTEI), based on clinical, echocardiographic and microbiological findings, implemented in 2008 in a tertiary hospital. Methods Cohort study comparing our historical data series (1996-2007) with the number of patients diagnosed with left-sided endocarditis from 2008-2011 (AMULTEI). Results The AMULTEI cohort included 72 patients who were compared with 155 patients in the historical cohort. AMULTEI patients were significantly older (62.5 vs 57.9 years in the historical cohort; P=.047) and had higher comorbidity (Charlson index, 3.33 vs 2.58 in the historical cohort; P=.023). There was also a trend toward more enterococcal etiology in the AMULTEI group (20.8% vs 11.6% in the historical cohort; P=.067). In the AMULTEI group, early surgery was more frequently performed (48.6% vs 23.2%; P

Aortitis is an infrequent cause of aortic root dilatation and aortic valve regurgitation. Valve-sparing procedures have been proposed, but there is not clear evidence of which is the treatment of choice. We report the case of a 38-year-old pregnant lady with a diagnosis of idiopathic aortitis associated with aortic root aneurysm and severe aortic valve regurgitation.

ResumenIntroducciónLa afección valvular tricúspide se asocia con frecuencia a trastornos del ritmo y la conducción. Tradicionalmente se evitaba la implantación de electrodos endocavitarios en pacientes portadores de bioprótesis tricúspides.MétodosSe recogen 4 casos de implantación de electrodos endocavitarios en portadores de bioprótesis tricúspides.ResultadosNo se observa ninguna disfunción protésica en el seguimiento, siendo la evolución similar a la de pacientes sin marcapasos. No encontramos ningún caso de mortalidad.ConclusionesLos resultados iniciales nos invitan a continuar con este tipo de procedimientos.AbstractIntroductionTricuspid valve disease is frequently associated with disorders of rhythm and conduction. Endocardial electrode implantation in patients with tricuspid bioprosthesis was traditionally avoided.MethodsFour cases of endocardial electrode implantation in patients with tricuspid bioprosthesis are reviewed.ResultsNo prosthetic dysfunction was observed in monitoring, being similar to the outcome of patients without pacemakers. There were no deaths.ConclusionsInitial results suggest continuing this type of procedure.

Resumen Introduccion y objetivos En nuestro medio hay pocos datos sobre los resultados del tratamiento quirurgico de la insuficiencia tricuspidea grave. Nuestro objetivo es analizar los resultados clinicos y ecocardiograficos de nuestra poblacion con insuficiencia tricuspidea grave sometida a cirugia comparandolos segun el tipo de reparacion o de sustitucion valvular. Metodos Realizamos un estudio retrospectivo incluyendo a 119 pacientes consecutivos con insuficiencia tricuspidea grave sometidos a cirugia de dicha valvula entre abril de 1996 y febrero de 2010. Resultados Se realizaron 61 anuloplastias sin anillo y 23 con anillo, y se implantaron 11 protesis biologicas y 24 mecanicas. La mortalidad perioperatoria fue del 18,5%, y se asociaron a ella la edad y el tiempo de circulacion extracorporea. Durante el seguimiento clinico (mediana, 41 [intervalo intercuartilico, 24-89] meses), el grupo anuloplastia con anillo preciso dos reoperaciones, al igual que el grupo de protesis mecanica, en el que se diagnostico trombosis protesica a 4 pacientes. La mortalidad total tras seguimiento fue del 29,9%, y se asociaron a ella la edad > 70 anos y el tiempo de circulacion extracorporea. La aparicion de nueva insuficiencia tricuspidea grave se asocio a la edad y la anuloplastia sin anillo (p = 0,04). Conclusiones La reparacion sin anillo se asocio significativamente con recurrencia de insuficiencia tricuspidea grave. El implante de protesis mecanica se asocio a una elevada tasa de trombosis en el seguimiento. No se encontraron diferencias significativas en la mortalidad perioperatoria o total segun el tipo de reparacion o sustitucion valvular.

Objectives Recent studies have shown that patients with syndromic thoracic aortic aneurysm, particularly patients with bicuspid aortic valve, have increased blood levels of transforming growth factor β1 (TGF-β1), indicating this molecule as a prognostic biomarker. However, it is not known whether TGF-β1 is also elevated in the blood of patients with tricuspid aortic valve and aortic dilatation. Methods We analysed the plasma levels of TGF-β1 in 52 patients with tricuspid or bicuspid aortic valve and with normal or dilated ascending aorta who underwent cardiac surgery in our hospital. Results TGF-β1 blood level was significantly increased two-fold in patients with tricuspid aortic valve and dilated aorta compared to patients with tricuspid aortic valve and normal aorta. Conclusions Our results suggest that TGF-β1 blood levels may serve as a prognostic biomarker for patients with syndromic and non-syndromic thoracic aortic aneurysm. Further studies with larger cohorts of patients should be performed to confirm these results.

OBJECTIVES: Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. METHODS: From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. RESULTS: During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). CONCLUSIONS: Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.

Introduction and objectives There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation . The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. Methods Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. Results A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty ( P=.04). Conclusions Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.

Journal Article; Dilatation of the ascending aorta (AAD) is a prevalent aortopathy that occurs frequently associated with bicuspid aortic valve (BAV), the most common human congenital cardiac malformation. The molecular mechanisms leading to AAD associated with BAV are still poorly understood. The search for differentially expressed genes in diseased tissue by quantitative real-time PCR (qPCR) is an invaluable tool to fill this gap. However, studies dedicated to identify reference genes necessary for normalization of mRNA expression in aortic tissue are scarce. In this report, we evaluate the qPCR expression of six candidate reference genes in tissue from the ascending aorta of 52 patients with a variety of clinical and demographic characteristics, normal and dilated aortas, and different morphologies of the aortic valve (normal aorta and normal valve n = 30; dilated aorta and normal valve n = 10; normal aorta and BAV n = 4; dilated aorta and BAV n = 8). The expression stability of the candidate reference genes was determined with three statistical algorithms, GeNorm, NormFinder and Bestkeeper. The expression analyses showed that the most stable genes for the three algorithms employed were CDKN1β, POLR2A and CASC3, independently of the structure of the aorta and the valve morphology. In conclusion, we propose the use of these three genes as reference genes for mRNA expression analysis in human ascending aorta. However, we suggest searching for specific reference genes when conducting qPCR experiments with new cohort of samples. Yes

ResumenDurante las últimas 2 décadas, la cirugía cardíaca ha evolucionado hacia procedimientos menos invasivos, buscando una menor agresión corporal y la rápida recuperación del paciente, resultando estos procedimientos más atractivos para los pacientes y para los cardiólogos clínicos. En la actualidad, la cirugía mitral mínimamente invasiva (CMIVMi) se ha consolidado como una alternativa para los pacientes con patología de la válvula mitral. Comparada con la cirugía mitral convencional (mediante esternotomía media completa), y tras superar una curva de aprendizaje inicial, resulta ser una técnica segura y efectiva, con equivalentes resultados en el seguimiento a corto y largo plazo. A pesar de acompañarse de un incremento en los tiempos quirúrgicos (tiempo de isquemia y de circulación extracorpórea), la CMIVMi se asocia a menor estancia hospitalaria y en unidades de cuidados intensivos, menores pérdidas hemáticas y transfusiones, extubación precoz y menos arritmias, y permite una recuperación más rápida del paciente junto con un mejor resultado cosmético. Por ello, la CMIVMi resulta ser una técnica en continuo auge en distintos centros, aunque serían recomendables estudios prospectivos aleatorizados, que permitan una mejor valoración de los resultados clínicos y en términos de coste-eficiencia.AbstractDuring the last two decades cardiac surgery has evolved into less-invasive procedures, looking for a lesser body aggression and faster patient recovery, these procedures becoming more attractive to patients and clinical cardiologists. Currently, minimally invasive mitral valve surgery (MIMVS) has established itself as an alternative for patients with mitral valve pathology. Compared with conventional mitral surgery (full sternotomy approach) and after overcoming initial learning curve, it turns out to be a safe and effective technique, with equivalent short- and long-term follow-up results. Despite involving an increase in operative times (ischemic and cardiopulmonary bypass time), the MIMVS is associated with shorter in-hospital and intensive care unit stay, reduced blood loss and transfusions, earlier extubation and fewer arrhythmias and allows a faster patient recovery with better cosmetic result. Therefore, MIMVS is a steadily growing technique in different centers, being recommended prospective randomized studies that allow a better assessment of clinical outcomes and in terms of cost-efficiency.