Schaff, Hartzell

Objectives We investigated haemodynamics and clinical outcomes according to type of pulmonary hypertension (PH) in patients with constrictive pericarditis (CP). Background As the prevalence of CP with concomitant myocardial disease (mixed CP) grows, PH is more commonly seen in patients with CP. However, haemodynamic and outcome data according to the presence or absence of PH are limited. Methods 150 patients with surgically confirmed CP who underwent echocardiography and cardiac catheterisation within 7 days at two tertiary centres were divided into three groups: no-PH, isolated postcapillary PH (Ipc-PH) and combined postcapillary and precapillary PH (Cpc-PH). Primary outcome was all-cause mortality during follow-up. Result In this retrospective cohort study, 110 (73.3%) had PH (mean pulmonary artery pressure ≥25 mm Hg). Cpc-PH, using defined cut-offs for pulmonary vascular resistance (>3 Wood units) or diastolic pulmonary gradient (≥7 mm Hg), was seen in 18 patients (12%). The Cpc-PH group had a higher prevalence of comorbidities (diabetes and atrial fibrillation) and concomitant myocardial disease as an aetiology of CP than other groups. Pulmonary vascular resistance had a significant direct correlation with medial E/e′ by Doppler echocardiography (r=0.404, p<0.001). Survival rate was significantly lower in the Cpc-PH than the no-PH (p=0.002) and Ipc-PH (p=0.024) groups. On multivariable analysis, age, New York Heart Association functional class IV, medial e′ velocity, Cpc-PH and Ipc-PH were independently associated with long-term mortality. Conclusion Combined postcapillary and precapillary PH develops in a subset of patients with CP and is associated with long-term mortality after pericardiectomy.

AbstractOBJECTIVESFunctional tricuspid regurgitation (fTR) has been amenable to tricuspid valve repair (TVr), with fewer patients needing tricuspid valve replacement (TVR). We sought to review our experience of tricuspid valve surgery for fTR.METHODSA retrospective analysis of adult patients (≥18 years) who underwent primary tricuspid valve surgery for fTR (n = 926; mean age 68.6 ± 12.5 years; 67% females) from January 1993 through June 2018 was conducted. There were 767 (83%) patients who underwent TVr (ring annuloplasty, 67%; purse-string annuloplasty, 33%) and 159 (17%) underwent TVR (bioprosthetic valves, 87%; mechanical valves, 13%). The median follow-up was 8.2 years [95% confidence interval (CI) 7.2–8.9 years].RESULTSA greater proportion of patients who underwent TVR had severe right ventricular dysfunction (P &lt; 0.001), severe tricuspid regurgitation (P &lt; 0.001) and congestive heart failure (P = 0.001) while the TVr cohort had a greater proportion with severe mitral valve (MV) regurgitation (P &lt; 0.001) and concomitant cardiac procedures. Early mortality (TVR, 9% vs TVr, 3%; P = 0.004), renal failure (TVR, 10% vs TVr, 5%; P = 0.014) and hospital stay (TVR, 15 ± 15 days vs TVr, 12 ± 11 days; P &lt; 0.001) were greater in TVR patients. The TVR cohort had worse survival [hazard ratio (HR) 1.57; 95% CI 1.23–1.99]. Multivariable analysis identified congestive heart failure (HR 1.37; 95% CI 1.10–1.72), renal failure (HR 1.79; 95% CI 1.14–2.82), previous MV surgery (HR 1.35; 95% CI 1.05–1.72) and TVR (HR 1.36; 95% CI 1.03–1.79) as independent risk factors for late mortality.CONCLUSIONSTricuspid repair for fTR appears to have better early and late outcomes. Since previous MV surgery and TVR are identified as independent risk factors for late mortality, concomitant TVr at the time of index MV surgery may be considered. Early referral before the onset of advanced heart failure may improve outcomes.

Objective To determine whether echocardiography-derived left ventricular filling pressure influences survival in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). Methods We retrospectively reviewed 1383 consecutive patients with severe AS, normal ejection fraction and interpretable filling pressure undergoing AVR. Left ventricular filling pressure was determined according to current guidelines using mitral inflow, mitral annular tissue Doppler, estimated right ventricular systolic pressure and left atrial volume index. Cox proportional hazards regression was used to assess the influence of various parameters on mortality. Results Age was 75±10 years and 552 (40%) were female. Left ventricular filling pressure was normal in 325 (23%), indeterminate in 463 (33%) and increased in 595 (43%). Mean follow-up was 7.3±3.7 years, and mortality was 1.2%, 4.2% and 18.9% at 30 days and 1 and 5 years, respectively. Compared with patients with normal filling pressure, patients with increased filling pressure were older (78±9 vs 70±12, p<0.001), more often female (45% vs 35%, p=0.002) and were more likely to have New York Heart Association class III–IV symptoms (35% vs 24%, p=0.004), coronary artery disease (55% vs 42%, p<0.001) and concentric left ventricular hypertrophy (63% vs 37%, p<0.001). After correction for other factors, increased left ventricular filling pressure remained an independent predictor of mortality after successful AVR (adjusted HR 1.45 (95% CI 1.16 to 1.81), p=0.005). Conclusions Preoperative increased left ventricular filling pressure is common in patients with AS undergoing AVR and has important prognostic implications, regardless of symptom status. Future prospective studies should consider whether patients with increased filling pressure would benefit from earlier operation.

We present a novel case of acute ischemic stroke in the postoperative setting of open septal myectomy. A 24-year-old woman developed acute left hemiparesis and rightward eye deviation the morning after surgery. She underwent emergent endovascular stoke therapy by mechanical embolectomy with successful retrieval of a fragment of myocardium that was obstructing the right middle cerebral artery. To our knowledge there has been no previous case described of a myocardial fragment causing a proximal intracranial artery occlusion with resulting ischemia and infarction.