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- Surgical aortic valve replacement in octogenarians: single-center perioperative outcomes and five-year survivalPublication . Velho, Tiago R.; Goncalves, Joao; Pereira, Rafael Maniés; Ferreira, Ricardo; Sena, André; Junqueira, Nádia Viviana; Ângelo, Eurídice; Carvalho Guerra, Nuno; Mendes, Mário; Arruda Pereira, Ricardo; Nobre, AngeloIntroduction and objectives: Aortic stenosis is the most common valvular heart disease. The number of octogenarians proposed for intervention is growing due to increased lifespan. In this manuscript we aim to evaluate perioperative outcome and long-term survival after surgical aortic valve replacement (SAVR) in octogenarians, comparing patients with low surgical risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). Methods: A retrospective observational single-center cohort study with 195 patients aged ≥80 years old, who underwent SAVR between 2017 and 2021, was conducted. Patients were divided into two groups according to EuroscoreII: (1) Low risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). Continuous variables are presented in median (IQR), analyzed using Wilcoxon rank sum test; categorical variables in percentages, analyzed using chi-squared test; and survival was analyzed by Kaplan-Meier, open cohort, and the log-rank test was performed. Results: The overall median age was 82 (IQR 81-83), with 4.6% of the patients ≥85 years old. 23.6% of the patients presented EuroscoreII ≥4%. No complications were observed in 26.2%, with a significantly higher rate in intermediate-high risk patients. Postoperative need for hemodynamic support was the most frequent complication, followed by postoperative acute kidney injury and the use of blood products. Overall median ICU stay was three days (2-4) and hospital length of stay (LOS) six days (5-8). Patients with intermediate-high risk and those with complications had longer ICU LOS. At 12 months, overall survival was 96.4%, at three years 94.1% and 5 years 75.4%. Patients with low surgical risk had higher survival proportions up to 5 years. Conclusion: SAVR in patients ≥80 years is associated with low in-hospital mortality, although a significant proportion of patients develop complications. Long-term follow-up up to five years after surgery is acceptable in octogenarians with low surgical risk.
- Sutureless bioprosthesis for aortic valve replacement: surgical and clinical outcomesPublication . Ferreira, Ricardo; Rua, Nuno; Sena, André; Velho, Tiago R.; Goncalves, Joao; Junqueira, Nádia; Almeida, Ana G.; Nobre, Angelo; Pinto, Fausto J.Background: Aortic valve stenosis is the most common adult valve disease in industrialized countries. The aging population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis has shown promising results, especially in complex procedures and in patients requiring concomitant surgeries. Objectives: Assess the clinical and hemodynamic performance, safety, and durability of the Perceval® prosthetic valve. Methods: This single-center retrospective longitudinal cohort study collected data from all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20 ± 5.08 years; 45.4% female; mean EuroSCORE II 2.91 ± 2.20%), the majority had aortic stenosis. Results: Overall mean cross-clamp and cardiopulmonary bypass times were 33.31 ± 14.09 min and 45.55 ± 19.04 min, respectively. Mean intensive care unit and hospital stay were 3.32 ± 3.24 days and 7.70 ± 5.82 days, respectively. Procedural success was 98.99%, as two explants occurred. Four valves were reimplanted due to intraoperative misplacement. Mean transvalvular gradients were 7.82 ± 3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary for 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes, or endocarditis, and one successfully treated valve thrombosis. Conclusions: Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to a 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for the treatment of isolated aortic valve disease.
- Growth differentiation factor 15 as a biomarker for risk stratification in the cardiothoracic surgery intensive care unitPublication . Ferreira, Ricardo; Velho, Tiago R.; Pereira, Rafael Maniés; Pedroso, Dora; Draiblate, Beatriz; Santos, Susana Constantino Rosa; Nobre, Angelo; Almeida, Ana G.; Moita, Luis; Pinto, Fausto J.Growth Differentiation Factor 15 (GDF15) is an emerging biomarker that significantly increases during acute stress responses, such as infections, and is moderately elevated in chronic and inflammation-driven conditions. While evidence suggests that high levels of GDF15 in cardiac surgery are associated with worse outcomes, its utility as an evaluator of early postoperative complications remains unclear. This study aims to characterize the postoperative profile of GDF15 in patients undergoing isolated surgical aortic valve replacement, evaluating its association with short-term outcomes. Serum samples from patients undergoing cardiac surgery were collected preoperatively and at defined postoperative time points (1 h, 6 h, 12 h, 24 h, and 48 h) to measure GDF15 levels. GDF15 levels significantly increased after surgery, peaking at 6 h. A positive correlation was observed between GDF15 levels and both cardiopulmonary bypass and aortic cross-clamp times. Notably, patients who developed postoperative acute kidney injury (AKI) or required prolonged hemodynamic support had significantly higher GDF15 levels, with increased mechanical ventilation time and extended intensive care unit length of stay. Furthermore, GDF15 levels correlated with postoperative SOFA scores at 24 h after surgery. GDF15 may be a valuable biomarker for risk stratification and guiding therapeutic decisions in cardiac surgery patients. Higher GDF15 levels were significantly associated with prolonged hemodynamic support, postoperative AKI, and measures of illness severity.
- Predicting the burden for surgical aortic valve replacement in a tertiary centre: the impact of aged populations for the next decadesPublication . Pereira, Rafael Maniés; Carvalho Guerra, Nuno; Moreira Gonçalves, João; Ferreira, Ricardo; Nobre, Angelo; Brito, Dulce; Rodrigues, Teresa Ferreira; Velho, Tiago R.Background/Objectives: The incidence of aortic stenosis (AS) is predicted to rise with the aging population, emerging as a growing public health challenge in developed countries, leading to an increased demand for intervention. Our aim is to predict the evolution of proposed cases for SAVR in the geographic referral area of our tertiary hospital until 2041. Methods: We used data from the Portuguese Census for 2001, 2011, and 2021 to analyze the resident population within the Cardiothoracic Surgery Department's referral area. Applying population projection methods (rate of geometric growth), we projected demographic trends over 20 years, from 2021 to 2041. Our analysis focused on AS cases who underwent SAVR in our department between 2001-2011 and 2011-2021. Results: Between 2001 and 2021, there was an increase in the overall population, particularly among the elderly (1.4% growth rate in the population ≥ 65 years old). The aging index increased from 128.4 (110.5-180.6) in 2001 to 189.1 (155.9-222.5) in 2021 (p-value < 0.001). Similarly, the longevity index significantly increased between 2001 [42.6 (40.8-44.80)] and 2021 [49.30 (47.7-51.8)] (p-value < 0.001). The number of SAVRs performed increased, with a mean increase of 8.11 surgeries/year (R2 = 0.6457, p < 0.001). By 2041, our referral center will increase SAVR by at least 51 surgeries/year in a decreasing growth rate scenario, and 67 surgeries/year in a growth rate stagnation scenario. Conclusions: The ongoing trend of population aging will increase the demand for healthcare resources, particularly within the cardiovascular domain. Accurately assessing the volume of SAVR is imperative for reformulating strategies to address the increasing demand effectively.
- Post-cardiotomy bronchopericardial fistulaPublication . Ângelo, Eurdice; Ferreira, Ricardo; Velho, Tiago R.; Nobre, AngeloWe report a case of a 65 years-old woman submitted to an aortic and mitral valve replacement with mechanical prosthesis (St Jude 19mm and St Jude 21mm, respectively), who developed a postoperative cardiogenic shock, with necessity of mechanical support with extracorporeal membrane oxygenation and intra-aortic pump balloon.
- Role of omega-6 fatty acid metabolism in cardiac surgery postoperative bleeding riskPublication . Velho, Tiago R.; Ferreira, Ricardo; Willmann, Katharina; Pedroso, Dora; Paixão, Tiago; Pereira, Rafael Maniés; Junqueira, Nádia; Carvalho Guerra, Nuno; Brito, Dulce; Almeida, Ana G.; Nobre, Angelo; Köcher, Thomas; Pinto, Fausto J.; Moita, Luís FerreiraCardiac surgery is frequently associated with significant postoperative bleeding. Platelet-dysfunction is the main cardiopulmonary bypass (CPB)-induced hemostatic defect. Not only the number of platelets decreases, but also the remaining are functionally impaired. Although lipid metabolism is crucial for platelet function, little is known regarding platelet metabolic changes associated with CPB-dysfunction. Our aim is to explore possible contribution of metabolic perturbations for platelet dysfunction after cardiac surgery. Design: Prospective cohort study. Setting: Tertiary academic cardiothoracic-surgery ICU. Patients: Thirty-three patients submitted to elective surgical aortic valve replacement. Interventions: Samples from patients were collected at three time points (preoperative, 6- and 24-hr postoperative). Untargeted metabolic analysis using high-performance liquid chromatography-tandem mass spectrometry was performed to compare patients with significant postoperative bleeding with patients without hemorrhage. Principal component analyses, Wilcoxon matched-pairs signed-rank tests, adjusted to FDR, and pairwise comparison were used to identify pathways of interest. Enrichment and pathway metabolomic complemented the analyses. Measurements and main results: We identified a platelet-related signature based on an overrepresentation of changes in known fatty acid metabolism pathways involved in platelet function. We observed that arachidonic acid (AA) levels and other metabolites from the pathway were reduced at 6 and 24 hours, independently from antiagreggation therapy and platelet count. Concentrations of preoperative AA were inversely correlated with postoperative chest tube blood loss but were not correlated with platelet count in the preoperative, at 6 or at 24 hours. Patients with significant postoperative blood-loss had considerably lower values of AA and higher transfusion rates. Values of postoperative interleukin-6 were strongly correlated with AA variability. Conclusions and relevance: Our observations suggest that an inflammatory-related perturbation of AA metabolism is a signature of cardiac surgery with CPB and that preoperative levels of AA may be more relevant than platelet count to anticipate and prevent postoperative blood loss in patients submitted to cardiac surgery with CPB.
- The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary centerPublication . Lopes, Alice; Pedro, Luís M; Melo, Ryan; Moutinho, Mariana; Sobrinho, Gonçalo; Amorim, Pedro; Silvestre, Luís; Fernandes E Fernandes, Ruy; Ministro, Augusto; Martins, Carlos; Almeida, Ana G.; Nobre, Angelo; Pinto, Fausto J.; Fernandes E Fernandes, JoseIntroduction and objectives: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. Methods: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. Results: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. Conclusion: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.