Arribas Leal, José María

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Arribas Leal, José María

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Arribas Leal, José María

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Universidad de Murcia. Departamento de Cirugía, Pediatría, Obstetríciay Ginecología

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Risk factors for postoperative pacemaker implantation after rapid deployment aortic valve replacement: results from the RADAR registry
(Springer, 2021-03-04) González Barbeito, Miguel; Vazquez, Alejandro; Carnero, Manuel; Sarralde, José Aurelio; Cal Purriños, Natalia; Cánovas López, Sergio; Martoto, Luis; Gutiérrez, Francisco; Hornero, Fernando; Bautista Hernández, Victor; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Introduction: Rapid deployment aortic valve replacement has been recently introduced in clinical practice. Different studies have reported a significant reduction in surgical times with excellent hemodynamic profiles and short-term results. However, an increase in permanent pacemaker requirements compared with conventional aortic valve replacement has been described. Nevertheless, risk factors for postoperative pacemaker implantation are not well known. The aim of this study is to report our early outcomes with rapid deployment aortic valve replacement within the RADAR Registry, especially focusing on risk factors for postoperative pacemaker implantation. Methods: Between April 2012 and January 2016, 164 patients undergoing isolated or combined aortic valve replacement with Edwards INTUITY Elite (Edwards Lifesciences, Irvine, CA, USA) were included in the RADAR Registry. Pre-, intra- and postoperative clinical data results and complications were recorded, especially focusing on risk factors for the development of postoperative complete or high-grade AV block requiring pacemaker implantation. Patients were followed up for up to 1 year with evaluation of clinical and echocardiographic outcomes. Results: A total of 164 consecutive patients were included in this study, where 128 patients (78.05%) had an isolated aortic valve replacement (group 1) and 36 (21.95%) a concomitant procedure (group 2). The surgical approach was ministernotomy in 61 patients (37.20%) and median sternotomy in 100 patients (60.98%). Complications with valve implantation were observed in three patients. Postoperative complete or high-degree AV block requiring a permanent pacemaker implantation developed in ten patients (6.9%). Seven patients died in-hospital (4.27%). No significant differences between groups were found in terms of stroke, postoperative infection, mortality, atrial fibrillation and postoperative atrioventricular block. Seven patients presented acute renal impairment (5.51%) in group 1 versus seven patients (20%) in group 2 (p = 0.007). In multivariate analysis, low weight and preoperative arrhythmia (atrial fibrillation, bifascicular block, left bundle branch block) emerged as risk factors for postoperative AV block requiring a pacer. In median follow-up of 1 year, seven (4.27%) patients died, and no cases of structural valve deterioration or endocarditis were observed. Significant patient-prosthesis mismatch was found in seven (4.27%) patients. Conclusion: Initial experience with rapid deployment aortic valve replacement in the RADAR Registry demonstrates low rates of implantation complications and good perioperative and 1-year clinical and echocardiographic outcomes. Incidence of postoperative AV block requiring a pacer correlated with low weight and preoperative arrythmias (atrial fibrillation, bifascicular block and left bundle branch block). Avoidance of oversizing and careful consideration of implantation of this technology in patients with pre-existing arrythmias could minimize the risk for postoperative pacemaker implantation.
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Molecular mechanisms of postoperative atrial fibrillation in patients with obstructive sleep apnea
(Wiley, 2023-04-28) López Gálvez, Raquel; Rivera Caravaca, José Miguel; Mandaglio Collados, Darío; Lahoz, Álvaro; Carpes, Marina; Cánovas López, Sergio; Lip, Gregory Y. H.; Marín, Francisco; Martínez Cáceres, Carlos Manuel; Orenes-Piñero, Esteban; Hernández Romero, Diana; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Obstructive sleep apnea (OSA) promotes atrial remodeling and fibrosis, providing a substrate for atrial fibrillation (AF). Herein, we investigate the pathophysiological mechanisms of AF in association with OSA in a cohort of cardiac surgery patients. A prospective study including patients undergoing cardiac surgery. Biomarkers reflective of AF pathophysiology (interleukin [IL-6], C-reactive protein [CRP], von Willebrand factor [vWF], N-terminal pro-brain natriuretic peptide [NT-proBNP], high-sensitivity Troponin T [hs-TnT], and Galectin-3 [Gal-3]) was assessed by functional or immunological assays. miRNAs involved in AF were analyzed by reverse transcription-polymerase chain reaction (RT-PCR). Using atrial tissue samples, fibrosis was assessed by Masson's trichrome. Connexin 40 and 43 (Cx40; Cx43) were evaluated by immunolabeling. Fifty-six patients (15 with OSA and 41 non-OSA) were included in this hypothesis-generating pilot study. OSA group had a higher incidence of postoperative AF (POAF) (46.7% vs. 19.5%; p = .042), presented an increased risk of POAF (OR 3.61, 95% CI 1.01–12.92), and had significantly higher baseline levels of NT-proBNP (p = .044), vWF (p = .049), Gal-3 (p = .009), IL-6 (p = .002), and CRP (p = .003). This group presented lower levels of miR-21 and miR-208 (both p < .05). Also, lower Cx40 levels in POAF and/or OSA patients (50.0% vs. 81.8%, p = .033) were found. The presence of interstitial fibrosis (according to myocardial collagen by Masson's trichrome) was raised in OSA patients (86.7% vs. 53.7%, p = .024). Several biomarkers and miRNAs involved in inflammation and fibrosis were dysregulated in OSA patients, which together with a higher degree of interstitial fibrosis, altered miRNA, and Cxs expression predisposes to the development of a substrate that increases the AF risk.
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Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus
(Oxford University Press, 2021-06-28) Rivera Caravaca, José Miguel; Aranda Domene, Ramón; Moreno Moreno, José A.; Espinosa García, Dolores; Jiménez Aceituna, Antonio; Pérez Andreu, Joaquín; Taboada Martín, Rubén; Saura Espín, Daniel R.; Cánovas López, Sergio; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
OBJECTIVES: The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19–21 mm) in comparison to larger Intuity prostheses (>21 mm). METHODS: This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19–21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups. RESULTS: A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62). CONCLUSIONS: This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.
Open Access
Von Willebrand factor is associated with atrial fibrillation development in ischaemic patients after cardiac surgery
(Oxford University Press, 2016-09) Lahoz, Álvaro; Roldan, Vanessa; Jover, Eva; Romero Aniorte, Ana I.; Jara Rubio, Rubén; García Alberola, Arcadio; Cánovas López, Sergio; Valdés, Mariano; Marín, Francisco; Martínez Cáceres, Carlos Manuel; Hernández Romero, Diana; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Aims Atrial fibrillation (AF) is associated with an increased morbidity and mortality after cardiac surgery. Von Willebrand factor (vWF) has been proposed as a biomarker of endothelial damage/dysfunction. We hypothesized that vWF levels could be used as valuable biomarker for AF occurrence after cardiac surgery. Moreover, we explored the potential association between vWF and tissue remodelling as possible implication in post-surgical AF. Methods and results We prospectively recruited 100 consecutive patients who undergoing programmed cardiac surgery with cardiopulmonary bypass and with no previous history of AF. Plasma vWF levels were determined from citrated plasma samples. Right atrial appendage tissue was obtained during cardiac surgery, and vWF expression as well as interstitial fibrosis was analysed by immunostaining and Masson's trichrome, respectively. We found raised vWF plasma levels in ischaemic vs. valvular patients (200.2 ± 66.3 vs. 157.2 ± 84.3 IU/dL; P = 0.015). Fibrosis degree was associated with plasma vWF levels. Plasma vWF was an independent prognostic marker for AF development in ischaemic patients [odds ratio, OR 6.44 (95% confidence interval, CI 1.40–36.57), P = 0.035]. Conclusion Plasma vWF levels are associated with tissue fibrosis in patients undergoing cardiac surgery and with post-surgical AF development in ischaemic patients. These findings suggest an association among vWF levels, atrial remodelling, and AF development. It is supported by higher vWF expression in right atrial tissue in ischaemic patients, who developed post-surgical AF.
Open Access
Comparison of aortic gradient and ventricular mass after valve replacement for aortic stenosis with rapid deployment, sutureless, and conventional bioprostheses
(Sociedad Española de Cardiología, 2021-06-11) Taboada Martín, Rubén; Esteve Pastor, María Asunción; Abellán Alemán, José; Marín, Francisco; Rivera Caravaca, José Miguel; Cánovas López, Sergio; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Background: The use of rapid deployment and sutureless aortic prostheses is increasing. Previous reports have shown promising results on haemodynamic performance and mortality rates. However, the impact of these bioprostheses on left ventricular mass (LVM) regression remains unknown. We decided to study the changes in remodelling and LVM regression in isolated severe aortic stenosis treated with conventional or Perceval® or Intuity® valves. Method and Results: From January 2011 to January 2016, 324 bioprostheses were implanted in our centre. The collected characteristics were divided into 3 groups: conventional valves, Perceval®, and Intuity®, and they were analysed after 12 months. There were 183 conventional valves (56%), 72 Perceval® (22%), and 69 Intuity® (21.2%). The statistical analysis showed significant differences in transprosthetic postoperative peak gradient (23 [18–29] mm Hg vs. 21 [16–29] mm Hg and 18 [14–24] mm Hg, p < 0.001), ventricular mass electrical criteria regression (Sokolow and Cornell products), and 1-year survival (90 vs. 93% and 97%, log rank p value = 0.04) in conventional, Perceval®, and Intuity® groups. Conclusions: We observed differences in haemodynamic, electrocardiographic, and echocardiographic parameters related to the different types of prosthesis. Patients with the Intuity® prosthesis had the highest reduction in peak aortic gradient and the higher ventricular mass regression. Besides, patients with the Intuity® prosthesis had less risk of mortality during follow-up than the other two groups. Further studies are needed to confirm these findings.
Open Access
Incidencia y mecanismo etiológico de ictus en cirugía cardiaca
(Elsevier, 2020-09) García, E.; Jara, R.; Gutiérrez, F.; Albert, L.; Bixquert, D.; García Puente, J.; Albacete, C.; Cánovas López, Sergio; Morales, A.; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Objetivo Estudiar a los pacientes que tuvieron un ictus en el postoperatorio de cirugía cardiaca, para ver la evolución y determinar los factores que influyen en su pronóstico y tratamiento. Métodos Establecimos un protocolo para la detección precoz de ictus en los pacientes tras cirugía cardiaca. Recogimos la aparición de ictus y datos clínicos, quirúrgicos y pronósticos; posteriormente realizamos un análisis descriptivo. Resultados Durante los 15 meses del estudio hubo 16 ictus, un 2,5% de los pacientes operados. Edad media 69 ± 8 años, 63% varones. La incidencia de ictus en pacientes octogenarios fue del 5,1%. Cinco (31%) fueron cirugías urgentes. Por enfermedad cardiaca intervenida: un 7% recibió cirugía mitral, 6,5% cirugía combinada, un 3% cirugía valvular aórtica y un 2,24% cirugía coronaria. La mayoría de los ictus (44%) fueron por embolia, seguida por hipoperfusión (25%). El 69% de los ictus ocurrieron en los 2 primeros días de postoperatorio. La media de la puntuación en la escala NIHSS en el ictus fue 9, se activó código ictus en 10 (62%), y se realizó trombectomía en uno de ellos (14%). La evolución fue favorable en la mayoría, con una escala de Rankin a los 3 meses ≤ 2 en 13 (80%). No hubo muertes hospitalarias entre estos pacientes. Conclusión En nuestro medio, los ictus tras cirugía cardiaca son de pequeño tamaño y tienen una buena evolución a largo plazo. La mayoría ocurren en los primeros 2 días de postoperatorio y su mecanismo es principalmente embólico. La incidencia de ictus en los pacientes octogenarios intervenidos fue del doble que en la población general. -------------------------
Open Access
Haematic antegrade repriming to enhance recovery after cardiac surgery from the perfusionist side
(EDP Sciences, 2023-03-24) Blanco Morillo, Juan; Farina, Piero; Puis, Luc; Sornichero Caballero, Angel J.; Cánovas López, Sergio; Salmerón Martínez, Diego; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
New era of cardiac surgery aims to provide an enhanced postoperative recovery through the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact of cardiopulmonary bypass (CPB). Hematic Antegrade Repriming (HAR) provides a standardized procedure combining several measures to reduce haemodilutional priming to 300 mL. Once the safety of the procedure in terms of embolic release has been proven, the evaluation of its beneficial effects in terms of transfusion and ICU stay should be assessed to determine if could be considered for inclusion in Enhanced Recovery After Cardiac Surgery (ERACS) programs. Methods: Two retrospective and non-randomized cohorts of high-risk patients, with similar characteristics, were assessed with a propensity score matching model. The treatment group (HG) (n = 225) received the HAR. A historical cohort, exposed to conventional priming with 1350 mL of crystalloid confirmed the control group (CG) (n = 210). Results: Exposure to any transfusion was lower in treated (66.75% vs. 6.88%, p < 0.01). Prolonged mechanical ventilation (>10 h) (26.51% vs. 12.62%; p < 0.01) and extended ICU stay (>2 d) (47.47% vs. 31.19%; p < 0.01) were fewer for treated. HAR did not increase early morbidity and mortality. Related savings varied from 581 to 2741.94 $/patient, depending on if direct or global expenses were considered. Discussion: By reducing the gaseous and crystalloid emboli during CPB initiation, HAR seems to have a beneficial impact on recovery and reduces the overall transfusion until discharge, leading to significant cost savings per process. Due to the preliminary and retrospective nature of the research and its limitations, our findings should be validated by future prospective and randomized studies
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Incidence and causes of pacemaker implantation during postoperative period of aortic valve replacement with rapid deployment prosthesis
(Wiley, 2019-12) Soriano, Laura; Rivera Caravaca, José Miguel; Lorenzo, Maydelin; Muñoz, Carmen; Taboada, Rubén; Jiménez, Antonio; Martínez, Juan; García Puente, Julio; Gutiérrez, Francisco; Manzano, Sergio; Cánovas López, Sergio; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología
Background Aortic stenosis is currently the most frequently occurring valve pathology. Developments, such as transcatheter prostheses and rapid deployment prostheses, allow for the offer of a valve replacement to higher risk patients, but these techniques are linked with a higher need for a permanent pacemaker during the immediate postoperative period. Methods We studied the incidence and the factors associated with permanent pacemaker implantation after aortic valve replacement with Edwards Intuity rapid deployment prosthesis. Results Between October 2012 and December 2016, the Edwards Intuity prosthesis was implanted in 71 patients (68% male, 75.3 ± 5 years old). Six patients (8%) required a permanent pacemaker during immediate postoperative period. Univariate analysis showed that a history of acute myocardial infarction (AMI) (P = .046, B = 7.5, 95% CI [1.039-54.1]) and preoperative amiodarone (P = .009, B = 31.5; 95% CI [2.32-426]) were associated with a higher need for a pacemaker during the postoperative period. Conclusions The incidence of permanent pacemaker implantation during the immediate postoperative period of aortic valve replacement with Edwards Intuity prosthesis was 8%, a value which is within the limits reported for conventional aortic prostheses. Preoperative amiodarone treatment and previous AMI may increase the need for a pacemaker during the postoperative period of these aortic prostheses.
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Hematic antegrade repriming: a reproducible method to decrease the cardiopulmonary bypass Insult
(EDPSciences, 2021-03-15) Blanco Morillo, Juan; Farina, Piero; Fernández González, Angel Luis; Sornichero Caballero, Ángel; Chen, Tyler N.; Cánovas López, Sergio; Salmerón Martínez, Diego; Arribas Leal, José María; Ramírez, Pablo (Ramírez Romero); Cirugía, Pediatría y Obstetricia y Ginecología
The current practice of cardiopulmonary bypass (CPB) requires a preoperative priming of the circuit that is frequently performed with crystalloid solutions. Crystalloid priming avoids massive embolism but is unable to eliminate all microbubbles contained in the circuit. In addition, it causes a sudden hemodilution which is correlated with transfusion requirements and an increased risk of cognitive impairment. Several repriming techniques using autologous blood, collectively termed retrograde autologous priming (RAP), have been demonstrated to reduce the hemodilutional impact of CPB. However, the current heterogeneity in the practice of RAP limits its evidence and benefits. Here, we describe hematic antegrade repriming as an easy and reliable method that could be applied with any circuit in the market to decrease transfusion requirements, emboli, and inflammatory responses, reducing costs and the impact of CPB on postoperative recovery.
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Bleeding risk prediction in patients with dual antiplatelet therapy undergoing coronary artery bypass grafting surgery using a rapid point-of-care platelet function test
(Lippincott, Williams & Wilkins, 2018-12-11) Tello Montoliu, Antonio; Albaladejo, Paula; Taboada, Rubén; Albacete, Carlos L.; Jara, Rubén; Veliz, Andrea; López García, Cecilia; Cánovas López, Sergio; Valdés, Mariano; Rivera Caravaca, José Miguel; Marín, Francisco; Hernández Romero, Diana; Arribas Leal, José María; Cirugía, Pediatría y Obstetricia y Ginecología