Postoperative Changes in Pulmonary Function after Valve Surgery: Oxygenation Index Early after Cardiopulmonary Is a Predictor of Postoperative Course

Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. Results: Median age and EuroSCORE II were 71.0 years (25–75 percentile: 59.5–77.0) and 2.46 (1.44–5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122–193). PaO₂/FiO₂ and AaDO₂/PaO₂ significantly deteriorated two hours, but not immediately, after CPB (both p < 0.0001). Decreased PaO₂/FiO₂ and AaDO₂/PaO₂ were correlated with ventilation time (r² = 0.318 and 0.435) and intensive care unit (ICU) (r² = 0.172 and 0.267) and hospital stays (r² = 0.164 and 0.209). Early and delayed extubations (<6 and >24 h) were predicted by PaO₂/FiO₂ (377.2 and 213.1) and AaDO₂/PaO₂ (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700–0.911 and 0.677–0.859). Conclusions: PaO₂/FiO₂ and AaDO₂/PaO₂ two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations.

Is redo mitral mortality getting better or getting worse?

Zubarevich et al. present the 30 day and 1-year outcomes of redo mitral valve replacement in 58 high-risk patients. The authors conclude that careful patient selection and risk stratification provides acceptable surgical results in this cohort. This series reminds us that increased use of bioprostheses, increased use of mitral replacement instead of repair, and an aging population drive the volume of high-risk redo mitral replacement. It remains to be seen whether redo mitral mortality is getting better or worse, but the risk and the patients will be with us for some time.

STratification risk analysis in OPerative management (STOP score) for drug-induced endocarditis

BACKGROUND

The opioid epidemic has seen a drastic increase in the incidence of drug-associated infective endocarditis (IE). No clinical tool exists to predict operative morbidity and mortality in patients undergoing surgery.

METHODS

A multi-institutional database was reviewed between 2011 and 2018. Multivariate logistic regression was fitted in an automated stepwise fashion. The STratification risk analysis in OPerative management of drug-associated IE (STOP) score was constructed. Morbidity was defined as reintubation, prolonged ventilation, pneumonia, renal failure, dialysis, stroke, reoperation for bleeding, and a permanent pacemaker. Cross-validation provided an unbiased estimate of out-of-sample performance.

RESULTS

A total of 1181 patients underwent surgery for drug-associated IE (median age, 39; interquartile range [IQR], 30-54, 386 women [32.7%], 341 reoperations for prosthetic valve endocarditis [28.9%], 316 patients with multivalve disease [26.8%]). Operative morbidity and mortality were 41.1% and 5.9%, respectively. Predictors of morbidity were dialysis (95% confidence interval [CI], 1.16-2.82), emergent intervention (1.83-4.73), multivalve procedure (1.01-1.98), causative organisms other than Streptococcus (1.09-2.02), and type of valve procedure performed [aortic valve procedure (1.07-2.15), mitral valve replacement (1.03-2.05), tricuspid valve replacement (1.21-2.60)]. Predictors of mortality were dialysis (1.29-5.74), active endocarditis (1.32-83), lung disease (1.25-5.43), emergent intervention (1.69-6.60), prosthetic valve endocarditis (1.24-3.69), aortic valve procedure (1.49-5.92) and multivalve disease (1.00-2.95). Variables maximizing explanatory power were translated into a scoring system. Each point increased odds of morbidity and mortality by 22.0% and 22.4% with an accuracy of 94.0% and 94.1%, respectively.

CONCLUSION

Drug-related IE is associated with significant morbidity and mortality. An easily-applied risk stratification score may aid in clinical decision-making.

Update on surgical repair in functional mitral regurgitation

BACKGROUND

Functional mitral regurgitation (FMR) is common in patients with myocardial infarction or dilated cardiomyopathy, and portends a poor prognosis despite guideline-directed medical therapy (GDMT). Surgical or transcatheter mitral repair for FMR from recent randomized clinical trials showed disappointing or conflicting results.

AIMS

To provide an update on the role of surgical repair in the management of FMR.

MATERIALS AND METHODS

A literature search was conducted utilizing PubMed, Ovid, Web of Science, Embase, and Cochrane Library. The search terms included secondary/FMR, ischemic mitral regurgitation, mitral repair, mitral replacement, mitral annuloplasty, transcatheter mitral repair, and percutaneous mitral repair. Randomized clinical trials over the past decade were the particular focus of the current review.

RESULTS

Recent data underlined the complexity and poor prognosis of FMR. GDMT and cardiac resynchronization, when indicated, should always be applied. Accurate assessment of the interplay between ventricular geometry and mitral valve function is essential to differentiate proportionate FMR from the disproportionate subgroup, which could be helpful in selecting appropriate transcatheter intervention strategies. Surgical repair, most commonly performed with an undersized ring annuloplasty, remains controversial. Adjunctive valvular or subvalvular repair techniques are evolving and may produce improved results in selected FMR patients.

CONCLUSION

FMR resulted from complex valve-ventricular interaction and remodeling. Distinguishing proportionate FMR from disproportionate FMR is important in exploring their underlying mechanisms and to guide medical treatment with surgical or transcatheter interventions. Further studies are warranted to confirm the clinical benefit of appropriate surgical repair in selected FMR patients.

Surgical risk scores: A roadmap to improved outcome?

Habertheuer et al. present a risk scoring system for predicting morbidity and mortality in 1181 patients undergoing surgery for drug associated endocarditis. The authors conclude that drug-related endocarditis is associated with significant morbidity and mortality and that an easily-applied risk stratification score may aid in clinical decision making. The authors demonstrate excellent predictive accuracy in a multi-institutional dataset, and the system is applicable to multivalve patients. Time will tell if application of this or other risk scoring systems can truly provide a roadmap to improved outcomes.

The duration of mediastinal chest tube drainage is not associated with postoperative pain or opioid consumption after cardiac surgery

Objectives. Mediastinal chest tubes are considered to be a significant factor causing postoperative pain after cardiac surgery. The aim of the study was to ascertain whether the duration of mediastinal drainage is associated with postoperative pain and opioid consumption. Design. A total of 468 consecutive patients undergoing cardiac surgery at the Tampere University Hospital between December 2015 and August 2016 were retrospectively analyzed. The first 252 patients were treated according to short and the following 216 patients according to extended drainage protocol, in which the mediastinal chest tubes were habitually removed on the first and second postoperative day, respectively. The oxycodone hydrochloride consumption, as well as daily mean pain scores assessed by numeric/visual rating scales, were compared between the groups. Results. The mean daily pain scores and cumulative opioid consumption were similar in both groups. Patients with reduced ejection fraction, diabetes, and peripheral vascular disease reported lower initial pain scores. The median cumulative oxycodone hydrochloride consumption did not differ according to the drainage protocol but was higher in males, smokers, and after aortic surgery. In contrast, patients with advanced age, hypertension, and peripheral vascular disease had lower consumption. In multivariable analysis, male sex and aortic surgery were associated with higher and advanced age with lower opioid use. Conclusions. The length of mediastinal chest tube drainage is not associated with the amount of postoperative pain or need for opioids after cardiac surgery. Male sex and aortic surgery were associated with higher and advanced age with lower overall opioid consumption.

Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study

Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb^® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%; p = 0.001), milrinone (42.2 vs. 17.2%; p = 0.046), red blood cell concentrates (65.2 vs. 30.6%; p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%; p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %; p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days; p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery.

Combined Mitral and Aortic Valve Surgery: 17 Years' Experience in a Single Center

Background and objective:

It is not uncommon that patients requiring valve surgery have several simultaneous valvular dysfunctions. Combined aortic and mitral valve surgery is the most common form of double-valve surgery. The aim of this study was to analyze and present the outcomes of simultaneous aortic and mitral valve surgery in a single center in a real-life setting.

Methods:

The study population consisted of 150 patients operated in the Kuopio University Hospital from 2004 to 2020. All patients undergoing concomitant mitral and aortic valve surgery were included. Four groups were formed based on either the etiology or pathophysiology of the valvular dysfunction. The most common combination was mitral regurgitation with aortic regurgitation (n = 72, 48%), followed by mitral regurgitation with aortic stenosis (n = 37, 25%), endocarditis (n = 29, 19%), and mitral stenosis with aortic regurgitation or stenosis (n = 12, 8%). Concomitant coronary artery revascularization was performed in 37 (25%) patients and tricuspid valve repair in 26 (17%) patients.

Results:

Operative mortality was 2% and 30-day mortality was 7%. Overall survival was 86%, 78%, and 61% in 3, 5, and 10 years, respectively. Patients with endocarditis were significantly more morbid, and more often than other patients had to undergo an emergency operation. There were no significant differences between the groups in terms of early and late survival. In the overall cohort, the EuroSCORE II value, increased pulmonary artery pressure, decreased glomerular filtration, and length of the operation displayed a negative correlation with survival.

Conclusions:

Despite the challenging nature of multivalvular heart disease, surgery is a safe method of treatment with good short- and long-term outcomes.

Center-level CABG and valve operative outcomes and volume-outcome relationships in New York State

BACKGROUND

We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types.

METHODS

We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures.

RESULTS

Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R²  = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase.

CONCLUSION

In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Preliminary Outcome of a Novel Edge-to-Edge Closure Device to Manage Mitral Regurgitation in Dogs

Background: Veterinary management of mitral valve regurgitation due to mxyomatous valve disease in dogs is limited to medical treatments, which only postpones the onset of congestive heart failure or alleviates clinical symptoms. Most surgical procedures to manage this condition in humans require cardiopulmonary bypass and have a high risk of complications.

Animals: Eight dogs with naturally occurring mitral valve regurgitation.

Methods: Prospective observational study. All dogs were treated with a novel edge-to-edge transcatheter device named ValveClamp. The total surgical procedural time and total catheterization time were recorded. Echocardiographic variables measured pre- and post-procedure were compared using Wilcoxin-signed rank test with a P < 0.05 considered significant. Data were expressed as median and interquartile range and absolute numbers and percentages.

Results: The procedural success rate was 100% and all the dogs survived without complications. The median (interquartile range) total surgical procedural time was 86.5 (76–96.2) minutes and catheterization time was 23.5 (22–33.8) minutes. Echocardiography revealed a significant reduction in mitral regurgitation severity in all dogs following the procedure based on both a reduced mitral regurgitant maximum jet area (P = 0.012) and a reduced mitral regurgitant maximum jet area to left atrial area (P = 0.018).

Conclusion: The ValveClamp device is effective at reducing the severity of mitral regurgitation in dogs with naturally occurring myxomatous valve disease.

Widening volume and persistent outcome disparity in valve operations: New York statewide analysis, 2005-2016

OBJECTIVES

Volume concentration of complex noncardiac operations to high-volume centers has been observed, but whether this is also occurring in cardiac surgery is unknown. We examined the relationship between volume concentration and mortality rates for valve surgery and coronary artery bypass grafting (CABG) between 2005 and 2016 in New York State.

METHODS

We analyzed publicly available, hospital-level case volume and risk-adjusted mortality rates (RAMRs) from 2005 to 2016 for isolated CABG and isolated or concomitant valve operations performed in New York. We identified hospitals in the top- and bottom-volume quartiles for each procedure type and compared changes in percent market share and outcomes. Bivariate and univariate longitudinal analysis was used to evaluate the statistical significance of the temporal trend.

RESULTS

Among 36 centers, percent market share of the top-volume quartile increased for valve cases from 54.4% to 59.4%, whereas CABG share increased from 41.4% to 44.3%. No significant changes were noted in market share for the bottom quartile. The top-volume quartile demonstrated significant trends in improving outcomes over the study period for both valve procedures (RAMR: -0.261%/year, P < .001) and CABG (RAMR: -0.071%/year, P = .018). No significant trends were noted in the bottom quartile for either procedure.

CONCLUSIONS

In New York, over the last decade, highest-volume hospitals increased their market share for valve operations while maintaining lower mortality rates than lowest-volume hospitals. Valve volume is regionalizing in the setting of a persistent outcome gap between the highest- and lowest-volume hospitals, suggesting that volume-based referrals for specialized cardiac procedures may improve surgical mortality.

Minithoracotomy versus full sternotomy for isolated aortic valve replacement: Propensity matched data from two centers

BACKGROUND

Minimally invasive approaches to isolated aortic valve replacement (AVR) continue to gain popularity. This study compares outcomes of AVR through right anterolateral thoracotomy (RALT) to those of AVR through full median sternotomy (MS).

METHODS

Outcomes of two propensity-matched groups of 85 each, out of 250 patients that underwent isolated AVR through RALT or MS at our two institutions, were compared in a retrospective study.

RESULTS

Propensity score matching resulted in 85 matched pairs with balanced preoperative characteristics. Procedure times were significantly shorter in the RALT group (median difference: 13 min [-25 to -0.5]; p = .039), cardiopulmonary bypass times were longer (median difference: 17 min [10-23.5]; p = < .001) and ventilation times shorter (median difference: 259 min [-390 to -122.5]; p = < .001). There was no significant difference in aortic cross-clamp times (median difference: 1.5 min [-3.5 to 6.5]; p = .573). The RALT group had lower rates of perioperative platelet transfusions (odds ratio [OR] = 0.00 [0.00-0.59]; p = .0078) and postoperative pneumonia (OR = 0.10 [0.00-0.70]; p = .012), as well as shorter hospitalization times (median difference: 2.5 days [-4.5 to -1]; p = .005). There were no significant differences regarding paravalvular leakage (p = .25), postoperative stroke (p = 1), postoperative atrial fibrillation (p = .12) or 1-year-mortality (p = 1).

CONCLUSIONS

This study found RALT to be an equally safe approach to surgical AVR as MS. Furthermore, RALT showed advantages regarding important aspects of postoperative recovery, especially concerning pulmonary function.

Essen-Commando: How we do it

In rare cases of extensive aortic root or mitral valve infective endocarditis (IE), severe calcification of the aortic and mitral valves, or double-valve procedures in patients with small aortic and mitral annuli, surgical reconstruction of the intervalvular fibrous body (IVFB) is required. A high mortality is generally associated with this procedure, and it is frequently avoided by surgeons due to a lack of experience. It is crucial to radically resect all tissues that are severely affected by IE to prevent recurrence in the patient. Our experience with the Commando procedure in patients with extensive double-valve IE involving the IVFB is presented in this article.

Drug Use and Postoperative Mortality Following Valve Surgery for Infective Endocarditis: A Systematic Review and Meta-analysis

BACKGROUND

Infective endocarditis (IE) often requires surgical intervention. An increasingly common cause of IE is injection drug use (IDU-IE). There is conflicting evidence on whether postoperative mortality differs between people with IDU-IE and people with IE from etiologies other than injection drug use (non-IDU-IE). In this manuscript, we compare short-term postoperative mortality in IDU-IE vs non-IDU-IE through systematic review and meta-analysis.

METHODS

The review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publication databases were queried for key terms included in articles up to September 2017. Randomized controlled trials, prospective cohorts, or retrospective cohorts that reported on 30-day mortality or in-hospital/operative mortality following valve surgery and that compared outcomes between IDU-IE and non-IDU-IE were included.

RESULTS

Thirteen studies with 1593 patients (n = 341 [21.4%] IDU-IE) were included in the meta-analysis. IDU-IE patients more frequently had tricuspid valve infection, Staphylococcus infection, and heart failure before surgery. Meta-analysis revealed no statistically significant difference in 30-day postsurgical mortality or in-hospital mortality between the 2 groups.

CONCLUSIONS

Despite differing preoperative clinical characteristics, early postoperative mortality does not differ between IDU-IE and non-IDU-IE patients who undergo valve surgery. Future research on long-term outcomes following valve replacement is needed to identify opportunities for improved healthcare delivery with IDU-IE.

Hemodynamic outcomes after undersizing ring annuloplasty and focal suture annuloplasty for surgical repair of functional tricuspid regurgitation

OBJECTIVE

Surgical annuloplasty for functional tricuspid regurgitation (FTR) is on the rise and can be performed in several ways with varied outcomes. In this study, we sought to compare the hemodynamic outcomes of tricuspid annuloplasty performed with a commercially available annuloplasty ring (tricuspid valve annuloplasty [TVA]) compared with focal suture annuloplasty (Hetzer) in an experimental FTR model.

METHODS

An ex vivo FTR model was developed by inducing right ventricular dilatation by acute afterload elevation, causing severe tricuspid valve tethering and annular dilatation, leading to regurgitation. Ten porcine hearts in which FTR was induced underwent TVA with a 26-mm Edwards MC3 ring and Hetzer annuloplasty with a pledgeted suture cinching the anteroposterior and septal annulus. FTR was measured before after each repair, and tenting geometry, valve kinematics, and subvalvular geometry were measured with echocardiography.

RESULTS

At baseline, none of the hearts had FTR, but upon afterload elevation an FTR volume of 17.7 ± 9.2 mL (26.38 ± 17.47% regurgitant fraction) was measured (P < .0001). TVA reduced regurgitation by 50% and Hetzer annuloplasty by 56% , respectively, but both left persistent FTR. Anteroseptal tenting area was 279.0 ± 158.9 mm² before repair and decreased significantly to 147.2 ± 134.8 mm² (P = .0195) with Hetzer but not with TVA. Posteroseptal tenting area was 425.1 ± 169.2 mm² before repair and was significantly reduced by both techniques (TVA: 200.3 ± 102.9 mm² [P = .0012]; Hetzer: 237.6 ± 127.6 mm² [P = .0270]).

CONCLUSIONS

Tricuspid annuloplasty with a ring or a focal suture can reduce FTR but not eliminate it. Annular approaches did not relieve tricuspid valve tethering and reduced leaflet mobility persisted. Either subannular repairs or judicious use of valve replacement may be necessary.

Immediate outcome following valve surgery for rheumatic heart disease: the first local experience from Ethiopia

BACKGROUND

Rheumatic heart disease is the most common cardiac diseases in developing countries including Ethiopia. The current study aimed to describe the immediate surgical outcome following valve surgery for rheumatic heart disease in Ethiopia.

METHODS

Data were collected through chart abstraction from two centres in Addis Ababa, Ethiopia: the Cardiac Center of Ethiopia and El Ouzier cardiac centre. Included were all patients who were operated for rheumatic valvular heart disease in the mentioned centres by local cardiac surgical team during the period from June 2017 to April 2020. Demographic and clinical characteristics of the study population at admission and within 30 days of the index cardiac surgery were collected. Statistical Package for Social Sciences version 20.0 for windows was used to analyse the data.

RESULT

Of the 114 patients included in the study (median age 31 years with interquartile range of 23-40), 62 (54.4%) of them were female. Surgical procedures done were triple valve surgery 9 (7.9%) patients, mitral and tricuspid valves 26 (22.8%) patients, double-valve 16 (14.0%) patients, single-valve surgery 50.9% (11 aortic and 47 mitral valves) of patients, redo mitral valve surgery 3 (2.6%) patients, and left maze with mitral valve surgery 2 (1.8%) patients. Of the total, 103 (90.4%) of them had mitral valve surgery. Post-operatively, 5 (4.4%) patients died within 30 days following the index surgery.

CONCLUSION

Immediate surgical outcome following valve surgery for rheumatic heart disease had excellent outcome in our setting. This evidence can be taken as a show of success in building local capacity to manage rheumatic heart disease surgically.

Valve surgery for infective endocarditis complicated by stroke: surgical timing and perioperative neurological complications

BACKGROUND AND PURPOSE

Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing.

METHODS

The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14 days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14 days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging.

RESULTS

Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8 days (interquartile range 6-11); 91 had late surgery at a median of 28 days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P < 0.01). An acute infarct was present on pre-surgical magnetic resonance imaging of 134 patients (74%) and was not associated with perioperative neurological complications. Thirty-five patients (19.3%) had intracranial hemorrhage on pre-surgical imaging. SAH on pre-surgical imaging was associated with developing SAH perioperatively (66.7% vs. 13.5%, P < 0.01).

CONCLUSION

Early valve surgery for patients with IE complicated by stroke was not associated with perioperative neurological complications.

Clinical Profile and Management of Rheumatic Heart Disease in Children and Young Adults at a Tertiary Cardiac Center in Indonesia

Introduction: Rheumatic heart disease (RHD) remains a major public health issue affecting children and young adults in developing countries. This study aimed to evaluate the clinical characteristics, management, and reactivation of RHD among children and young adults.

Patients and Methods: This was a hospital-based retrospective study conducted at the National Cardiovascular Center Harapan Kita, Indonesia; we retrieved relevant data from patients diagnosed with RHD between 2012 and 2018.

Results: Two hundred and seventy-nine patients were diagnosed with rheumatic heart disease, of whom 108 were children (mean age of 12.02 ± 3.36 years) and 171 were young adults (mean age was 24.9 ± 3.84). RHD was more common in female than in male young adults (1.5:1). Hospitalization due to RHD complications such as congestive heart failure was seen in 11.11% of cases in children, while pulmonary hypertension was present in 19.95% young adult cases. Reactivation of RHD occurred in 17.2% (48/279) cases, significantly in children (p < 0.001). Overall, the mitral valve (either isolated or combined) was the organ most affected in children (39.13%) and young adults (44.81%). Isolated mitral regurgitation was more common in children (13/21, 61.9%), while isolated mitral stenosis was more common in young adults (19/47, 40.42%). There was a high rate of rheumatic tricuspid valve disease in all populations (193/279, 69.17%) and reported involvement of pulmonary regurgitation (46/279, 16.48%). Multivalve lesions were more common than single lesions in both groups, with a combination of mitral and tricuspid regurgitation the predominant type in children (32/43, 74.41%) and mixed mitral lesion and tricuspid regurgitation in young adults (22/72, 30.56%). We observed a significant occurrence of quadrivalve lesions in children (p = 0.039). Valve repair was more common in children (49.07%) and replacement in young adults (32.16%), with low in-hospital mortality. Compliance with secondary prophylaxis was a significant challenge.

Conclusion: Chronic RHD often presented with complications of the disease or reactivation of rheumatic fever (RF). Inadequate treatment of RF/RHD leads to extensive valvular damage and consequent disabilities. Efforts toward active early diagnosis and prompt treatment of RF/RHD and effective preventive measures are essential.

High-sensitivity C-reactive protein as a prognostic marker in patients undergoing valve surgery

Introduction

An inflammatory reaction is a local or systemic response of the organs or tissues of the body to many damaging factors. One of the exponents of the inflammatory process is C-reactive protein (CRP).

Aim

To investigate the prognostic value of C-reactive protein (CRP) in patients undergoing valve surgery.

Material and methods

A prospective study was conducted on a group of consecutive patients with haemodynamically significant valve defects who underwent elective valve repair or replacement surgery. The primary end-point was in-hospital death from all causes. Patients were followed by direct observation during hospitalization. The risk of surgery using Euro-SCORE II was calculated for each patient. The plasma levels of C-reactive protein were measured by the Cardiac C-Reactive Protein (Latex) High Sensitive Test (Roche, Germany).

Results

The study group included 562 patients. The mean age in the studied population was 63 (standard deviation (SD) ±12). The mean plasma preoperative CRP level was 0.39 ±0.3 mg/dl. The primary endpoint occurred in 25 patients. At multivariate analysis age (p = 0.01), CRP (p = 0.02) and NT-proBNP (p = 0.03) remained independent predictors of the primary endpoint. A significant correlation was found between the level of CRP and haemoglobin (r = -0.3; p < 0.0001), red cell distribution width (r = 0.22; p < 0.0001), ejection fraction (r = -0.24, p = 0.007), troponin T (r = 0.3; p < 0.0001), creatinine (r = 0.26; p = 0.001) and body mass index (r = -0.29; p = 0.005). The average total time of hospitalization after the operation in patients with occurrence of the primary endpoint was 25 ±13 days.

Conclusions

Elevated preoperative CRP was associated with a poorer outcome following valve surgery.

Usefulness of FRAIL Scale in Heart Valve Diseases

Background

The frailty syndrome is a serious health problem for an aging population. The occurrence of frailty in the group of symptomatic patients undergoing heart valve surgery may have additional clinical implications. The predictive ability of the FRAIL scale in patients undergoing heart valve surgery during a 30-day follow-up has not yet been described.

Patients and Methods

A prospective study was conducted on a group of consecutive patients with hemodynamically significant valve disease (aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) that underwent elective valve surgery in 2014–2019. The primary endpoint was 30-day mortality. Univariate analysis, followed by multivariate regression analysis, was performed.

Results

The study group included 672 consecutive patients (aortic valve stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) who underwent replacement or repair of the valve. Twenty-five patients died during the 30-day follow-up. At multivariate analysis, FRAIL scale result (OR 2.802; 95% CI 1.275–6.157; p=0.01) and red cell distribution width (RDW) (OR 1.810; 95% CI 1.181–2.775; p=0.006) remained independent predictors of the primary endpoint.

Conclusion

The presented study showed the predictive ability of the FRAIL scale result in patients undergoing heart valve surgery for 30-day mortality.

Axillary Approach for Venoarterial Extracorporeal Membrane Oxygenation Cannulation

Extracorporeal membrane oxygenation support (ECMO) is a form of mechanical circulatory support that is used in patients with severe dysfunction of heart or lung or both. Depending on whether it is venovenous or venoarterial support, it can temporarily substitute for circulation and ventilation while the underlying cause is addressed. Traditional approach for cannulation usually involves the femoral vessels. This is due to the easy accessibility, larger lumen of vessels, and physician expertise and training in femoral approach. However, in certain circumstances like critical lower extremity ischemia, crush injury or trauma to lower extremity, and lower extremity infections (like necrotizing fasciitis), this approach is not practical. In these situations, axillary vasculature provides a good substitute for ECMO cannulation. 

Influence of Age on Cardiac Surgery Outcomes in United States Veterans

OBJECTIVE

Heart disease is still the leading cause of death for both men and women in the United States, and the rate of cardiovascular disease in veterans is even higher than in civilians. This study examines age-related outcomes for veterans undergoing cardiac surgeries at a single institution.

METHODS

We included all veterans undergoing coronary artery bypass grafting (CABG) and/or valve surgery between 1997 to 2017 at a single Veterans Affairs (VA) medical center. We stratified this cohort into 4 age groups: ≤59 years old, 60-69 years old, 70-79 years old, and ≥80 years old. Outcomes in age groups were compared using standard statistical methods with the ≤59 years old group as reference.

RESULTS

A total of 2,301 patients underwent open cardiac procedures at our institution. The frequency of simultaneous CABG and valve operations increased with age. Usage of cardiopulmonary bypass versus off-pump CABG and operative time was not associated with age. Increased pulmonary and renal complications as well as rates of postoperative arrhythmias all were associated with increasing age. There was no statistically significant difference in 30-day mortality. However, multivariable analysis adjusted for covariates showed all-cause mortality significantly was increased with older age groups (aHR ≥80 years old: 2.94 [2.07-4.17], P < .01; aHR 70-79 years old: 2.15 [1.63-2.83], P < 0.01, with ≤59 years old as reference).

CONCLUSIONS

Older patients may have comparable perioperative mortality as their younger counterparts. However, age still is a significant predictor of all-cause mortality, pulmonary and renal complications, and postoperative arrhythmia, and should be considered as a major factor in preoperative risk assessment.

Outcomes of cardiac surgery after mediastinal radiation therapy: A single-center experience

Background

Mediastinal radiation therapy (MRT) is a widely used therapy for thoracic malignancies. This therapy has the potential to cause cardiovascular injuries, which may require surgery. The primary aim of this study is to identify the perioperative outcomes of cardiac surgery in patients with a history of MRT. Second, potential predictors of mortality and adverse events were identified.

Methods

A retrospective study was conducted among 59 patients with prior MRT who underwent cardiac surgery between December 2009 and March 2015. Included surgeries consisted of procedures through median‐ and ministernotomy. Baseline, perioperative, and follow‐up data were obtained and analyzed.

Results

The majority of patients had a history of breast cancer (n = 43), followed by Hodgkin lymphoma (n = 10) and non‐Hodgkin lymphoma (n = 3). Preoperative estimated mortality with the Euroscore II was 3.4%. Overall 30‐day mortality was 6.8% (n = 4), with a total in‐hospital mortality of 10.2% (n = 6). Postoperatively, nine rethoracotomies (15.3%) had to be performed. During a mean follow‐up of 53 months, an additional 10 patients (16.9%) died, of which 60% (n = 6) as a result of cancer‐related events. Cox proportional modeling showed no differences in mortality between primary malignancies (P  > .05).

Conclusion

This study shows that cardiac surgery after mediastinal radiotherapy is associated with increased short‐ and long‐term mortality when compared to preoperative mortality risks predicted by the Euroscore II. Surgery‐related events caused all short‐term mortality cases, while malignancy‐related events were the main cause of death during the follow‐up. Mortality was higher in patients with a previous stroke and a lower estimated glomerular filtration rate.