Survival after resection of primary cardiac tumors: a 48-year experience

BACKGROUND

Primary cardiac tumors are rare but have the potential to cause significant morbidity if not treated in an appropriate and timely manner. To date, however, there have been no studies examining survival characteristics of patients who undergo surgical resection.

METHODS AND RESULTS

From 1957 to 2006, 323 consecutive patients underwent surgical resection of primary cardiac tumors; 163 (50%) with myxomas, 83 (26%) with papillary fibroelastomas, 18 (6%) with fibromas, 12 (4%) with lipomas, 28 (9%) with other benign primary cardiac tumors, and 19 (6%) with primary malignant tumors. Operative (30 day) mortality was 2% (n=6). Univariate analysis indicated that patients who underwent resection of fibromas and myxomas had superior survival characteristics in comparison to the remainder of tumor variants; these results were consistent after adjusting for age at surgery, year of surgery, and cardiovascular risk factors. Based on actuarial characteristics of the 2002 U.S. population, patients who underwent myxoma resection had survival characteristics that were not significantly different from that of an age and gender matched population (SMR 1.11, P=0.57) whereas those who underwent resection of fibromas (SMR 11.17, P=0.002), papillary fibroelastomas (SMR 3.17, P=0.0003), lipomas (SMR 5.0, P=0.0003), other benign tumors (SMR 4.63, P=0.003), and malignant tumors (SMR 101, P<0.0001) had significantly poorer survival characteristics. Furthermore, malignant tumors in younger patients were highly fatal (HR 0.899, P<0.0001). Although the most significant predictor of mortality was tumor histology, survival was also influenced the by the duration of CPB and NYHA III/IV; the impact of these risk factors varied with time. The cumulative incidence of myxoma recurrence was 13% and occurred in a younger population (42 versus 57 years, P=0.003) with the risk of recurrence decreased after 4 years.

CONCLUSIONS

Surgical resection of primary cardiac tumors is associated with excellent long-term survival; patients with cardiac myxomas have survival characteristics that are not significantly different from that of a general population. Predictors of mortality are primarily related to tumor histology but also include clinical characteristics such as symptomatology and duration of CPB.

Autologous stem cell transplant after heart transplant for light chain (Al) amyloid cardiomyopathy

BACKGROUND

Historically, patients with AL amyloidosis and overt congestive heart failure have had an ominous prognosis with median survival of approximately 6 months.

METHODS

Between 1994 and 2005, 11 patients underwent sequential orthotopic heart transplantation (HT) followed by autologous peripheral blood stem cell transplantation (SCT) for treatment of AL amyloidosis. Patients were accepted for this approach if they had heart-dominant AL with minimal/no other organ impairment and no evidence of multiple myeloma. Conditioning chemotherapy consisted of melphalan 200 mg/m(2) (6 patients) or melphalan 140 mg/m(2) (5 patients).

RESULTS

Two patients died of complications from the SCT (18% transplant-related mortality). Nine patients survived both the HT and the SCT. Three patients subsequently died from progressive amyloidosis at 66, 56.7 and 55 months after SCT. The 1- and 5-year survival for HT was 82% and 65%. The median survival was 76 months from HT and 57 months from SCT.

CONCLUSIONS

These data suggest that aggressive treatment of the underlying plasma cell clone after HT may improve long-term outcomes in patients with cardiac amyloid. HT followed by SCT is feasible and offers the possibility of remission for carefully selected patients with cardiac amyloidosis.

Mitral regurgitation surgery in heart failure due to ischemic cardiomyopathy: a 24-year experience

BACKGROUND AND AIM OF THE STUDY

The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are controversial. Herein are reported the results and trends of this surgical approach over the past 24-year period.

METHODS

Patients were identified in refractory heart failure due to ICM with NYHA functional class III/IV symptoms, left ventricular ejection fraction < or =35% and MR who underwent mitral surgery between 1979 and 2002. The early and late outcomes were analyzed and compared for the different surgical eras classified as early (1979 to 1986), middle (1987 to 1994), and late (1995 to 2002).

RESULTS

Mitral repair (70%) and replacement (30%) were performed with coronary artery bypass grafting (CABG) (85%) and tricuspid valve repair (7%) in 179 patients (mean age 68 +/- 9 years). The overall one- and five-year survival rates were 84% and 51%, respectively, and the corresponding freedom from recurrent MR after repair 86% and 55%. An increasing number of patients underwent surgery from the early to the late era. Whereas patients more frequently presented with cardiomegaly and renal failure during the early era, they were older, more often had prior CABG, concurrent tricuspid regurgitation and underwent mitral repair during the late era. A progressive improvement was observed in operative mortality from the early to late eras (24%, 11% and 5%, respectively; p = 0.009), and also for the one-and five-year survivals (68%, 85% and 89%; 46%, 43% and 57%, respectively; p = 0.06). Preoperative renal failure and concomitant tricuspid valve repair were predictors of late mortality.

CONCLUSION

During the past 24 years, operative results for the surgical correction of MR in patients with heart failure due to ICM have steadily improved. Currently, while the early and mid-term survival are satisfactory the long-term survival is limited, especially when heart failure is complicated by renal failure and severe tricuspid regurgitation.

Effect of infectious diseases on outcome after heart transplant

OBJECTIVE

To determine how often cardiac allograft recipients develop infectious diseases and how the infections affect these patients.

PATIENTS AND METHODS

We retrospectively studied 313 patients who underwent heart transplant at Mayo Clinic's site in Rochester, MN, from January 1, 1988, through June 30, 2006.

RESULTS

In the early postoperative period (ie, period between heart transplant and discharge from the hospital), infectious diseases occurred in 70 (22%) of 313 patients but were not associated with 1-year mortality; the most commonly infected sites were the lungs (7%), bloodstream (6%), upper respiratory tract (5%), and urinary tract (4%). In the 18 years after transplant, the cumulative incidence of infectious diseases was 93%; the most common infectious complications were skin and soft tissue (63%), urinary tract (46%), cytomegalovirus (40%), lung (36%), upper respiratory tract (23%), and varicella zoster virus (15%) infections. After adjustment for baseline predictors, lung (hazard ratio [HR], 3.87; 95% confidence interval [CI], 2.49-6.02; P less than .001) and central nervous system (HR, 4.48; 95% CI, 1.75-11.46; P equals .002) infections were predictive of mortality. Serum creatinine levels (HR, 1.74; 95% CI, 1.07-2.81; P equals .02) and sirolimus use (HR, 2.72; 95% CI, 1.00-7.36; P equals .05) were predictive of lung infection. Death occurred during the study period in 95 (30%) of 313 patients, with a cumulative incidence of 71% at 18 years. The cause of death was infection in 17 (18%) of 95 patients.

CONCLUSION

Early postoperative infectious complications are frequent in cardiac allograft recipients but are not associated with 1-year mortality. Lung and central nervous system infections are predictors of mortality.

Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation

BACKGROUND

Disruptions in surgical flow have the potential to increase the occurrence of surgical errors; however, little is known about the frequency and nature of surgical flow disruptions and their effect on the etiology of errors, which makes the development of evidence-based interventions extremely difficult. The goal of this project was to study surgical errors and their relationship to surgical flow disruptions in cardiovascular surgery prospectively to understand better the effect of these disruptions on surgical errors and ultimately patient safety.

METHODS

A trained observer recorded surgical errors and flow disruptions during 31 cardiac surgery operations over a 3-week period and categorized them by a classification system of human factors. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of experts in operative and human factors.

RESULTS

Flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and issues in resource accessibility. Surgical errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors.

CONCLUSION

These findings provide preliminary data to develop evidence-based error management and patient safety programs within cardiac surgery with implications to other related surgical programs.

Central nervous system infections in heart transplant recipients

OBJECTIVE

To study central nervous system infections after heart transplantations.

DESIGN

Retrospective cohort study.

SETTING

Cardiac Transplant Program at Mayo Clinic, Rochester, Minnesota. Patients Three hundred fifteen consecutive patients who underwent heart transplantation from January 1988 through June 2006.

RESULTS

Central nervous system infections developed in 8 patients (3%), all of whom presented within the first 4 years after transplantation. The most common presentations were acute or subacute confusion or headache (88%), often without the classic symptoms of fever and neck stiffness. Direct cerebrospinal fluid examination was unrevealing in most cases, though cerebrospinal fluid protein levels were elevated in all patients with infections. Diagnoses included cryptococcal meningitis (n = 3), progressive multifocal leukoencephalopathy (n = 2), varicella-zoster virus encephalitis (n = 2), and Aspergillus fumigatus infection (n = 1). Three of 8 patients died (38%) and 2 (25%) survived with mild sequelae. Central nervous system infection was a significant predictor of mortality (hazard ratio, 4.39; 95% confidence interval, 1.72-11.18; P = .002).

CONCLUSIONS

Central nervous system infections are rare but devastating complications of heart transplantations. Recognition of these infections is difficult owing to a paucity of clinical manifestations. We report here, for the first time, varicella-zoster virus central nervous system infection in heart transplantations.

Intermediate-term results of ascending–descending posterior pericardial bypass of complex aortic coarctation

OBJECTIVE

Extra-anatomic bypass of complex thoracic aortic disease through a median sternotomy has been reported as a safe alternative to thoracotomy. Our objective was to examine intermediate-term outcomes.

METHODS

We retrospectively reviewed 50 consecutive patients with congenital aortic coarctation or recurrent coarctation who underwent ascending-descending posterior pericardial aortic bypass between January 1985 and November 2005. Demographic data, in-hospital and postoperative morbidity and mortality, and resolution of hypertension were determined by examination of the medical record.

RESULTS

The mean age at operation was 42 years; 27 (54%) were men. There were no perioperative deaths. Upper-extremity blood pressure after coarctation repair with ascending-descending aortic bypass was significantly improved. Mean systolic blood pressure decreased from 158 +/- 25 mm Hg preoperatively to 123 +/- 14 mm Hg postoperatively (P < .001). There were no graft-related deaths or complications in follow-up extending up to 20 years.

CONCLUSIONS

The ascending-descending aortic bypass through a posterior pericardial approach is a safe operation and is effective in relieving obstruction and improving hypertension.

Off-pump strategy in high-risk coronary artery bypass reoperations

OBJECTIVE

To determine the role of off-pump coronary artery bypass grafting in the treatment of patients with severe recurrent angina after coronary artery bypass grafting who are not suitable for percutaneous coronary intervention and are considered too high risk for conventional on-pump revascularization.

PATIENTS AND METHODS

All patients who needed single- or double-vessel revascularization at reoperation with a predicted operative mortality of 10% or higher between March 4, 1994, and December 31, 2002, were studied. Risk stratification was performed using both the Parsonnet risk scoring system and the European System for Cardiac Operative Risk Evaluation. Active follow-up by questionnaire investigated major adverse cardiac events.

RESULTS

This study consisted of 84 patients with a median age of 69 years (interquartile range, 62-75 years); 14 (17%) were female. All patients had class III/IV symptoms. Previous operations included multiple coronary artery bypass grafts (15 patients [18%]) and heart transplantation (1 patient [1%]). Internal thoracic artery graft from a previous operation was patent in 43 patients (51%). Perioperative hemodynamic support with inotropes (35%) and intra-aortic balloon pump (14%) or ventricular assist device (2%) was common. The surgical approach varied for each patient. One operative death (1%) occurred. Estimated survival at 5 and 7 years was 77% and 67%, respectively. Late major adverse cardiac events observed during follow-up were cardiac death (n=66), nonoperative reintervention (n=8), and nonfatal myocardial infarction (n=5).

CONCLUSION

Off-pump coronary artery bypass grafting can mitigate reoperative risk in patients with an estimated risk of 10% or higher who are undergoing single- or double-vessel revascularization with satisfactory long-term outcome.

Cardiac Surgery in Patients With Body Mass Index of 50 or Greater

BACKGROUND

The seemingly inexorable rise in obesity worldwide is creating a new set of challenges for healthcare providers. Demand for cardiac surgical intervention among patients at extreme levels of obesity (body mass index [BMI] > or = 50) is increasing; however, the risks, benefits, and resources required to meet this need have not been established.

METHODS

Between 1993 and 2004, 57 patients with a BMI of 50 or more underwent cardiac surgical procedures at our institution. The mean BMI was 54 +/- 4, weight range was 124 to 226 kg. The mean age of the study group was 55 +/- 12 years, and comorbidities included diabetes mellitus in 29 (51%), hypertension in 40 (70%), hyperlipidemia in 22 (39%), and obstructive sleep apnea in 16 (28%).

RESULTS

The operative mortality was 7% (4 patients). Eleven patients (20%) required prolonged intubation (more than 24 hours), and mean intensive care unit stay was 5 +/- 9 days. Wound complications requiring surgery occurred in 3 (5%). Survival at 1 and 5 years was 93% +/- 4% and 76 +/- 8%, respectively. By univariate analysis, age and endocarditis were associated with long-term mortality and major perioperative complications. As a dichotomous variable, BMI greater than 54 was a significant predictor of renal failure and prolonged mechanical ventilation.

CONCLUSIONS

Cardiac surgery in the patient with a BMI of 50 or greater is associated with significant resource utilization, including prolonged intensive care unit and hospital stay, with prolonged intubation and wound complications relatively common.

Ten-year Experience With the Cox-Maze Procedure for Atrial Fibrillation: How Do We Define Success?

BACKGROUND

The Cox-maze procedure is the standard to which other surgical treatments of atrial fibrillation (AF) are compared. However, evaluation of new devices and lesion sets is difficult because of variable methods of reporting success in eliminating AF. We analyzed 10-year outcome with the "cut and sew" Cox-maze procedure and present rhythm at last follow-up, interval contact, and actuarial AF freedom.

METHODS

Between March 1993 and December 2002, 335 patients (211 men) underwent the Cox-maze procedure (age, 22 to 83 years; median, 62 years). Atrial fibrillation was chronic (CAF) in 175 patients and paroxysmal (PAF) in 160.

RESULTS

Concomitant mitral valve procedures were performed in 59%, coronary artery bypass grafting in 19%, and tricuspid valve repairs in 7%. Early mortality was 0.9%. During hospitalization, transient AF occurred in 29% of patients and 10% required implantation of a new permanent pacemaker (PPM). Dismissal electrocardiogram was normal sinus rhythm in 64%, junctional rhythm in 18%, AF in 11%, and PPM in 7%. At last follow-up (mean 42 +/- 6 months), 88% of patients were free of AF. However, when analyzed by the Kaplan-Meier method, freedom from AF was lower for patients with preoperative lone PAF (5 years, 90%; 10 years, 64%), preoperative lone CAF (5 years, 80%; 10 years, 62%), and patients undergoing combined maze-mitral valve surgery (5 years, 68%; 10 years, 41%).

CONCLUSIONS

Ten-year results with the standard Cox-maze procedure confirm high effectiveness, but reporting methods should be standardized to account for patients who have transient atrial arrhythmias during long-term follow-up.

Application of the Human Factors Analysis and Classification System Methodology to the Cardiovascular Surgery Operating Room

BACKGROUND

Improving patient safety by reducing human error is a priority in all surgical specialties. A model for assessing the myriad of factors affecting performance in the operating room (OR) has yet to be developed. We hypothesized that human factors identified in other domains would similarly be viewed as contributors to error in cardiac surgery.

METHODS

As a first step, we utilized a model previously employed in aviation to develop structured interviews of individuals in multiple roles (surgeons and allied health staff). To enhance relevance to the OR, Likert scale questions were formulated based on published sentinel event analyses and focus group studies in which specific factors found to be causally related to error in health care were described. Additional items from other high risk-consequence industries were generated to address theoretically important factors not highlighted previously.

RESULTS

Application of the modified model to the interview responses allowed the identification of factors impacting performance in the OR and estimation of their relative importance. Analysis of correlations among responses were consistent with predictions of the model that the origin of errors can be traced to organizational influences that impact supervisory processes, which in turn establish preconditions predisposing to errors.

CONCLUSIONS

These data demonstrate a model of error causation derived from aviation can be modified and applied to the cardiac surgery OR. This tool may prove useful in identifying systemic factors impacting human performance and patient safety.

Superiority of cut-and-sew technique for the Cox maze procedure: comparison with radiofrequency ablation

OBJECTIVE

Although radiofrequency ablation is increasingly used to create the atrial lesions of the Cox maze procedure, its effectiveness in ablating atrial fibrillation compared with the standard cut-and-sew method is not known. We compare the freedom from atrial fibrillation in patients undergoing both methods with identical lesion sets.

METHODS

Radiofrequency ablation was used to create full Cox maze lesions in 56 patients between January 2002 and February 2005; these patients were matched with those who underwent the standard cut-and-sew method. Matched variables were gender (33 male, 23 female, both), age (67.5 vs 67.2 years), New York Heart Association class (mean 2.28 vs 1.96), atrial fibrillation type (37 paroxysmal, 19 continuous, both), and concomitant mitral valve surgery (37 in both). Hypertension, preoperative left atrial size, and preoperative duration of atrial fibrillation were similar between groups.

RESULTS

When compared with matched controls, fewer patients undergoing radiofrequency ablation were free from atrial fibrillation at dismissal (63% vs 88%; P = .0039) and at last follow-up (62% vs 92%; P = .016). According to logistic regression for matched pairs, patients undergoing radiofrequency ablation were 4.5 times more likely to be in atrial fibrillation at dismissal (95% confidence intervals [CI], 1.8, 10.9) and 5 times more likely to be in atrial fibrillation at follow-up (95% CI, 1.4, 17.3). No other covariate was associated with atrial fibrillation status at hospital dismissal or follow-up.

CONCLUSION

Creating Cox maze lesions with radiofrequency ablation is associated with less freedom from atrial fibrillation both early and late postoperatively. Because transmurality can be assured, the standard cut-and-sew Cox maze procedure remains the gold standard for the surgical treatment of atrial fibrillation.

Does preoperative atrial fibrillation influence early and late outcomes of coronary artery bypass grafting?

OBJECTIVE

The study objective was to describe the independent effect of preoperative atrial fibrillation on the outcome of coronary artery bypass grafting, including the causes of death (cardiac vs noncardiac).

METHODS

We analyzed the outcome of patients with preoperative atrial fibrillation who underwent on-pump coronary artery bypass grafting between 1993 and 2002 and compared them with matched controls in sinus rhythm; matching variables were age, gender, ejection fraction, and numbers of diseased coronary arteries and distal anastomoses. Direct patient follow-up focused on late complications and reinterventions, and we investigated causes for all deaths.

RESULTS

Operative mortality (1.6% vs 1.9%, P = .79) was similar in patients with preoperative atrial fibrillation (n = 257) compared with patients in sinus rhythm (n = 269). The patients with atrial fibrillation had longer hospital stays (9 +/- 6 days vs 8 +/- 6 days, P = .0008) and a trend to more frequent early readmissions (13% vs 9%, P = .08). During follow-up (median 6.7 years, maximum 12 years), late hospital admission was more frequent in patients with atrial fibrillation (59% vs 31%, P < .0001). Risk of late mortality (all causes) in patients with atrial fibrillation was increased by 40% compared with patients in sinus rhythm (P = 0.02), and the late cardiac death rate in the atrial fibrillation group was 2.8 times that of the sinus rhythm group (P = .0004). Major adverse cardiac events occurred in 70% of patients with preoperative atrial fibrillation compared with 52% of patients in preoperative sinus rhythm (P < .0001). Subsequent rhythm-related intervention, including pacemaker implantations, was more common in the atrial fibrillation group (relative risk = 2.1, P = .0027).

CONCLUSIONS

Uncorrected preoperative atrial fibrillation in patients undergoing coronary artery bypass grafting is associated with increased late cardiac morbidity and mortality and poor long-term survival. These data support consideration of atrial fibrillation surgery at the time of coronary artery bypass grafting.

Recurrent mitral regurgitation after repair: Should the mitral valve be re-repaired?

OBJECTIVE

We sought to evaluate the clinical and echocardiographic outcomes of reoperation for failed mitral valve repair.

METHODS

One hundred forty-five patients with recurrent mitral regurgitation after primary mitral valve repair of degenerative leaflet prolapse underwent mitral valve reoperations between January 1, 1970, and January 1, 2005. The mean age was 66 years, and 102 (70%) were men.

RESULTS

The mean duration from initial repair to reoperation was 4.1 years (standard deviation = +/- 5.1 years). Indications for reoperation were regurgitation alone (n = 109 [75%]), hemolysis (n = 27 [19%]), obstruction from systolic anterior motion (n = 3 [2%]), endocarditis (n = 3 [2%]) and stenosis-other (n = 3 [2%]). New pathology was found in 80 (55%) patients, and failure of the initial repair was found in 61 (42%) patients. The mitral valve was re-repaired in 64 (44%) patients and replaced in 81 (56%) patients. Early operative mortality was similar after re-repair and replacement (1.6% vs 4.9%, P = .38). Independent predictors of improved survival on multivariate analysis were mitral re-repair (hazard ratio = 0.44, P = .03), younger age (hazard ratio = 1.06, P = .001), and an operative indication of mitral regurgitation alone (hazard ratio = 0.31, P = .005). Seven patients had a third mitral operation (all replacements), 6 after re-repair and 1 after replacement. At last follow-up echocardiogram (n = 96), ejection fraction was greater (P < .001) and left ventricular end-systolic dimension was smaller (P = .009) in patients undergoing re-repair compared with values in those undergoing valve replacement.

CONCLUSION

Recurrent mitral regurgitation after prior repair is frequently caused by new valve pathology. Mitral re-repair is performed in almost half of patients and is associated with superior survival, improved ejection fraction, and greater regression in ventricular dimension compared with valve replacement.

Surgical treatment of cardiac papillary fibroelastoma: a single center experience with eighty-eight patients

BACKGROUND

Cardiac papillary fibroelastoma is a rare benign tumor that can cause thromboembolism. We have found no large surgical series describing its treatment and outcome.

METHODS

A retrospective review of all patients treated surgically for this tumor from 1985 to 2002.

RESULTS

There were 88 patients with a mean age of 62 +/- 16 years. Sixty-two (71%) were male. Cardiac papillary fibroelastoma was a primary indication for surgery in 47 (group 1, 53%) and an incidental finding in 41 (group 2, 47%). The common clinical symptoms were neurologic (group 1) and cardiac (group 2). Cardiac valves were predominantly involved (77%); the aortic valve was the most affected (52%). Other common sites were the left ventricular outflow tract (18%) and anterior mitral leaflet (11%). All heart valves were involved in one patient. Seventy-three patients (83%) had shave excision and 8 (9%) excision with valve repair. Of 5 (6%) valve replacements, 2 were for concurrent degenerative valve disease. Concomitant procedures included repair or replacement of another valve (32%), CABG (28%), and septal myectomy (19%). Surgical mortality occurred in 1 patient (2.1%) in group 1 who had concomitant lung resection for bronchiolitis obliterans. There was no tumor recurrence, and no tumor-related late morbidity or mortality at a mean follow-up of 3 years.

CONCLUSIONS

Cardiac papillary fibroelastoma has a propensity to affect the anatomically contiguous structures of the aortic valve, left ventricular outflow tract, and anterior mitral leaflet. Surgical treatment by simple shave excision is low risk and can achieve good results.

Prognostic Implications of Preoperative Atrial Fibrillation in Patients Undergoing Aortic Valve Replacement: Is There an Argument for Concomitant Arrhythmia Surgery?

BACKGROUND

The prognostic significance of preoperative atrial fibrillation (AF) at the time of aortic valve replacement is unknown, as is the potential role for concomitant arrhythmia surgery.

METHODS

We performed a cohort comparison of patients with preoperative AF (n = 129) and preoperative sinus rhythm (SR, n = 252) undergoing aortic valve surgery between 1993 and 2002; patients were matched for age, gender, and left ventricular ejection fraction. Follow-up (mean interval, 4.5 years) was 98% complete. Primary endpoints were late cardiac and all-cause mortality, as well as major adverse cardiac or cerebrovascular event.

RESULTS

Patients with preoperative AF presented with more severe congestive heart failure (p = 0.03) and more often had significant tricuspid regurgitation (p = 0.01) preoperatively. They also had worse late survival (risk ratio [RR] for death = 1.5, p = 0.03) with 1-, 5-, and 7-year survival rates substantially reduced at 94%, 87%, and 50%, respectively, for those in AF versus 98%, 90%, and 61% for patients in sinus rhythm preoperatively. Individuals in AF had a greater probability of subsequent rhythm-related intervention (RR = 4.7, p = 0.0002), and more frequently developed congestive heart failure (25% vs 10%, p = 0.005) and stroke (16% vs 5%, p = 0.005). By multivariable analysis, preoperative AF was an independent predictor of late adverse cardiac and cerebrovascular events, but not late death.

CONCLUSIONS

Performance of concomitant arrhythmia surgery in patients undergoing aortic valve surgery may reduce late morbidity; however, its potential impact on late mortality in this high-risk subset of patients remains unclear.

Survival Advantage and Improved Durability of Mitral Repair for Leaflet Prolapse Subsets in the Current Era

BACKGROUND

Factors predicting long-term survival and reoperative risk after mitral valve repair for subsets with prolapse involving the anterior leaflet in the current era are unclear.

METHODS

Between January 1, 1980 and December 31, 1999, surgical correction of mitral regurgitation was performed in 2,219 patients. We analyzed a subset of 1,411 patients with isolated mitral regurgitation due to leaflet prolapse undergoing mitral repair or replacement (+/- coronary bypass).

RESULTS

Mean age was 64 years, and 1,003 (71%) were men. Mitral repair was performed in 1,173 (83%) patients. Factors independently predicting overall long-term survival included valve repair, younger age, better functional class, and the absence of significant coronary artery disease. After adjusting for these, smaller preoperative left ventricular end-systolic dimension and greater preoperative ejection fraction were associated with superior survival. Mitral reoperation occurred in 97 patients (75 repairs, 22 replacements), at a mean of 4.8 years after initial procedure. Cumulative risk of reoperation was similar for patients having valve repair or replacement. Factors predictive of need for reoperation after initial repair were younger age, anterior leaflet prolapse, chordal shortening, no leaflet resection, no prosthetic annuloplasty, greater than mild residual mitral regurgitation, and coronary artery disease. After valve replacement, the sole determinant of reoperation was use of a biological prosthesis. The durability of repair for prolapse of the anterior leaflet improved significantly during the second decade of the study.

CONCLUSIONS

Mitral repair affords superior long-term survival, with permanence comparable with mechanical valve replacement. In all categories of mitral leaflet prolapse, durability of valve repair has improved over the past decade.

Left Ventricular Dysfunction in Atrial Fibrillation: Restoration of Sinus Rhythm by the Cox-Maze Procedure Significantly Improves Systolic Function and Functional Status

BACKGROUND

Atrial flutter or fibrillation with rapid, uncontrolled ventricular response may lead to left ventricular dysfunction, and conversion to sinus rhythm with control of heart rate can improve left ventricular ejection fraction. Little is known about the effects of the Cox-maze procedure on this form of tachycardia-induced cardiomyopathy.

METHODS

Four hundred forty-three patients underwent the Cox-maze procedure from 1993 to 2002. Ninety-nine had atrial flutter or fibrillation without associated valvular or congenital heart disease, and 37 (37%) had decreased left ventricular function (ejection fraction < 0.35 in 11 [severe], ejection fraction 0.36 to 0.45 in 8 [moderate], and ejection fraction 0.46 to 0.55 in 18 [mild]). Ages of these 37 patients (34 male) ranged from 35 to 74 years (median, 55 years).

RESULTS

Atrial flutter or fibrillation was present for 3 months to 19 years (median, 48 months) preoperatively, and 24 patients (65%) exhibited symptoms of heart failure. Preoperative ejection fraction ranged from 0.25 to 0.55 (median, 0.45). At last follow-up (median, 63 months), the Cox-maze procedure eliminated atrial flutter or fibrillation in all but 1 patient, and the greatest improvement was observed in patients with severe preoperative impairment (0.31 to 0.53; p = 0.01, preoperative versus follow-up), and patients with preoperative chronic atrial flutter or fibrillation (0.43 to 0.55; p < 0.05 preoperative versus follow-up). This improvement was observed immediately postoperatively and was sustained at last follow-up. Further, improvement in left ventricular function correlated with enhancement of functional status.

CONCLUSIONS

In some patients, atrial flutter or fibrillation may be the cause rather than the consequence of left ventricular dysfunction. Importantly, systolic function and functional status can be significantly improved with the restoration of sinus rhythm by the Cox-maze procedure.

Sirolimus in cardiac transplantation: use as a primary immunosuppressant in calcineurin inhibitor-induced nephrotoxicity

BACKGROUND

Calcineurin inhibitor (CNI) immunosuppressants are a major cause of renal dysfunction in cardiac transplant recipients, leading to increased morbidity and mortality. The aim of this study was to evaluate the efficacy and safety of CNI withdrawal and substitution with sirolimus as the primary immunosuppressant, and assess the effect on renal function in cardiac transplant recipients with CNI-induced renal impairment.

METHODS

Thirty-four stable cardiac transplant recipients (range 1 to 14 years post-transplant) with CNI-induced nephrotoxicity (iothalamate clearance 25 to 50 ml/min) or cardiac allograft vasculopathy (CAV) were enrolled. Twelve patients (Group A) were prospectively enrolled for renal dysfunction. The remaining patients (n = 22, Group B) were converted to sirolimus on clinical grounds because of poor renal function or the presence of CAV. CNI was withdrawn gradually over 12 weeks. Sirolimus was started at 1 mg/day with titration over 2 weeks to achieve levels of 10 to 15 ng/ml. Echocardiograms and cardiac biopsies were performed to determine rejection. Adjunct immunosuppression was left unchanged. Follow-up iothalamate clearance was performed. A further 24 patients (Group C) were retrospective controls, stable (range 2 to 10 years post-transplant), and maintained on a standard CNI-based immunosuppressant regimen.

RESULTS

Iothalamate clearance (C(i)) improved significantly (Group A baseline: 36.08 +/- 2.4 ml/min to 48.67 +/- 4.1 ml/min, p = 0.004; Group B baseline: 48.14 +/- 3.2 ml/min to 55.77 +/- 4.2 ml/min, p < 0.001) without exacerbating rejection or compromising cardiac function. By contrast, in controls, Group C, the baseline renal clearance declined from 40.04 +/- 1.86 ml/min to 34.63 +/- 1.6 ml/min over the course of 1 year (p < 0.01).

CONCLUSIONS

Substitution of CNIs with sirolimus in cardiac transplant recipients is safe and effective and leads to an improvement in renal function, without compromise in cardiac function and rejection.

Outcome of Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting: Renal Function and Mortality After 3.8 Years

BACKGROUND

There are few data regarding medium-term outcome of coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction, particularly in the modern era, and even less assessing preoperative factors that might identify patients at highest risk.

METHODS AND RESULTS

Three hundred seventy-nine consecutive patients with LV ejection fraction < or = 35%, who underwent isolated first CABG between 1995 and 1999 were studied. Potential preoperative and perioperative predictors of outcome were recorded and patients followed-up for a median of 3.8 years. The primary study end-point was all-cause mortality. The 30-day, 1-year, and 3-year survival rates were 94.5%, 88%, and 81%, respectively. The independent predictors of mortality were preoperative estimated glomerular filtration rate (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.97 to 0.99 per mL/min/1.73 m2; P<0.001) and age (HR, 1.03; 95% CI, 1.01 to 1.06 per year; P=0.005).

CONCLUSIONS

Patients with significant LV systolic dysfunction undergoing isolated CABG using contemporary techniques have a good medium-term survival. Renal dysfunction is the strongest independent predictor of mortality.

Thoracic Aorta False Aneurysm: What Surgical Strategy Should Be Recommended?

BACKGROUND

Thoracic aorta false aneurysms (TAFA) are a surgical challenge. The best technical approach remains uncertain.

METHODS

Between 1981 and 2004, 57 patients underwent operation for TAFA (mean age 57 +/- 18 years; 43 [75%] were male). Symptoms included dyspnea 25 (44%), chest pain 22 (39%), and fever 18 (32%). Twelve (21%) were asymptomatic. Thirty-seven (65%) had undergone previous operation with a mean interval between operations of 80 +/- 90 months. Fifteen (26%) had a mycotic etiology. The TAFA involved the aortic root in 10 (18%), ascending aorta in 28 (49%), arch in 6 (11%), and descending aorta in 13 (32%). Twenty-one (37%) required femorofemoral cannulation and 28 (49%), circulatory arrest. Surgical techniques included graft replacement in 27 (47%), composite root in 10 (18%), patch repair in 10 (18%), and direct suture in 10 (18%).

RESULTS

Operative mortality was 7% (4 patients). Four of 32 (13%) had massive hemorrhage during redo sternotomy, and all of these had planned extramediastinal cannulation (all survived). Follow-up was 100% for 349 patient-years. Actuarial survival was 77% +/- 6%, 63% +/- 8%, and freedom from recurrent TAFA was 87% +/- 5% and 83% +/- 7%, at 5 and 10 years, respectively. Univariate analysis identified TAFA greater than 55 mm, urgent operation, and NewYork Heart Association functional class III or IV as predictors of hemorrhage during redo sternotomy. Obesity and ejection fraction of 35% or less were predictors of operative death.

CONCLUSIONS

Thoracic aorta false aneurysm symptoms may be minimal, and consequently a high degree of suspicion plus serial imaging is warranted. Extramediastinal cannulation, deep hypothermia, and circulatory arrest are required for large mediastinal TAFA. Despite serious risks, TAFA correction is possible with good long-term results.