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Smenes BT, Pettersen Ø, Karlsen Ø, Stenseth R, Wahba A. Phase of care mortality analysis and failure to rescue in a Norwegian cardiothoracic unit. SCAND CARDIOVASC J 2019; 53:220-224. [DOI: 10.1080/14017431.2019.1628294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Benedikte Therese Smenes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Øystein Pettersen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Cardiothoracic Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Øystein Karlsen
- Department of Cardiothoracic Anesthesiology and Intensive Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Roar Stenseth
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Cardiothoracic Anesthesiology and Intensive Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Alexander Wahba
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Cardiothoracic Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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2
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Dayan V, Arocena MJ, Fernandez A, Silva E, Zerpa DP. Previous Cardiac Surgery: a Predictor of Mortality in Aortic Valve Replacement? Braz J Cardiovasc Surg 2019; 34:173-178. [PMID: 30916127 PMCID: PMC6436787 DOI: 10.21470/1678-9741-2018-0251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/19/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Previous cardiac surgery (PCS) is a risk factor for operative mortality in
pa-tients undergoing reoperative aortic valve replacement (AVR) and may be
influenced by the volume of patients in each center. The aim of this study
was to evaluate the results of AVR in patients with previous cardiac surgery
in a low volume cardiac center (400 cases per year). Methods Between January 2006 and December 2016, 854 patients underwent isolated AVR
surgery at our institution. Of these, 70 had PCS. Propensity match (PM) was
per-formed to balance basal covariates. Operative mortality and survival
were the primary outcomes. Results The PCS and first-time surgery (FTS) groups had significant differences in
base-line characteristics (PCS group were older, higher incidence of
hypertension, endocarditis, NYHA III/IV, lower LVEF, higher creatinine and
higher EuroSCORE). In the unmatched population, patients with PCS had higher
operative mortality (17.1% vs. 4.6%,
P=0.001). In the PM groups, this difference was not
significant (12.5% and 3.6%, P=0.08). The only independent
predictors for operative mortality found in the PCS group were age and
fe-male gender. Age and diabetes were identified as the only independent
predictors of sur-vival. Conclusion PCS was not a predictor for operative mortality nor long-term survival in
pa-tients undergoing isolated aortic valve replacement.
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Affiliation(s)
- Victor Dayan
- Instituto Nacional de Cirugía Cardíaca. Montevideo, Uruguay
| | | | | | - Eloísa Silva
- Instituto Nacional de Cirugía Cardíaca. Montevideo, Uruguay
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Nalluri N, Atti V, Patel NJ, Kumar V, Arora S, Nalluri S, Nelluri BK, Maniatis GA, Kandov R, Kliger C. Propensity matched comparison of in-hospital outcomes of TAVR vs. SAVR in patients with previous history of CABG: Insights from the Nationwide inpatient sample. Catheter Cardiovasc Interv 2018; 92:1417-1426. [PMID: 30079611 DOI: 10.1002/ccd.27708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/03/2018] [Accepted: 05/30/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR). METHODS The Nationwide inpatient sample (NIS) from 2012 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥ 18 years with prior CABG who underwent TAVR (35.05 and 35.06) or SAVR (35.21 and 35.22). Propensity score matching (1:1) was performed and in-hospital outcomes were compared between matched cohorts. RESULTS From 2012 to 2014, there was progressive increase in the annual number of TAVR procedures from 1485 to 4020, with a decrease in patients undergoing SAVR from 2330 to 1955 (Ptrend < 0.0001) in the above population. There was no significant difference in in-hospital mortality rates. Compared to SAVR, TAVR was associated with lower risk of stroke (1.2% vs. 3.3%, P = 0.009), AKI (12.9% vs. 21.3%, P < 0.0001), myocardial infarction (0.9% vs. 2.7%, P = 0.01) and major bleeding (9.1% vs. 25.1%, P < 0.0001). TAVR was associated with higher risk of pacemaker implants (9.6% vs. 4.9%, P = 0.001) and trend toward lower risk of vascular complications (2.3% vs. 4.1%, P = 0.05). CONCLUSION In this large cohort of patients with previous CABG, there is no significant difference in in-hospital mortality between TAVR and SAVR. TAVR was associated with lower risk of in-hospital outcomes.
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Affiliation(s)
- Nikhil Nalluri
- Department of Cardiology, Staten Island University Hospital, New York City, New York
| | - Varunsiri Atti
- Department of Internal medicine, Michigan State University-Sparrow Hospital, East Lansing, Michigan
| | - Nileshkumar J Patel
- Department of Cardiology, University of Miami-Jackson Memorial Hospital, Miami, Florida
| | - Varun Kumar
- Department of Cardiology, Mount Sinai St Luke's Roosevelt hospital, New York City, New York
| | - Shilpkumar Arora
- Department of Internal medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | | | | | - Gregory A Maniatis
- Department of Cardiology, Staten Island University Hospital, New York City, New York
| | - Ruben Kandov
- Department of Cardiology, Staten Island University Hospital, New York City, New York
| | - Chad Kliger
- Department of Cardiology, Structural Heart Disease Lenox Hill Hospital, New York City, New York
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4
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Thiagarajan K, Jeevanantham V, Van Ham R, Gleason TG, Badhwar V, Chang Y, Thirumala PD. Perioperative Stroke and Mortality After Surgical Aortic Valve Replacement: A Meta-Analysis. Neurologist 2018; 22:227-233. [PMID: 29095324 DOI: 10.1097/nrl.0000000000000151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Perioperative stroke rate after surgical aortic valve replacement (SAVR) varies between 1.3% and 6.2%, whereas the operative mortality ranges between 1% and 16.4%. The aim of this study was to determine whether perioperative stroke is a risk factor for operative mortality after SAVR by performing a meta-analysis of relevant studies. MATERIALS AND METHODS PubMed, EMBASE, and Web of Science databases were searched to retrieve relevant literature. Screening of the articles was done independently on the basis of predetermined criteria. Data from the relevant studies were extracted and a random effects model was used to calculate the odds of mortality among patients with perioperative strokes after aortic valve replacement compared with those without such strokes. Subgroup analyses of patients (1) aged above and below 70 years and (2) undergoing isolated valve replacement procedure were performed. Metaregression to check for association of effect estimate and (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation was performed. RESULTS Statistical analyses using a random effects model showed that patients with perioperative strokes had 4.74 times greater odds for operative mortality after SAVR, independent of the following covariates: (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation. CONCLUSIONS Patients with perioperative strokes after SAVR have nearly 5 times greater odds of experiencing operative mortality compared with those without. Thus, perioperative strokes are associated with increased risk of early mortality and require further examination of preventive strategies.
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Affiliation(s)
- Karthy Thiagarajan
- Departments of *Neurological Surgery §Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh Medical Center ‡University of Pittsburgh School of Medicine, Pittsburgh, PA †Saint Anthony Hospital, Oklahoma City, OK ∥Division of Cardiothoracic Surgery, West Virginia University, Morgantown, WV
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5
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Ejiofor JI, Ramirez-Del Val F, Nohria A, Norman A, McGurk S, Aranki SF, Shekar P, Cohn LH, Kaneko T. The risk of reoperative cardiac surgery in radiation-induced valvular disease. J Thorac Cardiovasc Surg 2017; 154:1883-1895. [PMID: 28870399 DOI: 10.1016/j.jtcvs.2017.07.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mediastinal radiation therapy (MRT) increases the risk for adverse outcomes after cardiac surgery and is not incorporated in the Society of Thoracic Surgeons (STS) risk algorithm. We aimed to quantify the surgical risk conferred by MRT in patients undergoing primary and reoperative valvular operations. METHODS A retrospective analysis of 261 consecutive patients with prior MRT who underwent valvular operations between January 2002 and May 2015. Short- and long-term outcomes were compared for STS predicted risk of mortality, surgery type, gender, year of surgery, and age-matched patients stratified by reoperative status. RESULTS Mean age was 62.6 ± 12.1 years and 174 (67%) were women. The majority had received MRT for Hodgkin lymphoma (48.2%) and breast cancer (36%). Overall, 214 (82%) were primary and 47 (18%) were reoperative procedures. Reoperation carried a higher operative mortality than primary cases (17% vs 3.7%; P = .003). Compared with the 836 nonradiated matches, operative mortality and observed-to-expected STS mortality ratios were higher in primary (3.8% [1.4] vs 0.8% [0.32]; P = .004) and reoperative (17% [3.35] vs 2.3% [0.45]; P = .001) patients with prior MRT. Cox proportional hazard modeling revealed that in patients with previous MRT, primary (hazard ratio, 2.24; 95% confidence interval, 1.73-2.91) and reoperative status (hazard ratio, 3.19; 95% confidence interval, 1.95-5.21) adversely affected long-term survival compared with nonradiated matches. CONCLUSIONS Surgery for radiation-induced valvular heart disease has a higher operative mortality than predicted by STS predicted risk of mortality. Reoperations are associated with increased morbidity and mortality compared with primary cases. Careful patient selection is paramount and expanded indications for transcatheter therapies should be considered, especially in reoperative patients.
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Affiliation(s)
- Julius I Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Anju Nohria
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anthony Norman
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lawrence H Cohn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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6
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Ohira S, Miyata H, Doi K, Motomura N, Takamoto S, Yaku H. Risk model of aortic valve replacement after cardiovascular surgery based on a National Japanese Database. Eur J Cardiothorac Surg 2017; 51:347-353. [PMID: 28186293 DOI: 10.1093/ejcts/ezw247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/06/2016] [Accepted: 06/09/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Suguru Ohira
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Miyata
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Kiyoshi Doi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Voudris KV, Wong SC, Kaple R, Kampaktsis PN, de Biasi AR, Weiss JS, Devereux R, Krieger K, Kim L, Swaminathan RV, Feldman DN, Singh H, Skubas NJ, Minutello RM, Bergman G, Salemi A. Transapical transcatheter aortic valve replacement in patients with or without prior coronary artery bypass graft operation. J Cardiothorac Surg 2016; 11:158. [PMID: 27899140 PMCID: PMC5129212 DOI: 10.1186/s13019-016-0551-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 11/23/2016] [Indexed: 11/10/2022] Open
Abstract
Background Transapical approach (TA) is an established access alternative to the transfemoral technique in patients undergoing transcatheter aortic valve replacement (TAVR) for treatment of symptomatic aortic valve stenosis. The impact of prior coronary artery bypass grafting (CABG) on clinical outcomes in patients undergoing TA-TAVR is not well defined. Methods A single center retrospective cohort analysis of 126 patients (male 41%, mean age 85.8 ± 6.1 years) who underwent TA balloon expandable TAVR (Edwards SAPIEN, SAPIEN XT or SAPIEN 3) was performed. Patients were classified as having prior CABG (n = 45) or no prior CABG (n = 81). Baseline clinical characteristics, in-hospital, 30-day, 6 months and one-year clinical outcomes were compared. Results Compared to patients without prior CABG, CABG patients were more likely to be male (62.2 vs. 29.6%, p < 0.001) with a higher STS score (11.66 ± 5.47 vs. 8.99 ± 4.19, p = 0.003), history of myocardial infarction (55 vs. 21.1%, p < 0.001), implantable cardioverter defibrillator (17.8 vs. 3.7%, p = 0.017), left main coronary artery disease (42.2 vs. 4.9%, p < 0.001), and proximal left anterior descending coronary artery stenosis (57.8 vs. 16%, p < 0.001). They also presented with a lower left ventricular ejection fraction (%) (42.3 ± 15.3 vs. 54.3 ± 11.6, p < 0.01) and a larger effective valve orifice area (0.75 ± 0.20 cm2 vs. 0.67 ± 0.14 cm2, p = 0.025). There were no intra-procedural deaths, no differences in stroke (0 vs. 1.2%, p = 1.0), procedure time in hours (3.50 ± 0.80 vs. 3.26 ± 0.86, p = 0.127), re-intubation rate (8.9 vs. 8.6% p = 1.0), and renal function (highest creatinine value 1.73 ± 0.71 mg/ml vs.1.88 ± 1.15 mg/ml, p = 0.43). All-cause mortality at 6 months was similar in both groups (11.4, vs. 17.3% p = 0.44), and one-year survival was 81.8 and 77.8% respectively (p = 0.51). On multivariate analysis, the only factor significantly associated with one-year mortality was prior history of stroke (HR, 2.76; 95% CI, 1.06-7.17, p = 0.037). Conclusion Despite the higher baseline clinical risk profile, patients with history of prior CABG undergoing TA-TAVR had comparable in-hospital, 6 months and one-year clinical outcomes to those without prior CABG.
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Affiliation(s)
- Konstantinos V Voudris
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - S Chiu Wong
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Ryan Kaple
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Polydoros N Kampaktsis
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Andreas R de Biasi
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiothoracic Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Jonathan S Weiss
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiothoracic Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Richard Devereux
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Karl Krieger
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiothoracic Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Luke Kim
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Rajesh V Swaminathan
- Department of Cardiology, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC, USA
| | - Dmitriy N Feldman
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Harsimran Singh
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Nikolaos J Skubas
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Robert M Minutello
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Geoffrey Bergman
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.,Department of Cardiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA
| | - Arash Salemi
- William Acquavella Heart Valve Center, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA. .,Department of Cardiothoracic Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 East 68th St., New York, NY, USA.
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Impact of previous cardiac surgery on patients undergoing transcatheter aortic valve implantation: A meta-analysis. Heart Lung 2016; 45:350-8. [DOI: 10.1016/j.hrtlng.2016.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/01/2016] [Accepted: 04/10/2016] [Indexed: 11/21/2022]
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Castellant P, Didier R, Bezon E, Couturaud F, Eltchaninoff H, Iung B, Donzeau-Gouge P, Chevreul K, Fajadet J, Leprince P, Leguerrier A, Lievre M, Prat A, Teiger E, Laskar M, Boschat J, Gilard M. Comparison of Outcome of Transcatheter Aortic Valve Implantation With Versus Without Previous Coronary Artery Bypass Grafting (from the FRANCE 2 Registry). Am J Cardiol 2015; 116:420-5. [PMID: 26071993 DOI: 10.1016/j.amjcard.2015.04.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/21/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
Previous coronary artery bypass grafting (CABG) increases operative risk in conventional valve replacement. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high-risk patient subgroups. The present study compared outcome and overall survival in patients who underwent TAVI with and without history of CABG. From January 2010 to December 2011, 683 of the 3,761 patients selected for TAVI in 34 French centers (18%) had a history of CABG. Outcomes (mortality and complications) were collected prospectively according to the Valve Academic Research Consortium (VARC) criteria. Patients with previous CABG were younger, with higher rates of diabetes and vascular disease and higher logistic European System for Cardiac Operative Risk Evaluation (29.8 ± 16.4 vs 20.1 ± 13.0, p <0.001) but lower rates of pulmonary disease. Two types of valve (Edwards SAPIEN and Medtronic CoreValve) were implanted in equal proportions in the 2 groups. The 30-day and 1-year mortality rates from all causes on Kaplan-Meier analysis (9.2% vs 9.7%, p = 0.71; and 19.0% vs 20.2%, p = 0.49, respectively) did not differ according to the history of CABG. There were no significant differences in the Valve Academic Research Consortium complications (myocardial infarction, stroke or vascular, and bleeding complications). On multivariate analysis, CABG was not associated with greater 1-year post-TAVI mortality. In conclusion, previous CABG did not adversely affect outcome in patients who underwent TAVI, which may be an alternative to surgery in high-risk patients with severe aortic stenosis and history of CABG.
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Gandji W, Azarnoush K, Mulliez A, Innorta A, Farhat M, Combaret N, Durel N, Souteyrand G, Lusson JR, Camilleri L. [Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]. Ann Cardiol Angeiol (Paris) 2015; 65:7-14. [PMID: 25641084 DOI: 10.1016/j.ancard.2015.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization. PATIENTS AND METHODS This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013. RESULTS The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment. CONCLUSION Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.
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Affiliation(s)
- W Gandji
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - K Azarnoush
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France; Inra, UMR 1019 nutrition humaine, 63122 Saint-Genès-Champanelle, France.
| | - A Mulliez
- Bio-statistics unit, délégation recherche clinique & innovation. CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - A Innorta
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - M Farhat
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - N Combaret
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - N Durel
- Service de cardiologie, pôle santé république, 105, avenue de la République, 63050 Clermont-Ferrand, France
| | - G Souteyrand
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - J R Lusson
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
| | - L Camilleri
- Pôle cardiologie médicale et chirurgicale, CHU de Clermont-Ferrand, place H.-Dunant, B.P. 69, 63000 Clermont-Ferrand, France
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11
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Iturra SA, Greason KL, Suri RM, Joyce LD, Stulak JM, Pochettino A, Schaff HV. Repeat sternotomy for surgical aortic valve replacement in octogenarian patients with aortic valve stenosis and previous coronary artery bypass graft operation: What is the operative risk? J Thorac Cardiovasc Surg 2014; 148:1899-902. [DOI: 10.1016/j.jtcvs.2013.11.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/16/2013] [Accepted: 11/22/2013] [Indexed: 12/01/2022]
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Savage EB, Saha-Chaudhuri P, Asher CR, Brennan JM, Gammie JS. Outcomes and prosthesis choice for active aortic valve infective endocarditis: analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2014; 98:806-14. [PMID: 25085561 DOI: 10.1016/j.athoracsur.2014.05.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 04/29/2014] [Accepted: 05/05/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND National prosthesis use in active aortic valve infective endocarditis (IE) is unreported. Prosthesis usage and outcomes in patients undergoing an aortic valve operation with active IE was evaluated. METHODS The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with active IE who underwent an aortic valve operation from January 1, 2005, to June 30, 2011. All patients with active IE were included. Demographics, procedures, outcomes, and trends were analyzed. RESULTS Of 11,560 patients who were identified as having active IE, 8,421 (73%) had no prior operations (primary) and 3,139 (27%) had a history of any prior cardiac operation (reoperative). Operations for primary vs reoperative patients included isolated replacement in 88.5% vs 58.7% and root replacement in 7.2% vs 29.9%. Major morbidity was 60.8% vs 68%, and the unadjusted mortality rate was 9.8% vs 21.1%. Over time, for primary operations, biologic valve use increased (57% to 67%), and mechanical and homograft valve use decreased (30% to 24% and 9% to 6%; p < 0.001). For reoperations, biologic valve use increased (38% to 52%), and mechanical and homograft use decreased (20% to 17% and 38% to 28%; p < 0.001). Homografts were used more often in reoperations (32% vs 7%). CONCLUSIONS Morbidity and mortality rates death are high for operations for active IE. Biologic valves were increasingly used vs mechanical and homograft valves. Homograft valves were used more often in reoperative patients after any prior cardiac operation. The mortality rate varied among prosthesis groups but may be related to the severity of infection and type of procedure performed.
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Affiliation(s)
- Edward B Savage
- Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Weston, Florida.
| | | | - Craig R Asher
- Department of Cardiology, Cleveland Clinic Florida, Weston, Florida
| | - J Matthew Brennan
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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Minha S, Magalhaes MA, Barbash IM, Ben-Dor I, Dvir D, Okubagzi PG, Chen F, Torguson R, Kent KM, Suddath WO, Satler LF, Pichard AD, Waksman R. Impact of previous coronary artery bypass grafting on patients undergoing transcatheter aortic valve implantation for aortic stenosis. Am J Cardiol 2014; 113:1222-7. [PMID: 24513466 DOI: 10.1016/j.amjcard.2013.12.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
Re-operation after coronary artery bypass grafting (CABG) is associated with increased risk for morbidity and mortality. Transcatheter aortic valve implantation (TAVI) is an alternative for patients with aortic stenosis, but the outcomes of patients with a history of CABG are unknown. The aim of this study was to explore the association between previous CABG and the outcome of patients undergoing TAVI. Out of 372 consecutive patients who underwent TAVI from 2007 to 2013, 122 (32.8%) had previous CABG, whereas 250 (67.2%) did not. A comparison was made between groups. Subgroup analysis compared patients with and without previous CABG in 3 patient subsets: inoperable, operable, and those who underwent transapical TAVI. Patients with previous CABG were younger (81.99±6.78 vs 84.81±7.06 years, respectively, p<0.001). These patients also had more high-risk features (e.g., peripheral vascular disease, previous myocardial infarction, past cerebrovascular disease, and lower average left ventricular ejection fraction (p<0.05 for all). Procedural aspects were mostly similar between groups. No disparities in mortality rates at 1 year were noted (22.1% vs 21.6%, respectively, p=0.91). Subgroup analyses yielded similar outcomes for all 3 groups. In conclusion, although patients with previous CABG present with more high-risk features, they share similar short- and long-term outcomes with patients without previous CABG, irrespective of their surgical risk. This includes patients who underwent transapical access. TAVI in patients with previous CABG is safe and does not confer a significant risk for adverse outcome.
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The “no-dissection” technique is safe for reoperative aortic valve replacement with a patent left internal thoracic artery graft. J Thorac Cardiovasc Surg 2012; 144:1036-40. [DOI: 10.1016/j.jtcvs.2012.07.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/13/2012] [Accepted: 07/26/2012] [Indexed: 11/21/2022]
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Pauperio GS, Pinto CS, Antunes PE, Antunes MJ. Aortic valve surgery in patients who had undergone surgical myocardial revascularization previously. Eur J Cardiothorac Surg 2012; 42:826-30; discussion 830-1. [DOI: 10.1093/ejcts/ezs178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dobrilovic N, Fingleton JG, Maslow A, Machan J, Feng W, Casey P, Sellke FW, Singh AK. Midterm outcomes of patients undergoing aortic valve replacement after previous coronary artery bypass grafting. Eur J Cardiothorac Surg 2012; 42:819-24; discussion 824-5. [DOI: 10.1093/ejcts/ezs070] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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D'Onofrio A, Rubino P, Fusari M, Musumeci F, Rinaldi M, Alfieri O, Gerosa G. Impact of previous cardiac operations on patients undergoing transapical aortic valve implantation: results from the Italian Registry of Transapical Aortic Valve Implantation. Eur J Cardiothorac Surg 2012; 42:480-5. [DOI: 10.1093/ejcts/ezs027] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ducrocq G, Al-Attar N, Himbert D, Messika-Zeitoun D, Iung B, Descoutures F, Nataf P, Vahanian A. Early and mid-term outcomes in patients undergoing transcatheter aortic valve implantation after previous coronary artery bypass grafting. Eur J Cardiothorac Surg 2011; 41:499-504. [PMID: 22345175 DOI: 10.1093/ejcts/ezr041] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Surgical aortic valve replacement in patients with previous coronary artery bypass grafting (CABG) carries a high mortality. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high risk subgroups of patients. Our goal is therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI. METHODS From October 2006 to June 2010, among the 201 patients selected to undergo TAVI, 54 (27%) had a history of CABG. Outcomes were prospectively collected. RESULTS The 30-day outcome was not different between patients with previous CABG vs. those without, in particular as regards mortality (respectively, 5.6% vs. 10.9%; P = 0.25). Mid-term survival (mean FU: 7 ± 9 months) was not different at 2 years between patients with previous CABG vs. patients without (65.7 ± 6.2% vs. 80.0 ± 7.7% respectively; P = 0.12). In multivariate analysis, CABG was not associated with an excess mid-term mortality after TAVI. CONCLUSIONS Previous CABG does not adversely affect outcome in patients undergoing TAVI. If confirmed by larger prospective series and ideally by a randomized trial comparing CABG vs. redo surgery, this observation might lead the heart team to consider TAVI as an attractive option in the population of high risk patients with aortic stenosis and previous CABG.
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Affiliation(s)
- Gregory Ducrocq
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France.
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Transcatheter aortic valve implantation or surgical aortic valve replacement as redo procedure after prior coronary artery bypass grafting. Ann Thorac Surg 2011; 92:1324-30; discussion 1230-1. [PMID: 21880298 DOI: 10.1016/j.athoracsur.2011.05.106] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 05/23/2011] [Accepted: 05/27/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The perioperative risk for redo surgical aortic valve replacement (S-AVR) in patients with severe aortic stenosis and prior coronary artery bypass grafting (CABG) is increased. Transcatheter aortic valve implantation (TAVI) represents an alternative. We assessed the perioperative and mid-term clinical outcome of patients undergoing S-AVR or TAVI. METHODS In a retrospective observational, comparative study, 40 consecutive patients underwent redo operation with S-AVR or TAVI between April 2005 and April 2010. Median sternotomy and extracorporeal circulation were used for S-AVR; TAVI access was transfemoral (n = 27; 67.5%), transapical (n = 11; 27.5%), or transsubclavian (n = 2; 5.0%). Clinical and echocardiographic follow-up was at 30 days and 6 months. RESULTS TAVI patients were older (78.5 ± 6 vs 70.6 ± 8 years, p < 0.001) and presented higher logistic (33.5 ± 17 vs 20.2 ± 14, p < 0.001) European System for Cardiac Operative Risk Evaluation scores. All-cause mortality was 2.5% in both groups and major adverse cardiac and cerebrovascular event rates were comparable (7.5% TAVI vs 17.5% S-AVR, p = 0.311) after 30 days. TAVI was associated with a higher rate of permanent pacemaker implantation (30% vs 0%, p < 0.001) and grade II residual aortic regurgitation in 14%. Incidence of cerebrovascular events was 7.5% in S-AVR vs 2.5% in TAVI (p = 0.61). CONCLUSIONS In elderly, high-risk patients after prior CABG, conventional aortic valve replacement and TAVI are comparable treatment options with favorable clinical outcome. A redo operation itself does not sufficiently justify a TAVI approach.
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Lee Henry C, Ko JM, Henry AC, Roberts WC, Matter GJ. Aortic valve replacement for stenosis with or without coronary artery bypass grafting after 2 previous isolated coronary artery bypass grafting operations. Proc (Bayl Univ Med Cent) 2011; 24:6-8. [PMID: 21307968 DOI: 10.1080/08998280.2011.11928673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Aortic valve replacement following an earlier coronary artery bypass grafting (CABG) procedure is fairly common. When this situation occurs, the type of valve dysfunction is usually stenosis (with or without regurgitation), and whether it was missed at the time of the earlier CABG or developed subsequently is usually unclear. We attempted to determine the survival in patients who had had aortic valve replacement after 2 previous CABG procedures. We describe 12 patients who had aortic valve replacement for aortic stenosis; rather than one previous CABG operation, all had had 2 previous CABG procedures. Only one patient died in the early postoperative period after aortic valve replacement, and the remaining 11 were improved substantially: all have lived at least 11 months, and one is still alive at over 101 months after aortic valve replacement. Aortic valve replacement remains beneficial for most patients even after 2 previous CABG procedures.
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Affiliation(s)
- Christopher Lee Henry
- Baylor Heart and Vascular Institute (C. L. Henry, Ko, Roberts), Department of Cardiothoracic Surgery (A. C. Henry, Matter), Division of Cardiology, Department of Internal Medicine (Roberts), and Department of Pathology (Roberts), Baylor University Medical Center at Dallas. C. L. Henry is now a freshman at the American University of the Caribbean School of Medicine N.V., St. Maarten, Netherlands Antilles
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Dagenais F, Mathieu P, Doyle D, Dumont É, Voisine P. Moderate aortic stenosis in coronary artery bypass grafting patients more than 70 years of age: to replace or not to replace? Ann Thorac Surg 2010; 90:1495-9; discussion 1499-500. [PMID: 20971247 DOI: 10.1016/j.athoracsur.2010.06.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 06/01/2010] [Accepted: 06/07/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Moderate aortic stenosis in coronary artery bypass graft surgery (CABG) patients more than 70 years old is not unusual. The risk-benefit of performing a concomitant aortic valve replacement (AVR) is often difficult to assess. To stratify the risk-benefit ratio, we reviewed outcomes of CABG patients more than 70 years old with preoperative moderate aortic stenosis (valve area 1.0 to 1.6 cm(2) or indexed valve area 0.6 to 1.0 cm(2)/m(2)). METHODS Among 263 CABG patients more than 70 years old with moderate aortic stenosis, 167 patients underwent only CABG and 96 had CABG+AVR. RESULTS Cross-clamp time (p < 0.0001) and perioperative transient ischemic attack-cerebrovascular accident (p < 0.04) were significantly higher in the CABG+AVR group. In-hospital mortality was comparable among groups (CABG 6.0% versus CABG+AVR 4.2%; p = 0.8). At a mean follow-up of 4.5 ± 3.0 years, 5-year survival (CABG 64.2% ± 4.3% versus CABG+AVR 62.3% ± 5.5%) and freedom from AVR (CABG 97.8% ± 1.2% versus CABG+AVR 98.9% ± 1.1%; p = 0.13) were comparable among both groups. Among patients treated with CABG alone, receiver operating characteristic curve analysis identified 26 mm Hg and 15 mm Hg as maximum and mean aortic valve gradients, respectively, for increased risk of reoperation for late AVR. Multivariate analyses for predictors of operative mortality were preoperative renal failure (odds ratio [OR] 7.64, p < 0.001) and intubation more than 48 hours (OR 11.10, p < 0.0002); for late death, ejection fraction less than 40% (OR 3.35, p < 0.02), New York Heart Association functional class III or IV (OR 2.37, p < 0.002), chronic obstructive pulmonary disease (OR 2.26, p < 0.02), and renal failure (OR 3.03, p < 0.003); for perioperative transient ischemic attack-cerebrovascular accident, cross-clamp time (OR 1.02, p < 0.02) and Parsonnet score (OR 1.09, p < 0.05). CONCLUSIONS For CABG patients more than 70 years old with minimal comorbidities especially in the presence of aortic gradients of 26/15 mm Hg or greater, concomitant AVR for moderate aortic stenosis should be performed during CABG and may be performed with minimal additional operative risk. Patients with significant comorbidities should be managed with CABG alone, owing to an increased perioperative risk, poor midterm survival, and minimal risk of AVR at 5 years.
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Affiliation(s)
- François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Ontario, Canada.
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22
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Identifying patients at particular risk of injury during repeat sternotomy: Analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg 2010; 140:1028-35. [DOI: 10.1016/j.jtcvs.2010.07.086] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 07/19/2010] [Accepted: 07/30/2010] [Indexed: 11/24/2022]
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LaPar DJ, Yang Z, Stukenborg GJ, Peeler BB, Kern JA, Kron IL, Ailawadi G. Outcomes of reoperative aortic valve replacement after previous sternotomy. J Thorac Cardiovasc Surg 2009; 139:263-72. [PMID: 20006357 DOI: 10.1016/j.jtcvs.2009.09.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 07/17/2009] [Accepted: 09/04/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Increasingly, patients with previous sternotomy require aortic valve replacement. We compared outcomes of reoperative aortic valve replacement after previous sternotomy and primary aortic valve replacement by surgical era. Effect of initial cardiac operation on reoperative aortic valve replacement was also investigated. METHODS Between January 1996 and December 2007, a total of 1603 patients undergoing elective aortic valve replacement were entered prospectively into our clinical database. Patients were divided into eras A (1996-1999), B (2000-2003), and C (2004-2007). A total of 191 patients (12%) had previous sternotomy for coronary artery bypass grafting (n = 88), coronary artery bypass grafting with aortic valve replacement (n = 16), aortic valve replacement with or without other aortic procedure (n = 70), and other cardiac procedures (n = 17). Mean ages were 66.5 +/- 13.1 years in reoperative group and 65.5 +/- 14.9 years in primary group. RESULTS Mortality in reoperative group decreased significantly with time (A 15.4% vs B 15.1% vs C 2.0%, P = .004) and was equivalent to primary group in era C (3.5% vs 2.0%, P = .65). Major complications also significantly decreased with time in reoperative group (A 25.6% vs B 17.0% vs C 6.1%, P = .006). Importantly, patients had more comorbidities with time and increased preoperative risk in era C. There were no differences in outcome by initial cardiac operation in reoperative group. CONCLUSIONS Reoperative aortic valve replacement now carries similar morbidity and mortality to primary replacement. Risk of reoperation is not affected by primary operation.
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Affiliation(s)
- Damien J LaPar
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Tekumit H, Cenal AR, Tataroglu C, Uzun K, Polat A, Akinci E. Cusp shaving for concomitant mild to moderate rheumatic aortic insufficiency. J Card Surg 2009; 25:16-22. [PMID: 19874414 DOI: 10.1111/j.1540-8191.2009.00948.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to assess the early and mid-term results of patients who underwent cardiac operations due to cardiac pathologies other than aortic valve (AV) disease, but also had mild-to-moderate aortic valve insufficiency that was repaired during the same session. METHODS A total of 43 patients who underwent AV repair for mild-to-moderate aortic insufficiency between January 2003 and February 2009, in addition to the procedure performed for their main pathology necessitating the surgical intervention, were included in the present study. Cardiac function was evaluated, before and after the operation. RESULTS Hospital mortality rate was 4.6% (two patients). After the operations, significant improvements were observed in aortic insufficiency (0.57 +/- 0.50 vs. 2.86 +/- 0.48, p = 0.001), New York Heart Association class (1.08 +/- 0.28 vs. 3.03 +/- 0.44, p = 0.001), and left atrial diameter (47.37 +/- 9.28 vs. 42.35 +/- 7.02; p = 0.001). However, left ventricular end diastolic and end-systolic diameters remained unchanged. Two patients were re-operated for AV disease during the follow-up period; thus, at five years, the rate of freedom from re-operation due to AV pathology was 90.7 +/- 6.3%. CONCLUSIONS Cusp shaving is a feasible option that can be performed with low risk for concomitant aortic insufficiency.
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Sareyyupoglu B, Sundt TM, Schaff HV, Enriquez-Sarano M, Greason KL, Suri RM, Burkhart HM, Park SJ, Dearani JA, Daly RC, Orszulak TA. Management of Mild Aortic Stenosis at the Time of Coronary Artery Bypass Surgery: Should the Valve Be Replaced? Ann Thorac Surg 2009; 88:1224-31. [DOI: 10.1016/j.athoracsur.2009.05.085] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 05/23/2009] [Accepted: 05/27/2009] [Indexed: 11/28/2022]
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Cardiac Reoperation in Patients Aged 80 Years and Older. Ann Thorac Surg 2009; 87:1379-85. [DOI: 10.1016/j.athoracsur.2009.01.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 01/17/2009] [Accepted: 01/20/2009] [Indexed: 11/20/2022]
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Nakajima M, Tsuchiya K, Fukuda S, Morimoto H, Mitsumori Y, Kato K. Aortic operation after previous coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2006; 54:155-9. [PMID: 16642921 DOI: 10.1007/bf02662470] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. METHODS From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. RESULTS The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. CONCLUSION Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.
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Affiliation(s)
- Masato Nakajima
- Department of Cardiovascular Surgery, Yamanashi Central Hospital, Yamanashi, Japan
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Davierwala PM, Borger MA, David TE, Rao V, Maganti M, Yau TM. Reoperation is not an independent predictor of mortality during aortic valve surgery. J Thorac Cardiovasc Surg 2006; 131:329-35. [PMID: 16434261 DOI: 10.1016/j.jtcvs.2005.09.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2005] [Revised: 08/14/2005] [Accepted: 09/09/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Reoperations on aortic valves are associated with increased mortality, which may affect valve prosthesis selection at the time of initial aortic valve replacement. We analyzed our experience to determine whether reoperation itself independently predicts mortality during aortic valve surgery. METHODS Demographic, intraoperative, and outcome data were collected prospectively on patients undergoing primary or redo aortic valve replacement or Bentall procedures after previous aortic valve replacement with or without concomitant coronary bypass grafting at a single institution from 1990 through 2002. Logistic regression analyses validated by means of bootstrap methodology identified the predictors of hospital mortality and the independent effect of reoperation. RESULTS Of 2673 patients undergoing aortic valve surgery, 2375 were primary operations, 216 were reoperations, and 82 were Bentall-after-aortic valve replacement procedures. Of 298 reoperations, 32 were third and 5 were fourth procedures. Mortality was 2.3% for primary operations, 4.6% for redo aortic valve replacement, and 2.4% for Bentall-after-aortic valve replacement procedures. Most patients underwent elective procedures, with mortalities of 1.6%, 1.7%, and 2.5%, respectively. Hospital mortality was independently predicted by peripheral vascular disease (odds ratio, 3.6), active endocarditis (odds ratio, 2.9), worsening New York Heart Association class (odds ratio, 2.3), and need for annular enlargement (odds ratio, 2.1). Reoperation itself did not predict hospital mortality. CONCLUSIONS The risk of mortality during aortic valve surgery is due mostly to active endocarditis, New York Heart Association class, and comorbidity. We failed to find a significant effect of reoperation on perioperative mortality. Mechanical valves, with their attendant anticoagulation-related morbidity, should not be implanted solely because of anticipated high mortality associated with bioprosthetic rereplacement.
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Affiliation(s)
- Piroze M Davierwala
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Pereira JJ, Balaban K, Lauer MS, Lytle B, Thomas JD, Garcia MJ. Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery. Am J Med 2005; 118:735-42. [PMID: 15989907 DOI: 10.1016/j.amjmed.2005.01.072] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2003] [Revised: 12/28/2004] [Accepted: 01/04/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess whether there is survival benefit for patients with mild or moderate aortic stenosis if they undergo aortic valve replacement at the time of coronary artery bypass surgery. METHODS From 1985 to 1995 we evaluated all patients at our institution who underwent coronary artery bypass surgery and who had the echocardiographic diagnosis of mild (mean gradient <0 mm Hg and/or valve area >1.5 cm(2)) or moderate (mean gradient > or =30 and < or =40 mm Hg and/or valve area >1.0 < or =1.5 cm(2)) aortic stenosis. Using propensity analysis, survival was compared between 129 patients who underwent coronary artery bypass surgery alone and 78 patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. RESULTS Perioperative mortality was similar among patients who underwent coronary artery bypass surgery alone compared with patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. By Kaplan-Meier analysis, 1-year and 8-year survival were better at 90% and 55% for patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement compared with 85% and 39% for patients who underwent coronary artery bypass surgery alone (P <0.001). This benefit was limited to patients with moderate aortic stenosis (propensity-adjusted relative risk = 0.43; 95% confidence interval: 0.20 to 0.96; P = 0.04). CONCLUSION Concomitant aortic valve replacement at the time of coronary artery bypass surgery for mild or moderate aortic stenosis appears to convey a survival advantage for patients with moderate aortic stenosis but not for those with mild aortic stenosis.
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Affiliation(s)
- Jeremy J Pereira
- Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Kirali K, Goksedef D, Yakut C. Reverse "U" aortotomy for aortic valve replacement after previous coronary artery bypass grafting. J Card Surg 2005; 20:269-70. [PMID: 15854092 DOI: 10.1111/j.1540-8191.2005.200452.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The presence of patent vein grafts on the proximal aorta may give technical difficulties during exposure to aortic valve replacement after previous coronary artery bypass operations. A tongue or reverse "U" shape aortotomy allows excellent exposure of the aortic valve and antegrade cardioplegic administration without mobilizing vein grafts. This approach may facilitate uni- or bidirectional aortic root enlargement in patients with small aortic root.
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Affiliation(s)
- Kaan Kirali
- Department of Cardiovascular Surgery, Koşuyolu Heart and Research Hospital, Istanbul, Turkey.
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Gillinov AM, Garcia MJ. When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization? Curr Cardiol Rep 2005; 7:101-4. [PMID: 15717955 DOI: 10.1007/s11886-005-0020-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesis-related complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.
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Affiliation(s)
- A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Akins CW, Hilgenberg AD, Vlahakes GJ, Madsen JC, MacGillivray TE. Aortic valve replacement in patients with previous cardiac surgery. J Card Surg 2004; 19:308-12. [PMID: 15245459 DOI: 10.1111/j.0886-0440.2004.4055_11.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whether minimally diseased aortic valves should be replaced during other necessary cardiac operations remains controversial. Part of the decision-making process in that issue revolves around the risks of subsequent aortic valve replacement. This study evaluated the results of aortic valve replacement in patients following prior cardiac surgery. METHODS From February, 1984 through December, 2001 first-time aortic valve replacement was performed in 132 consecutive patients who had previous cardiac surgery utilizing cardiopulmonary bypass. Of those patients 89 (67%) had aortic valve replacement at a mean of 8.3 years after prior coronary artery bypass grafting, and 43 (33%) had aortic valve replacement at a mean of 13.0 years after previous procedures other than myocardial revascularization. Hospital records of all patients were retrospectively reviewed. RESULTS Early complications included operative mortality in six (6.7%) of the patients with prior coronary grafting and no mortality in the group with other prior operations. Patients having prior coronary grafting had more nonfatal complications than those with other previous procedures. CONCLUSIONS Aortic valve replacement in patients following previous cardiac surgery can be accomplished with acceptable mortality and morbidity. Routine replacement of aortic valves that are minimally diseased during coronary artery bypass grafting may not be warranted.
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Affiliation(s)
- Cary W Akins
- Cardiac Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Hirose H, Gill IS, Lytle BW. Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting. Ann Thorac Surg 2004; 78:782-5. [PMID: 15336991 DOI: 10.1016/j.athoracsur.2004.02.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement (AVR) after coronary artery bypass using bilateral internal thoracic arteries (ITAs) is a challenge. Management of these patent grafts and myocardial protection are important issues. Moreover the risk and outcome of these complex operations have not been clearly defined. METHODS Eighteen consecutive patients (all male) who exhibited previous bilateral ITA grafts underwent subsequent AVR surgery from 1990-2001 at the Cleveland Clinic Foundation. Their medical records were retrospectively analyzed. RESULTS At the time of reoperation, the mean age of the patients was 67 +/- 6.4 years and 33 out of 36 (92%) ITAs were patent. The interval between previous coronary bypass and aortic valve surgery was 10.3 +/- 5.3 years. All patients underwent redo-median sternotomy with aortic cannulation in 12 patients (67%) and femoral or axillary artery cannulation in 6 patients (33%). The patent ITAs were clamped during aortic cross-clamping in 15 patients. In 3 patients the ITAs were not dissected. These 3 patients underwent deep hypothermic arrest for myocardial protection. Concomitant coronary revascularization was performed in 8 patients (44%). There were no hospital deaths. One stroke occurred but there were no other major complications. Average intubation time was 23.1 +/- 27.1 hours, intensive care unit stay was 2.3 +/- 3.1 days, and postoperative hospital stay was 10.3 +/- 7.6 days. CONCLUSIONS Reoperative aortic valve surgery in the patients with patent bilateral ITA grafts can be performed safely.
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Affiliation(s)
- Hitoshi Hirose
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44109-1998, USA.
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Gardner SC, Grunwald GK, Rumsfeld JS, Cleveland JC, Schooley LM, Gao D, Grover FL, McDonald GO, Shroyer AL. Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery. Ann Thorac Surg 2004; 77:549-56. [PMID: 14759436 DOI: 10.1016/s0003-4975(03)01585-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. METHODS Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. RESULTS Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29-2.09) and MVR patients (OR 2.21, 95% CI 1.48-3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93-1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. CONCLUSIONS Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.
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Affiliation(s)
- Sheila C Gardner
- Department of Veterans Affairs Medical Center, Denver, Colorado, USA
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Abstract
Aortic stenosis is a common valvular abnormality. Surgical valve replacement is the standard of care for symptomatic patients with severe aortic stenosis and is appropriate for certain asymptomatic patients. Statin therapy may slow progression of the disease. Contrary to conventional wisdom, vasodilator therapy may in fact be safe and effective in certain instances of severe aortic stenosis. Chronic aortic regurgitation is commonly treated with vasodilator therapy, which is certainly indicated for the asymptomatic patient with hypertension. Surgery is recommended for left ventricular dilatation, diminished ventricular systolic function, or symptoms.
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Affiliation(s)
- Naomi F Botkin
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
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Phillips BJ, Karavas AN, Aranki SF, Cohn LH, Rawn JD, Mihaljevic T, Byrne JG. Management of Mild Aortic Stenosis During Coronary Artery Bypass Surgery:. J Card Surg 2003; 18:507-11. [PMID: 14992101 DOI: 10.1046/j.0886-0440.2003.02060.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND "Prophylactic" aortic valve replacement (AVR) in patients with asymptomatic, mild-to-moderate aortic stenosis (AS) at the time of CABG is controversial. In 1994, we reported our initial experience involving 44 patients and have now updated our series in an attempt to further evaluate outcomes. METHODS Between January 1992 and July 2001, 100 consecutive patients underwent reoperative AVR following previous CABG. Forty patients had their initial surgery at the Brigham & Women's Hospital (BWH) and 60 patients had their coronary surgery elsewhere. None of the 40 BWH patients had a mean valve gradient greater than 25 mmHg at the time of CABG. RESULTS The mean time interval from CABG to AVR for the entire group was 9.0 years (range: 1.4-21 years). Overall operative mortality (OM) was 7% including 5 deaths (10.2%) among 49 patients requiring additional CABG at the time of AVR and 2 deaths (3.9%) among 51 patients without additional coronary artery intervention. This OM rate was a notable decrease from our earlier report of 18.2% (P = 0.07). Furthermore, operative mortality decreased progressively from 15.4% in 1992-1993 to 0% in 2000-2001 (P = NS). CONCLUSION The OM of reoperative AVR following CABG has fallen in recent years. Given the relevance of newer techniques and approaches, it may be reasonable to adopt an expectant management approach in patients with asymptomatic mild-to-moderate AS (i.e., mean systolic gradient less than 25 mmHg) at the time of CABG.
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Affiliation(s)
- Bradley J Phillips
- Division of Cardiac Surgery, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02116, USA
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Florath I, Rosendahl UP, Mortasawi A, Bauer SF, Dalladaku F, Ennker IC, Ennker JC. Current determinants of operative mortality in 1400 patients requiring aortic valve replacement. Ann Thorac Surg 2003; 76:75-83. [PMID: 12842517 DOI: 10.1016/s0003-4975(03)00341-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Determinants of operative mortality after aortic valve replacement vary with a changing patient population due to advances in operative management and increasing life expectancy. In order to predict current groups of high risk patients, a statistically valid large study population base recruited over a short period of time is required. METHODS Between January 1996 and June 2001, 1408 aortic valves were replaced in 1400 patients (572 of them with simultaneous coronary artery bypass grafting). The data were analyzed by multivariate logistic regression to evaluate the operative risk. Mean age of the study population was 68 +/- 11 years (range 19 to 90 years old, 44% female). RESULTS Overall operative mortality (within 30 days) was 3.8%. Independent predictive factors for operative mortality were previous bypass surgery, emergency operation, simultaneous mitral valve replacement, renal dysfunction, more than 80 years old, simultaneous bypass surgery in female patients with a body mass index greater than 29 kg/m(2), and height smaller than 1.57 m for patients more than 71 years old. Simultaneous coronary artery bypass grafting in general (p = 0.6), previous aortic valve replacement (p = 0.59), and implantation of stented bioprostheses (p = 0.39) or stentless bioprostheses (p = 0.7) were not identified as independent risk factors. CONCLUSIONS Certain groups of patients with a high operative risk were identified: patients more than 80 years old, women with a body mass index greater 29 kg/m(2) undergoing simultaneous coronary artery bypass surgery, and "small" patients more than 71 years old.
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Affiliation(s)
- Ines Florath
- Department of Cardiothoracic Surgery, Heart Institute Lahr/Baden, Lahr, Germany
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Nakajima M, Tsuchiya K, Naito Y, Hibino N, Inoue H. How to establish myocardial protection during aortic arch operation in patients with patent left internal thoracic artery graft: careful dissection or no touch technique? J Thorac Cardiovasc Surg 2002; 124:1254-5. [PMID: 12447204 DOI: 10.1067/mtc.2002.126384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Masato Nakajima
- Department of Cardiovascular Surgery, Yamanashi Central Hospital, Kofu City, Yamanashi, Japan.
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Byrne JG, Karavas AN, Filsoufi F, Mihaljevic T, Aklog L, Adams DH, Cohn LH, Aranki SF. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts. Ann Thorac Surg 2002; 73:779-84. [PMID: 11899181 DOI: 10.1016/s0003-4975(01)03456-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic valve surgery after coronary artery bypass grafting (CABG) in the setting of patent pedicled internal mammary artery (IMA) grafts poses a high risk because of the underlying ischemic and valve disease. Unlike mitral valve surgery or CABG, in which aortic clamping (AoX) may be optional, aortic valve surgery uniformly requires AoX unless circulatory arrest is used. Management of the IMA graft in these circumstances has traditionally involved dissection and clamping to prevent regional myocardial warming and cardioplegia "washout" during AoX. An alternative strategy involves avoiding dissection of the IMA, leaving the IMA graft open and establishing moderate-to-deep hypothermia during AoX and cardioplegic arrest. To date, no study has been published documenting the safety and efficacy of the latter practice. METHODS A total of 94 patients who had patent IMA graft and underwent aortic valve surgery under AoX and cardioplegia between April 1992 and March 2001 were analyzed. The IMA was avoided and left open during AoX, and the patients were cooled systemically (median 20 degrees C). Patients ranged in age from 55 to 90 years (median 73.5 years). Ejection fraction was 15% to 83% (median 50%). Of the patients, 18 (19%) underwent minimally invasive upper hemi-resternotomy. Analysis for predictors of outcome was performed. RESULTS The operative mortality, perioperative myocardial infarction (MI), and stroke rates were 6.4%, 7%, and 11%, respectively. No significant independent predictors of operative mortality or MI could be identified in the multivariate analysis, although a trend was shown for operative mortality with urgent procedures and patients requiring concomitant surgery of the ascending or arch aorta or aortic root. Advanced age and prolonged cardiopulmonary bypass predicted stroke in the multivariate analysis. There were five (5%) IMA injuries, all occurring during reentry or mediastinal dissection, but none in the subgroup of patients who underwent minimally invasive procedures. All patients survived. CONCLUSIONS Patients undergoing aortic valve surgery after CABG in the presence of patent IMA represent a potentially high-risk group. Because AoX is almost uniformly required, a decision regarding the management of the IMA pedicle is needed. We have found that leaving the IMA undissected and unclamped is a reasonable strategy, provided that systemic cooling for myocardial protection is established to prevent regional warming and to compensate for cardioplegia washout effect during AoX.
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Affiliation(s)
- John G Byrne
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts 02115, USA.
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Tovar EA, Sherman JR, Weinberg DM, Suh YC, Rathod RH, Borsari A. Aortoscopy: a less invasive intraoperative method to assess the aortic valve. Ann Thorac Surg 2002; 73:284-6. [PMID: 11834027 DOI: 10.1016/s0003-4975(01)02864-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Surgical management of mild aortic stenosis coexisting with severe coronary artery disease remains controversial. Direct examination of the aortic root under these circumstances may be decisive. At present, intraoperative assessment of the aortic valve requires an aortic incision which, in itself, may increase the risk of intraoperative complications, particularly when this portion of the aorta is needed to construct proximal graft anastomoses. We present a simple aortoscopic method for direct intraoperative assessment of the aortic valve while performing coronary bypass grafting that obviates the need for aortic incisions.
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Affiliation(s)
- Eduardo A Tovar
- Department of Cardiothoracic Surgery, University of California, Irvine Medical Center, Orange, USA.
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Rahimtoola SH. Should patients with asymptomatic mild or moderate aortic stenosis undergoing coronary artery bypass surgery also have valve replacement for their aortic stenosis? Heart 2001; 85:337-41. [PMID: 11179280 PMCID: PMC1729639 DOI: 10.1136/heart.85.3.337] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- S H Rahimtoola
- Division of Cardiology, Department of Medicine, University of Southern California and LAC+USC Medical Center, Los Angeles, California 90033, USA
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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