Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: early and late results

Mortality and rehospitalization after mitral valve surgery as a function of age and key comorbidities

BACKGROUND

Mitral valve surgery is associated with substantial perioperative risk and long-term complications. Data on long-term outcomes following surgery remain scarce and are hypothetically modified by age and comorbidities.

METHODS

This Danish nationwide study included patients ≥60 years of age undergoing mitral valve surgery from 2000-2018. Patients were observed from day of surgery until outcome of interest (ie, rehospitalization or death) or maximum 1 year of follow-up. The absolute risks of outcomes were assessed, and associated factors were evaluated. Based on age and comorbidities, patients were stratified in 4 groups: low (<75 years + 0 comorbidities), low intermediate (≥75 years/1 comorbidity), high intermediate (≥75 years + 1 comorbidity/2 comorbidities), and high risk of death (≥75 years + ≥2 comorbidities).

RESULTS

In total, 4,202 patients (62.9% men) were identified. Within 1 year after surgery, 504 (12.0%) died and 2,456 (58.5%) were rehospitalized. Factors associated with death included older age (>75 years), chronic obstructive lung disease, heart failure, prior myocardial infarction, prior stroke, liver disease, and kidney disease. The 1-year risks of death among patients in low, low-intermediate, high-intermediate, and high risk of death were 3.6%, 10.3%, 19.6%, and 27.7%, respectively. Diabetes mellitus and chronic obstructive lung disease were associated with an increased incidence of rehospitalization, and the incidence of rehospitalization was similar among the 4 abovementioned groups (57.8%-62.8%).

CONCLUSIONS

Mortality and rehospitalization risks after mitral valve surgery varied substantially with age and comorbidities. High-risk patients with >25% 1-year mortality may be easily identified using readily available clinical features.

TRIAL REGISTRATION

In Denmark, registry-based studies that are conducted for the sole purpose of statistics and scientific research do not require ethical approval or informed consent by law. However, the study is approved by the data responsible institute (the Capital Region of Denmark [approval number: P-2019-348]) in accordance with the general data protection regulation.

Factors associated with postoperative atrial fibrillation and other adverse events after cardiac surgery

OBJECTIVE

The study objective was to evaluate the impact of various surgical characteristics and practices on the risk of postoperative atrial fibrillation and other adverse outcomes after cardiac surgery.

METHODS

By using the prospectively collected data of patients who underwent cardiac surgery in 28 centers across the United States, Italy, and Argentina, the details of surgery characteristics were collected for each patient and the outcomes, including postoperative atrial fibrillation, major adverse cardiovascular events, and mortality. These were evaluated via multivariable-adjusted models.

RESULTS

In 1462 patients, a total of 460 cases of postoperative atrial fibrillation, 33 major adverse cardiovascular events, 23 cases of 30-day mortality, and 46 cases of 1-year mortality occurred. We found that type of surgery and cardiopulmonary bypass use predicted the occurrence of postoperative atrial fibrillation. Compared with coronary artery bypass grafting alone, there was a higher risk of postoperative atrial fibrillation with valvular surgery alone (odds ratio, 1.4; 95% confidence interval, 1.1-1.9), and the risk was even higher with concomitant valvular and coronary artery bypass grafting surgery (odds ratio, 1.8; 95% confidence interval, 1.2-2.7). Compared with no bypass, use of cardiopulmonary bypass was associated with higher risk of postoperative atrial fibrillation (odds ratio, 2.4; 95% confidence interval, 1.7-3.5), but there were significant age and sex differences of the impact of bypass use among patients undergoing coronary artery bypass grafting (P for interaction = .04). In addition, compared with spontaneous return of rhythm, ventricular pacing was associated with a higher risk of major adverse cardiovascular events (odds ratio, 5.0; 95% confidence interval, 1.4-18), whereas concomitant coronary artery bypass grafting and valvular surgery was associated with a higher risk of 30-day mortality (hazard ratio, 4.3; 95% confidence interval, 1.2-14) compared with coronary artery bypass grafting alone. Occurrence of postoperative atrial fibrillation was associated with greater length of stay and 1-year mortality (hazard ratio, 2.2; 95% confidence interval, 1.2-3.9).

CONCLUSIONS

In this multicenter trial, we identified specific adverse outcomes that are associated with concomitant valvular and coronary artery bypass graft surgery, cardiopulmonary bypass, ventricular pacing, and occurrence of postoperative atrial fibrillation.

Cardiac rehabilitation is associated with reduced long-term mortality in patients undergoing combined heart valve and CABG surgery

BACKGROUND

No reports have been published to date on the impact of cardiac rehabilitation (CR) on mortality in patients undergoing combined heart valve and coronary artery bypass graft (CABG) surgery (V + CABG), a procedure that has increased significantly in frequency in recent years.

METHODS

We identified consecutive patients who underwent V + CABG surgery in the Olmsted County from 1996 to 2007. Propensity scores were developed using more than 40 clinical, operative, and post-operative characteristics. The impact of CR on long-term mortality was assessed via landmark analysis and using propensity score regression adjustment and stratification techniques.

RESULTS

A total of 201 patients were included in our study, in whom 86 deaths occurred over a mean follow up of 6.8 years. Forty-seven per cent of patients participated in CR, with a significant trend towards increased participation in recent years (p = 0.04). Conditional on 6-month survival and controlling for propensity factors as well as mortality risk factors, CR participation was associated with a significant reduction in mortality (propensity score adjustment: HR 0.48, p = 0.009; propensity score stratification: HR 0.48, p = 0.016). The absolute risk reduction over 10 years was 14.5% (number needed to treat = 7). Results did not differ significantly based on age, gender, emergent status, or history of heart failure or arrhythmias, but CR participation was more beneficial for patients who underwent a mitral valve procedure (HR 0.24, 95% CI 0.08-0.77).

CONCLUSIONS

This is the first study reporting a significant survival benefit with CR participation in patients who have undergone combined V + CABG surgery. These findings provide evidence in support of recommendations for CR participation after V + CABG surgery.

Comparison of the health related quality of life of patients following mitral valve surgical procedures in the 6-months follow-up: a prospective study

PURPOSE

The aim of the present study is to evaluate the health-related quality of life of the patients who underwent mitral valve repair (MvRp) and mitral valve replacement (MVR).

METHODS

Within the scope of this prospective study design, 56 patients who had mitral valve operation between the years of 2011-2012 were enrolled in the study. 24 (42.8%) of these patients had MVR while 32 (57.1%) of them had MvRp. The health-related quality of life was evaluated according to the Turkey norms of Short Form 36 Quality-Of-Life Measures (SF-36), which were filled in by the patients before and 6 months after the operation. Moreover, preoperative risk factors affecting the quality of life (age, gender, functional capacity, rhythm, hypertension, diabetes, applied surgical method and echocardiographic results) were investigated for all the patients (n = 56) by using independent sample t test analysis.

RESULTS

When the pre and postoperative changes were compared between the two groups, it was found out that there were no significant difference between the groups in terms of restraints on physical role functioning (PR), and the social role functioning values (SF) (respectively; p = 0.097, p = 0.105). However, in the comparison of pre-/postoperative changes between the groups, the changes in physical functioning (PF), bodily pain (BP), general health (GH), vitality (VT) and restraints on emotional role functioning (RE) and mental health (MH) values were found out to be significantly superior in the MvRp group than in the MVR group (respectively; p <0.01, p <0.05, p <0.01, p <0.01, p <0.05 and p <0.01). It was also confirmed that female gender, atrial fibrillation (AFR), and MVR method negatively affected the physical and mental components (respectively; p = 0.033, p = 0.003, p = 0.015).

CONCLUSION

RESULTS of the SF-36 quality of life measures show that quality of life may be better in patients that have had MvRp. It should be considered that the planned surgical treatment method can affect the patient's quality of life, and this effect can indicate the success of the surgical treatment.

Cellular mechanisms by which proinsulin C-peptide prevents insulin-induced neointima formation in human saphenous vein

AIMS/HYPOTHESIS

Endothelial cells (ECs) and smooth muscle cells (SMCs) play key roles in the development of intimal hyperplasia in saphenous vein (SV) bypass grafts. In diabetic patients, insulin administration controls hyperglycaemia but cardiovascular complications remain. Insulin is synthesised as a pro-peptide, from which C-peptide is cleaved and released into the circulation with insulin; exogenous insulin lacks C-peptide. Here we investigate modulation of human SV neointima formation and SV-EC and SV-SMC function by insulin and C-peptide.

METHODS

Effects of insulin and C-peptide on neointima formation (organ cultures), EC and SMC proliferation (cell counting), EC migration (scratch wound), SMC migration (Boyden chamber) and signalling (immunoblotting) were examined. A real-time RT-PCR array identified insulin-responsive genes, and results were confirmed by real-time RT-PCR. Targeted gene silencing (siRNA) was used to assess functional relevance.

RESULTS

Insulin (100 nmol/l) augmented SV neointimal thickening (70% increase, 14 days), SMC proliferation (55% increase, 7 days) and migration (150% increase, 6 h); effects were abrogated by 10 nmol/l C-peptide. C-peptide did not affect insulin-induced Akt or extracellular signal-regulated kinase signalling (15 min), but array data and gene silencing implicated sterol regulatory element binding transcription factor 1 (SREBF1). Insulin (1-100 nmol/l) did not modify EC proliferation or migration, whereas 10 nmol/l C-peptide stimulated EC proliferation by 40% (5 days).

CONCLUSIONS/INTERPRETATION

Our data support a causative role for insulin in human SV neointima formation with a novel counter-regulatory effect of proinsulin C-peptide. Thus, C-peptide can limit the detrimental effects of insulin on SMC function. Co-supplementing insulin therapy with C-peptide could improve therapy in insulin-treated patients.

Surgical management of coexisting coronary artery and valvular heart disease

PURPOSE

Combined coronary artery bypass (CAB) and valve surgery is one of the most challenging surgical procedures, but the operative results have improved over the years.

MATERIALS AND METHODS

From 1989 through 2004, combined CAB and valve operations were performed in 125 patients. Mean age was 63 years, and 86 patients were male. Forty-six patients were diagnosed with coronary artery disease during preoperative evaluation for valvular heart disease (VHD). All patients underwent CAB, and one or more underwent valve replacement or repair (mitral: 54, aortic: 61, tricuspid: 3, DVR: 7) simultaneously.

RESULTS

Mean number of distal graft was 1.98 +/- 1.07, and LIMA was used in 68% of patients. Early mortality occurred in 6 patients (4.8%), and the causes were heart failure (4) and sepsis (2). Mean follow-up duration was 91.4 +/- 40.9 months (range: 47-245), and late mortality occurred in 4 patients. Kaplan Meier estimated survival rates at 1, 5, and 10 years were 94.4 %, 92.3%, and 89.9%, respectively.

CONCLUSION

Combined coronary and valve operations can be performed safely with optimal surgical results. Although the surgical mortality of coexisting coronary and VHD is higher than either isolated coronary or valvular operations, it may not affect the long-term survival.

Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis

BACKGROUND

We investigated whether mitral valve repair (MVP) is superior to mitral valve replacement (MVR) in terms of survival and quality of life during the long-term follow-up.

METHODS

One hundred eighty-four consecutive patients underwent MVP or MVR for mitral regurgitation with or without concomitant coronary artery bypass grafting. Clinical data were recorded prospectively, and the data for the Nottingham Health Profile quality-of-life analysis was collected cross-sectionally. Propensity score analysis was used for the study group matching.

RESULTS

The mean follow-up time was 7.3 +/- 1.4 years. After adjustment for baseline characteristics by the propensity score method, there was a statistically significant survival benefit for the patients who underwent MVP (p = 0.02). Risk factors for death were preoperative unstable angina pectoris (relative risk ratio, 4.4; 95% confidence interval, 2.2 to 8.8), age older than 60 years (relative risk ratio, 1.1; 95% confidence interval, 1.0 to 1.1), use of mitral prosthesis (relative risk ratio, 2.7; 95% confidence interval, 1.4 to 5.3), preoperative renal insufficiency (relative risk ratio, 1.0; 95% confidence interval, 1.0 to 1.007), and preoperative cerebrovascular disorder (relative risk ratio, 2.7; 95% confidence interval, 1.0 to 5.3). The quality of life of the MVP and MVR groups did not differ from each other, but the MVP and the MVR patients had lower energy and mobility scores than an age- and sex-matched reference population.

CONCLUSIONS

Survival is longer after MVP than after MVR. The quality of life of MVP and MVR patients does not differ from each other. In terms of most quality-of-life variables, patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population. Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population.

Impact of a telehealth intervention to augment home health care on functional and recovery outcomes of elderly patients undergoing coronary artery bypass grafting

OBJECTIVE

This pilot study examined the effect of a home communication intervention (HCI) to augment home health care (HHC) on functioning and recovery outcomes of elderly patients undergoing coronary artery bypass graft.

DESIGN

A randomized, experimental two-group (N = 50) repeated-measures design was used. Both HCI and control subjects received HHC, and the HCI group also received the 12-week HCI delivered by a telehealth device, the Health Buddy (Health Hero Network). The Medical Outcome Study Short Form-36 measured physiologic and psychosocial functioning at baseline, 6 weeks, and 3 months after surgery. Follow-up subject interviews ascertained self-report of postoperative problems and health care use.

SAMPLE

Subjects had an average age of 75.3 years and included males (56%) and females (44%).

RESULTS

By using repeated-measures analyses of covariance, covariating for the total number of HHC visits, HCI subjects, compared with the HHC group only, had a significantly higher adjusted mean general health functioning score (F = 8.41 [1, 36], P < .01). There were significant time effects on physical, role-physical, and mental health functioning, indicating that both groups improved over time. The groups reported similar postoperative problems; however, the control group had more emergency department visits than the HCI group.

CONCLUSIONS

Findings demonstrate the potential benefit of using an HCI to further augment outcomes of high-risk patients undergoing coronary artery bypass graft surgery referred to HHC after hospitalization.

Staged initial percutaneous coronary intervention followed by valve surgery (“hybrid approach”) for patients with complex coronary and valve disease

OBJECTIVES

The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients.

BACKGROUND

With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery.

METHODS

We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality.

RESULTS

There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively.

CONCLUSIONS

Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Bypass graft material and myocardial protective procedure in combined coronary artery bypass grafting and valve surgery

OBJECTIVE

The aortic cross clamping time is prone to be longer when coronary artery bypass grafting (CABG) is combined with valve surgery. Therefore, the myocardium that is revascularized by in-situ internal thoracic artery graft is at risk to ischemia, and, myocardial protection is especially important in such operation. In this study, the effect of myocardial preservation of combined antegrade, retrograde and terminal warm blood cardioplegia during combined valve surgery and CABG using the internal thoracic artery as a bypass conduit was evaluated.

METHODS

From November 1992 to August 1999, 15 patients received combined CABG and valve surgery. Among these 15 patients, 13 patients who did not need hemodialysis were divided into 2 groups, and a comparative study was done. In Group I (n = 5), only the saphenous vein graft was employed for combined CABG and valve surgery, and myocardial protection was done by combined antegrade and terminal warm blood cardioplegia. In Group II (n = 8), at least 1 in-situ internal thoracic artery graft was employed for CABG and valve surgery, and myocardial protection was done by combined antegrade, retrograde and terminal warm blood cardioplegia.

RESULTS

Despite longer aortic cross clamping time in Group II, the peak creatine kinase-MB of Group II was significantly lower. In addition, the postoperative administration of dopamine tended to be less in Group II.

CONCLUSION

Myocardial protection by combined antegrade, retrograde and terminal warm blood cardioplegia may be an effective adjunct to combined valve surgery and CABG employing the in-situ internal thoracic artery graft.