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Braun C, Schroeter F, Laux ML, Kuehnel RU, Ostovar R, Hartrumpf M, Necaev AM, Sido V, Albes JM. The Impact of Gender and Age in Obese Patients on Sternal Instability and Deep-Sternal-Wound-Healing Disorders after Median Sternotomy. J Clin Med 2023; 12:4271. [PMID: 37445306 DOI: 10.3390/jcm12134271] [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: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between age and sex in regard to the development of deep sternal wound infections and sternal instability following median sternotomy. METHODS A propensity-score-matching analysis was conducted on 4505 patients who underwent cardiac surgery between 2009 and 2021, all of whom had a BMI of ≥30 kg/m2. A total of 1297 matched pairs were determined in the sex group, and 1449 matched pairs we determined in the age group. The distributions of sex, age, diabetes mellitus, delirium, unstable sterna, wire refixation, wire removal, superficial vacuum-assisted wound closure, deep vacuum-assisted wound closure, clamp time, bypass time, logistic EuroSCORE, and BMI were determined. RESULTS The 30-day in-hospital mortality was found to be similar in the older and younger groups (8.149% vs. 8.35%, p = 0.947), and diabetes mellitus was also equally distributed in both groups. However, postoperative delirium occurred significantly more often in the older group (29.81% vs. 17.46%, p < 0.001), and there was a significantly higher incidence in men compared with women (16.96% vs. 26.91%, p < 0.001). There were no differences found in the incidence of sternum instability, fractured sternum, superficial vacuum-assisted wound closure, and deep vacuum-assisted wound closure between the age and sex groups. CONCLUSIONS In conclusion, this study found that sternal instability and deep-wound-healing problems occur with equal frequency in older and younger patients and in men and women following median sternotomy. However, the likelihood of postoperative delirium is significantly higher in older patients and in men. These findings suggest that a higher level of monitoring and care may be required for these high-risk patient groups to reduce the incidence of postoperative delirium and improve outcomes following median sternotomy.
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Affiliation(s)
- Christian Braun
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Filip Schroeter
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Magdalena Lydia Laux
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Ralf-Uwe Kuehnel
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Roya Ostovar
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Martin Hartrumpf
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Anna-Maria Necaev
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Viyan Sido
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Johannes Maximilian Albes
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
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Alozie A, Öner A, Löser B, Dohmen PM. Minimally invasive direct coronary artery bypass and percutaneous coronary intervention followed by transcatheter aortic valve implantation: A promising concept in high-risk octogenarians. Ann Card Anaesth 2023; 26:143-148. [PMID: 37706377 PMCID: PMC10284489 DOI: 10.4103/aca.aca_165_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/20/2022] [Accepted: 05/06/2022] [Indexed: 09/15/2023] Open
Abstract
Objectives In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid). Background The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature. Methods Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis. Results From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II. Conclusions In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.
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Affiliation(s)
- Anthony Alozie
- Department of Cardiac Surgery, Heart Centre Rostock, University of Rostock, Germany
| | - Alper Öner
- Department of Cardiology, Heart Centre Rostock, University of Rostock, Germany
| | - Benjamin Löser
- Department of Anesthesiology and Intensive Care Medicine, University of Rostock, Germany
| | - Pascal M. Dohmen
- Department of Cardiac Surgery, Heart Centre Rostock, University of Rostock, Germany
- Department of Cardiothoracic Surgery, Faculty of Health Sciences, University of the Free State Bloemfontein, South Africa
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Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome? Heart Vessels 2019; 35:487-501. [PMID: 31642980 PMCID: PMC7222122 DOI: 10.1007/s00380-019-01519-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
Early and long-term outcomes in elderly patients who underwent isolated aortic valve replacement (iAVR) are well defined. Conflicting data exist in elderly patients who underwent AVR plus coronary artery bypass grafting (CABG). We sought to evaluate the early and long-term outcomes of combined AVR + CABG in patients older than 75 years of age. From June 1999 to June 2018, 402 patients ≥ 75 years who underwent iAVR (n = 200; 49.7%) or combined AVR plus CABG (n = 202; 50.3%) were retrospectively analysed. AVR + CABG patients were older than iAVR patients (78.5 ± 2.5 vs 77.6 ± 2.8 years; p < 0.0001), with greater co-morbidities and more urgent/emergency surgery. 30-day mortality was 6.5% in the AVR + CABG and 4.5% in the iAVR group (p = 0.38). Multivariate analysis identified EuroSCORE II [odd ratio (OR) 1.13] postoperative stroke (OR 12.53), postoperative low cardiac output syndrome (OR 8.72) and postoperative mechanical ventilation > 48 h (OR 8.92) as independent predictors of 30-day mortality; preoperative cerebrovascular events (OR 3.43), creatinine (OR 7.27) and extracorporeal circulation time (OR 1.01) were independent predictors of in-hospital major adverse cardiovascular and cerebral events (MACCE). Treatment was not an independent predictor of 30-day mortality and in-hospital MACCE. Survival at 1, 5 and 10 years was 94.7 ± 1.6%, 72.6 ± 3.6% and 31.7 ± 4.8% for iAVR patients and 89.1 ± 2.3%, 73.9 ± 3.5% and 37.2 ± 4.8% for AVR + CABG subjects (p = 0.99). Using adjusted Cox regression model, creatinine [hazard ration (HR) 1.50; p = 0.018], COPD (HR 1.97; p = 0.003) and NYHA class (HR 1.39; p < 0.0001) were independent predictors of late mortality; the combined AVR + CABG was not associated with increased risk of late mortality (HR 0.83; p = 0.30). In patients aged ≥ 75 years, combined AVR + CABG was not associated with increased 30-day mortality, in-hospital MACCE and long-term mortality. Surgical revascularization can be safely undertaken at the time of AVR in elderly patients.
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Aortic Valve Replacement and Concomitant Right Coronary Artery Bypass Grafting Performed via a Right Minithoracotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 9:302-5. [DOI: 10.1097/imi.0000000000000081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective We present our experience of concomitant right coronary artery bypass grafting (CABG) and aortic valve replacement performed via a right minithoracotomy in patients with coronary lesions not amenable to percutaneous intervention. Methods A total of 17 patients underwent concomitant aortic valve replacement and right CABG between April 2008 and July 2013.A5-to 6-cm minithoracotomy incision was made over the right second or third intercostal space, and the costochondral cartilage was transected. A saphenous vein bypass to the right coronary artery was then performed, initiating the anastomosis from the toe of the graft. Subsequently, the aortic valve was replaced using standard techniques. Results There were 6 men and 11 women. The median European System for Cardiac Operative Risk Evaluation II score mortality risk was 5% [interquartile range (IQR), 2%-8%]. The mean (SD) age was 77 (10) years, the left ventricular ejection fraction was 59% (8%), and the New York Heart Association functional class was 2.4 (0.8). One patient had a history of CABG. The mean (SD) cardiopulmonary bypass time was 168 (57) minutes, and the aortic cross-clamp time was 133 (36) minutes. Three patients underwent concomitant mitral valve surgery (replacement, 2; repair, 1). The median intensive care unit and hospital lengths of stay were 47 hours (IQR, 24–90) and 9 days (IQR, 5–13), respectively. There was one reoperation for bleeding, and there was one postoperative stroke. All patients were alive at a mean (SD) follow-up of 2 (1.1) years. Conclusions Aortic valve replacement with concomitant CABG performed via a right minithoracotomy approach is feasible.
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Crudeli E, Lazzeri C, Stefàno P, Chiostri M, Blanzola C, Rossi A, Olivo G, Pace SD, Gensini GF, Valente S. Age as a Prognostic Factor in Patients with Acute Coronary Syndrome undergoing Urgent/Emergency Cardiac Surgery. Heart Lung Circ 2015; 24:845-53. [PMID: 25769662 DOI: 10.1016/j.hlc.2015.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/09/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients presenting with acute coronary syndrome (ACS) who require urgent/emergency coronary artery bypass grafting (CABG) are increasing, as is the complexity of their clinical characteristics, one of which is advanced age. We evaluated the prognostic role of age in patients undergoing urgent/emergency cardiac surgery for ACS. METHODS From January to December 2013, 452 consecutive patients underwent CABG at our institution. Among these, 213 presented with ACS, were enrolled in the study and divided into tertiles of age: First: 40-65 years old (n=73), Second: 66-74 (n=70), Third: 75-89 (n=70). Patients were followed post-operatively for 30 days. RESULTS No differences between tertiles were found for baseline clinical and angiographic characteristics. Off-pump interventions were 67.6%. Older patients more frequently required an associate intervention to CABG for a mechanical complication of ACS. Overall 30-day all-cause mortality was 4.7% (n=10); 0.6% (n=1) in patients undergoing isolated CABG (n=168, 78.9%). The STEMI diagnosis was an independent risk factor for 30-day mortality, and age was not. CONCLUSIONS The 30-day mortality rate of older ACS patients who undergo urgent/emergency CABG is comparable to that of younger ones. Pre-operative risk assessment should rely on evaluation of the clinical complexity of each patient independent of their chronological age, to customise the therapeutic strategy.
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Affiliation(s)
- Elena Crudeli
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Chiara Lazzeri
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pierluigi Stefàno
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Claudio Blanzola
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandra Rossi
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giuseppe Olivo
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gian Franco Gensini
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Serafina Valente
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Mihos CG, Santana O, Pineda AM, La Pietra A, Lamelas J. Aortic Valve Replacement and Concomitant Right Coronary Artery Bypass Grafting Performed via a Right Minithoracotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014. [DOI: 10.1177/155698451400900408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Orlando Santana
- Divisions of Cardiology, Columbia University, Miami Beach, FL USA
| | - Andres M. Pineda
- Divisions of Cardiology, Columbia University, Miami Beach, FL USA
| | - Angelo La Pietra
- Divisions of Cardiac Surgery, Mount Sinai Heart Institute, Columbia University, Miami Beach, FL USA
| | - Joseph Lamelas
- Divisions of Cardiac Surgery, Mount Sinai Heart Institute, Columbia University, Miami Beach, FL USA
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Seco M, Edelman JJB, Forrest P, Ng M, Wilson MK, Fraser J, Bannon PG, Vallely MP. Geriatric cardiac surgery: chronology vs. biology. Heart Lung Circ 2014; 23:794-801. [PMID: 24851829 DOI: 10.1016/j.hlc.2014.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 01/25/2023]
Abstract
Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".
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Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Ng
- Sydney Medical School, The University of Sydney, Sydney, Australia; Cardiology Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Böning A. Combined aortic valve replacement and coronary artery bypass grafting in octogenarians: results not as excellent as reported. Eur J Cardiothorac Surg 2014; 47:198. [PMID: 24711508 DOI: 10.1093/ejcts/ezu156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andreas Böning
- Department of Cardiovascular Surgery, Justus-Liebig University Gießen, Giessen, Germany
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Fukui T, Takanashi S. Reply to Böning. Eur J Cardiothorac Surg 2014; 47:198. [PMID: 24711506 DOI: 10.1093/ejcts/ezu159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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