Technical considerations and sizing of external annuloplasty in the Ross procedure

Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus.

Left atrial appendage occlusion: Percutaneous and surgical approaches in everyday practice

Prophylactic left atrial appendage occlusion has been suggested as a means of reducing cardioembolism risk in patients with atrial fibrillation. Its clinical benefits have been discussed together with potential endocrine or hemodynamic adverse effects, with conflicting conclusions. We aimed to provide a thorough overview of the current literature and a recommendation for daily clinical decision-making. A comprehensive Medline search through PubMed was conducted to search for relevant articles, which were further filtered using the title and abstract. Sixty-five articles were selected as relevant to the topic. Concomitant left atrial appendage occlusion during cardiac surgery for other reasons is effective in terms of thromboembolism risk reduction in patients with a history of atrial fibrillation and higher CHA2DS2-VASc scores. Surgical occlusion is safe, and epicardial closure techniques are preferred. Thoracoscopic and transcatheter techniques are also feasible, and the individual treatment choice must be tailored to the patient. The concerns about endocrine imbalance or risk of heart failure after occlusion are not supported by evidence. Current evidence is conflicting with regard to hemodynamic consequences of appendage occlusion.

Aorto-mitral curtain reconstruction in invasive double-valve endocarditis: mid-term outcomes

Background

Invasive double-valve endocarditis with structural damage (abscess or perforation) of the aorto-mitral curtain is a relatively rare but fatal diagnosis requiring complex surgical reconstruction. This study presents the short-term and mid-term outcomes from a single center.

Methods

From 2014 to 2021, 20 patients with double-valve endocarditis with structural damage of the aorto-mitral curtain underwent surgical reconstruction (Hemi-Commando procedure n = 16 and Commando procedure n = 4). Data were obtained retrospectively.

Results

In 13 cases, the procedure was a reoperation. The mean cardiopulmonary bypass time was 239 ± 47 min and the mean cross-clamp time was 186 ± 32 min. Concomitant procedures were tricuspid valve repair in two, coronary revascularization in one, closure of a ventricular septal defect in one and hemiarch (using circulatory arrest) in one patient. Eleven patients (55%) required surgical revision for bleeding. Thirty-day mortality was 30% (6 patients)-3 patients from the Hemi-Commando group (19%) and 3 patients from the Commando group (75%). Overall survival at 1, 3 and 5 years was 60%, 50% and 45% respectively. Reoperation was required by 4 patients. Freedom from reoperation at 1, 3 and 5 years was 86%, 71% and 71% respectively.

Conclusion

Despite the high postoperative morbidity and mortality, complex surgical reconstruction of the aorto-mitral continuity of patients with double-valve endocarditis represents the only real chance for survival. Mid-term outcomes are acceptable, but strict follow-up is required due to the risk of valve failure.

Renal cell carcinoma with intracardiac tumor thrombus extension: Radical surgery yields 2 years of postoperative survival in a single-center study over a period of 30 years

Background

Renal cell carcinoma (RCC) with tumor thrombus extension into the right atrium (level IV) is a rare life-threatening clinical condition that can only be managed by means of a combined urological and cardiac surgical approach. The early and late outcomes of this radical treatment were analyzed in a large single-institution series over a period of 30 years.

Methods

In 37 patients with RCC and intracardiac tumor thrombus extension, nephrectomy was performed followed by the extraction of the intracaval and intracardiac tumor thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Recently, in 13 patients, selective aortic arch perfusion (SAAP) was instituted during DHCA.

Results

In all patients, precise removal of the tumor thrombus was accomplished in a bloodless field. The mean duration of isolated DHCA was 15 ± 6 min, and 31.5 ± 10.2 min in the case of DHCA + SAAP, at a mean hypothermia of 22.7 ± 4°C. In-hospital mortality was 7.9% (3 patients). In Kaplan-Meier analysis, the estimated median survival was 26.4 months whereas the 5-year cancer-related survival rate was 51%.

Conclusions

Despite its complexity, this extensive procedure can be performed safely with a generally uneventful postoperative course. The use of cardiopulmonary bypass with DHCA, with the advantage of SAAP, allows for a safe, precise, and complete extirpation of intracaval and intracardiac tumor mass. Late outcomes after radical surgical treatment in patients with RCC and tumor thrombus reaching up in the right atrium in our series justify this extensive procedure.

Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty

OBJECTIVE

We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.

METHODS

Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.

RESULTS

Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).

CONCLUSIONS

BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.

Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis

OBJECTIVES

The choice of optimal surgical treatment for young and middle-aged adults with aortic valve disease remains a challenge. Mechanical aortic valve replacement (mAVR) is generally preferred despite promising recent outcomes of the Ross procedure. Our goal was to compare the strategies at a nationwide level.

METHODS

This study was a retrospective analysis of prospectively recorded data from the National Registry of Cardiac Surgery of the Czech Republic. Using propensity score matching, we compared the outcomes of patients undergoing the Ross procedure in 2 dedicated centres with all mAVRs performed in country between 2009 and 2020.

RESULTS

Throughout the study period, 296 adults underwent the Ross procedure and 5120 had an mAVR. We found and compared 291 matched pairs. There were no in-hospital deaths, and the risk of perioperative complications was similar in both groups. Over the average follow-up period of 4.1 vs 6.1 years, the Ross group had a lower all-cause mortality (0.7 vs 6.5%; P = 0.015). This result remained significant even when accounting for cardiac- and valve-related deaths only (P = 0.048). Unlike the Ross group, the mAVR group had a significantly lower relative survival compared with the age- and sex-matched general population. There was no difference in the risk of reoperation (4.5 vs 5.5%; P = 0.66).

CONCLUSIONS

The Ross procedure offers a significant midterm survival benefit over mAVR. The procedures have a comparable risk of perioperative complications. Patients after mAVR have reduced survival. Thus, the Ross procedure should be the preferred treatment option for young and middle-aged adults with aortic valve disease in dedicated centres.

Longer-term outcomes after bicuspid aortic valve repair in 142 patients

BACKGROUND

The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement.

METHODS

From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively.

RESULTS

In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6).

CONCLUSIONS

Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Histopathological changes in dilated ascending aorta associated with aortic valve cuspidity

OBJECTIVES

Patients with a bicuspid aortic valve (BAV) often present with a dilated ascending aorta. However, the underlying pathogenesis for the observed changes in the aortic wall and the resulting aneurysmal dilation remains a subject of debate. This study aims to compare the histological abnormalities of the ascending aorta in BAV and tricuspid aortic valve (TAV) patients and their correlation with aortic diameter and patient age.

METHODS

A total of 376 patients from our institution's clinical database were included in the retrospective analysis. These patients underwent either elective surgery for ascending aorta dilation or emergency surgery for aortic dissection, either isolated or with a structurally diseased aortic valve. After excision, the ascending aorta samples were analysed by a pathologist.

RESULTS

On histological examination, a higher degree of elastic fibre fragmentation and loss and mucoid extracellular matrix accumulation was present in the samples from TAV patients when compared with that from BAV patients (P < 0.001). However, correlation was poor for all variables when considering aortic diameter and histological abnormalities or age and histological abnormalities in both BAV and TAV patients.

CONCLUSIONS

Our study demonstrates a greater incidence of severe histological abnormalities in TAV patients when compared with BAV patients.

Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach

OBJECTIVES

Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty).

METHODS

Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair.

RESULTS

The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007).

CONCLUSIONS

Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.

Subcoronary Ross/Ross-Konno operation in children and young adults: initial single-centre experience

OBJECTIVES

We sought to evaluate the outcome after modified subcoronary Ross/Ross-Konno operation in children and young adults.

METHODS

Between January 2013 and January 2019, a total of 50 patients with median age of 6.3 years (range 0.02-36.5 years, 58% males), including 10 infants (20%), received modified subcoronary Ross/Ross-Konno operation at our institution. Survival, morbidity, reinterventions, aortic valve function and aortic root dimensions were analysed.

RESULTS

At a median follow-up of 31.2 months (range 14.4-51 months), there were 1 early death and 1 late death, both in the infant group. The overall survival at 5 years after the operation was 95%. Two patients needed aortic valve replacement, 11 and 15 months after their Ross operation. At 5 years, freedoms from reoperation on the autograft and on the right ventricle to pulmonary artery conduit were 94% and 97%, respectively. Freedom from aortic valve regurgitation greater than mild was 97% at 5 years. Median dimensions of the aortic root at all levels remained in normal range at last visit. Forty-four patients (95%) were in New York Heart Association class I with normal left ventricular function.

CONCLUSIONS

The initial experience with the subcoronary Ross/Ross-Konno operation in children and young adults showed excellent outcome. The mortality and morbidity among infants remain significant. The described technique is reproducible and might be advantageous in situations when prosthetic supporting techniques interfere with somatic growth.

Lipidomic characterization of omega-3 polyunsaturated fatty acids in phosphatidylcholine and phosphatidylethanolamine species of egg yolk lipid derived from hens fed flaxseed oil and marine algal biomass

Membrane phospholipids, including phosphatidylcholine (PC) and phosphatidylethanolamine (PE), consist of distinct fatty acids occupying the sn-1 and sn-2 positions, reflecting the highly regulated nature of lipid biosynthesis. However, little is known about the influence of dietary lipids on the positional nature of fatty acids in tissues, including the enrichment of omega-3 polyunsaturated fatty acid (PUFA) in chicken egg yolk phospholipids. This study was undertaken to characterize the PC and PE species in egg lipids derived from Lohmann hens (n=10/treatment) randomly allocated to either a control (no supplementation), a flaxseed oil (FO) or a marine algal oil (MA) diet. Each of the FO or MA diets supplied three levels of total omega-3 PUFA (0.20, 0.40 and 0.60% of diet) that were provided for 6 weeks. A combination of multiplexed mass spectrometry (MS) experiments are used to determine total, isobaric, and position molecules for PC and PE in egg yolk. The distribution of phospholipids in the yolk was predominantly PC over PE (~72 vs. 23%, respectively) across treatments. The longer chain PUFA existed in the sn-2 position in the PC and PE. Although docosahexaenoic acid (22:6) formed isomers with fatty acids 16:0, 18:0 and 18:1; it was preferentially enriched in the egg in combination with 16:0 with both the FO and MA-fed groups in both lipid pools. All 22:6-containing isomers were enriched by ~2-fold more (P < 0.0001) with MA than FO, however, all isomers exhibited a plateau with the FO-fed group. In addition, the MS analyses of PCs revealed several isobaric species containing eicosapentaenoic acid (EPA, 20:5), however, in the PE, EPA formed only one isomer (i.e. in combination with 16:0). These results may assist to elucidate potential aspects regulating the limited enrichment of omega-3 PUFA, particularly EPA and docosahexaenoic acid (22:6) in chicken eggs.

Suture Annuloplasty and Simplified Root Wrapping in the Full Root Ross Operation

This report describes our reinforcement technique for the free-standing autograft in the full root Ross operation, using external suture annuloplasty and simplified root wrapping with native aortic wall. After implantation of the autograft in the aortic annulus, an expanded polytetrafluoroethylene suture is fixed outside the root at the basal plane and tied around a Hegar dilator placed into the autograft. By including the tongues of aortic root tissue at the distal anastomosis of the autograft, three tongues of original root wall lie outside the autograft commissures. This technique preserves autograft valve geometry and provides sufficient reinforcement of the free-standing autograft.

An Expansible Aortic Ring in Aortic Root Remodeling: Exact Position, Pulsatility, Effectiveness, and Stability in Three-Dimensional CT Study

BACKGROUND

The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT).

METHODS

Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured.

RESULTS

We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole (p = 0.004, p < 0.001, respectively) and diastole (p = 0.001, p < 0.001, respectively) compared with preoperative. There was 22% reduction of the postoperative AB area in systole and 24% in diastole (p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole (p < 0.001 for both) compared with the preoperative period. Nearly all measured variables in the follow-up period showed a slight increase compared with the postoperative period; however, they did not reach statistical significance. The postoperative systolic-diastolic differences in the three measured variables at the level of AB and ARB were statistically significant and were maintained throughout the follow-up period. The base of the ring was implanted 2 ± 2 mm at the right, 0 ± 1 mm at the left above the AB, and 2 (-3 to 2) mm at the noncoronary nadir below the AB.

CONCLUSIONS

This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.

Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study

Background

In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement.

Methods

Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y – aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O – aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R – Ross procedure, mean age 37.8 years and M – mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months).

Results

In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns.

Conclusions

Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

Valve cuspidity: a risk factor for aortic valve repair?

BACKGROUND

The aim of this study was to analyze short- and mid-term results after aortic valve (AV) repair with particular regard to the impact of valve cuspidity (bicuspid versus tricuspid aortic valve).

METHODS

One hundred patients with aortic regurgitation (AR) undergoing aortic valve repair between November 2007 and October 2012 were included in the study. Sixty patients had bicuspid AV (BAV group; 11 females) and 40 patients had tricuspid AV (TAV group; 13 females). AR > grade 2 was present in 47 (78%) patients in the BAV and in 35 (88%) patients in the TAV group. Follow-up was complete in 100% and median was 25 months.

RESULTS

Isolated aortic valve repair was performed in 27 (45%) of BAV patients and in six (15%) of TAV patients. Replacement of the ascending aorta and/or aortic root was performed in 33 (55%) of BAV patients and in 34 (86%) of TAV patients. There was no death within 30 days postoperatively, while two patients died (TAV group) during the follow-up period. There was no statistical difference between BAV and TAV groups with regard to the survival (100 ± 0% vs. 95 ± 4%, p = 0.102), the three-year freedom from AV-related reoperation (90 ± 5% vs. 89 ± 6%, p = 0.456), and the three-year freedom from AR grade > 2 (86 ± 6% vs. 82 ± 7%, p = 0.866), respectively.

CONCLUSIONS

This study demonstrates no difference in mid-term results after regurgitant bicuspid and tricuspid aortic valve repair, suggesting that bicuspid valve may not be a risk factor for aortic valve repair.

One-step supraclavicular approach to the treatment of Dysphagia lusoria

A one-step supraclavicular approach for the surgical treatment of the aberrant right subclavian artery is described in a case of dysphagia lusoria in a 38-year-old female. The approach allows for safe division of the arteria lusoria and its re-anastomosis to the common carotid artery while the patient benefits from a mini-invasive extrathoracic procedure. doi: 10.1111/jocs.12287 (J Card Surg 2014;29:519-522).

Selective aortic arch perfusion enables to avoid deep hypothermic circulatory arrest for extirpation of renal cell carcinoma with tumour thrombus extension into the right atrium

OBJECTIVES

Renal cell carcinoma with a tumour thrombus extending into the right heart chambers necessitates extensive combined urological and cardiac surgery. Maximum safety and exactness in extirpation of the caval and intracardiac thrombus is achieved under deep hypothermic circulatory arrest, at a price of its non-physiological burden and time constraints. We propose a simple surgical manoeuvre enabling selective arch perfusion allowing for a milder hypothermia and liberal interval of circulatory arrest.

METHODS

On a routine cardiopulmonary bypass via median sternotomy, the dissection is extended along the aortic arch to identify the origins of the supra-aortic vessels. After standard aortic cross-clamping and cardioplegic cardiac arrest at moderate hypothermia, a second cross-clamp is applied at the aortic arch beyond the left carotid artery. A selective closed aortic arch perfusion is started while the extirpation of the tumour thrombus from the right atriotomy and abdominal cavotomy is being performed under conditions of circulatory arrest.

RESULTS

Using selective aortic arch perfusion, successful and uncomplicated extirpation of voluminous caval and intracardiac tumour thrombi was accomplished in 3 presented patients. Unexpectedly difficult thrombus adhering to hepatic veins in 1 patient required 42 min of circulatory arrest. Postoperative courses were uneventful in all 3 patients.

CONCLUSIONS

Second aortic cross-clamp to start selective closed aortic arch perfusion provides excellent surgical control of the operative field over a liberal time interval during circulatory arrest under milder hypothermia.

Coronéo extra-aortic annuloplasty ring could stabilize even the pulmonary autograft annulus in a Ross operation

The Ross procedure is an alternative technique to mechanical prosthesis and recent evidence suggests that it is associated with improved long-term survival and quality of life. However, late pulmonary autograft failure can occur more frequently in patients with significant dilation of the aortic annulus. Here, we present a technical modification of the Ross procedure--a case report of a patient who underwent a Ross procedure in which the gross dilation of the aortic annulus was reduced by implantation of an extra-aortic Coronéo annuloplasty ring. Before discharge, we performed a multidetector computed tomography (MDCT) to verify the effect of extra-aortic annuloplasty on the geometry of the neoaortic root and particularly on the dimension of the aortic annulus. The result of the MDCT demonstrated that the ring sits in the optimal position at the level of aortoventricular base and that aortic annulus is significantly reduced.

Cardiac Amyloidosis in the Cardiosurgical Operating Room - A Rare but Fatal Trap

Coronary artery bypass grafting resulted in a fatal outcome in two patients with unsuspected cardiac amyloidosis. Despite preoperative symptoms of myocardial ischemia, each case represented a different pathophysiological combination of cardiac amyloidosis and coronary artery disease. Pitfalls preventing correct diagnosis and possible patterns of treatment are discussed.

Coronary artery bypass grafting in the elderly: pros and cons after three-year follow-up

AIM

The elderly represent an ever-growing proportion of the candidates for coronary artery bypass grafting (CABG) surgery. We analyzed the effect of anticipated risks on the early and mid-term outcome of coronary surgery in septuagenarians compared with younger patients.

METHOD

We analyzed 1,475 consecutive isolated CABG procedures performed at the Charles University Hospital during the 1995-1997 period and assessed their early and mid-term (3-year follow-up) results with respect to patient age. The patients were divided into two groups: younger (n = 1,324, age < 70 years) and older (n = 151, age > or = 70 years). We studied potential preoperative risk factors, perioperative parameters, and postoperative course. Data on functional status, incidence of major cardiac events, and patient satisfaction with the outcome of surgery 3 years after the operation were collected from the patients by a questionnaire survey.

RESULTS

The elderly had lower body mass index and body surface area, more advanced stage of disease according to the New York Heart Association and Canadian Cardiovascular Society classifications, higher prevalence of diabetes, renal dysfunction, and extracardiac arteriopathy. CABG was performed in both groups, with no procedural differences. The older group had higher mortality (7.3% vs 2.3%), incidence of NearMiss+ (outcome measure index; 36.4% vs 18.4%), and post-operative morbidity (56.3% vs 34.6%). Older patients also required longer stay at the intensive care unit and longer hospitalization. Three-year follow-up revealed identical relief of symptoms and improvement of functional status in both groups, with higher mortality in the elderly (15.3% vs 4.5%). The stroke was also more frequent in the elderly (8.6% vs 3.0%), whereas the occurrence of other non-fatal cardiac events was similar in both groups.

CONCLUSION

Coronary revascularization in the elderly carries higher but still acceptable risk. The elderly survivors showed similar functional improvement as the younger patients, but the actuarial survival was worse, mainly due to perpetuating cardiovascular illness. Surgical procedure should not be denied to elderly population based on age alone and each patient should be carefully evaluated.