Independent Predictor Of Reoperation Research Articles

Smoking as an independent predictor of reoperation after lumbar laminectomy: a study of 500 cases.

This study aimed to identify the factors predicting an increased risk for reoperation in patients who had undergone a lumbar laminectomy. The authors retrospectively reviewed the electronic medical records of all patients who had undergone firsttime, bilateral laminectomy at 1, 2, or 3 levels for lumbar spondylosis at the authors' institution. Patients who underwent fusion, laminotomy, discectomy, or complete facetectomy were excluded. The patients' preoperative symptoms and comorbidities were also obtained from their medical records. Over an average follow-up period of 46.8 months, of 500 patients who had undergone laminectomy at 1, 2, or 3 levels, 81 patients (16.2%) developed subsequent spinal disorders that required a reoperation. A multiple logistic regression analysis identified smoking as an independent predictor of reoperation (OR 2.15, p = 0.01). Smoking was also an independent predictor of reoperation after a single-level laminectomy (OR 11.3, p = 0.02) and after a multilevel (that is, involving 2 or 3 levels) laminectomy (OR 1.98, p = 0.05). For 72 patients undergoing reoperation only for spinal degeneration, smoking remained an independent, statistically significant predictor of reoperation (OR 2.06, p = 0.04). Nine patients underwent reoperation for nondegenerative conditions (hematoma, wound infection, or wound dehiscence), and in these patients, chronic obstructive pulmonary disease was the only statistically significant predictor of reoperation (OR 8.92, p = 0.03). Smoking was the strongest predictor of reoperation in patients who had undergone single-level laminectomy, multilevel laminectomy, or reoperation for progression of spinal degeneration. These findings suggest that smokers have worse outcomes of lumbar decompression than nonsmokers.

Is rheumatic aetiology a predictor of poor outcome in the current era of mitral valve repair? Contemporary long-term results of mitral valve repair in rheumatic heart disease†

Contemporary experience with mitral valve (MV) repair in the rheumatic population is limited. We aimed to examine the long-term outcomes of rheumatic MV repair, to identify the predictors of durability and to compare the repair for rheumatic and degenerative MVs. MV repairs for both rheumatic and degenerative lesions were analysed prospectively from our valve-repair registry. The primary outcomes investigated were mortality, survival, freedom from reoperation and freedom from valve failure. Logistic and Cox regression analyses were performed to define the predictors of reoperation and valve failure. Between 1997 and 2010, 627 consecutive rheumatic MV repairs were performed (46.7% of all mitral repair procedures). The mean age of our study group was 32 ± 19 (range 3-75 years). In-hospital mortality was 2.4% and late mortality was 0.3%. Freedoms from reoperation for rheumatics at 5 and 10 years were 91.8 ± 4.8 and 87.3 ± 3.9%, respectively, comparable with that for degenerative valves at 92.0 ± 1.7 and 91.8 ± 4.8%, respectively (P = 0.79). Freedoms from valve failure for rheumatics at 5 and 10 years were 85.6 ± 2.3 and 72.8 ± 4.6%, respectively, whereas those for degenerative repairs were 88.7 ± 5.1 and 82.4 ± 7.7%, respectively (P = 0.45). Independent predictors for reoperation and valve failure in rheumatic patients were residual mitral regurgitation >2+ and performance of commissurotomy. The durability of MV repair for rheumatic disease in the current era has improved and is comparable with the outstanding durability of repairs for degenerative disease. Modifications of standard repair techniques, adherence to the importance of good leaflet coaptation and strict quality control with stringent use of intraoperative transoesophageal echocardiography have all contributed to the improved long-term results.

Improving Left Ventricular Outflow Tract Obstruction Repair in Common Atrioventricular Canal Defects

Left ventricular outflow tract obstruction (LVOTO) is the second most frequent reason for reoperation after atrioventricular canal (AVC) defect repair. Limited data are available on the mechanisms of LVOTO, their treatment, and outcomes. Between 1998 and 2010, 56 consecutive children with AVC underwent 68 LVOTO procedures. The AVC was partial in 4, transitional in 9, and complete in 43. The LVOTO procedure was required in 21 patients at the primary AVC repair, and the initial LVOTO procedure in 35 patients was a late reoperation after AVC repair. During a mean follow-up of 50±41 months, 5 patients (24%) with LVOTO repair at AVC repair required a reoperation for LVOTO, and 7 patients (20%) whose initial LVOTO repair was a reoperation required a second reoperation for LVOTO repair. Overall freedom from LVOTO reoperation was 98.5% at 1 year, 92.5% at 3 years, 81% at 5 years, 72.2% at 7 years, and 52.5% at 10 and 12 years. The freedom from reoperation was neither significantly different between partial, transitional, and complete AVC (p=0.78) nor between timing of the LVOT procedure (p=0.49). Modified single-patch AVC repair was associated with a higher LVOTO reoperation rate (p=0.04). Neither the mechanisms leading to LVOTO nor the surgical techniques used were independent predictors of reoperation. LVOTO in AVC is a complex and multifactorial disease. Aggressive surgical repair has improved late outcomes; however, risk factors for reoperation and the ideal approach for repair remain to be defined.

Aortic valve repair for active infective endocarditis

Aortic valve repair for active infective endocarditis

Invited Commentary

Alghamdi and associates [1Alghamdi A.A. Yanagawa B. Singh S.K. Horton A. Al-Radi O.O. Caldarone C.A. Balancing stenosis and regurgitation during mitral valve surgery in pediatric patients.Ann Thorac Surg. 2011; 92: 680-684Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] have highlighted the delicate balance that can be achieved between mitral stenosis and mitral regurgitation when repairing the mitral valve in children in order to achieve a more durable outcome and avoid mitral valve replacement. They show that greater than mild to moderate mitral regurgitation is poorly tolerated and an independent predictor of reoperation or death. The reduction of mitral regurgitation to less than moderate to mild by the creation of mild mitral stenosis makes for a better long-term repair. This approach of avoiding mitral valve replacement at the expense of a less-than-perfect repair, but one that is well tolerated with balanced regurgitation and stenosis, does allow for growth of the patient and removes the risks of anticoagulation with mitral valve replacement. Deferring mitral valve replacement to the older and larger patient allows a bigger valve to be placed. This article deals with patients of a median age of 4 years, with dysplastic valve morphology rather than the complex morphology seen in infancy, such as parachute mitral valve and where multiple obstructive lesions are present on the left side of the heart (Shone syndrome). Patients in the first few months and year of life are almost certainly more challenging than the cohort in article by Alghamdi and colleagues. However, the approach of achieving balanced mitral stenosis and mitral regurgitation, and a repaired valve, is certainly applicable to this younger, more difficult group. Long-term evaluation outcome for these patients should include the ability of the patient to thrive and develop and the lack of development of pulmonary hypertension. The mitral valve hemodynamics were assessed on the operating table under anaesthetic and probably underestimates the degree and severity of mitral stenosis and regurgitation. However, because this assessment mode was uniformly applied to all patients, it would seem to be acceptable. Mitral valve repair in young patients, particularly in the first few months of life, is difficult and challenging. The underlying morphology is complex, and individual variation in morphology from patient to patient makes each case a separate challenge. Although this report is in older children, the concept that a balanced repair that leaves mild to moderate valve regurgitation together with mild mitral stenosis to compensate for what otherwise would be severe mitral regurgitation, with a very bad outcome, seems eminently sensible. Balancing Stenosis and Regurgitation During Mitral Valve Surgery in Pediatric PatientsThe Annals of Thoracic SurgeryVol. 92Issue 2PreviewThe objectives of this study were to evaluate the composite outcome of reoperation or death for mitral valve repair and replacement and to determine the relative importance of regurgitation and stenosis during mitral valve repair to guide intraoperative decision making. Full-Text PDF

Primary Biventricular Repair of Atrioventricular Septal Defects: An Analysis of Reoperations

The purpose of this study was to analyze the factors affecting reoperation after primary biventricular atrioventricular septal defect (AVSD) repair. Between April 1997 and April 2007, 93 consecutive patients underwent surgery for biventricular correction of AVSD with a median age of 5.8 months (range, 9 days to 68.9 years). Fifty-three patients had complete AVSD, 6 patients had an intermediate type, and 29 patients had partial AVSD; 4 patients had a complete AVSD with associated tetralogy of Fallot, and 1 patient had a complete AVSD with double-outlet right ventricle. There was no in-hospital mortality. There were 2 late deaths (2.2%). Forty-three reoperations were performed in 23 patients (24.7%), of which 18 were for repair of significant left atrioventricular valve regurgitation and 8 were mitral valve replacements. Seven patients (7.5%) required insertion of a permanent pacemaker. The overall 5-year freedom from reoperation after AVSD repair was 73.6% +/- 4.8%. In the multivariate analysis for complete AVSDs, Down syndrome (p = 0.01) and the presence of right ventricular dominance (p = 0.03) were independent predictors of reoperation. At last follow-up, 76 patients (83.5%) were in New York Heart Association class I, and 68 patients (74.7%) were not taking any heart failure medications. Echocardiographic examination showed absent to mild left atrioventricular valve regurgitation in 76.5%; moderate, in 19.8%; and severe, in 3.7% of patients. Down syndrome and right ventricular dominance are independent predictors of reoperation after complete AVSD repair. Biventricular repair of isolated AVSD with a small left ventricle can be successfully accomplished with no mortality.

When is the Ross operation a good option to treat aortic valve disease?

We sought to identify suitable patients for the Ross operation. A cohort of 212 patients (mean age, 34 + or - 9 years; 66% men; 82% with congenital aortic valve disease) underwent the Ross operation and was prospectively followed with clinical evaluations and echocardiographic analysis for 3.1 to 18 years (mean, 10.1 + or - 4.2 years). In addition to longitudinal outcomes determined by means of Kaplan-Meier analysis, Cox regression analysis was used to identify predictors of valve failure. There were 1 operative and 4 late deaths, none of which were valve related. Survival at 15 years was 96.6% + or - 1.5% and similar to that seen in the general population matched for age and sex. There were 20 reoperations: 13 in the pulmonary autograft, 3 in the pulmonary homograft, and 4 others. Freedom from reoperation in the pulmonary autograft at 15 years was 92.1% + or - 2.3%. Aortic insufficiency was the only independent predictor of reoperation. Freedom from moderate or severe aortic insufficiency at 15 years was 89.7%, and greater than mild aortic insufficiency was 63.2%. Male sex, aortic/pulmonary annular mismatch, aortic annulus of 27 mm or larger, and preoperative aortic insufficiency were associated with higher risk of late aortic insufficiency by means of log-rank analysis. Cox regression analysis identified male sex as the only independent predictor of postoperative aortic insufficiency. Freedom from moderate or severe pulmonary insufficiency, peak gradient of 40 mm Hg or greater, or both at 15 years was 70.8% + or - 6.8%, and event-free survival was 81% + or - 3.7%. The Ross operation provided suboptimal results in male patients with aortic insufficiency. The best outcomes were in female patients, those with aortic stenosis, and those with an aortic annulus of less than 27 mm in diameter.

Chordae Replacement Versus Resection for Repair of Isolated Posterior Mitral Leaflet Prolapse: À Ègalité

Mitral valve (MV) repair for posterior mitral leaflet (PML) prolapse has proven excellent results. The loop technique, which involves insertion of polytetrafluoroethylene neochordae while preserving the native PML tissue, was developed to facilitate MV repair through a minimally invasive approach. The aim of this study was to assess the medium-term results of the loop technique in comparison with the widely adopted leaflet resection technique for repair of isolated PML prolapse. Between March 1999 and January 2008, a total of 1,708 patients underwent minimally invasive MV repair. Six hundred and seventy patients (39.2%) had isolated PML prolapse and were treated with either the loop technique (n = 317) or the leaflet resection (n = 353) technique, according to surgeon preference. Mean follow-up time was 2.8 +/- 2.2 years, and follow-up was 99% complete. Early postoperative echocardiography showed a significantly larger mitral orifice area (3.3 +/- 0.3 cm(2) versus 3.0 +/- 0.8 cm(2), p < 0.001) and lower mean pressure gradient (2.7 +/- 1.7 mm Hg versus 3.1 +/- 1.7 mm Hg, p = 0.03) after implantation of loops. Other perioperative outcomes were similar for the two groups of patients. Freedom from reoperation at 5 years was significantly higher after the loop technique (98.7%, 95% confidence interval [CI]: 96.7% to 99.5%) when compared with leaflet resection (93.9%, 95% CI: 90.7% to 96.1%, log-rank p = 0.005). Cox regression analysis revealed that implantation of a flexible, incomplete band was an independent predictor of reoperation (hazard ratio 6.2, 95% CI: 1.3 to 110.7), whereas use of leaflet resection had a nonsignificant trend toward an increased reoperation rate (hazard ratio 2.6, 95% CI: 0.9 to 9.1). Reoperation for excessive systolic anterior motion did not occur in any loop patient. Both the loop technique and conventional leaflet resection yield excellent results for repair of isolated PML prolapse. The technical ease of performing the loop technique through a minimally invasive approach, however, makes this method a particularly valuable alternative for MV repair surgery.

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis

Surgical treatment of native valve endocarditis remains challenging, especially in cases with paravalvular destruction. Basic principles include complete debridement and reconstruction. This study is designed to evaluate the outcomes of surgical reconstruction of complex annular endocarditis using standard techniques and materials, including autologous and bovine pericardium. From 1975 to 2000, 358 cases (357 patients, mean age 49 +/- 16 years, range 18-88 years) of native valve endocarditis were surgically managed. Bioprosthetic valves were implanted in 189 cases, and mechanical prostheses were implanted in 169 cases. A total of 78 cases of paravalvular destruction were identified: 62 annular abscesses, 8 fistulas, and 8 combined abscesses/fistulas. These were managed with 46 pericardial patches and 32 isolated suture reconstructions after radical debridement and prosthetic valve replacement. The overall early mortality was 8.4% (n = 30). The mortality with paravalvular destruction was 17.9%, and the mortality with simple leaflet infection was 5.7% (P = .001). The unadjusted survival at 20 years was 26.4% +/- 4.9% for bioprosthetic valves and 56.5% +/- 8.1% for mechanical prostheses (P = .007). The freedom from recurrent prosthetic valve endocarditis was 78.9% +/- 4.4% at 15 years. The freedom from reoperation for recurrent prosthetic valve endocarditis was 85.8% +/- 4.2% at 15 years. The freedom from reoperation after reconstruction for paravalvular destruction was 88.2% +/- 6.9% at 15 years. The freedom from mortality for recurrent prosthetic valve endocarditis was 92.7% +/- 3.4% at 15 years. The independent predictors of reoperation were age (hazard ratio 0.930, P = .005) and intravenous drug use/human immunodeficiency virus plus surgical technique (hazard ratio 12.8, P = .003 for patch reconstruction plus valve and hazard ratio 3.6, P = .038 for valve replacement only). Prosthesis type was not predictive when separated from intravenous drug use/human immunodeficiency virus (hazard ratio 3.268, P = .088). Paravalvular destruction is associated with a higher operative mortality. Native valve endocarditis can be managed with reasonable long-term survival and low rates of reinfection with radical debridement and pericardial reconstruction with bioprostheses and mechanical prostheses. The type of prosthesis implanted does not influence long-term outcome. Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

Risk Factors for Reoperation After Repair of Discrete Subaortic Stenosis in Children

This study aimed to identify independent predictors of reoperation after successful resection of discrete subaortic stenosis (DSS). Recurrence of DSS has been reported to range from 0% to 55% of patients. Factors associated with recurrence have not been adequately defined. Patients were included if they had a diagnosis of DSS, normal segmental cardiac anatomy, previous resection of DSS, and at least 36 months' follow-up. Demographic, surgical, and echocardiographic data were analyzed. Primary outcome was repeat resection of DSS in patients after successful primary resection. Of 111 subjects who had successful surgical resection of DSS, 16 patients (14%) required reoperation. Median follow-up time was 8.2 years. Form of DSS and gender did not differ significantly between those with reoperation and those without. In multivariate analysis, independent predictors of reoperation that would be available before first surgery were <6 mm distance between the aortic valve (AoV) and the obstruction (hazard ratio [HR] 5.1; p = 0.013) and peak gradient by Doppler > or =60 mm Hg (HR 4.2; p = 0.016). If intraoperative variables are also considered, peeling of the membrane from the AoV or mitral valve at first surgery, <6 mm distance between the DSS and AoV, and peak gradient by Doppler > or =60 mm Hg were independent predictors of reoperation. Proximity of the obstructive lesion to the AoV and severe obstruction determined by preoperative echocardiography, as well as involvement of valve leaflets requiring surgical peeling, predict recurrent DSS requiring reoperation.

A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse

We sought to compare the clinical and echocardiographic outcomes of mitral valve repair for mitral regurgitation in patients with degenerative disease of the mitral valve with posterior, anterior, or bileaflet prolapse. Patients underwent operations from 1981 through 2001: 359 had posterior (mean age, 60.4 years), 92 had anterior (mean age, 53.3 years), and 250 had bileaflet (means age, 56.4 years) prolapse. Patients with anterior prolapse were younger (P = .04) and had more associated aortic valve disease (P = .02), particularly bicuspid aortic valve disease (P < .001). Anterior prolapse was corrected by using chordal replacement with Gore-Tex sutures in most patients, but early on in this series, leaflet resection, chordal shortening, and chordal transfer were also used. Echocardiograms were done annually, and clinical follow-up was complete at a mean of 6.9 +/- 4.0 years (range, 0-23 years). The overall survival at 12 years was 75% +/- 5%, with no difference among the posterior, anterior, and bileaflet prolapse groups (P = .3). The freedom from reoperation at 12 years was 96% +/- 2% for posterior, 88% +/- 4% for anterior, and 94% +/- 2% for bileaflet prolapse (P = .019). Anterior prolapse was the only independent predictor of reoperation. The freedom from moderate or severe mitral regurgitation at 12 years was 80% +/- 4% for posterior, 65% +/- 8% for anterior, and 67% +/- 6% for bileaflet prolapse (P = .001). Anterior and bileaflet prolapse, age, ejection fraction of less than 40%, and aortic valve disease were independent predictors of recurrent moderate or severe mitral regurgitation. The pathophysiology of mitral regurgitation affects the durability of mitral valve repair for degenerative disease, and the results of posterior prolapse are better than those of anterior and bileaflet prolapse. This study indicates that rates of reoperation underscore the rates of failure of mitral valve repair.

Human tissue valves in aortic position: determinants of reoperation and valve regurgitation.

Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography. In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age <40 years was the only independent predictor of aortic regurgitation. Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults.

Mitral commissurotomy, a technique outdated? long-term follow-up over a period of 35 years

Background. The objective of this study was to evaluate long-term survival, valve-related complications as well as prognostic factors for early and late outcome after open and closed mitral commissurotomy covering a follow-up period of 35 years.Methods. From 1955 to 1977, 183 patients with mitral stenosis underwent mitral commissurotomy at our institution. Closed valvotomy was performed on 143 patients (group A) and open valvotomy on 40 patients (group B).Results. Survival rates after 10, 20, and 30 years were 89%, 67.8%, and 49.1% in group A and 91.7%, 66.7%, and 45.9% in group B (p = not significant). The risk of late death increased significantly with an advanced preoperative New York Heart Association functional class, atrial fibrillation, higher age at operation, pre- or postoperative mitral regurgitation, and leaflet calcification. Forty-four patients in group A and 5 patients in group B required reoperation (p < 0.05). Independent predictors for reoperation in a multivariate analysis were a remaining postoperative mitral stenosis or regurgitation. A total of 68 patients showed valve-related complications. The linearized rate of valve-related morbidity and mortality was 2.1% per patient-years in group A versus 1.1% per patient-years in B (p < 0.01).Conclusions. Long-term survival for open and closed commissurotomy are excellent, showing no difference between the groups. However, both the incidence of reoperation as well as valve-related morbidity and mortality were significantly lower after open commissurotomy. In well-selected patients with pure mitral stenosis and no leaflet calcification, open commissurotomy still remains a valid surgical option.