Late Cardiac Mortality Research Articles

Long-term prognosis after a first myocardial infarction in Turkey: determinants of mortality and reinfarction.

Long-term prognosis of a first myocardial infarction and factors associated with late cardiac mortality and reinfarction were studied in 718 survivors. Patients have been followed up for 1-10 years (mean 57.6 +/- 39.6 months). None of the patients underwent coronary bypass surgery in the follow-up period. Cumulative mortality rates were 8.6% in the first year, 17.9% in 3 years, 26.4% in 5 years and 36.5% in 10 years. The type and site of myocardial infarction (Q-wave versus non-Q-wave and anterior versus infero-posterior) were found to have no independent prognostic importance. The cardiac mortality was best predicted by the occurrence of congestive heart failure in the coronary care unit. Other determinants of late outcome were the presence of ventricular arrhythmias, left bundle branch block, and the occurrence of stable or unstable angina pectoris or reinfarction during the follow-up period. Usage of antiplatelet or anticoagulant drugs was not found to affect mortality. Reinfarction rates were 4, 9.9, 15.5 and 28% in 1, 3, 5 and 10 years, respectively, and no relation was found between the type and location of myocardial infarction and reinfarction rate. Reinfarction was higher in patients receiving anticoagulants and in patients with postmyocardial infarction angina. Our findings suggest that the prognosis of patients with a first acute myocardial infarction in Turkey is not different from that in Western populations and factors influencing prognosis are similar to those previously reported.

Late nonfatal and fatal cardiac events after infrainguinal bypass for femoropopliteal occlusive disease during a thirty-one-year period

Purpose and Methods: In patients with peripheral vascular disease the complications of associated coronary artery disease have always been a leading cause of morbidity and mortality. Therefore we evaluated the risk for late cardiac morbidity and mortality in 376 consecutive patients after infrainguinal bypass. Follow-up was complete for 373 patients (99.3%) with a mean follow-up period of 5.9 years. After operation all but four patients were treated with lifelong warfarin (Coumadin therapy.)Results: During follow-up 129 patients (34.3%) had 183 late cardiac events. Of these patients, 79 (61.2%) died of late cardiac events and 13 (10.0%) required either coronary angioplasty or bypass. The risk of late cardiac events was 34% at 5 years and increased to 56% at 15 years. Multivariate analysis demonstrated that age, cardiac disease, and impaired renal function at the time of operation were associated with an increased risk of cardiac events during follow-up. Independent predictors of cardiac death were age, cardiac disease, hypertension, diabetes, and impaired renal function. Morbidity and mortality was particularly high in patients with critical ischemia. The subset of patients with claudication had a life expectancy that appeared to be similar to that of a matched sample of the normal population.Conclusions: Our findings clearly demonstrate that some patients undergoing infrainguinal bypass are at high risk for late cardiac events of which many are fatal, whereas others may have an almost normal life expectancy. Most important, the occurrence of cardiac events may be predicted by simple and readily obtainable clinical variables at the time of the initial infrainguinal bypass procedure. Because these events were related to late cardiac death, this may be the key for angiographic evaluation and possible prevention of cardiac death.

Importance of a patent infarct-related artery for hospital and late survival after direct coronary angioplasty for acute myocardial infarction

The importance of a patent infarct-related artery (IRA) for hospital and late survival was examined in 383 patients with acute myocardial infarction treated with direct coronary angioplasty. At hospital discharge, 317 of 348 patients (91%) had a patent IRA and mean follow-up left ventricular (LV) ejection fraction (EF) was 58%. Cardiac survival after hospital discharge at 1, 3 and 6 years was 99,95 and 90%. Patency of the IRA was the most important determinant of hospital mortality: patent versus occluded IRA, 5 vs 39% mortality, p < 0.001. Follow-up LVEF was the most important determinant of late cardiac mortality: follow-up LVEF ≥45 versus <45%, 2 versus 24% mortality, p < 0.001. Patency of the IRA was not a significant predictor of late cardiac mortality in the group as a whole: patent versus occluded IRA, 4.7 versus 6.5% mortality, p = 0.67. In the subgroup of patients with depressed initial LVEF <45%, patency was a significant predictor of late cardiac mortality: patent versus occluded IRA, 9.2 versus 40% mortality, p = 0.03. Patients with a patent IRA had better recovery of LV function than patients with an occluded IRA (follow-up LVEF 58.5 versus 47.6%, p < 0.001). When late cardiac mortality was adjusted for differences in follow-up LVEF, patency was no longer a significant predictor of late mortality. Our results indicate patency of the IRA is the most important determinant of hospital survival, and LV function (measured after recovery) is the most important determinant of late cardiac survival. Patency of the IRA is important for preservation of LV function, but is not an independent determinant of late cardiac survival.

25-Year Mortality After Surgical Repair of Congenital Heart Defect in Childhood

To determine long-term survival and the cause of death after repair of one of eight congenital heart defects in childhood. Cohort study. General community. All Oregon residents with one of eight congenital heart defects, which was repaired surgically between 1958 and 1989 when the patient was aged 18 years or younger, including (1) tetralogy of Fallot; (2) isolated ventricular septal defect; (3) isolated atrial septal defect; (4) coarctation of the aorta; (5) aortic valvular stenosis; (6) pulmonary valvular stenosis; (7) transposition of the great arteries; and (8) patent ductus arteriosus. Follow-up of this cohort of 2701 individuals was obtained from 94%. Mortality from cardiac and noncardiac causes. Age at surgery and operative mortality have decreased significantly over the last 30 years. Late cardiac mortality at 25 years after surgery was 5% for tetralogy of Fallot and isolated ventricular septal defect, 10% for coarctation of the aorta, 17% for aortic stenosis, 5% for pulmonic stenosis, and less than 1% for patent ductus arteriosus; there were no late cardiac deaths after atrial septal defect repair. For transposition, late cardiac mortality was 15% at 15 years after the Mustard operation and was 2% at 10 years after the Senning operation. Surgical repair of most congenital heart defects is associated with lingering cardiac mortality, particularly for aortic stenosis, coarctation, and transposition.

Heart valve replacement with the Björk-Shiley and St Jude Medical prostheses: A randomized comparison in 178 patients

In 178 patients, a randomized prospective comparison between the 60 degrees spherical disc Björk-Shiley (BS) and the St Jude Medical (SJM) heart valve prostheses was performed. Four-week perioperative mortality was zero in the BS (n = 84) and 4.3% in the SJM group (n = 94). During a mean (+/- SD) follow-up of 52 +/- 20 months or 778 patient-years, late cardiac mortality per year was 2.4% in the BS and 2.2% in the SJM group. The yearly thromboembolic rates were 1.4% in the BS and 2.0% in the SJM group. There was no mechanical valve failure or haemolytic anaemia. Paravalvular leaks and major bleeding complications occurred at low rates in both groups (1.1% and 2.2% per year in BS; 0.7% and 1.7% per year in SJM). Functional results were similarly good with 96% of patients with BS valves and 95% of patients with SJM prostheses being in NYHA classes I and II, respectively. We conclude that heart valve replacement with mechanical prostheses can be performed with equally good results using either the Björk-Shiley spherical disc valve or the St Jude Medical bileaflet prosthesis.

Late results of aortic valvotomy for congenital valvar aortic stenosis

Fifty-one patients, aged 1 to 18 years, having aortic valvotomy for congenital valvar aortic stenosis between 1956 and 1986 were followed up. The average age at operation was 11.5 years, with an operative mortality of 3.9%. The aortic valve gradient decreased from a mean preoperative value of 91 mm Hg to 27 mm Hg postoperatively. Current follow-up was 90% and averaged 16.8 years. Late cardiac mortality was 17.6%, with actuarial survival of 93.7% at 10 and 15 years, 81.8% at 20 and 25 years, and 70.9% at 28 years. Nineteen patients required reoperation (39%) at a mean of 17.7 years postoperatively, with a reoperation-free survival of 98% at 10 years. The reoperation rate accelerated in the following decade to 3.3% per year. Ten patients without reoperation were evaluated by continuous-wave Doppler echocardiography. The mean gradient was 21.6 mm Hg, and 90% had mild to moderate aortic insufficiency. This study confirms the efficacy of valvotomy in this age group and suggests that long-term survival and time to reoperation may be longer than previously reported.

Reduction in sudden late death by concomitant revascularization with aortic valve replacement

To determine the impact of coronary atherosclerosis and myocardial revascularization on survival after aortic valve replacement, we reviewed our experience with single aortic valve replacement between 1969 and 1984. Of 474 patients (mean age 62 +/- 13 years), 185 (39%) had no associated coronary artery disease, 233 (49%) had coronary artery bypass grafting, and 56 (12%) had unbypassed coronary artery disease. Early (30-day) mortality rates were 2.2%, 8.2%, and 7.1%, respectively (p less than 0.01, coronary disease absent versus present). Actuarial survival rates at 10 years were 77% +/- 4%, 41% +/- 6%, and 26% +/- 11% (p less than 0.001, coronary disease absent versus present), with 1 to 177 months of follow-up (mean 56 +/- 40). Preoperative angina (39%) did not predict the presence of coronary artery disease (61%). Multivariate logistic regression analysis showed that early deaths were associated with advanced preoperative New York Heart Association functional class (p less than 0.001), advanced age (p less than 0.05), more extensive coronary artery disease (p less than 0.05), and lack of cardioplegic myocardial protection (p less than 0.05). Complete revascularization did not increase operative risk when coronary artery disease was present (early mortality 6.8%, p = not significant). Late deaths were strongly associated with the presence of coronary artery disease (p less than 0.001) and reduced left ventricular ejection fraction (less than or equal to 55%, p less than 0.01). Late cardiac mortality was most commonly attributable to sudden death (30/71, 42%), especially in the unbypassed coronary disease cohort (9/14, 64%). The actuarial rate of freedom from sudden death at 10 years was 52% +/- 17% in the unbypassed coronary artery disease group (p = 0.009), compared with 90% +/- 3% and 91% +/- 3% in the revascularized and no coronary disease patients, respectively. Thus, coexistent coronary atherosclerosis has a detrimental impact on early and late survival after aortic valve replacement. Revascularization does not increase operative risk when associated coronary artery disease is present and significantly reduces the occurrence of late sudden death. Strategies that minimize operative risk when associated coronary artery disease is present include use of cardioplegia and complete revascularization.

Early and late results of operation after thrombolytic therapy for acute myocardial infarction

Recent reports have established the efficacy of thrombolytic therapy in limiting myocardial infarction. Between September 1981 and September 1984, 355 patients were treated with intracoronary (87) or intravenous (268) streptokinase within 6 hours of acute myocardial infarction. Thrombolysis was successful in 63% of patients receiving intracoronary streptokinase and 81% of those receiving intravenous streptokinase. Because residual critical stenosis is usually present and predisposes the patient to reinfarction, revascularization procedures were investigated as an extension of thrombolytic therapy. One hundred ninety-one patients aged 56 +/- 10 (25 to 77) years underwent early surgical revascularization 4.1 +/- 3.6 days after intracoronary or intravenous streptokinase for acute myocardial infarction. Results of this treatment were successful in 89% (170/191) of the patients. Thirteen patients (6.8%) underwent emergency coronary artery bypass grafting for failed percutaneous angioplasty. There were 3.2 +/- 1.4 grafts per patient and 3.8 +/- 2.9 units of blood were administered in the perioperative period. Operative mortality was 4.2% (8/191) with a 15.4% mortality (2/13) in the group in which angioplasty failed. Mean hospitalization time after operation was 10.9 +/- 6.8 days. Follow-up was 27 +/- 8 (12 to 48) months and was obtained on all patients. Late cardiac mortality was 1.0% (2/183). Ninety percent of the follow-up group was without angina and only 1.7% showed no improvement after operation. Reinfarction occurred in four patients (2.2%), with graft failure documented by coronary arteriography in two of these patients. This experience indicates that early revascularization after thrombolytic therapy may be performed with low operative mortality and morbidity and is associated with excellent late results.

Extended Follow‐Up After Atrial Repair for Transposition of the Great Arteries: A Younger Age at Surgery Improves Late Survival

Abstract Background: Surgical treatment for transposition of the great arteries (TGA) usually involves anatomic repair, although atrial repair is used in cases with special coronary artery patterns. Methods: Records of all 239 patients surviving at least 30 days after atrial correction of TGA between 1962 and 1987 at the University Hospital in Zurich were reviewed. The mean length of follow‐up time was 13.7 years (median 14.9 years; range from 0.05 to 30.1 years). The average age at surgery was 45.7 months (range from 7 days to 24.4 years). One hundred twenty‐one patients had a simple TGA, whereas the remaining 118 had a complex TGA. Results:The surviving patients were in NYHAclassI at time of follow‐up. The most common reasons for death were systemic right ventricular dysfunction and sudden rhythm disturbances. There was a major risk for late cardiac event in patients over 3 years old at operation (p = 0.02) and also in patients with complex TGA (p = 0.03). However, date of surgery, previous surgery, or the postoperative requirement for a pacemaker did not greatly affect late cardiac mortality. Conclusions: Although the procedure of choice for TGA is the arterial switch operation, the promising findings of the current long‐term study, which reports the longest follow‐up to date, indicate that the atrial switch operation is a good alternative procedure for the rare cases where the use of arterial switch procedures is limited. (J Card Surg 1999;14:246–251)

Long-term experience with mitral valve replacement: An evolving strategy for prosthesis selection

MVR was examined in 181 patients undergoing 188 consecutive operations during a 12 1 2 - year observation time. Hospital mortality for MVR without aortic valve disease was 7 of 156 or 4.5% and was independent of the valve type employed and the presence of coronary artery pathology. Late cardiac mortality in isolated MVR was significantly greater in those patients receiving a Starr-Edward 6120 prosthesis when compared to those receiving an MPX. The presence of coronary artery pathology, however, defines the patient subgroup with the poorest late survival. Tissue durability has not significantly altered late survival after MPX. However, the actuarial analysis of tissue failure reveals important increases in tissue failure incidence 5 years after placement. Although MPX is our prosthesis of choice for MVR, limited tissue durability creates an important subgroup for judicious use of a mechanical prosthesis. We conclude that no valve type should be championed as “the valve” for all patients undergoing MVR. The selection of a valve for MVR remains a difficult judgment which must be tempered by the patients age, history of previous operations, severity of his present illness, and the feasibility of a second MVR.

Isolated coronary artery bypass grafting in patients seventy years of age and older: Early and late results

Increasing longevity makes the consideration of coronary bypass common in elderly patients. Seventy-five patients 70 years of age or older undergoing coronary artery bypass grafting (CABG) for angina pectoris were compared to a control group of 75 patients under 70 years of age. The groups were matched for male:female ratio (46:29), previous infarction (28/75), unstable angina (27/75), and the requirement for preoperative intra-aortic balloon pumping (7/75). Patients under 70 years of age had an average preoperative New York Heart Association (NYHA) class of 3.0 +/- 0.6 (SEM) and an average left ventricular end-diastolic pressure of 15.5 +/- 0.8 mm Hg, compared to 3.3 +/- 0.6 and 12.9 +/- 1.1 mm Hg, respectively, for the older group. Average grafts per patient were 2.7 +/- 0.8 in the younger group and 2.8 +/- 0.1 in the older group. Overall operative mortality for patients under 70 was 4% (3/75) versus 12% (9/75) (p = 0.06) for patients 70 and older. The incidence of chronic stable angina was 2% (1/48) versus 6% (3/48) (p = 0.30). Perioperative infarctions occurred in 7% of those under 70 and 5% of those 70 or older (p = 0.54). Those under 70 averaged 13.8 +/- 0.6 postoperative hospital days versus 18.4 +/- 1.2 hospital days for the older group (p less than 0.05). Follow-up ranged from 2 to 94 months, averaging 22 months for patients under 70 and 24 months for those 70 or older. Late cardiac mortality rates were 4% (3/70) in the younger patients and 3% (2/66) in the older patients (p = 0.53). Current NYHA class was 1.3 +/- 0.7 for those under 70, with 9% reporting angina, and 1.4 +/- 0.7 for those who were 70 or older, with 6% reporting angina. CABG can be performed with acceptable risk in older patients and leads to encouraging symptomatic improvement and late survival.

Elective aortic and mitral valve surgery in patients over 70 years of age.

The results of elective cardiac surgery carried out between 1970 and 1975 on 29 patients over 70 years of age are reported. Operative mortality was 10%, late cardiac mortality 14%, with 72% survival at a mean follow-up of 38.6 months. Before operation 96% were in functional classes 3 and 4. After operation 90.5% of late survivors were in functional classes 1 and 2 at a mean follow-up of 43.5 months. These results compare favourably with those in younger patients. Complication rate and length of hospital stay were unremarkable. The risks of neurological damage and of long-term anticoagulation are not increased. Emergency surgery carries a very high risk in this age group. The importance of biological youth and good left ventricular function is emphasised. For aortic stenosis at least prognosis is improved by surgery.

Aortic valve replacement in the elderly. Encouraging postoperative clinical and hemodynamic results.

Seventy-three patients aged 60 and over and 277 patients under 60 years of age underwent isolated aortic valve replacement (AVR) for aortic stenosis, regurgitation, and mixed disease from 1966 through 1975. Cardiac catheterization was performed five to nine months following operation in 77% of these patients. Follow-up averaged 55 months per patient. The hospital mortality in the elderly group was 2.7%, compared to 5.8% in the younger group. The late cardiac mortality was 21% and 19%, respectively. There was significant improvement (P less than .001) in the left ventricular end-diastolic pressure, cardiac index, and functional class in each of the three disease groups in the younger as well as the elderly patients. More important, the magnitude of improvement in each of these variables in patients over and under 60 years of age was not significantly different. Increasing longevity will make cardiac operations more common in the older population. These findings indicate that AVR carries the same low risk and brings about a similar improvement in left ventricular pump function in patients older and younger than 60.