Low-output Failure Research Articles

Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era.

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

Abstract 18794: Relationships Between Sex and Size and Morbidity and Mortality Among Patients Undergoing Cardiovascular Procedures

Background. Recent large studies reported improvements in outcomes of cardiovascular procedures over time but have not benefited women. Objective. To explore the role that smaller physical stature may play in explaining differential outcomes of these procedures among men and women. Methods. We used regional data (2003-17) to examine differences in in-hospital complications (bleeding, infection, stroke, low output failure, respiratory failure, RF), mortality and long-term survival among men and women of different body surface area (BSA) categories (<1.6, 1.6-1.7, 1.8-1.9, >=2) undergoing PCI (n=97,205), isolated CABG (27,128), or valve (17,414) while controlling for baseline age, comorbidity, disease severity, and year. Results. Smaller size was associated with worse outcomes among both men and women. In-hospital mortality rates were highest among the smallest men for CABG (5.1% versus 1.8% in largest men (OR=3.1; 95%CI=1.5-6.5; p=0.002)) and PCI (2.4% versus 1.1% (OR=2.5; 95%CI=1.4-4.3; p=0.002)) but not valve where smallest women had the highest mortality (9.3% versus 4.6% in the largest men (OR=2.3; 95%CI=1.7-3.2; p<0.001)). In-hospital complications were highest among smallest men for CABG (18% versus 13% (OR=1.5; 95%CI=0.9-2.3; p=0.100)) and valve (29% versus 26% (OR=1.2; 95%CI=0.7-2.1; p=0.502)) but highest among smallest women for PCI (5.9% versus 2.4% in the largest men (OR=2.7; 95%CI=2.3-3.1; p<0.001)). Long-term survival was worst among smallest men for CABG (HR=2.0; 95% CI=1.5-2.7; p<0.001) and PCI (HR=1.9; 95% CI=1.7-2.2; p<0.0001). Bleeding complications were significantly higher in smaller men (3.4% versus 1.6% (OR=2.2; 95%CI=1.4-3.6; p=0.001)) and women (4.8% versus 1.6% (OR=3.2; 95%CI=2.8-3.8; p<0.001)) undergoing PCI. Conclusions. Peri-operative devices and/or processes of care better tailored to the size of the patient might help to improve outcomes of cardiovascular procedures among women as well as smaller men.

The little ones are catching up-mechanical circulatory support with a pulsatile pneumatic ventricular assist device.

It has been a little over 3 decades since the first child, 8 years old, was bridged to heart transplantation with an adult-sized Berlin Heart EXCOR ventricular assist device (VAD) (Berlin Heart AG, Berlin, Germany) with a ventricle of 50 ml of stroke volume. This 27-kg bodyweight boy suffered from terminal heart failure and life-threatening ventricular tachycardia, the sequelae of a congenital heart defect. With the EXCOR, cardiogenic shock could be reversed and after no more than an 8-day waiting period on the pump, orthotopic heart transplantation was successful [1]. During the following year, this pump underwent miniaturization with 25/30-ml pumps fitting children above 15 kg bodyweight. This was the kick-off for multiple support in children, first reported in those with fulminant myocarditis: in the mid-1990s, the outcome of fulminant myocarditis with cardiogenic shock was poor. With the artificial replacement of heart function in 4 previously healthy children suffering from myocarditis with low cardiac output and multiorgan failure, the temporary support with biventricular assist devices (BVAD) was lifesaving for all 4 [2]. We learned during those years that prolonged VAD support was an effective method not only in adults but also in children.

Lymphedema in Hydrocephalus: A Case Study

Background: Lymphedema is a combination of pathologic condition characterized by excessive local accumulation of interstitial fluid which is rich in proteins [1-3]. It may be an isolated phenomenon or associated with a multitude of other disabling local sequelae or even life-threatening systemic syndromes. In its purest form, the central disturbance is a low output failure of the lymphvascular system, that is, overall lymphatic transport is reduced. Lymphedema can be either primary or secondary [4]. Hydrocephalus is a build-up of fluid in the brain. The excess fluid puts pressure on the brain, which can damage it. Congenital hydrocephalus is when a baby is born with excess fluid in their brain which will cause permanent brain damage such as: speech problems and vision problems [5] Study Design: The case study was used to highlight the role of physical therapy interventions in the management of primary lower extremity lymphedema in patient with congenital hydrocephalus patient. Case Description: 37 years-old Saudi female, case of congenital hydrocephalus, deaf, mute, blind with shunting. Patient with severe bilateral lower limb primary lymphedema, which altered her level of function. Referred to physical therapy department by vascular clinic. PT Management and Outcome: The patient received daily sessions of complete decongestive therapy (CDT) for two weeks included: multi-layer bandaging (compression therapy), manual lymphatic drainage, skin / nail care education and decongestive exercises. At the end of second week, the patient’s circumference measurements improved significantly, and her level of independency improved. Discussion: The case study showed that the physical therapy interventions are safe, effective, in reducing lymphedema and overall quality of life (QOL) with hydrocephalus patients.

Interdependence of VA-ECMO output, pulmonary congestion and outcome after cardiac surgery

BackgroundVenoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method for patients with low-output failure after cardiac surgery. However, VA-ECMO therapy may increase left ventricular afterload due to retrograde blood flow in the aorta, which may lead to progression of pulmonary congestion. We examined the predictive value of pulmonary congestion in patients that need VA-ECMO support after cardiovascular surgery. MethodsWe enrolled a total of 266 adult patients undergoing VA-ECMO support following cardiovascular surgery at a university-affiliated tertiary care centre into our single-center registry. Pulmonary edema was assessed on bedside chest X rays at day 0, 3, 5 after VA-ECMO implantation. ResultsMedian age was 65 (57–72) years, 69% of patients were male and 30-day survival was 63%. At ICU-admission 20% of patients had mild, 54% had moderate and 26% showed severe pulmonary congestion. Pulmonary congestion at day 0 was not associated with outcome (adjusted HR 1.31; 95%-CI 0.89–1.93;P = 0.18), whereas pulmonary congestion at day 3 (adj. HR 2.81; 95%-CI 1.76–4.46;P<0.001) and day 5 (adj. HR 3.01;95%-CI 1.84–4.93;P<0.001) was significantly associated with survival. Linear regression revealed that out of left ventricular function, cardiac output, central venous saturation, maximum dobutamine and norepinephrine dose as well as fluid balance solely ECMO rotation was associated with the evolution of pulmonary congestion (P = 0.007). ConclusionsPulmonary edema three and five days after ECMO implantation are associated with poor survival. Interestingly, a high VA-ECMO output was the most important determinant of worsening pulmonary congestion within the first five days.

Underweight is associated with inferior short and long-term outcomes after MitraClip implantation: Results from the German TRAnscatheter mitral valve interventions (TRAMI) registry

Underweight and obesity represent classical risk factors for adverse outcome in patients treated for cardiovascular disease. The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy. From August 2010 until July 2013, 799 patients (age 75.3 ± 8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicenter German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into 4 groups: BMI <20 kg/m2 (underweight), BMI 20.0 to <25.0 kg/m2 (normal weight, reference group), BMI 25.0 to <30.0 kg/m2 (overweight) and BMI ≥30 kg/m2 (obese). Significant increased rates of procedural failure, transfusion/bleeding, sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, P < .01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine ≥1.5 mg/dL, diabetes, left ventricular ejection fraction <30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95% confidence interval (CI): 1.01-2.46, P = .044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55-0.93; P = .011). Compared to other weight groups, underweight patients undergoing MitraClip implantation are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates and should therefore be carefully discussed in the heart-team.

Early- and mid-term results of cryoablation of atrial fibrillation concomitant with robotic mitral valve surgery.

Atrial fibrillation (AF) is the most common arrhythmia, which is also associated with mitral valve disease. Surgical ablation is still known to be an important procedure in restoring sinus rhythm (SR) concomitant with mitral valve surgery (MVS). In this study, we aimed to pres-ent our early- and mid-term result of AF cryoablation during robotic MVS. Between November 2014 and January 2020, total 34 patients who underwent robotic MVS with concomitant AF ablation were ret-rospectively analyzed. Ten patients had a <1 year AF history, 14 had 1-5 years, and 10 had >5 years. The primary end point of the study was postoperative AF recurrence. Total 32 and 2 patients underwent mitral valve replacement and mitral valve repair, respectively. Mean aortic cross-clamp and cardio-pulmonary bypass times were 141.8±32.1 min and 196±25.6 min, respectively. The SR was restored with the removal of cross-clamp and cardiac junctional rhythm was observed in 29 (85.3%) and 5 (14.7%) patients, respectively. Two in-hospital deaths secondary to low cardiac output and hepatorenal failure were recorded. Among the rest, 24 (75%) patients were in SR, 6 (18.75%) in AF, and 2 (6.25%) in paced rhythm at discharge. Robotic cryoablation of AF during MVS is a feasible method with favorable early- and mid-term results.

The 30-Year Influence of a Regional Consortium on Quality Improvement in Cardiac Surgery

The Northern New England Cardiovascular Disease Study Group (NNECDSG) was founded in 1987 as a regional consortium to improve cardiovascular quality in Maine, New Hampshire, and Vermont. We sought to assess the longitudinal impact of the NNECDSG on quality and cost of coronary artery bypass grafting (CABG) during the past 30 years. Patients undergoing isolated CABG at 5 medical centers from 1987-2017 were retrospectively reviewed (n= 67,942). They were divided into 4 time periods: 1987-1999 (n= 36,885), 2000-2005 (n= 14,606), 2006-2011(n= 8470), and 2012-2017 (n= 7981). The first period was the time the NNECDSG initiated a series of quality improvement initiatives including data feedback, quality improvement training, process mapping, and site visits. Throughout the 4 time intervals, there was a consistent decline in in-hospital mortality, from 3.4% to 1.8% despite an increase in predicted risk of mortality (P < .001), and a significant decline in in-hospital morbidity, including return to the operating room for bleeding, acute kidney injury, mediastinitis, and low output failure (P < .001). Median length of stay decreased from 7 to 5 days (P < .001), which translated into potential savings of $82,722,023. There was a decrease in use of red blood cells from 3.1 units to 2.6 units per patient in the most current time, which translated into potential savings of $1,985,456. By using collaborative quality improvement initiatives, the NNECDSG has succeeded in significant, sustained improvements in quality and cost for CABG during the past 30 years. These data support the utility of a regional consortium in improving quality.

P4730Underweight is associated with unfavourable short- and long-term outcomes after MitraClip therapy: a body mass index derived subgroup analysis of the German Transcatheter Mitral Valve Interventions (

Abstract Background Underweight and obesity represent classical risk factors for patients undergoing cardiac surgery or interventional treatment. The multicentre German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises a large and prospectively enrolled real-world cohort of patients treated by MitraClip implantation. Aims The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy. Methods and results From 08/2010 until 07/2013, 799 patients (age 75.3±8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicentre, industry-independent German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into four groups: BMI&lt;20 kg/m2 (underweight, n=49), BMI 20.0 to &lt;25.0 kg/m2 (normal weight, n=293), BMI 25.0 to &lt;30.0 kg/m2 (overweight, n=296) and BMI≥30 kg/m2 (obese, n=132). Procedure and radiation time were comparable among all groups. Significant increased rates of procedural failure (12.2% vs. 2.1 [normal weight], p&lt;0.001), transfusion/bleeding (20.8% vs. normal weight: 5.6%, obesity: 7.0%, p&lt;0.01), sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, p&lt;0.01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine≥1.5mg/dl, diabetes, left ventricular ejection fraction&lt;30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95%-confidence interval (CI): 1.01–2.46, p=0.044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55–0.93; p=0.011). Conclusion Underweight patients are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates when undergoing MitraClip implantation and should therefore be carefully discussed within the heart team. Acknowledgement/Funding The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott.

Postoperative heart failure after stage 1 palliative surgery for single ventricle cardiac disease.

Outcomes for patients with single ventricle congenital heart disease (SV-CHD) continue to improve over time. However, the prognosis for patients who develop heart failure immediately after surgery is poorly understood. We conducted a single-center, retrospective cohort study of patients with SV-CHD, who suffered postoperative heart failure. Of 1038 cardiac surgeries performed on 621 SV-CHD patients between 2004 and 2010, 125 patients met inclusion criteria, including non-septatable anatomy, stage 1 surgery, and verified low cardiac output or heart failure state per STS definition. Overall survival was 73.2% at 2months, 64.9% at 1year, 60.5% at 2years, and 54.6% at 4years. Inotrope dependence beyond 7days post-op yielded 45% 2-year survival versus 68% for those who weaned from inotropes within 7days (p = 0.02). Atrioventricular valve regurgitation (AVVR) influenced survival, and patients who developed renal failure or required ECMO fared poorly, even when they survived their hospitalization. Patients with postoperative heart failure and low cardiac output syndrome constitute a high-risk population beyond the term of the initial hospitalization and have an overall mid-term survival of 55% at 4years. Wean from inotropic therapy is not completely reassuring in this population, as they have ongoing elevated risk of cardiac failure and death in the medium term. Ventricular dysfunction, AVVR, renal failure, and need for ECMO are all important prognostic factors for mid-term mortality. Inotrope dependence for > 7days has important implications reaching beyond the hospitalization.

The influence of less invasive ventricular assist device implantation on renal function.

End-stage heart failure is associated with severe after-effects such as heart valve insufficiency, cardiac arrhythmias or end-organ dysfunctions. Renal failure or 'cardiorenal syndrome' is a critical end-organ disorder associated with advanced heart failure, which occurs due to low-output failure. Drug therapy or surgical interventions involving left ventricular assist device (LVAD) implantation may impede the progress of heart insufficiency and its after-effects including renal failure. In this study, we investigated the impact of a minimally invasive ventricular assist device implantation through upper hemisternotomy combined with anterolateral thoracotomy on renal function, in patients with perioperative renal failure. We analyzed data obtained from 103 patients (80 males, 23 females; mean age 53.8±11.7) who underwent LVAD implantation at our clinic within a 15-year interval (2001-2016) and were dialyzed due to renal dysfunction. 90 patients were operated with the conventional LVAD implantation technique (standard approach surgery, SAS) and 13 underwent less invasive approach implantation (less invasive surgery, LIS). For all patients, data analysis showed significant increase of glomerular filtration rate (GFR) (44.2±56.48 mL/min; 95% CI: 33.81-55.28; P<0.001) along with a significant decrease in the levels of creatinine (-1.08±1.83 mg/dL; 95% CI: 0.75-1.46; P<0.001) and urea (-4.62±13.66 mmol/L; 95% CI: 1.95-7.29; P<0.001). There was a considerable difference in change of renal parameters in patients treated with LIS in comparison to patients who underwent SAS, which was however not statistically significant (GFR: P=0.494; creatinine: P=0.543; urea P=0.918). LVAD implantation improves kidney function in patients with renal dysfunction. A considerable difference in the change of renal parameters was detected in patients with LIS as compared to SAS, which was not significant possibly due to the limited size of the patient cohort (n=13).

Cardiac Output and Renal Function: An Association

In this article, we discussed a clinical problem known as cardio renal syndrome (CRS). In CRS, both, the affected cardiovascular system, either low output or high output failure leads to the renal dysfunction or vice versa. As already known, the heart failure is the leading cause of readmission in the US and worldwide. The patients suffering with cardiac failure need extra care, as they may develop various complications. Cardiac output is affected in heart failure and does have an impact on the renal function. High cardiac output and low cardiac output, both can lead to renal dysfunction. In conclusion, we will also highlight some information about the prevention of the renal damage associated with the CVS. However, future research is recommended to understand more about the exact pathophysiology involved in this association.

Differentiation of High and Low Output Lymphatic Failure Using Qualitative Lymphangioscintigraphy.

To use qualitative lymphangioscintigraphy (LAS) findings to differentiate leg edema caused by high and low output lymphatic failure. LAS was performed in legs with secondary lymphedema (LE), i.e., low output failure (N = 79), and functional venous insufficiency (FVI), i.e., high output failure (N = 56), and normal legs (N = 26). Whole body images were obtained, 15, 60, and 180 min after technetium-99m injection. The rate and timing of visualization of lymphatic structures, washout out of tracer, and presence of dermal backflow were assessed. The most significant finding for differentiating LE from other conditions was not the visualization of lymphatic structures, but the washout of the tracer from the leg trunk (LE 27%, FVI 100%, normal leg 100%, P <.0001). On the other hand, the most significant finding for differentiating FVI from other legs was the visualization of inguinal lymph nodes at 15 min (LE 11%, FVI 82%, normal leg 8%, P <.0001). We found that the lack of washout from the leg trunk was most suggestive of a low output status of the lymphatic system, while earlier visualization of inguinal lymph nodes was suggestive of a high output status.

237-I * IMMEDIATE AND MID-TERM OUTCOMES OF CARDIAC SURGICAL PATIENTS AFTER POSTOPERATIVE CARDIOPULMONARY RESUSCITATION

Objectives: Data reporting outcomes of patients needing cardiopulmonary resuscitation (CPR) after cardiac surgery during their primary hospital stay are scarce. The present study evaluated (1) reasons for CPR, (2) immediate and (3) further outcomes after CPR. Methods: In 2007 and 2008, a total of 4021 patients underwent any cardiac surgery. Out of these, 129 patients (3.2%) needed CPR during their primary hospital stay. Further hospital and post-hospital outcome was retrospectively analysed. The patients were predominantly male (61.5%), with average age 70.9 ± 9.9 years. Mean follow-up was 56.0 ± 149.2 days, ranging up to 878 days. Results: Surgery consisted of isolated aortic valve replacement (35.2%), isolated coronary artery bypass graft (CABG) (31.3%) and AV-valve surgery (30.0%). Further procedures were combined aortic valve replacement (AVR)/CABG (2.5%) and ventricular sept defect (VSD)-closure (1.3%). CPR took place after a median of 3.5 days after surgery with a mean duration of 21.1 ± 19.3 min. Neuroprotective hypothermia (32°C for 24 h) was established in 22.2% of the patients. Reasons for CPR were rhythm-disturbances (67.1%), low cardiac output (27.5%) and respiratory failure (5.4%). CPR was primary successful in 69.5%, but subsequently a further 58.9% died, equalling an overall mortality of 71.3%. Morbidity after CPR consisted of neurologic deficit (12.2%), airway infection (28.1%), impaired wound healing (13.3%) and renal failure (41.8%). Mean ventilation time after CPR was 68.8 ± 192.4 h, ICU-stay averaged 2.5 ± 7.2 days. Conclusion: Despite immediate results after CPR being characterised by a high initial success rate, consecutive secondary morbidity subsequently causes discouragingly high mortality during further follow-up. Additionally, significant demands on hospital resources are made. The only effective strategy is prevention of CPR. Most observed reasons could be influenced positively by simple prevention strategies.

Evaluation and Management of ST-elevation Myocardial Infarction and Shock.

Cardiogenic shock is the deadliest complication of acute ST-elevation myocardial infarction. Prompt recognition and intervention are critical for patient survival. The diagnosis of cardiogenic shock is primarily a clinical one based on signs and symptoms of low cardiac output and heart failure, and can be confirmed with placement of a pulmonary arterial catheter. Vasopressor and inotropic therapies are typically required, and in severe cases, an intra-aortic balloon pump can provide additional haemodynamic support. Although mortality for cardiogenic shock associated with ST-elevation myocardial infarction remains high, early reperfusion strategies primarily via percutaneous coronary intervention or coronary artery bypass graft surgery have led to improved outcomes.

Double valve replacement and reconstruction of the intervalvular fibrous body in patients with active infective endocarditis

Destruction of the intervalvular fibrous body, though uncommon, occurs due to paravalvular abscess formation following active infective endocarditis. This warrants a highly complex operation involving radical surgical debridement of the intervalvular fibrous body, followed by double valve (aortic and mitral) replacement with patch reconstruction of the anterior mitral annulus, the left ventricular outflow tract and the left atrial roof. The objective of this study was to review the early and mid-term outcomes in patients undergoing this operation. A total of 25 patients underwent double valve replacement with reconstruction of the intervalvular fibrous body for extensive infective endocarditis between January 1999 and March 2012. The mean age was 64.3 ± 10.5 years. Most of the patients (60%) were in New York Heart Association Class III-IV, 12% and in cardiogenic shock. Associated comorbidities like acute renal insufficiency and cerebrovascular accidents were observed in 40 and 20% of patients, respectively. Twenty patients had previous heart valve surgeries. The logistic EuroSCORE predicted risk of mortality was 55.1 ± 22.9%. Overall, 30-day mortality was 32%. Postoperative complications like low cardiac output, stroke and acute renal failure developed in 16, 28 and 56%, respectively. Thirty-two percent of patients required re-exploration for bleeding. Nine patients were alive at a mean follow-up of 406 days (0-8 years). The 2- and 5-year survivals were 37.0 ± 11.1 and 24.6 ± 12.5%, respectively. Double valve replacement with reconstruction of the intervalvular fibrous body for infective endocarditis is a complex, technically challenging operation associated with high perioperative morbidity and mortality. Nevertheless, being the only option available for such complex disease, it should be performed in these patients who, otherwise, face 100% mortality.

Circulation: Cardiovascular Quality and Outcomes Editors’ Picks

<i>Circulation: Cardiovascular Quality and Outcomes</i> Editors’ Picks

Baseline systolic left ventricular function determines hemodynamic adaptation following percutaneous mitral valve repair

MitraClip therapy constitutes a novel therapeutic approach that demonstrated to be beneficial in patients with severe left ventricular dysfunction [1–3]. Elimination of mitral regurgitation in these patients has been the subject of much debate as it has been suggested to be associated with the risk of low output failure according to the “pop-off valve” theory [4]. Although put to question in recent years [4] it has not been formally investigated to date. We herein report left ventricular pressure–volume relationship analyses derived by conductance catheter (CD Leycom CA-71103-PL connected to a CD Leycom Inca® IntraCardiac Analyzer) from 13 patients (age: 73±9y, 5 females) undergoing percutaneous mitral valve repair with the MitraClip system.

Registry Studies for Improving the Quality of Cardiovascular Care

In this issue of Circulation: Cardiovascular Quality and Outcomes, 2 seemingly unrelated articles appear that utilize clinical registry data: Curtis et al1 utilize the American College of Cardiology’s CathPCI Registry to calculate hospital-specific 30-day risk standardized mortality rates following percutaneous coronary intervention whereas Likosky and colleagues2 exploit the Northern New England Cardiovascular Disease Study Group’s cardiac surgery registry to identify factors associated with patient-specific low output failure after coronary bypass grafting surgery. The former is concerned with estimating between-hospital variation in patient outcomes and the latter aims to quantify between-surgeon and between-patient variations in patient outcomes. Although the questions are similar, the authors have focused on different statistical summary measures. Curtis and colleagues use > 100 000 admissions to assess quality of hospital care across 602 hospitals and estimate hospital-specific performance measures using hierarchical (or random effects) logistic regression models. Likosky and colleagues study …

Variability in Surgeons’ Perioperative Practices May Influence the Incidence of Low-Output Failure After Coronary Artery Bypass Grafting Surgery

Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF. We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80-766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury. Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.