Preoperative NYHA Functional Class Research Articles

Demora en el tratamiento quirúrgico de la insuficiencia tricuspídea grave y resultados en pacientes con valvulopatía izquierda

Introduction and objectivesThe influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. MethodsWe conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. ResultsA total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. ConclusionsThe variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

Delay of surgical treatment of severe tricuspid regurgitation and outcomes in patients with left-sided heart valve disease

Introduction and objectivesThe influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. MethodsWe conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. ResultsA total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. ConclusionsThe variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

Predictors of postoperative complication and prolonged intensive care unit stay after complete pericardiectomy in tuberculous constrictive pericarditis

BackgroundThe risk factors of postoperative outcomes after pericardiectomy in tuberculous constrictive pericarditis have still been unclear. This study aimed to investigate the predictors of postoperative complication and prolonged intensive care unit (ICU) stay in the patients with tuberculous constrictive pericarditis undergoing pericardiectomy.MethodsA total of 88 patients with tuberculous constrictive pericarditis undergoing pericardiectomy were retrospectively enrolled. Logistic regression and Cox regression analysis were performed to identify the predictors of postoperative complication and prolonged ICU stay, respectively.ResultsAll patients underwent complete pericardiectomy and 35 (39.8%) had postoperative complication with no mortality within 30 days after surgery and no in-hospital deaths. Postoperative complication prolonged postoperative ICU stay (P < 0.001), duration of chest drainage (P < 0.001) and postoperative hospital stay (P < 0.001). Preoperative NYHA functional class (P = 0.004, OR 4.051, 95%CI 1.558–10.533) and preoperative central venous pressure (CVP) (P = 0.031, OR 1.151, 95%CI 1.013–1.309) were independent risk factors of postoperative complication. Postoperative complication (P < 0.001, HR 4.132, 95%CI 2.217–7.692) was the independent risk factor for prolonged ICU stay.ConclusionComplete pericardiectomy was associated with high risk of postoperative complication in tuberculous constrictive pericarditis. Poor preoperative NYHA functional class and high preoperative CVP were shown to predict postoperative complication which was the predictor of prolonged ICU stay.

INDIRECT CORONARY REIMPLANTATION IS ASSOCIATED WITH INCREASED OPERATIVE RISK IN PATIENTS UNDERGOING A BENTALL PROCEDURE AFTER PREVIOUS CARDIAC SURGERY

We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. From 1990 to 2014, 473 patients underwent a redo Bentall procedure with a composite valve graft (CVG) at a single institution (CVG with a mechanical prosthesis, n = 256; CVG with a bioprosthesis, n = 217). The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality (MMOM): stroke, renal failure, prolonged mechanical ventilation, deep sternal infection or reoperation during the same admission. Median age was 57 (IQR: 44 – 67) years and 349 (74%) patients were male. Median time between index surgery and reoperation was 13 (IQR: 8-21) years. One hundred seventy-eight (38%) patients underwent urgent or emergent intervention, 61 (13%) had active endocarditis, 87 (19%) had an LVEF < 40%, and 262 (55%) patients had undergone more than one previous operation. Previous surgery included CABG (n=58, 12%), aortic valve/root repair (n=36, 8%) or replacement (n=376, 80%), and other surgical interventions (n=245, 52%). Ninety-five (20%) patients had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 80 patients, a Ross operation in 8, a valve-sparing root replacement in 4, and an arterial switch in 3. At the time of the reoperative Bentall, both coronaries were reimplanted directly in 352 (74%) patients, whereas 72 (15%) patients received at least one interposition graft (saphenous vein in 42, and synthetic in 30). In 32 (7%) patients, at least one of the native coronary arteries was oversewn and a vein graft bypass performed. Thirty-day mortality occurred in 37 patients (7.8%) and 152 (32%) patients suffered MMOM. On multivariable analysis, risk factors associated with increased 30-day mortality included older age (OR per 5-year age increment [95% CI]: 1.20 [1.04-1.38], p = 0.01) and coronary reimplantation by a technique other than direct anastomosis (OR 3.71 [1.76-7.87], p < 0.001). Indirect coronary reimplantation was also associated with a higher incidence of MMOM (OR 1.71 [1.05-2.77], p=0.03), as were older age (OR per 5-year age increment: 1.08 [1.01-1.17], p = 0.03), preoperative NYHA functional class IV (OR 3.44 [1.55-7.62], p=0.002), and more than one previous cardiac operation (OR 1.75 [1.11-2.76], p=0.02). In the largest reported cohort of aortic root replacement after previous cardiac surgery, reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important predictor of adverse perioperative events.

A retrospective audit of mitral valve repair surgery at Tygerberg Hospital

Background: Mitral valve repair is well established as the preferred treatment modality for the majority of patients with degenerative mitral valve disease requiring intervention. Valve repair offers a distinct event-free survival advantage compared with replacement with either a bioprosthetic or mechanical valve. At present, there are little data available on the management and outcome of mitral valve repair in South Africa. The aim of this study is to describe and compare the indications, specific pathology and outcomes of patients accepted for mitral valve repair. Internationally published figures for peri-operative mortality are less than 2% for degenerative mitral regurgitation, with a freedom from mitral valve reoperation of 94% at 10 years. Methods: All patients referred for mitral valve repair at Tygerberg Hospital, Cape Town, South Africa, between 1 December 2010 and 30 June 2015, were retrospectively included. Demographic characteristics, cardiovascular risk factors, pre-operative (NYHA) functional class, the pre- and post-operative transthoracic and transoesophageal echocardiograms, immediate in hospital mortality and 6-month post-surgical mortality and functional class were analysed. Repair failure was defined as either intra-operative conversion to MVR or need for reoperation at 6 months. Results: A total of 147 patients were referred for mitral valve repair, of which 114 patients were accepted for mitral valve repair by the local heart team. In total, 106 of the 114 patients underwent surgical intervention, 6 defaulted their surgical dates, and 2 refused surgery. Of those accepted for surgery, 57.9% were males, 42.1% were females, with a mean age of 47.7 years in both groups combined, 44.7% had hypertension, 43.9% were smokers and 21.1% had concomitant IHD; 56.1% were pre-operative NYHA functional class III, 29.8% were class II, 7% class IV, and 7% were class I; 60.2% had a 6-month post-operative NYHA functional class I, 32.3% had class II, 5.4% class III, and 2.2% had class IV. Mitral valve prolapse (MVP) with flail segment due to chord rupture was the predominant etiology (29%); P2 was the most common segment involved (36%), followed by A2 (29.8%). For MVP, including patients with infective endocarditis, the mortality rate was 4.8% at 30 days and 6 months. The overall mortality rates for all patients accepted for mitral valve repair were 4.7% and 6.6% at 30 days and 6 months respectively. Freedom from reoperation was 98% at 6 months. There was a significant association between bileaflet involvement and mitral valve repair failure (p=0.006). Chordal insertion with annuloplasty was the most common intervention used (45.5%). Conclusion: Mitral valve prolapse was the predominant etiology in patients referred for mitral valve repair. The mortality rate for mitral valve repair in the prolapse group was 4.8% at 6 months. Chordal insertion with annuloplasty was the most common intervention used. Bileaflet involvement was found to be an independent risk factor for repair failure. The mortality rate for all patients accepted for mitral valve repair was 6.6% at 6 months.

Abstract 13085: Isolated Tricuspid Valve Surgery: Failure of Its Principle? Long-Term Outcome Analysis

Introduction: Isolated tricuspid valve (TV) surgery for acquired TV disease is high-risk surgery and the decision to operate is still controversial. We describe a single-centre experience with isolated TV surgery and our long-term analysis for adverse outcome. Methods: A retrospective analysis of 62 consecutive patients who underwent isolated TV surgery for acquired TV disease between 2002 and 2014 has been performed. Associated cardiac procedures and congenital TV disease were exclusion criteria. The Kaplan-Meier, Univariate and Cox regression analysis were respectively used to evaluate mortality and identify risk factors at long-term follow-up. The Duke Activity Status Index (DASI) questionnaire, to measure the functional status related to daily living, has been used to assess the survivors’ quality of life. Results: Mean patient age was 60.2±18.9 years, 38% were male and the average log EuroSCORE was 16.8%±15.9%. TV repair was performed in 38 cases (61%), replacement in the remainder and 38% were reoperations. 30-day mortality was 15% (n=9) , similar for repair and replacement. Follow-up (median=35.7 months, range=0.1-150) was 100% complete. Survival at 1, 5 and 10 years was 79.5%±5%, 69.8%±6% and 53.5%±9.7% respectively. Sinus rhythm, NYHA class &lt; III, age &lt; 60 years were identified as independent predictors of survival at long-term follow-up. Furthermore, we found that survivors with a lower pre-operative NYHA functional class were also those with the best quality of life at follow-up (DASI score 20.5 ± 8.6 vs 12.7 ± 7, p=0.028). Conclusions: Patients who undergo isolated TV surgery continue to be a high-risk group in with high early and late mortality. There is no difference in mortality between TV repair and replacement at long-term follow-up. Our experience suggests that a shift towards earlier surgery may be proven to confer an advantage, as surgery before the onset of NYHA class 3 symptoms is associated with improved outcome and better quality of life.

Outcome and determinants of prognosis in patients undergoing isolated tricuspid valve surgery: Retrospective single center analysis

AimsAlthough tricuspid valve (TV) surgery has become more popular, isolated TV surgery is infrequently performed. The aims of this study were (1) to evaluate the postoperative and long-term mortality of patients undergoing isolated TV surgery, (2) to compare the outcomes of patients undergoing their first TV surgery or TV reoperation, and (3) to assess the additive value of echocardiographic and invasive hemodynamic evaluations for predicting postoperative outcome. MethodsWe followed a contemporary cohort of patients undergoing isolated TV surgery from January 1, 1995, through December 31, 2011. Preoperative demographic, echocardiographic, hemodynamic, and operative data were included. Outcome was all-cause mortality. ResultsNinety-two patients (38% male; mean age: 56±14years) were included. Kaplan-Meier survival analyses showed that 30-day, 3-month, 5-year, and 10-year mortality were 7.9%, 15.2%, 25.7%, and 53.7%, respectively. No difference in outcome was found between patients undergoing first TV surgery (n=61) and TV reoperation (n=31) (p=0.669). Univariable Cox analysis identified age (p<0.0001), extracardiac vascular disease (p=0.001), glomerular filtration rate (p=0.022), NYHA classification (p=0.010), and mean pulmonary artery pressure (p=0.005) as predictors of mortality. Multivariable analysis identified significant associations with outcome, only for age (p=0.010) and NYHA functional class (p=0.044). In younger patients (<59years), mean pulmonary artery pressure was associated with the worse outcome (p=0.024). ConclusionsIsolated TV surgery is still associated with important postoperative and long-term mortality, both for first TV surgery and TV reoperation. Pre-operative NYHA functional class and, in younger patients, pulmonary hypertension appear to determine prognosis.

Outcome and determinants of prognosis in patients undergoing isolated tricuspid valve surgery

Background: Although tricuspid valve (TV) surgery has become more popular, isolated TV surgery is infrequently performed. The aims of this study were (1) to evaluate the postoperative and long-term mortality of patients undergoing isolated TV surgery, (2) to compare the outcomes of patients undergoing their first TV surgery or TV reoperation, and (3) to assess the additive value of echocardiographic and invasive hemodynamic evaluations for predicting postoperative outcome. Methods and results: We followed a contemporary cohort of patients undergoing isolated TV surgery from January 1, 1995, through December 31, 2011. Preoperative demographic, echocardiographic, hemodynamic, and operative data were included. Outcome was all-cause mortality. We compared the outcomes of patients undergoing their first TV surgery (n=61) with those undergoing TV reoperation (n=31). Ninety-two patients (38% male; mean age: 56±14 years) were included. Kaplan-Meier survival analyses showed that 30-day, 3-month, 5-year, and 10-year mortality were 7.9%, 15.2%, 25.7%, and 53.7%, respectively. Mortality of the two groups of patients did not differ (log-rank test, p=0.339). Univariate Cox proportional hazards analysis identified age (p<0.0001), extracardiac vascular disease (p=0.001), glomerular filtration rate (p=0.022), NYHA classification (p=0.001), and pulmonary hypertension (p=0.005) as predictors of mortality. In younger patients (<59 years), NYHA classification and pulmonary hypertension were the only determinants of mortality (p=0.021; HR 6.716 [1.327-33.992]). ![Figure][1] Conclusions: Isolated TV surgery is still associated with significant postoperative and long-term mortality. Pre-operative NYHA functional class and pulmonary hypertension in younger patients appear to determine prognosis. [1]: pending:yes

Impact of preoperative exercise pulmonary hypertension on postoperative outcome in asymptomatic patients with primary mitral regurgitation: a multicenter study

Introduction: The management and the timing of surgery of asymptomatic patients with primary mitral regurgitation (MR) remain controversial. Exercise-induced pulmonary hypertension (ExPHT) was recently reported as a strong predictor of rapid and frequent occurrence of symptoms, leading to surgery. However, the postoperative outcome of patients with ExPHT is unknown. We aimed to describe the postop. outcome of patients with primary MR, purposely according to the presence of preop. ExPHT. Method: We prospectively included 129 asymptomatic patients (70% male, 68±12 yrs) with primary MR and no left ventricular dysfunction/dilatation, in whom we performed exercise echocardiography, in 3 centers (Fr, Bel and Can). Patients with concomitant >mild other valve disease or atrial fibrillation (AF) were excluded. The presence of ExPHT was defined as an exercise systolic pulmonary arterial pressure >60mmHg. All patients were closely followed up and operated when indication for surgery, according to most recent guidelines, was reached. Postop. events were defined as the occurrence of AF, stroke, cardiac-related hospitalization or death. Results: Among the 129 patients included, 70 have developed ExPHT (54%) and these patients were significantly older than those without ExPHT (70±11 vs. 64±14, p=0.03). There was no difference between the 2 groups regarding gender distribution, baseline LV ejection fraction, left atrial volume or MR severity. Only 15 patients underwent mitral valve replacement (12%), without significant difference between the 2 groups (ExPHT: 10% vs. no ExPHT: 14%, p=0.55). The 114 remaining patients had successful mitral valve repair. Following surgery, 28 predefined end-point were reached (22%): 17 (61%) postop. AF, 5 (18%) strokes, 3 (11%) cardiac-related hospitalization and 3 (11%) cardiac deaths. Of interest, patients with ExPHT had significant higher rate of postop. cardiac event (82% vs. 18%, p=0.0006) and all strokes occurred in ExPHT group. Using multivariate analysis, after adjustment for age, gender and preoperative NYHA functional class, ExPHT was independently associated with higher risk of postop. cardiovascular events (odds-ratio: 5.4, 95% of confidence interval: 1.8-20, p=0.002). Conclusion: The present study show that ExPHT is associated with reduced postop. event-free survival in asymptomatic patients with primary MR and no LV dysfunction/dilatation. These results emphasize the use of exercise echocardiography and suggest that early surgery could be considered to improve the outcome of these patients. Nevertheless, further data are needed to confirm these findings.

PHP86 Outcomes and Factors Associated with Hospital Mortality in Patients with Impaired Left Ventricular Function Undergoing Coronary Bypass Grafting; Where Do We Stand?

To find the hospital mortality and mid term functional improvement in patients with impaired ventricular function undergoing coronary artery by pass grafting and identify the risk factors for mortality. Retrospective analysis of preoperative, operative and postoperative variables of patients with impaired ventricular function who were operated for isolated first time coronary artery bypass between October 2006 to April 2009. Total 190 patients with impaired ventricular function underwent isolated first time coronary artery bypass grafting during this period with a male predominance (82.6%). This constituted 12% of all coronary artery surgery performed at our institution during this period. Mean ejection fraction of the group was 25.4±5.3%. Mean predicted mortality on logistic Euro score was 10.9±2.7%. Actual in hospital mortality of the group was 4.7% which is comparable to contemporary published results. Multivariate analysis identified use of intra aortic balloon pump, non use of internal mammary artery and preoperative NYHA functional class as factors associated with mortality. Coronary artery bypass grafting can be performed in patients with impaired ventricular function with acceptable hospital mortality and mid term functional improvement.

Mid-term results of coronary artery bypass graft surgery in patients 70 years of age or older

Background: This study aims to analyze the mid-term results of the coronary artery bypass graft (CABG) surgery in a group of patients 70 years of age or over. Methods: Between September 2001 and June 2009, 621 patients who were more than 70 years of age (453 males, 168 females; mean age 73.6±2.9 years; range 70 to 89 years) who underwent isolated cardiopulmonary CABG were analyzed retrospectively. Of these patients, 604 (97.3%) were followed up postoperatively. The mean duration of the follow-up was 2.5±1.4 years (range 0.3-6.9 years) with a total of 1532.5 patient/years. Results: The mean number of distal anastomoses and grafts per patient was 3.0±0.7 (range 2-5) and 2.8±1.1 (range 2-5), respectively. The 30-day mortality rate was 2.7% (n=17). Of the surviving 604 patients, 30 (4.8%) died during the follow-up period. The mean survival of these patients was 3.1±1.9 years (range 0.8-6.7 years). The preoperative advanced NYHA functional class and postoperative renal complications were associated with increased late mortality while comorbid preoperative diabetes and the use of the left internal thoracic artery graft were associated with lower mortality. Conclusion: Our study results suggest that patients who were more than 70 years old may benefit from CABG surgery. We found that early mortality is related to patientspecific factors, while mid-term mortality is associated with renal complications and preoperative advanced NYHA functional class. Diabetic patients who were administered left internal thoracic artery grafts benefit the most from CABG surgery during the mid-term follow-up.

Left Ventricular Aneurysm Repair: A Comparison of Linear Versus Patch Remodeling

Surgical repair of left ventricular (LV) aneurysm has been performed for around 50 years. However, the most appropriate surgical approach remains undetermined. This study was undertaken to compare the efficacy of 2 established techniques, linear versus patch remodeling, for repair of dyskinetic LV aneurysms. We retrospectively reviewed the records of 49 patients (mean age, 69.8 +/- 7.3 years) who had operation for postinfarction dyskinetic LV aneurysm between 1996 and 2006. Thirty-one patients underwent patch remodeling and 18 underwent linear repair. Short-term and mid-term outcomes, including complications, cardiac function and mortality, were assessed. Overall inhospital surgical mortality, major complications and early hemodynamics showed no significant differences between the 2 groups. During a mean follow-up of 44.0 +/- 34.4 months, 8 patients died, with 4 due to cardiac-related causes. Actuarial survival rates at 1, 5 and 10 years were 85.7%, 69.9% and 45.7%, respectively. Functional class improved from 2.51 +/- 0.59 to 1.66 +/- 0.54 among the mid-term survivors (p < 0.001), with no significant difference between the 2 groups. Multivariate analysis identified preoperative NYHA functional class >or= 3 as an independent risk factor for overall mortality (p = 0.008). Mid-term follow-up revealed that LV ejection fraction improved from 26.5 +/- 7.2% to 34.1 +/- 7.9% (p < 0.001) in the patch group, and from 26.3 +/- 9.0% to 32.0 +/- 9.2% in the linear group (p = 0.032). In contrast, right ventricular ejection fraction improved from 49.4 +/- 10.1% to 52.0 +/- 7.3% (p = 0.190) in the patch group, but deteriorated from 55.0 +/- 6.3% to 50.3 +/- 8.6% in the linear group (p = 0.029). These findings indicate that the 2 repair techniques have similar effectiveness with respect to short- and mid-term outcomes except for right ventricular ejection fraction. We suggest that the selection of repair technique for LV aneurysms should be individualized for each patient based on aneurysm size and extent of the scarring process into the septum and subvalvular mitral apparatus.

Valvoplastia sem suporte para insuficiência mitral degenerativa: resultados a longo prazo

The advantages of valve repair for treatment of degenerative mitral regurgitation are well established. The procedure is associated with low mortality and morbidity rates, and low indices of reoperation, thromboembolic events and endocarditis have been reported. In most series, annuloplasty rings are implanted, but some institutions give preference to unsupported valvuloplasty. To assess the clinical outcome of patients submitted to unsupported valvuloplasty for degenerative mitral regurgitation. Between January 1980 and January 2003, 116 patients were submitted to the procedure. A total of 62 (53.4%) were men, and mean age was 47.2 +/- 16.5 years. The procedures included: Wooler annuloplasty (65.5%), unilateral annuloplasty (15.5%), quadrangular resection of the posterior leaflet (35.3%), anterior chordal shortening (20.7%), posterior chordal shortening (6.9%), and calcium debridement (0.9%). Mean follow-up was 6.5 +/- 5.1 years, and the longest follow-up was 24 years. Mortality was 0.86% (1 pt) early and 6.03% (7 pt) late. Actuarial survival was 85.3% in 20 years. Most patients (55.2%) presented preoperative NYHA functional class III, whereas class I was more frequent in the postoperative period (66.4%). Thromboembolic complications were observed in 4 patients (3.4%), and no correlation was seen with atrial fibrillation. Freedom from thromboembolic events was 94.8%, and similar results were observed for bacterial endocarditis. Survival free from reoperation was 79%, and 53% at 5 and 10 years, respectively. Unsupported valvuloplasty is effective and safe for treatment of degenerative mitral regurgitation, representing an adequate therapeutic alternative for selected cases.

Long-Term Results of Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

In this prospective study, we investigated the determinants of long-term outcome, symptoms, and left ventricular function after coronary artery bypass grafting in patients with a moderate to severely decreased left ventricular ejection fraction. Between 1997 and 1998, 75 consecutive patients with moderate to severe left ventricular dysfunction underwent coronary artery bypass grafting procedures. The operative mortality rate was 4.0%, and the 72 survivors were monitored for 8 years. The end points were mortality, symptomatic status (New York Heart Association [NYHA] functional class), and left ventricular function. The total survival rate after 8 years was 89.3%. During follow-up, 8 patients died. Death was attributed to a cardiac cause in 5 patients and to a noncardiac cause in 3. There was no statistically significant difference between preoperative and late postoperative NYHA functional class, despite a statistically significant improvement that persisted for up to 4 years after CABG. The results of echocardiography showed a statistically significant improvement in the left ventricular ejection fraction (from 0.322 +/- 0.06 preoperatively to 0.463 +/- 0.02 at follow-up, p < 0.001). Multivariate analysis revealed that the left ventricular end-systolic volume index, the presence of angina pectoris, and absence of symptoms of congestive heart failure were preoperative indicators of freedom from heart failure after coronary operations (p < 0.05). Coronary artery bypass grafting for patients with moderate-to-severe left ventricular dysfunction is associated with acceptable long-term results. The left ventricular end-systolic volume index is a simple noninvasive method to aid in the preoperative decision making in such patients.

Aortic valve surgery in the elderly patient: a retrospective review

Elderly patients are referred with increasing frequency for aortic valve replacement (AVR), due to the ageing of the population and to improved results of surgery. We retrospectively analysed the in-hospital and short-term (up to three years) results of AVR in 185 patients aged >or=75 years, operated on at our institution from January 2000 to December 2003. Follow-up was completed by a telephone interview during January 2005. Hospital mortality was 6.5% (12 patients). A non-elective operation (P=0.001), preoperative NYHA functional class >or=III (P=0.06), and chronic renal failure (P=0.02) were associated with increased operative mortality. Of note, age >or=80 years did not increase the surgical risk. The 4-year actuarial survival was 70.5%, the event-free survival was 60.6%, and almost all of the interviewed patients thought that they had benefited from the operation. Preoperative intubation, a NYHA class >or=III, and a non-elective operation were univariate predictors of a poorer outcome. Our data show that aortic valve replacement may be performed with low morbidity and mortality in the elderly patient (age >or=75 years), and that an age >or=80 years neither increases the surgical risk, nor significantly worsens the short-term outcome.

Septal anterior ventricular exclusion operation (Pacopexy) for ischemic dilated cardiomyopathy: treat form not disease

Restoration of left ventricle size and shape is an effective surgical procedure in patients with dilated cardiomyopathy. This report defines early and intermediate results following the reshaping of the left ventricle from spherical to ellipsoid configuration in patients with ischemic cardiomyopathy, employing a technique for LV restoration (LVR) that uses form rather than disease as the endpoint for oblique patch placement. Between 1998 and 2004, a cohort of 83 patients with dilated ischemic cardiomyopathy underwent an operation to reshape the left ventricle. In 54 patients the Dor procedure was done, and 29 underwent the septal anterior ventricular exclusion (SAVE) procedure to emphasize the elliptical shape, whereby patch placement followed an oblique trajectory between the LV apex and septum below the aortic valve. Ventricular form, rather than the disease scar marked the suture placement site endpoint to create an ellipse. The mean age was 58+/-27, but SAVE patients had larger end systolic volume index (135+/-38 vs 95+/-25). Overall preoperative NYHA functional class III was in 69% and IV in 31 patients, but more SAVE patients were in class IV (38% vs 28%). The procedures were elective in 72 and emergent in 11, with similar entry criteria for each procedure. In combination with LVR operation, mitral surgery was performed in 49/83 and tricuspid annuloplasty in 23/83 patients, but these procedures were more common after SAVE (59% vs 44% and 45% vs 19%, respectively), because of larger LV volumes in SAVE patients; 2.8+/-1.3 coronary artery bypass grafts were used. Perioperative use of IABP or LVAD was 15 and 1, respectively in 83 patients. Hospital death was in 1/11 or 9% after emergent operations and 3/72 or 4% in elective procedures, with no difference between groups. After discharge from the hospital, NYHA class improved to class I or II in 57 patients, class III/IV in 14 patients, with 10 late deaths. The 5-year survival rate after the elective operation was 80.3% in SAVE and with elective operation and 77.4% in the Dor procedure. The SAVE or Pacopexy technique is easy to reshape the dilated left ventricle from spherical to ellipsoid form after the LVR, and the resultant improved configuration may contribute to the overall results for patients with ischemic dilated cardiomyopathy.

Stentless Mitral Valve Implantation in Comparison to Conventional Mitral Valve Repair or Replacement at Five Years

A chordally supported stentless mitral valve (SMV) may be a suitable prosthesis for patients with severe degenerative mitral valve disease. We analyzed the five-year results and compared them with results after conventional mitral valve repair or replacement. 155 patients, operated on since August 1997, were evaluated. 53 patients (ages, 68 +/- 8 years, 37 female, valve repair not feasible) received a SMV (Quattro), 51 patients (69 +/- 9 years, 32 female) had mitral valve repair (MVR) and 51 patients (66 +/- 9 years, 32 female) had a conventional mitral valve replacement (MVP). There were no significant differences with respect to preoperative NYHA functional class, left ventricular ejection fraction, cardiac index and surgical risk, according to the EuroSCORE. Mean follow-up is 64 +/- 18 (21-89) months. Surgery was performed using a median sternotomy (32 [SMV]/20 [MVR]/34 [MVP]) or a lateral mini-thoracotomy 21/31/17 approach. The SMV was safely attached to the papillary muscles. In-hospital mortality was 1, 2 and 4 respectively; re-operation was required in 6, 2 and 3 patients. Five-year survival rate was 80.6 +/- 4.4 % (SMV), 80.2 +/- 5.6 % (CMV) and 82.6 +/- 5.6 % (MVP), p = n.s. After hospital discharge, there was no significant difference in mortality in comparison to an age-matched control population. Echocardiography revealed acceptable SMV hemodynamics with preservation of left ventricular function. Midterm results after SMV implantation are comparable to conventional approaches. Complete preservation of the annulo-ventricular continuity is advantageous and close to physiologic hemodynamics can be achieved. Long term follow-up is required.

Isolation of the pulmonary veins in patients with permanent atrial fibrillation secondary to mitral valve disease.

To assess the efficacy of surgical isolation of the pulmonary veins for re-establishing sinus rhythm in patients with atrial fibrillation secondary to mitral valve disease. Thirty-three (67% were women) patients with permanent atrial fibrillation and indication for surgical correction of the mitral valve underwent surgical isolation of the pulmonary veins. Their mean age was 56.3+/-10 years, preoperative NYHA functional class was 3.2+/-0.6, left atrial size was 5.5+/-0.9 cm, and ejection fraction was 61.3+/-13%. The surgical technique consisted of a circumferential incision surrounding the 4 pulmonary veins, excision of the left atrial appendage, and a perpendicular incision originating in the inferior margin of the circumferential incision isolating the pulmonary veins down to the mitral valve. Early arrhythmias were aggressively treated with cardioversion. The mean follow-up was 23.9+/-17 months, and 3 patients died in the postoperative period. Ten patients required electrical cardioversion in the postoperative period; 87% had sinus rhythm in the last medical visit, and 33% were using amiodarone. Isolation of the pulmonary veins associated with mitral valve surgery is an effective and safe technique for maintaining sinus rhythm in patients with permanent atrial fibrillation.

Resultados de la cirugía de revascularización coronaria aislada y combinada en pacientes mayores de 75 años

Increase in life expectancy is causing an increase of surgical myocardial revascularization procedures in the elderly. We evaluate the evolution of this type of interventions in people older than 75 years, taking into account the risk factors, results and survival. Between July 1988 and May 2001, 237 isolated or combined myocardial revascularization procedures were carried out in patients older than 75 years (Group I), while 1177 were performed in younger patients (Group II). We retrospectively analyzed the mortality risk factors, surgical procedures, postoperative complications and survival in Group I patients. Preoperatively, Group I patients showed a more frequent left ventricular dysfunction, left main coronary stenosis, emergency surgery and combined procedures, while Group II patients displayed more common preoperative myocardial infarction and dyslipemia. Mortality in Group I was 20.7% vs 9.09% in Group II. Mortality was higher for mixed procedures (27.1%) than for isolated myocardial revascularization (13.8%). Postoperative complications were present in 48.5% patients. Significant preoperative risk factors of mortality in Group I were: female sex, high-risk ergometry, III-IV NYHA functional class, and atrial arrhythmia. The preoperative NYHA functional class was also a morbidity risk factor. Survival at 1, 3 and 5 years was present in 98.4%, 92.1% and 81% patients, respectively, NYHA functional class I-II being present in 94.18% patients. Myocardial revascularization surgery in people older than 75 years leads to an increase of morbimortality. Anyway, long-term survivors' quality of life makes us think of surgery as a valid treatment alternative.

Quadrileaflet stentless mitral valve replacement.

The study evaluates clinical results and hemodynamic parameters one year after implantation of a stentless quadrileaflet mitral valve (QMV). Since August 1997 28 patients received the QMV, patient age was 69 +/- 8 years; 13 had predominant mitral stenosis and 15 incompetence, preoperative NYHA functional class was III or IV and cardiac index 1.8 +/- 0.6 L/min/m2. Surgery was performed using a conventional (25) or a minimally invasive approach (3). 20 patients received a medium and 8 a large-size prosthesis, crossclamp time was 58 +/- 19 min. Additional procedures were myocardial revascularization in four, tricuspid repair in two, and left-atrial radiofrequency ablation to restore sinus rhythm in six patients. Perioperative mortality (1) was not valve-related. All other patients were discharged on time. At postoperative, 6-, and 12-months follow-up mean transvalvular pressure gradients were 4.2 +/- 1.5 / 4 +/- 0.9/ 3.8 +/- 1.4 mmHg and mitral valve orifice area index was 1.5 +/- 0.3 / 1.6 +/- 0.3 / 1.6 +/- 0.4, NYHA class was I or II. The QMV is well suited for mitral valve replacement. The anulo-ventricular continuity is preserved and the QMV function resembles native mitral valve function. If its performance is maintained in the long term the QMV may be the mitral prosthesis of choice.