Long-term results and determinants of mortality after surgery for native and prosthetic valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: The study aim was to describe the long-term results and determinants of mortality after operative treatment of native and prosthetic valve endocarditis at a single institution. METHODS: Between March 1985 and October 1999, 171 patients underwent surgery for native (NVE) or prosthetic valve endocarditis (PVE). NVE was present in 98 patients (57%), and PVE in 73 patients (43%). Mean follow up was 5.6+/-3.9 years (range: 0 to 15 years). RESULTS: Overall hospital mortality was 9.9% (n = 17). Hospital mortality was higher among patients with PVE (15.1%) than those with NVE (6.1%; p = 0.05). Overall survival at 10 years was 46+/-5%. Patients with NVE had a higher 10-year survival rate (53+/-7%) than those with PVE (37+/-7%; p = 0.02). At 10 years, overall freedom from any late complication was 47+/-6% and from residual or recurrent endocarditis was 78+/-5%. Predictors of hospital death were emergency surgery (p <0.003) and preoperative renal insufficiency (p <0.008). Predictors of late death were age >70 years (p <0.002), renal failure (p <0.03) and fungal endocarditis (p <0.04). CONCLUSION: These findings demonstrate the increased perioperative, as well as postoperative, risks associated with PVE versus NVE. Cardiac and extracardiac manifestations of the disease, as well as fungal organisms, but not the activity of the endocarditis, were significant adverse determinants of late outcome.

Full sternotomy through a minimally invasive incision: a cardiac surgeon's true comfort zone.

Increasing attention is being paid by cardiac surgeons to performing cardiac surgical procedures through less invasive approaches, including the use of limited incisions. A limited incisional approach is described that achieves full sternotomy, allows the use of standard operative instruments and techniques, permits rapid, easy conversion to normal sternotomy exposure, and is easy to learn.

Combined carotid endarterectomy and coronary revascularization operation.

The increasing risk of perioperative stroke after coronary artery bypass grafting can in part be attributed to the increased incidence of carotid stenosis with increasing patient age. The efficacy of carotid endarterectomy has been demonstrated for both symptomatic and asymptomatic patients. Combined operations yield acceptable mortality and stroke risks, provide good freedom from late events, and cost less than staged operations.

Repeat aortic root replacement.

BACKGROUND: Aortic root replacement in patients who have undergone previous aortic root replacement presents a formidable technical challenge, which may lead to increased surgical mortality. METHODS: We reviewed our experience from January 1989 through November 1995. Seven consecutive patients (6 men and 1 woman) underwent eight repeat aortic root replacements. Mean follow-up was 19 months. Previous root replacement had been performed with homograft in 1 patient, with a bioprosthetic valve composite graft in 1 patient, and with a mechanical valve composite graft in 6 patients. The techniques used at the previous procedures were the Cabrol technique (2 patients), Bentall technique (3 patients), and the coronary button technique (3 patients). Reoperation was indicated for pseudoaneurysm formation in 4 patients and for endocarditis in the others. RESULTS: Aortic homografts were implanted in all patients with endocarditis and mechanical valve composite grafts were used in the others. In all reoperations, the coronary button technique was used. No procedures were done emergently. Concomitant procedures were performed in 2 patients, including mitral valve replacement and aortic arch aneurysm repair. One patient had recurrence of his endocarditis 36 months after operation because of continued intravenous drug use requiring a second successful homograft root replacement. There were no early deaths and one late death at 16 months after operation. CONCLUSIONS: Repeat aortic root replacement, even in the setting of endocarditis, can be done with low mortality.

Risk of reoperative valve replacement for failed mitral and aortic bioprostheses.

BACKGROUND: One factor influencing the choice of mechanical versus bioprosthetic valves is reoperation for bioprosthetic valve failure. To define its operative risk, we reviewed our results with valve reoperation for bioprosthetic valve failure. METHODS: Records of 400 consecutive patients having reoperative mitral, aortic, or mitral and aortic bioprosthetic valve replacement from January 1985 to March 1997 were reviewed. RESULTS: Reoperations were for failed bioprosthetic mitral valves in 219 patients, failed aortic valves in 153 patients, and failed aortic and mitral valves in 28 patients. Including 26 operations (6%) for acute endocarditis, 153 operations (38%) were nonelective. One hundred nine patients (27%) had other valves repaired or replaced, and 72 (18%) had coronary bypass grafting. The incidence of death in the mitral, aortic, and double-valve groups was respectively, 15 (6.8%), 12 (7.8%), and 4 (14.3%); and the incidence of prolonged postoperative hospital stay (>14 days) was, respectively, 57 (26.0%), 41 (26.8%), and 8 (28.6%). Only 7 of 147 patients (4.8%) having elective, isolated, first-time valve reoperation died. Multivariable predictors (p < 0.05) of hospital death were age greater than 65 years, male sex, renal insufficiency, and nonelective operation; and predictors of prolonged stay were acute endocarditis, renal insufficiency, any concurrent cardiac operation, and elevated pulmonary artery systolic pressure. CONCLUSIONS: Reoperative bioprosthetic valve replacement can be performed with acceptable mortality and hospital stay. The best results are achieved with elective valve replacement, without concurrent cardiac procedures.

Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography.

BACKGROUND: Appropriate patient selection for surgical repair of the mitral valve depends on the specific location and mechanism of regurgitation, which, in turn, has necessitated a more detailed method to accurately describe mitral pathology. This study tests a strategy of using multiplane transesophageal echocardiography to systematically localize mitral regurgitant defects and compares these results with the surgical findings. METHODS: Fifty patients with mitral regurgitation underwent intraoperative transesophageal echocardiography for the evaluation of mitral pathology and potential repair. Mitral regurgitant defects were localized using a systematic strategy and a simple nomenclature that divides each mitral valve into six sections (three sections per leaflet) and each prosthetic sewing ring into six sections (60 radial degrees = one section). RESULTS: Thirty-nine patients with native mitral valves were studied, for a total of 234 sections evaluated. Eighty-seven of these sections contained regurgitant defects by transesophageal echocardiography (mean number of regurgitant defects per valve, 2.2; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 96% (224/234; p < 0.0001) of the sections. Eleven patients with prosthetic mitral valves were studied, for a total of 66 sections evaluated. Twenty-three of these sections contained paravalvular leaks by transesophageal echocardiography (mean number of leaks per prosthesis, 2.1; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 88% (58/66; p < 0.001) of the sections. CONCLUSIONS: This transesophageal echocardiographic strategy provides a systematic method to accurately localize mitral regurgitant lesions and has the potential to improve the preoperative assessment of patients with significant mitral regurgitation.

Cardiac operations in patients 80 years old and older.

BACKGROUND: Because the elderly are increasingly referred for operation, we reviewed results with cardiac surgical patients 80 years old or older. METHODS: Records of 600 consecutive patients 80 years old or older having cardiac operations between 1985 and 1995 were reviewed. Follow-up was 99% complete. RESULTS: Two hundred ninety-two patients had coronary grafting (CABG), 105 aortic valve replacement (AVR), 111 AVR + CABG, 42 mitral valve repair/ replacement (MVR) +/- CABG, and 50 other operations. Rates of hospital death, stroke, and prolonged stay (> 14 days) were as follows: CABG: 17 (5.8%), 23 (7.9%) and 91 (31.2%); AVR: 8 (7.6%), 1 (1.0%), and 31 (29.5%); AVR + CABG: 7 (6.3%), 12 (10.8%), and 57 (51.4%); MVR +/- CABG: 4 (9.5%), 3 (7.1%), and 16 (38.1%); other: 9 (18.0%), 3 (6.0%), and 23 (46.0%). Multivariate predictors (p < 0.05) of hospital death were chronic lung disease, postoperative stroke, preoperative intraaortic balloon, and congestive heart failure; predictors of stroke were CABG and carotid disease; and predictors of prolonged stay were postoperative stroke and New York Heart Association class. Actuarial 5-year survival was as follows: CABG, 66%; AVR, 67%; AVR + CABG, 59%; MVR +/- CABG, 57%; other, 48%; and total, 63%. Multivariate predictors of late death were renal insufficiency, postoperative stroke, chronic lung disease, and congestive heart failure. Eighty-seven percent of patients believed having a heart operation after age 80 years was a good choice. CONCLUSIONS: Cardiac operations are successful in most octogenarians with increased hospital mortality, postoperative stroke, and longer hospital stay. Long-term survival is largely determined by concurrent medical diseases.

Intraaortic balloon pumping for cardiac support: trends in practice and outcome, 1968 to 1995.

OBJECTIVES: A total of 4756 cases of intraaortic balloon pump support have been recorded at the Massachusetts General Hospital since the first clinical insertion for cardiogenic shock in 1968. This report describes the patterns of intraaortic balloon use and associated outcomes over this time period. METHODS: A retrospective record review was conducted. RESULTS: Balloon use has increased to more than 300 cases a year at present. The practice of balloon placement for control of ischemia (2453 cases, 11.9% mortality) has become more frequent, whereas support for hemodynamic decompensation (congestive heart failure, hypotension, cardiogenic shock) has been relatively constant (1760 cases, 38.2% mortality). Mean patient age has increased from 54 to 66 years, and mortality has fallen from 41% to 20%. Sixty-five percent (3097/4756) of the total patient population receiving balloon support underwent cardiac surgery. Placement before the operation (2038 patients) was associated with a lower mortality (13.6%) than intraoperative (771 patients, 35.7% mortality) or postoperative use (276 patients, 35.9% mortality). Independent predictors of death with balloon pump support were insertion in the operating room or intensive care unit, transthoracic insertion, age, procedure other than angioplasty or coronary artery bypass, and insertion for cardiogenic shock. Independent predictors of death with intraoperative balloon insertion were age, mitral valve replacement, prolonged cardiopulmonary bypass, urgent or emergency operation, preoperative renal dysfunction, complex ventricular ectopy, right ventricular failure, and emergency reinstitution of cardiopulmonary bypass. CONCLUSIONS: Balloons are being used more frequently for control of ischemia in more patients who are elderly with lower mortality. An institutional bias toward preoperative use of the balloon pump appears to be associated with improved outcomes.

Composite aortic root replacement with direct coronary artery implantation.

BACKGROUND: Composite aortic root replacement is accepted treatment for aneurysms of the ascending aorta involving the root with aortic valve regurgitation, but controversy continues regarding the best technique of operation. We excise the aneurysm, implant a composite valve graft, directly attach the coronary arteries to the aortic graft, and make the distal anastomosis to the divided aorta. METHODS: We reviewed the records and collected complete follow-up data on 110 consecutive patients having composite aortic root replacement with this technique from 1979 to 1995. RESULTS: Average age was 54 years. Marfan's syndrome was present in 22 patients, acute dissections in 26, chronic dissections in 11, and active endocarditis in 13. Operative characteristics were: 25 emergency procedures, 33 urgent procedures, 52 elective procedures, 24 reoperations, and 19 with coronary artery bypass grafting. Hospital death occurred in 8 patients (7.3%). Multivariate predictors of hospital death were postoperative renal failure and acute dissection. Actuarial survival was 70% at 10 years (standard error, 5%). Multivariate predictors of total mortality were porcine valve, Björk-Shiley valve, preoperative stroke, reoperation on a composite valve graft, and coronary artery bypass grafting. Only 3 patients required late reoperation, all for valve dysfunction. Actuarial freedom from reoperation on the aortic root was 97.3% (standard error, 1.9%) at 10 years. Late echocardiograms in 47 patients showed no anastomotic aneurysms. CONCLUSIONS: Composite aortic root replacement with direct coronary implantation is effective and durable treatment for a variety of aortic pathologic conditions in elective and emergency situations.

Aprotinin in primary valve replacement and reconstruction: a multicenter, double-blind, placebo-controlled trial.

BACKGROUND: Patients having cardiac operations often require blood transfusions. Aprotinin reduces the need for blood transfusions during coronary artery bypass graft operations. To determine the safety and effectiveness of aprotinin in reducing the use of allogeneic blood and postoperative mediastinal chest tube drainage, we studied 212 patients undergoing primary sternotomy for valve replacement or repair. METHODS: This study was multicenter, randomized, prospective, double-blind, and placebo-controlled. Patients received high-dose aprotinin (n = 71), low-dose aprotinin (n = 70), or placebo (n = 71). The study medication was given as a loading dose followed by a continuous infusion and pump prime dose. Heparin administration was standardized. Transfusions, postoperative mediastinal shed blood, and adverse events were tracked. RESULTS: Demographic profiles were similar among the treatment groups. Aprotinin did not decrease the percentage of patients receiving transfusions when compared with placebo (high-dose aprotinin, 63%, p = 0.092; low-dose aprotinin, 52%, p = 0.592; placebo, 48%). Aprotinin was associated with a reduction in the volume of mediastinal shed blood (high-dose aprotinin vs placebo, p = 0.002; low-dose aprotinin vs placebo, p = 0.017). Adverse events were equally distributed among the treatment groups except for postoperative renal dysfunction (high-dose aprotinin, 11%; low-dose aprotinin, 7%; placebo, 0%; p = 0.01). A disproportionate number of patients in the high-dose aprotinin group with postoperative renal dysfunction also had diabetes mellitus. CONCLUSIONS: Aprotinin treatment in this population did not reduce allogeneic blood use, although there were significant reductions in the volume of mediastinal shed blood.

Medtronic-Hall prosthetic aortic valve.

The unique design of the Medtronic-Hall single-tilting disc aortic valvular prosthesis includes a wider opening angle and larger lesser orifice for its pyrolytic carbon disc, translation of the disc downstream in systole, machining of the support struts and the central post from one piece of titanium, and a sewing ring made of knitted polytetrafluoroethylene fabric. These design features have achieved the goals of unsurpassed durability, excellent hemodynamic function, and acceptably low rates of valve-related complications. Gradient relief, even in the smaller sizes, is as good as any other mechanical valve. There has never been a report of clinical loss of structural integrity of a Medtronic-Hall aortic valve. The composite linearized rates (% per patient-year) from the global literature for valve-related complications are as follows: nonstructural dysfunction, 0.5; thromboembolism, 1.4; thrombosis, 0.2; anticoagulant-related bleeding, 0.9; and prosthetic endocarditis, 0.5. The Medtronic-Hall aortic prosthesis is an excellent choice for mechanical replacement of the aortic valve.

Long-term results with the Medtronic-Hall valvular prosthesis.

BACKGROUND: Although more than 170,000 Medtronic-Hall mechanical valvular prostheses have been inserted world-wide, long-term results are available on only a small percent of those valves inserted. METHODS: A prospective data registry of all Medtronic-Hall cardiac prostheses inserted by one surgeon was used to identify 460 valves inserted during 391 operations from 1983 to 1994: single aortic (n = 210), single mitral (n = 115), or double aortic and mitral (n = 66) replacements, including three tricuspid valve replacements. Follow-up was sought five times in 10 years and was available for 280 (99%) of 283 survivors with only an isolated aortic or mitral Medtronic-Hall valve followed up for at least 1 year (1,246 patient years). RESULTS: Hospital mortality was 4.6% (18 patients). Of 40 late deaths, eight were valve-related (0.6% per patient-year). The linearized rates of complications for aortic and mitral valve replacements (percent per patient-year) were, respectively: structural deterioration, 0 and 0; nonstructural dysfunction, 0.1 and 2.1; thromboembolism, 1.3 and 2.1; thrombosis, 0 and 0.2; anticoagulant-related bleeding, 1.7 and 1.9; and prosthetic valve endocarditis, 0.6 and 1.0. Actuarial freedom from reoperation at 10 years was 97% for aortic and 88% for mitral valves. CONCLUSIONS: The Medtronic-Hall mechanical valvular prosthesis has excellent durability and acceptably low rates of valve-related complications and remains my mechanical prosthetic valve of choice for both aortic and mitral valve replacements.

Results with mechanical cardiac valvular prostheses.

Mechanical cardiac valvular prostheses continue to be more popular than bioprostheses for heart valve replacement operations. Five different brands of mechanical heart valves are now approved for implantation in the United States: Starr-Edwards models 1260 and 6120, Medtronic-Hall, St. Jude Medical, Omniscience, and CarboMedics. Each model of mechanical valve has certain positive and negative attributes, but none is functionally mechanically perfect. A review of the published long term results with these valves favors the Medtronic-Hall and St. Jude Medical valves. A new method of assessing the thrombogenic potential and requirement for anticoagulation of the different mechanical valves, namely the composite thromboembolism and bleeding index, is proposed. Evaluation of the new index demonstrates a modest advantage for the Medtronic-Hall valve, particularly in the aortic position.

Safety and efficacy of concomitant carotid and coronary artery operations.

BACKGROUND: Controversy exists concerning the best management for patients with concurrent severe carotid and coronary artery disease. METHODS: The records of 200 consecutive patients having concurrent carotid endarterectomy and coronary artery bypass grafting from 1979 to 1993 were reviewed, and follow-up was obtained (99% complete). Of the group (77% male; mean age, 67 years), 134 (67%) had unstable angina, 130 (65%) had triple-vessel disease, and 86 (43%) had left main coronary stenosis. Preoperative investigation revealed asymptomatic bruits in 116 (58%), transient ischemia in 65 (32%), strokes in 31 (16%), and bilateral carotid disease in 44 patients (22%). Nonelective operations were required in 66 patients (33%). RESULTS: Hospital death occurred in 7 patients (3.5%), myocardial infarction in 5 (2.5%), and permanent stroke in 6 (3%). Ten-year actuarial event-free rates were as follows: death, 58%; myocardial infarction, 81%; stroke, 92%; percutaneous angioplasty, 98%; redo coronary artery grafting, 94%; and all morbidity and mortality, 56%. Significant multivariate predictors of hospital death were postoperative stroke, failure to use an internal mammary artery graft, intraoperative intraaortic balloon, and nonelective operation. Significant predictors of postoperative stroke were peripheral vascular disease and unstable angina. Significant predictors of prolonged hospital stay were postoperative stroke, advanced age, and nonelective operation. CONCLUSIONS: Concomitant carotid endarterectomy and coronary bypass grafting can be performed with acceptably low operative risk and good long-term freedom from coronary and neurologic events.

Pregnancy and bioprostheses: influence on structural valve deterioration.

The long-term performance of bioprostheses was evaluated in women 35 years of age or less to determine the influence of pregnancy on structural valve deterioration. Between 1972 and 1992, 237 female patients received 255 biological prostheses. Of the total operations, 53 were performed in patients who experienced pregnancy (P) and 202 in patients who were never pregnant (nonpregnant [NP]). The mean age of the P group was 23.0 +/- 5.8 years (standard deviation) (12 to 34 years) and of the NP group it was 27.1 +/- 6.3 years (8 to 35 years) (p < 0.05). The mean follow-up for the NP group was 6.8 years and for the P group it was 7.9 years. The late mortality was 2.26%/patient-year overall, 2.71%/patient-year for the NP group and 0.89%/patient-year for the P group (p = not significant [NS]). The P group of 52 patients had 94 pregnancies: 70 deliveries (74.5%) and 24 abortions (25.5%) (therapeutic, 14 [15%]). There were a total of 143 valve-related complications (P, 35; NP, 108); the majority for structural valve deterioration (SVD) 43% (109 patients), P 51% (27 patients) and NP 41% (82 patients) (p = NS). The valve-related reoperation rate paralleled the SVD rate at 42% (107 patients), P 51% (27 patients) and NP 40% (80 patients) (p = NS). The overall reoperative mortality rate was 6.0%. The interval from initial implant to reoperation was 99.6 +/- 3.6 months (p = NS groups P and NP).(ABSTRACT TRUNCATED AT 250 WORDS)