Is There a Need for a Pulmonary Artery Catheter in Cardiac Surgery Today?

Pulmonary artery catheters are a useful tool for hemodynamic monitoring in high-risk patients during surgery and while in intensive care. However, there are major risks inherent to the device, and with modern day technology, their routine use has decreased. We discuss the need for routine insertion of pulmonary artery catheters in cardiac surgery. We also present a case of a left ventricular assist device implantation complicated by serious pulmonary hemorrhage due to pulmonary artery catheter insertion, highlighting the potentially life-threatening risks involved.

Delayed aortic dissection and valve thrombosis after transcatheter aortic valve implantation.

We report a case of a 78-year-old female who presented with type A aortic dissection 22 months following transcatheter aortic valve implantation (TAVI). In addition, preoperative echocardiogram showed high gradients across the aortic prosthesis which was found to be thrombosed. At surgery, the intimal tear appeared to be non-acute and anatomically related to the rim of the valve cage. The thrombosed valve was not replaced and the patient received anticoagulation therapy following surgery with significant improvement in valve gradients.

Hyponatremia Predicts Poor Outcomes in Patients With Chronic Kidney Disease Undergoing Heart Operation.

BACKGROUND: Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in patients with chronic kidney disease, the association of sodium levels on postoperative events has never been evaluated. We investigated the impact of preoperative hyponatremia on outcomes after cardiac operation in patients with non-dialysis-dependent chronic kidney disease. Primary end points were operative mortality and acute kidney injury that required dialysis. Secondary end points were major infection and long-term survival. METHODS: The study is observational and includes all patients with stage III to IV chronic kidney disease (non-dialysis) undergoing cardiac operation between February 2000 and January 2016. Patients were stratified into two groups by preoperative sodium levels: sodium less than 135 mEq/L and sodium of 135 mEq/L or more. RESULTS: There were 1,008 patients (mean estimated glomerular filtration rate [GFR]: 43 ± 14 mL • min-1 • 1.73 m-2) with 92 patients (9%) in the low-sodium group. Patients with low sodium had higher operative mortality (p = 0.0004), need for new dialysis (p = 0.0008), and infection (p = 0.002). Predictors of operative mortality were European System for Cardiac Operative Risk Evaluation (EuroSCORE) (hazard ratio [HR] 1.03. 95% confidence interval [CI]: 1.02 to 1.05, p < 0.0001), decreasing values of sodium (HR 1.14. 95% CI: 1.07 to 1.2, p = 0.0002), and decreasing values of GFR (HR 1.01, 95% CI: 1.003 to 1.03, p = 0.007). Sodium less than 135 mEq/L was independently associated with increased need for dialysis (HR 1.3, 95% CI: 1.1 to 1.7, p = 0.0008). By linear regression, decreasing values of preoperative sodium were proportionate to the incidence of operative mortality (p < 0.0001) and need for dialysis (p < 0.0001). CONCLUSIONS: Preoperative hyponatremia is a predictor of increased mortality and other adverse events in patients with non-dialysis-dependent chronic kidney disease undergoing cardiac operation. These findings are similar to those in hyponatremic patients without kidney disease.

Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
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BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients with severe aortic valve stenosis (AS) who are at a higher risk if they have surgery. Preoperative chronic kidney disease (CKD) influences outcomes of cardiac surgery and is associated with a higher mortality and more complicated hospital course. The aims of our study were to evaluate the comparative outcomes of TAVI versus surgical aortic valve replacement (SAVR) in geriatric patients with preoperative CKD. MATERIALS AND METHODS: We prospectively collected data on patients > 75 years of age who underwent either SAVR or TAVI at Shaare Zedek Medical Center, Jerusalem, Israel. The outcomes studied were postoperative acute kidney injury (AKI), in-hospital and long-term mortality, and major neurologic and infectious morbidity. RESULTS: A total of 318 patients were analyzed, of those, 199 and 119 underwent SAVR and TAVI, respectively. In patients with CKD, there was no statistically significant difference in postoperative AKI. SAVR patients had significantly higher in-hospital mortality (OR 5.9; 95% CI 1.6 - 29.6, p = 0.02), postoperative infection (OR 4.2; 95% CI 1.6 - 12.4, p = 0.005), and longer duration of hospital stay. Mortality at 1 and 2 years was lower in the SAVR group, although the difference was not statistically significant (p = 0.059). CONCLUSION: For elderly patients with CKD who are at a higher risk if they have surgery. TAVI offers a good alternative with lower procedural risk.
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Neutrophil-Lymphocyte Ratio: Prognostic Impact in Heart Surgery. Early Outcomes and Late Survival.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor outcomes in various clinical situations. We analyzed the prognostic significance of preoperative elevated NLR in patients undergoing cardiac surgery. METHODS: We performed a retrospective review of 3,027 consecutive patients undergoing cardiac surgery. Receiver-operating-characteristic was used to determine the cutoff value for elevated NLR. Multivariate regression was used to determine the predictive value of preoperative NLR on clinical outcomes. Cox proportional hazards functions were used to determine predictors of late events. Late survival data to 16 years was obtained from the Ministry of Interior. RESULTS: The cutoff value for elevated NLR was 2.6. Patients with elevated NLR were older (p < 0.0001), had a higher incidence of cardiac comorbidity (p < 0.0001), and higher European System for Cardiac Operative Risk Evaluation score (p < 0.0001). An elevated NLR emerged as an independent predictor of operative mortality (hazard ratio [HR] 2.15, 95% confidence interval [CI]: 1.51 to 3.08, p < 0.0001); pleural effusion (HR 1.42, 95% CI: 1.13 to 1.80, p = 0.003); low output syndrome (HR 1.54, 95% CI: 1.23 to 1.93, p = 0.0002); prolonged ventilation (HR 1.49, 95% CI: 1.23 to 1.82, p = 0.0001); or composite outcomes (HR 1.61, 95% CI: 1.36 to 1.91, p < 0.0001). The NLR emerged as an independent predictor of late mortality (HR 1.19, 95% CI: 1.11 to 1.28; p < 0.0001). CONCLUSIONS: Elevated NLR is associated with a higher incidence of adverse outcomes after cardiac surgery. It is a predictor of operative as well as late mortality. Further studies are warranted to determine whether prophylactic treatment with antiinflammatory agents can prevent such outcomes. It may be warranted to include the baseline NLR as another variable in risk stratification of patients about to undergo cardiac surgery.

Preoperative aldosterone receptor blockade and outcomes of cardiac surgery in patients with chronic kidney disease
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BACKGROUND AND AIMS: Recent clinical evidence demonstrates that chronic low-dose mineralocorticoid receptor antagonists (MRA), when added to optimal treatment, result in reductions in cardiovascular mortality. However, continuation of MRAs before cardiac surgery in patients with CKD has never been evaluated and its potential benefit or harm in this specific clinical setting is largely unknown. MATERIALS AND METHODS: This is an observational study that included adult CKD patients undergoing cardiac surgery. Patients were divided into two groups according to preoperative use of spironolactone (SPL). The studied outcomes were postoperative acute kidney injury (AKI) requiring dialysis, mortality, and major morbidities (cardiovascular, neurologic, and infectious). RESULTS: Data on 698 patients with preoperative CKD stage III and IV were analyzed: 99 received SPL preoperatively and 599 did not. At baseline, patients on SPL had higher EuroScore and had more complicated surgery. No significant differences in the incidence of postoperative AKI, myocardial infarction (MI), cardiovascular accident (CVA), sepsis, and mortality were detected between groups in both univariate and multivariate analyses. However, incidence of postoperative low cardiac output state (p < 0.008) was significantly higher in the SPL group. Propensity score matching analyses yielded similar results. CONCLUSIONS: Although SPL is usually administered to significantly sicker patients, its use is not associated with increased major postoperative complications. However, the modulating effect of SPL in this clinical study remains to be elucidated in a prospective randomized trial.
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The role of SU-AVR in tomorrow's practice of AVR.

Conventional aortic valve replacement (C-AVR) is the golden standard in the treatment of severe aortic stenosis (AS). Despite its tremendous success there are many problems associated with the procedure. A large segment of the AS population is not suitable for surgery because of the excessive risk. Over the few last years, transcatheter aortic valve implantation and the use of sutureless valves are new technologies that aim to replace the C-AVR. In this review we compare the three therapeutic modalities in treating severe AS. Based on accumulated data we aspire to describe the clinical landscape of AVR in the near future. We will try to delineate how sutureless valves will be used in treating severe AS.

Safety and Tolerability Study of an Intravenously Administered Small Interfering Ribonucleic Acid (siRNA) Post On-Pump Cardiothoracic Surgery in Patients at Risk of Acute Kidney Injury.

INTRODUCTION: Patients undergoing on-pump cardiac surgery are at an increased risk of acute kidney injury. QPI-1002, a small interfering ribonucleic acid, is under clinical development for the prevention of acute kidney injury. The safety, tolerability, and pharmacokinetics of QPI-1002 was evaluated in this first-in-man, Phase 1 study of a small, interfering ribonucleic acid in patients at risk of acute kidney injury after on-pump cardiac surgery. METHODS: In this phase 1 randomized, placebo-controlled dose-escalation study, a single i.v. dose of QPI-1002 was administered in subjects undergoing on-pump cardiac surgery. Subjects received placebo (n = 4), or QPI-1002 in increasing doses of 0.5 mg/kg (n = 3), 1.5 mg/kg (n = 3), 5 mg/kg (n = 3), and 10 mg/kg (n = 3). RESULTS: A total of 16 subjects were enrolled in the study. The average maximum concentration and area under the curve from the time of dosing to the last measurable concentration of QPI-1002 were generally dose proportional, indicating that exposure increased with increasing dose. The average mean residence time (mean residence time to the last measurable concentration) was 10 to 13 minutes in all 4 drug-dosing cohorts. Adverse events occurred at a similar rate in all study groups. Of the total 109 reported adverse events, the events were distributed as 26 in the placebo group and 21, 19, 24, and 19 in the QPI-1002 0.5, 1.5, 5.0, and 10.0 mg/kg groups, respectively. Eight of the 16 subjects experienced at least 1 serious adverse event: 4 (100%) in the placebo group and 4 (33.3%) in the combined QPI-1002 cohorts. DISCUSSION: QPI-1002 was rapidly eliminated from plasma. QPI-1002 was safe and well tolerated across all dose groups. Overall, no dose-limiting toxicities or safety signals were observed in the study. Further development of QPI-1002 for prophylaxis of acute kidney injury is warranted.

Untreated Mitral Regurgitation Does Not Affect Survival of Elderly Patients Undergoing TAVI.

BACKGROUND: The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation (TAVI). TAVI has become an acceptable mode of treatment for high-surgical risk patients with aortic stenosis (AS) requiring valve replacement. A significant number of patients have concomitant MR which cannot be addressed by TAVI alone, and therefore may not be considered candidates for this procedure. A comparison was conducted of results obtained from patients undergoing TAVI with or without MR. METHODS: Between 2008 and 2013, a total of 164 patients (mean age 81 ± 8 years) underwent TAVI at the authors' institution. Of these patients, 87 (53%) had MR of moderate or greater degree. The groups were similar with respect to age, gender, presence of congestive heart failure, left ventricular function and co-morbid conditions. The logistic EuroSCORE was higher in the MR group (p = 0.02). RESULTS: Procedural (30-day) mortality was 12% (n = 19) and similar between groups. Kaplan-Meier estimates showed the overall survival at three years to be 68% and 76% for the MR and non-MR groups, respectively (p = 0.6). By Cox regression, age (p = 0.007) and peripheral vascular disease (p = 0.03) were the only predictors of late survival. Regression of MR was seen in patients with functional MR. Neither the presence of MR nor residual MR emerged as predictors of late mortality. CONCLUSIONS: In elderly patients undergoing TAVI the presence of MR does not impact survival. TAVI should not be withheld from this group of patients because of concomitant MR.

Preoperative hemoglobin and outcomes in patients with CKD undergoing cardiac surgery.

BACKGROUND AND OBJECTIVES: Preoperative anemia adversely affects outcomes of cardiothoracic surgery. However, in patients with CKD, treating anemia to a target of normal hemoglobin has been associated with increased risk of adverse cardiac and cerebrovascular events. We investigated the association between preoperative hemoglobin and outcomes of cardiac surgery in patients with CKD and assessed whether there was a level of preoperative hemoglobin below which the incidence of adverse surgical outcomes increases. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study included adult patients with CKD stages 3-5 (eGFR<60 ml/min per 1.73 m(2)) undergoing cardiac surgery from February 2000 to January 2010. Patients were classified into four groups stratified by preoperative hemoglobin level: <10, 10-11.9, 12-13.9, and ≥ 14 g/dl. The outcomes were postoperative AKI requiring dialysis, sepsis, cerebrovascular accident, and mortality. RESULTS: In total, 788 patients with a mean eGFR of 43.5 ± 3.7 ml/min per 1.73 m(2) were evaluated, of whom 22.5% had preoperative hemoglobin within the normal range (men: 14-18 g/dl; women: 12-16 g/dl). Univariate analysis revealed an inverse relationship between the incidence of all adverse postoperative outcomes and hemoglobin level. Using hemoglobin as a continuous variable, multivariate logistic regression analysis showed a proportionally greater frequency of all adverse postoperative outcomes per 1-g/dl decrement of preoperative hemoglobin (mortality: odds ratio, 1.38; 95% confidence interval, 1.23 to 1.57; P<0.001; sepsis: odds ratio, 1.31; 95% confidence interval, 1.14 to 1.49; P<0.001; cerebrovascular accident: odds ratio, 1.31; 95% confidence interval, 1.00 to 1.67; P=0.03; postoperative hemodialysis: odds ratio, 1.38; 95% confidence interval, 1.11 to 1.75; P<0.01). Moreover, preoperative hemoglobin<12 g/dl was an independent risk factor for postoperative mortality (odds ratio, 2.6; 95% confidence interval, 1.1 to 7.3; P=0.04). CONCLUSIONS: Similar to the general population, preoperative anemia is associated with adverse postoperative outcomes in patients with CKD. Whether outcomes could be improved by therapeutically targeting higher preoperative hemoglobin levels before cardiac surgery in patients with underlying CKD remains to be determined.

[Does mitral valve annuloplasty improve long-term survival in patients having moderate ischemic mitral regurgitation undergoing CABG?].

BACKGROUND: The best surgical approach for patients with moderate ischemic mitral regurgitation (IMR) is still undetermined. We examined long term outcomes in patients with moderate IMR undergoing coronary bypass (CABG), and compared outcomes between those undergoing isolated CABG to those undergoing concomitant restrictive annuloplasty. METHODS: Between the years 1993-2011, 231 patients with moderate IMR underwent CABG: group 1 (n = 186) underwent isolated CABG, group 2 (n = 15) underwent CABG with concomitant mitral valve annuloplasty. Univariate analysis was used to compare baseline parameters. Kaplan-Meier estimates were used to compare survival. Cox multivariate regression was used to determine predictors for late survival. Survival data up to 20 years is 97% complete. RESULTS: The groups were similar with respect to age, prior MI, LV function, and incidence of atrial fibrillation. Patients undergoing mitral repair had a higher incidence of congestive heart failure (CHF) (p < 0.0001). After surgery more repair patients required use of inotropes (p = 0.0005). Overall operative mortality was 7% and similar between groups. Ten year survival was 55% and 52% for groups 1 and 2 respectively (p = 0.2). Predictors of late mortality included age, CHF, LV dimensions and LV dysfunction. Neither the addition of a mitral procedure and type of ring implanted nor residual MR after surgery, emerged as predictors of survival. CONCLUSIONS: In patients with moderate ischemic MR, neither operative mortality nor long term survival are affected by the performance of a restrictive annuloplasty. For patients with CHF, mitral repair may be beneficial in terms of survival.

Comparison between transcatheter and surgical aortic valve replacement: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: A comparison was made of the outcomes after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) in high-risk patients. METHODS: All patients aged > 75 years that underwent a procedure for severe aortic stenosis with or without coronary revascularization at the authors' institution were included in the study; thus, 64 patients underwent TAVI and 188 underwent AVR. Patients in the TAVI group were older (mean age 84 +/- 5 versus 80 +/- 4 years; p < 0.0001) and had a higher logistic EuroSCORE (p = 0.004). RESULTS: Six patients (9%) died during the procedure in the TAVI group, and 23 (12%) died in the AVR group (p = 0.5). Predictors for mortality were: age (p < 0.0001), female gender (p = 0.02), and surgical valve replacement (p = 0.01). Gradients across the implanted valves at one to three months postoperatively were lower in the TAVI group (p < 0.0001). Actuarial survival at one, two and three years was 78%, 64% and 64%, respectively, for TAVI, and 83%, 78% and 75%, respectively, for AVR (p = 0.4). Age was the only predictor for late mortality (p < 0.0001). CONCLUSION: TAVI patients were older and posed a higher predicted surgical risk. Procedural mortality was lower in the TAVI group, but mid-term survival was similar to that in patients undergoing surgical AVR. Age was the only predictor for late survival. These data support the referral of high-risk patients for TAVI.

Diagnosis and treatment of early bioprosthetic malfunction in the mitral valve position due to thrombus formation.

Bioprosthetic valve thrombosis is uncommon and the diagnosis is often elusive and may be confused with valve degeneration. We report our experience with mitral bioprosthetic valve thrombosis and suggest a therapeutic approach. From 2002 to 2011, 149 consecutive patients who underwent mitral valve replacement with a bioprosthesis at a single center were retrospectively screened for clinical or echocardiographic evidence of valve malfunction. Nine were found to have valve thrombus. All 9 patients had their native valve preserved, representing 24% of those with preserved native valves. Five patients (group 1) presented with symptoms of congestive heart failure at 16.4 ± 12.4 months after surgery. Echocardiogram revealed homogenous echo-dense film on the ventricular surface of the bioprosthesis with elevated transvalvular gradient, resembling early degeneration. The first 2 patients underwent reoperation: valve thrombus was found and confirmed by histologic examination. Based on these, the subsequent 3 patients received anticoagulation treatment with complete thrombus resolution: mean mitral gradient decreased from 23 ± 4 to 6 ± 1 mm Hg and tricuspid regurgitation gradient decreased from 83 ± 20 to 49 ± 5 mm Hg. Four patients (group 2) were asymptomatic, but routine echocardiogram showed a discrete mass on the ventricular aspect of the valve: 1 underwent reoperation to replace the valve and 3 received anticoagulation with complete resolution of the echocardiographic findings. In conclusion, bioprosthetic mitral thrombosis occurs in about 6% of cases. In our experience, onset is early, before anticipated valve degeneration. Clinical awareness followed by an initial trial with anticoagulation is warranted. Surgery should be reserved for those who are not responsive or patients in whom the hemodynamic status does not allow delay. Nonresection of the native valve at the initial operation may play a role in the origin of this entity.

Very prolonged stay in the intensive care unit after cardiac operations: early results and late survival.

BACKGROUND: Prolonged intensive care unit (ICU) stay is a surrogate for advanced morbidity or perioperative complications, and resource utilization may become an issue. It is our policy to continue full life support in the ICU, even for patients with a seemingly grim outlook. We examined the effect of duration of ICU stay on early outcomes and late survival. METHODS: Between 1993 and 2011, 6,385 patients were admitted to the ICU after cardiac surgery. Patients were grouped according to length of stay in the ICU: group 1, 2 days or less (n = 4,631; 73%); group 2, 3 to 14 days (n = 1,423; 22%); group 3, more than 14 days (n = 331; 5%). Length of stay in ICU for group 3 patients was 38 ± 24 days (range, 15 to 160; median 31). Clinical profile and outcomes were compared between groups. RESULTS: Patients requiring prolonged ICU stay were older, underwent more complex surgery, had greater comorbidity, and a higher predicted operative mortality (p < 0.0001). They had a higher incidence of adverse events and increased mortality (p < 0.0001). Of the 331 group 3 patients, 60% were discharged: survival of these patients at 1, 3, and 5 years was 78%, 65%, and 52%, respectively. Operative mortality as well as late survival of discharged patients was proportional to duration of ICU stay. CONCLUSIONS: Current technology enables keeping sick patients alive for extended periods of time. Nearly two thirds of patients requiring prolonged ICU leave hospital, and of these, 50% attain 5-year survival. These data support offering full and continued support even for patients requiring very prolonged ICU stay.

Buddy balloon for TAVI.

Percutaneous transfemoral aortic valve replacement is a new rapidly evolving technique that has made significant progress in recent years. The technology is however limitted and in some cases has resulted in failure to deliver the prosthetic valve. We describe a new technique using a buddy balloon, from the contralateral femoral artery, to assist in crossing the native aortic valve in those cases where extreme calcification and or tortuosity have caused the delivery system to hang up on the aortic wall. The technique is easily applied and facilitates the success of the procedure in cases which may otherwise have to be converted to open surgical aortic valve replacement.

Surgery for ischemic mitral regurgitation: should the valve be repaired?

BACKGROUND AND AIM OF THE STUDY: Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) often have concomitant mitral regurgitation (MR). Repairing the valve at the time of surgery is not universally accepted. The results of CABG with or without mitral valve annuloplasty (MVA) were compared in patients with reduced left ventricular (LV) function and ischemic MR. METHODS: Among a total of 195 patients, 108 underwent isolated CABG, and 87 underwent CABG with MVA. The study end-points included survival, degree of MR, and NYHA functional class. RESULTS: Patients in the MVA group were younger (mean age 63 +/- 10 versus 68 +/- 9 years; p <0.001), but had a more severe cardiac pathology, with severe LV dysfunction in 45% versus 26% (p = 0.006) and severe MR in 82% versus 14% (p < 0.001). The operative mortality was 9%, and similar in both groups. The follow up was complete, with a mean survival period of 87 +/- 50 months. Although, overall, no improvement was seen in LV function, symptomatic improvement was more pronounced in the MVA group (p = 0.006). At follow up, residual MR was present in 2% of the MVA group and in 47% of the CABG-only group (p < 0.0001). For the MVA and CABG-only groups, respectively, survival at five and 10 years was 68% and 46% versus 77% and 52% (p = NS). By multivariate analysis, neither degree of MR nor LV function at follow up had any impact on survival. CONCLUSION: In patients with a reduced LV function undergoing CABG, the addition of a mitral annuloplasty does not increase the operative risk. Although patients in the MVA group were more ill, there was a better symptomatic improvement in this group, and they attained a similar survival. It is recommended that MVA be performed at the time of CABG in patients having moderate or greater MR associated with a reduced LV function.

Repair of ischemic mitral regurgitation: comparison between flexible and rigid annuloplasty rings.

BACKGROUND: The surgical treatment of ischemic mitral regurgitation (MR) usually involves implantation of an annuloplasty ring. We compared results of mitral valve repair using a flexible or a rigid annuloplasty ring in patients with ischemic MR undergoing coronary artery bypass graft surgery. METHODS: There were 169 patients. A flexible ring was implanted in 117 and a rigid ring in 52. Age and clinical profile, degree of left ventricular dysfunction, and degree of MR (mean 3.2) were similar between groups. RESULTS: Operative mortality was 9% in each group. Follow-up (58 +/- 30 months for flexible group and 14 +/- 7 months for rigid group) was available for 91%. For the flexible and rigid ring groups, respectively, mean New York Heart Association functional class was 1.9 and 1.6, with 33% and 14% in classes III to IV (p = 0.03); mean MR grade was 1.25 and 0.7 (p = 0.006). There was no difference in left ventricle function or dimensions. At follow-up, 29 patients (34%) in the flexible group had residual MR of moderate degree or greater compared with 6 (15%) in the rigid group (p = 0.03). Mean tricuspid incompetence gradient was 39 and 34 mm Hg (p = nonsignificant); however, the degree of reduction was greater in the rigid group (p = 0.001). Late mortality was observed in 32 patients, all in the flexible group. CONCLUSIONS: Clinical and hemodynamic results are better with rigid mitral annuloplasty rings compared with flexible rings. That result may be due to ring design, which dictates not only the annular diameter but also annular configuration. Longer follow-up is needed to determine differences in survival.