Risk Factors for Permanent Pacemaker after Implantation of Surgical or Percutaneous Self-Expanding Aortic Prostheses.

BACKGROUND: The use of transcatheter aortic valve implantation (TAVI) following the introduction of Nitinol autoexpandable devices has spread rapidly during recent years. In addition, cardiac surgery has been revolutionized due to the use of Nitinol-based sutureless prostheses for aortic valve replacement (AVR). During the same period, however, permanent pacemaker (PPM) implantation has emerged as a frequent complication. The study aim was to identify the risk factors of PPM following the implantation of a Nitinol self-expanding prosthesis (for AVR or TAVI). METHODS: A study group was created between two institutions experienced in the use of nitinol devices, and a pool of 336 patients (56.6% CoreValve - Medtronic; 43.4% Perceval - Sorin) was available for a retrospective analysis. Pre-procedural clinical and electrocardiography (ECG) variables and postprocedural ECG variables were compared between the PPM group and control patients who had not received a PPM during their index hospitalization. RESULTS: A PPM was required in 12.8% of patients (TAVI 17.5% versus AVR 6.8%, p = 0.007). PPM patients had a higher logistical EuroSCORE (median 20.77% versus 15.59%, p = 0.015), a lower use of statins (18.6% versus 34.2%, p = 0.04), a pre-procedural longer QRS interval (median 117 ms versus 98 ms, p = 0.002), and a higher incidence of conduction disturbances (29.3% versus 16.8%, p = 0.034), with a prevalence of right bundle branch block. At the first postprocedural ECG, non-stimulated PPM patients had a longer QRS interval (median 150 ms versus 113 ms, p<0.001) and a longer QTc interval (487.3 ± 46 ms versus 510.8 ± 53.8 ms, p = 0.005). Prevalent intra-ventricular conduction disorders in both groups included left bundle branch block. AVR patients received a PPM later than the TAVI group (median 6 days versus 3 days, p = 0.01). TAVI was an independent predictor of PPM at logistic regression analysis (OR 3.18; 95% CI 1.19-8.48, p = 0.021), but the significance disappeared after incorporating post-procedural ECG variables. CONCLUSIONS: Nitinol technology is a ground-breaking option for aortic valve procedures. However, the radial forces of the self-expandable mechanism may be implicated in the increased need for PPM, mostly in cases of TAVI compared to AVR, that most likely are due to displacement of the stent provoked by in situ calcium clusters. Given the clinical and economic impact of PPM, new parameters are required to understand the stent/tissue interaction and to help with device selection.

Remote muscle salvage by regional substrate enhancement during on-bypass beating-heart treatment of cardiogenic shock.

Surgical revascularization for postinfarction cardiogenic shock carries 20-50% mortality. Beating-heart techniques have been favoured, but their impact on the avoidance of additional myocardial injury is unknown. Ten consecutive patients with postinfarction cardiogenic shock, unsuitable anatomy for percutaneous coronary intervention (Syntax score 34.0±7.5; triple-vessel disease, 10/10; left main stenosis, 5/10), and no associated cardiac procedure, were selected for salvage/emergent on-pump beating-heart coronary bypass surgery. Remote muscle was sequentially substrate-enhanced reperfused through the grafts after construction of distal anastomoses. Early/late mortality, preoperative/peak postoperative enzyme release, and baseline/pre-discharge ventricular function were analysed. One early death occurred. Patients received 2.9±0.6 grafts, always employing the left internal mammary artery. Cardiopulmonary bypass duration was 140±62 min. Left ventricular ejection fraction (29.4±5.8 vs. 37.5±8.3%), wall motion score index (2.10±0.29 vs. 1.86±0.28), and end-systolic volume index (42.1±11.5 vs. 33.1±14.0 ml/m(2)) acutely improved (P≤0.001), whereas functional mitral regurgitation decreased from 1.4±0.8 to 0.8±0.4 (P=0.051). Total creatine kinase levels significantly increased (P=0.017), but myocardial band isoenzyme did not (P=0.18). After 3.1±1.4 years, eight patients are alive and seven are free of recurrent heart failure. Satisfactory functional outcome can be achieved with beating-heart on-pump revascularization for postinfarction cardiogenic shock. Perioperative enzyme releases and ventricular functional variables may suggest reduced perioperative myocardial injury.

Recovery of severe neurological dysfunction after restoration of cerebral blood flow in acute aortic dissection.

Emergency repair has been successfully performed in acute type A aortic dissection complicated by cerebral malperfusion. Despite the lack of criteria to define irreversible brain damage, immediate surgery is often denied in case of stroke or coma. We report two patients presenting with coma and altered brainstem reflexes shortly after onset of aortic dissection, in whom aortic repair was successfully undertaken.

Predictors of adverse events after surgical ventricular restoration for advanced ischaemic cardiomyopathy.

OBJECTIVE: Post-infarction ventricular remodelling has been graded (I-III) according to the loss of systolic left ventricular silhouette curvature changes. Although surgical ventricular restoration (SVR) has been extended to type III ischaemic cardiomyopathy, the results are less satisfactory. We sought to identify geometric and functional predictors of late outcome after SVR. METHODS: Among 144 patients who underwent SVR since 1998, a subgroup of 31 patients (age: 65.2+/-7.6 years) was analysed. Inclusion criteria were: type III cardiomyopathy, no associated procedure except coronary artery bypass grafting, prior anterior infarction, absent-to-2+ mitral regurgitation, elective operation, follow-up > or =18 months (mean: 44+/-26; longest: 96 months). Probability of events was estimated with the Kaplan-Meier method. A Cox multivariable regression model was constructed selecting eight potential predictors of four adverse events: death, cardiac death, recurrent heart failure (New York Heart Association class III or IV) and left ventricular re-remodelling, defined as a 25% increase of end-systolic volume index after SVR, or an end-systolic volume index > or =50 ml.m(-2). RESULTS: Early and late mortality were zero and 6% (2/31 patients, one cardiac-related death). NYHA class and all echocardiographic functional variables significantly improved early after SVR. Freedom (+/-standard error (SE)) from heart failure was 97%+/-3%, 93%+/-5%, 77%+/-11% and 64%+/-15%, whereas freedom from left ventricular re-remodelling was 97%+/-3%, 80%+/-8%, 60%+/-12% and 39%+/-15%, respectively, 1, 3, 5 and 7 years after SVR. Multivariable analysis identified baseline mitral regurgitation degree and sphericity index as independent predictors of recurrent heart failure (p=0.025; hazard ratio (HR)=7.80 (95% confidence intervals (CIs): 1.29-47.19)) and left ventricular re-remodelling (p=0.047; HR=2.84 (95% CIs: 1.01-7.95)). Both predictors also correlated with a higher recurrence of end-systolic volume index > or =50 ml.m(-2) at late follow-up. CONCLUSIONS: Despite advanced cardiomyopathy, SVR determines left ventricular volume reduction and improved systolic function. Baseline absent-to-moderate mitral regurgitation and a more spherical left ventricular geometry predict a less favourable clinical and functional outcome, suggesting a possible rationale for wider indications for combined correction of 2+ mitral regurgitation and undersizing of the mitral annulus, particularly in patients with sphericity index > or =0.75.

Femoro-axillary cardiopulmonary bypass for giant abdominal aortic aneurysm repair prior to staged cardiac operation for ischaemic cardiomyopathy.

The optimal surgical management of simultaneous abdominal aortic aneurysm and cardiac disease remains a major challenge in case of larger aneurysms and severe cardiac disease. In case of symptomatic aneurysms or impending rupture, a single-stage combined operation is the most widely accepted procedure. We report the successful use of closed-chest cardiopulmonary bypass, with femoral venous and axillary arterial peripheral cannulation, to support cardiac function on the beating heart during resection of a giant abdominal aortic aneurysm and ischaemic cardiomyopathy. One month later, the patient underwent a second-stage deferred cardiac operation, consisting of triple coronary bypass grafting, undersized mitral annuloplasty and epicardial left ventricular lead implantation for cardiac resynchronisation therapy.

Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation.

OBJECTIVE: We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. METHODS: Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. RESULTS: Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). CONCLUSIONS: Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.

Late thoracic pseudo-aneurysm causing collapse of vascular prostheses.

The outcome of patients with thoracic vascular prostheses is usually uneventful. We report two cases of collapse of thoracic vascular prostheses which occurred ten and forty years, respectively, after the implantation. The diagnoses were obtained preoperatively by CT-scan or NMR and angiography. Both patients were successfully treated with prosthetic replacement by an open approach.

Primary and redo valve replacement before and after liver transplantation.

We report the case of a 39-year-old man who underwent life-saving aortic valve replacement with a bioprosthesis for acute endocarditis while on the liver transplant waiting list, followed by successful transplantation and late valve re-replacement with a mechanical prosthesis, 10.8 years after primary valve surgery.

Coronary artery bypass for heart failure in ischemic cardiomyopathy: 17-year follow-up.

BACKGROUND: Coronary artery bypass grafting (CABG) has been safely extended to ischemic cardiomyopathy and heart failure, but outcome beyond 5 years remains poorly defined. METHODS: We retrospectively analyzed 45 consecutive angina-free patients with ischemic left ventricular dysfunction (ejection fraction < or = 0.35) and heart failure (New York Heart Association functional class III to IV) who were selected for CABG between 1988 and 1995. Positron emission tomography was used for preoperative identification of myocardial viability. RESULTS: The 30-day mortality was 4.4%. At a median follow-up of 117 months (longest observation, 205 months), the probability of survival at 1, 5, 10, and 15 years after CABG was 93.3%, 84%, 65%, and 44%, respectively. At multivariable analysis, a left ventricular end-diastolic pressure (LVEDP) of 25 mm Hg or more predicted a threefold increase of the hazard of death (p = 0.02), whereas a LVEDP of 20 mm Hg or more correlated with the requirement of an intraaortic balloon pump perioperatively (p = 0.04). Other independent predictors of survival were age older than 70 years and peripheral vascular disease. Cardiac events accounted for 88% of late deaths, which were primarily related to sudden death or progressive heart failure. Most patients were in New York Heart Association functional class I to II at late follow-up. CONCLUSIONS: CABG alone yields good long-term outcome in selected angina-free patients with ischemic systolic dysfunction and advanced heart failure. However, associated diastolic impairment, reflected by elevated LVEDP, predicts reduced long-term survival despite myocardial viability.

Coma might not preclude emergency operation in acute aortic dissection.

BACKGROUND: Syncope or new onset focal neurologic deficits are described in as many as one fifth of patients with acute aortic dissection referred for surgery. Coma or stroke caused by involvement of the arch vessels and secondary brain malperfusion is considered a major contraindication for emergency aortic repair. Initial experience with emergency operation in selected patients with acute type A aortic dissection complicated by coma is described. METHODS: Five comatose (median Glasgow coma score, 5.5), hemodynamically stable (systolic blood pressure > or = 100 mm Hg) patients with preserved pupillary reactivity and coma duration of less than 12 hours underwent emergency surgical repair. The ascending aorta was always replaced using profound hypothermic circulatory arrest. RESULTS: There were no operative deaths. No hemorrhagic brain infarction developed postoperatively. Ischemic strokes were documented by radiology in 3 patients, and were always right-sided. Four patients returned to normal life with no neurologic sequelae, whereas 1 patient showed partially recovered left hemiparesis and mild cognitive impairment. CONCLUSIONS: Coma may not represent an absolute contraindication for resuscitative surgery in hemodynamically stable patients with acute type A aortic dissection. A larger experience is necessary to draw more definitive conclusions.