Right ventricular assessment can improve prognostic value of Euroscore II.

BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Similar outcome of tricuspid valve repair and replacement for isolated tricuspid infective endocarditis.

AIMS: To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement. METHODS: Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30 days after surgery) and long-term survival free from TVIE recurrence. RESULTS: A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1 years (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20 years (80 ±â€Š6% Repair Group vs 59 ±â€Š13% Replacement Group, P = 0.3). CONCLUSIONS: Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.

Bilateral internal thoracic artery grafting with and without cardiopulmonary bypass: six-year clinical outcome.

OBJECTIVES: We sought to evaluate whether early and late results in patients who underwent off-pump or on-pump myocardial revascularization with bilateral internal thoracic artery grafting were similar. METHODS: From November 1994 through December 2001, 1835 patients underwent isolated myocardial revascularization with bilateral internal thoracic artery grafting. By applying propensity score pairwise matching, 1194 patients were selected and operated on either off pump (n = 597) or on pump (n = 597). RESULTS: The overall 30-day mortality was 1.5% (1.2% in the off-pump group and 1.8% in the on-pump group, P = .342). There was no difference for all the other complications between the 2 groups. Mean follow-up was 5.2 +/- 1.8 years. Forty-two patients died over the follow-up period (22 in the off-pump group and 20 in the on-pump group), 15 of them of cardiac causes (7 in the off-pump group and 8 in the on-pump group). Six-year outcomes (freedom from death, cardiac death, acute myocardial infarction and reoperation in all or in the grafted area, target cardiac events, and any other event) were similar for both categories. After a mean of 30.7 +/- 20.1 months, 202 patients had a postoperative angiography showing similar results. CONCLUSIONS: Our results with extensive arterial revascularization clearly show that with the technical improvements achieved in the most recent years, off-pump operations can be performed safely with the same quality of late results as those obtained with on-pump operations.

The Role of Ivabradine in Cardiac Rehabilitation in Patients With Recent Coronary Artery Bypass Graft.

BACKGROUND: Little is known about ivabradine in cardiac rehabilitation in patients with coronary artery bypass graft (CABG). METHODS: In this prospective, randomized study, suitable patients admitted for cardiac rehabilitation after recent CABG were randomized to ivabradine 5 mg twice a day + standard medical therapy including bisoprolol 1.25 mg once daily (group I-BB, n = 38) or standard medical therapy including bisoprolol 2.5 to 3.75 mg once daily (group BB, n = 43). Patients were evaluated at admission, discharge, and 3 months. The primary end point was improvement in functional status, and other end points were improvement in diastolic function and recovery of systolic function. End points were assessed by distance covered in 6-minute walking test (6MWT), percentage with normal diastolic function, and percentage increase in left ventricular ejection fraction (LVEF). RESULTS: Cardiac rehabilitation improved functional capacity in both groups. In group BB, distances covered in the 6MWT at admission, discharge, and 3 months were 215 ± 53, 314 ± 32, and 347 ± 42 m, respectively. Corresponding distances in group I-BB were 180 ± 91, 311 ± 58, and 370 ± 55 m. Normal diastolic function was restored in I-BB patients, increasing from 24% at admission to 50% and 79% at discharge and 3 months; in BB patients, it decreased from 23% to 19% and 16%. The LVEF improved in I-BB patients, from 57% ± 3% at admission to 62% ± 4% at discharge and 66% ± 3% at 3 months, while remaining unchanged in BB patients (57% ± 3%, 59% ± 4%, and 59% ± 3%). CONCLUSION: Adding ivabradine to low-dose bisoprolol during cardiac rehabilitation in patients with CABG improved functional capacity, enhanced recovery of systolic function, and reduced diastolic dysfunction.

Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization.

BACKGROUND: The impact of aortic manipulation on incidence of cerebrovascular accidents (CVAs) was evaluated in patients who underwent myocardial revascularization. METHODS: From January 1988 to December 2000, 4,875 patients had coronary operations; 33 who survived less than 24 hours and 19 who had aortic cannulation without cross-clamping were excluded. According to the degree of aortic manipulation, patients were divided into two groups: group A, aortic cannulation, cross-clamping, with (A1, n = 597) or without (A2, n = 2,233) side-clamping, and group B, with (B1, n = 460) or without (B2, n = 1,533) side-clamping. Patients in group A (n = 2,830) were operated on with and patients in group B (n = 1,993) were operated on without cardiopulmonary bypass (CPB). Univariate and multivariate analyses were applied to identify independent predictors of higher incidence of CVAs. RESULTS: Forty-nine patients (1.0%) had a postoperative CVA, 24 early and 25 delayed, with a 30-day mortality of 34.7%. Independent CVA predictors were low output syndrome, presence of extracoronary vasculopathy, conversion from off to on pump, and any aortic manipulation. This latter risk factor was significant in patients with extracoronary vasculopathy, but not in patients without. Side-clamping was not a risk factor in patients operated on with CPB, but it was in no-CPB cases. Patients in group B1 had the same CVA incidence as patients in group A2. Therefore CPB, per se, was not a risk factor for higher CVA incidence. CONCLUSIONS: Aortic manipulation must be avoided in patients with extracoronary vasculopathy. Maintenance of a good hemodynamic status is crucial for any patient to reduce CVA incidence. Patients with extracoronary vasculopathy are at higher risk, and a correct surgical strategy should be tailored for each case. In no-CPB cases use of side-clamping provides the same CVA risk as in patients in whom CPB, aortic cannulation, and cross-clamping were used.

Off-pump revascularization of chronically occluded left anterior descending artery through left anterior small thoracotomy: early and late angiographic and clinical follow-up.

BACKGROUND: The aim of this retrospective study was to evaluate the safety and efficacy of left anterior small thoracotomy for treatment of isolated chronic total occlusion of the left anterior descending artery. METHODS: From November 21, 1994, to December 31, 2002, 143 patients with isolated left anterior descending artery chronic occlusion underwent off-pump surgery through left anterior small thoracotomy. Safety was evaluated analyzing 30-day mortality, major adverse cardiac events, and major complications; efficacy was evaluated analyzing 6-month angiographic results and 12-month survival, freedom from cardiac death, freedom from acute myocardial infarction, either in all areas or in the grafted one, freedom from redo or percutaneous coronary intervention, freedom from target vessel revascularization, and freedom from major adverse cardiac events and from any event. Eight-year outcome was reported as well. RESULTS: Thirty-day mortality was 0.7% (1 patient). No patient experienced acute myocardial infarction, cerebrovascular accident, or urgent repeat revascularization. One-year survival was 98.6% +/- 0.7%; freedom from cardiac death was 99.3% +/- 0.7%; freedom from acute myocardial infarction in either all areas or in the grafted one was 100%; freedom from redo or percutaneous coronary intervention or from target vessel revascularization was 99.3% +/- 0.7%, and freedom from major adverse cardiac events or any event was 97.9% +/- 1.2%. Eight-year survival was 94.9% +/- 1.9%; freedom from cardiac death was 96.3% +/- 1.6%, from acute myocardial infarction in all or in the grafted area 99.2% +/- 0.8%, from redo or percutaneous coronary intervention 94.4% +/- 2.1, from target vessel revascularization 97.8% +/- 1.3%, from major adverse cardiac events 92.8% +/- 2.2%, and from any event 89.5% +/- 2.7%. Six months after surgery, 56% of survivors underwent angiographic control, showing a patency rate of 98.2%. CONCLUSIONS: In our experience, left anterior small thoracotomy operation can be considered a suitable choice for treatment of left anterior descending artery chronic occlusion.

Predictive value of intraoperative transit-time flow measurement for short-term graft patency in coronary surgery.

OBJECTIVE: The aim of this retrospective study was to evaluate the possibility to predict postoperative graft patency in coronary surgery by means of intraoperative transit-time flow measurement. METHODS: Of 3567 patients submitted to isolated myocardial revascularization from June 1997 through June 2003, 157 (4.4%) underwent both intraoperative transit-time flow measurement and angiography at follow-up. Thirty-six have been revascularized on a beating heart. Three hundred four grafts, 227 arterial conduits, and 77 saphenous vein grafts were checked. RESULTS: No patients died, and none of them had an acute myocardial infarction within 12 months after the operation. After a mean of 6.7 +/- 4.8 months from the operation, 266 grafts (group A) were completely functioning, whereas 38 grafts (group B) had failed. The transit-time flow parameters recorded in the latter group had significantly lower mean flow and higher pulsatility index and percentage of backward flow values at both univariate and multivariate analysis. Moreover, mean flow values of 15 mL/min or less, pulsatility index values of 3.0 or greater, and percentage of backward flow values of 3.0% or greater were found to be independent variables for higher incidence of graft failure. CONCLUSIONS: Transit-time flow measurement represents a quick, easy, and reproducible method for intraoperative evaluation of graft function. The combination of the 3 major parameters (mean flow, pulsatility index, and percentage of backward flow) results in the chance to predict a graft failure (either anatomic or functional) within the first postoperative year.

Reoperative coronary artery bypass grafting: analysis of early and late outcomes.

BACKGROUND: The purpose of this study was to evaluate early and late results of reoperative coronary artery bypass grafting compared with those of first coronary artery bypass grafting. METHODS: From November 21, 1994, to December 31, 2001, 4,381 patients underwent isolated coronary revascularization: among these patients, 274 (6.3%) underwent a redo. Applying the propensity score, 239 redo patients (group R) were matched with 239 who underwent the first revascularization (group F). RESULTS: Early mortality was 2.1% (group F) and 4.2% (group R), not significantly different. Group R showed significantly higher creatine kinase myocardial band release, length of intensive care unit stay, and incidence of incomplete myocardial revascularization than group F. In group R, off-pump patients showed higher incidence of incomplete revascularization. Redo was a risk factor for abnormal (>19 IU/L) creatine kinase myocardial band release (odds ratio, 1.7; p = 0.0066) and incomplete myocardial revascularization (odds ratio, 2.4; p = 0.0060). Five-year clinical outcome was significantly worse in group R, except for freedom from redo or percutaneous transluminal coronary angioplasty. Redo was an independent variable for lower freedom from death of any cause, cardiac death, acute myocardial infarction, cardiac events, and any event. Patients with higher creatine kinase myocardial band release or incomplete myocardial revascularization showed lower freedom from cardiac-related events. Incidence of incomplete myocardial revascularization and creatine kinase myocardial band release were significantly higher in group R by both univariate and multivariate analysis. This could explain the worse late outcome of redo patients. CONCLUSIONS: Complete revascularization without damaging the heart, whichever technique is used, is the target of redo surgery, to achieve the same quality of results obtained in the first operation.

Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?

BACKGROUND: The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients. METHODS: Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared. RESULTS: From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant and trainee groups, respectively (hazard ratio = 0.60 [95% confidence interval, 0.37 to 0.99]; p = 0.05). CONCLUSIONS: Off-pump coronary artery bypass grafting surgery in high-risk patients can be safely performed by trainees.

Left ventricular aneurysmectomy: endoventricular circular patch plasty or septoexclusion.

BACKGROUND: Septoexclusion is a technique described by Guilmet in the mid 1980s. Its indications and midterm results are evaluated and compared to those obtained with the Dor operation. METHODS: From January 1998 to April 2001, 79 patients had an exclusion of scars following myocardial infarction in left anterior descending artery (LAD) territory. Fifty of them (63.3%) had the Dor operation (Group D) and 29 (36.7%) the Guilmet operation (Group G). Dor technique was used when the involvement of the septum and the free wall was roughly similar. Guilmet technique was indicated when the septum was involved at a greater extent than the free wall. Ejection fraction (EF) was lower and end-diastolic volumes were higher in Group G. Incidence of functional mitral regurgitation was similar in both groups. RESULTS: Thirty-day mortality was 7.6% (8.0% in Group D versus 6.9% in Group G, p = ns). After a mean of 21.0 +/- 8.5 months, five patients (6.9%) died, two in Group D and three in Group G. Causes of death were cardiac related in four and not cardiac related in one. Mean follow-up of the 68 survivors was 24.3 +/- 12.0 months (range: 4-38 months). Fifty patients (73.5% of the survivors) improved (28 in Group D and 22 in Group G, p = 0.026), whereas in 18, New York Heart Association (NYHA) class remained unchanged or worsened. Both groups showed an increase of EF and a volumetric reduction, whereas stroke volume remained unchanged. Fewer patients had mitral regurgitation than in the preoperative period (41.3% versus 65.8%, p = 0.013) and at a lesser extent (1.7 +/- 0.7 versus 0.7 +/- 0.6, p < 0.001). CONCLUSIONS: Our results show that both Dor and Guilmet techniques are effective in the surgical treatment of left ventricular dyskinetic or akinetic areas related to LAD territory. Each technique has its own indications and has to be addressed to patients with different extension of septal scars.