Long-term impact of diabetes and its comorbidities in patients undergoing isolated primary coronary artery bypass graft surgery.

BACKGROUND: The objective of this study was to identify the impact of diabetes and related comorbidities, namely chronic renal failure, peripheral vascular disease, and low ejection fraction (<35%), on long-term survival of patients undergoing coronary artery bypass graft surgery. METHODS AND RESULTS: A unicenter study was conducted on 9125 survivors of isolated coronary artery bypass graft surgery between 1992 and 2002. There were 6581 nondiabetic patients and 2544 diabetics, including 1809 patients with noninsulin-dependent diabetes mellitus and 735 patients with insulin-dependent diabetes mellitus. Cardiac-specific survival at 5 and 10 years was lower in insulin-dependent diabetes mellitus compared with both nondiabetic mellitus patients and patients with noninsulin-dependent diabetes mellitus (P<0.0001). However, freedom from cardiac-related death was similar for patients with noninsulin-dependent diabetes mellitus and nondiabetes mellitus patients up to 6 years (P=0 0.08) after surgery and was significantly lower thereafter (P=0.004). Cardiac-specific survival after coronary artery bypass graft surgery in patients with one or more comorbidities was comparable (P=0.4) for both nondiabetes mellitus patients and patients with noninsulin-dependent diabetes mellitus, but was significantly lower for those requiring insulin therapy (P<0.0001). Noninsulin-dependent diabetes mellitus was not an independent predictor of long-term cardiac death (hazard ratio: 1.09, P=0.41); however, insulin-dependent diabetes mellitus, chronic renal failure, peripheral vascular disease, and low ejection fraction were all independent risk factors for late cardiac death (all P<0.0001). The impact of comorbidities on the long-term risk of cardiac death was similar for the 3 groups. CONCLUSIONS: Noninsulin-dependent diabetes is not an independent predictor of late cardiac death after coronary artery bypass graft surgery, because cardiac-related survival is similar to that of nondiabetic patients for 6 years after surgery. In diabetic and nondiabetic patients, cardiac survival is adversely affected by the need for insulin therapy and/or the presence and number of comorbidities such as chronic renal failure, peripheral vascular disease, and low ejection fraction.

The Gelweave Valsalva Graft to Better Reconstruct the Anatomy of the Aortic Root.

The Bentall procedure introduced in 1968 represents an undisputed cure to treat multiple pathologies involving the aortic valve and the ascending thoracic aorta. Over the years, multiple modifications have been introduced as well as a standardized approach to the operation with the goal to prevent long-term adverse events. The Gelweave Valsalva graft provides a novel manner to more efficiently reconstruct the anatomy of the aortic root either with a valve-sparing procedure or with the implantation of a valved conduit (bioprosthesis or mechanical valve). The prosthesis holds three sections: the collar anchoring the valve; the skirt mimicking the Valsalva, which is suitable for the anastomoses with the coronary arteries; and the main body of the graft, which is designed to replace the ascending aorta. The Gelweave Valsalva graft allows the Bentall operation to be standardized, and it provides a potential for longer durability with reduced adverse events.

The Triplex BioValsalva Prostheses To Reconstruct the Aortic Valve and the Aortic Root.

The Bentall procedure introduced in 1968 represents an undisputed cure to treat multiple pathologies involving the aortic valve and the ascending thoracic aorta. Over the years, multiple modifications have been introduced as well as a standardized approach to the operation with the goal to prevent long-term adverse events. The BioValsalva prosthesis provides a novel manner to more efficiently reconstruct the aortic valve together with the anatomy of the aortic root with the implantation of a valved conduit. This prosthesis comprises three sections: the collar supporting the valve; the skirt mimicking the Valsalva, which is suitable for the anastomoses with the coronary arteries; and the main body of the graft, which is designed to replace the ascending aorta. The BioValsalva prosthesis allows the Bentall operation to be used in patients whose aortic valve cannot be spared.

The ROVT Elan Valved Biplex Conduits for the Reconstruction of the Right Ventricular Outflow Tract.

The reconstruction of the right ventricular outflow tract (RVOT) system represents a considerable challenge for both manufacturers and surgeons because the patients requiring this type of devices have a very diverse set of anatomical challenges that can lead to complications and subsequent early device failures. We conducted an indepth investigation of a porcine-valve conduit explanted from a patient following an adverse event. A control device was analyzed as a reference. The rapid aging of the porcine valve in the right side of the heart together with major thrombus formation raises several questions. The difficulties encountered with materials used and also the design features of the conduits are once again highlighted. This group of patients continues to increase in number due to success in the surgical outcomes in early childhood. Therefore, there is a greater demand for an appropriate device. However, much work is still needed to achieve this goal, and the best approach to achieving success remains unanswered.

Determinants of stroke after coronary artery bypass grafting.

OBJECTIVES: Cerebrovascular accidents (CVA) after CABG are deleterious complications whose prevention remains poorly defined. The aim of this study was to identify the determinants for CVA after CABG. METHODS: Nine thousand nine hundred and sixteen patients underwent CABG at our institution from January 1992 to June 2002. Data were prospectively collected and univariate/multivariate analyses conducted. RESULTS: Two hundred and eight patients (2.1%) suffered perioperative CVA. Univariate analysis showed a higher risk profile in the CVA group including advanced age, depressed percent left ventricular ejection fraction (LVEF), unstable angina, diabetes mellitus (DM), chronic renal failure (CRF), redo surgery, peripheral vascular disease (PVD), previous CVA, and higher Parsonnet score (P<0.001). Furthermore, the CVA group had longer myocardial ischemia (CVA 56.2 +/-40.9 vs. Control 50.4+/-20.9 min, P=0.03) and cardiopulmonary bypass (CPB) times (CVA 87.4+/-30.0 min vs. Control 78.9 +/-25.9 min, P<0.0001), and lower off-pump surgery rate (CVA 1.4% vs. Control 4.7%, P=0.01). Multivariable analysis identified seven preoperative and two perioperative determinants for CVA: LVEF<30% (odds ratio (OR)=2.49), previous CVA (OR=2.15), DM (OR=1.78), redo (OR=1.76), PVD (OR=1.66), CRF (OR=1.55), age (OR=1.03), perioperative intra-aortic balloon pump (OR=1.83), and transfusion rate (OR=1.59). Perioperative mortality was higher in the CVA group (CVA 18.6% vs. Control 2.6%, P<0.0001). CONCLUSIONS: Although occurrence of CVA seems mainly related to preoperative comorbidities, perioperative surgical variables, such as off-pump surgery, myocardial ischemia and cardiopulmonary bypass time, do not seem to independently influence CVA rate after CABG. In this regard CVA prevention should be performed before posing an indication to CABG, and closer evaluation of patients' risk profiles and tailored clinical/surgical strategies for those patients at higher risk for CVA occurrence should be included.

Mitral valve cleft in both anterior and posterior leaflet: an extremely rare anomaly.

We herein report the case of a woman with clefts in the anterior and posterior mitral leaflets causing mitral insufficiency. The patient developed heart failure symptoms in the eighth decade of life and underwent mitral valve repair, with suture closure of both clefts. The reasons of its late presentation are discussed.

Pacemaker contact sensitivity: case report and review of the literature.

Pacemaker contact sensitivity is a rare condition. Less than 25 reports of pacemaker skin reaction have been described over the past 30 years. This report describes one patient who developed contact dermatitis after implantation of two subsequent pacemakers. The diagnosis was made with skin patch tests that were positive to polyurethane 75D and polysulfone beige, two of the pacemaker and connector components. Review of the literature and general guidelines for the management of this unusual condition is depicted in this report.

Permanent pacemaker lead entrapment: role of the transesophageal echocardiography.

Numerous complications induced by pacemaker electrodes have been reported. Although mild tricuspid regurgitation is a well-documented complication of transvenous right ventricular pacemaker leads secondary to abnormal valve coaptation, severe tricuspid regurgitation resultingfrom perforation of the tricuspid valve itself is a rare complication. This case report details a patient with severe tricuspid regurgitation secondary to impingement of the tricuspid valve by a permanent pacing lead that was diagnosed by transesophageal echocardiography. Surgical repair was advocated because of symptomatic significant tricuspid regurgitation.