Long-term survival for patients with metabolic syndrome after bioprosthetic or mechanical valve replacement.

BACKGROUND: Metabolic diseases are thought to negatively impact the long-term survival of cardiac patients and have been shown to be associated with reduced durability of bioprosthetic heart valves. The purpose of this study is to determine whether long-term survival of post-valve replacement patients is affected by the presence of metabolic disease, and whether choice of tissue versus mechanical prosthesis impacts survival. METHODS: A retrospective review was conducted of all isolated valve replacements performed between 2002 and 2011 from the STS adult cardiac database of Emory Healthcare Hospitals. A total of 1,222 cases were reviewed, of which 909 patients had AVR (661 tissue, 248 mechanical), and 313 MVR (190 tissue, 123 mechanical). Cardiometabolic syndrome (CMS), in accordance with the World Health Organization (WHO) definition, was present in 242 of 1,222 (19.8%) cases in entire cohort, 203 of 909 (22.3%) in AVR, and 39 of 313 (12.5%) in MVR. Cox proportional hazard regression analysis was used to calculate long-term survival after adjusting for propensity score (PS), Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM), and direct covariates for valve and implant type and stratifying by CMS. RESULTS: In PS adjusted AVR, patients with CMS risk factors had worse survival compared to metabolic risk-free patients (AHR = 3.47), as was the case for MVR (AHR = 4.06). Tissue MVR patients with CMS had higher hazard of death compared to patients with no diabetes and no metabolic risk factors after adjusting for PROM (AHR = 3.33) and direct covariates (AHR = 3.91). CONCLUSIONS: Metabolic diseases negatively impact long-term survival of aortic and mitral valve replacement (MVR) patients. Tissue prostheses are associated with worse long-term survival following MVR.

What happens after discharge? An analysis of long-term survival in cardiac surgical patients requiring prolonged intensive care.

BACKGROUND: Cardiac surgical patients with postoperative complications frequently require prolonged intensive care yet survive to hospital discharge. METHODS: From January 1, 2002 to December 31, 2007, 11,541 consecutive patients underwent cardiac operations at a single academic institution. Of these, 11,084 (95.9%) survived to hospital discharge and comprised the study sample. Patients were retrospectively categorized into four groups according to intensive care unit (ICU) length of stay (LOS): <3 days, three to seven days, 7 to 14 days, and >14 days. Survival at 12 months was determined using the Social Security Death Index. Kaplan-Meier (KM) survival curves and Cox proportional hazards regression modeling (hazard ratio, HR) were used to analyze group differences in survival. RESULTS: One-year survival among the four groups according to ICU LOS was: <3 days, 97.0% (8407/8666); three to seven days, 91.2% (1481/1625); 7 to 14 days, 87.9% (356/405); and >14 days, 68.3% (265/388) (p < 0.001). Using multivariable regression analysis, adjusted overall mortality was significantly greater in patients with ICU LOS of three to seven days (HR = 1.51), 7 to 14 days (HR = 1.40), and >14 days (HR = 1.90) compared to patients with ICU LOS <3 days. Mortality among patients who survived more than six months postsurgery was significantly greater in patients with ICU LOS of three to seven days (HR = 1.37), 7 to 14 days (HR = 1.34), and >14 days (HR = 1.63). CONCLUSIONS: Although cardiac surgery patients with major postoperative complications frequently survive to hospital discharge, survival after discharge is significantly reduced in patients requiring prolonged ICU care. Reduced survival in patients with a high risk of complications and anticipated long ICU stays should be considered when discussing surgical versus nonsurgical options.

Off-pump techniques disproportionately benefit women and narrow the gender disparity in outcomes after coronary artery bypass surgery.

BACKGROUND: Women experience greater morbidity and mortality than men after conventional coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). The objective of this study was to determine whether off-pump CABG (OPCAB) alters this gender-based disparity. METHODS AND RESULTS: Retrospective review of risk factors and clinical outcomes for 11 413 consecutive patients having isolated CABG between January 1, 1997, and May 31, 2005, at a US academic center. Interventions were OPCAB or CABG/CPB, performed at the discretion of 14 faculty surgeons. Main outcome measures included in-hospital death, stroke, myocardial infarction or combined major adverse cardiac events (MACE = death or stroke or myocardial infarction). Odds ratios of adverse events, adjusted for 31 risk factors, were compared between women and men who had OPCAB versus CABG/CPB. Covariates included Propensity Score, Society of Thoracic Surgeons' Predicted Risk, surgeon and body habitus. Female patients (n=3248) and those treated with OPCAB (n=4492) were older, had more comorbidities and higher predicted risk than male patients (n=8165) and those treated with conventional CABG/CPB (n=6921), respectively. Women treated with CABG/CPB had a risk-adjusted odds ratio of 1.60 for death (P=0.01), 1.71 for stroke (P=0.007), 2.26 for myocardial infarction (P=0.008) and 1.71 for MACE (P<0.001) compared with men who had CABG/CPB. In contrast, women treated with OPCAB had outcomes statistically similar to men who had either OPCAB or CABG/CPB. Among women, OPCAB was associated with a significant reduction in death (OR 0.39, P=0.001), stroke (OR 0.43, P=0.002) and MACE (OR 0.43, P<0.001). CONCLUSIONS: OPCAB is associated with fewer major adverse cardiac events and benefits women disproportionately, thereby narrowing the gender disparity in clinical outcomes after CABG.

High Risk of Prosthetic Valve Endocarditis and Death After Valve Replacement Operations in Dialysis Patients.

BACKGROUND: Despite a high burden of dialysis access-related bloodstream infections and an increasing incidence of endocarditis, few data are available addressing the risk of prosthetic valve endocarditis (PVE) in the dialysis population. We sought to assess the risk of PVE and death after valve replacement operations in patients receiving long-term dialysis. METHODS: A matched retrospective cohort study was conducted comprising patients admitted for valve replacement operations at two university hospitals. Patients without dialysis were matched 1:1 with dialysis patients by valve(s) replaced, year of operation, and presence of active endocarditis as the indication for valve replacement. Patient characteristics were compared using χ(2) and t tests. The development of PVE was defined by use of the modified Duke criteria and analyzed with Cox proportional hazards regression. RESULTS: Two hundred seventy-eight patients were included, with 139 in either cohort. The PVE risk per year of follow-up was 0.14 in the dialysis cohort and 0.03 in the nondialysis cohort. Dialysis remained a risk factor (adjusted hazard ratio 5.61 [95% confidence interval, 2.17 to 14.5], p = 0.0004) after age and race were controlled for. The 5-year survival rate was lower after valve replacement operation in the dialysis group (25.4%) than in the nondialysis group (75.9%, p < 0.001). CONCLUSIONS: The risk of PVE and death after valve replacement operations in dialysis patients is substantial and significantly higher than in patients without dialysis. These findings highlight the importance of a careful preoperative risk-benefit assessment and underscore the need to prevent hemodialysis-related bloodstream infections.

Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank.

Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures <35 degrees C, and 802 had temperatures <32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures <32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P < 0.001) and BD (7.8 vs. 3.7, P < 0.001) when compared with patients with temperatures >or=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures <35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P < 0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at <32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.

Outcomes for Transcatheter Aortic Valve Replacement in Nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) may offer extreme-aged patients a treatment alternative to surgical aortic valve replacement (SAVR). The objective of this study was to describe outcomes of TAVR in nonagenarians using transfemoral and alternative access techniques. METHODS: In a retrospective review, we found 95 nonagenarians who underwent TAVR from September 2007 through February 2014 at Emory University using a balloon expandable valve: transfemoral (n = 66), transapical (n = 14), transaortic (n = 14), and transcarotid (n = 1). Morbidity and 30-day and midterm mortality were assessed. Kaplan-Meier plots were used to determine midterm survival rates. RESULTS: The mean age of the patients was 91.8 ± 1.8 years, and 49 (52%) were female. Postoperative morbidity included 1 patient (1%) each with stroke, myocardial infarction, pneumonia, and renal failure. The mean postoperative length of stay was 6.8 ± 5.1 days for all patients. Overall 30-day mortality was 3.2%, much less than The Society of Thoracic Surgeons predicted risk of mortality of 14.5% ± 7.3%. There were no deaths in the transfemoral patients, but there were 2 transapical deaths (14.3%) and 1 transaortic death (7.1%). The Kaplan-Meier estimate of median survival was 2.6 years. CONCLUSIONS: Extreme-aged nonagenarian patients may have excellent outcomes from TAVR at 30-day and midterm follow-up. Alternative access TAVR is associated with higher morbidity and mortality than transfemoral TAVR. Referral for TAVR of nonagenarians should not be precluded based on age alone.

Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors.

Acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality in trauma patients. Although many injuries and conditions are believed to be associated with ARDS independent risk factors in trauma patients and their relative importance in development of the syndrome are undefined. The aim of this project is to identify independent risk factors for the development of ARDS in blunt trauma patients and to examine the contributions of each factor to ARDS development. Patients with ARDS were identified from the registry of a Level I trauma center over a 4.5-year period. Records were reviewed for demographics, injury characteristics, transfusion requirements, and hospital course. Variables examined included age >65 years, Injury Severity Score (ISS) >25, hypotension on admission (systolic blood pressure <90), significant metabolic acidosis (base deficit <-5.0), severe brain injury as shown by a Glasgow Coma Scale score (GCS) <8 on admission, 24-hour transfusion requirement >10 units packed red blood cells, pulmonary contusion (PC), femur fracture, and major infection (pneumonia, empyema, or intra-abdominal abscess). Both univariate and stepwise logistic regression were used to identify independent risk factors, and receiver operating characteristic curve (ROC) analysis was used to determine the relative contribution of each risk factor. A total of 4397 patients having sustained blunt trauma were admitted to the intensive care unit and survived >24 hours between October 1995 and May 2000. Of these patients 200 (4.5%) developed ARDS. All studied variables were significantly associated with ARDS in univariate analyses. Stepwise logistic regression, however, demonstrated age >65 years, ISS >25, hypotension on admission, 24-hour transfusion requirement >10 units, and pulmonary contusion as independent risk factors, whereas admission metabolic acidosis, femur fracture, infection, and severe brain injury were not. Using a model based on the logistic regression equation derived yields better than 80 per cent discrimination in ARDS patients. The risk factors providing the greatest contribution to ARDS development were ISS >25 (ROC area 0.72) and PC (ROC area 0.68) followed by large transfusion requirement (ROC area 0.56), admission hypotension (ROC area 0.57), and age >65 (ROC area 0.54). Independent risk factors for ARDS in blunt trauma include ISS >25, PC, age >65 years, hypotension on admission, and 24-hour transfusion requirement >10 units but not admission metabolic acidosis, femur fracture, infection, or severe brain injury. Assessment of these variables allows accurate estimate of risk in the majority of cases, and the most potent contributors to the predictive value of the model are ISS >25 and PC. Improvement in understanding of which patients are actually at risk may allow for advances in treatment as well as prevention in the future.

Total arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion.

OBJECTIVE: To examine the clinical outcomes and impact of using moderate hypothermic circulatory arrest (MHCA) and unilateral selective antegrade cerebral perfusion (uSACP) in the setting of total aortic arch replacement (TOTAL). METHODS: From 2004 to 2012, 733 patients underwent open arch reconstruction with MHCA and SACP. Of these, 145 (20%) underwent TOTAL. Measured outcomes included death, stroke, temporary neurologic dysfunction (TND), and renal failure. Mean follow-up time was 33 months and ranged from 0 to 95 months. RESULTS: Core temperature at the onset of MHCA was 25.8°C. Cardiopulmonary bypass and myocardial ischemic times were 236 minutes and 181 minutes, respectively. Twenty-three patients (16%) underwent emergency repair of acute type A dissection. Fifty-four cases (37%) were reoperative and 52 (34%) were stage I elephant trunk procedures. Concomitant root replacement was performed in 50 (35%) patients, including 20 David V valve-sparing procedures. Mean duration of circulatory arrest was 55 minutes. Operative mortality was 9.7%. Overall incidence of stroke and TND was 2.8% and 5.6%, respectively. Four patients (2.8%) required postoperative dialysis. Seven-year survival was significantly reduced (P = .04) after repair of type A dissection (83.8%) compared with elective surgery (89.5%). Higher temperature during TOTAL was not found to be a significant risk factor for adverse events. CONCLUSIONS: TOTAL using MHCA and uSACP can be accomplished with excellent early and late results. MHCA was not associated with adverse neurologic outcomes or higher operative risk, despite prolonged periods of circulatory arrest.

Comparison of injury mortality risk in motor vehicle crash versus other etiologies.

The mortality risk ratio (MRR), a measure of the proportion of people who died that sustained a given injury, is reported to be among the most powerful discriminators of mortality following trauma. The primary aim was to determine whether mechanistic differences exist and are quantifiable when comparing MRR-based injury severity across two broadly defined etiologies (motor vehicle crash (MVC) versus non-MVC) for the clarification of important injury types that have some room for improvement by emergency treatment and vehicle design. All International Classification of Diseases, 9th revision (ICD-9) coded injuries in the National Trauma Data Bank (NTDB) database were stratified into MVC and non-MVC groups and the MRR for each injury was computed within each group. Injuries were classified as 11 different types for MRR comparison between etiologies. Overall, MRRs for specific injuries were 10-18% lower for MVC compared to non-MVC etiologies. MVCs however produced much higher mean MRRs for crushing injuries (0.184 versus 0.072) and internal injuries to the thorax, abdomen, and pelvis (0.200 versus 0.169). Non-MVCs produced much higher MRRs for intracranial injuries (0.199 versus 0.250). Analysis of the top 95% most frequent MVC injuries revealed higher MVC MRR values for 78% of the injuries with MRR ratios indicating an average 50% increase in a given injury's MRR when MVC was the etiology. Addressing the large differences in MRR in between etiologies for identical injuries could provide a reduction in fatalities and may be important to patient triage and vehicle safety design.

Reduced intraocular pressure after cataract surgery in patients with narrow angles and chronic angle-closure glaucoma.

PURPOSE: To evaluate the effect of cataract surgery on intraocular pressure (IOP) in patients with narrow angles and chronic angle-closure glaucoma (ACG) and to determine whether the change in IOP was correlated with the preoperative pressure, axial length (AL), and anterior chamber depth (ACD). SETTING: Private practice, Atlanta, Georgia, USA. DESIGN: Retrospective case series. METHODS: Charts of patients with narrow angles or chronic ACG who had cataract surgery were reviewed. All eyes had previous laser iridotomies. Data recorded included preoperative and postoperative IOP, AL, and ACD. The preoperative IOP was used to stratify eyes into 4 groups. RESULTS: The charts of 56 patients (83 eyes) were reviewed. The mean reduction IOP in all eyes was 3.28 mm Hg (18%), with 88% having a decrease in IOP. There was a significant correlation between preoperative IOP and the magnitude of IOP reduction (r = 0.68, P < .001). The mean decrease in IOP was 5.3 mm Hg in eyes with a preoperative IOP above 20 mm Hg, 4.6 mm Hg in the over 18 to 20 mm Hg group, 2.5 mm Hg in the over 15 to 18 mm Hg group, and 1.4 mm Hg in the 15 mm Hg or less group. The mean follow-up was 3.0 years ± 2.3 (SD). CONCLUSIONS: Cataract surgery reduced IOP in patients with narrow angles and chronic ACG. The magnitude of reduction was highly correlated with preoperative IOP and weakly correlated with ACD. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Intrapyloric botulinum injection increases postoperative esophagectomy complications.

BACKGROUND: Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy. METHODS: We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both. RESULTS: Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping. CONCLUSIONS: Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.

Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting.

BACKGROUND: An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG. METHODS: A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model. RESULTS: TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p = 0.61). The preoperative ejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p = 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p = 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p = 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients. Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p = 0.46). CONCLUSIONS: Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.

Incidence of postoperative stroke using the Heartstring device in 1,380 coronary artery bypass graft patients with mild to severe atherosclerosis of the ascending aorta.

BACKGROUND: Atherosclerotic disease of the ascending aorta during coronary artery bypass graft surgery (CABG) increases the risk for postoperative stroke. The objective of this study was to examine the incidence of postoperative stroke in CABG utilizing the Heartstring (Maquet Cardiovascular, San Jose, CA) proximal anastomotic device. METHODS: Intraoperative epiaortic ultrasonography was used to grade atherosclerosis in CABG patients at Emory University from April 2003 to December 2012. The Heartstring device was utilized in 1,380 patients: 407 (29.5%) grade I (minimal atherosclerosis), 367 (26.6%) grade II, 437 (31.7%) grade III, 110 (8.0%) grade IV, and 59 (4.3%) grade V (severe atherosclerosis). Logistic regression analysis was used to estimate the effect of aortic grade on outcomes adjusted for Society of Thoracic Surgeons predicted risk of mortality and predicted risk of stroke scores. RESULTS: The mean age of all patients was 66.7 ± 10.5 years, and 31.9% were female. An increasing risk profile was apparent with rising aortic grade. Most CABG was done off pump (n = 1,277, 92.5%). There was no significant association between aortic grade and frequency of postoperative stroke (p = 0.83). In all patients, use of the Heartstring device reduced the predicted risk of stroke by 44% (O:E risk 0.56). The benefit for postoperative stroke was least apparent in the grade I aorta patients (O:E 0.8) compared with patients having grade II and greater. There were no strokes among patients with severe atherosclerosis using the Heartstring device. CONCLUSIONS: Compared with the Society of Thoracic Surgeons predicted risk for stroke, the Heartstring proximal anastomotic device can be safely used with all aortic grades. The most prominent benefit appears to be for patients with grade II disease and greater.

Improved left ventricular function and remodeling after the david v for significant aortic insufficiency.

BACKGROUND: Valve-sparing root replacement is controversial in patients with significant aortic insufficiency (AI) because the aortic valve cusps often require repair, which may potentially jeopardize long-term valve function. The purpose of this study was to evaluate valve function and left ventricular reverse remodeling in patients undergoing valve-sparing root replacement in the setting of significant AI. METHODS: A review of the Emory Aortic Surgery database between 2004 and 2012 identified 616 aortic root replacements. Of these procedures, 169 were performed for patients with 3+ or greater AI. Fifty-one patients (30%) underwent a David V procedure. Echocardiography was used to evaluate the degree of AI, left ventricular end-diastolic diameter, and left ventricular end-systolic diameter. RESULTS: The mean echocardiographic follow-up was 18 ± 21 months (range, 1 to 89). Patients undergoing valve-sparing root replacement had an increase in ejection fraction (preoperative 51% ± 7% versus postoperative 57% ± 6%, p < 0.01) and a reduction in left ventricular end-diastolic diameter (preoperative 58 ± 8 mm versus postoperative 48 ± 6 mm, p < 0.01) and left ventricular end-systolic diameter (preoperative 40 ± 8 mm versus postoperative 32 ± 6 mm, p < 0.01). During the follow-up period, freedom from greater than 1+ AI was 96%, and freedom from aortic valve replacement was 98%. The addition of cusp repair did not represent a significant risk factor for recurrent postoperative AI (p = 0.21). CONCLUSIONS: The David V technique produces significant left ventricular reverse remodeling and improved ventricular function in patients with chronic severe AI. Long-term data and close follow-up will be paramount in evaluating the durability of valve repair in this patient population.

Mortality-based Quantification of Injury Severity for Frequently Occurring Motor Vehicle Crash Injuries.

The study purpose was to develop mortality-based metrics of injury severity for frequent motor vehicle crash (MVC) injuries. Injury severity was quantified with mortality-based metrics for 240 injuries comprising the top 95% most frequently occurring AIS 2+ injuries in the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) 2000-2011. Mortality risk ratios (MRRs) were computed by dividing the number of deaths by occurrences for each of the 240 injuries using National Trauma Data Bank Research Data System (NTDB-RDS) MVC cases. MRRMAIS was computed using only patients with a maximum AIS (MAIS) equal to the AIS severity of a given injury. Each injury had an associated MRR and MRRMAIS which ranged from zero (0% mortality representing low severity) to one (100% or universal mortality representing high severity). Injuries with higher MRR and MRRMAIS values are considered more severe because they resulted in a greater proportion of deaths among injured patients. The results illustrated an overall positive trend between AIS severity and the MRR and MRRMAIS values as expected, but showed large variations in MRR and MRRMAIS for some injuries of the same AIS severity. Mortality differences up to 83% (MRR) and 54% (MRRMAIS) were observed for injuries of the same AIS severity. The MRR-based measures of injury severity indicate that some lower AIS severity injuries may result in as many deaths as higher AIS severity injuries. This data-driven determination of injury severity using MRR and MRRMAIS provides a supplement or an alternative to AIS severity classification.

Off-pump coronary artery bypass grafting attenuates morbidity and mortality for patients with low and high body mass index.

BACKGROUND: Patients at high and low body mass index have been shown to experience higher morbidity and mortality when undergoing coronary artery bypass grafting. The purpose of this research was to compare outcomes of patients at body mass index extremes who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. METHODS: A retrospective review of 6801 patients with a body mass index <25 or >35 undergoing isolated, primary coronary artery bypass grafting from 1996 to 2009 at Emory Healthcare Hospitals was performed. Patients were compared by therapy either on-pump coronary artery bypass grafting (n = 3210) or off-pump coronary artery bypass grafting (n = 3591). Salvage patients or those with concomitant operations were excluded. Comparisons were made using multivariable regression analysis, using a propensity score covariate calculated from 41 preoperative risk factors. RESULTS: A total of 6801 patients, including 4312 with a body mass index <25 (off-pump coronary artery bypass grafting, n = 2083; on-pump coronary artery bypass grafting, n = 2229) and 2489 with a body mass index >35 (off-pump coronary artery bypass grafting, n = 1127; on-pump coronary artery bypass grafting, n = 1362) were included for analysis. Society of Thoracic Surgeons predicted risk of mortality was significantly higher for both body mass index strata in patients undergoing off-pump coronary artery bypass grafting (2.8% vs 3.1% for body mass index <25 [P = .043] and 1.7% vs 1.8% for body mass index >35 [P = .049]). For patients with a body mass index <25, multivariable analysis of outcomes showed a significant decrease in in-hospital mortality (adjusted odds ratio, 0.48; 95% confidence interval, 0.28-0.82), stroke (adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56), new-onset renal failure (adjusted odds ratio, 0.59; 95% confidence interval, 0.36-0.96), and prolonged ventilation (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.64). Long-term survival was unaffected by method of revascularization for either body mass index strata (P > .05). CONCLUSIONS: Patients with high and low body mass indices experience reduced morbidity and in-hospital mortality when undergoing off-pump coronary artery bypass grafting. Despite a higher risk profile, patients with a body mass index <25 who underwent off-pump coronary artery bypass grafting experienced a significant reduction in in-hospital mortality.

The impact of specific preoperative organ dysfunction in patients undergoing aortic valve replacement.

BACKGROUND: Optimizing treatment strategies to risk profile patients undergoing aortic valve replacement remains a priority. The role that specific and combinations of preoperative organ dysfunction (OD) plays in informing these decisions remains uncertain. This study sought to determine the relative effect that OD in particular systems has on short- and long-term outcomes. METHODS: A total of 1,759 aortic valve replacement cases with and without coronary artery bypass grafting performed from January 2002 to June 2010 at Emory University are the basis for this retrospective analysis. Patients were classified by the presence or absence of preoperative OD: (1) cardiac: congestive heart failure (ejection fraction <0.35), (2) pulmonary: forced expiratory volume in 1 second less than 50% predicted, (3) neurologic (prior stroke), and (4) renal: chronic renal failure. The impact of individual and combined OD on outcomes was evaluated. Kaplan-Meier survival estimates and Cox regression models were used to assess the relationship between OD and long-term survival. RESULTS: A total of 513 patients (29.2%) had at least one OD, including 95 patients (5.4%) with more than one OD. Organ dysfunction in each organ system was associated with poorer survival. Renal (hazard ratio, 3.90) and pulmonary (hazard ratio, 2.40) OD patients had poorer long-term survival, including 30-day mortality. Seven-year survival for OD patients is as follows: prior stroke, 48.6%; severe chronic obstructive pulmonary disease, 30.8%; congestive heart failure, 55.9%; and chronic renal failure, 11.7%. The sequential addition of OD systems was a powerful predictor of poorer long-term survival. CONCLUSIONS: The presence of chronic renal failure most profoundly decreases survival, followed by severe chronic obstructive pulmonary disease and prior stroke. Furthermore, multiple OD systems significantly decrease short- and long-term survival.

Acute type a dissection: impact of antegrade cerebral perfusion under moderate hypothermia.

BACKGROUND: The optimal method of arterial cannulation and circulation management for acute type A aortic dissection (type A) remains debated. Moderate hypothermic circulatory arrest (MHCA) and unilateral selective antegrade cerebral perfusion (uSACP) is effective in the elective setting. In this study, the impact of MHCA and uSACP on outcomes for type A repair was evaluated. METHODS: A retrospective review identified 346 patients who underwent type A repair under circulatory arrest, including 193 patients who had MHCA/uSACP. Measured outcomes included operative mortality, permanent neurologic deficit (PND) and temporary neurologic deficit, renal failure, and tracheostomy. Propensity-adjusted, multivariable logistic regression analysis was used to model adverse outcomes. RESULTS: The mean age of MHCA/uSACP patients was 56 years. The mean temperature during MHCA was 26.9 ± 2.0°C. Operative mortality for MHCA/SACP patients was 9.8% compared with 20.3% for the non-MHCA/SACP group (p < 0.01). Propensity score analysis found that MHCA/uSACP did not represent an adverse risk factor for mortality, temporary neurologic deficit, PND, renal failure, or the need for tracheostomy compared with non-MHCA/uSACP techniques. There was a 2.32-fold higher incidence of PND among patients who underwent cross-clamping of the dissected aorta during cooling before circulatory arrest (p < 0.05). CONCLUSIONS: Emergent type A repair can be accomplished with respectable operative risk using MHCA/uSACP. Cross-clamping the dissected aorta before MHCA increases the incidence of PND. These data suggest that MHCA/uSACP represents an effective circulation management strategy for patients undergoing repair of type A and obviates the need for deep hypothermic circulatory arrest.

Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement.

BACKGROUND: Renal impairment portends adverse outcomes in patients undergoing valvular heart surgery. The relationship between renal dysfunction in patients undergoing transcatheter aortic valve replacement (TAVR) is incompletely understood. METHODS: A retrospective review of 1336 patients undergoing surgical aortic valve replacement (SAVR; 2002-2012) and 321 patients undergoing TAVR (2007-2012) was performed. Patients were divided into 3 glomerular filtration rate (GFR) groups: GFR greater than 60 mL/min, GFR 31 to 60 mL/min, and GFR 30 mL/min or less. Logistic and linear regression analysis was performed to estimate the TAVR effect on outcomes. Risk adjustments were made using the Society for Thoracic Surgeons (STS) predicted risk of mortality (PROM). RESULTS: TAVR patients were older (82 vs 65 years; P < .001), had a poorer ejection fraction (48% vs 53%; P < .001), were more likely female (45% vs 41%; P = .23), and had a higher STS PROM (11.9% vs 4.6%; P < .001). In-hospital mortality rates for TAVR and SAVR were 3.5% and 4.1%, respectively (P = .60), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio = .52, P = .06). In SAVR patients, worsening preoperative renal failure was associated with increased in-hospital mortality (P = .004) and hospital (P < .001) and intensive care unit (ICU) (P < .001) lengths of stay. In contrast, worsening renal function did not influence in-hospital mortality (P = .78) and hospital (P < .23) and ICU (P = .88) lengths of stay in TAVR patients. CONCLUSIONS: Worsening renal function was associated with increased in-hospital mortality, hospital length of stay, and ICU length of stay in SAVR patients, but not in TAVR patients. This unexpected finding may have important clinical implications in patients with aortic stenosis and preoperative renal dysfunction.

Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients.

BACKGROUND: This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in which diabetes mellitus and obesity are more prevalent. METHODS: The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients. RESULTS: A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p<0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p=0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients (p=0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%). CONCLUSIONS: BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.