TAVR in Low-Risk Patients: 1-Year Results From the LRT Trial.

OBJECTIVES: This study sought to evaluate clinical outcomes and transcatheter heart valve hemodynamics at 1 year after transcatheter aortic valve replacement (TAVR) in low-risk patients. BACKGROUND: Early results from the LRT (Low Risk TAVR) trial demonstrated that TAVR is safe in patients with symptomatic severe aortic stenosis who are at low risk for surgical valve replacement. METHODS: The LRT trial was an investigator-initiated, prospective, multicenter study and was the first Food and Drug Administration-approved Investigational Device Exemption trial to evaluate feasibility of TAVR in low-risk patients. The primary endpoint was all-cause mortality at 30 days. Secondary endpoints included clinical outcomes and valve hemodynamics at 1 year. RESULTS: The LRT trial enrolled 200 low-risk patients with symptomatic severe AS to undergo TAVR at 11 centers. Mean age was 73.6 years and 61.5% were men. At 30 days, there was zero mortality, zero disabling stroke, and low permanent pacemaker implantation rate (5.0%). At 1-year follow-up, mortality was 3.0%, stroke rate was 2.1%, and permanent pacemaker implantation rate was 7.3%. Two (1.0%) subjects underwent surgical reintervention for endocarditis. Of the 14% of TAVR subjects who had evidence of hypoattenuated leaflet thickening at 30 days, there was no impact on valve hemodynamics at 1 year, but the stroke rate was numerically higher (3.8% vs. 1.9%; p = 0.53). CONCLUSIONS: TAVR in low-risk patients with symptomatic severe aortic stenosis appears to be safe at 1 year. Hypoattenuated leaflet thickening, observed in a minority of TAVR patients at 30 days, did not have an impact on valve hemodynamics in the longer term.

Transcatheter Aortic Valve Replacement in Low-Risk Patients With Symptomatic Severe Aortic Stenosis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is now the standard of care for patients with symptomatic severe aortic stenosis who are extreme, high, or intermediate risk for surgical aortic valve replacement (SAVR). OBJECTIVES: The authors sought to evaluate TAVR in a prospective multicenter trial involving low-risk patients. METHODS: The Low Risk TAVR (Feasibility of Transcatheter Aortic Valve Replacement in Low-Risk Patients With Symptomatic, Severe Aortic Stenosis) trial was the first U.S. Food and Drug Administration-approved Investigational Device Exemption trial to enroll in the United States. This investigator-led trial was a prospective, multicenter, unblinded, comparison to historical controls from the Society of Thoracic Surgeons (STS) database. The primary endpoint was all-cause mortality at 30 days. RESULTS: The authors enrolled 200 low-risk patients with symptomatic severe aortic stenosis at 11 centers to undergo TAVR. The authors compared outcomes with an inverse probability weighting-adjusted control cohort of 719 patients who underwent SAVR at the same institutions using the STS database. At 30 days, there was zero all-cause mortality in the TAVR group versus 1.7% mortality in the SAVR group. There was zero in-hospital stroke rate in the TAVR group versus 0.6% stroke in the SAVR group. Permanent pacemaker implantation rates were similar between TAVR and SAVR (5.0% vs. 4.5%). The rates of new-onset atrial fibrillation (3.0%) and length of stay (2.0 ± 1.1 days) were low in the TAVR group. One patient (0.5%) in the TAVR group had >mild paravalvular leak at 30 days. Fourteen percent of TAVR patients had evidence of subclinical leaflet thrombosis at 30 days. CONCLUSIONS: TAVR is safe in low-risk patients with symptomatic severe aortic stenosis, with low procedural complication rates, short hospital length of stay, zero mortality, and zero disabling stroke at 30 days. Subclinical leaflet thrombosis was observed in a minority of TAVR patients at 30 days. (Feasibility of Transcatheter Aortic Valve Replacement in Low-Risk Patients With Symptomatic, Severe Aortic Stenosis [Low Risk TAVR; NCT02628899).

Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A.

BACKGROUND: The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. METHODS: From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. RESULTS: Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis-patient mismatch (n = 260, 33%) had similar survival to patients without (p > 0.9), as did patients undergoing less-invasive SAVR (p = 0.3). Risk factors for death included cachexia (p = 0.004), tricuspid regurgitation (p = 0.01), coronary artery disease (p = 0.02), preoperative atrial fibrillation (p = 0.001), higher white blood cell count (p < 0.0001), and lower hemoglobin (p = 0.0002). CONCLUSIONS: In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important.

Impact of Functional Versus Organic Baseline Mitral Regurgitation on Short- and Long-Term Outcomes After Transcatheter Aortic Valve Replacement.

The impact of the specific etiology of mitral regurgitation (MR) on outcomes in the transcatheter aortic valve replacement (TAVR) population is unknown. This study aimed to evaluate the longitudinal changes in functional versus organic MR after TAVR in addition to their impact on survival. Consecutive patients who underwent TAVR from May 2007 to May 2015 who had baseline significant (moderate or greater) MR were included. Transthoracic echocardiography was used to evaluate the cohort at baseline, post-procedure, 30-day, 6-month, and 1-year follow-up. The primary outcomes included mortality at 30 days and 1 year. Longitudinal, mixed-model regression analyses were performed to assess the differences in the magnitude of longitudinal changes of MR, left ventricular (LV) ejection fraction, and New York Heart Association functional class. Seventy patients (44% men, mean 83 years) with moderate or greater MR at baseline (30 functional vs 40 organic) were included, with the functional group having a statistically significant mean younger age and higher rates of previous coronary artery bypass grafting. Kaplan-Meier cumulative mortality rates were similar: 30 days (10% vs 17.5%, unadjusted log-ranked p = 0.413) and 1 year (29.4% vs 23.2%, unadjusted log-ranked p = 0.746) in the functional versus organic MR groups, respectively. There were greater degrees of short- and long-term improvement in MR severity (slope difference p = 0.0008), LV ejection fraction (slope difference p = 0.0009), and New York Heart Association class (slope difference p = 0.0054) in the functional versus organic group. In conclusion, patients with significant functional versus organic MR who underwent TAVR have similar short- and long-term survival; nevertheless, those with a functional origin are more likely to have significant improvements in MR severity, LV-positive remodeling, and functional class. These findings may help strategize therapies for MR in patients with combined aortic and mitral valve disease who are undergoing TAVR.

Heparin-Induced Thrombocytopenia in Contemporary Cardiac Surgical Practice and Experience With a Protocol for Early Identification.

This analysis was designed to (1) examine the impact of heparin-induced thrombocytopenia (HIT) on contemporary cardiac surgical practice and (2) describe the results of a protocol designed for early identification of the presence of the immune mechanisms involved. Consecutive patients who underwent cardiac surgery were screened postoperatively for thrombocytopenia. Patients with thrombocytopenia were tested for antiplatelet factor 4 (PF4)/heparin antibodies by ELISA and clinical evidence of thrombosis sought. Demographics, co-morbidities, operative details, and outcomes were abstracted from the departmental registry. Of 14,415 consecutive patients undergoing cardiac surgery, 1,849 patients (13%) had thrombocytopenia. Of them, 277 patients (15%) had PF4/heparin antibodies and 76 patients (4%) had both antibodies and clinical thrombosis. Antibodies were more frequent: (1) in women (p = 0.01), (2) in patients with an increased body mass index (p <0.01), and (3) in patients with clinical heart failure before surgery (p <0.01). Thirty-day mortality was greatest among the 76 patients with the triad of thrombocytopenia, antibodies, and clinical thrombosis (30%). Of the 1,849 patients with thrombocytopenia, the presence of PF4/heparin antibodies was an independent predictor of 30-day mortality (odds ratio 2.09, 95% CI 1.46 to 2.49; p <0.001). HIT remains an infrequent but very serious complication of heparin therapy in contemporary cardiac surgical practice. The possibility that the presence of HIT antibodies in patients with thrombocytopenia independently increases operative mortality deserves further study.

Appropriate patient selection or health care rationing? Lessons from surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves I trial.

OBJECTIVES: The study objectives were to (1) compare the safety of high-risk surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves (PARTNER) I trial with Society of Thoracic Surgeons national benchmarks; (2) reference intermediate-term survival to that of the US population; and (3) identify subsets of patients for whom aortic valve replacement may be futile, with no survival benefit compared with therapy without aortic valve replacement. METHODS: From May 2007 to October 2009, 699 patients with high surgical risk, aged 84 ± 6.3 years, were randomized in PARTNER-IA; 313 patients underwent surgical aortic valve replacement. Median follow-up was 2.8 years. Survival for therapy without aortic valve replacement used 181 PARTNER-IB patients. RESULTS: Operative mortality was 10.5% (expected 9.3%), stroke 2.6% (expected 3.5%), renal failure 5.8% (expected 12%), sternal wound infection 0.64% (expected 0.33%), and prolonged length of stay 26% (expected 18%). However, calibration of observed events in this relatively small sample was poor. Survival at 1, 2, 3, and 4 years was 75%, 68%, 57%, and 44%, respectively, lower than 90%, 81%, 73%, and 65%, respectively, in the US population, but higher than 53%, 32%, 21%, and 14%, respectively, in patients without aortic valve replacement. Risk factors for death included smaller body mass index, lower albumin, history of cancer, and prosthesis-patient mismatch. Within this high-risk aortic valve replacement group, only the 8% of patients with the poorest risk profiles had estimated 1-year survival less than that of similar patients treated without aortic valve replacement. CONCLUSIONS: PARTNER selection criteria for surgical aortic valve replacement, with a few caveats, may be more appropriate, realistic indications for surgery than those of the past, reflecting contemporary surgical management of severe aortic stenosis in high-risk patients at experienced sites.

Impact of pre-procedural serum albumin levels on outcome of patients undergoing transcatheter aortic valve replacement.

Risk assessment for transcatheter aortic valve replacement (TAVR) patients is challenging, and surgical scores do not optimally correlate with outcome. The aim of this study was to assess the correlation between serum albumin and survival of patients with symptomatic severe aortic stenosis undergoing TAVR. Patients with severe aortic stenosis who underwent TAVR were categorized into 2 groups according to low and normal preprocedural serum albumin (<3.5 and ≥3.5 g/dl, respectively). The all-cause mortality rates at hospital discharge, at 30-day and 1-year follow-up were compared across the groups. Additionally, a Cox proportional-hazards model was generated to assess the independent effect of serum albumin at 1-year follow-up. Among 567 consecutive patients who underwent TAVR, 476 (84%) had documented preprocedural serum albumin measurements. Of these, 50% had low serum albumin levels, and 50% had normal serum albumin levels. Baseline and procedural characteristics, including age, gender, and transapical access, were similar among the groups. Prevalence of left ventricular ejection fraction<40% was higher in patients with low albumin (29% vs 20%, p=0.02), and risk assessment according to Society of Thoracic Surgeons score tended to be higher in the low-albumin group (10±4.7 vs 9.4±4.4, p=0.09). Patients presenting with low albumin had higher in-hospital mortality (11% vs 5%), as well as at 30-day (12% vs 6%, p=0.01) and 1-year (29% vs 19%, p=0.02) follow-up. Serum albumin was independently associated with 1-year mortality (adjusted hazard ratio per 0.1 g/dl decrease 1.64, 95% confidence interval 2.50 to 1.75, p=0.02), along with body mass index<20 kg/m2 (hazard ratio 1.89, 95% confidence interval 3.33 to 1.75, p=0.03). In conclusion, preprocedural serum albumin level and low body mass index are independently associated with mortality in patients who undergo TAVR. Patients with severe aortic stenosis and low albumin levels should undergo careful evaluation before and after TAVR.

Mortality predicted by preinduction cerebral oxygen saturation after cardiac operation.

BACKGROUND: An intraoperative decline in regional cerebral oxygen saturation (rSO2) has been associated with postoperative injury to the central nervous system. Wide individual variation in steady-state cerebral oxygen saturation limits the clinical use of rSO2 to monitoring during anesthesia and surgical procedures. Recently, low preoperative rSO2 has been proposed as a predictor of adverse postoperative outcomes in cardiovascular operations. We compared the sensitivity and specificity of preinduction rSO2 as a predictor of adverse operative events and compared this to the widely accepted risk index developed by the Society for Thoracic Surgeons. METHODS: 2,097 consecutive white patients who underwent cardiac operations from 2010 through 2012 were included. In 1,496 patients (group 1) the preinduction rSO2 was equal to or greater than 60%, whereas in the remaining 601 patients (group 2) it was below 60%. We compared the predictive accuracy of preinduction rSO2 with that of the STS mortality risk score by means of standard statistical techniques, including a receiver operating curve characteristic analysis. RESULTS: Patients with a preinduction rSO2 below 60% had significantly higher STS mortality risk scores than did patients with an rSO2 equal to or greater than 60% (2.0 vs 4.0, p<0.001). Those with an rSO2 below 60% experienced higher operative mortality (p<0.001) and after adjustment this determination emerged as an independent predictor of increased mortality (p<0.001). Receiver operating characteristic curve analysis demonstrated that the rSO2 was slightly less accurate as a mortality predictor (area under the curve: 0.71 vs 0.85). CONCLUSIONS: Measurement of rSO2 is considerably less complex than calculation of the STS score and is only slightly less accurate as a predictor of operative mortality. It may be useful when the STS mortality risk score cannot be calculated.

Ten-year screening for thrombocytopenia after aortic valve replacement.

OBJECTIVES: Thrombocytopenia is very common after cardiac surgery, but rarely studied systematically. Heparin-induced thrombocytopenia has been studied extensively, but the diagnosis remains clouded by the lack of sensitivity and specificity of laboratory tests. It remains unknown whether a local initiative of screening program has been successful in the management of postoperative thrombocytopenia. METHODS: We have implemented a screening protocol since 2002. Cardiac surgery patients were postoperatively screened for thrombocytopenia. Thrombocytopenia was stratified by the anti-platelet factor 4/heparin antibody (enzyme-immune assay, Elisa) test. The presence of clinical embolithrombosis was sought in patients with antibodies. Preoperative and operative characteristics and outcomes were obtained from the departmental registry of cardiac surgical procedures. RESULTS: A total of 16 529 patients were screened for thrombocytopenia from January 2003 to 2012. One thousand two hundred and sixty-one patients undergoing isolated aortic valve replacement (AVR) were included in this study. The overall incidence of thrombocytopenia after AVR was 26.8%. Elisa (+) occurred in 43 of the 1261 patients (3.4%), Elisa (+) plus thrombosis occurred in 14 (1.1%) and in 32.6% of Elisa (+) patients. Age and preoperative lower platelet count were independent predictors of thrombocytopenia. Elisa (+) alone was associated with increased operative mortality, stroke and bleeding. Patients developed thrombocytopenia and Elisa (+) were more likely to receive bioprosthetic valves. CONCLUSIONS: Thrombocytopenia and Elisa (+) are more common after AVR than after other procedures, and both were associated with increased adverse clinical outcomes. Age and lower preoperative platelet count were associated with postoperative thrombocytopenia and Elisa (+).

Ascending aortic injuries following blunt trauma.

BACKGROUND: The diagnosis and the management of traumatic thoracic aortic injuries have undergone significant changes due to new technology and improved prehospital care. Most of the discussions have focused on descending aortic injuries. In this review, we discuss the recent management of ascending aortic injuries. METHODS: We found 5 cohort studies on traumatic aortic injuries and 11 case reports describing ascending aortic injuries between 1998 to the present through Medline research. RESULTS: Among case reports, 78.9% of cases were caused by motor vehicle accidents (MVA). 42.1% of patients underwent emergent open repair and the operative mortality was 12.5%. 36.8% underwent delayed repair. Associated injuries occurred in 84.2% of patients. Aortic valve injury was concurrent in 26.3% of patients. The incidence of ascending aortic injury ranged 1.9-20% in cohort studies. CONCLUSIONS: Traumatic injuries to the ascending aorta are relatively uncommon among survivors following blunt trauma. Aortography has been replaced by computed tomography and echocardiography as a diagnostic tool. Open repair, either emergent or delayed, remains the treatment of choice.

The role of right ventricular function in mitral valve surgery.

BACKGROUND: An impaired right ventricular function is associated with a poor survival rate in patients with heart failure. Few investigations have analyzed the prognostic value of right ventricular function on the outcomes of mitral valve (MV) surgery. The objectives of this study were to define the effect of right ventricular function on postoperative outcomes after MV repair (MVP) or replacement (MVR). METHODS: From September 2007 to February 2012, 335 consecutive patients underwent MVP or MVR at our institution. Preoperative transthoracic and transesophageal echocardiography (TEE) and postoperative TEE were used to define right ventricular function and MV performance. Preoperative right ventricular function was graded as normal to mild (grade 1-2) or as moderate to severe (grade 3-4). MV or tricuspid valve regurgitation was graded as non-trivial to mild (grade 0-2) or as moderate to severe (grade 3-4) preoperatively and postoperatively. Survival rate was evaluated at 1 year after surgery. RESULTS: Of the 334 patients in the study, 280 patients showed a normal to a mildly impaired right ventricular function preoperatively (group 1). Fifty-four patients presented with moderate to severe right ventricular dysfunction (group 2). Patients with a compromised right ventricular function were more likely to undergo MVR (28.6% versus 53.7%, P <.001). The mean pulmonary artery pressure was 23.6 mm Hg in group 1 and 34 mm Hg in group 2 (P <.001). The left atrial diameter was 4.6 cm in group 1 and 5.3 cm in group 2 (P <.001). The 2 groups were not different with respect to operative mortality, but the patients in group 2 experienced more transfusion of blood products (588.4 mL versus 1180.6 mL, P <.001), longer intensive care unit stays (83.9 versus 149.6 hours, P <.001), and hospital stays (8.9 versus 12.8 days, P = .005). The rate of postoperative MV regurgitation was significantly higher in group 2 (1.8 versus 14.8%, P <.001). The overall 1-year survival rate was 92.5% in group 1 and 94.5% in group 2 (P = .59). CONCLUSIONS: This study has shown that a dysfunctional preoperative right ventricular function uses more resources and is associated with postoperative MV regurgitation, but it is not associated short- and mid-term mortality after MV surgery.

Prevalence and effect of myocardial injury after transcatheter aortic valve replacement.

The incidence and prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR) have not been consistently studied. We aimed to assess the incidence and extent of myocardial injury after TAVR performed using transfemoral and transapical approaches. The clinical data from patients with aortic stenosis who underwent TAVR were retrospectively analyzed. The myocardial necrosis markers cardiac troponin I and creatine kinase (CK)-MB were assessed during hospitalization. Of the 150 TAVR patients, 95% and 50% had an abnormally elevated cardiac troponin I and CK-MB level, respectively. The transapical patients had significantly greater elevations of both cardiac troponin I (13.8 ± 14.0 vs 2.5 ± 5.8 ng/ml, p <0.001) and CK-MB (28.4 ± 24.2 vs 7.4 ± 8.6 ng/ml, p ≤0.001). On receiver operating curve analysis, postprocedural CK-MB (twofold increase) had high predictive power for 30-day mortality (area under the curve 0.85, p <0.001). Patients with high CK-MB levels had greater rates of postprocedural kidney injury (22% vs 6%, p = 0.026), in-hospital (22% vs 0%, p <0.001), 30-day (27% vs 1.5%, p <0.001), and 1-year mortality (41% vs 18%, p = 0.01). Baseline renal failure and no ß-blocker treatment on admission were independent predictors of an elevated postprocedural CK-MB level. In conclusion, a cardiac biomarker increase after TAVR was common and more frequent among transapical access patients. A twofold increase (>7 ng/ml) in CK-MB after transfemoral TAVR was a surrogate for poor long-term outcomes.

Impact of transapical aortic valve replacement on apical wall motion.

BACKGROUND: Recent reports indicate that the transapical approach for transcatheter aortic valve replacement may be associated with elevated cardiac enzymes, poor recovery of left ventricular function, and poor outcomes. The aim of this study was to evaluate whether transapical access is associated with apical dysfunction and to assess consequences on patient outcomes. METHODS: In patients undergoing transapical aortic valve replacement, apical regional function was retrospectively assessed using the three standard echocardiographic long-axis views. Patients with abnormal baseline apical motion were excluded. Apical regional wall motion abnormality was assessed on preprocedural (baseline), immediate postprocedural (early [6 ± 2 days]), and late postprocedural (late [95 ± 76 days]) examinations. Apical regional wall motion abnormalities were categorized as normal, hypokinesis, or akinesis. RESULTS: A total of 58 patients undergoing transapical aortic valve replacement were included in the present analysis. Of those, 16 (28%) developed early apical dysfunction. There were no differences in baseline characteristics between the patients who developed early apical dysfunction and those who did not. Patients who received 26-mm valves were more likely to develop apical dysfunction (40% vs. 69%, P = .05). In total, 50% of patients with apical dysfunction (eight of 16) had complete recovery of apical function but tended to have lower ejection fractions (50% vs. 60%, P = .045) at long-term follow-up. No difference in short-term or long-term mortality was detected in these small patient cohorts. CONCLUSIONS: Myocardial injury during transapical access resulted in apical dysfunction early after the procedure in 28% of patients. This apical dysfunction was transient in half of the patients and was associated with a decrease in left ventricular function but did not affect mortality.

Relationship between routine multi-detector cardiac computed tomographic angiography prior to reoperative cardiac surgery, length of stay, and hospital charges.

While multi-detector cardiac computed tomography angiography (MDCCTA) prior to reoperative cardiac surgery (RCS) has been associated with improved clinical outcomes, its impact on hospital charges and length of stay remains unclear. We studied 364 patients undergoing RCS at Washington Hospital Center between 2004 and 2008, including 137 clinically referred for MDCCTA. Baseline demographics, procedural data, and perioperative outcomes were recorded at the time of the procedure. The primary clinical endpoint was the composite of perioperative death, myocardial infarction (MI), stroke, and hemorrhage-related reoperation. Secondary clinical endpoints included surgical procedural variables and the perioperative volume of bleeding and transfusion. Length of stay was determined using the hospital's electronic medical record. Cost data were extracted from the hospital's billing summary. Analysis was performed on individual categories of care, as well as on total hospital charges. Data were compared between subjects with and without MDCCTA, after adjustment for the Society of Thoracic Surgeons score. Baseline characteristics were similar between the two groups. MDCCTA was associated with shorter procedural times, shorter intensive care unit stays, fewer blood transfusions, and less frequent perioperative MI. There was additionally a trend towards a lower incidence of the primary endpoint (17.5 vs. 24.2 %, p = 0.13) primarily due to a lower incidence of perioperative MI (0 vs. 5.7 %, p = 0.002). MDCCTA was also associated with lower median recovery room [$1,325 (1,250-3,302) vs. $3,217 (1,325-5,353) p < 0.001] and nursing charges [$6,335 (3,623-10,478) vs. $6,916 (3,915-14,499) p = 0.03], although operating room charges were higher [$24,100 (22,300-29,700) vs. $23,500 (19,900-27,700) p < 0.05]. Median total charges [$127,000 (95,000-188,000) vs. $123,000 (86,800-226,000) p = 0.77] and length of stay [9 days (6-19) vs. 11 days (7-19), p = 0.21] were similar. Means analysis demonstrated a strong trend towards lower mean total hospital charges [$163,000 (108,426) vs. $192,000 (181,706), p = 0.06] in the MDCCTA group. In conclusion, preoperative MDCCTA is associated with a number of improved perioperative outcomes and does not significantly effect the length of stay or total hospital charges during the index hospitalization.

Silent brain injury after cardiac surgery: a review: cognitive dysfunction and magnetic resonance imaging diffusion-weighted imaging findings.

The appearance of cognitive dysfunction after cardiac surgery in the absence of focal neurologic signs, a poorly understood but potentially devastating complication, almost certainly results from procedure-related brain injury. Confirmation of the occurrence of perioperative silent brain injury has been developed through advances in magnetic resonance imaging (MRI) techniques. These techniques detect new brain lesions in 25% to 50% of patients after both coronary artery bypass graft and valve surgery. Use of post-operative cognitive dysfunction as a marker of brain injury is problematic because of potential difficulties in ascertainment. It can be hypothesized that post-operative appearance of MRI lesions may serve as a more objective marker of brain injury in research efforts. If MRI examination can be used in this way, then 2 vitally important questions can be addressed. 1) What is the frequency of important, but silent, brain injury during cardiac surgery? 2) Does long-term cognitive impairment ensue? This review briefly discusses clinical features of post-operative cognitive dysfunction and reviews the evidence supporting a possible association with MRI evidence of perioperative brain injury and its potential for long-term dementia. We conclude that this association is plausible, but not yet firmly established.

Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation.

AIMS: Most transcatheter aortic valve replacement (T-AVR) using the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA) is done under general anesthesia. The present study aimed to examine the feasibility and safety of T-AVR under monitored anesthesia care and aimed to compare the clinical outcome to the outcome of patients who underwent general anesthesia. METHODS: The analysis included 92 consecutive patients undergoing T-AVR via the transfemoral approach guided by transesophageal echocardiography using the Edwards SAPIEN valve. The cohort was divided into two groups: I, monitored anesthesia care (n=70; 76.1%) and II, intubation (n=22; 23.9%). Monitored anesthesia care was given by anesthesiologists in one of two protocol regimens: Ketamine & Propofol or Dexmedetomidine. The crossover rate to general anesthesia and the clinical outcome of these two groups were compared. RESULTS: Baseline clinical characteristics of the two groups were similar, except for higher logistic EuroSCORE and prior stroke in the monitored anesthesia care group. Surgical access of the femoral artery was performed in 15 (68.1%) from the general anesthesia group and in 24 (34.2%) from the monitored anesthesia care group, p=0.05. The median procedure duration was significantly lower in the monitored anesthesia care group (91 vs. 155 min, p=0.008) and there was a trend to lower median intensive care unit stay and hospital stay (27 vs. 72 h, p=0.07 and 5 vs. 7.5 days, p=0.06, respectively). Of the patients with monitored anesthesia care, 8 (11.4%) converted to general anesthesia. CONCLUSION: T-AVR using the Edwards SAPIEN valve can be performed in the majority of cases with controlled monitored anesthesia care, thereby avoiding the necessity of general anesthesia and resulting in shorter procedure time and in-hospital length of stay.

Fluoroscopy use and left anterior descending artery angiography to guide transapical access in patients with prior cardiac surgery.

BACKGROUND: Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. Transapical AVR might reduce the risk in patients not suitable for the transfemoral approach. We aimed to describe the fluoroscopy and left anterior descending artery (LAD) angiography guidance technique for transapical AVR access and the initial related procedural results. METHODS: Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD angiographic-guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Minithoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque marker to ensure puncture lateral to the LAD. Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root. RESULTS: The population had a mean age of 83 years and was more frequently male (89%) with a high-risk profile (mean Society of Thoracic Surgeons score of 11%). Two patients received the 23-mm Edwards SAPIEN valve, and seven patients received the 26-mm SAPIEN device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications. CONCLUSION: Fluoroscopy and angiography for guidance of the transapical approach facilitate a safe and rapid access to the apex, insuring no risk of damage to the LAD or to large diagonals.

Patients with severe asymptomatic carotid artery stenosis do not have a higher risk of stroke and mortality after coronary artery bypass surgery.

BACKGROUND AND PURPOSE: Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain. METHODS: A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed. RESULTS: Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P=1.0) and mortality (3.4% versus 4.2%; P=1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P=0.51). CONCLUSIONS: Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

Comparison of frequency of atrial fibrillation after coronary artery bypass grafting in African Americans versus European Americans.

In the general population, African Americans experience atrial fibrillation (AF) less frequently than European Americans. This difference could also exist in the incidence of this arrhythmia after cardiac surgery, but this possibility has been insufficiently examined. To test the association of such an ethnic difference, we compared the incidence of postoperative AF in a consecutive series of 2,312 African Americans and 6,054 European Americans who underwent isolated coronary artery bypass grafting from July 2000 to June 2007. Raw differences between the cohorts in the incidence of new AF were adjusted to take into account the baseline differences. Postoperatively, new-onset AF developed in 504 (22%) of 2,312 African-American patients and in 1,838 (30%) of 6,054 European-American patients (p <0.01). After adjustment with logistic regression analysis for numerous baseline differences, African Americans remained less likely to develop AF (odds ratio 0.63, 95% confidence interval 0.55 to 0.72; p <0.001). Risk was also adjusted using propensity matching. In that analysis, 457 (22%) of 2,059 African-American patients had postoperative AF, as did 597 (29%) of 2,059 matched European-American patients (p <0.01). In conclusion, AF was significantly less common among African-American patients than among European-American patients after coronary artery bypass grafting.