Giant intracardiac medullary thyroid cancer metastasis.

We report an unusual case of giant intracardiac medullary thyroid cancer metastasis. A 76-year-old woman with a 9-year history of medullary thyroid cancer presented an unexpected 7.5 cm mass in the right ventricle. Complete resection and tricuspid valve replacement led to 40 months survival.

Which echocardiographic parameters improve the risk prediction for peri-operative outcomes in patients undergoing coronary bypass surgery: a prospective study.

OBJECTIVE: To assess the performance of transthoracic echocardiographic parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting, and to assess its incremental prognostic value as compared to the Society of Thoracic Surgeons (STS) score. MATERIALS AND METHODS: We prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalised for coronary artery bypass grafting. Preoperative transthoracic echocardiography was performed for each patient. The primary endpoint was 30-day mortality or major morbidity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. The secondary endpoint was prolonged hospitalisation for over 14 days. RESULTS: A total of 172 patients was included (mean age 66.1±10.2 years, 12.2% were women). The primary endpoint occurred in 33 patients (19.2%), and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary endpoint were an increased left atrial volume (>31 mL/m²; odds ratio (OR) 3.55, 95% confidence interval (CI) 1.38-9.12; P=0.004) and a decreased tricuspid annular plane systolic excursion (<20 mm; OR 3.45, 95% CI 1.47-8.21; P=0.008). The predictive value of the multivariate model increased when the two echocardiographic parameters were added to the STS score (area under the curve 0.598 vs. 0.695, P=0.001; integrated discrimination improvement 7.44%). CONCLUSION: In patients undergoing coronary artery bypass grafting, preoperative assessment of left atrial size and tricuspid annular plane systolic excursion should be performed systematically, as it provides additional prognostic information to the STS score.

Metabolic alterations of uterine grafts after extended cold ischemic storage: experimental study in ewes.

Uterine transplantation from a deceased donor could become an available option for widely treating uterine infertility. However, this procedure requires more precise knowledge about the graft's tolerance to extended cold ischemia. Here, we sought to assess the uterine metabolic alterations after extended cold ischemic storage in a model of auto-transplantation in ewe. A total of 14 uterine auto-transplantations were performed, divided into 2 groups: 7 after 3 h of cold ischemia time (CIT) and 7 after 24 h. Venous uterine blood was collected before uterus retrieval and during reperfusion (30, 60 and 90 min); thereafter, blood gases, lactate, glucose and amino acids (AAs) were analyzed. Apoptosis analyses were performed before uterus retrieval and following reperfusion in uterus biopsies. A total of 12 uterine auto-transplantations were successfully performed and 7 ewes were alive ≥8 days after transplantation. After reperfusion, a decrease in pH, a rise of lactate and lactate/glucose ratio and a delayed decrease of pO2 were found in the 3 h CIT group. No significant variation of these parameters was observed in the 24 h CIT group. Significant decreases of AAs were observed during reperfusion and these decreases were more pronounced and concerned a larger number of compounds in the 24 h CIT group than in the 3 h CIT group. There was no significant uterine apoptotic signal in either group. Overall, these results suggest that extended CIT storage delayed restoration of aerobic glycolysis and induced an increase in AA requirements of the uterus after reperfusion. However, this biochemical alteration did not reduce success rate for uterine transplantation.

Mid- and long-term prognosis of off- vs. on-pump coronary artery bypass graft in patients with multisite artery disease.

BACKGROUND: Among patients with coronary artery disease (CAD), around 25% have multisite artery disease (MSAD). Patients with CAD and MSAD are at higher risk of peri-operative and long-term cardiovascular events. Whether off-pump coronary bypass grafting (CABG) can improve their prognosis is unknown. We aimed to assess the benefits of off- vs. on-pump cardiac surgery in patients undergoing CABG, according to coexistence of extra-cardiac artery disease. METHODS: Between April 1998 and September 2008, 1221 patients undergoing CABG without any other intervention were enrolled. Overall death and major cardiovascular events were recorded at 1-month and during long-term follow-up. A propensity score (PS), derived from all relevant variables (P<0.25) associated with on-pump as compared to off-pump CABG, and representing the likelihood for each individual patient to receive off-pump CABG, was calculated. RESULTS: MSAD was observed in 279 patients (23%). Off-pump CABG was performed in 208 (17%) patients. The median follow-up was 7.6 years. The 10-year mortality was significantly lower in off- vs. on-pump CABG group (74±4% vs. 68±2%, P=0.024). In patients with MSAD, there was a trend for better survival for off- vs. on-pump CABG (63±8% vs. 50±4%, P=0.078). After adjustment for PS, we found no further difference between on- and off-pump CABG both in the whole cohort (HR=1.30, P=0.10), as well as in MSAD patients (HR=1.51, P=0.14). CONCLUSIONS: Patients with MSAD receiving CABG are at worst prognostic than those with isolated CAD. In these patients, we found no significant difference in the long-term mortality and cardiovascular events between on- and off-pump CABG.

Echocardiography is useful to predict postoperative atrial fibrillation in patients undergoing isolated coronary bypass surgery: A prospective study.

OBJECTIVE:: Postoperative atrial fibrillation is a major complication following coronary artery bypass graft. We hypothesized that, beyond clinical and electrocardiogram (ECG) data, transthoracic echocardiography could improve the prediction of postoperative atrial fibrillation. METHODS:: We prospectively studied 169 patients in sinus rhythm who underwent isolated coronary artery bypass graft in our institution. Clinical, biological, ECG and transthoracic echocardiography data were collected within 24 h before surgery. The patients were continuously monitored during the first five days, and then had daily 12-lead ECG afterwards until discharge. Postoperative atrial fibrillation was defined by any episode >10 min. RESULTS:: Postoperative atrial fibrillation was found in 65 patients (38%). Compared with those without, patients with postoperative atrial fibrillation were significantly older ( p=0.008), had more frequently a history of hypertension ( p=0.009), history of atrial fibrillation ( p<0.001) and New York Heart Association class ⩾III ( p=0.004). They also had longer PR interval ( p=0.005), higher preoperative NT-pro brain natriuretic peptide level ( p=0.006), left ventricle end-diastolic volume ( p=0.002), indexed left ventricle mass ( p<0.0001), indexed maximal left atrial volume ( p<0.0001), maximal right atrial area ( p<0.001) and lower left ventricle ejection fraction ( p=0.04). In multivariate analysis, history of atrial fibrillation (odds ratio =6.1, 95% confidence interval: 1.4-26.0, p=0.02) and indexed maximal left atrial volume (odds ratio =1.13, 95% confidence interval: 1.1-1.2, p=0.001) were the only two independent predictive factors of postoperative atrial fibrillation. The addition of echocardiographic parameters improved the predictive value (χ2) of the model, from 34 to 57. CONCLUSION:: A history of atrial fibrillation and indexed left atrial maximal volume are the best predictors of the occurrence of postoperative atrial fibrillation following coronary artery bypass graft. The identification of high risk population of postoperative atrial fibrillation using these two factors could lead to the development of targeted strategies to limit this frequent complication in these patients.

Porous alumina ceramic sternum: A reliable option for sternal replacement.

CONTEXT: To date, there is no gold standard technique for sternum replacement. Current techniques rely on metallic prosthesis, meshes and bars, or bone grafts. However, they have several pitfalls. AIMS: The aim of this article is to report the results of sternal replacement with a porous alumina ceramic sternum. SETTINGS AND DESIGN: Surgeries were performed in two teaching hospitals in France. METHODS: We designed a porous alumina ceramic prosthesis which possesses interesting characteristics for this surgery such as great biocompatibility, a certain level of bacterial resistance, radiolucency, and compatibility with radiotherapy. The implant is stitched to the ribs with suture thread and does not require osteosynthesis material. RESULTS: Six patients with a mean age of 60.6 years received this prosthesis. Indication was tumor in five cases and mediastinitis in one case. The mean follow-up is 20 months (3-37 months). No major complication occurred and healing was fine for all patients. Patients did not complain of breathing discomfort or pain related to the prosthesis. CONCLUSIONS: This new technique is promising even if there are only six patients in this study.

Immature Granulocytes: A Risk Factor of Infection after Cardiac Surgery.

BACKGROUND: Similarly, to sepsis, cardiac surgery with cardiopulmonary bypass (CPB) induces major changes in leukocyte subsets. Immature granulocytes (IGs) increase both in sepsis and after open-heart surgery. Secondary infections are a major complication of cardiac surgery with CPB. We hypothesized that the assessment of leukocyte subsets with multicolor flow cytometry (FCM) could help the front-line clinician to better identify patients at high risk of infectious complications in this clinical setting. METHODS: In this single-center observational pilot study, we identified 26 leukocyte subsets using three combinations of antibodies (from 5 to 10 colors per combinations): one devoted to granulocytes, one to lymphocyte subpopulations and one for rare cells (plasma cells and dendritic cells). Blood samples were obtained preoperatively and immediately after open-heart surgery under CPB in 59 patients without immuno-depression, chronic or neoplastic inflammatory disease, and immunosuppressive treatment. Secondary infections during hospital stay were recorded. RESULTS: Patients exhibited postoperative NK and T-cell lymphopenia, increased levels of IGs and monocytes with low levels of surface HLA DR. Twelve patients developed secondary infectious complications. Only immediate postoperative IG levels were significantly higher in these patient (6.6 [6; 7.39] G/L vs. 3.8 [2.67; 5.72] G/L, P = 0.01). Patients with immediate postoperative increase of IGs developed more frequently infectious complication (10/22 [46%] vs. 2/37 [5%]: P < 0.001). CONCLUSIONS: This study suggests that postoperative increase of IGs is related to postoperative organ failure and promises to help in early identification of patients at risk of infectious complications after open-heart surgery under CPB. © 2018 International Clinical Cytometry Society.

Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis.

Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.

Uterus tolerance to extended cold ischemic storage after auto-transplantation in ewes.

OBJECTIVE: To assess how the uterus tolerates extended cold ischemic storage before auto-transplantation in ewes. STUDY DESIGN: Fourteen uterine auto-transplantations were performed in ewes from November 2014 to June 2015 at the Analysis and Research Laboratory of Limoges, France. The animals were divided into 2 groups: 7 after 3h of cold ischemia timeand 7 after 24h. Transplant was assessed ≥8days after transplantation. Histology and apoptosis analyses (TUNEL method and indirect immunohistochemistry of cleaved Caspase 3) were performed before uterus retrieval (control), after 90min following reperfusion and ≥8days after transplantation. RESULTS: Twelve uterine auto-transplantations were successfully performed. The histological analysis at 90min following reperfusion revealed a moderate inflammation of the endometrium and serosa in the 3-h group and severe inflammation in the 24-h group, but no significant apoptotic signal was found in either group. Seven ewes were alive at ≥8days after transplantation: the macroscopic and histological analyses revealed two viable uteri in the 3-h group and three in the 24-h group. In each group one uterus was necrotic. CONCLUSION: These first results in ewes suggest that the uterus is an organ with a good tolerance to extended cold ischemic storage before transplantation.

Impact of Pulmonary Hypertension on Outcome in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction.

AIMS: The prognostic impact of elevated pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused on patients with preserved left ventricular ejection fraction (LVEF). We aimed to investigate the impact of pulmonary hypertension (PH), invasively derived, on survival in severe AS with preserved LVEF. METHODS AND RESULTS: Between 2000 and 2010, 749 patients (74 ± 8 years, 57% males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization. PH was defined as mean PAP > 25 mmHg. The mean follow-up was 4.6 ± 3.0 years. Overall, 32% (n = 241) of patients had PH. Surgical aortic valve replacement (SAVR) was performed in 91% of patients with 4.5% of 30-day mortality rate, significantly higher in patients with PH than without PH (7.5 vs. 3.5%, p = 0.014). In logistic regression, PH was an independent predictor of increased 30-day mortality (odds-ratio = 2.2, p = 0.04). Overall long-term survival was significantly reduced in patients with PH as compared to those without (10-year: 52 ± 5 vs. 68 ± 3%, p < 0.0001). Likewise, focusing on patients with SAVR showed significant reduced survival in those with PH (10-year: 57 ± 5 vs. 72 ± 3%, p < 0.0001). In multivariate analysis, after adjustment for relevant cofactors, PH was an independent predictor of mortality (hazard ratio = 1.5, p = 0.009). Using quartiles of mean PAP, only patients with most elevated values (Q4: mean PAP: 27-67mmHg) had significantly reduced survival, as compared to other quartiles (all p < 0.0001). CONCLUSION: In patients with severe AS and preserved LVEF, PH is an independent predictor of 30-day and long-term mortality patients. Nevertheless, only severely elevated PAP seems associated with reduced survival.

Outcomes after surgery for acute type A aortic dissection in "non-Marfan syndrome" patients with long life expectancy: A 24-year follow-up.

BACKGROUND: Long-term survival and risk of reoperation in "non-Marfan syndrome" patients with a long life expectancy who undergo emergency surgery for acute type A aortic dissection (aTAAD) are not well known. AIM: To analyse survival, risk of reoperation and quality of life in this population. METHODS: From 1990 to 2010, all patients aged≤50 years and not affected by Marfan syndrome, who underwent emergency surgery for aTAAD at two institutions, were included in this analysis. Patients were categorized into four groups according to the extension of the aortic replacement: SUPRACORONARY, ROOT, ARCH and EXTENSIVE. RESULTS: Sixty-six patients (mean age 45±4 years; range 34-50 years) were considered eligible for this analysis. Overall in-hospital mortality was 24% (16/66 patients); and 25%, 23%, 20.5% and 43% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Mean follow-up among survivors was 10.5±7.2 years (range: 0.1-24.7 years). Overall 10-year survival was 55±6%; and 75±12%, 69±13%, 47±8% and 28±17% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Overall freedom from reoperation on the aorta was 73±7.5%; and 40±20%, 75±21%, 78±8% and 100% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. CONCLUSIONS: In our experience, patients who underwent isolated supracoronary ascending aorta or root replacement showed the most satisfactory late survival. However, because the risk of reoperation is low when the replacement is extended to the root, our data suggest that root replacement could represent a good compromise between operative mortality and long-term survival.

Fate of aortic bioprostheses: An 18-year experience.

OBJECTIVE: To report our experience in aortic valve replacement with the Mitroflow (Sorin, Vancouver, Canada) aortic bioprosthesis. METHODS: We retrospectively reviewed all patients who underwent aortic valve replacement with a Mitroflow bioprosthesis at our institution from January 1994 to December 2011. No exclusion criteria were retained. Patients were followed yearly. Echocardiography follow-up was performed systematically before the hospital discharge and annually by patients' cardiologists. RESULTS: Seven hundred twenty-eight patients (mean age, 76 ± 6 years; range, 33-91 years) underwent aortic valve replacement with Mitroflow 12A or LX model and were included in this analysis. 30-day mortality for nonemergent isolated aortic valve replacement was 5.5%. Eight patients (1%) underwent reoperation for structural valve deterioration (SVD) and 30 patients (5.8%) presented echocardiographic signs of SVD. Actuarial freedom from reoperation for SVD was 99% ± 0.5% and 95% ± 5% at 10 and 15 years. Actuarial freedom from echocardiographic signs of SVD was 77% ± 5% and 56% ± 11% at 10 and 15 years, respectively. At the univariate analysis, only the mean gradient at discharge (P = .0200), the prevalence of size 19 (P = .0273), and severe patient-prosthesis mismatch (P = .0384) were significantly different in patients developing SVD at follow-up. Freedom from echocardiographic signs of SVD at 8 years were 88% ± 4% and 64% ± 13% in patients with a Mitroflow > 19 and Mitroflow 19, respectively (log-rank test, P = .0056; Wilcoxon test, P = .0589). CONCLUSIONS: Overall outcomes were satisfactory. However the risk of early SVD seems higher for the Mitroflow size 19. This size should be reserved for applications when annulus enlargement is risky or there is an anatomic contraindication to sutureless or stentless valve.

Hemodynamic monitoring using a single-use indwelling transesophageal echocardiography probe in an unstable patient after open-heart surgery.

BACKGROUND: Hemodynamic monitoring is frequently needed in ventilated patients with unstable hemodynamics after open-heart surgery. Novel miniaturized single-use transesophageal echocardiographic probe has been scarcely used in this clinical setting. CASE PRESENTATION: A patient who underwent a scheduled open-heart surgery developed a ventilator-associated pneumonia and was referred to the intensive care unit for post-operative acute respiratory distress syndrome. Hemodynamic monitoring was performed with a single-use indwelling transesophageal echocardiography probe during 50 h. Initially, a contrast study depicted a patent foramen ovale with a right-to-left shunt. Nitric oxide was administered and positive end-expiration pressure was reduced. Subsequently, the patient became hemodynamically unstable and the identification of a localized tamponade due to compressive left atrial hematoma prompted reoperation. CONCLUSIONS: The novel hemodynamic monitoring device described here appears valuable to help identifying severe post-operative complications and guide acute care.

Biological and clinical outcomes in the elderly with left ventricular dysfunction: Are there differences between on-pump and off-pump coronary artery bypass grafting?

AIM: To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. MATERIAL OF STUDY: We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77.6% at 10 years and no significant difference in MACCE was observed (p=0.3016). DISCUSSION: Our results show a lower incidence of myocardial injury in OPCABG group, but there aren't differences in term of MACCE in both groups. Recent studies have indicated the advantages of OPCABG in the elderly patients, reporting a reduction of postoperative morbidity and organ dysfunction. However these studies not analyzed the impact of LV dysfunction on early and late postoperative outcomes in high-risk patients. CONCLUSIONS: In the elderly with LV dysfunction, the OPCABG technique showed lower incidence of postoperative myocardial injury. However, at the follow-up, this does not reflect any significant differences in incidence of MACCE.

Coronary artery bypass grafting in the octogenarian. Is complete revascularization always necessary?

AIM: The aim of this study was to investigate whether the completeness of revascularization affects the outcomes in the octogenarian. MATERIAL OF STUDY: We retrospectively reviewed 130 consecutive octogenarians who underwent isolated coronary artery bypass grafting (CABG) between January 2003 and September 2010. According to operative technique, patients were categorized in Complete Revascularization (CRV) Group (96 patients) and in Incomplete Revascularization (IRV) Group (34 patients). Follow-up was 98% complete (mean: 30 ± 25 months). RESULTS: The overall in-hospital mortality was 13% and was similar in both groups (p=0.0553). Multivariate regression analysis identified preoperative left ventricular ejection fraction ≤ 40% (p= 0.0060; OR= 0.19) and NHYA class > II (p= 0.0042; OR= 0.17) as risk factor for in-hospital death. Cox regression analysis not identified incomplete revascularization as risk factor for early or late death (p= 0.1381 and p= 0.8865). No differences in 5-year survival and freedom from major adverse cardiac and cerebrovascular events (MACCE) was found between two groups (p=0.8865 and p=0.6283). DISCUSSION: CRV is important in young patients undergoing CABG, but this principle remains less absolute in elderly patients. In our study, the survival benefit of CRV was less in octogenarians. Probably, the major benefit of CRV was seen in patients less than 80 years of age. This makes sense because these patients have a longer expected survival, and there were more patients available to statistically confirm any difference in outcome. CONCLUSIONS: In octogenarians undergoing CABG, IRV does not affect survival and freedom from MACCE. Patients' preoperative conditions are important in determining short and long term outcomes.

Uterus retrieval process from brain dead donors.

OBJECTIVE: To describe the feasibility of human uterus retrieval after donation after brain death. DESIGN: Single-center, prospective study. SETTING: University hospital. PATIENT(S): Female brain dead donors. INTERVENTION(S): The families of female brain dead donors were informed about consent to uterus donation. A specific organ retrieval procedure was performed. At the end of the procedure the uterus was removed together with the hypogastric vessels, parametria, and vaginal fornix. The tolerance of the uterus to cold ischemia was evaluated with histology and TUNEL reaction up to 24 hours. MAIN OUTCOME MEASURE(S): Rate of uterus donation refusal. RESULT(S): Between August 1, 2012 and July 31, 2013, seven uteri were retrieved from 14 female multiorgan donors. No refusal to uterus donation occurred. Our surgical protocol did not interfere with vital organ retrieval and was readily accepted by the other transplantation teams. The hypogastric vessels could be preserved in all cases but for one vein loss in the first retrieval. Histology studies did not find major morphologic changes after 24 hours of cold ischemia. Apoptosis was rare. CONCLUSION(S): Uterus retrieval could be part of a reproducible multiorgan procurement procedure. Uterus donation seems readily accepted. This preliminary study is a necessary step before any transplantation project.

Octogenarians with uncomplicated acute type a aortic dissection benefit from emergency operation.

BACKGROUND: The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS: Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). RESULTS: The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p<0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p<0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. CONCLUSIONS: Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.

Aortic valve replacement with smaller prostheses in elderly patients: does patient prosthetic mismatch affect outcomes?

BACKGROUND AND AIM OF THE STUDY: To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. METHODS: Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2)/m(2). Patients having IEOA < 0.75 cm(2)/m(2) and IEOA < 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. RESULTS: PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. CONCLUSIONS: PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.