Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery.

BACKGROUND: There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB. METHODS: A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation. RESULTS: From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischaemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days. CONCLUSION: Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.

Five-Year Survival of Transcatheter Aortic Valve Implantation in High-Risk Patients.

BACKGROUND: Although transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic stenosis in high-risk patients in Australia, there is still limited data on long term survival. METHODS: All patients undergoing TAVI at a single tertiary institution between September 2009 and December 2015 were included. The primary outcome was survival, by linkage of patients with the National Death Index of the Australian Institute of Health and Welfare. Post-procedure data and echocardiographic measurements were retrospectively analysed for all patients. RESULTS: A total of 186 patients were included. It was a high-risk patient population (mean EuroSCORE 31.5±20.5, mean age 83.0±8.2 years). Valve prostheses used were Edwards SAPIEN (ES) (Edwards, Irvine, CA, USA) in 16.1%, Edwards SAPIEN XT (ESXT) in 74.2%, and Medtronic CoreValve (MCV) (Medtronic, Minneapolis, MN, USA) in 9.7%. Median survival time for the entire cohort was 68.2 months (95% Confidence Interval [CI]; Lower Limit [LL] 58.0 months, Upper Limit [UL] not defined). The 2- and 5-year estimates of survival were 85% (LL 80%, UL 90%) and 56% (LL 48%, UL 66%), respectively. There was no statistically significant difference in median survival between the ES and ESXT valves, or implantation approach. Survival was greater in patients with creatinine <200 µmol/L compared to >200 µmol/L (68.8 months [LL 61.4, UL n/a] vs 48.0 months [LL 25.5, UL n/a]). Over the study period, there was a statistically significant trend in increasing mean transvalvular gradient (ES: 1.66 mmHg/yr, p=0.0058; ESXT: 2.50 mmHg/yr, p≤0.001) and maximum velocity (ESXT: 0.16 m/s/yr, p=0.004) and decreasing valve area (ESXT: -0.07 cm2/yr, p<0.001). There was substantial attrition of patient echocardiographic follow-up (number of echocardiograms followed up at 5 years=6, number at risk=41). CONCLUSIONS: This study has demonstrated acceptable survival in a high-risk cohort of patients undergoing TAVI, with comparable results to larger international experiences. There was a trend for worsening haemodynamics that needs to be monitored. Future studies need to examine patient quality of life and the performance of newer generation prostheses.

Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Aortic Valve Replacement for Aortic Stenosis (SAVR): A Cost-Comparison Study.

BACKGROUND: Comparative costing studies using real-world data stratified by patient case-mix, are valuable to decision makers for making reimbursement decisions of new interventions. This study evaluated real-world hospital admissions and short-term costs of transcatheter aortic valve implantation (TAVI) and isolated surgical aortic valve replacement (SAVR) for patients with aortic stenosis, stratified by the Society of Thoracic Surgeons (STS) risk scores. METHODS: Retrospective analysis of consecutive patients with a principal diagnosis of aortic stenosis who underwent isolated valve replacement at a single tertiary hospital, January 2012-December 2017. Patients were followed-up for 30 days post-procedure or until hospital discharge if index hospitalisation was greater than 30 days. Intensive care unit (ICU) and hospital length of stay (days), and costs in 2018 Australian dollars for the index procedure and 30-day follow-up were assessed. Multivariable generalised linear and two-part models with gamma distribution and log link function adjusting for Society of Thoracic Surgeons (STS) risk group and key sociodemographic characteristics were used. RESULTS: Of 488 patients, 61% males, median age 78 years (IQR 14 years), 221 (45%) received transcatheter aortic valve replacement (TAVI) and 267 (55%) received surgical aortic valve replacement (SAVR). STS risk scores were low (28%), intermediate (46%) and high (26%) for TAVI patients, and low (85%), intermediate (12%) and high (3%) for SAVR patients. When adjusted, TAVI length of stay was 57% shorter than SAVR (95% CI 31-83%, p<0.001) for intensive care unit (ICU) admission, and 64% shorter (95% CI 47-81%, p<0.001) for hospital admissions. TAVI costs were 13% lower than SAVR (95% CI 4-22%, p=0.005). CONCLUSION: This data suggests short-term health care costs are lower for patients with aortic stenosis undergoing TAVI than SAVR. A further roll-out of the TAVI program in hospitals across Australia may result in savings to the health system.

Extracorporeal membrane oxygenation support in refractory perioperative anaphylactic shock to rocuronium: a report of two cases.

In recent years, extracorporeal membrane oxygenation has become increasingly common in the treatment of in-hospital cardiac arrest in non-cardiac surgery patients. This includes cardiac arrest secondary to perioperative anaphylactic shock refractory to standard advanced life support protocols, which is a rare but catastrophic event associated with significant mortality. Neuromuscular blocking drugs are most commonly implicated in perioperative anaphylaxis, with rocuronium playing a major role. In this article, we report two cases of young and otherwise fit and well patients who experienced a perioperative arrest secondary to rocuronium anaphylaxis before elective surgery; both patients did not respond to conventional advanced life support, but survived neurologically intact after institution of urgent veno-arterial extracorporeal membrane oxygenation.

Management of aortic regurgitation and bilateral carotid occlusion in severe Takayasu arteritis.

We present a patient with Takayasu arteritis and severe aortic valve regurgitation and bilateral carotid artery occlusions, who underwent aortic valve replacement and aorto-bicarotid bypass. The management of the cardiovascular manifestations of Takayasu arteritis is reviewed.

Robotically Assisted Minimally Invasive Off-Pump Coronary Artery Bypass Surgery in a Patient With Permanent Tracheostomy.

BACKGROUND: Patients with a permanent tracheostomy requiring coronary surgery represent a unique challenge, being at increased risk of sternal wound complications, mediastinitis and stoma necrosis. Several techniques have been described including manubrium sparing sternotomy, thoracoscopic internal mammary harvest and hybrid revascularisation. METHODS: We report a case of robotic assisted (daVinci®Xi™ Surgical System) total arterial off-pump revascularisation in a patient with previous laryngectomy and permanent tracheostomy. The main advantage of this approach was to minimise the risk of postoperative sternal complication and mediastinatis, whilst still providing the prognostic benefit of total arterial grafting and the neurological advantage of the aorta no-touch technique.

The Aortic Root Replacement Procedure: 12-year Experience from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database.

BACKGROUND: The aortic root replacement procedure (ARR), is often considered the gold standard in the management of aortic root and ascending aorta aneurysms. Our aim was to review the Australian experience with this procedure to ascertain early and late outcomes of mortality and morbidity. METHODS: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for patients undergoing ARR. Preoperative, intraoperative and postoperative variables were analysed. Multiple regression was performed to determine independent predictors of 30-day mortality and permanent stroke, and predictors of late death. Survival estimates were obtained by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index database. RESULTS: Between January 2001 and December 2011, 954 patients underwent ARR with a mean age of 56±15.2 years. The overall 30-day mortality was 5.9% (n=56) with a permanent stroke rate of 2.3% (n=21). The elective surgery mortality was 3.6%. Long-term survival was estimated as 84.4% and 68.7% at 5 and 10 years, respectively. CONCLUSIONS: Aortic root replacement surgery reveals acceptable early mortality, low postoperative stroke rates, and acceptable long-term survival.

Cardiac Magnetic Resonance Imaging Predictors of Short-Term Outcomes after High Risk Coronary Surgery.

BACKGROUND: The euroSCORE II is a widely used pre-coronary artery bypass graft surgery (CAGS) risk score, but its predictive power lacks the specificity to predict outcomes in high-risk patients (16) and left ventricular (LV) dysfunction (<40%) based on 2D-echocardiography who underwent CAGS and in whom CMRI (1.5T) was performed preoperatively were retrospectively studied. Cardiac magnetic resonance imaging parameters were assessed in patients who either had complications immediately post-surgery (n=35), six weeks post-surgery (n=20) or were uncomplicated. RESULTS: The average age of patients recruited was 69±5 years with high euroSCORE II (22±4) and low 2D-echocardiography LV ejection fraction (38%±2%). Cardiac magnetic resonance imaging results demonstrated that those with immediate complications had higher LV scar/infarct burden as a proportion of LV mass (17±3% vs 10±3%; p=0.04) with lower circumferential relaxation index (2.5±0.46 vs 2.8±0.56; p=0.05) compared to those with no complications. Early mortality from surgery was 17% (n=9) and was associated with lower RV stroke volume (55±12 vs 68±18; p=0.03) and higher LV infarct scar/burden (18±2% vs 10±2%, p=0.04). Cardiac magnetic resonance imaging showed patients with complications at six weeks post-surgery had higher LV scar/infarct burden (14.5±2% vs 6.8±2%, p=0.03) compared to those without complications. CONCLUSION: Cardiac magnetic resonance imaging preoperative LV and RV parameters are valuable in assessing the likelihood of successful outcomes from CAGS in high-risk patients with LV dysfunction.

Early and Late Outcomes Following Valve Sparing Aortic Root Reconstruction: The ANZSCTS Database.

BACKGROUND: Valve sparing aortic root reconstruction (VSARR) has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia. METHODS: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained five- and 10-year survival estimates by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index. RESULTS: Between January 2001 and January 2012, 169 consecutive patients underwent VSARR procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, nine patients (5.9%) died within 30 days post procedure and five patients (3%) had permanent strokes. However, out of 132 elective cases, only five patients died (3.8%). Independent predictors of 30-day mortality were female gender [OR 5.65(1.24-25.80), p=0.025], preoperative atrial arrhythmia [OR 6.07(1.14-32.35), p=0.035] and acute type A aortic dissection [OR 7.71(1.63-36.54), p=0.01]. Long-term survival was estimated as 85.3% and 72.7% at five- and 10-years, respectively. CONCLUSIONS: Along with an acceptable rate of early mortality and stroke, VSARR procedures provide good long-term survival according to the ANZSCTS database. As promising procedure for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery.

Long Term Outcomes Following Freestyle Stentless Aortic Bioprosthesis Implantation: An Australian Experience.

BACKGROUND: The Freestyle stentless bioprosthesis (FSB) has been demonstrated to be a durable prosthesis in the aortic position. We present data following Freestyle implantation for up to 10 years post-operatively and compare this with previously published results. METHODS: A retrospective cohort analysis of 237 patients following FSB implantation occurred at five Australian hospitals. Follow-up data included clinical and echocardiographic outcomes. RESULTS: The cohort was 81.4% male with age 63.2±13.0 years and was followed for a mean of 2.4±2.3 years (range 0-10.9 years, total 569 patient-years). The FSB was implanted as a full aortic root replacement in 87.8% patients. The 30-day all cause mortality was 4.2% (2.0% for elective surgery). Cumulative survival at one, five and 10 years was 91.7±1.9%, 82.8±3.8% and 56.5±10.5%, respectively. Freedom from re-intervention at one, five and 10 years was 99.5±0.5%, 91.6±3.7% and 72.3±10.5%, respectively. At latest echocardiographic review (mean 2.3±2.1 years post-operatively), 92.6% had trivial or no aortic regurgitation. Predictors of post-operative mortality included active endocarditis, acute aortic dissection and peripheral vascular disease. CONCLUSIONS: We report acceptable short and long term outcomes following FSB implantation in a cohort of comparatively younger patients with thoracic aortic disease. The durability of this bioprosthesis in the younger population remains to be confirmed.

Comparison of the Safety and Efficacy of On-Pump (ONCAB) versus Off-Pump (OPCAB) Coronary Artery Bypass Graft Surgery in the Elderly: A Review of the ANZSCTS Database.

BACKGROUND: The elderly population (age >70 years) incurs greater mortality and morbidity following CABG. Off-pump coronary artery bypass (OPCAB) may mitigate these outcomes. A retrospective analysis of the results of OPCAB in this population was performed. METHODS: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for elderly patients (n=12697) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=11676) with OPCAB (n=1021) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analyses was performed after cross-matching the database with the national death registry to identify long-term mortality. RESULTS: High-risk patients were more prevalent in the ONCAB group (p<0.05). OPCAB patients received fewer distal anastomoses than ONCAB patients (2.4±1.1 vs 3.3±1.0, p<0.001). Thirty-day mortality and stroke rates between OPCAB and ONCAB were not significantly different (2% vs 2.5% and 1.1% vs 1.8%, respectively). There was a non-significant trend towards improved 10-year survival in OPCAB patients using multivariate analysis (78.8% vs. 73.3%, p=0.076, HR 0.83; 95% CI 0.67-1.02). CONCLUSIONS: Mortality and stroke rates following CABG surgery are extremely low in the elderly suggesting that surgery is a safe management option for coronary artery disease in this population. OPCAB did not offer a significant advantage over ONCAB with regards to 30-day mortality, stroke and long-term survival. Further prospective randomised trials will be necessary to clarify risks or benefits in the elderly.

Outcomes of On-Pump versus Off-Pump Coronary Artery Bypass Graft Surgery in the High Risk (AusSCORE > 5).

BACKGROUND: Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. Off-pump coronary artery bypass (OPCAB) may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand. METHODS: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality. RESULTS: The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133). CONCLUSIONS: In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients.

Replacement of the aortic root with a composite valve-graft conduit: risk factor analysis in 246 consecutive patients.

BACKGROUND: Composite valve-graft (CVG) replacement of the aortic root is a well-studied and recognised treatment for various aortic root conditions, including valvular disease with associated aortopathy. There have been few previous studies of the procedure in large numbers in an Australian setting. METHOD: From January 2006 to June 2013, 246 successive patients underwent CVG root replacements at our institution. Mean age was 56.8 years, 85.4% were male, and 87 had evidence of bicuspid aortic valve. Indications for operation included ascending aortic aneurysm in 222 patients, annuloaortic ectasia in 67 patients, and aortic dissection in 38 patients. RESULTS: The overall unit 30-day mortality was 5.7%, including: elective 30-day mortality of 2.2%, and emergent 30-day mortality of 17.2%. Statistically significant multivariate predictors of 30-day mortality were: acute aortic dissection (OR=20.07), peripheral vascular disease (OR=11.17), new ventricular tachycardia (OR=30.17), re-operation for bleeding (OR=14.42), concomitant mitral stenosis (OR=68.30), and cerebrovascular accident (OR=144.85). CONCLUSIONS: Low postoperative mortality in our series matches closely with results from similar sized international studies, demonstrating that this procedure can be performed with low risk in centres with sufficient experience in the operative procedure.

Geriatric cardiac surgery: chronology vs. biology.

Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. METHOD: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. RESULTS: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue. CONCLUSIONS: Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.

The freestyle aortic bioprosthesis: a systematic review.

BACKGROUND: The Medtronic Freestyle bioprosthesis (FSB) provides an alternative to other prostheses for both aortic valve and aortic root surgery. This paper is a systematic review of the post-operative outcomes in patients with aortic valve and/or aortic root disease following FSB implantation. METHODS: Electronic databases were searched for primary analysis, prospective randomised studies comparing the FSB with an alternative aortic prosthesis were included. Additionally, case series that included data for at least 100 individual operated patients were used for secondary analysis. RESULTS: Among three identified randomised studies, 199 FSB cases were compared with homografts, and stented and an alternative stentless bioprosthesis. The FSB showed comparable hospital mortality (4.5% vs. 5.3%) and eight-year actuarial survival (80±5.0% versus 77±6.0%) with the homograft (respectively) and comparable reduction in left ventricular mass index relative to other prosthesis types. Over 6000 individual patients were included in the selected 15 case series. Weighted mean operative mortality, neurological event rate and five-year actuarial survival was 5.2%, 5.5% and 77.8%, respectively. CONCLUSION: The FSB performed comparably against alternative prostheses regarding in-hospital mortality, long-term survival and reduction in left ventricular mass index. Included case series demonstrated robust post-operative outcomes in both the short and long term.

Transapical aortic valve implantation - an Australian experience.

BACKGROUND: The aim of this study was to report our initial experience with the transapical approach to transcatheter aortic valve implantation (TAVI) at an Australian institution. METHODS: All patients with severe, symptomatic aortic stenosis were assessed by our multidisciplinary team. A total of 32 patients received a transapical TAVI using an Edwards SAPIEN prosthesis. Data were prospectively collected and analysed according to the Valve Academic Research Consortium version 2 guidelines. RESULTS: Intraoperative outcomes included: 100% device success with no conversion to surgical valve replacement, extracorporeal membrane oxygenation was used electively in 15.6% and emergently in 6.3%, and no valve migration or malpositioning requiring prosthesis retrieval and re-implantation. Outcomes at 30 days post-TAVI included: No mortality, 3.1% myocardial infarction, no disabling stroke, 3.1% non-disabling stroke, no transient ischaemic attacks, 6.3% life-threatening bleeding, 15.6% major bleeding, 3.1% major vascular complications, and 12.5% postoperative acute kidney injury requiring renal replacement therapy. Mild paravalvular regurgitation was present in 29%, and there was no moderate or severe regurgitation. Mean follow-up time was 28.8±12.9 months. Cumulative results included: 9.4% mortality, 6.3% stroke, 6.3% myocardial infarction, and no repeat procedures. At one year postoperation, echocardiography demonstrated that the mean pressure across the prosthesis was 10.1±1.7mmHg, and the mean aortic valve area was 1.4±0.2cm(2). CONCLUSION: Good short-term outcomes and low or zero mortality are achievable with transapical TAVI at an Australian institution.

Anaortic off-pump coronary artery bypass grafting in the elderly and very elderly.

BACKGROUND: Elderly patients undergoing surgical revascularisation may disproportionately benefit from avoiding manipulation of the ascending aorta and cardiopulmonary bypass. In this multi-centre observational study, we sought to determine the 30-day outcomes of anaortic off-pump coronary artery bypass (OPCAB) in an elderly and very-elderly population. METHODS: Data were prospectively collected for all patients aged >70 years old (y) undergoing anaortic OPCAB at three hospitals between January 2002 and October 2011. Analysis was carried out on two age sub-groups (70-79 y vs. ≥80 y). Multiple logistic regression was used to identify predictors of post-operative 30-day mortality. RESULTS: In total, 1135 patients >70 years underwent anaortic OPCAB - 817 (72%) patients were aged 70-79 y while 318 (28%) were aged ≥80 y. The rate of mortality and morbidity for both groups was low: 30-day mortality (70-79 y: 1.8%; ≥80 y: 2.8%) or permanent stroke (70-79 y: 0.2%; ≥80 y: 0.9%). Chronic lung disease, a history of previous myocardial infarction and left main disease were independent predictors of 30-day mortality. CONCLUSIONS: OPCAB is associated with low rates of 30-day mortality and peri-operative stroke in this elderly and very elderly patient cohort. Anaortic OPCAB can provide excellent short-term post-operative outcomes and may give the elderly and very elderly population the opportunity to benefit from surgical coronary revascularisation.

Outcomes of surgical aortic valve replacement in octogenarians.

BACKGROUND: In the era of TAVI, there has been renewed interest in the outcomes of conventional AVR for high-risk patients. This study evaluates the short- and long-term outcomes of AVR in octogenarians. METHODS: A retrospective review was performed of all 117 patients aged ≥ 80 years who underwent AVR, (isolated AVR (n = 60) or AVR+CABG (n = 57),) from August 2005 to February 2011 at Royal Prince Alfred Hospital and Strathfield Hospital. Univariate analysis was used to compare pre- and post-operative variables between younger and older subgroups (age 80-84, n = 82; age 85-89, n = 35 respectively). Long-term survival data was obtained from the National Death Index at the Australian Institute of Health and Welfare and survival curves were constructed using the Kaplan-Meier method. RESULTS: The median age was 83 years (interquartile range, 81-85 years), 46.2% were females, the median EuroSCORE was 10.89% (interquartile range, 8.20-16.45%) and 16.2% of patients had a EuroSCORE ≥ 20%. The difference between subgroups for history of stroke was significant (p = .042). Post-operative complications included pleural effusion (12.8%), new renal failure (4.3%) and respiratory failure (4.3%). The rate of major adverse events was extremely low, with no cases of stroke. The 30-day mortality rate was 3.4%. There was a significant difference between subgroups for 30-day mortality (p = .007). 38.9% of patients were discharged home, 11.5% were transferred to another hospital and 38.9% spent a period of time in a rehabilitation institution post discharge. In terms of long-term survival, the six-month, one-year and three-year survival was 95.6%, 87.6% and 58.4% respectively. CONCLUSIONS: Surgical AVR yields excellent short- and long-term outcomes for potentially high-risk, elderly patients.

Coronary artery bypass grafting with and without manipulation of the ascending aorta--a meta-analysis.

BACKGROUND: The main criticism of surgery in the SYNTAX trial was increased rate of stroke when compared to percutaneous coronary intervention. We aimed to determine whether avoiding aortic manipulation would decrease the rate of stroke. METHOD: We performed a meta-analysis of seven studies comparing coronary artery bypass grafting (CABG) with and without manipulation of the ascending aorta. RESULTS: When anaortic off-pump coronary artery bypass grafting (OPCAB) was compared with conventional CABG, the rate of stroke was 0.38% vs. 1.87% (p<0.0001). When anaortic OPCAB was compared with OPCAB using a side-clamp or proximal graft anastomosis device the rate of stroke was 0.31% vs. 1.35% (p=0.003). CONCLUSION: Avoiding aortic manipulation during CABG may decrease the rate of peri-operative stroke.