Elective Primary or Secondary Delayed Sternal Closure Improves Outcome in Severely Compromised Patients.

BACKGROUND: Delayed sternal closure (DSC) in patients with severely compromised preoperative hemodynamics can be helpful as the chest sometimes cannot be able to contain both lungs and heart. We report our experience to evaluate the midterm results of this strategy in an adult population. MATERIALS AND METHODS: From May 2009 till July 2015, 33 patients had DSC as first treatment of severe hemodynamic deterioration after cardiac surgery. Surgical procedures were valvular (9.27%) or coronary artery bypass grafting + others (24.73%). Stepwise logistic regression (SLR) showed that patients with lower ejection fraction, dilated right ventricle, and severe pulmonary hypertension were more likely to need DSC. Patients were divided in two groups: group A (n = 17), when the sternum was reopened before any hemodynamic collapse, or was never closed, and group B (n = 16), when the sternum was reopened after hemodynamic collapse. RESULTS: Inhospital mortality was 39% (n = 13), 18% in group A and 62% in group B (p < 0.0001). In 28 patients where the sternum was reopened, cardiac index increased from 1.7 (1.6, 1.9) L/m2 to 2.8 (2.4, 3) L/m2, p < 0.0001. The sternum was closed in 28 patients (85%), 94% in group A and 75% in group B (p = 0.13), after a median of 4 (2.5) days. SLR showed that only group B (p < 0.0001) was a risk factor for early death. Two-year survival was 48 ± 9%, higher in group A (71 ± 13) than in group B (25 ± 11), p < 0.0001. Cox's analysis showed that group B (p < 0.0001) and redo (p < 0.0001) were risk factors for lower survival. CONCLUSION: Elective DSC represents a useful strategy in severely compromised patients, entailing an improvement of hemodynamics and a higher survival.

Severe ischemic cardiomyopathy with mechanical complications: Still a surgical disease.

BACKGROUND: Surgical treatment of ischemic cardiomyopathy (ICM) with mechanical complications has been limited in favor of suboptimal treatments because of the perception of poor outcome. METHODS AND RESULTS: From May 2009 till June 2014 115 patients with severe ICM (ejection fraction, EF, ≤25%) and mechanical complications were operated on. Median EF was 24% (19, 24), mean end-systolic volume index (ESVi) was 86±27ml/m2 and all patients had an MR grade of 2 or more. The right ventricle (RV) was hypokinetic in 33 patients. All of them underwent mitral valve surgery. Left ventricular (LV) surgical remodeling was performed in 60 patients (52.2%) and tricuspid surgery in 58 (50.4%). In-hospital mortality was 4.3% (5 patients). Six-year freedom from death any cause and from death any cause and NYHA class III/IV were, respectively, 70.5±4.9% and 66.4±4.8%. Cox regression analysis showed that risk factors were lower EF (cutpoint≤20%) and RV hypokinesia. Eighty-six patients had a follow up echocardiogram after a median of 31 (19, 51) months. EF increased by 60%, from 24 (19, 24) to 35 (27 ,46) (p=0.00), and ESVi decreased by 32%, from 87±29 to 59±27ml/m2 (p=0.00). SVi increased by 32%, from 23±7 to 32±12ml/m2. MR grade was ≥2 only in 6 patients (7%) and was not severe in any of them. CONCLUSIONS: Surgery for severe ICM with MR can be performed with low surgical risk and good midterm survival. These findings have to be taken into account while abandoning a clear surgical indication in favor of suboptimal alternative therapies.

Bilateral internal mammary artery grafting: in situ versus Y-graft. Similar 20-year outcome.

OBJECTIVE: The aim of this study was to evaluate the 20-year clinical outcome of patients undergoing coronary artery bypass grafting with bilateral internal mammary arteries (BIMAs) using two different configurations, in situ versus Y-graft. METHODS: From September 1991 to December 2002, 2150 patients with multivessel coronary artery disease underwent isolated myocardial revascularization with BIMA grafting. BIMA was used as an in situ or Y-configuration in 1332 and 818 cases, respectively. A propensity score model was applied to calculate a standardized difference of ≤10% between groups (BIMA in situ vs BIMA Y-graft), and a cohort of 1468 matched patients was identified (734 in each group). Death, non-fatal myocardial infarction and the need for repeat revascularization were defined as 'major adverse cardiac events'. RESULTS: Late mortality was 24.3% (n = 357) [BIMA in situ vs BIMA Y-graft: 26.9% (n = 197) vs 21.8% (n = 160)]; in 11.6% (n = 170) of cases death was due to cardiac causes [11.9% (n = 87) vs 11.3% (n = 83)]. The rate of major adverse cardiac events was 37.1% (n = 545) [40.8% (n = 299) vs 33.5% (n = 246)]. The 20-year survival was 59 ± 6% and the event-free survival was 45 ± 7%. CONCLUSIONS: The clinical outcome of BIMA grafting is independent of surgical configuration. Y-grafting increases the flexibility of BIMA grafting and should be taken into account when a surgical strategy for myocardial revascularization needs to be planned.

Outcome of left ventricular surgical remodelling after the STICH trial.

OBJECTIVES: After the publication of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, surgical indications to left ventricular surgical remodelling (LVSR) have become more restrictive. The experience we report reflects the changes in the real world after the publication of STICH trial. METHODS: From May 2009 to July 2014, 113 patients underwent LVSR, targeted mainly to the left anterior descending territory (89.4%). Of these, 18 patients (15.9%) were operated on an emergency basis. Early and mid-term outcomes were assessed to identify clinical and echocardiographic risk factors. RESULTS: Most patients (90.3%) had chronic ischaemic mitral regurgitation (CIMR) and were in New York Heart Association (NYHA) class III/IV (77.9%). The median ejection fraction (EF) was 26% [95% confidence interval (CI): 26, 28] and scarred areas were akinetic (86.7%) in most cases. Severe left ventricular diastolic dysfunction (LVDD) was found in 33.6% of patients. Mitral valve surgery was performed in 84.1% of patients. Five patients (4.4%) died while in hospital, all from cardiac causes. Risk factors were abnormal bilirubin and emergency status. After a median follow-up of 12 (95% CI: 6, 18) months, 22 patients died, 17 from cardiac causes. Five-year freedom from death any from cause was 73 ± 5%, emergency status and MR Grade 4 being the only risk factors. Five-year freedom from death from any cause and NYHA class III/IV was 61 ± 6%. Severe LVDD and emergency status were risk factors, along with high bilirubin and diabetes mellitus on insulin. Five-year freedom from death from any cause and non-fatal cardiovascular events (rehospitalization, reoperation and stroke) was 55 ± 6%. LVDD and atrial fibrillation were found to be risk factors. After a median follow-up of 31 (95% CI: 19, 38) months, 91 patients underwent postoperative echocardiography. EF increased by 20%, but stroke volume remained unchanged. Postoperatively, patients with severe LVDD had lower EF and higher end-systolic volumes than patients without LVDD. CONCLUSIONS: Our findings show that patients, who are candidates for LVSR, have mostly akinetic areas and CIMR requiring surgical correction and are severely symptomatic. Severe LVDD is common and, along with emergency status, is the most important risk factor for early and late outcome.