Early mortality and neurologic outcomes following mitral valve surgery in the very elderly.

OBJECTIVES: Valve repair is the gold standard for treatment of degenerative mitral valve disease. As the population ages, patients undergoing valve degeneration and therefore considered for mitral valve surgery will naturally be getting older. We sought to evaluate whether mitral repair retained a survival advantage over replacement in patients ≥80 years old. METHODS: A retrospective cohort study was performed using data acquired from the United Kingdom National Adult Cardiac Surgery Audit for the outcomes of in-hospital mortality and postoperative cerebrovascular event (CVA). Individual multivariable logistic regression models were created to investigate adjusted associations between these outcomes and type of mitral valve operation, repair or replacement. Additionally, associations between the individual model parameters and in-hospital mortality and CVA were investigated. RESULTS: A total of 1140 patients underwent mitral repair (66.4%, median age 82.3), and 577 patients underwent mitral replacement (33.6%, median age 82.1). The overall age range was 80-92. The incidence of in-hospital mortality favored the repair group (4.4% vs. 8.3%, p = .001). Multivariable logistic regression modeling demonstrated an increased adjusted odds of in-hospital mortality for mitral valve replacement (MVR) (odd ratio [OR]: 2.01, 1.15-3.50, p = .01). The only other parameter associated with an increased adjusted odds of in-hospital mortality was postoperative dialysis (OR: 14.2, 7.67-26.5, p < .001). There was not a demonstrated association between MVR and perioperative CVA (OR: 1.11, 0.49-2.4, p = .8). CONCLUSIONS: In patients ≥80 years old, mitral valve repair (MVr) was shown to be associated with a decreased adjusted odds of mortality, with a null association with CVA. These results suggest that, if feasible, MVr should remain the preferred management strategy, even in the very elderly.

Convergent approach to persistent atrial fibrillation ablation: long-term single-centre safety and efficacy.

Background: Efforts to maintain sinus rhythm in patients with persistent atrial fibrillation (PsAF) remain challenging, with suboptimal long-term outcomes. Methods: All patients undergoing convergent PsAF ablation at our centre were retrospectively analysed. The Atricure Epi-Sense® system was used to perform surgical radiofrequency ablation of the LA posterior wall followed by endocardial ablation. Results: A total of 24 patients underwent convergent PsAF ablation, and 21 (84%) of them were male with a median age of 63. Twelve (50%) patients were obese. In total, 71% of patients had a severely dilated left atrium, and the majority (63%) had preserved left ventricular function. All were longstanding persistent. Eighteen (75%) patients had an AF duration of >2 years. There were no endocardial procedure complications. At 36 months, all patients were alive with no new stroke/transient ischaemic attack (TIA). Freedom from documented AF at 3, 6, 12, 18, 24, and 36 months was 83%, 78%, 74%, 74%, 74%, and 61%, respectively. There were no major surgical complications, with five minor complications recorded comprising minor wound infection, pericarditic pain, and hernia. Conclusions: Our data suggest that convergent AF ablation is effective with excellent immediate and long-term safety outcomes in a real-world cohort of patients with a significant duration of AF and evidence of established atrial remodelling. Convergent AF ablation appears to offer a safe and effective option for those who are unlikely to benefit from existing therapeutic strategies for maintaining sinus rhythm, and further evaluation of this exciting technique is warranted. Our cohort is unique within the published literature both in terms of length of follow-up and very low rate of adverse events.

Body mass index and early outcomes following mitral valve surgery for degenerative disease.

OBJECTIVE: Using a large national database, we sought to better define the relationship between obesity measures and early clinical outcomes following mitral valve surgery for degenerative disease. METHODS: For the outcomes of in-hospital mortality, postoperative cerebrovascular event (CVA), and deep sternal wound infection (DSWI), a retrospective cohort study was performed using data acquired from the United Kingdom National Adult Cardiac Surgery Audit. Multivariable Cox proportional hazard regression modeling was used to investigate associations with individual measures of obesity. Progressively adjusted body mass index (BMI)-specific hazard ratios (HRs) were plotted against mean BMI values in each World Health Organization category using floated variances to investigate specific shapes of association. RESULTS: Multivariable Cox proportional hazard modeling failed to demonstrate an association between mortality and an increase in BMI of 5 points (HR, 0.93, 95% confidence interval [CI], 0.81-1.07), a BMI quintile increase (HR, 0.98; 95% CI, 0.90-1.07), or being classed "obese" by World Health Organization standards (HR, 1.03; 95% CI, 0.74-1.42). A 5-point BMI increase was associated with an increased hazard of DSWI (HR, 1.38; 95% CI, 1.08-1.77) but was not associated with perioperative CVA (HR, 1.05; 95% CI, 0.91-1.21). The shape of association between BMI and mortality appeared approximately U-shaped. DSWI appeared linear, whereas CVA demonstrated an inverted U, or a possible hourglass. CONCLUSIONS: Although individual measures of obesity were not associated with an increased mortality risk on regression modeling, the U-shaped relationship between mortality and increasing BMI demonstrates lower mortality risks in lower obesity classes. Increasing BMI was associated with an increased hazard for DSWI.

Minimally invasive versus conventional sternotomy for Mitral valve repair: protocol for a multicentre randomised controlled trial (UK Mini Mitral).

INTRODUCTION: Numbers of patients undergoing mitral valve repair (MVr) surgery for severe mitral regurgitation have grown and will continue to rise. MVr is routinely performed via median sternotomy; however, there is a move towards less invasive surgical approaches.There is debate within the clinical and National Health Service (NHS) commissioning community about widespread adoption of minimally invasive MVr surgery in the absence of robust research evidence; implementation requires investment in staff and infrastructure.The UK Mini Mitral trial will provide definitive evidence comparing patient, NHS and clinical outcomes in adult patients undergoing MVr surgery. It will establish the best surgical approach for MVr, setting a standard against which emerging percutaneous techniques can be measured. Findings will inform optimisation of cost-effective practice. METHODS AND ANALYSIS: UK Mini Mitral is a multicentre, expertise based randomised controlled trial of minimally invasive thoracoscopically guided right minithoracotomy versus conventional sternotomy for MVr. The trial is taking place in NHS cardiothoracic centres in the UK with established minimally invasive mitral valve surgery programmes. In each centre, consenting and eligible patients are randomised to receive surgery performed by consultant surgeons who meet protocol-defined surgical expertise criteria. Patients are followed for 1 year, and consent to longer term follow-up.Primary outcome is physical functioning 12 weeks following surgery, measured by change in Short Form Health Survey (SF-36v2) physical functioning scale. Early and 1 year echo data will be reported by a core laboratory. Estimates of key clinical and health economic outcomes will be reported up to 5 years.The primary economic outcome is cost effectiveness, measured as incremental cost per quality-adjusted life year gained over 52 weeks following index surgery. ETHICS AND DISSEMINATION: A favourable opinion was given by Wales REC 6 (16/WA/0156). Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer reviewed publication. TRIAL REGISTRATION NUMBER: ISRCTN13930454.

Propensity-matched analysis of outcomes after mitral valve surgery between trainees and consultants (institutional report).

OBJECTIVES: We aimed to determine whether early outcomes and long-term survival after mitral valve surgery performed by trainee residents are equivalent in terms of safety and efficacy when compared with consultant surgeons. METHODS: Between January 2000 and December 2015, a total of 1742 patients who underwent mitral valve surgery were identified. Of these, 1622 operations were performed by consultants (Group I) and 120 operations were performed by trainees (Group II). A propensity score-matched analysis has been used to minimize selection bias. Early postoperative outcomes were defined as in-hospital mortality, cerebrovascular accident, postoperative requirement of renal replacement therapy, reoperation for bleeding and postoperative length of hospital stay. Long-term outcomes were evaluated using late survival data after discharge. RESULTS: Before matching, the 2 groups differed significantly in terms of gender and reduced left ventricular ejection fraction, but these differences were solved after matching. Also, Group I included significantly more patients with mitral regurgitation (83% vs 62%; P < 0.01), but after matching, this difference was corrected (62% vs 59%; P = 0.71). Consultant group was associated with a higher in-hospital mortality (6% vs 2%; P = 0.04) in the unmatched population. Moreover, in the unmatched cohort, this group had longer cross-clamp time compared with the trainees group (91 ± 38 vs 89 ± 26 min; P = 0.47) and longer cardiopulmonary bypass time (132 ± 58 vs 121 ± 33 min; P = 0.27); these differences were not statistically significant. There were no significant differences in postoperative dialysis, cerebrovascular accident, reoperation for bleeding and length of hospital stay. Even after matching, no significant differences were found in terms of perioperative complications. The Kaplan-Meier survival curves at 1, 5 and 10 years were similar between the 2 groups. CONCLUSIONS: Mitral valve surgery can be safely performed by trainees and provides similar short- and long-term results compared with consultant surgeons.

Impact of body mass index on outcomes following mitral surgery: does an obesity paradox exist?

OBJECTIVES: This study was conducted to clarify the relationship between body mass index and mitral valve (MV) surgery and to determine whether an 'obesity paradox' exists in the context of surgery for degenerative MV disease. METHODS: In this retrospective single-centre study, we analysed data from 715 patients who underwent mitral surgery for degenerative disease from 2000 to 2015. Patients were classified according to body mass index: underweight (<20 kg/m2), normal weight (20-24.99 kg/m2), overweight (25-29.99 kg/m2) and obese (≥30 kg/m2). Early and long-term results were investigated. Multivariable analysis was conducted to identify risk factors for long-term mortality. RESULTS: Mean follow-up was 67 ± 44 months (range 0-190 months). There were no differences between groups regarding 30-day mortality (P = 0.35), stroke (P = 0.45), reoperation for bleeding (P = 0.9) and length of hospital stay (P = 0.31). Obese patients were at increased risk of acute kidney injury when compared with normal weight patients (17% vs 5%; P = 0.03) but not when compared with the other groups; this was confirmed within the subgroup with depressed ejection fraction (42% vs 10%, P = 0.02). No differences in long-term survival were found across groups for all patients (P = 0.62) and for patients with depressed ejection fraction (P = 0.6), with a trend towards worse survival in obese patients undergoing MV repair (P = 0.06). Survival in obese patients undergoing repair was significantly worse than that in obese patients undergoing replacement (P = 0.04). CONCLUSIONS: An 'obesity paradox' was not demonstrated after surgery for degenerative MV disease. Obese patients are more prone to acute kidney injury and have worse late survival after MV repair.

Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study.

OBJECTIVES: An increasing number of octogenarians are referred to undergo mitral valve surgery for degenerative disease, and percutaneous approaches are being increasingly used in this subgroup of patients. We sought to determine the survival and its predictors after Mitral Valve Surgery in Octogenarians (MiSO) in a multicenter UK study of high-volume specialized centers. METHODS: Pooled data from 3 centers were collected retrospectively. To identify the predictors of short-term composite outcome of 30 days mortality, acute kidney injury, and cerebrovascular accident, a multivariable logistic regression model was developed. Multiple Cox regression analysis was performed for late mortality. Kaplan-Meier curves were generated for long-term survival in various subsets of patients. Receiver operating characteristic analysis was done to determine the predictive power of the logistic European System for Cardiac Operative Risk Evaluation. RESULTS: A total of 247 patients were included in the study. The median follow-up was 2.9 years (minimum 0, maximum 14 years). A total of 150 patients (60.7%) underwent mitral valve repair, and 97 patients (39.3%) underwent mitral valve replacement. Apart from redo cardiac surgery (mitral valve repair 6 [4%] vs mitral valve replacement 11 [11.3%], P = .04) and preoperative atrial fibrillation (mitral valve repair 79 [52.6%] vs mitral valve replacement 34 [35.1%], P < .01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was lower in the mitral valve repair group (10.2 ± 11.8 vs 13.7 ± 15.2 in mitral valve replacement; P = .07). No difference was found between groups for duration of cardiopulmonary bypass and aortic crossclamp times. The 30-day mortality for the whole cohort was 13.8% (mitral valve repair 4.7% vs mitral valve replacement 18.6%; P < .01). No differences were found in terms of postoperative cerebrovascular accident (2% vs 3.1%; P = .9), acute kidney injury requiring dialysis (6.7% vs 13.4%; P = .12), and superficial or deep sternal wound infection (10% vs 16.5%, P = .17; 2% vs 3.1%, P = .67, respectively). The final multiple regression model for short-term composite outcome included previous cardiac surgery (odds ratio [OR], 4.47; 95% confidence interval [CI], 1.37-17.46; P = .02), intra-aortic balloon pump use (OR, 4.77; 95% CI, 1.67-15.79; P < .01), and mitral valve replacement (OR, 7.7; 95% CI, 4.04-14.9; P < .01). Overall survival for the entire cohort at 1, 5, and 10 years was 82.4%, 63.7%, and 45.5% (mitral valve repair vs mitral valve replacement: 89.9% vs 70.7% at 1 year, 69.6% vs 54% at 5 years, and 51.8% vs 35.5% at 10 years; P = .0005). Cox proportional hazard model results showed mitral valve replacement (hazard ratio, 1.88; 95% CI, 1.22-2.89; P < .01) and intra-aortic balloon pump use (hazard ratio, 2.54; 95% CI, 1.26-5.13; P < .01) to be independent predictor factors affecting long-term survival. Logistic European System for Cardiac Operative Risk Evaluation did not perform well in predicting early mortality (area under the curve, 0.57%). CONCLUSIONS: In octogenarians, mitral valve repair for degenerative disease is associated with good survival and remains the gold standard, whereas mitral valve replacement is still associated with significant mortality. Logistic European System for Cardiac Operative Risk Evaluation was unable to predict early mortality in our cohort of patients. Larger international multicenter registries are required to optimize the decision-making process in such a high-risk subgroup.

The evolution of training in off-pump coronary surgery in a single institution.

BACKGROUND: This study analyses the development of off-pump coronary artery bypass (OPCAB) surgery training at a single institution, and compares the early and midterm clinical outcomes of OPCAB and conventional coronary artery bypass grafting (CABG) procedures performed by trainees with or without direct consultant cardiothoracic surgeon supervision. METHODS: Analysis was undertaken on data prospectively recorded on a computer database (Patient Analysis and Tracking System). Of the 2,422 CABG operations performed between January 1999 and December 2001, 969 (40%) were carried out by trainees either off pump (422) or on pump (547). RESULTS: Although the total number of CABG operations performed by trainees remained constant, there was a significant increase in the number of OPCAB operations during the study period compared with conventional CABG, as well as an increase in the average number of grafts per patient in the OPCAB group (both p < 0.05). Furthermore, a significant trend towards using two or more arterial conduits in the OPCAB group was observed in the study period. The number of OPCAB operations performed by trainees as independent operators without direct consultant supervision also increased significantly (p < 0.05). Early and midterm clinical outcomes were similar between patients operated by trainees on pump or off pump as independent operators versus under direct consultant supervision. CONCLUSIONS: The significant increase in OPCAB operations performed by trainees as independent operators or under direct consultant supervision, as well as the increase in the number of grafts per patient and arterial conduits used for myocardial revascularization, demonstrate a progression of training in beating heart surgery for cardiothoracic trainees. Improvements in the techniques have made it safe to teach trainees off-pump multivessel coronary artery revascularization.

Novel repair for late posttraumatic aortic valve injury and root pseudoaneurysm.

We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable.

Evolution of OPCAB surgery in a single institution.

Off-pump coronary artery bypass (OPCAB) grafting is becoming popular worldwide. The development of exposure and stabilization techniques have made this surgery a simple, safe, and routine procedure. The evolution of OPCAB surgery at our institution is presented and discussed.