Successful use of bivalirudin for combined carotid endarterectomy and coronary revascularization with the use of cardiopulmonary bypass in a patient with an elevated heparin-platelet factor 4 antibody titer.

We report a combined carotid endarterectomy and coronary revascularization surgery with cardiopulmonary bypass using bivalirudin for systemic anticoagulation in a patient with a positive titer for the heparin-platelet factor 4 antibody. The patient experienced procedural success for both the carotid and coronary surgeries. Increased blood and blood product transfusion was required postoperatively.

Early and late results of the surgical correction of cardiac prosthetic paravalvular leaks.

BACKGROUND AND AIM OF THE STUDY: Although the incidence of paravalular leaks, the most common cause of non-structural dysfunction after valve replacement, is well defined, the results of their surgical correction are not. Given the growing enthusiasm for interventional catheter-based correction of paravalvular leaks, a current surgical baseline against which to compare these results is important. METHODS: All patients who had surgical correction of an aortic or mitral paravalvular leak unrelated to acute bacterial endocarditis between 1986 and 2001 were identified from a computerized registry. Hospital records were reviewed, and follow up data obtained. RESULTS: A total of 136 consecutive patients (73 males, 63 females; mean age 64 years) underwent surgical correction of a paravalvular leak. Of the valves, 44 (32%) were aortic and 92 (68%) mitral. More than one previous cardiac operation had been performed in 68 patients (50%). In 107 patients (79%; 32 aortic (73%), 75 mitral (82%)), the leak was the primary indication for reoperation, while for 29 patients (21%; 12 aortic (27%), 17 mitral (18%)) the correction was secondary to another cardiac procedure. In 65 patients (48%; 12 aortic (27%), 53 (58%) mitral)) the leak was repaired primarily, while in 71 patients (52%; 32 aortic (73%), 39 (42%) mitral)) the prosthesis was replaced. Operative mortality was 6.6% (n = 9). There were no significant multivariable predictors of hospital death. Perioperative stroke occurred in seven cases (5.1%), and hospital stay was >14 days in 40 patients (29%). The 10-year Kaplan-Meier survival was 30 (CI 20-39)%. Ten-year actual versus actuarial freedom from repeat paravalvular leak was 84 (CI 68-92)% versus 63 (CI 49-76)%. CONCLUSION: Surgical correction of cardiac paravalvular leaks can be performed with acceptable mortality and morbidity. Patients with surgically corrected paravalvular leaks have a limited life expectancy, but reasonable freedom from recurrent paravalvular leak.

Composite aortic root replacement with a bovine pericardial valve conduit.

In order to offer selected patients undergoing composite aortic root replacement the advantages of a tissue valve, we have constructed conduits intraoperatively by suturing a stented bovine pericardial valve (Edwards Life-sciences LLC, Irvine, CA) inside of a Dacron tube graft (Boston Scientific Corp, Natick, MA). The conduit is quickly made from readily available materials, is easily implanted, and can accommodate any of the anatomic situations encountered in repair of aortic root aneurysms. It is particularly suitable for patients 65 years of age and older.

Results of bioprosthetic versus mechanical aortic valve replacement performed with concomitant coronary artery bypass grafting.

BACKGROUND: Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG). METHODS: From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease. RESULTS: Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p < 0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p < 0.005; reoperation, 98% versus 98%, p = NS. CONCLUSIONS: AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.

Surgical coronary revascularization and antiarrhythmic therapy in survivors of out-of-hospital cardiac arrest.

BACKGROUND: Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population. METHODS: One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed. RESULTS: Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF <40%. Predictors of increased mortality included age >65 years, Cleveland Severity Score >8, and female gender. Predictors of therapeutic ICD discharge included age >65 years, reoperative CABG, LVEF <40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up. CONCLUSIONS: Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

Endoscopic versus open saphenous vein harvest: a comparison of postoperative wound complications.

BACKGROUND: Wound complications associated with long incisions used to harvest the greater saphenous vein are well documented. Recent reports suggest that techniques of endoscopic vein harvest may result in decreased wound complications. A prospective, nonrandomized study was developed to compare outcomes of open versus endoscopic vein harvest procedures. METHODS: There were 106 patients in the open vein harvest group, and 154 patients in the endoscopic vein harvest group. Patient characteristics and demographics were similar in both groups. Wound complications identified were dehiscence, drainage for greater than 2 weeks postoperatively, cellulitis, hematoma, and seroma/lymphocele. RESULTS: Wound complications were significantly less in the endoscopic vein harvest group (9 of 133, 6.8%) versus the open vein harvest group (26 of 92, 28.3%), p less than 0.001. By multivariable analysis with logistic regression, the open vein harvest technique was the only risk factor for postoperative leg wound complication (relative risk 4.0). CONCLUSIONS: Endoscopic vein harvest offered improved patient outcomes in terms of wound healing compared with the open vein harvest technique.

Surgical management and long-term outcomes for acute ascending aortic dissection.

OBJECTIVE: We sought to assess early and late survival and cardiovascular-specific mortality after surgical repair of acute ascending aortic dissection and the effect of differences in surgical technique, patient characteristics, and preoperative diagnostic testing. METHODS: Between 1979 and 2003, 195 consecutive patients underwent repair for acute ascending aortic dissection within 2 weeks of the onset of symptoms. Mean follow-up was 7.0 +/- 5.9 years (range, 0-26 years) and was 100% complete. RESULTS: Patients were aged 62 +/- 15 years on average and were mostly male (66%) and hypertensive (69%). Risk of death early and late after the operation decreased over the study period, with hospital mortality decreasing from 21% to 4% when comparing the first and most recent quartiles (P = .007, chi(2) test for trend). At 1, 5, 10, and 20 years postoperatively, survival was 84%, 69%, 55%, and 30%, respectively, and freedom from cardiovascular death was 86%, 80%, 71%, and 51%, respectively. Additional independent risk factors for death were older age (P < .001), renal dysfunction (P < .003), syncope (P = .007), and peripheral vascular disease (P = .006). During the study period, echocardiographic and computed tomographic diagnostic imaging replaced routine aortic angiographic analysis, and operative techniques involved more frequent use of open distal anastomoses, retrograde cerebral perfusion, earlier restoration of antegrade perfusion, and a conservative approach to aortic arch repair. Freedom from reoperation on the aorta or aortic valve was 93% and 84% at 5 and 10 years, respectively. CONCLUSIONS: Early and late survival after repair of acute ascending aortic dissection has improved progressively over 25 years in association with noticeable changes in preoperative and intraoperative management. Aortic reoperations were infrequent during follow-up.

Late results of combined carotid and coronary surgery using actual versus actuarial methodology.

BACKGROUND: Controversy exists over the short-term results and long-term efficacy of concomitant coronary artery bypass grafting and carotid endarterectomy. Additionally, in this population actual versus actuarial assessment of nonfatal late events has not been previously reported. METHODS: Hospital records of 500 consecutive patients having concomitant carotid endarterectomy and coronary artery bypass grafting between 1979 and 2001 were reviewed, allowing at least 1 year of follow-up on all patients. Long-term nonfatal complications were assessed by actual and actuarial methods. RESULTS: Patient demographics revealed a mean age of 69 years; 74% (370 patients) were male; 75% (377 patients) presented with unstable coronary syndromes; 10% (50 patients) had an intraaortic balloon pump; and 66% (329 patients) were neurologically asymptomatic. Hospital mortality was 3.6% (18 patients). Significant multivariable predictors of hospital death were preoperative transient ischemic attack or myocardial infarction, and nonelective operation. Perioperative strokes were 4.6% (23 patients), of which 2.4% (12 patients) were ipsilateral and 2.2% (11 patients) were contralateral. Significant multivariable predictors of stroke were peripheral vascular disease and use of the right internal mammary artery. Ten-year actuarial survival was 43%. Ten-year actual versus Kaplan-Meier actuarial freedoms with 95% confidence limits from late events were myocardial infarction 87% (78% and 92%) versus 81% (75% and 87%); percutaneous coronary intervention 92% (85% and 96%) versus 89% (84% and 94%); reoperative coronary grafting 96% (89% and 99%) versus 94% (90% and 98%); total stroke 85% (77% and 91%) versus 82% (76% and 87%); ipsilateral stroke 90% (83% and 94%) versus 87% (82% and 92%); carotid endarterectomy 82% (73% and 88%) versus 75% (69% and 82%). CONCLUSIONS: Concomitant carotid and coronary artery surgery is safe and effective, particularly in preventing ipsilateral stroke, and neutralizes the impact of unilateral carotid stenosis on early and late stroke. Actual, not actuarial, methods more accurately represent the true risk of nonfatal late events.

Long-term survival after surgical revascularization for moderate ischemic mitral regurgitation.

BACKGROUND: We sought to characterize patient survival and degree of late mitral regurgitation (MR) in patients undergoing surgical revascularization with moderate ischemic MR. METHODS: We retrospectively reviewed 251 patients undergoing coronary artery bypass graft (CABG) surgery between 1991 and 2001 with 3+ ischemic MR, including 31 patients who had concomitant mitral annuloplasty. Univariate and multivariable testing was employed. RESULTS: Actuarial 1-, 5-, and 10-year survival was 84.0%, 67.5%, and 37.1% in the overall group of 251 patients. Independent predictors of long-term mortality were age 70 years or more (hazard ratio 2.50 [95% confidence interval 1.82 to 3.44]), prior myocardial infarction (3.99 [2.15 to 7.39]), unstable angina (2.27 [1.69 to 3.04]), chronic renal failure (4.87 [3.13 to 7.58]), atrial fibrillation (2.21 [1.65 to 2.96]), left internal mammary artery to left anterior descending artery graft (0.28 [0.18 to 0.43]), preoperative beta-blocker (0.43 [0.28 to 0.67]), ejection fraction (0.71/10% [0.64 to 0.80]), left atrium size (0.88/mm [0.84 to 0.92]), diffuse wall motion abnormalities (2.83 [1.77 to 4.55]), and mitral leaflet restriction (3.85 [2.46 to 5.99]). The model controlled for the performance of annuloplasty, which did not emerge as an independent predictor. Patients undergoing annuloplasty did have less mean late MR than those having CABG alone (p = 0.005). Overall, 57.8% of patients (63 of 109) with follow-up echocardiograms had improvement in grade of MR compared with baseline. In 54 of 95 patients (56.8%), intraoperative transesophageal echocardiography downgraded the degree of MR compared with the preoperative study. CONCLUSIONS: Patients with moderate ischemic MR undergoing CABG had relatively poor long-term survival, with significant differences when stratified according to preoperative characteristics. Performance of mitral annuloplasty reduced the degree of regurgitation but was not a predictor of long-term survival. Intraoperative transesophageal echocardiography frequently downgraded the degree of MR.

Aortic valve replacement in patients with previous cardiac surgery.

BACKGROUND: Whether minimally diseased aortic valves should be replaced during other necessary cardiac operations remains controversial. Part of the decision-making process in that issue revolves around the risks of subsequent aortic valve replacement. This study evaluated the results of aortic valve replacement in patients following prior cardiac surgery. METHODS: From February, 1984 through December, 2001 first-time aortic valve replacement was performed in 132 consecutive patients who had previous cardiac surgery utilizing cardiopulmonary bypass. Of those patients 89 (67%) had aortic valve replacement at a mean of 8.3 years after prior coronary artery bypass grafting, and 43 (33%) had aortic valve replacement at a mean of 13.0 years after previous procedures other than myocardial revascularization. Hospital records of all patients were retrospectively reviewed. RESULTS: Early complications included operative mortality in six (6.7%) of the patients with prior coronary grafting and no mortality in the group with other prior operations. Patients having prior coronary grafting had more nonfatal complications than those with other previous procedures. CONCLUSIONS: Aortic valve replacement in patients following previous cardiac surgery can be accomplished with acceptable mortality and morbidity. Routine replacement of aortic valves that are minimally diseased during coronary artery bypass grafting may not be warranted.