Adult Congenital Heart Disease Transplantation: Does Univentricle Physiology Impact Early Mortality?

BACKGROUND: With patients with congenital heart disease increasingly living into adulthood, there is a growing population of patients with adult congenital heart disease (ACHD) who have heart failure. Limited data exist on evaluating heart transplantation in this population. METHODS: A retrospective review was performed of patients with ACHD who underwent heart transplantation from November 1990 to January 2023. Kaplan-Meier, cumulative incidence accounting for competing risk of death, and subgroup analyses comparing those patients with biventricular (BiV) and univentricular (UniV) physiology were performed. Data are presented as median (interquartile range [IQR]) or counts (%). RESULTS: A total of 77 patients with a median age of 36 years (IQR, 27-45 years) were identified, including 57 (74%) BiV and 20 (26%) UniV patients. Preoperatively, UniV patients were more likely to have cirrhosis (9 of 20 [45.0%] vs 4 of 57 [7.0%]; P < .001) and protein losing enteropathy (4 of 20 [20.0%] vs 1 of 57 [1.8%]; P = .015). Multiorgan transplantation was performed in 23 patients (30%) and more frequently in UniV patients (10 [50%] vs 13 [23%]; P = .04). Operative mortality was 6.5%, 2 of 20 (10%) among UniV patients and 2 of 57 (4%) among BiV patients (P = .276). Median clinical follow-up was 6.0 years (IQR, 1.4-13.1 years). Survival tended to be lower among UniV patients compared with BiV patients, particularly within the first year (P = .09), but it was similar for survivors beyond 1 year. At 5 years, the incidence of rejection was 28% (IQR, 17%-38%) and that of coronary allograft vasculopathy was 16% (IQR, 7%-24%). CONCLUSIONS: Underlying liver disease and the need for heart-liver transplantation were significantly higher among UniV patients. Survival tended to be lower among UniV patients, particularly within the first year, but it was similar for survivors beyond 1 year.

Postoperative Cardiac Arrest in Cardiac Surgery-How to Improve the Outcome?

BACKGROUND: In the early postoperative period after cardiac surgery the heart may be temporarily dysfunctional and prone to arrhythmias due to the phenomenon of myocardial stunning, vasoplegic syndrome, systemic inflammatory response syndrome (SIRS), electrolyte disturbances, operative trauma and myocardial edema. Most cases of cardiac arrest after cardiac surgery are reversible. OBJECTIVE: To analyse the factors that may influence the outcome of cardiac arrest after adult and pediatric cardiac surgery. METHODS: Retrospective analysis that included cardiac surgical procedures (886 adult and 749 pediatric patients) performed during the 18 month period of this study at Queen Alia Heart Institute/ Amman, Jordan. All cardiac arrest events were recorded and analysed. Data was collected on Utstein style templates designed for the purpose of this study. The outcome of cardiac arrest is examined as an early outcome (ROSC or lethal outcome) and late outcome (full recovery, recovery with complications, or in-hospital mortality). Factors that may influence the outcome of cardiac arrest were recorded and statistically analysed. Ethical committee approval obtained. RESULTS: The overall mortality rate was 3.3%. Cardiac arrest occurred in 114 patients (6.97%). The age of patients ranged from 5 days to 82 years and constituted 66 pediatric and 48 adult patients. Most pediatric cardiac arrests manifested as non-shockable rhythms (77%). Most in-hospital cardiac arrests occurred in the intensive care unit (86.5%). The majority of patients were mechanically ventilated at the time of occurrence of arrest (62.5% and 54.5% in adult and pediatric patients, respectively). Average time of cardiopulmonary resuscitation was 32.24 minutes. Overall, CA survival was 20% higher in the paediatric sub-group (full recovery rate of 51.5%). Neurological injury was slightly lower in pediatric than adult cardiac arrest survivals. (2% vs. 3%). CONCLUSION: Shockable rhythms are more common in adult cardiac arrest, while non-shockable rhythms are more frequent in the pediatric sub-population. Hemodynamic monitoring, witnessed-type of cardiac arrest, non-interrupted cardiac massage, and early recognition of cardiac tamponade are the factors associated with higher rates of survival.

Home health care visits may reduce the need for early readmission after coronary artery bypass grafting.

BACKGROUND: The Center for Medicaid and Medicare Services penalizes hospitals with high readmission rates after coronary artery bypass grafting (CABG). Home health care (HHC) is a proven discharge support tool. We performed a propensity-matched analysis to determine impact of HHC on readmissions after CABG. METHODS: We queried the National Readmissions Database (January 2012-December 2014) for patients undergoing isolated CABG discharged home with and without HHC. Primary end point was 30-day readmission. A well-balanced subset of patients with and without HHC was created with propensity matching. Weight-adjusted logistic regression was performed to determine impact of HHC on readmissions after CABG. RESULTS: In our study, 204,184 patients (mean age. 64 years; 22% female) were discharged home after CABG; 86,206 (42%) received HHC. Old age (66 vs 63 years; P < .01), diabetes (46% vs 41%; P < .001), COPD (21% vs 18%; P < .01), peripheral arterial disease (14% vs 11%; P < .001), and chronic kidney disease (2% vs 1.5%; P = .01) were factors associated with HHC. With nearest-neighbor 1:1 matching without replacement, we identified 66,610 patient pairs (unweighted) for further analysis. Readmission occurred in 11.1% and 12.5% of patients with and without HHC, respectively. After adjustment for 21 clinical covariates, use of HHC (odds ratio, 0.816; 95% confidence interval, 0.808-0.823) led to significantly lower readmission rates (P < .001). CONCLUSIONS: HHC after coronary artery bypass surgery is more often provided to women, older patients, and those with diabetes mellitus, peripheral arterial disease, and chronic lung or kidney dysfunction. HHC appears to be associated with reduced rates of early readmission.

Giant right coronary artery aneurysm in the setting of the acute coronary syndrome: A case report.

Giant right coronary artery (RCA) aneurysm is a rare coronary artery pathology. We describe a 45-year-old gentleman who presented with unstable angina of recent onset. Diagnostic workup including chest computed tomography angiography and left heart catheterization demonstrated three-vessel coronary artery disease with giant proximal RCA aneurysm. In the view of the severity of the coronary artery disease and the risk of rupture associated with the giant RCA aneurysm and the clinical presentation, the patient was successfully treated by coronary artery bypass surgery. During this procedure, the RCA aneurysm was ligated at both inflow and outflow. The patient recovered well and was discharged home.

Stability After Initial Decline in Coronary Revascularization Rates in the United States.

BACKGROUND: It remains uncertain how advances in revascularization techniques, availability of new evidence, and updated guidelines have influenced the annual rates of coronary revascularization in the United States. METHODS: We used the Nationwide Inpatient Sample data from 2005 to 2014 with appropriate weighting to determine national procedural volumes. To present accurately overall percutaneous coronary intervention (PCI) rates, PCI with same-day discharge numbers per year were estimated from the available literature and added to annual PCI procedures performed. RESULTS: Annual PCI rate declined from 353 per 100,000 adults in 2005 to 277 per 100,000 adults in 2009 (P < .001) but remained stable thereafter (P = .50). Annual coronary artery bypass grafting (CABG) rate declined steadily, at a shallower slope than PCI, from 120 per 100,000 in 2005 to 93 per 100,000 in 2009 (P = .02) but remained stable thereafter (P = .60). Similar trends were seen in men and women. Both PCI and CABG rates were lower in women than men over the study period (PCI, 482 to 324/100,000 in men vs 232 to 153/100,000 in women; CABG, 172 to 118/100,000 in men vs 64 to 38/100,000 in women). Annual PCI rates were higher than CABG rates in patients of all age groups including in younger patients (age < 50) and octogenarians. The proportion of coronary revascularization procedures performed per insurance type remained relatively similar across the study period. CONCLUSIONS: Annual rates of coronary revascularization have changed significantly over time, potentially because of advances in revascularization techniques, availability of new evidence, and updated guidelines. Rates of PCI declined more steeply than CABG before plateauing but remained higher than rates of CABG across the study period.

Risk Calculator to Predict 30-Day Readmission After Coronary Artery Bypass: A Strategic Decision Support Tool.

BACKGROUND: Re-admission is an important source of patient dissatisfaction and increased hospital costs. A simple calculator to determine the probability of re-admission may help guide patient dismissal planning. METHODS: Using the national readmissions database (NRD), we identified admissions for isolated primary coronary artery bypass (CABG) and stratified them according to 30-day readmission. Including pre, intra and postoperative variables, we prepared a logistic regression model to determine the probability for re-admission. The model was tested for reliability with boot-strapping and 10-fold cross-validation. RESULTS: From 135,699 procedures, 19,355 were readmitted at least once within 30days of dismissal. Patients who were readmitted were older (67±10 vs 65 ± 10 years, p<0.01), females (32% vs 24%; p<0.01) and had a higher Elixhauser comorbidity score (1.5±1.4 vs 1.1±1.2; p<0.01). Our final model (c- statistic=0.65) consisted of 16 pre and three postoperative factors. End-stage renal disease (OR 1.79 [1.57-2.04]) and length of stay>9days (OR 1.60 [1.52-1.68]) were most prominent indicators for readmission. Compared to Medicaid beneficiaries, those with private insurance (OR 0.62 [0.57-0.68]) and Medicare (OR 0.85 [0.79-0.92]) coverage were less likely to be readmitted. CONCLUSIONS: Our simple 30-days CABG readmission calculator can be used as a strategic tool to help reduce readmissions after coronary artery bypass surgery.

Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-Analysis.

BACKGROUND: Limited data exist studying the outcomes of the 2 minimally invasive aortic valve replacement (AVR) strategies-mini-sternotomy (AVR-st) and right anterior thoracotomy (AVR-th). We conducted an indirect meta-analysis to compare the outcomes of these minimally invasive approaches with each other and with conventional AVR (cAVR). METHODS: We Searched Medline, PubMed, Embase, and Web of Science in December 2017 for studies comparing AVR-st, AVR-th, and cAVR. Clinical outcomes were compared between cohorts with inverse weighted random effects modeling. Endpoints studied included hospital mortality, stroke, atrial fibrillation, cardiopulmonary bypass (CPB) time, and length of stay. RESULTS: A total of 19 studies (>10,000 pooled patients) met the inclusion criteria. Mortality (p = 0.06) and stroke (p = 0.15) were comparable between minimally invasive and conventional AVR. CPB times were longer with AVR-th versus cAVR (12.4 minutes [range, 5 to 19]; p < 0.01). In the AVR-th cohort, CPB duration was weakly inversely related to study size (p = 0.06). Atrial fibrillation was much less after AVR-th (odds ratio 0.47 [0.35 to 0.63]; p < 0.001). Hospital stay was significantly lower after minimally invasive surgery (0.8 [0.4 to 1.3] days; p < 0.01). AVR-th patients were dismissed 2.1 (1.6 to 2.7) days earlier than cAVR patients. CONCLUSIONS: Minimally invasive approaches to AVR yield excellent outcomes in high-volume centers. They reduce hospital stay and incidence of postoperative atrial fibrillation, and therefore should be considered in patients undergoing AVR. The operative approach should be selected according to surgeon's technical expertise and what is best for specific patient profile, however.

A Systemic Review and Meta-Analysis of Sutureless Aortic Valve Replacement Versus Transcatheter Aortic Valve Implantation.

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are increasingly adopted methods to treat high-risk patients with severe aortic valve stenosis. We conducted a systematic review and meta-analysis to compare the clinical outcomes between these two recent methods to treat aortic valve disease. METHODS: We systematically searched multiple databases (January 2000 to October 2016) to identify original studies comparing clinical outcome between SU-AVR and TAVI. End points studied were early mortality, development of paravalvular leak, early stroke, bleeding events, and the need for pacemaker insertion. A random-effect inverse-variance weighted analysis was performed. Event rates were compared as odds ratio (OR) and 95% confidence interval (CI). RESULTS: The meta-analysis included seven observational studies comprising 617 SU-AVR and 621 TAVI patients. Early mortality was 2.5% and 5% in the SU-AVR and TAVI cohorts, respectively (OR, 0.52; 95% CI, 0.30 to 0.90; p = 0.02; I2 = 2%). Postprocedural significant paravalvular leak was much lower after SU-AVR (OR, 0.18l; 95% CI, 0.11 to 0.30; p < 0.0001). Postprocedural stroke (OR, 0.71; 95% CI, 0.24 to 2.08; p = 0.53) and the need for pacemaker insertion (OR, 0.884; 95% CI, 0.364 to 2.18; p = 0.7) were comparable between the two cohorts. CONCLUSIONS: Our meta-analysis of observational studies demonstrates that early mortality is lower after SU-AVR than after TAVI in selected patients. The rates of stroke and pacemaker implant are comparable between procedures; however, the incidence of paravalvular leak is higher after TAVI.

Novel Surgical Management of Giant Aortic Arch Pseudoaneurysm.

Pseudoaneurysm of the aortic arch is a rare entity, usually seen after cardiac operations or chest trauma. Here we report a 32-year-old man who presented 10 years after blunt chest trauma with a giant aortic arch pseudoaneurysm. He finally underwent surgical intervention in which the pseudoaneurysm was closed from inside with use of an inlay patch method.

Meta-Analysis of Usefulness of Concomitant Mitral Valve Repair or Replacement for Moderate Ischemic Mitral Regurgitation With Coronary Artery Bypass Grafting.

Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p <0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p <0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p = 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference -0.73 (-1.64 to 0.18; p = 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p = 0.001; mean MR grade, mean difference = 0.39 [0.26 to 0.59]; p <0.001). Midterm survival rate (mean follow-up 5 years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p = 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5 years of follow-up.

Hawthorn Herb Increases the Risk of Bleeding after Cardiac Surgery: An Evidence-Based Approach.

OBJECTIVES: Hawthorn extract consumption is becoming more widespread among the Jordanian population with cardiovascular disorders. We conducted this prospective observational longitudinal study to determine the impact of hawthorn extract on bleeding risk in patients who undergo cardiac surgery. METHODS: A prospective observational study was performed on 116 patients who underwent cardiac surgery in the period between June 2014 and May 2015. Patients were divided into two groups: Group I (patients recently consumed hawthorn extract) and Group II (patients never consumed hawthorn extract). Endpoint measures included the rates of reopening to control bleeding, early mortality, duration of intensive care unit stay, total in-hospital stay period, and duration and amount of chest tube drainage. RESULTS: Hawthorn patients had a significantly higher rate of postoperative bleeding necessitating take back to the operating room compared to the control group (10% versus 1%; P = .03) respectively. The overall mortality rate for group I and II was 4% and 0% respectively; P = .17. Chest tubes were kept in for longer times in group I compared to group II (54 ± 14.6 versus 49 ± 14.7 hours respectively; P = .01). Group I stayed longer in the intensive care unit compared to group II (24 versus 22 hours respectively; P = .01). The total in-hospital stay period was comparable between the two groups. CONCLUSION: Hawthorn extract consumption does increase the potential for bleeding and the amount of chest tube output after cardiac surgery.

Tissue valves are preferable for patients with end-stage renal disease: an aggregate meta-analysis.

BACKGROUND: Valve selection in patients with end-stage renal disease (ESRD) is uncertain. We performed a systematic review and meta-analysis to compare clinical outcome in ESRD patients undergoing valve replacement. METHODS: We systematically searched multiple databases (2000-October 2015) to identify original studies comparing adverse events between mechanical and biological valve replacement in ESRD patients. End-points studied were: postoperative mortality, bleeding events, need for re-operation, and late survival. A random-effect inverse-variance weighted analysis was performed; event rates are compared as odds ratio (OR and 95% confidence interval) and hazard ratios (HR) for time-to-event data. Mechanical valve and tissue valve replacement were considered as study and control cohorts, respectively. RESULTS: Fifteen retrospective studies (5523 mechanical and 1600 tissue valve) were included in our meta-analysis. Early mortality was comparable (OR 1.15 [0.77; 1.72]; p = 0.49). The mean follow-up among studies ranged from 1.6-15 years. Bleeding was significantly higher after mechanical valve replacement (OR 2.55 [1.53; 4.26]; p = 0.0003). Structural valve degeneration was present in only 0.6% patients after a tissue valve replacement. Overall survival after valve replacement was poor (median 2.61 years); valve choice did not influence this outcome (pooled HR 0.87 [0.73; 1.04]; p = 0.14). CONCLUSION: Operative mortality in ESRD patients is comparable between mechanical and tissue valve replacement. Major bleeding episodes are significantly higher after mechanical valve replacement but structural degeneration in tissue valves during the follow-up period is low. Based on the findings from this meta-analysis, we would recommend using tissue valves in patients with ESRD.

N-Acetyl Cysteine Therapy Does Not Prevent Renal Failure in High-Risk Patients Undergoing Open-Heart Surgery.

BACKGROUND: Renal dysfunction is a common complication after cardiovascular surgery. Controversial issues have been discussed regarding the role of N-acetyl cysteine in the prevention of postoperative renal dysfunction. The purpose of this meta-analysis is to assess whether N-acetyl cysteine offers any protection against the development of acute renal dysfunction after cardiac surgery. METHODS: Multiple databases were searched for randomized trials comparing the role of N-acetyl cysteine and placebo in human patients undergoing cardiac surgery. End-points studied were: the incidence of acute renal failure, hemodialysis, early mortality, duration of hospital stay, and maximal change in creatinine values. Dichotomous variables were compared using the risk difference (RD) calculated with inverse weighting; continuous data was pooled as (standardized) mean difference. Results are presented with 95% confidence interval (P < .05 is significant); results are presented within 95% confidence interval. RESULTS: Thirteen randomized trials (713 and 707 patients in the N-acetyl cysteine and control groups, respectively) were included in the present analysis; nine dealing with patients at high-risk for acute renal failure. The incidence of postoperative acute renal dysfunction was 23% and 36% in the N-acetyl cysteine and control cohorts, respectively. N-acetyl cysteine therapy did not reduce acute renal dysfunction in the high-risk cohort [RD -0.03 (-0.09 to 0.02); P = .22; I2 = 24%]. Maximal change in creatinine levels after surgery was also comparable [standardized mean difference 0.07 (-0.23, 0.09); P = .39]. Early mortality was 2.9% and 3.7% in the N-acetyl cysteine and control cohorts respectively; [RD 0 (-0.03 to 0.02); P = .63; I2 = 20%]. Hospital stay (mean length of stay 10.4 and 10.1 days in the N-acetyl cysteine and control cohorts, respectively) was also similar in both cohorts [WMD 0.17 (-0.02 to 0.37) days; P = .81]. CONCLUSION: Prophylactic N-acetyl cysteine therapy does not reduce the incidence of renal dysfunction in high-risk patients undergoing cardiac surgery.

A Successful Endovascular Treatment of an Ischemic Stroke following Cardiac Surgery.

Ischemic stroke following cardiac surgery is one of the devastating complications that surgeons may encounter, and may lead to serious disabilities for the patient. The clinical course of such a complication may be prolonged if it is not treated properly. Making a quick decision when choosing a revascularization method is very helpful in this matter. Effective treatment options are usually limited. Neurointerventional maneuvers have recently emerged as a possible therapeutic modality in this field. We present the case of a 52-year-old woman who had open heart surgery in Queen Alia Heart Institute, Jordan, to replace a severely stenotic rheumatic mitral valve and repair a leaking tricuspid valve. Her surgery went smoothly with no major event. However, she developed a massive ischemic stroke during her recovery period despite being on adequate anticoagulation therapy. Urgent radiological work-up confirmed the diagnosis of ischemic stroke in the territory of the right middle cerebral artery. We chose a neuro-interventional method for her treatment, and mechanical thrombectomy was performed with a successful outcome and no apparent complications.

Levosimendan Reduces Mortality in Adults with Left Ventricular Dysfunction Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis.

INTRODUCTION: Levosimendan is implemented in patients with low cardiac output after cardiac surgery. However, the strength of evidence is limited by randomized controlled trials enrolling a small number of patients. Hence we have conducted a systematic review to determine the role of levosimendan in adult cardiac surgery. METHODS: PUBMED, WoS, Cochrane database, and SCOPUS were systematically queried to identify original English language peer-reviewed literature (inception-October 2014) comparing clinical results of adult cardiac surgery between levosimendan and control. Pooled odds ratio (OR) was calculated using the Peto method; p < 0.05 is significant; results are presented within 95% confidence intervals. Continuous data was compared using standardized mean difference/mean difference. RESULTS: Fourteen studies were included in the analysis. Levosimendan reduced early mortality in patients with reduced ejection fraction (5.5% vs. 9.1%) (OR 0.48 [0.23-0.76]; p = 0.004). This result was confirmed using sensitivity analysis. Postoperative acute renal failure was lower with levosimendan therapy (7.4% vs. 11.5%). Intensive care unit stay was shorter in the levosimendan cohort comparable in both groups (standardized mean difference -0.31 [-0.53, -0.09]; p = 0.006; I(2) = 33.6%). Levosimendan-treated patients stayed 1.01 (1.61-0.42) days shorter when compared to control (p = 0.001). CONCLUSION: Our meta-analysis demonstrates that Levosimendan improves clinical outcomes in patients with left ventricular dysfunction undergoing cardiac surgery. Results of the ongoing multicenter randomized controlled trial are awaited to provide more conclusive evidence regarding the benefit of this drug.

Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis.

BACKGROUND: We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited. METHODS: A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A random-effect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant. RESULTS: Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p = 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p = 0.06). Patients undergoing pCABG were 14% (0% to 55%; p = 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p = 0.014), the stroke rates were comparable in both cohorts (p = 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p = 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p = 0.36). CONCLUSIONS: Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.

Off-pump coronary artery bypass reduces early stroke in octogenarians: a meta-analysis of 18,000 patients.

BACKGROUND: Data comparing results of off-pump and conventional operations in octogenarians is very limited. Thus we chose to compare early adverse events between off-pump coronary artery bypass grafting (OPCABG) and on-pump CABG (ONCABG) in patients older than 80 years. METHODS: Systematic review of multiple databases was performed to obtain original studies fulfilling search criteria. End points--early mortality, stroke, respiratory failure, atrial fibrillation, and myocardial infarction--were compared between these cohorts. A random-effects weighted analysis was performed using the trim-fill adjustment when necessary. Results are presented as risk ratios (RRs) with 95% confidence intervals (CIs); p < 0.05 is considered statistically significant. RESULTS: Sixteen retrospective studies (9,744 ONCABG and 8,566 OPCABG patients) were included in the systematic review. OPCAGB patients received significantly fewer grafts (2.54 ± 0.16) compared with ONCABG patients (3.22 ± 0.41). Early mortality was comparable at 4.6% and 5.2% in the OPCABG and ONCABG cohorts, respectively (risk ratio [RR], 0.91; 95% CI, 0.64-1.28; p = 0.598). Stroke rates were higher in the ONCABG cohort (RR, 0.65; 95% CI, 0.49- 0.87; p < 0.01). Respiratory failure was higher with ONCABG (RR, 0.74; 95% CI, 0.57-0.97; p = 0.03). New-onset renal failure (p = 0.99), atrial fibrillation (p = 0.27), and myocardial infarction (p = 0.99) were comparable. CONCLUSIONS: Coronary artery bypass in octogenarians can be performed safely with low early mortality. Although off-pump operations reduce the risk of early stroke, all other adverse events are comparable in on- and off-pump coronary artery bypass operations. Data regarding late mortality is at present limited; however, both on- and off-pump procedures appear to produce comparable survival.

Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly: a systematic review and meta-analysis.

INTRODUCTION: Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. METHOD: We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. RESULT: Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I(2) = 0%; p < 0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p = 0.86), stroke [OR 0.7(0.4-1.1); p = 0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p = 0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. CONCLUSION: The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.

Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data.

BACKGROUND: Minimally invasive aortic valve replacement (mAVR) is increasingly preferred over conventional AVR (cAVR). However, data comparing these procedures present conflicting results. Hence, we conducted a systematic review and meta-analysis comparing clinical results in these cohorts. METHOD: Only randomized controlled trials (RCT) and propensity-matched observational studies (POS) (1998-2013) comparing clinical outcome of patients subjected to mAVR or cAVR were pooled. Continuous data was compared using mean/standardized mean difference (MD/SMD) while categorical results were pooled to obtain an odds ratio (OR) with a 95% confidence interval. RESULTS: A total of 18 studies (6 RCT and 12 POS) (1973 mAVR patients; 2697 cAVR patients) were analyzed. The mean ischemic time was significantly longer with mAVR (MD 9.42 minutes [4.25-14.59]; p < 0.01). However, early mortality (mAVR [1.8%] and cAVR [3%]) was comparable (OR 0.70 [0.46-1.06]; p = 0.09). Postoperative ventilation time was slightly shorter after mAVR (7.5 vs 11.1 hours; p = 0.07), and hospital discharge was earlier after mAVR (MD -1.05 [-1.64 to -0.46]; p < 0.01). However, mAVR failed to reduce transfusion requirement (OR 0.77 [0.51-1.14]; p = 0.19) or pain scores (SMD -0.25 [-0.65 to 0.13]; p = 0.20). Postoperative atrial fibrillation (p = 0.67) and stroke (p = 0.79) rates were comparable. Pooled rate of conversion to full sternotomy was 2.5%. Cosmetic satisfaction could not be pooled due to reporting heterogeneity. CONCLUSION: Minimally invasive aortic valve replacement can be performed safely despite the longer ischemic time. While minimally invasive surgery does demonstrate some advantages in postoperative recovery, we failed to find any other substantial improvement in outcome over conventional aortic valve replacement.