Repair of aorto-left ventricular and aorto-right ventricular fistulas following prosthetic valve endocarditis.

We report a case of a 77-year-old male who presented with an aorto-left ventricular fistula and an aorto-right ventricular fistula secondary to prosthetic valve endocarditis.

Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study.

BACKGROUND: Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED).In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants' CR referral and enrollment was examined using generalized estimating equations. RESULTS: A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95). CONCLUSIONS: These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration.

Improving results for coronary artery bypass graft surgery in the elderly.

OBJECTIVES: The proportion of elderly patients undergoing isolated coronary artery bypass grafting (CABG) surgery has steadily increased. We have evaluated temporal trends in hospital outcomes of patients who were 75 years and older undergoing CABG (1990-2010) at our institution. METHODS: Data were collected prospectively for 3483 consecutive patients who were 75 years and older (median 78 years; range 75-94) undergoing isolated CABG at our institution over three time cohorts: 1990-96 (n = 817), 1997-2003 (n = 1534) and 2004-10 (n = 1132). RESULTS: Overall mortality declined from 6.0% (49/817) in the earliest era (1990-96) to 1.9% (22/1132) in the most recent era (2003-10; P < 0.001). Mortality in low-risk patients (elective, primary surgery with the ejection fraction >40%) was 5.9% (13/220), 0.8% (4/514) and 0% (0/411) in the first, second and third eras, respectively (P < 0.001). Despite the overall increase in comorbidities in our elderly patients, the prevalences of certain risk factors such as poor LV function, urgency of surgery and reoperation have all declined with time. The independent risk factors for mortality in our population were congestive heart failure, left main disease, earlier year of operation, reoperation, preoperative myocardial infarction, cardiopulmonary bypass time, emergent/urgent surgery and peripheral vascular disease. Of these, earlier year of operation (OR: 3.0; 95% CI: 1.8-5.2) was the most significant predictor. Also, age >80 did not predict mortality. CONCLUSIONS: The principle finding from this analysis is a contemporary low operative mortality for CABG in an elderly patient cohort. Risk of death is particularly low in a low-risk subset of elderly patients with reasonable LV function undergoing elective, primary CABG.

Changing pattern of reoperative coronary artery bypass grafting: a 20-year study.

BACKGROUND: Fewer patients are undergoing reoperative coronary artery bypass grafting (CABG). We investigated the prevalence of redo vs primary CABG and previous percutaneous coronary intervention (PCI), changing trends in preoperative risk profiles, and independent predictors of operative death. METHODS: Data on demographic characteristics, preoperative risk factors, and hospital outcomes were collected prospectively for patients undergoing isolated reoperative CABG from January 1, 1990, to December 31, 2009. To examine the effect of time on the prevalence of redo CABG cases and previous PCI, we divided patients into four groups: 1990 through 1994, 470; 1995 through 1999, 415; 2000 through 2004, 240; and 2005 through 2009, 79. To examine risk profiles and outcomes, we created two groups: 1990 through 1999, 885; 2000 through 2009, 319. RESULTS: Redo CABG decreased from 7.2% (1990 through 1994) to 2.2% (2005 through 2009). PCI before redo CABG significantly increased from 14.5% (1990 through 1994) to 26.6% (2005 through 2009). Patients with diabetes, dyslipidemia, hypertension, peripheral vascular disease, and left main disease increased. In-hospital mortality did not change significantly, but postoperative low cardiac output syndrome dropped. Age (odds ratio [OR], 1.04), peripheral vascular disease (OR, 2), congestive heart failure (OR, 5.8), and preoperative shock (OR. 9.7) independently predicted higher operative mortality. CONCLUSIONS: Reoperative CABG has significantly decreased. The increased prevalence of PCI before redo CABG is one of the reasons. Despite an increasing risk profile, hospital outcomes have remained largely the same. Preoperative shock and congestive heart failure are the most important predictors of operative mortality.

Surgical management of a left anterior descending pseudoaneurysm related to Behcet's disease.

A 22-year-old woman suffering from Behcet's disease and severe angina was diagnosed with a left anterior descending coronary artery giant pseudoaneurysm. Preoperative investigations, surgical management, and its principles, as well as specific postoperative follow-up considerations are described.

Changing trends in emergency coronary bypass surgery.

BACKGROUND: Patients undergoing emergency coronary artery bypass grafting represent a unique and high-risk population that remains challenging for cardiac surgeons. We examined the changing trends in patients undergoing emergency bypass grafting over the past 20 years. METHODS: We conducted a retrospective review of our database between 1990 and 2009 and patients were divided into 2 groups based on year of operation: 1990-1999, n = 393; 2000-2009, n = 184. The primary outcomes of interest for this study are operative mortality and incidence of low cardiac output syndrome. RESULTS: The percentage of patients undergoing emergency coronary bypass grafting has decreased from 2.7% to 1.7% over time. The percentage of patients with dyslipidemia, hypertension, triple vessel disease, peripheral vascular disease, and left main disease increased over time (P < .05). Operative mortality remained at 8.1% in both year groups. Preoperative hypertension, congestive heart failure, left ventricular ejection fraction less than 20%, and previous cardiac surgery independently predicted operative mortality by logistic regression analysis. Low cardiac output syndrome developed in 25% of the patient population undergoing emergency bypass grafting. The independent predictors of low cardiac output syndrome were small body surface area, congestive heart failure, shock, myocardial infarction, earlier decade (1990-1999) and increased age. CONCLUSIONS: Despite a changing preoperative risk profile, the operative mortality of emergency coronary artery bypass grafting has remained stable over the years. However, mortality remains significantly above the observed mortality in elective bypass grafting. Continued improvements in the management of heart failure and the care of the elderly will likely result in reduced risks of emergency coronary artery bypass grafting.

Persistent left ventricular false aneurysm after transapical insertion of an aortic valve.

Transcatheter aortic valve implantation (TAVI), via either a femoral or apical approach, has been developed as an alternative to conventional aortic valve replacement for patients whose operative risks are considered too high for conventional surgery. Complications with these relatively new procedures are being reported with increasing frequency. We report a case of transapical TAVI, in which the patient developed a false aneurysm at the apex of the left ventricle as a complication of the procedure.

A giant cavernous hemangioma of the heart.

Cardiac hemangiomas are exceptionally rare, vascular neoplasms of the heart, with an incidence of 1% to 2% among all detected benign heart tumors. With the availability of the advanced imaging modalities of the heart, asymptomatic cardiac tumors are detected more frequently. These tumors are composed either of capillaries or larger cavernous channels. Herein, we report a rare case of a huge cardiac hemangioma involving both ventricles, which is not amenable to a curative surgical resection.

The successful management of severe protamine-induced pulmonary hypertension using inhaled prostacyclin.

Acute pulmonary hypertension is a severe and life-threatening reaction that rarely occurs secondary to protamine administration. Management of systemic hypotension combined with severe pulmonary hypertension causing right ventricular failure is challenging. We describe a case of acute pulmonary hypertension induced by protamine during elective coronary artery bypass surgery refractory to multiple systemic inotropic and vasopressor therapies. After inhaled prostacyclin administration, our patient's pulmonary artery pressures decreased from 70/37 to 45/23 mm Hg within 10 min. The case highlights a role for inhaled nebulized prostacyclin as a selective pulmonary vasodilator with minimal systemic hypotensive effects.

Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: a position statement of the Canadian Cardiovascular Society.

UNLABELLED: Acute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) during the index admission. Most studies show that patients who receive ASA and clopidogrel within five days of CABG have an increase in operative bleeding. Current consensus guidelines recommend discontinuation of clopidogrel therapy at least five days before planned CABG to reduce bleeding-related events. However, high-risk individuals may require urgent surgery without delay, to reduce the risk of potentially fatal ischemic events. The present multidisciplinary position statement provides evidence- based recommendations for the optimal use of dual antiplatelet therapy to balance ischemic and bleeding risks in patients with recent ACS who may require urgent CABG. RECOMMENDATIONS: 1. All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG. 2. For patients who have received clopidogrel and ASA, and require CABG: * Those at high risk of an early fatal event (eg, with refractory ischemia despite optimal medical treatment, and with high-risk coronary anatomy (eg, severe left main stenosis with severe right coronary artery disease), should be considered for early surgery without discontinuation of clopidogrel. * In patients with a high bleeding risk (eg, previous surgery, complex surgery) who are also at high risk for an ischemic event, consideration should be given to discontinuing clopidogrel for three to five days before surgery. * Patients at a lower risk for ischemic events (most patients) should have clopidogrel discontinued five days before surgery. 3. For patients who have CABG within five days of receiving clopidogrel and ASA, the risk of major bleeding and transfusion can be minimized by applying multiple strategies before and during surgery. 4. Patients who receive clopidogrel pre-CABG for a recent ACS indication should have clopidogrel restarted after surgery to decrease the risk of recurrent ACS. 5. For patients with a recent coronary stent, the decision to continue clopidogrel until the time of surgery or to discontinue will depend on the risk and potential impact of stent thrombosis. Restarting clopidogrel after CABG will depend on whether the stented vessel was revascularized, the type of stent and the time from stent implantation. Clopidogrel should be restarted when hemostasis is assured to prevent recurrent acute ischemic events.

Decreasing mortality for coronary artery bypass surgery in octogenarians.

BACKGROUND: Octogenarians are the fastest growing population in Canada and have also been referred for coronary artery bypass grafting (CABG) with increasing frequency during the past decade. OBJECTIVE: To examine the changing trends in preoperative risk profiles, postoperative outcomes and hospital resource use in the octogenarian population. METHODS: A retrospective review was conducted to identify all patients 80 years of age or older who underwent isolated CABG at the Toronto General Hospital (Toronto, Ontario) between 1990 and June 2005. To examine the effect of time on preoperative risk, patients were divided into three groups based on year of operation: 1990 to 1994, n=92; 1995 to 1999, n=202; and 2000 to June 2005, n=314. RESULTS: The preoperative risk profile of octogenarians undergoing CABG has changed over the years. The percentage of patients with diabetes, dyslipidemia, hypertension and left main disease increased over time (P<0.05). However, the requirement for urgent/emergent operations decreased. In-hospital mortality declined from 7.1% (1990 to 1999) to 3.2% (2000 to June 2005, P=0.02). The prevalence of low cardiac output syndrome, intra-aortic balloon pump insertion and stroke decreased over time. Preoperative myocardial infarction (OR 4, P=0.0004), left main disease (OR 3.7, P=0.0013) and year of operation (1990 to 1994 [OR 3.3, P=0.03]; 1995 to 1999 [OR 2.9, P=0.02]) independently predicted in-hospital mortality. Hospital resource use in terms of hours on ventilator, length of stay in the intensive care unit and postoperative length of stay decreased over time (P<0.0001). CONCLUSION: Despite a changing risk profile, hospital outcomes of octogenarians were improved over time with a reduction in hospital resource use. The results suggest that CABG can and should be performed in this expanding population.

Degree and correlates of cardiac knowledge and awareness among cardiac inpatients.

OBJECTIVE: To investigate the degree of CHD awareness as well as symptom, risk factor, and treatment knowledge in a broad sample of cardiac inpatients, and to examine its sociodemographic, clinical and psychosocial correlates. METHODS: 1308 CHD inpatients (351 [27.0%] female), recruited from 11 acute care sites in Ontario, participated in this cross-sectional study. Participants were provided with a survey which included a knowledge questionnaire among other measures, and clinical data were extracted from medical charts. RESULTS: 855 (68.8%) respondents cited heart disease as the leading cause of death in men, versus only 458 (37.0%) in women. Participants with less than high school education (p<.001), an annual family income less than $50,000CAD (p=.022), low functional capacity (p=.042), who were currently smoking (p=.022), who had no family history of heart disease (p<.001), and who had a perception of low personal control (p=.033) had significantly lower CHD knowledge. CONCLUSIONS: Awareness of CHD is not optimal, especially among women, South Asians, and those of low socioeconomic status. CHD patients have a moderate level of disease knowledge overall, but greater education is needed. PRACTICE IMPLICATIONS: Tailored educational approaches may be necessary for those of low socioeconomic status, particularly with regard to the nature of CHD, tests and treatments.

Ethnic diversity: South Asian ethnicity is associated with increased coronary artery bypass grafting mortality.

OBJECTIVE: South Asian ethnicity might result in a higher atherosclerotic vascular risk compared with white ethnicity. However, the effect of South Asian ethnicity on clinical outcomes after cardiac surgery is unknown. Thus, we determined whether South Asian ethnicity is a predictor of a poorer outcome after coronary artery bypass grafting. METHODS: We examined data from 6177 South Asian and white patients who underwent coronary artery bypass grafting at the Toronto General Hospital from January 1994 through June 2003 and used propensity score matching techniques to analyze 917 patients from each group in more detail. Patients were matched for age, sex, body surface area, left ventricular ejection fraction, New York Heart Association class, previous cardiac surgery, number of diseased vessels, and other factors. Independent predictors of operative morbidity and mortality were determined by means of multivariate logistic regression. RESULTS: Overall operative mortality was 1.8%. Mortality was higher in South Asian patients than in white patients (2.5% vs 1.1%, P = .02). Postoperative morbidity (eg, myocardial infarction, sepsis, sternal wound infection, postoperative hospital stay, and use of inotropes) also was higher in the South Asian group. In addition to the standard independent predictors of mortality, South Asian ethnicity was an independent predictor of mortality (odds ratio, 3.1; 95% confidence interval, 1.4-6.8). CONCLUSIONS: These data indicate that South Asian ethnicity per se is an independent predictor of a poorer outcome after coronary artery bypass grafting and suggest that ethnicity is a cardiovascular risk factor that should be considered when assessing clinical outcomes preoperatively before coronary artery bypass grafting or other interventional revascularization procedures.

Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs.

BACKGROUND: Allogeneic blood transfusion is associated with transfusion reactions, infection transmission, and postoperative morbidity and mortality. The objective of this study was to develop and validate an accurate and simple clinical index to stratify cardiac surgery patients according to their blood transfusion needs. METHODS AND RESULTS: Data on consecutive adult patients who underwent cardiac surgery at Toronto General Hospital (n = 11,113) and Sunnybrook and Women's College Health Sciences Center (n = 5316) between May 1999 and June 2004 were collected for the development, validation, and external validation of the index. Primary outcome was the exposure to blood transfusion in the operative and first postoperative days. Multivariable logistic regression modeling techniques were used to determine the relationship between each independent variable and the exposure to allogeneic blood transfusion. Score assignment for each predictor variable was based on its regression coefficient. The predicted probabilities at each total score were compared to the observed proportions of patients exposed to blood transfusion. The clinical tool consists of eight preoperative variables: preoperative hemoglobin, weight, female sex, age, nonelective procedure, preoperative creatinine, previous cardiac surgical procedure, and nonisolated procedure. CONCLUSIONS: Based on the standards of measurement in clinical research, a valid clinical tool was developed for predicting the need for blood transfusion in patients undergoing cardiac surgery. The clinical tool was internally and externally validated, and the results suggest that it should perform well at other institutions.

Does the use of erythropoietin reduce the risk of exposure to allogeneic blood transfusion in cardiac surgery? A systematic review and meta-analysis.

BACKGROUND: The use of blood conservation techniques is important in cardiac surgery as postoperative bleeding is common and allogeneic blood transfusion carries the risk of transfusion reactions and infection transmission. Erythropoietin with and without preoperative autologous blood donation is one of the modalities to avoid allogeneic blood transfusion. The objective of this review was to assess the effectiveness of erythropoietin in reducing the risk of exposure to allogeneic blood transfusion during or after cardiac surgery. METHODS: A meta-analysis of 11 identified randomized controlled trials, reporting comparisons between erythropoietin and control, was undertaken. The primary outcome was the number of patients exposed to allogeneic blood transfusion during or after cardiac surgery. RESULTS: Eleven studies, involving 708 patients, met the inclusion criteria for this review. In total, 471 patients were given erythropoietin, and 237 patients formed the control group. The administration of erythropoietin with and without preoperative autologous blood transfusion prior to cardiac surgery is associated with a significant risk reduction: RR = 0.28 (95% CI 0.18-0.44, P < 0.001) and RR = 0.53 (95% CI 0.32-0.88, P < 0.01), respectively. CONCLUSION: The administration of erythropoietin before cardiac surgery is associated with a significant reduction in the risk of exposure to allogeneic blood transfusion. Further studies are warranted to define the patients' subgroups that may benefit the most from EPO administration.

Sex-specific long-term outcomes after combined valve and coronary artery surgery.

BACKGROUND: The purpose of this study is to compare sex-specific, long-term outcomes after combined valve and coronary artery bypass graft surgery (CABG). METHODS: Between 1990 and 2000, 1,567 patients underwent combined valve and CABG surgery at our institution. Our surgical database was linked to a governmental administrative hospital discharge database and a registry of deaths to obtain long-term follow-up. All patients underwent CABG plus aortic (62%), mitral (31%), or multiple valve surgery (7%). RESULTS: Women had more preoperative risk factors than men (namely, hypertension, diabetes mellitus, congestive heart failure, atrial fibrillation, and stroke; all p < 0.001). The prevalence of triple-vessel disease was the same between men and women, but women received fewer mammary grafts and fewer total bypass grafts (both p < 0.01). Women received fewer mitral valve repairs and more mitral valve replacements than men (p = 0.014). Length of follow-up was 5.3 +/- 3.2 years (mean +/- SD; range, 0 to 12.5) and was 99.8% complete. Both sexes had similar long-term survival rates. Women were at higher risk of stroke during follow-up (risk ratio = 1.52, 95% confidence interval: 1.1 to 2.1). There were no sex differences in rehospitalization for acute myocardial infarction (p = 0.9), heart failure (p = 0.4), redo cardiac surgery (p = 0.5), or endocarditis (p = 0.4). CONCLUSIONS: Women have a higher preoperative risk profile than men undergoing combined valve and CABG surgery, but long-term survival rates are similar. Female sex is an independent predictor of stroke during follow-up. Further studies should focus on the cause of increased risk of stroke and methods of prevention.

Is South Asian ethnicity an independent cardiovascular risk factor?

People of South Asian origin constitute a large, visible minority in Canada and are known to be at heightened risk for premature coronary artery disease. Conventional risk factors clearly confer risk in South Asians but do not adequately explain their excess risk compared with other populations. Rates of smoking, hypertension and levels of low density lipoprotein-cholesterol tend to be similar or lower in South Asians, although diabetes is more prevalent. Recent studies have suggested that the metabolic syndrome and abdominal obesity may play a causative role in both the prevalence of diabetes and the premature atherosclerosis noted in South Asians. It is possible that genetically susceptible individuals develop abdominal obesity and insulin resistance when exposed to a toxic environment of reduced energy expenditure and increased caloric consumption. This pattern is increasingly noted in parallel with urbanization, suggesting that the increased cardiovascular risk in South Asians may be preventable through lifestyle interventions and the judicious use of medicines to attain optimal levels of blood pressure, lipids and glucose.

Activation of the coagulation system during coronary artery bypass grafting: comparison between on-pump and off-pump techniques.

OBJECTIVE: The activation of the coagulation and fibrinolytic systems and platelet function in patients undergoing coronary artery bypass surgery on-pump or off-pump techniques was compared. METHODS: Thirty-two patients were randomly assigned to on-pump or off-pump coronary artery bypass grafting. Heparin was given at the same dose. Activation of the coagulation and fibrinolytic systems was evaluated by measurement of several markers. Platelet function was evaluated by in vitro bleeding time test. Blood samples were collected at 7 different times, up to postoperative day 6. RESULTS: Overall tissue factor production was similar in the two groups. Thrombin formation was more elevated in the on-pump group (P < .001), particularly during the operation; prothrombin fragment 1.2 discharge values were higher than the preoperative ones (P = .002). Levels of tissue-plasminogen activator showed no difference between the groups (P = .1). D-dimers release was higher in the on-pump group (P = .0002). In vitro bleeding time was longer in the on-pump group (P < .0001), particularly in the first 24 hours; it was not prolonged in the off-pump group. In both groups, regardless of aspirin treatment, discharge in vitro bleeding times were lower than the preoperative ones (P < .01). CONCLUSION: Although the extrinsic coagulation pathway is similarly activated, thrombin formation is more pronounced in patients having on-pump bypass grafting. Patients subjected to off-pump bypass grafting have normally functioning platelets and a weak activation of the fibrinolytic system. At discharge, both groups have preserved platelet function and increased thrombin formation. Further studies with angiographic evaluation are needed to establish a correlation between coagulation parameters, platelet function, and graft patency.

Sex differences in depression after coronary artery bypass graft surgery.

BACKGROUND: Previous research suggests that after coronary artery bypass graft (CABG) surgery, women fare worse than men. This study investigates sex differences in depression during recovery from CABG surgery. METHODS: We followed 137 patients (72 men, 65 women) undergoing elective isolated first CABG surgery between July 2003 and April 2004. Patients were interviewed < or = 28 days before surgery and between 6 and 12 weeks after surgery. Patients completed a structured diagnostic interview for major depressive disorder (MDD) and the Beck Depression Inventory (BDI). Clinical data were retrieved from patient charts. RESULTS: Prevalence of MDD before surgery was 28.2%, but decreased to 16.4% after surgery (P = .038). Women had significantly more depressive symptoms than men pre-CABG, with a mean BDI of 12.5 (95% CI 10.6-14.4) for women versus 8.0 (95% CI 6.3-9.8) for men (P = .0001), but not post-CABG. There was a significant sex-by-time interaction with depressive symptoms in women improving almost 6-fold more than in men, with BDI change scores of 4.1 (95% CI 2.0-6.1) for women versus 0.7 (95% CI-1.0-2.5) for men (P = .008). The interaction remained significant after adjusting the model for the predetermined baseline characteristics education, social support, and operative risk. CONCLUSIONS: Women had more depressive symptoms than men pre-CABG, but improved to a level comparable to men post-CABG. Women benefited from CABG as much or more than men in terms of their mental health. Preoperative depressive symptoms should not preclude women from CABG surgery.