The Role of Ivabradine in Cardiac Rehabilitation in Patients With Recent Coronary Artery Bypass Graft.

BACKGROUND: Little is known about ivabradine in cardiac rehabilitation in patients with coronary artery bypass graft (CABG). METHODS: In this prospective, randomized study, suitable patients admitted for cardiac rehabilitation after recent CABG were randomized to ivabradine 5 mg twice a day + standard medical therapy including bisoprolol 1.25 mg once daily (group I-BB, n = 38) or standard medical therapy including bisoprolol 2.5 to 3.75 mg once daily (group BB, n = 43). Patients were evaluated at admission, discharge, and 3 months. The primary end point was improvement in functional status, and other end points were improvement in diastolic function and recovery of systolic function. End points were assessed by distance covered in 6-minute walking test (6MWT), percentage with normal diastolic function, and percentage increase in left ventricular ejection fraction (LVEF). RESULTS: Cardiac rehabilitation improved functional capacity in both groups. In group BB, distances covered in the 6MWT at admission, discharge, and 3 months were 215 ± 53, 314 ± 32, and 347 ± 42 m, respectively. Corresponding distances in group I-BB were 180 ± 91, 311 ± 58, and 370 ± 55 m. Normal diastolic function was restored in I-BB patients, increasing from 24% at admission to 50% and 79% at discharge and 3 months; in BB patients, it decreased from 23% to 19% and 16%. The LVEF improved in I-BB patients, from 57% ± 3% at admission to 62% ± 4% at discharge and 66% ± 3% at 3 months, while remaining unchanged in BB patients (57% ± 3%, 59% ± 4%, and 59% ± 3%). CONCLUSION: Adding ivabradine to low-dose bisoprolol during cardiac rehabilitation in patients with CABG improved functional capacity, enhanced recovery of systolic function, and reduced diastolic dysfunction.

On-pump versus off-pump coronary artery bypass surgery in patients with preoperative anemia.

OBJECTIVES: The study objective was to evaluate the effects on early outcome and midterm survival of performing coronary artery bypass grafting with the off-pump technique in comparison with cardiopulmonary bypass (on-pump) in patients with preoperative anemia. METHODS: Consecutive adult anemic patients (preoperative hemoglobin <13.0 g/dL in men and <12.0 g/dL in women) resident in Puglia region who underwent isolated coronary artery bypass grafting between January 2011 and November 2013 were considered. Vital status was ascertained from the date of surgery to December 31, 2013. Odds ratio and hazard ratio (HR) were estimated. Propensity score methods were used to control for confounders. RESULTS: Of 939 anemic patients (234 female, aged 71 ± 9 years), 361 underwent operation with the off-pump technique and 578 underwent operation with the on-pump technique. Patients undergoing off-pump coronary artery bypass had a shorter intensive care unit length of stay, lower blood transfusion rate, and postoperative reduction in creatinine clearance. During a median follow-up of 18 months, 126 patients died: 46 in hospital (35 on-pump) and 80 after discharge (33 on-pump). In comparison with the off-pump technique, the on-pump technique had greater hospital mortality (odds ratio, 2.57; P = .028) and 30-day incidence of fatal events (HR, 2.67; P = .026). After a period without risk differences between groups (1-6 months; HR, 0.79; P = .618), a lower mortality in those undergoing the on-pump technique was detected (after 6 months HR, 0.35; P = .014). All results were confirmed in the 157 pairs of patients matched for propensity score, anemia grade, and surgery center. CONCLUSIONS: In patients with low levels of preoperative hemoglobin, off-pump coronary artery bypass was associated with lower early morbidity and mortality but a greater risk of mortality during follow-up compared with on-pump coronary artery bypass.

Incremental value of anemia in cardiac surgical risk prediction with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II model.

BACKGROUND: Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations. METHODS: Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin <11.0 g/dL) in 593 patients (12.9%). The EuroSCORE II was used to evaluate predicted hospital death after operations. Logistic regression analysis for in-hospital death was performed including EuroSCORE II risk factors and anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI). RESULTS: Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p < 0.001) and also at multivariate analysis correcting for EuroSCORE II (p < 0.001). When anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p < 0.001), preserving the calibration with good concordance between predicted probabilities and outcome. CONCLUSIONS: Preoperative anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk.

Development and results of Puglia adult cardiac surgery registry.

AIMS: To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS: A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS: From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION: Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.

Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.

OBJECTIVE: This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. METHODS: From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. RESULTS: Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. CONCLUSIONS: In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation.

BACKGROUND: The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). METHODS: From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with organic mitral or tricuspid valve disease were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/3+). No statistical difference was found between two groups concerning preoperative and operative variables. MV was repaired in 137 and replaced in 28 cases; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. RESULTS: Thirty-day mortality was 6.7 (5.9% group A vs 7.9% group B, p=0.607). Five-year actuarial survival was 73.5% (66.6-80.4%); 88.2% (83.0-93.4%) group A versus 46.0% (33.7-58.3%) group B, p<0.001; the possibility to be alive in NYHA class I-II was 65.8% (58.4-73.2%); 78.4% (72.3-84.5%) group A versus 41.2% (29.1-53.3%) group B, p<0.001. Cox analysis confirmed the impact of untreated moderate-or-more FTR on 5-year survival (HR=3.1, 95% CI=1.8-5.1, p<0.001) and possibility to be alive in NYHA class I-II (HR=3.0, 95% CI=1.8-4.9, p<0.001). After a median interval time of 28 months (IQR=11-60), TR grade was echocardiographically assessed in 122 (79.2%) of 154 patients surviving the first month. In group A (87 patients), TR grade decreased significantly from 0.7+/-0.5 to 0.3+/-0.5 (p<0.001) in the early postoperative period. Then, it increased again to 0.6+/-0.7 at follow-up (p<0.001); no difference was found between preoperative and follow-up time (p=ns). In group B (35 cases), TR grade decreased significantly from 2.2+/-0.4 to 1.3+/-0.7 in the early postoperative period (p<0.001), but then increased again to 2.2+/-0.9 (p<0.001 vs postoperative value; p=0.838 vs preoperative value). Cox analysis confirmed that the progression of TR grade at follow-up is a risk factor for lower survival and possibility to be alive in NYHA class I-II. CONCLUSIONS: Patients with untreated moderate-or-more FTR had survival and survival in NYHA class I-II lower than patients with untreated less-than-moderate FTR at 5-year follow-up.

Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? a propensity score analysis.

BACKGROUND: The aim of this retrospective study was to evaluate the clinical outcome of treating or not treating moderate-or-more functional tricuspid regurgitation in patients with functional mitral regurgitation undergoing mitral valve surgery. METHODS: From January 1988 to March 2003, 110 patients with functional mitral regurgitation undergoing mitral valve surgery showed moderate-or-more functional tricuspid regurgitation, which was treated (group T) in 51 and untreated in 59 (group UT) patients. Propensity score was used to adjust midterm results. The tricuspid valve was always repaired using the DeVega technique. The mitral valve was repaired in 84 and replaced in 26 patients; no residual moderate-or-more functional mitral regurgitation was assessed at hospital discharge. RESULTS: Thirty-day mortality was 5.5% (8.5% for group UT versus 2% for group T; p= 0.245). Adjusted 5-year survival was 45.0% +/- 6.1% in group UT and 74.5% +/- 5.1% in group T (p= 0.004), whereas the possibility to be alive in New York Heart Association class I or II was 39.8% +/- 6.0% in group UT versus 60.0% +/- 6.5% in group T (p= 0.044). Proportional Cox analysis, forcing propensity score into the model, demonstrated that untreated moderate-or-more tricuspid regurgitation was a risk factor for lower midterm survival (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.4) and survival in New York Heart Association class I or II (hazard ratio, 1.9; 95% confidence interval, 1.1 to 3.4). Follow-up functional tricuspid regurgitation progression rate (3+/4+) was 5% in group T versus 40% in group UT (p < 0.001). The progression of functional tricuspid regurgitation grade at follow-up was a risk factor for worse survival and the possibility to be alive in New York Heart Association class I or II. CONCLUSIONS: Tricuspid annuloplasty is an easy and safe procedure, mandatory in case of at least moderate functional tricuspid regurgitation to achieve better mid-term outcome in patients with functional mitral regurgitation undergoing mitral valve surgery.

Impact of ischemic mitral regurgitation on long-term outcome of patients with ejection fraction above 0.30 undergoing first isolated myocardial revascularization.

BACKGROUND: We evaluated the impact of ischemic mitral regurgitation (IMR) on long-term outcome of patients with an ejection fraction (EF) exceeding 0.30 undergoing isolated coronary artery bypass grafting (CABG). METHODS: From November 1994 to December 2002, 4226 patients (EF > 0.30) underwent a first isolated CABG. Preoperative IMR was present in 1421 (33.6%, group IMR), of which 1254 had mild (1/4) and 167 had moderate (2/4). The remaining 2805 patients (66.4%, group no-IMR) showed no IMR. A nonparsimonious regression model was built to determine the propensity score. Ten-year freedom from death from any cause, cardiac death, and cardiac events was evaluated by the Kaplan-Meier method. Results of Cox analysis were adjusted by entering the propensity score as an independent variable. RESULTS: All patients had similar early mortality (2.1% no-IMR vs 2.5% IMR, p = 0.502) and morbidity (6.5% no-IMR vs 6.6% IMR, p = 0.840). In patients with EF of 0.31 to 0.40, but not in those ones with EF exceeding 0.40, IMR grade was an independent variable for worse long-term freedom from cardiac death (82.8 +/- 3.2 vs 91.4 +/- 2.4; Cox hazard ratio [HR], 2.1 [95% confidence interval (CI), 1.1 to 4.1]; p = 0.0324) and cardiac events (78.6 +/- 3.5 vs 88.5 +/- 2.7; Cox HR, 2.0 [95% CI, 1.1 to 3.7]; p = 0.0174). CONCLUSIONS: Mild or moderate IMR in patients with an EF exceeding 0.30 undergoing first isolated CABG influences long-term outcome when EF is 0.31 to 0.40, but not when it exceeds 0.40.

A single-size band, 50 mm long, for tricuspid annuloplasty.

A technique for tricuspid annuloplasty is presented, using a flexible 50mm long band, where the annular circumference is reduced to a fixed value of 78.5mm (circumference of #25 mm sizer). From June to February 2007, 15 consecutive patients with tricuspid regurgitation (TR) underwent tricuspid repair using this technique. The first suture is passed at the level of the anteroseptal commissure, the last one in the zone of the septal annulus, 28.5mm from the first one. The remaining sutures are passed as usual. All the sutures are then adapted to a 50mm long band. After a mean of 5.4 months from surgery, all patients are alive and asymptomatic. One patient showed residual 2/4 TR, due to enlarged RV with high pulmonary pressure despite a well functioning mitral prosthesis. Mean gradient across the tricuspid valve was 2.5+/-0.4 mmHg. This technique for tricuspid repair is simple and reliable, providing effective and reproducible results.

A simple method to obtain the correct length of the artificial chordae in complex chordal replacement.

BACKGROUND: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. METHOD: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. RESULTS: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 +/- 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. CONCLUSIONS: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair.

Does off-pump coronary surgery reduce postoperative acute renal failure? The importance of preoperative renal function.

BACKGROUND: Off-pump was compared with on-pump coronary artery bypass graft surgery to evaluate the impact of cardiopulmonary bypass on the incidence of postoperative acute renal failure (ARF). METHODS: From November 1994 to December 2001, 2,943 patients having multivessel surgical disease underwent myocardial revascularization. Ninety patients were excluded because of incompleteness of data, intraoperative death, or preoperative chronic dialysis. The analysis was split: one analysis included 1,724 (862 each group) of 2,618 patients with normal preoperative creatinine (<1.5 mg/dL), and the second analysis included 160 (80 each group) of 215 patients with preoperative abnormal renal function; in both analyses matched groups were selected applying propensity score. RESULTS: In the group with normal preoperative creatinine, the incidence of 30-day ARF was 5.4% (2.9% off-pump versus 7.9% on-pump; p < 0.001). Stepwise logistic regression confirmed that cardiopulmonary bypass was an independent variable for increased postoperative ARF incidence (odds ratio, 3.3), as well as age and reduced left ventricular ejection fraction. Receiver operating characteristic curves showed that cardiopulmonary bypass duration was a predictor of higher ARF incidence (area under the curve, 0.79) with a cutoff value of 66 minutes. In the patients with abnormal renal function preoperatively, the incidence of ARF was similar between the groups (16.3% on-pump versus 12.5% off-pump; p = 0.499). Acute renal failure had an important impact on early (odds ratio, 3.6) and late mortality (hazard ratio, 4.1). CONCLUSIONS: Off-pump surgery plays an important renoprotective role and provides better early and late outcome in patients with normal preoperative creatinine. When the preoperative creatinine is abnormal, the surgical strategy does not seem to have any influence. The occurrence of ARF significantly impairs early and long-term mortality, and the surgical strategy does not improve outcomes.

Mitral valve repair for degenerative mitral regurgitation.

Mitral valve repair for degenerative mitral regurgitation is nowadays one of the most common valvular procedures. Different technical modifications were added to the original Carpentier's method, trying to maximise the stability of the results and to reduce the incidence of immediate complications and of late failure of the correction. Survival is good, even if recent reports showed that recurrence of mitral regurgitation can be higher than expected. Prolapse of the anterior leaflet remains challenging and is related to higher reintervention rates. Nevertheless, the overall success rate is high, and the increasing experience of the different surgical teams approaching this procedure will help maintain satisfactory and stable long-term results.

Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy.

BACKGROUND: This study analyzes retrospectively a cohort of patients with ischemic cardiomyopathy (ejection fraction < or = 0.30) who underwent isolated coronary artery bypass grafting to evaluate the impact of no-to-moderate mitral regurgitation (MR) on long-term results. METHODS: From January 1988 to December 2002, 6,108 patients had isolated coronary artery bypass grafting. Two hundred thirty-nine (3.9%) had ischemic cardiomyopathy; 60 patients had no, 102 had mild, and 77 had moderate MR. Using propensity score, a group of 70 patients with no or mild MR (group A) was case-matched with a group of 70 patients with moderate MR (group B) to obtain two groups with similar preoperative characteristics. RESULTS: Nine patients (6.4%) died within the first 30 days; all deaths were cardiac-related. There was no difference in the early results between groups. Patients in group B showed lower freedom from death, from cardiac death, from cardiac death and ischemic events, and from death and New York Heart Association class III and IV than patients in group A. Cox analysis confirmed that moderate MR was an independent variable for worse late outcome in this subgroup of patients. Functional and echocardiographic results, after a mean of 62 +/- 28 months in 87.8% of survivors, showed a significant impairment of New York Heart Association class (from 2.2 +/- 0.5 to 2.8 +/- 0.6; p < 0.001) and MR degree (from 2.0 to 2.7 +/- 1.0; p = 0.023) in patients with preoperative moderate MR. CONCLUSIONS: This study confirms that moderate ischemic MR has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone.

Single versus bilateral internal mammary artery for isolated first myocardial revascularization in multivessel disease: long-term clinical results in medically treated diabetic patients.

BACKGROUND: We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG. METHODS: From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA +/- SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 +/- 2.0). RESULTS: There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 +/- 3.2 versus 79.5 +/- 4.1, p = 0.0274), cardiac death (96.3 +/- 1.4 versus 88.4 +/- 4.0, p = 0.0406), acute myocardial infarction (99.5 +/- 0.5 versus 92.0 +/- 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 +/- 0.5 versus 93.4 +/- 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410). CONCLUSIONS: In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA +/- SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.

Bilateral internal thoracic artery grafting with and without cardiopulmonary bypass: six-year clinical outcome.

OBJECTIVES: We sought to evaluate whether early and late results in patients who underwent off-pump or on-pump myocardial revascularization with bilateral internal thoracic artery grafting were similar. METHODS: From November 1994 through December 2001, 1835 patients underwent isolated myocardial revascularization with bilateral internal thoracic artery grafting. By applying propensity score pairwise matching, 1194 patients were selected and operated on either off pump (n = 597) or on pump (n = 597). RESULTS: The overall 30-day mortality was 1.5% (1.2% in the off-pump group and 1.8% in the on-pump group, P = .342). There was no difference for all the other complications between the 2 groups. Mean follow-up was 5.2 +/- 1.8 years. Forty-two patients died over the follow-up period (22 in the off-pump group and 20 in the on-pump group), 15 of them of cardiac causes (7 in the off-pump group and 8 in the on-pump group). Six-year outcomes (freedom from death, cardiac death, acute myocardial infarction and reoperation in all or in the grafted area, target cardiac events, and any other event) were similar for both categories. After a mean of 30.7 +/- 20.1 months, 202 patients had a postoperative angiography showing similar results. CONCLUSIONS: Our results with extensive arterial revascularization clearly show that with the technical improvements achieved in the most recent years, off-pump operations can be performed safely with the same quality of late results as those obtained with on-pump operations.

Mitral valve repair in ischemic mitral regurgitation.

Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (≦10 mm) or replacement (≫10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6±4.7 and 59.8±5.4, respectively. After a mean of 38±35 months, the NYHA class decreases from 3.2±0.5 to 2.1±0.6 (P≪0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2±0.8 to 1.2±1.1 (P≪0.001). 97.5% of the survivors have MR equal to or less than moderate.

Reoperative coronary artery bypass grafting: analysis of early and late outcomes.

BACKGROUND: The purpose of this study was to evaluate early and late results of reoperative coronary artery bypass grafting compared with those of first coronary artery bypass grafting. METHODS: From November 21, 1994, to December 31, 2001, 4,381 patients underwent isolated coronary revascularization: among these patients, 274 (6.3%) underwent a redo. Applying the propensity score, 239 redo patients (group R) were matched with 239 who underwent the first revascularization (group F). RESULTS: Early mortality was 2.1% (group F) and 4.2% (group R), not significantly different. Group R showed significantly higher creatine kinase myocardial band release, length of intensive care unit stay, and incidence of incomplete myocardial revascularization than group F. In group R, off-pump patients showed higher incidence of incomplete revascularization. Redo was a risk factor for abnormal (>19 IU/L) creatine kinase myocardial band release (odds ratio, 1.7; p = 0.0066) and incomplete myocardial revascularization (odds ratio, 2.4; p = 0.0060). Five-year clinical outcome was significantly worse in group R, except for freedom from redo or percutaneous transluminal coronary angioplasty. Redo was an independent variable for lower freedom from death of any cause, cardiac death, acute myocardial infarction, cardiac events, and any event. Patients with higher creatine kinase myocardial band release or incomplete myocardial revascularization showed lower freedom from cardiac-related events. Incidence of incomplete myocardial revascularization and creatine kinase myocardial band release were significantly higher in group R by both univariate and multivariate analysis. This could explain the worse late outcome of redo patients. CONCLUSIONS: Complete revascularization without damaging the heart, whichever technique is used, is the target of redo surgery, to achieve the same quality of results obtained in the first operation.

Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts.

OBJECTIVE(S): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. METHODS: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n=576) or BIMA (one IMA on the LAD) with or without SVG(s) (n=1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3+/-4.8 years). RESULTS: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5+/-0.8 versus 91.3+/-1.4, P=0.0288), AMI (98.0+/-0.6 versus 94.3+/-1.2, P=0.0180), AMI in a GA (98.4+/-0.6 versus 94.7+/-1.1, P=0.0057) and target cardiac events (93.9+/-1.1 versus 86.3+/-1.8, P=0.0388). Cox analysis confirmed that LIMA+SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. CONCLUSIONS: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease patients.

BACKGROUND: Off-pump coronary artery bypass surgery is widely performed because of its proved safety, but its effectiveness remains controversial. The aim of this retrospective study was to compare early and late results in patients with multivessel disease, operated on off-pump and on-pump. METHODS: From November 1994 to December 2001, 2957 patients with multivessel disease underwent isolated coronary revascularization, on-pump (n = 1924) and off-pump (n = 1033). Sixty-five patients (2.2%) who were converted from off-pump to on-pump were considered as part of the off-pump group. RESULTS: Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, early negative primary endpoints, and early major events. Conversion to on-pump was an independent risk factor for a higher incidence of death due to any cause and cardiac death, early negative primary endpoints, and early major events. Conversion, however, did not affect late clinical outcome. The 6-year freedom from death (any cause, cardiac cause), myocardial infarction, redo/coronary angioplasty and any events was similar in the two groups. CONCLUSIONS: These results suggest that off-pump surgery reduces early mortality and morbidity. These benefits are not at the expense of the long-term clinical outcome which seems to be similar in the two groups. Patients who require conversion from off-pump to on-pump have a much higher mortality and morbidity although this does not seem to influence their long-term clinical outcome.