Surgical Heritage: You Had to Be There, Ross: The Comeback Kid.

Half a century after the first pulmonary autograft operation (Ross operation), performed in 1967 by Donald Ross in central London, there is a very strong conviction that the Ross operation is the best available valve substitute today, not only for children, but also for younger and older adults. The Ross operation has stimulated a lot of science to do with tissue-engineering and biology of heart valves, which is a promising avenue for the future. For one of us (M.Y.), it has certainly been a privilege to be associated with the comeback of the Ross operation.

Reconstruction of the heart and the aorta for radical resection of lung cancer.

INTRODUCTION: We report a single-center experience of resection and reconstruction of the heart and aorta infiltrated by lung cancer in order to prove that involvement of these structures is no longer a condition precluding surgery. METHODS: Twenty-seven patients underwent surgery for lung cancer presenting full-thickness infiltration of the heart (n = 6) or the aorta (n = 18) and/or the supra-aortic branches (subclavian n = 3). Cardiac reconstruction was performed in 6 patients (5 atrium, 1 ventricle), with (n = 4) or without (n = 2) cardiopulmonary bypass, using a patch prosthesis (n = 4) or with deep clamping and direct suture (n = 2). Aortic or supra-aortic trunk reconstruction (n = 21) was performed using a heart-beating crossclamping technique in 14 cases (8 patch, 4 conduit, 2 direct suture), or without crossclamping by placing an endovascular prosthesis before resection in 7 (4 patch, 3 omental flap reconstruction). Neoadjuvant chemotherapy was administered in 13 patients, adjuvant therapy in 24. RESULTS: All resections were complete (R0). Nodal staging of lung cancer was N0 in 14 cases, N1 in 10, N2 in 3. No intraoperative mortality occurred. Major complication rate was 14.8%. Thirty-day and 90-day mortality rate was 3.7%. Median follow-up duration was 22 months. Recurrence rate is 35.4% (9/26: 3 loco-regional, 6 distant). Overall 3- and 5-year survival is 60.9% and 40.6%, respectively. CONCLUSIONS: Cardiac and aortic resection and reconstruction for full-thickness infiltration by lung cancer can be performed safely with or without cardiopulmonary bypass and may allow long-term survival of adequately selected patients.

Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial.

Importance: The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. Objective: To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. Design, Setting, and Participants: This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Exposure: Ross procedure. Main Outcomes and Measures: The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. Results: This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). Conclusions and Relevance: This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. Trial Registration: isrctn.org Identifier: ISRCTN03530985.

Robotic mitral valve repair-the Bruxelles experience.

Background: Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period. Methods: Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively. Results: Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively. Conclusions: Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Long-term survival after xenograft versus homograft aortic root replacement: Results from a prospective randomized trial.

OBJECTIVE: The study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. METHODS: A total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. RESULTS: The mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan-Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P = .90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P = .74). CONCLUSIONS: This is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.

Obesity-induced activation of JunD promotes myocardial lipid accumulation and metabolic cardiomyopathy.

AIMS: Metabolic cardiomyopathy (MC)-characterized by intra-myocardial triglyceride (TG) accumulation and lipotoxic damage-is an emerging cause of heart failure in obese patients. Yet, its mechanisms remain poorly understood. The Activator Protein 1 (AP-1) member JunD was recently identified as a key modulator of hepatic lipid metabolism in obese mice. The present study investigates the role of JunD in obesity-induced MC. METHODS AND RESULTS: JunD transcriptional activity was increased in hearts from diet-induced obese (DIO) mice and was associated with myocardial TG accumulation and left ventricular (LV) dysfunction. Obese mice lacking JunD were protected against MC. In DIO hearts, JunD directly binds PPARγ promoter thus enabling transcription of genes involved in TG synthesis, uptake, hydrolysis, and storage (i.e. Fas, Cd36, Lpl, Plin5). Cardiac-specific overexpression of JunD in lean mice led to PPARγ activation, cardiac steatosis, and dysfunction, thereby mimicking the MC phenotype. In DIO hearts as well as in neonatal rat ventricular myocytes exposed to palmitic acid, Ago2 immunoprecipitation, and luciferase assays revealed JunD as a direct target of miR-494-3p. Indeed, miR-494-3p was down-regulated in hearts from obese mice, while its overexpression prevented lipotoxic damage by suppressing JunD/PPARγ signalling. JunD and miR-494-3p were also dysregulated in myocardial specimens from obese patients as compared with non-obese controls, and correlated with myocardial TG content, expression of PPARγ-dependent genes, and echocardiographic indices of LV dysfunction. CONCLUSION: miR-494-3p/JunD is a novel molecular axis involved in obesity-related MC. These results pave the way for approaches to prevent or treat LV dysfunction in obese patients.

Preliminary results of the Multicenter Observational Study with Enoximone in Cardiac surgery (MOSEC).

BACKGROUND: Perioperative administration of Enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study was to evaluate the effects of Enoximone after on-pump cardiac surgery. METHODS: A protocol for a multicenter observational study was reviewed and approved by local ethic committee. This preliminary report involves the first 29 patients enrolled, in whom Enoximone was perioperatively administered in the context of on-pump cardiac surgery. All patients enrolled were propensity-matched 1:1 with controls not receiving Enoximone, renal function was evaluated in terms of estimated glomerular filtration rate (eGFR) with the CKD-EPI equation. RESULTS: After propensity matching, the two cohorts of patients receiving Enoximone or not did not show any significant differences among baseline characteristics. Patients receiving Enoximone showed a progressive improvement of eGFR at each time-point of follow-up: roughly +4.3, +10.0, and +12.3 mL/min/1.73 m2 on postoperative days 2, 7, and 30; respectively. Consistently, maximum difference versus baseline was +12.6 mL/min/1.73 m2 (or +19.3%) among Enoximone patients vs +3.3 mL/min/1.73 m2 (or +4.4%) among controls (p = 0.02). Multivariable regression analysis (R2-adjusted 0.47) showed only age (ß -0.53; p = 0.01), preoperative eGFR (ß -0.39; p = 0.02), diabetes (ß 2.1; p = 0.01), cardio-pulmonary bypass duration (ß 0.08; p = 0.05), and Enoximone administration (ß -0.74; p = 0.05) to be independently correlated with delta eGFR variation on day 30. CONCLUSION: These preliminary results show that perioperative Enoximone administration improved renal function in patients undergoing on-pump cardiac surgery. Further studies are needed to confirm these findings.

Clinical SYNTAX score predicts outcomes of patients undergoing coronary artery bypass grafting.

BACKGROUND: The SYNTAX score (SS) is a determinant of outcome in patients undergoing percutaneous coronary intervention. In addition, it has been recently shown that the clinical SYNTAX score (cSS), obtained by adding clinical variables to the SS, improves the predictive power of the resulting risk model. We assessed the hypothesis that the use of the cSS may predict outcomes of patients undergoing coronary artery bypass grafting (CABG). METHODS: We measured the SYNTAX score in 874 patients undergoing isolated first time on-pump CABG. The clinical SYNTAX score was calculated at the time of the study using age, creatinine clearance and ejection fraction, the modified ACEF score, and analyses performed for major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality at 3-year follow-up. RESULTS: The mean age of the study population was 70.9 ± 8.1 years, and the median cSS 14.2 (range 2.1-286.5). The ROC curve analysis showed that a cSS >14.5 (81.4% sensitivity and 67.8% specificity) was a reliable tool in discrimination of patients for the occurrence of MACCE (AUC 0.78) and all-cause mortality (AUC 0.74). Kaplan-Meier survival analysis confirmed that patients belonging to higher cSS quartiles have poorer 3-year survival (P = .0001) and MACCE-free survival (P = .0001), with respect to those with lower cSS. CONCLUSIONS: This observational study has shown that the clinical SYNTAX score, incorporating the lesion-based SS and clinical-based ACEF score, predicted mid-term adverse outcomes of patients undergoing CABG and may play an important role in the risk stratification of this population. Further studies are needed to confirm these findings.

Residual SYNTAX score following coronary artery bypass grafting.

Objectives: To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG). Methods: We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N = 537), intermediate (rSS mid >11-18.5, N = 539) and high residual SS (rSS high >18.5, N = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Results: The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P < 0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N = 8/537), 4.5% ( N = 24/539) in the intermediate and 8.8% ( N = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P < 0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group. Conclusions: These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Unilateral Versus Bilateral Antegrade Cerebral Protection During Aortic Surgery: An Updated Meta-Analysis.

BACKGROUND: In the context of complex aortic surgery, despite the wide consensus about the use of moderate hypothermia in association with antegrade selective cerebral perfusion (ASCP), its bilateral administration is not always warranted. The aim of the present meta-analysis was to investigate outcomes of unilateral versus bilateral ASCP. METHODS: Outcomes investigated were postoperative mortality and neurologic permanent and temporary disease (PND and TND); separate analysis of heterogeneity using the Cochrane Q statistic was used to perform comparisons. Circulatory arrest (CA) time and temperature, and sample size were explored as potential causes for heterogeneity with meta-regression analysis. RESULTS: The study population consisted of 3,723 patients receiving bilateral ASCP and 3,065 patients receiving unilateral ASC. Pooled analysis showed similar rates of postoperative mortality: 9.8% (95% confidence interval [CI], 7.8% to 12.3%) for bilateral ASCP versus 7.6% (95% CI, 5.7% to 10.2%) for unilateral ASCP; p = 0.19. Postoperative PND rates as well did not differ significantly: 6.9% (95% CI, 5.0% to 9.4%) for bilateral ASCP versus 5.8% (95% CI, 3.8% to 8.7%) for unilateral ASCP; p = 0.53. Similar results yielded from TND analysis: 9.3 % (95% CI, 7.0% to 12.2%) versus 6.5% (95% CI, 4.5% to 9.5%), respectively, p = 0.14. Meta-regression analysis showed that longer CA times were associated with significantly increased mortality only among patients administered with unilateral ASCP (model Q 65.8, p < 0.0001). Furthermore, higher CA temperatures were associated with significantly reduced rates of mortality (Q 64.1, p = 0.001), PND (Q 52.3, p = 0.01), and TND (Q 62.2, p = 0.002) in both groups. CONCLUSIONS: Unilateral versus bilateral ASCP administration did not result in different mortality and neurologic morbidity rates. Nevertheless, among prolonged CA times unilateral ASCP resulted in poorer outcomes with respect to bilateral ASCP. Furthermore, moderate hypothermia was associated with best outcomes in both groups.

Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients.

OBJECTIVE: Our objective was to determine whether the use of unilateral (u-ACP) or bilateral antegrade cerebral perfusion (b-ACP) results in different mortality and neurologic outcomes after complex aortic surgery. METHODS: PubMed, Embase, and the Cochrane Library were searched for studies reporting on postoperative mortality and permanent (PND) and temporary neurologic dysfunction (TND) in complex aortic surgery requiring circulatory arrest with antegrade cerebral protection. Analysis of heterogeneity was performed with the Cochrane Q statistic. RESULTS: Twenty-eight studies were analyzed for a total of 1894 patients receiving u-ACP versus 3206 receiving b-ACP. Pooled analysis showed similar rates of 30-day mortality (8.6% vs 9.2% for u-ACP and b-ACP, respectively; P = .78), PND (6.1% vs 6.5%; P = .80), and TND (7.1% vs 8.8%; P = .46). Age, sex, and cardiopulmonary bypass time did not influence effect size estimates. Higher rates of postoperative mortality and PND were among nonelective operations and for highest temperatures and duration of the circulatory arrest. The Egger test excluded publication bias for the outcomes investigated. CONCLUSIONS: This meta-analysis shows that b-ACP and u-ACP have similar postoperative mortality and both PND and TND rates after circulatory arrest for complex aortic surgery.

Impact of prosthesis-patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement.

BACKGROUND: Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). METHODS: A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm(2)/m(2). Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) > 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. RESULTS: There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2+ (57%vs.22%; p = 0.0001), and PH (62%vs.24%;p < 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p < 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p < 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p < 0.0001) and LV ejection fraction (p < 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. CONCLUSIONS: This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.

Lack of protective role of HDL-C in patients with coronary artery disease undergoing elective coronary artery bypass grafting.

AIMS: Primary prevention studies have confirmed that high-density lipoprotein cholesterol (HDL-C) levels are strongly associated with reduced cardiovascular events. However, recent evidence suggests that HDL-C functionality may be impaired under certain conditions. In the present study, we hypothesize that HDL-C may lose their protective role in the secondary prevention of coronary artery disease (CAD). METHODS AND RESULTS: A consecutive series of 1548 patients undergoing isolated first-time elective CABG at one institution between 2004 and 2009 was studied. According to the ATPIII criteria, pre-operative HDL-C values were used to identify patients with high (Group A) vs. low HDL-C (Group B). To eliminate biased estimates, a propensity score model was built and two cohorts of 1:1 optimally matched patients were obtained. Cumulative survival and major adverse cardiovascular events (MACE) were analysed by means of Kaplan-Meier method. Cox proportional-hazards regression models were used to identify independent predictors of MACE and death. Propensity matching identified two cohorts of 502 patients each. At a median follow-up time of 32 months, there were 44 out of 502 (8.8%) deaths in Group A and 36 out of 502 deaths in Group B (7.2%, HR 1.19; P = 0.42). MACE occurred in 165 out of 502 (32.9%) in Group A and 120 out of 502 (23.9%) in Group B (P = 0.04). Regression analysis showed that pre-operative HDL-C levels were not associated with reduced but rather increased MACE occurrence during follow-up (HR 1.43, P = 0.11). CONCLUSION: Higher HDL-C levels are not associated with reduced risk of vascular events in CAD patients undergoing CABG. Our findings may support efforts to improve HDL-C functionality instead of increasing their levels.

n-3 Polyunsaturated fatty acids for the prevention of postoperative atrial fibrillation: a meta-analysis of randomized controlled trials.

BACKGROUND: n-3 Polyunsaturated fatty acids (n-3 PUFAs) have been proposed as prophylactic therapy in the prevention of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. We conducted a meta-analysis of randomized controlled trials to better clarify this issue. METHODS: An electronic database search for randomized controlled trials on the effect of n-3 PUFAS on POAF was conducted, limited to English language publications until December 2010. For each study, data regarding the incidence of POAF were used to generate risk ratio (<1, favors n-3 PUFA; >1, favors placebo). Pooled summary effect estimate was calculated by means of a fixed or random effect according to heterogeneity. Meta-regression was used to investigate the effect of eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) ratio and preoperative ß-blockers on the effect of n-3 PUFA on POAF. RESULTS: Three publications were included in the analysis, enrolling a total of 431 patients. Overall incidence of POAF ranged from 24 to 54%. Pooling data, n-3 PUFA did not show a significant effect on the risk of POAF [risk ratio 0.89; 95% confidence interval (CI) 0.55-1.44; P=0.63]. However, meta-regression analysis showed a trend toward a benefit from n-3 PUFA supplementation when the EPA/DHA ratio was 1:2 (Q model=7.4; p model=0.02) and when preoperative ß-blocker rate was lower (Q model=8.0; p model=0.01). CONCLUSION: In conclusion, the results of the present meta-analysis of randomized controlled trials suggest that preoperative n-3 PUFA therapy may not reduce POAF in patients undergoing cardiac surgery. However, several aspects may have influenced this negative result, which need to be investigated.

Complexity of coronary artery disease affects outcome of patients undergoing coronary artery bypass grafting with impaired left ventricular function.

OBJECTIVE: To determine whether the SYNTAX score can predict the outcomes of patients with left ventricular dysfunction undergoing coronary artery bypass grafting. METHODS: We studied a consecutive series of 191 patients (mean age, 67 ± 10 years) with a left ventricular ejection fraction of 40% or less who were undergoing isolated coronary artery bypass grafting. All patients were stratified according to their SYNTAX score, indicating coronary artery disease complexity: low, 0 to 22; intermediate, 23 to 32; and high, 33 or more. The primary outcome was all-cause mortality. Secondary outcomes included the late occurrence of major adverse cardiac and cerebrovascular events, left ventricular function, and New York Heart Association functional class. RESULTS: The mean SYNTAX score was 32 ± 13, and the mean preoperative left ventricular ejection fraction was 35% ± 6%. At a median follow-up of 43 months, the primary outcome had occurred in 46 of 191 patients (24%). Kaplan-Meier analysis showed a survival of 81% ± 15% for low, 77% ± 7% for intermediate, and 53% ± 7% for high coronary artery disease complexity (χ(2), 29.4; P = .001). The rate of major adverse cardiac and cerebrovascular events was significantly greater in patients with a SYNTAX score of 33 or more (P = .002). Greater degrees of left ventricular ejection fraction improvement were found in patients with a SYNTAX score of 32 or less (+15% ± 10% vs +4% ± 11%; P = .17) and translated into a better New York Heart Association functional class among patients with a lower SYNTAX score (P = .01). Receiver operating characteristic curve analysis showed the SYNTAX score (area under the curve, 0.70; 95% confidence interval, 0.63-0.77) to have the best predictive power for late mortality with respect to the preoperative left ventricular ejection fraction (area under the curve, 0.59; difference, P = .04) and incomplete revascularization (area under the curve, 0.55; difference, P = .02). CONCLUSIONS: The results of the present study have shown a direct relationship between coronary artery disease complexity and late outcomes of patients with left ventricular dysfunction who are undergoing coronary artery bypass grafting. Additional studies are needed to confirm these findings.

ß-Blockers improve survival of patients with chronic obstructive pulmonary disease after coronary artery bypass grafting.

BACKGROUND: ß-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of ß-blocker administration in patients with COPD undergoing coronary artery bypass grafting. METHODS: A total of 388 consecutive patients with COPD who underwent isolated coronary artery bypass grafting were studied, and clinical follow-up was completed. Diagnosis of COPD was based on preoperative forced expiration volume; exacerbation episodes were defined as a pulsed-dose prescription of prednisolone or a hospital admission for an exacerbation. Two propensity-matched cohorts of 104 patients each either receiving or not receiving ß-blockers were identified. RESULTS: At baseline, there was no significant difference among groups. After a median follow-up of 36 months, there were 8 deaths in 104 patients (7.7%) receiving ß-blockers versus 19 deaths in 104 patients (18.3%) who did not receive ß-blockers (p = 0.03). Kaplan-Meyer analysis showed a survival of 91.8% ± 2.8% for patients taking ß-blockers versus 80.6% ± 4.0% for control subjects (χ(2), 29.4; p = 0.003; hazard ratio, 0.38). In addition, ß-blocker administration did not increase rates of COPD exacerbation, which was experienced by 46 of 104 patients (44.2%) receiving ß-blockers versus 45 of 104 patients (43.3%) not receiving ß-blockers (p = 0.99). CONCLUSIONS: This study showed that in patients with COPD undergoing coronary artery bypass grafting the administration of ß-blockers is safe and significantly improves survival at mid-term follow-up. Further randomized studies are needed to confirm these findings.