Streptomyces lasalocidi sp. nov. (formerly 'Streptomyces lasaliensis'), an actinomycete isolated from soil which produces the polyether antibiotic lasalocid.

Strain ATCC 31180T was isolated from soil collected in Hyde Park, Massachusetts (USA), and found to produce the polyether antibiotic lasalocid. The name 'Streptomyces lasaliensis' has been in common use since 1974, without a recognized taxonomic description. The most closely related type cultures determined by rRNA gene sequence similarity were Streptomyces longwoodensis DSM 41677T (100 %) and Streptomyces galbus DSM 40089T (100 %). OrthoANI values with S. longwoodensis and S. galbus were 95.50 and 94.41 %, respectively. Chemotaxonomic characteristics supported inclusion within the genus Streptomyces. The cell wall peptidoglycan contained ll-diaminopimelic acid, and the major whole-cell sugars were glucose and ribose. Polar lipids were phosphatidylethanolamine, diphosphatidylglycerol, phosphatidylinositol, phosphatidylglycerol, one unidentified lipid and one unidentified glycolipid. The major menaquinones detected were MK9(H4), MK9(H6) and MK9(H8). The major cellular fatty acids were anteiso-C15 : 0, anteiso-C17 : 0, iso-C16 : 0, iso-C15 : 0 and anteiso-C17 : 1. Its DNA had a G+C content of 72.6 %. Differentiation of ATCC 31180T from the closely related species was evident from digital DNA-DNA hybridization values of 61.80 and 56.90 % for S. longwoodensis and S. galbus respectively. Significant differences were seen in the polyphasic phenotypic analyses. ATCC 31180T produced lasalocid, grew from 10 to 45 °C, pH4-8 and in the presence of 0-10 % NaCl, 0.01 % NaN3 and 1 % phenol. Melanin was produced; H2S and indole were not. Nitrate was not reduced. Spore chains were retinaculum-apertum and spore surfaces were smooth. Spore colour, mycelia colour and soluble pigment production were medium-dependent. The proposed name is Streptomyces lasalocidi sp. nov.; the type strain being ATCC 31180T (=NRRL 3382T=DSM 46487T).

Immediate outcome after sutureless versus transcatheter aortic valve replacement.

The aim of this study was to compare the immediate outcome of patients undergoing transcatheter (TAVI) versus surgical aortic valve replacement with the sutureless Perceval bioprosthesis (SU-AVR). This is a retrospective multicenter analysis of 773 patients who underwent either TAVI (394 patients, mean age, 80.8 ± 5.5 years, mean EuroSCORE II 5.6 ± 4.9 %) or SU-AVR (379 patients, 77.4 ± 5.4 years, mean EuroSCORE II 4.0 ± 3.9 %) with or without concomitant myocardial revascularization. Data on SU-AVRs were provided by six European institutions (Belgium, Finland, Germany, Italy and Sweden) and data on TAVIs were provided by a single institution (Catania, Italy). In-hospital mortality was 2.6 % after SU-AVR and 5.3 % after TAVI (p = 0.057). TAVI was associated with a significantly high rate of mild (44.0 vs. 2.1 %) and moderate-severe paravalvular regurgitation (14.1 vs. 0.3 %, p < 0.0001) as well as the need for permanent pacemaker implantation (17.3 vs. 9.8 %, p = 0.003) compared with SU-AVR. The analysis of patients within the 25th and 75th percentiles interval of EuroSCORE II, i.e., 2.1-5.8 %, confirmed the findings of the overall series. One-to-one propensity score-matched analysis resulted in 144 pairs with similar baseline characteristics and operative risk. Among these matched pairs, in-hospital mortality (6.9 vs. 1.4 %, p = 0.035) was significantly higher after TAVI. SU-AVR with the Perceval prosthesis in intermediate-risk patients is associated with excellent immediate survival and is a valid alternative to TAVI in these patients.

Meta-analysis on the performance of the EuroSCORE II and the Society of Thoracic Surgeons Scores in patients undergoing aortic valve replacement.

OBJECTIVE: To evaluate the performance of the EuroSCORE II (ESII) and the Society of Thoracic Surgeons (STS) scores in surgical (SAVR) or transcatheter aortic valve replacement (TAVR). DESIGN: Systematic review of the literature and meta-analysis. SETTING: University hospitals. PARTICIPANTS: Studies reporting data on the performance of ESII and STS scores in patients undergoing SAVR or TAVR. INTERVENTIONS: SAVR or TAVR. MEASUREMENTS AND MAIN RESULTS: Ten studies validated these scores in 13,856 patients who underwent either TAVR or SAVR. Operative mortality was 5.9% (SAVR 3.1%; TAVR 9.6%). ESII-expected mortality was 5.1% (O/E ratio: 1.15, SAVR, O/E ratio 0.94; TAVR, O/E ratio 1.23) and STS-expected mortality was 6.3% (O/E ratio: 0.94, SAVR, O/E ratio 0.84; TAVR, O/E ratio 1.13). The area under the ROC curve for ESII was 0.70 and for STS was 0.70 (SAVR patients: 0.73 for ESII and 0.75 for STS; TAVR patients; 0.66 for ESII and 0.63 for STS). The difference between observed/expected mortality was not significant for ESII (Peto's OR 0.99, p = 0.88) and was significant for STS (Peto's OR 0.86, p = 0.008). ESII (Peto's OR 1.35, p<0.00001) and STS (Peto's OR 1.23, p<0.00001) significantly underestimated the mortality risk in TAVR patients. The STS (Peto's OR 0.74, p<0.0001) and, to a lesser extent, the ESII (Peto's OR 0.86, p = 0.0.04) overestimated the mortality risk in SAVR patients. CONCLUSIONS: The ESII and STS scores have good O/E ratios for either TAVR or SAVR patients, but both scores significantly underpredicted the risk of TAVR patients. ESII seemed to be accurate in predicting the risk of SAVR patients.

First-time, isolated surgical aortic valve replacement after prior coronary artery bypass surgery: results from the RECORD multicenter registry.

BACKGROUND: This multicenter study was undertaken to determine the immediate and long-term outcomes in patients undergoing a primary surgical aortic valve replacement (AVR) who had a previous coronary artery bypass graft surgery with patent grafts. METHODS: One hundred and thirteen consecutive patients (mean EuroSCORE II, 10.3 ± 7.7%, median 8.0%) who underwent first-time isolated AVR after coronary artery bypass grafting (CABG) were the subjects of this multicenter study. The procedure was performed through a full sternotomy in 95.7% of cases, a patent internal mammary artery graft was clamped in 76.6% of patients. The temperature of cardioplegia was ≤12 °C in 62.8% of patients and systemic temperature was <32 °C in 23.9% of patients. RESULTS: Thirty-day mortality was 4.4%. Stroke was observed in 8.0% of patients, low cardiac output syndrome in 14.1%, prolonged tracheal intubation in 20.8%, and intensive care unit stay was longer than five days in 19.5% of patients. Among patients with a patent internal mammary graft (91 patients), clamping of this graft (5.7% vs. 0%, p = 0.57) was associated with a nonsignificant trend toward increased 30-day mortality. One-, three- and five-year survival rates were 91.5%, 90.4%, and 88.4%, respectively. CONCLUSIONS: Patients undergoing isolated AVR after prior CABG have a good immediate and late survival. A history of prior CABG should not be considered an absolute indication for transcatheter AVR.

Off-pump versus on-pump coronary artery bypass surgery in patients aged 80 years and older: institutional results and meta-analysis.

Patients aged ≥80 years are at high risk of adverse events after coronary artery bypass grafting. This study was performed to evaluate whether off-pump coronary artery bypass surgery (OPCAB) is superior to conventional surgery (CCAB) in these high-risk patients. The outcome of 185 patients aged ≥80 years who underwent OPCAB or CCAB at our institution was reviewed and a meta-analysis on this issue was performed. Similar immediate postoperative results were observed after OPCAB and CCAB at our institution, despite significantly different operative risk (mean logistic EuroSCORE, OPCAB 20.3% vs CCAB 13.4%, P = 0.003). Among 56 propensity score matched pairs a trend toward lower postoperative stroke (0%, 95% CI 0-0 vs 3.6%, 95% CI 0-10.0, P = 0.50) was observed after OPCAB. No significant differences were observed in the other outcome end points. Five-year survival was 81.0% after OPCAB and 78.1% after CCAB (P = 0.239). Pooled analysis of eight studies including 3416 patients showed a significantly higher risk of postoperative stroke after CCAB (pooled rates: 4.2%, 95% confidence interval (95% CI) 2.4-7.1 vs 1.5%, 95% CI 0.9-2.5, risk ratio (RR) 2.15, 95% CI 1.17-3.96, P = 0.01). A trend toward higher immediate postoperative mortality was observed after CCAB (15 studies including 4409 patients, pooled rates: 6.5%, 95% CI 5.2-8.0 vs 5.6%, 95% CI 4.2-7.4, RR 1.29, 95% CI 0.86-1.93, P = 0.21). Generic inverse variance analysis showed similar intermediate survival after CCAB and OPCAB (RR 1.31, 95% CI 0.85-2.01, P = 0.22). At 2 years, survival was 82.8% (95% CI 76.4-89.2) after CCAB and 88.3% (95% CI 82.9-93.7) after OPCAB. Current results indicate that OPCAB compared with CCAB in patients aged ≥80 years is associated with significantly lower postoperative stroke and with a trend toward better early survival. However, suboptimal quality of the available studies, particularly the lack of comparability of the study groups, prevents conclusive results on this controversial issue.

Individual surgeon's impact on the risk of re-exploration for excessive bleeding after coronary artery bypass surgery.

OBJECTIVE: Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication. DESIGN: Retrospective. SETTING: Tertiary referral center in a university hospital. PARTICIPANTS: Two thousand one patients. INTERVENTIONS: Isolated coronary artery bypass grafting. RESULTS: Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m(2) (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m(2) (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL. CONCLUSIONS: An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.

Timing of preoperative aspirin discontinuation and outcome after elective coronary artery bypass graft surgery.

OBJECTIVE: Whether aspirin should be discontinued before coronary artery bypass grafting is controversial. The potential benefits and harms associated with late use of aspirin (no discontinuation or discontinuation <3 days before surgery) were investigated in this retrospective, multicenter study. DESIGN: Retrospective, multicenter study. SETTING: Two university hospitals and one central hospital. PARTICIPANTS: A consecutive series of 859 patients who underwent elective coronary artery bypass grafting from January 2008 through December 2010. INTERVENTIONS: Aspirin (100 mg/day) was used <3 days before surgery in 240 patients and was discontinued >3 days before surgery in 619 patients. RESULTS: In the overall series, similar in-hospital mortality, amount of postoperative blood loss, rate of re-exploration for excessive bleeding, and use of blood products were observed in the study groups. However, aspirin discontinuation >3 days before surgery tended to be associated with a higher postoperative stroke rate (1.9% v 0.4%, p = 0.13). Such a trend was observed after off-pump (1.9% v 0%, p = 0.58) and on-pump (2.0% v 0.6%, p = 0.46) surgery. Among 153 pairs matched by the propensity score, patients with aspirin discontinued >3 days before surgery had a significantly higher rate of postoperative stroke (5.9% v 0.7%, p = 0.02) and tended to have a higher risk of the composite adverse outcome endpoint (19.6% v 12.4%, p = 0.09). The postoperative release of troponin I was similar in the study groups. CONCLUSIONS: Late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion. These findings and the risk of cardiovascular events possibly occurring at the time of its discontinuation suggest that the use of aspirin until the day of elective coronary surgery may be beneficial.

An efficient Pulsed-Field Gel Electrophoresis (PFGE) method for typing autolytic Lacticaseibacillus rhamnosus strains.

Species of lactic acid bacteria, due to their versatile metabolism, are commonly used in food and feed products, both as technological starters and as health- and welfare-promoting agents. Correct strain identification in microbe-containing products is vital, and the Pulsed-Field Gel Electrophoresis (PFGE) typing method is considered the 'gold standard' for this purpose. This typing technique is widely used in molecular epidemiology, especially for the early detection of emerging isolates with food-safety implications, for outbreak surveillance, and for infection control. The autolytic behavior that we encountered when typing Lacticaseibacillus rhamnosus strains using the PFGE technique led us to modify the current method used for typing lactic acid bacteria. This study describes a PFGE method for the molecular typing of autolytic members of the lactic acid bacteria.•An efficient method for overcoming DNA degradation during PFGE analysis for typing Lacticaseibacillus rhamnosus strains is described.•The method described herein could be considered for typing autolytic lactic acid bacteria.

Poor late survival after surgical treatment of pleural empyema.

BACKGROUND: We have evaluated the outcome of patients who underwent surgical treatment of parapneumonic pleural empyema. METHODS: This study included 143 consecutive patients older than 18 years who were operated on for parapneumonic pleural empyema. RESULTS: The overall survival at 30 days, 3 months, 5 years, and 10 years was 97.2, 92.3, 80.6, and 61.9%, respectively. Serum albumin (OR = 0.78, 95% CI = 0.65-0.94), cerebrovascular disease (OR = 30.49, 95% CI = 1.35-689.05), pulmonary embolism (OR = 984.63, 95% CI = 7.81-124206.8), and Thoracoscore (OR = 1.61, 95% CI = 1.10-2.35) were independent predictors of 3-month overall survival. Age (RR = 1.08, 95% CI = 1.03-1.14), serum albumin (RR = 0.89, 95% CI = 0.82-0.98), chronic obstructive pulmonary disease (COPD) (RR = 5.14, 95% CI = 1.3319.84), and cerebrovascular disease (RR = 6.76, 95% CI = 1.33-34.34) were independent predictors of pneumonia/pleural empyema-related death. Twenty-two patients required 33 reinterventions after the primary procedure: 19 patients after primary thoracoscopy and 3 patients after primary thoracotomy. Reintervention did not have any significant impact on 30-day mortality (4.5% vs. 2.5%, p = 0.49), but it affected 3-month mortality (26.1% vs. 4.2%, p < 0.0001). Reoperation was an independent predictor of late overall survival (at 10 years: 35.5% vs. 67.4%, RR = 2.95, 95% CI = 1.33-6.57) and freedom from pneumonia/pleural empyema-related death (at 10 years: 73.9% vs. 91.3%, RR = 4.40, 95% CI = 1.24-15.66). CONCLUSIONS: Surgical treatment of pleural empyema can be associated with good immediate results, but longer follow-up showed that pneumonia/pleural empyema-related mortality and all-cause mortality are rather poor.

Concentrations of bovine lactoferrin and citrate in milk during experimental endotoxin mastitis in early- versus late-lactating dairy cows.

Lactoferrin (Lf) is a molecule naturally present in bovine milk that affects the availability and transport systems of iron. Lf also binds endotoxin (lipopolysaccharide, LPS) of Gram-negative bacteria and modulates the immunological response. In the present study, concentrations of bovine Lf (bLf) and citrate in milk were determined in early (EL) and late (LL) lactating dairy cows, using an experimentally induced endotoxin mastitis model and a crossover design. Nine clinically healthy Finnish Ayrshire cows were challenged twice with 100 µg endotoxin infused into one udder quarter. Milk samples were collected from the challenged and control quarters of each cow before and after endotoxin infusion during 3 d, and bLf and citrate concentrations were measured. In all cows, clinical signs of mastitis were seen at both times of challenge, but the response was more severe in EL than in LL. Concentration of bLf in the milk started to rise approximately 8 h after endotoxin infusion and was still higher than normal on the third day, especially in the late-lactating cows. In milk of the LL group, concentrations of bLf were significantly higher than in the EL group. In contrast, concentrations of citrate were higher in milk of the EL cows compared with the LL cows. Concentration of bLf and citrate varied substantially among cows. The molar ratio of citrate to bLf before and after challenge was significantly higher during the EL period. The results of this study partly explain why cows in early lactation are more susceptible to intramammary infections and why mastitis is more severe in them.

Predicting immediate and late outcome after surgery for mitral valve regurgitation with EuroSCORE.

BACKGROUND AND AIM OF THE STUDY: The European system for cardiac operative risk evaluation score (EuroSCORE) has been shown to be a valid tool for predicting immediate and late outcome after coronary artery bypass surgery. As evidence also suggests its value in heart valve surgery, this issue was investigated in a series of patients who underwent surgery for mitral valve regurgitation. METHODS: Data obtained from 180 patients who underwent mitral valve repair (MVRep) or mitral valve replacement (MVR) were reviewed, and the patients' additive and logistic EuroSCOREs calculated. RESULTS: The 30-day postoperative mortality rate was 10.0% (n = 18); rates were 7.1% after MVRep and 20.5% after MVR (p = 0.013). The additive EuroSCORE (p <0.0001, area under the ROC curve: 0.804, 95% CI 0.689-0.919, SE 0.059), as well as logistic EuroSCORE (p <0.0001, area under the ROC curve: 0.806, 95% CI 0.695-0.918, SE 0.057) were predictors of 30-day postoperative death. The 10-year overall survival rate from any cause of death was 74.7%. Additive and logistic EuroSCOREs were significantly higher in the MVR group compared to the MVRep group (p <0.0001 in both cases), and also among operative survivors. Patients who underwent MVR had a significantly poorer long-term survival than those with MVRep (p = 0.01). Both the additive EuroSCORE (p <0.0001) and logistic EuroSCORE (p = 0.003) were predictors of late, all-cause mortality. Both scores remained significant predictors of late outcome also when adjusted for type of surgery (MVRep versus MVR). Survival was particularly dismal in patients with an additive EuroSCORE >6 (at 10 years, 54.4% versus 86.6%, p <0.00001) or a logistic EuroSCORE >4% (at 10 years, 58.7% versus 86.6%, p <0.00001). CONCLUSION: EuroSCORE is an important predictor of immediate and late outcome after surgery for mitral valve regurgitation.

Permanent work disability in patients ≤50 years old after percutaneous coronary intervention and coronary artery bypass grafting (the CRAGS study).

Background: The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and Results: The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P < 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P = 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P < 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions: Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.

Predictors of diseased ascending aorta in patients undergoing off-pump coronary artery bypass surgery.

OBJECTIVE: To identify the preoperative risk factors associated with increased prevalence of atherosclerotic lesions of the ascending aorta among patients undergoing off-pump coronary artery bypass surgery (OPCAB). MATERIAL AND METHODS: OPCAB was performed in 241 patients who were intraoperatively investigated by epiaortic ultrasound for the presence of atherosclerotic lesions of the ascending aorta. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) and the Multicenter Study of Perioperative Ischemia (McSPI) stroke risk scores were retrospectively calculated. RESULTS: A diseased ascending aorta was detected by intraoperative epiaortic ultrasound in 74 patients (30.7%). Patient's age (P = .002, odds ratio [OR] 1.067, 95% confidence interval [CI] 1.025-1.110), diabetes (P = .023; OR, 2.211; 95% CI, 1.117-4.378), extracardiac arteriopathy (P = .014; OR, 2.567; 95% CI, 1.214-5.428) and urgent/emergency operation (P < .0001; OR, 3.066; 95% CI, 1.685-5.580) were independent preoperative predictors of a diseased ascending aorta. The area under the ROC curve of the NNECVDSG score in predicting a diseased ascending aorta was 0.710 (95% CI, 0.642-0.778), and that of the McSPI score was 0.722 (95% CI, 0.655-0.788). The prevalence of a diseased ascending aorta was 11.2%, 34.7%, and 49.4% among the NNECVDSG score tertiles (P < .0001), and 11.3%, 31.7%, and 49.4% among the McSPI score tertiles (P < .0001). CONCLUSIONS: These findings confirm the reported high incidence of a diseased ascending aorta in patients undergoing coronary artery bypass surgery. Current stroke risk scores, particularly the simple NNECVDSG score, are valuable predictors of increased prevalence of a diseased ascending aorta.

Quality of life after mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair for degenerative and ischemic mitral valve regurgitation has been shown to be a durable procedure. The study aim was to evaluate the quality of life of patients who had undergone mitral valve repair, and to compare it to that of an age- and gender-adjusted Finnish general population. METHODS: Among 130 late survivors after mitral valve repair, 109 (83.8%) answered the RAND-36 Health Survey questionnaire; these patients form the basis of the present study. RESULTS: The Wilcoxon test showed significantly higher mental health (p = 0.04) and pain scores (p = 0.015) and a lower role functioning/physical score (p = 0.008) in the study group. The scores of the other RAND-36 Health Survey variables of the study group were similar to those of the age- and gender-adjusted general population. The mean total score for the study group was 512 (median 532, IQR 360-678), compared to 522 (median 538, IQR 468-549) in the general population (p = 0.72) (only 95 patients were included in the analysis due to isolated missing scores). CONCLUSION: The quality of life of long-term survivors after mitral valve repair, as assessed by the RAND-36 Health Survey, is similar to that of an age- and gender-adjusted general Finnish population.

Predictors of permanent work disability among ≤50-year-old patients undergoing percutaneous coronary intervention.

OBJECTIVES: This study aimed to describe the incidence and periprocedural predictors of permanent work disability (PWD) pension among patients ≤50 years old who underwent percutaneous coronary intervention (PCI). METHODS: Patient records of 910 consecutive patients undergoing PCI at four Finnish hospitals in 2002-2012 were reviewed for baseline and procedural data and late adverse events. Data on permanent work disability (PWD) pension allocation were acquired from the Finnish Centre for Pensions, which governs the statutory pension security in Finland. RESULTS: Mean follow-up was 41 [standard deviation (SD) 31] months. Altogether 103/910 (11.3%) of patients were on PWD by the end of follow-up, 60 (58.3%) for cardiac diagnoses (cumulative freedom from PWD 81% at 7 years). Independent predictors of PWD were post procedural stroke [hazard ratio (HR) 4.7, 95% confidence interval (95% CI) 1.8-11.9], post procedural myocardial infarction (MI) (HR 3.3, 95% CI 1.8-6.0), diabetes (HR 2.0, 95% CI 1.1-3.7), discharge diuretics (HR 3.5, 95% CI 2.1-5.9), and increasing age (HR 1.2, 95% CI 1.1-1.3). Predictors of PWD for cardiac diagnoses were post procedural stroke and MI, discharge diuretics, and use of calcium-channel blockers, diabetes and older age. CONCLUSIONS: Patients ≤50 years old undergoing PCI are at a high risk for subsequent permanent disability for cardiac diagnoses. This finding underscores the need for reinforcing adherence to secondary prevention by cardiac rehabilitation and early collaboration with occupational health care professionals.

Fatal complications after use of the Symmetry Aortic Connector in coronary artery bypass surgery.

During the last 2 years, 103 aortic saphenous vein graft anastomoses were performed in 68 patients undergoing off-pump coronary artery bypass by using the Symmetry Bypass System Aortic Connector. Of these patients, 2 died during the early postoperative period. In the first patient, after an episode of ventricular fibrillation and closed-chest cardiac massage, the sternum was opened and hemopericardium secondary to leakage of the proximal anastomotic device was found. The second patient died of ascending aortic dissection, the tear of which was likely to have originated from the proximal anastomotic site.

Clinical significance and determinants of the universal definition of perioperative bleeding classification in patients undergoing coronary artery bypass surgery.

OBJECTIVES: We evaluated the clinical significance and identified the predictors of the universal definition of perioperative bleeding (UDPB) classes in patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: Data on antithrombotic medication, perioperative bleeding, blood transfusion, and adverse events were available for 2764 patients who had undergone isolated CABG. RESULTS: The Papworth risk score correlated significantly with the UDPB classes (rate of UDPB class 3-4 and Papworth risk score of 0, 12.1%; 1, 23.9%; 2, 37.5%; and 3, 45.0%; P<.0001). Ordinal regression showed that increased age, female sex, low body mass index, low estimated glomerular filtration rate, low hemoglobin, dialysis, urgent or emergency operation, critical status, on-pump surgery, potent antiplatelet drug pause of <5 days, and warfarin pause of <2 days were independent predictors of high UDPB classes. These risk factors also predicted UDPB classes 3-4 in logistic regression analysis. Increasing UDPB classes were associated with an increased risk of in-hospital mortality (P=.002), stroke (P=.023), low cardiac output (P<.0001), prolonged use of inotropes (P<.0001), renal replacement therapy (P<.0001), length of stay in the intensive care unit (P<.0001), and late mortality (P<.0001) as assessed by multilevel propensity score-adjusted analysis. Similar findings were observed in the propensity score-adjusted analysis for the most severe grades of perioperative bleeding (ie, UDPB class 3-4). CONCLUSIONS: High UDPB classes were associated with significantly poorer immediate and late outcomes. The UDPB classification seems to be a valuable research tool to estimate the severity of bleeding and its prognostic impact affect after coronary surgery.

Early and intermediate outcome after aortic valve replacement with a sutureless bioprosthesis: Results of a multicenter study.

OBJECTIVE: The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). METHODS: This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. RESULTS: The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively (P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. CONCLUSIONS: The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.

Prognosis and disease progression in patients under 50 years old undergoing PCI: the CRAGS (Coronary aRtery diseAse in younG adultS) study.

OBJECTIVE: Young patients undergoing percutaneous coronary intervention (PCI) are generally considered at low procedural risk, but the potentially aggressive nature of coronary artery disease and long expectancy of life expose them to a high risk of recurrent coronary events. The extent and determinants of disease progression in this patient subset remain largely unknown. The aim of the present study was to evaluate general risk factors for late outcomes among patients ≤50 years old who underwent PCI. METHODS: Coronary aRtery diseAse in younG adults (CRAGS) is a multicenter European retrospective registry that enrolled 1617 patients (age ≤50 years) who underwent PCI over the years 2002-2012. The median follow-up was 3.0 years. RESULTS: The majority of patients were smokers who were nevertheless prescribed adequate secondary prevention medication, including statins, aspirin, beta blockers and/or ACE inhibitors/AT blockers. At 5 years, survival was 97.8%, while freedom from major adverse cardiac and cerebrovascular events was 74.1%, from repeat revascularization 77.8% and from myocardial infarction 89.9%. Altogether 13.5% of patients exhibited disease progression that indicated a need for repeat revascularization. Other indications for repeat revascularization were restenosis (7.1%) and stent thrombosis (2.1%) at the 5-year follow-up. Independent post-PCI predictors of disease progression were multivessel disease, diabetes and hypertension. CONCLUSION: PCI is associated with excellent survival in patients ≤50 years old. Nevertheless, despite guideline-adherent medication, every eighth patient underwent repeat revascularization due to disease progression diagnosed at the median follow-up of three years, underscoring the need for more effective secondary prevention than currently available.

Determinants of outcome after isolated coronary artery bypass grafting in patients aged ≤50 years (from the Coronary aRtery diseAse in younG adultS study).

This study was planned to identify the determinants of outcome after coronary artery bypass (CABG) in young patients. Data on 592 patients aged ≤50 years who underwent CABG from 9 European institutions were collected retrospectively. Twenty-eight percent of patients received at least 2 arterial grafts. Clopidogrel was used at discharge in 16.2% and statins in 67.2% of patients. Freedom from major adverse cardiac and cerebrovascular events at 1, 3, and 5 years was 93.8%, 90.1%, and 85.0%; survival rate was 98.3%, 96.3%, and 94.9%; freedom from myocardial infarction was 96.3%, 95.1%, and 92.5%; and freedom from repeat revascularization was 96.3%, 95.1%, and 92.5%, respectively. Neither types of grafts nor medication at discharge had any impact on the late outcome. Age <40 years (relative risk [RR] 2.19, 95% confidence interval [CI] 1.17 to 4.11), diabetes (RR 1.71, 95% CI 1.02 to 2.88), estimated glomerular filtration rate <60 ml/min/1.73 m(2) (RR 2.44, 95% CI 1.26 to 4.72), non-ST-elevation myocardial infarction/ST-elevation myocardial infarction (RR 2.12, 95% CI 1.27 to 3.55), emergency procedure (RR 2.34, 95% CI 1.13 to 4.88), and left ventricular ejection fraction <30% (RR 3.18, 95% CI 1.41 to 7.16) were independent predictors of major adverse cardiac and cerebrovascular events. Patients with left ventricular ejection fraction <30% had a particularly poor survival rate (at 5 years 67.7% vs 96.1%; adjusted analysis RR 14.01, 95% CI 5.16 to 38.03). Poor left ventricular function, myocardial infarction, diabetes, renal failure, and age <40 years are major determinants of late outcome after CABG in young patients. In conclusion, data from this real-world registry indicate that multiple arterial grafts and statin treatment are largely underutilized in these patients.