Early to midterm survival of patients with deep sternal wound infection managed with laparoscopically harvested omentum.

OBJECTIVE: The optimal management of deep sternal wound infection (DWSI) remains controversial. Our objective was to evaluate outcomes of patients with DSWI managed with transposition of laparoscopically harvested omentum (LHO). METHODS: Between 2000 and 2020, a total of 38,623 adult patients who underwent full median sternotomy for cardiac surgery were analyzed retrospectively at our institution. DSWI occurred in 455 (1.2%), of whom 364 (93.2%) were managed with pectoralis myocutaneous flap (PMF) and 33 (7.2%) with LHO. Univariate and multivariate analysis models were used to determine predictors of cumulative late mortality and adjusted survival curves were generated. RESULTS: Among patients who received LHO, average age was 65.7 ± 9.7 years and a larger proportion of patients were male. A majority of patients (88%) had coronary bypass surgery, with bilateral internal mammary arteries use in only 21.2%. Mean length of stay (LOS) was 58.90 days and early hospital mortality occurred in 4 patients (12.1%). Patients who received LHO compared to only PMF had larger body mass index and had more heart failure. Furthermore, the hospital LOS was also significantly prolonged in the LHO group (58.9 vs. 27.4 days, p = .002), with a slightly higher in-hospital mortality (12.1% vs. 3.3%, p = .03). Late survival for LHO patients at 5 and 10 years was 71.9% and 44.8%, respectively. CONCLUSION: Use of LHO is a safe and viable alternative to traditional myocutaneous flaps to manage complex DSWI. Early and late survival were favorable in this high-risk population.

Long-term clinical and echocardiographic follow-up of the Freestyle stentless aortic bioprosthesis.

BACKGROUND: Stentless aortic bioprostheses were designed to provide enhanced hemodynamic performance and potentially greater longevity. The present report describes the outcomes of patients with the Freestyle stentless bioprosthesis followed for ≤18 years. METHODS AND RESULTS: Between 1993 and 2011, 430 patients underwent primary aortic valve replacement with a Freestyle bioprosthesis in the subcoronary position. Mean age was 68.2 ± 8.2 years. All of the clinical and echocardiographic data were collected prospectively. Mean overall follow-up was 9.1 ± 4.4 years and was complete in all of the patients. In-hospital mortality was 3.5% (n=15). Overall, 10- and 15-year survival were 60.7% and 35.0%, respectively. Fifty-one patients required reoperation during follow-up, including 27 for structural valve deterioration (SVD). Overall, freedom from reoperation was 91.0% and 75.0% at 10 and 15 years, whereas freedom from reoperation for SVD was 95.9% and 82.3%, respectively. At 10 and 15 years, freedom from reoperation for SVD was 94.0% and 62.6% for patients <60 years of age and 96.3% and 88.4% for patients ≥60 years of age (P=0.002). The median time to explant for SVD was 10.7 years. SVD presented mostly as acute, severe aortic insufficiency attributed to leaflet tear (77.8%). The independent risk factors for reoperation for SVD were age <60 years (P=0.001) and dyslipidemia (P=0.02). CONCLUSIONS: Aortic valve replacement with the Freestyle bioprosthesis in a subcoronary position provides good long-term clinical and echocardiographic outcomes for patients >60 years of age. Severe aortic insufficiency with leaflet tear is the major mode of SVD leading to reoperation in these patients.

Impact of aortic stenosis severity and its interaction with prosthesis-patient mismatch on operative mortality following aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: The optimal timing of aortic valve replacement (AVR) in patients with severe aortic stenosis (AS) is a source of debate. Moreover, it has been shown previously that prosthesis-patient mismatch (PPM) is an independent predictor of operative mortality after AVR. The study aim was to assess the effect of the preoperative severity of AS and its interaction with PPM with respect to operative mortality after AVR. METHODS: The data were analyzed from 2,104 consecutive patients who had undergone AVR for severe AS. The patients were allocated to tertiles according to their preoperative indexed aortic valve area (AVAi) as: < 0.35 cm2/m2, 0.35 to 0.43 cm2/m2, and > 0.43 cm2/m2. PPM was defined as a projected postoperative indexed effective orifice area (EOAi) of the implanted prosthesis < 0.85 cm2/m2. RESULTS: The operative mortality was 5.7% (n = 120). On multivariate analysis, an independent association was identified between the preoperative severity of AS and operative mortality (odds ratio [OR] = 2.00, p = 0.03 for AVAi < 0.35 cm2/m2; OR = 1.39, p = 0.32 for AVAi 0.35-0.43 cm2/m2). Notably, the impact of PPM was more important in patients with more severe AS (p = 0.046 for AVAi x EOAi interaction). CONCLUSION: The study results confirmed that very severe AS (AVAi < 0.35 cm2/m2) is independently associated with operative mortality after AVR. The results also emphasized the importance of avoiding PPM in these patients.

Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery.

BACKGROUND: Early after coronary artery bypass surgery (CABG), activation of numerous neurohumoral and endogenous vasodilator systems occurs that could be influenced favorably by angiotensin-converting enzyme inhibitors. METHODS AND RESULTS: The Ischemia Management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme (IMAGINE) trial tested whether early initiation (< or = 7 days) of an angiotensin-converting enzyme inhibitor after CABG reduced cardiovascular events in stable patients with left ventricular ejection fraction > or = 40%. The trial was a double-blind, placebo-controlled study of 2553 patients randomly assigned to quinapril, target dose 40 mg/d, or placebo, who were followed up to a maximum of 43 months. The mean (SD) age was 61 (10) years. The incidence of the primary composite end point (cardiovascular death, resuscitated cardiac arrest, nonfatal myocardial infarction, coronary revascularization, unstable angina or heart failure requiring hospitalization, documented angina, and stroke) was 13.7% in the quinapril group and 12.2% in the placebo group (hazard ratio 1.15, 95% confidence interval 0.92 to 1.42, P=0.212) over a median follow-up of 2.95 years. The incidence of the primary composite end point increased significantly in the first 3 months after CABG in the quinapril group (hazard ratio 1.52, 95% confidence interval 1.03 to 2.26, P=0.0356). Adverse events also increased in the quinapril group, particularly during the first 3 months after CABG. CONCLUSIONS: In patients at low risk of cardiovascular events after CABG, routine early initiation of angiotensin-converting enzyme inhibitor therapy does not appear to improve clinical outcome up to 3 years after CABG; however, it increases the incidence of adverse events, particularly early after CABG. Thus, early after CABG, initiation of angiotensin-converting enzyme inhibitor therapy should be individualized and continually reassessed over time according to risk.

Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians.

BACKGROUND: The objective of the present study was to compare the midterm follow-up results of percutaneous coronary intervention (PCI) and coronary bypass graft surgery (CABG) for the treatment of unprotected left main coronary artery disease in octogenarians. METHODS AND RESULTS: A total of 249 consecutive patients > or =80 years of age diagnosed with left main coronary artery disease underwent coronary revascularization in our center between January 2002 and January 2008; 145 patients underwent CABG, and 104 patients had PCI. Major adverse cardiac and cerebrovascular events (MACCE [cardiac death, myocardial infarction, cerebrovascular event, revascularization]) were evaluated at a mean follow-up of 23 +/- 16 months. Patients who underwent PCI were older; had higher creatinine levels, lower ejection fraction, and higher EuroSCORE; and presented more frequently with an acute coronary syndrome. Drug-eluting stents were used in 48% of PCI patients. A propensity score analysis was performed to adjust for baseline differences between the 2 groups. Survival free of cardiac death or myocardial infarction (PCI, 65.4%; CABG, 69.7%) and MACCE-free survival (PCI, 56.7%; CABG, 64.8%) at follow-up were similar between the groups (adjusted hazard ratio for survival free of cardiac death or myocardial infarction, 1.28; 95% CI, 0.64 to 2.56; P=0.47; adjusted hazard ratio for MACCE-free survival, 1.11; 95% CI, 0.59 to 2.0; P=0.73). The EuroSCORE value was an independent predictor of MACCE regardless of the type of revascularization (hazard ratio, 1.17 for each EuroSCORE increase of 1 point; 95% CI, 1.09 to 1.25; P<0.0001). CONCLUSIONS: In this single-center, nonrandomized study, there were no significant differences in cardiac death or myocardial infarction and MACCE between CABG and PCI for the treatment of left main coronary artery disease in octogenarians after a mean follow-up of 2 years. Baseline EuroSCORE was the most important predictor of MACCE regardless of the type of revascularization. Randomized studies comparing both revascularization strategies in this high-risk coronary population are warranted.

Recent evolution in demographic and clinical characteristics and in-hospital morbidity in patients undergoing coronary surgery.

BACKGROUND: Over the last 12 years, the demographic and clinical characteristics of patients undergoing myocardial revascularization surgery have evolved rapidly. The goal of our study was to analyze the evolution of these trends and the results of these surgical interventions. METHODS: We identified patients who underwent a first or second myocardial revascularization between 1993 and 2004, and we arbitrarily divided them into 2 groups: 1 cohort of patients who underwent surgery between 1993 and 1998 and 1 cohort of patients who underwent surgery between 1999 and 2004. We compared demographic and clinical characteristics between the 2 cohorts and determined which variables were significant predictors of morbidity and mortality. RESULTS: From 1993 to 2004, 12 202 patients underwent a first (95.5%) or second (4.5%) myocardial revascularization. Patients in the later cohort presented with a high-risk profile. They were older and had metabolic syndrome or diabetes and peripheral vascular disease. On the other hand, there were fewer active smokers in this group. Whereas the rate of postoperative infarction and renal insufficiency was higher in the second cohort, this group had a lower incidence of stroke and prolonged mechanical ventilation and shorter hospital stays. Overall, observed mortality decreased in spite of a steady increase in predicted mortality. Identified predictors of mortality were age, stroke, female sex, nonelective surgery, renal insufficiency, peripheral vascular disease, chronic obstructive pulmonary disease, ventricular dysfunction and stenosis of the left main trunk. CONCLUSION: Our study confirmed current trends that show an increase in the at-risk population with dysmetabolic syndrome in cardiac surgery, as well as constant improvements in tertiary care in anesthesia and coronary surgery.

Rigid Primary Sternal Fixation Reduces Sternal Complications Among Patients at Risk.

BACKGROUND: The optimal sternal closure technique in patients at elevated risk after cardiac surgery has not been elucidated. METHODS: Between January 2006 and July 2015, 15,048 consecutive adult patients underwent cardiac surgery via median sternotomy using cardiopulmonary bypass. Rigid sternal fixation using 3 separate techniques (peristernal polyether ether-ketone banding, titanium plating, and stainless steel multibraided cables with cannulated screws) was used in 1111 patients (group A), whereas conventional peristernal/transsternal wiring was used in 13,937 patients (group B). Predictors of deep sternal wound infection or dehiscence were evaluated, and propensity score analysis was used to create 2 matched groups; 1050 group A patients (94.5%) were matched to group B patients. RESULTS: Mean time to presentation was 31 ± 70.3 days (median, 19) after surgery. There was a decreased incidence of deep sternal wound infection or dehiscence among propensity score-matched group A compared with group B patients (1.9% vs 2.7%, P = .13), although it was not statistically significant. On multivariate analysis, group A was associated with a 33% relative risk reduction of deep sternal wound infection or dehiscence (odds ratio, 0.67; 95% confidence interval, 0.48-0.94; P = .02); this was entirely due to a protective effect associated with polyether ether-ketone banding (odds ratio, 0.4; 95% confidence interval, 0.3-0.7; P = .0002). In the subgroup of bilateral internal mammary artery grafting patients (n = 886), there was a strong protective trend associated with preventative sternal fixation, although it was not statistically significant (odds ratio, 0.3; 95% confidence interval, 0.09-1.09; P = .06). CONCLUSIONS: Primary sternal fixation in patients at risk of sternal complications is associated with decreased sternal infection and/or dehiscence. Primary fixation may expand the use of bilateral internal mammary artery grafting to patient populations at increased risk for sternal complications.

Long-term impact of diabetes and its comorbidities in patients undergoing isolated primary coronary artery bypass graft surgery.

BACKGROUND: The objective of this study was to identify the impact of diabetes and related comorbidities, namely chronic renal failure, peripheral vascular disease, and low ejection fraction (<35%), on long-term survival of patients undergoing coronary artery bypass graft surgery. METHODS AND RESULTS: A unicenter study was conducted on 9125 survivors of isolated coronary artery bypass graft surgery between 1992 and 2002. There were 6581 nondiabetic patients and 2544 diabetics, including 1809 patients with noninsulin-dependent diabetes mellitus and 735 patients with insulin-dependent diabetes mellitus. Cardiac-specific survival at 5 and 10 years was lower in insulin-dependent diabetes mellitus compared with both nondiabetic mellitus patients and patients with noninsulin-dependent diabetes mellitus (P<0.0001). However, freedom from cardiac-related death was similar for patients with noninsulin-dependent diabetes mellitus and nondiabetes mellitus patients up to 6 years (P=0 0.08) after surgery and was significantly lower thereafter (P=0.004). Cardiac-specific survival after coronary artery bypass graft surgery in patients with one or more comorbidities was comparable (P=0.4) for both nondiabetes mellitus patients and patients with noninsulin-dependent diabetes mellitus, but was significantly lower for those requiring insulin therapy (P<0.0001). Noninsulin-dependent diabetes mellitus was not an independent predictor of long-term cardiac death (hazard ratio: 1.09, P=0.41); however, insulin-dependent diabetes mellitus, chronic renal failure, peripheral vascular disease, and low ejection fraction were all independent risk factors for late cardiac death (all P<0.0001). The impact of comorbidities on the long-term risk of cardiac death was similar for the 3 groups. CONCLUSIONS: Noninsulin-dependent diabetes is not an independent predictor of late cardiac death after coronary artery bypass graft surgery, because cardiac-related survival is similar to that of nondiabetic patients for 6 years after surgery. In diabetic and nondiabetic patients, cardiac survival is adversely affected by the need for insulin therapy and/or the presence and number of comorbidities such as chronic renal failure, peripheral vascular disease, and low ejection fraction.

Age cut-off for the loss of benefit from bilateral internal thoracic artery grafting.

OBJECTIVES: To identify the age-related benefit of single and bilateral internal thoracic artery (ITA) grafting on long-term cardiac-related survival in patients who survived from primary isolated coronary artery bypass grafting (CABG). METHODS: A unicenter study was conducted on 12,231 consecutive survivors from primary isolated CABG who received single (n=9566 patients) or bilateral (n=1388 patients) ITA grafts, or vein grafts only (n=1277 patients) between 1992 and 2005. Data was collected prospectively. The Cox regression model estimates the hazard ratio of each independent variable on cardiac-specific survival over the entire length of follow-up. Age was a significant covariate into the statistical model. The mean follow-up was 5.7+/-3.7 years and 100% complete as of December 2005. The date and cause of death were obtained from the regional statistical institute. RESULTS: After adjustments for different risk factors, the cardiac-related survival benefit in patients undergoing CABG with two ITAs was superior to that of single ITA grafting up to 60 years of age, displaying a constant decrease over time. The use of a single ITA was beneficial on cardiac-related survival in all age groups, including octogenarians, compared to patients receiving only vein grafts. CONCLUSIONS: The use of at least one ITA is associated with increased long-term cardiac-specific survival in all age groups compared to venous-only CABG, even in octogenarians. The additional survival benefit of using a second ITA decreases gradually with age, and is lost after 60 years of age.

Early diaphragmatic plication after cardiac surgery: a case report in an obese patient.

BACKGROUND: Diaphragmatic plication to help ventilation weaning of an adult obese patient after cardiac surgery is very uncommon. Diaphragm paralysis is usually treated with conservative measures and ventilator support, after which surgical management is considered after months of medical monitoring. CASE PRESENTATION: We report the case of a morbidly obese patient to whom ventilation weaning was unsuccessful following coronary artery bypass graft operation with mitral valve replacement. A de novo right hemidiaphragm elevation was seen on the chest X-ray. Diaphragmatic plication was performed promptly to treat severe respiratory insufficiency and generated favorable outcomes. CONCLUSIONS: Early diaphragmatic plication could be considered in the postoperative period of cardiothoracic surgery to facilitate management and ventilation weaning in the context of de novo diaphragm paralysis.

Angiotensin-converting enzyme inhibition in patients with coronary artery disease and preserved left ventricular function Ischemia Management with Accupril post-bypass graft via inhibition of angiotensin-converting enzyme (IMAGINE) compared with the other major trials in coronary artery disease.

It has been hypothesized that angiotensin-converting enzyme (ACE) inhibition, independent from its effect on ventricular function and blood pressure, could affect the atherosclerotic process and reduce the incidence of ischemic events and its complications. Several large clinical outcome trials were designed to test this hypothesis: QUIET, HOPE, EUROPA, PEACE, and IMAGINE. The results of the PEACE study were recently reported, leaving the IMAGINE study as the last chapter in our efforts to evaluate the role of ACE inhibition in coronary artery disease with preserved left ventricular function. In this report, we compare these studies with respect to their methodology and patient population and analyze the unique nature of the last ongoing study, IMAGINE. The reported studies show that patients with coronary artery disease who are at low-to-moderate or high risk should receive an ACE inhibitor if tolerated. However, when the absolute risk of a patient decreases, and intensive contemporary management is given, with good control of risk factors, the absolute and perhaps relative benefits of an ACE inhibitor decrease and their routine use in these patients may not be warranted. The role of ACE inhibition started early post-coronary artery bypass graft in patients with preserved left ventricular function, and intensive contemporary management remains to be determined and should get answered by the IMAGINE study. Moreover, the IMAGINE population is not only a lower risk population than those enrolled in HOPE or EUROPA, but also the risk for this population is bimodal in nature (early post-revascularization inflammation and thrombosis vs long-term atherosclerosis progression) and may provide further insight into underlying mechanisms.

Influence of time elapsed between myocardial infarction and coronary artery bypass grafting surgery on operative mortality.

OBJECTIVE: Optimal timing for CABG surgery after myocardial infarction (MI) remains controversial. We examined the influence of patient age and time elapsed between MI and isolated CABG surgery on operative mortality. METHODS: Perioperative data of 13,545 patients who underwent isolated CABG surgery from 1991 to 2005 were reviewed. A previous MI was found in 7219 patients, classified among groups A-E whether they underwent surgery less than 6h (A, n=26), between 6 and 24h (B, n=51), between 1 and 7 days (C, n=313), between 8 and 30 days (D, n=917), or more than 30 days (E, n=5912) after the event. Crude percentages and odds ratio estimates of operative mortality were calculated. RESULTS: In patients who had no history of MI, the mortality rate was 1.7%, while it was, respectively, 19.2, 9.8, 8.6, 3.2, and 2.4% in patients from groups A to E. Among 6589 patients over 65 years of age, 3027 had no history of MI. Their mortality was 2.4%, compared to, respectively, 35.7, 13.8, 11.3, 5.1, and 3.9% for those belonging to groups A-E. Overall odds ratio estimates of operative mortality were 3.92 (p=0.19), 5.08 (p=0.002), 4.33 (p=0.0001), 1.50 (p=0.08), and 1.18 (p=0.24) for groups A-E, respectively. CONCLUSIONS: Operative mortality is not influenced by a history of MI sustained more than 30 days prior to isolated CABG surgery, but is highly and most significantly increased between 6h and 1 week after MI, especially in older patients. That critical period should be avoided whenever possible.

The Underestimated Belly Factor: Waist Circumference Is Linked to Significant Morbidity Following Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Waist circumference (WC) and body mass index (BMI) are clinically used to assess adiposity. The aim of the present study was to evaluate the association of WC with postoperative morbidity and mortality in patients who underwent isolated coronary artery bypass grafting (CABG) in relation to patients' BMI category. METHODS: We analyzed the associations of WC and BMI with short-term postoperative outcomes in a cohort of 7446 patients who underwent isolated CABG. We performed univariate and adjusted analyses on main postoperative outcomes after CABG for WC and BMI. RESULTS: Adverse events researched included postoperative mortality, intensive care unit and hospital length of stay, cardiovascular and cerebrovascular events, respiratory complications, infectious, hemostasis complications, and renal complications. WC was independently associated with all postoperative outcomes except prolonged intubation and mortality. Overall, patients in the upper WC quartile in each BMI category were at increased risk of adverse events compared with patients in the lower 3 WC quartiles, with a maximal incremental risk of 1.91 (95% confidence interval, 1.23-2.95) among patients with a BMI ≥ 35. This association was observed for men and women, across all overweight and obesity categories. Neither WC nor BMI was associated with short-term postoperative mortality. CONCLUSIONS: In our large cohort of patients who underwent isolated CABG, WC was significantly associated with clinical adverse events, independently of BMI. These findings provide further evidence on the added value of measuring WC as a simple and easy to measure anthropometric marker to refine risk assessment beyond BMI among patients who undergo CABG.

Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement.

BACKGROUND: The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation. METHODS AND RESULTS: The indexed valve effective orifice area (EOA) was estimated for each type and size of prosthesis being implanted in 1266 consecutive patients and used to define PPM as not clinically significant if >0.85 cm2/m2, as moderate if >0.65 cm2/m2 and 120 minutes (P=0.001), and PPM (P=0.003). Relative risk of mortality was increased 2.1-fold (95% confidence interval, 1.2 to 3.7) in patients with moderate PPM and 11.4-fold (4.4 to 29.5) in those with severe PPM. Moreover, risk of mortality for every category of PPM was higher in patients with a left ventricular ejection fraction <40% as compared with >or=40% (nonsignificant PPM, 2.7 versus 1.0; moderate PPM, 7.1 versus 1.8; severe PPM, 77.1 versus 11.3). CONCLUSIONS: PPM is a strong and independent predictor of short-term mortality among patients undergoing AVR, and its impact is related both to its degree of severity and the status of left ventricular function. In contrast to other risk factors, moderate-severe PPM can be largely avoided with the use of a prospective strategy at the time of operation.

The Canadian off-pump coronary artery bypass graft registry: a one-year prospective comparison with on-pump coronary artery bypass grafting.

BACKGROUND: The authors sought to examine in-hospital and one-year outcomes of off-pump coronary artery bypass grafting (CABG) and to determine the subgroups of patients most likely to benefit from the off-pump procedure in a regular surgical practice. METHODS: From March 2001 to December 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. Propensity score modelling was performed to control for treatment and selection bias. A propensity-matched analysis was performed to identify factors associated with survival benefit from the off-pump procedure. RESULTS: The mortality was similar postoperatively and at one year after surgery. The rate of stroke was decreased in the off-pump group postoperatively (OR=0.49, 95% CI 0.23 to 1.06) and significantly at one year after surgery (OR=0.49, 95% CI 0.27 to 0.90). A significant reduction in acute renal dialysis and a significant increase in myocardial infarction rates were seen in off-pump patients during the initial hospitalization but these differences disappeared during the follow-up period. The number of grafts completed was significantly lower in off-pump CABG than in on-pump CABG (2.62+/-1.00 versus 3.36+/-0.92, respectively; P<0.001). Hospital length of stay and the percentage of patients who required mechanical ventilation were significantly lower in the off-pump group than in the on-pump group. At one year after surgery, the adjusted rate of coronary angiogram and revascularization was similar between the two groups, and the adjusted rate of self-reported angina and memory status was significantly better in the off-pump CABG group. Almost all subgroups of patients had a neutral effect or a survival benefit with the off-pump technique. CONCLUSIONS: The results from a Canada-wide multicentre registry showed the safety and effectiveness of off-pump CABG in most subgroups of patients in a regular surgical practice.

Surgical aortic valve replacement outcomes in the transcatheter era.

BACKGROUND: The primary objective of this study was to evaluate the influence of transcatheter aortic valve implantation (TAVI) on the characteristics and outcomes of patients undergoing surgical aortic valve replacement (SAVR) in a single high-volume Canadian center. METHODS: Between January 2003 and December 2013, 1593 patients underwent isolated SAVR at our institution. The study period was divided into 2 distinct cohorts of patients undergoing SAVR: before (n = 529) and after (n = 1064) the first TAVI procedure in May 2007. We compared the risk profiles and clinical outcomes of the 2 cohorts and assessed the multivariate predictors of in-hospital mortality. RESULTS: The ratio of isolated SAVR to the total number of cardiac surgery cases per year rose significantly after the introduction of TAVI (7.2% vs 9.1%; P < .0001). There was significantly more diabetes, obesity, recent myocardial infarction, and use of a bioprosthesis among SAVR patients in the post-TAVI era (all P values < .05). In-hospital mortality decreased significantly among SAVR patients following the introduction of TAVI (3.6% vs 1.8%; P = .03). Independent risk factors for in-hospital mortality among the entire study population were SAVR in the pre-TAVI era, baseline creatinine, age, and prosthesis size ≤ 21 mm for the pre-TAVI group only. CONCLUSIONS: The number of isolated SAVR cases increased following the introduction of TAVI. There was a significant reduction in operative mortality of SAVR in the post-TAVI era despite greater severity of several markers of risk. Patient referrals for TAVI should take into consideration the changing risk profiles and improved results of conventional surgery.

Surgical treatment of commissural prolapse: case report and review of the options.

Repair of commissural prolapse associated with chordal rupture may represent a challenging problem for the cardiac surgeon. The case of a patient with chronic mitral regurgitation and prolapse of the posterior commissural area associated with chordal rupture is presented. A technique was proposed that involved partial resection of the degenerative leaflet segment, plication of the posterior annulus and chordal transfer to create a neocommissure. An analysis of the options available for surgical treatment of commissural prolapse is included.

Determinants of stroke after coronary artery bypass grafting.

OBJECTIVES: Cerebrovascular accidents (CVA) after CABG are deleterious complications whose prevention remains poorly defined. The aim of this study was to identify the determinants for CVA after CABG. METHODS: Nine thousand nine hundred and sixteen patients underwent CABG at our institution from January 1992 to June 2002. Data were prospectively collected and univariate/multivariate analyses conducted. RESULTS: Two hundred and eight patients (2.1%) suffered perioperative CVA. Univariate analysis showed a higher risk profile in the CVA group including advanced age, depressed percent left ventricular ejection fraction (LVEF), unstable angina, diabetes mellitus (DM), chronic renal failure (CRF), redo surgery, peripheral vascular disease (PVD), previous CVA, and higher Parsonnet score (P<0.001). Furthermore, the CVA group had longer myocardial ischemia (CVA 56.2 +/-40.9 vs. Control 50.4+/-20.9 min, P=0.03) and cardiopulmonary bypass (CPB) times (CVA 87.4+/-30.0 min vs. Control 78.9 +/-25.9 min, P<0.0001), and lower off-pump surgery rate (CVA 1.4% vs. Control 4.7%, P=0.01). Multivariable analysis identified seven preoperative and two perioperative determinants for CVA: LVEF<30% (odds ratio (OR)=2.49), previous CVA (OR=2.15), DM (OR=1.78), redo (OR=1.76), PVD (OR=1.66), CRF (OR=1.55), age (OR=1.03), perioperative intra-aortic balloon pump (OR=1.83), and transfusion rate (OR=1.59). Perioperative mortality was higher in the CVA group (CVA 18.6% vs. Control 2.6%, P<0.0001). CONCLUSIONS: Although occurrence of CVA seems mainly related to preoperative comorbidities, perioperative surgical variables, such as off-pump surgery, myocardial ischemia and cardiopulmonary bypass time, do not seem to independently influence CVA rate after CABG. In this regard CVA prevention should be performed before posing an indication to CABG, and closer evaluation of patients' risk profiles and tailored clinical/surgical strategies for those patients at higher risk for CVA occurrence should be included.

Ischemia Management with Accupril post bypass Graft via Inhibition of angiotensin coNverting enzyme (IMAGINE): a multicentre randomized trial - design and rationale.

BACKGROUND: Coronary artery bypass grafting (CABG) remains the revascularization treatment of choice for patients with severely symptomatic or life-threatening coronary artery disease (CAD). However, 9% to 25% of the patients undergoing CABG will suffer a recurrent ischemic event such as death, recurrent infarction, angina or repeat revascularization. The pathophysiological processes particular to the CABG procedure that may affect graft endothelial function are most active in the early phase after surgery. Angiotensin-converting enzyme (ACE) inhibition has been shown to be effective in reducing or preventing ischemic events in patients with and without left ventricular dysfunction, and in those at high risk for CAD. Nonetheless, no large clinical trail has investigated this role of ACE inhibition in preventing ischemic events early after CABG. OBJECTIVE: The Ischemia Management with Accupril post bypass Graft via Inhibition of angiotensin coNverting Enzyme (IMAGINE) study addressed whether ACE inhibition initiated early after CABG improves short and long term outcomes in patients after CABG. PATIENTS AND METHODS: This multicentre, multinational trial recruited 2204 patients with an uncomplicated course early after CABG from 55 to 65 medical care facilities in Canada, The Netherlands, Belgium and France. Eligible patients with normal left ventricular function were randomly assigned to placebo or quinapril (titrated up to 40 mg daily where possible) within seven to 10 days after CABG. All patients were followed up closely for a minimum of 12 months after random placement. The median treatment period is expected to be approximately 27 months.