Long-Term Survival Benefits of Porcine versus Pericardial Bioprostheses in Elderly Patients Undergoing Isolated Aortic Valve Replacement: A 32-Year Study.

BACKGROUND: The elderly population is growing at an unprecedented rate. Aortic valve disease increases with age. Bioprostheses are the valves of choice for older patients; however, the optimal tissue valve remains undetermined. The purpose of this investigation was to perform a life-of-patient survival comparison of the prototypical porcine and pericardial prostheses in elderly patients. METHODS: The study population (N = 1480) consisted of patients 65 years of age and older who underwent isolated aortic valve replacement from 1990 through 2005 with a Carpentier-Edwards Porcine (n = 650) or Pericardial (n = 830) bioprosthesis. Propensity score-matched groups were created. RESULTS: Valve selection was not associated with operative mortality. Survival estimates at 10 years were better for Pericardial (41.8%; 95% CI: 37.9 to 45.7) than Porcine (32.6%; 95% CI: 28.8 to 36.3); and 5.2% (95% CI: 3.2 to 7.1) versus 2.0%; (95% CI: 0.8 to 3.2) at 20 years (p < 0.001). E-value analysis found minimal influence of unknown study confounders. Factors associated with long-term mortality were porcine valve (p < 0.001), age (p < 0.001), diabetes mellitus (p < 0.001), preop renal insufficiency (p < 0.001), peripheral artery disease (p = 0.011), congestive heart failure (p = 0.003), New York Heart Association Class III or IV (p = 0.004), surgical history-reoperation (p = 0.012), transient ischemic attack (p = 0.009), prolonged ventilation (p = 0.010), postop renal insufficiency (p < 0.001), and atrial fibrillation (p = 0.009). The indexed Effective Orifice Area (EOAi) was assessed and did not influence observed long-term survival differences. CONCLUSIONS: This unusual lifetime study provided substantial evidence for the superiority of the pericardial over the porcine bioprosthesis in the aortic position in elderly patients. It demonstrated enhanced long-term survival benefits for elderly patients without any increase in perioperative mortality. It is intended to inform future investigation into aortic valve design.

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study.

OBJECTIVE: To evaluate the perioperative and pathological outcomes associated with robot-assisted radical prostatectomy (RARP) in morbidly obese men. PATIENTS AND METHODS: Between January 2008 and March 2012, 3041 patients underwent RARP at our institution by a single surgeon (V.P.). In all, 44 patients were considered morbidly obese with a body mass index (BMI) of ≥40 kg/m(2) . A propensity score-matched analysis was conducted using multivariable analysis to identify comparable groups of patients with a BMI of ≥40 and <40 kg/m(2) . Perioperative, pathological outcomes and complications were compared between the two matched groups. RESULTS: There was no significant difference in operative time. However, the mean estimated blood loss was higher in morbidly obese patients, at a mean (sd) of 113 (41) vs 130 (27) mL (P = 0.049). Anastomosis was more difficult in morbidly obese patients (P = 0.001). There were no significant differences in laterality, ease of nerve sparing, or transfusion rate between the groups. There were no intraoperative complications in either group. Postoperative pathological outcomes were similar between the groups. Differences in positive surgical margins and ease of nerve sparing approached statistical significance (P = 0.097, P = 0.075 respectively). Postoperative complication rates, pain scores, length of stay and indwelling catheter duration were similar in the groups. CONCLUSIONS: RARP in morbidly obese patients is technically demanding. However, it can be accomplished with acceptable morbidity and resource use. In the hands of an experienced surgeon, it is a safe procedure and offers beneficial clinical outcomes.

Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30-year follow-up of propensity score-matched cohorts.

BACKGROUND: The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus SIMA grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. METHODS AND RESULTS: Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching with the propensity score was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years; mean, 8.9 years) determined long-term survival. There was no difference in operative mortality, sternal wound infection, or total complications between matched SIMA and BIMA groups (operative mortality, 10 of 414 [2.4%] versus 13 of 414 [3.1%]; P=0.279; sternal wound infection, 7 of 414 [1.7%] versus 13 of 414 [3.1%]; P=0.179); total complications, 71 of 414 [17.1%] versus 71 of 414 [17.1%]; P=1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival: SIMA, 9.8 years versus BIMA, 13.1 years; P=0.001). Use of BIMA was found to be associated with late survival on Cox regression (P=0.003). CONCLUSION: Compared with SIMA grafting, BIMA grafting in propensity score-matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality.

Mitral Repair vs Replacement for Degenerative Mitral Regurgitation in Patients Aged ≥65 Years.

BACKGROUND: The benefits of mitral valve repair vs replacement are well documented. However, survival benefits in the elderly population are more controversial. In this novel lifetime analysis, we hypothesize that survival benefits for valve repair vs replacement in the elderly are sustained throughout the patient's lifetime. METHODS: From January 1985 through December 2005, 663 patients, aged ≥65 years with myxomatous degenerative mitral valve disease underwent primary isolated mitral valve repair (n = 434) or replacement (n = 229). Propensity score matching was used to balance variables potentially related to outcome. RESULTS: Follow-up was complete in 99.1% of mitral repair and 99.6% of mitral replacement patients. In matched patients, perioperative mortality was 3.9% (9 of 229) for repair and 10.9% (25 of 229) for replacement (P = .004). Survival estimates (95% confidence limits) from 29-year follow-up for matched patients were 54.6% (48.0%, 61.1%) and 11.0% (6.8%, 15.2%) at 10 years and 20 years for repair patients, and 34.2% (27.7%, 40.7%) and 3.7% (1%, 6.4%) for replacement patients, respectively. Median survival (95% confidence limits) was 11.3 years (9.6, 12.2 years) for repair patients compared with 6.9 years (6.3, 8.0 years) for replacement patients (P < .001). CONCLUSIONS: This study demonstrates that although the elderly population is prone to multiple comorbidities, survival benefits of isolated mitral valve repair vs replacement are sustained throughout the patient's lifetime.

Resource utilization in off-pump versus conventional coronary artery bypass grafting in a community hospital: a comparative analysis using propensity scoring.

BACKGROUND: At a time when cost containment in health care is under increased scrutiny, coronary artery bypass grafting remains the most widely performed cardiac surgical procedure in the world. This study compares 30-day mortality, morbidity, and resource use for off-pump coronary artery bypass (OPCAB) versus conventional coronary artery bypass (CCAB) revascularization. METHODS: From January 2000 through December 2008, 1003 patients underwent OPCAB grafting by a single surgeon (S.C.S.). Data were prospectively collected, entered into a Society of Thoracic Surgeons adult cardiac surgery database, and analyzed retrospectively. We used propensity-matching techniques to match this cohort to a group of 1003 patients who underwent CCAB. RESULTS: The hospital mortality rate was lower for the OPCAB patients than for the CCAB patients: 2.0% (20/1003) versus 2.8% (28/1003). Predictors of hospital mortality for the entire cohort included age (P = .001), cardiogenic shock (P = .001), congestive heart failure (P = .019), history of myocardial infarction (P = .001), and reoperation (P = .007). The overall incidence of morbidity was lower for the OPCAB patients (reoperation for bleeding, P = .011; prolonged ventilation, P = .035; stroke, P = .045; cardiac arrest, P = .004). OPCAB patients experienced significantly reduced procedure times (P = .001), postoperative ventilation times (P = .035), post-operative lengths of stay (P = .035), and blood product use (intraoperative, P = .001; postoperative, P = .001). CONCLUSION: These outcomes clearly demonstrate that OPCAB is a safe and effective procedure for myocardial revascularization. This retrospective, nonrandomized observational study has shown that the patients who underwent OPCAB had reduced morbidity and mortality, as well as decreased resource use, compared with those who underwent CCAB.

Surgical management of aortic valve disease in the elderly: A retrospective comparative study of valve choice using propensity score analysis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve dysfunction is the most common form of valvular heart disease. As the population continues to age, a greater number of patients will become candidates for aortic valve replacement (AVR); hence, prosthetic valve choice becomes of paramount importance. METHODS: A retrospective analysis was conducted on 801 patients aged > or =65 years who underwent isolated AVR or AVR + coronary artery bypass grafting (CABG) between January 1989 and June 2003 with a Carpentier Edwards Perimount (CEP) pericardial bioprosthesis (n = 398) or a St. Jude Medical (SJM) mechanical valve (n = 403). The mean age of CEP patients was 74.5 years (range: 65-89 years), and of SJM patients 73.9 years (range: 65-90 years). The follow up was 96.2% and 96.5% complete for CEP and SJM patients, respectively. Propensity scoring was used to establish homogeneity of the groups and reduce bias. RESULTS: The operative mortality was 4.0% (n = 16) among CEP patients and 6.5% (n = 26) among SJM patients. Predictors of hospital mortality included: peripheral vascular disease (p = 0.018), surgical urgency (p = 0.010), preoperative intra-aortic balloon pump (IABP) (p = 0.010), intraoperative perfusion time (p = 0.046) and intraoperative IABP (p = 0.001). Postoperative morbidities were similar for the two groups. The mean follow up was 72.4 and 59.2 months for CEP and SJM patients, respectively. The five-year actuarial survival was 70.9 +/- 2.3% for CEP and 71.8 +/- 2.4% for SJM patients; at 10 years the actuarial survival was 32.6 +/- 3.3% and 38.2 +/- 3.8%, respectively. Freedom from reoperation for AVR, stroke and non-fatal myocardial infarction was 98.8% (159/161), 99.4% (160/161) and 99.4% (160/161), respectively, in CEP patients, and 100.0% (220/220), 97.7% (215/220) and 97.7% (215/220), respectively, in SJM patients (p = NS). Predictors of late death (>30 days) included chronic obstructive pulmonary disease (p = 0.001) and mechanical valve replacement (p = 0.001). CONCLUSION: In comparable elderly patients, the outcomes of CEP and SJM valves after AVR showed no significant differences in hospital morbidity, mortality, mid-term survival or late cardiac events. However, the cumulative risk of lifelong anticoagulation with a mechanical valve is a serious consideration that must be factored into the selection algorithm.

Routine use of the direct thrombin inhibitor bivalirudin for off-pump coronary artery bypass grafting is safe and effective.

Anticoagulation with unfractionated heparin has been the standard of care for more than a half-century for patients undergoing cardiac surgery. The risk of heparin-induced adverse reactions dictates the need for a safe and effective alternative, particularly in off-pump coronary artery bypass (OPCAB) surgery, an approach associated with a perioperative prothrombotic condition that may negatively influence graft patency. Between March 2003 and January 2005, 243 consecutive patients underwent OPCAB with bivalirudin (0.75 mg/kg bolus with 1.75 mg/kg per hour infusion). There were 171 men (70.4%) and 72 women (29.6%). The mean age was 64.9 +/- 10.9 years (age range 32-88 years). There were 147 patients (60.5%) with 3-vessel disease; 46 (18.9%) had substantial (>50%) stenosis of the left main coronary artery; 104 (42.8%) had a moderately reduced (0.30 to 0.50) ejection fraction; and 9 (3.7%) had a severely reduced (<0.30%) ejection fraction. Five patients (2.1%) required conversion to cardiopulmonary bypass and subsequently received heparin. Postoperative complications included perioperative myocardial infarction in 6 patients (2.5%), stroke in 3 (1.2%), prolonged ventilation in 4 (1.6%), reoperation for bleeding in 3 (1.2%), renal insufficiency in 14 (5.8%), atrial fibrillation in 26 (10.7%), low cardiac output in 3 (1.2%), and deep sternal infection in 1 (0.4%). Blood products were used in 117 patients (48.1%). The overall hospital mortality rate was 0.4% (1 of 243). Bivalirudin is a safe and effective anticoagulant that may be routinely used as an alternative to heparin and protamine in patients undergoing OPCAB. This is evidenced by low hospital mortality and morbidity rates. Further follow-up is warranted to discern the influence of bivalirudin on long-term clinical outcomes.

The valve of choice in elderly patients and its influence on quality of life: a long-term comparative study.

BACKGROUND AND AIM OF THE STUDY: Mechanical heart valves are preferred for younger patients in order to avoid valve structural deterioration, but bioprosthetic valves are favored for older patients to avoid long-term anticoagulation. With increasing patient longevity, controversy persists regarding the valve of choice in the 65- to 75-year-old population. With improving patient survival, long-term quality of life (QOL) is a critical element in helping to resolve this controversy. METHODS: A retrospective analysis was conducted of 1,104 consecutive patients, aged 65-75 years, who underwent valve replacement between July 1976 and December 1999. Valves implanted were either a Carpentier-Edwards (CE) porcine bioprosthesis (596 patients) or a St. Jude Medical (SJM) mechanical valve (508 patients), with and without concomitant coronary artery bypass grafting. QOL was assessed using the Short Form (SF-36) Health Survey for both groups at the time of follow up, which was 98.2% complete. Comparable patient groups were analyzed within quintiles by propensity score analysis. RESULTS: Operative mortality was 9.4% (n = 56) for CE patients, and 5.3% (n = 27) for SJM patients (p = 0.014). Propensity score analysis revealed no significant difference in operative mortality between groups in any of the five quintiles. Actuarial survival for hospital survivors favored SJM patients (p = 0.005). However, when compared within quintiles, there was no significant difference between groups. QOL summary scores were significantly higher for physical health (p = 0.007) for SJM patients, but similar between valve groups for mental health. Comparison within quintiles revealed no significant difference between the groups in either area. CONCLUSION: When comparing the outcomes of mechanical versus bioprosthetic valve replacement, considerable care must be exercised to ensure the clinically relevant similarity of groups. When evaluating comparable patient groups, there was no advantage in either survival or QOL for patients aged 65-75 years receiving a CE or SJM valve.

Is the St. Jude Medical mechanical valve an appropriate choice for elderly patients?: A long-term retrospective study measuring quality of life.

BACKGROUND AND AIM OF THE STUDY: The selection of a suitable valve substitute in patients requiring valvular heart surgery is an important element in the preoperative decision-making process between cardiologist, surgeon, and patient. Controversy persists regarding the use of mechanical valves in the elderly. With the population living longer, reoperative risk becomes of paramount importance. Quality of life (QOL) considerations are often as important to the patient as longevity. The influence of mechanical valve replacement on QOL in elderly patients has not been well documented. METHODS: Between June 1981 and December 1999, a total of 1,125 consecutive patients aged > or = 65 years (582 men, 543 women; mean age 71.4 +/- 4.9 years) underwent valve replacement with at least one St. Jude Medical (SJM) mechanical valve. Preoperatively, 138 patients (12.3%) were in NYHA class II, 775 (68.9%) in class III, and 212 (18.8%) in class IV. In 535 patients (47.6%), coronary artery disease required surgical intervention. Survivors were administered the Short Form (SF)-36 QOL Survey at follow up, which was 96.1% complete. RESULTS: Hospital mortality was 7.6% (85/1,125). Mean follow up was 5.9 years (range: 9 months to 18.4 years). Mean (+/- SEM) actuarial survival was 70.6 +/- 1.4% at five years, and 40.6 +/- 2.0% at 10 years. Male patients scored significantly higher on the SF-36 than controls in physical (p = 0.012) and mental health (p = 0.004). Comparing female patients with controls revealed no significant difference in physical health; however, they scored higher in mental health than controls (p = 0.001). CONCLUSION: The study results clearly demonstrate that heart surgery in the elderly with the SJM mechanical valve can be accomplished with acceptable hospital mortality, morbidity, and excellent long-term results. Moreover, long-term QOL in elderly patients with a SJM valve can be expected to meet or exceed that of age- and gender-matched controls.

Angiographic and clinical outcomes of bivalirudin versus heparin in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

BACKGROUND: Heparin with adjunctive glycoprotein IIb/IIIa platelet receptor (GP IIb/IIIa) inhibitors has demonstrated its effectiveness in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, has recently been shown to be an effective alternative for patients undergoing elective PCI. OBJECTIVES: To assess the angiographic and clinical outcomes of adjunctive pharmacological strategies in a high-risk population presenting with ACS. METHODS: Of 891 consecutive PCI patients with ACS, 304 received bivalirudin (60.5% male, 68+/-11 years) and were compared with 283 who received heparin (58.7% male, 66+/-12 years). A 30-day major adverse cardiac event was defined as the occurrence of cardiac death, nonfatal myocardial infarction, urgent revascularization or major hemorrhage. RESULTS: Adjunctive GP IIb/IIIa inhibitors were used in 14.1% of the bivalirudin group and in 72.4% of the heparin group (P<0.010). The occurrence of Thrombolysis In Myocardial Infarction (TIMI) flow less than grade 3 was lower and the achievement of angiographic success was higher in the bivalirudin group than in the heparin group (5.2% versus 8.2%, 94.7% versus 89.7%, P=0.039 and P<0.010, respectively). There was no difference between groups in the incidence of bleeding events (bivalirudin 2.0% versus heparin 3.5%, P not significant) and in 30-day major adverse cardiac events (bivalirudin 8.3% versus heparin 5.7%, P=0.223). CONCLUSIONS: In the high-risk cohort undergoing PCI, bivalirudin with provisional GP IIb/IIIa inhibitors achieved better angiographic results. Although not powered to show a difference, and while acknowledging that a selection bias could have affected the data, the present study showed that bivalirudin may be as clinically effective and safe as heparin with adjunctive GP IIb/IIIa inhibitors.

When should fractional flow reserve be performed to assess the significance of borderline coronary artery lesions: Derivation of a simplified scoring system.

OBJECTIVES: To derive a simplified scoring system (SSS) that can assist in selecting patients who would benefit from the application of fractional flow reserve (FFR). BACKGROUND: Angiographers base decisions to perform FFR on their interpretation of % diameter stenosis (DS), which is subject to variability. Recent studies have shown that the amount of myocardium at jeopardy is an important factor in determining the degree of hemodynamic compromise. METHODS: We conducted a retrospective multivariable analysis to identify independent predictors of hemodynamic compromise in 289 patients with 317 coronary vessels undergoing FFR. A SSS was derived using the odds ratios as a weighted factor. The receiver operator characteristics curve was used to identify the optimal cutoff (≥3) to discern a functionally significant lesion (FFR≤0.8). RESULTS: Male gender, left anterior descending artery apical wrap, disease proximal to lesion, minimal lumen diameter and % DS predicted abnormal FFR (≤0.8) and lesion location in the left circumflex predicted a normal FFR. Using a cutoff score of ≥3 on the SSS, a specificity of 90.4% (95% CI: 83.0-95.3) and a sensitivity of 38.0% (95% CI: 31.5-44.9) was generated with a positive predictive value of 89.0% (95% CI: 80.7%-94.6%) and negative predictive value of 41.6% (95% CI: 35.1%-48.3%). CONCLUSIONS: The decision to use FFR should be based not only on the % DS but also the size of the myocardial mass jeopardized. A score of ≥3 on the SSS should prompt further investigation with a pressure wire.

Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit.

BACKGROUND: Extensive evidence documents a survival benefit for bilateral internal mammary artery (BIMA) grafting compared with single internal mammary artery (SIMA) grafting for patients with advanced coronary artery disease. However, controversy continues to exist regarding the incremental benefit of broadly applied BIMA grafting in elderly patients. METHODS: Retrospective analysis was conducted of 4,503 consecutive isolated coronary artery bypass grafting operations (SIMA, n = 2,340 and BIMA, n = 2,163) performed from 1972 to 1994. Multivariate analysis was used to created propensity score-matched groups of SIMA (n = 1,063) and BIMA (n = 1,063) to compare patients 65 years of age and older, and 70 years of age and older (n = 612), with similar baseline characteristics. Survival status was obtained by periodic follow-up, query of the US National Death Index, and other Internet searches, and was 99.6% complete. RESULTS: The propensity score-matched groups experienced similar perioperative mortality and morbidity. Survival benefits were found for BIMA versus SIMA grafting across both age categories. Actuarial curves after 23,593 patient-years of follow-up (mean BIMA = 11.7 years; 6 weeks to 33.1 years; mean SIMA = 10.5 years; 6 weeks to 30.7 years) demonstrated improved long-term survival for BIMA versus SIMA patients at 12 years (51.0 ± 1.5% versus 39.0 ± 1.5%) and at 24 years (3.5 ± 0.7% versus 4.5 ± 0.7%; p < 0.001). Similarly, in matched groups of patients age 70 and older, overall survival was also enhanced with BIMA grafting (p = 0.005). CONCLUSIONS: Advanced age should not be a contraindication for BIMA grafting. Long-term follow-up clearly demonstrates that BIMA grafting when broadly applied in elderly patients results in improved long-term survival over SIMA grafting.

Coronary bypass surgery in women: a long-term comparative study of quality of life after bilateral internal mammary artery grafting in men and women.

BACKGROUND: Coronary bypass surgery carries a higher operative mortality and less favorable long-term clinical benefits for women than men. The impact of arterial revascularization on long-term results, including quality of life (QOL) in women, compared with men, has not been clearly defined. METHODS: A retrospective analysis was performed comparing 261 consecutive women patients from a single surgical practice receiving bilateral internal mammary artery (IMA) and supplemental vein grafts between January 1972 and October 1994 with a computer-matched cohort of 261 men undergoing bilateral IMA surgery during the same time period. Univariate analysis confirmed the homogeneity of the two groups based on multiple preoperative variables. The SF-36 QOL assessment tool was completed for all patients at follow-up, which ranged from 1 month to 25 years, with a mean follow-up of 9.1 years for women and 8.6 years for men. RESULTS: There was no significant difference in operative mortality, nor in the incidence of any of 10 postoperative complications evaluated. The actuarial survival at 15 years was 53.7% +/- 4.8% for women and 50.9% +/- 5.6% for men (p = 0.218). At follow-up, 97.0% of women and 94.3% of men were free of angina and in Canadian Cardiovascular Society (CCS) class I or II. The need for reoperation (1.8% vs 1.9%) and PTCA (4.8% vs. 3.2%) was comparable in both groups. However, a higher rate of late myocardial infarction was found in women than men (1.8% vs 0.6, p = 0.021). The long-term event-free survival was found to be no different in men than women (p = 0.084). QOL as measured by the SF-36 was compared with the general population corrected for age and gender. Men and women scored as well or better than the general population in a majority of the eight health scales. Moreover, with regard to the health summary scores, men scored significantly higher (p = 0.001) in physical health, whereas women scored significantly higher (p = 0.011) in mental health when compared with age-adjusted norms. CONCLUSIONS: Men and women undergoing coronary revascularization using bilateral internal mammary artery conduits experience comparable outcomes, excellent long-term results, and enjoy a QOL comparable to or better than the general population as measured by the SF-36.

Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians.

BACKGROUND: Despite well-established benefits of arterial (ART) grafting, surgeons have been reluctant to use this conduit in octogenarians. This study explores the influence of arterial revascularization on operative and long-term outcomes of coronary artery bypass grafting surgery. METHODS: A retrospective analysis was conducted of 987 consecutive patients 80 years of age or older who underwent isolated coronary artery bypass grafting between January 1989 and November 2000. Patients with saphenous vein graft only (SVG; n = 574) were compared with those receiving arterial and saphenous vein grafts (ART+SVG; n = 413). Mean follow-up for SVG patients was 3.8 years (range, 4 months to 12.6 years) and 98.6% complete, and mean follow-up was 3.1 years for ART+SVG patients (range, 2 months to 11.2 years) and 97.3% complete. RESULTS: Patients with SVG had a significantly higher (p = 0.009) operative mortality (11.1% versus 6.3%) and significantly longer postoperative length of stay (12.9 versus 10.7 days; p = 0.002) than ART+SVG recipients. More ART+SVG than SVG patients were free of all postoperative complications (290 of 413; 70.2% versus 372 of 574; 64.8%; p = 0.086). Multivariable analysis identified SVG as an independent predictor of operative mortality (p = 0.014) and late mortality (p = 0.040). When patients were matched by equivalent propensity scores to receive SVG only, operative mortality was higher for SVG patients in four of the five quintiles. At 10 years, 97.0% +/- 1.2% of SVG and 92.9% +/- 3.7% of ART+SVG current survivors were free of all late major adverse cardiac events (p = 0.565), and 95.5% of SVG patients and 97.5% of ART+SVG patients were in Canadian class 1 or 2 (p = 0.162). On the SF-36 quality-of-life assessment, ART+SVG patients scored significantly higher than both SVG patients and age-adjusted normal subjects. Physical health summary component scores were 36.8 +/- 11.0 for SVG and 41.0 +/- 10.3 for ART+SVG (p = 0.001). Mental health summary scores were comparable for the two groups. CONCLUSIONS: Arterial grafting confers an operative survival benefit, and an enhanced long-term quality of life in elderly patients.

The influence of coronary artery disease on quality of life after mechanical valve replacement.

BACKGROUND AND AIM OF THE STUDY: Coronary artery disease (CAD) is known to impact negatively on long-term survival following valve replacement (VR). However, its influence on quality of life (QOL) remains undefined in patients with mechanical VR. METHODS: A total of 318 consecutive patients undergoing VR with the St. Jude Medical (SJM) mechanical valve were matched for age and gender with 318 patients who had VR (SJM valve) and coronary artery bypass grafting (VR+CABG). The VR group comprised 197 men and 121 women; the VR+CABG group also comprised 197 men and 121 women. The mean age of all patients was 66.0 +/- 8.0 years (range: 40-87 years). The Short Form-36 (SF-36) health survey was administered to all survivors at follow up examination. RESULTS: Operative mortality was comparable between groups (4.7% for VR, 7.5% for VR+CABG; p = 0.186). Hospital complications were also similar, except for reoperation for bleeding (p = 0.049). The mean follow up was 6.0 years for VR patients and 4.7 years for VR+CABG patients. Actuarial survival was significantly better in VR patients than VR+CABG patients (79.4 +/- 2.4% versus 75.0 +/- 2.7% at five years; 58.6 +/- 4.3% versus 47.5 +/- 4.5% at 10 years; p = 0.018). The equality of survival distribution was significantly different (p = 0.008). Multivariate analysis identified CABG as a predictor of late mortality (p = 0.003) but not of late QOL. QOL was similar on the eight health scales and physical health (44.5 +/- 10.3 versus 45.5 +/- 10.7) and mental health (52.4 +/- 9.8 versus 52.5 +/- 10.1) summary components, respectively. Age (p = 0.004), time from surgery to SF-36 administration (p = 0.007) and gender (p = 0.029), but not CABG, were significantly associated with QOL as assessed by the SF-36. CONCLUSION: CAD is a predictor of late mortality after mechanical VR. However, provided CABG is performed concomitantly with VR, the patient's longterm QOL appears to return to that expected for the general population.

Bilateral internal mammary artery grafting reverses the negative influence of gender on outcomes of coronary artery bypass grafting surgery.

OBJECTIVES: Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been clearly defined. METHODS: A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, [SIMA]; 1886 bilateral IMA, [BIMA]) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete. RESULTS: Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790). CONCLUSIONS: When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery.

Detection of inadvertent catheter movement into the coronary sinus ostium or middle cardiac vein by real-time impedance monitoring prior to radiofrequency ablation in the right atrial posteroseptal region.

OBJECTIVE: The objective of this study was to evaluate the use of continuous catheter impedance monitoring prior to ablation to facilitate differentiation of the coronary sinus ostium (CSO) and the middle cardiac vein (MCV) from the right atrial posteroseptal region (RPS). BACKGROUND: Empiric observations have suggested that continuous catheter impedance monitoring could differentiate the CSO and MCV from the RPS region. Radiofrequency ablation in the MCV or coronary sinus has been associated with coronary artery injury. Differentiation of these areas may be difficult with either fluoroscopy or electrogram characteristics. METHODS AND RESULTS: Continuous impedance measurements using a 4-mm Navistar (Biosense Webster) ablation catheter were conducted in 17 consecutive patients undergoing ablation for supraventricular tachycardia. The average impedance value was recorded at the right atrial septum (RS) posterior to the bundle of His, the RPS region, within 1 cm inside the CSO and in the MCV. These areas were confirmed and demarcated with 3-D mapping and biplane fluoroscopy. A significant increase in impedance was observed between the CSO (X = 146.6 ± 24.8) and RPS [Formula: see text] regions (p < 0.001). Furthermore, a significant rise in impedance was seen between the MCV [Formula: see text] and RPS and CSO, respectively (p < 0.001). No significant change in impedance was found between the RS [Formula: see text] and RPS regions. CONCLUSIONS: Continuous impedance measurements during mapping can facilitate differentiation of catheter locations inside the CSO and MCV from extracoronary sinus regions. This may reduce the risk of inadvertent coronary artery damage during the ablation procedure.

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up.

OBJECTIVE: Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. METHODS: Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. RESULTS: There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). CONCLUSIONS: Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

Eighteen-year follow-up demonstrates prolonged survival and enhanced quality of life for octogenarians after coronary artery bypass grafting.

OBJECTIVE: Octogenarians comprise the fastest growing population segment. Numerous reports have documented improved accomplishment of coronary artery bypass grafting in this high-risk cohort. But what is the quality of life after surgery, and how sustainable are the clinical benefits? METHODS: Sequential cross-sectional analyses were performed on 1062 consecutive patients 80 years old and older who underwent isolated on-pump coronary artery bypass grafting at a single institution from 1989 to 2001. After mean follow-up of 3.4 years (1 month-12.6 years), the Short Form 36 quality of life survey was administered to all survivors. Late follow-up for survival was performed after a mean 5.6 years (1 month-17.9 years). Multivariate analyses assessed risk factors associated with operative mortality, Short Form 36 self-assessment, and late survival. RESULTS: Mean age at operation was 83.1±2.8 years (range, 80-99 years). Overall in-hospital mortality was 9.7%, decreasing progressively to 2.2% during the course of the study. At midterm follow-up, 97.1% of patients were in Canadian Cardiovascular Society class I or II; Short Form 36 scores were comparable to age-adjusted norms in both physical and mental health summary scores. Actuarial survivals were 42.2%±1.5% at 7 years and 9.9%±1.4% at 14 years. Median survival was 5.9 years; 5.2 years for male patients and 6.7 for female patients (P=004). CONCLUSIONS: The risk of coronary artery bypass grafting for octogenarians now rivals that of a younger population. Midterm quality of life and long-term survival approach those of the general population.