Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Daptomycin treatment in Gram-positive vascular graft infections.

BACKGROUND: Daptomycin is a bactericidal antibiotic approved for the treatment of skin and soft tissue infections and right-side endocarditis. However, there is a lack of published data outlining its usefulness in vascular graft infections (VGI). The aim of this study was to describe the clinical experience of daptomycin use in the treatment of VGI caused by Gram-positive bacteria. METHODS: This was a retrospective cohort study of patients diagnosed with VGI receiving daptomycin at a tertiary care hospital during the period January 2010 to December 2012. RESULTS: Of a total 1066 consecutive patients who had undergone vascular grafts (VG), 25 were diagnosed with VGI. Fifteen of these patients (11 prosthetic VG, three autologous VG, one both types) received daptomycin (median dose 6.7mg/kg/day, range 4.1-7.1mg/kg/day; median age 69 years, range 45-83 years; 80% male). The infected bypass was removed in 13 cases. The most common reason for selecting daptomycin was kidney failure (53%). The Gram-positive organisms isolated were coagulase-negative Staphylococcus (n=10), Staphylococcus aureus (n=3) (two methicillin-resistant S. aureus), Enterococcus faecium (n=2), and Enterococcus faecalis (n=1). The mean follow-up was 69 months (interquartile range 48-72 months). Ten patients (66.7%) achieved complete healing of the VGI. A recurrence of the infection was observed in 100% of patients in whom the bypass was not removed. Among patients who did not achieve complete healing, one needed a supracondylar amputation and one died as a consequence of infection. Five patients received treatment with rifampicin in addition to daptomycin and they were all cured. CONCLUSIONS: The use of daptomycin and surgery for Gram-positive VGI was effective and well tolerated, and this may be a good alternative for the treatment of VGI in patients with peripheral arterial disease in whom renal insufficiency is common.

Mutilating Purpura Fulminans in an Adult with Meningococcal Sepsis.

We report a dramatic case of meningococcal sepsis manifesting as purpura fulminans in an elderly diabetic woman. Hemodynamic instability and severe bilateral cutaneous lesions involving her hands and feet developed rapidly. Specific antibiotic therapy and the administration of inotropic and vasopressor drugs were initiated. The severity and extension of the cutaneous lesions (attributed to purpura fulminans) worsened because of the need for vasoconstrictors for the treatment of septic shock. Bilateral transmetatarsal and metacarpal amputations were required to stabilize the patient.

A concealed atriopleural fistula resulting from a cardiac stab wound.

A young male presented with a right parasternal stab wound. The chest radiography was normal and transthoracic echocardiography ruled out pericardial tamponade. He remained hemodynamically stable until three hours later when signs of progressive anemia were observed. Chest computed tomography showed massive right-sided hemothorax. The patient underwent surgery, which revealed an active bleeding atriopleural fistula connecting the right atrium and draining into the right pleura resulting from the negative pressure generated during respiration. This mechanism prevented cardiac tamponade and maintained initial hemodynamically stability.

The surgical option in the management of acute pulmonary embolism.

OBJECTIVE: Massive or submassive pulmonary embolism (PE) carries a high mortality. Traditionally this condition has been treated with thrombolysis or anticoagulation and support measures. Surgical embolectomy is carried out in situations of hemodynamic instability or contraindication for thrombolysis. We present our results of surgical embolectomy in patients with massive and submassive PE. METHODS: Over a three-year period, we have carried out 20 surgical embolectomies for acute PE. The mean age was 66 years, and there were 11 males. In all cases, the diagnosis had been made by a computerized tomography (CT) pulmonary artery angiography. Nine patients (45%) arrived to the operating theater on inotropes, and two of them (10%) with ventilatory support. All patients underwent a median sternotomy, bicaval cannulation for institution of cardiopulmonary bypass (CPB), and main pulmonary arteriotomy for the removal of the thrombus. RESULTS: The mean bypass time was 45 minutes. Two patients (12%) died after being unable to wean off CPB due to right heart failure. Among the 15 survivors, the median ventilation time in the intensive care unit was 24 hours. Twelve patients (60%) required inotropic support postoperatively for right heart failure. All but one survivor (94%) underwent an insertion of a permanent inferior vena cava filter and were anticoagulated with coumarin. The mean follow-up is 9.8 months and is 100% complete, with a survival of 94.5%. All patients were in the World Health Organization (WHO) functional class I, with no re-admissions for respiratory failure. CONCLUSION: In patients with acute massive or submassive PE, surgical embolectomy offers a valid therapeutic strategy. A right-sided heart failure is the main complication of this condition.

Video-assisted mitral surgery through a micro-access: a safe and reliable reality in the current era.

BACKGROUND AND AIM OF THE STUDY: Minimally invasive mitral valve surgery was introduced into clinical practice during the mid 1990s. The clinical benefits of the technique, namely a reduction of surgical trauma, increased patient comfort and shorter hospital stay, are achieved by using a video-assisted, minithoracotomy approach rather than a standard median sternotomy. Herein is described the authors' experience with video-assisted mitral surgery through a micro-access. METHODS: Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-assisted port-access mitral valve surgery through a 4- to 6-cm anterior mini-thoracotomy. Mitral valve repair was carried out in 36 patients (36%) and mitral valve replacement (MVR) in 64 (64%) for degenerative (n = 54), rheumatic (n = 44), functional (n = 1) or infective disease (n = 1). Redo procedures were performed in 14 patients. RESULTS: Peripheral extra-thoracic cardiopulmonary bypass (CPB) was used in all cases, and Endoclamp occlusion of the ascending aorta in 94%. The median intensive care unit and hospital stays were 20.0 +/- 30.8 h and 7.0 +/- 5.9 days, respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. Five patients (5%) underwent minimally invasive surgical revision for bleeding, and one patient (1%) had an early reoperation for MVR during the immediate postoperative course due to failure of a mitral valve repair. There were no perioperative myocardial infarctions, permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during the postoperative course, and no wound infections were observed. CONCLUSION: Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results and quality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.

Ruptured aneurysm of the mammary artery in a patient with neurofibromatosis type I.

We report a case of acute hemothorax caused by the rupture of a mammary artery aneurysm in a patient with neurofibromatosis type I.

One-hundred aortic valve replacements in octogenarians: outcomes and risk factors for early mortality.

BACKGROUND AND AIM OF THE STUDY: Today, ageing of the western population is causing aortic valve surgery to be performed in elderly patients with increasing frequency. The study aim was to evaluate surgical outcome in octogenarian patients undergoing aortic valve replacement (AVR). METHODS: A total of 100 patients (mean age 82.1 +/- 2.7 years; range: 80-95 years) who underwent AVR over a three-year period was reviewed. Concomitant coronary artery bypass grafting was performed in 34% of cases, and a bioprosthesis was implanted in 80%. The mean logistic EuroSCORE was 13.3%. RESULTS: Operative mortality was 8.0%. In multivariate analysis, a logistic EuroSCORE > or =13.5% (p = 0.02), cross-clamp time > or =75 min (p = 0.02) and postoperative acute renal failure were predictors for in-hospital mortality. Follow up was 100% complete; the mean follow up period was 10.6 months. At one year after surgery, the actuarial survival rate of those patients who survived surgery was 86.1%. Postoperative dyspnea at one month (p = 0.004) was the only predictor of short-term mortality. CONCLUSION: Age in itself should not contraindicate surgery, and healthcare systems should be prepared to accommodate elderly patients who may require special resources.

Performance at 10 years of the CarboMedics "Top-Hat" valve. Postclamping time is a predictor of mortality.

OBJECTIVE: The CarboMedics "Top-Hat" supraannular prosthesis was designed to permit the implantation of a larger prosthesis. We evaluated the outcome at 10 years in patients with this prosthesis. METHODS: Between June 1993 and May 2001, 269 patients (average age, 63.9 years) received a CarboMedics "Top-Hat" supraannular aortic prosthesis. Primary valve replacement was performed on 203 patients (75.5%) and repeat valve replacement on 66 (24.5%). The duration of myocardial ischemia was 70.2+/-31.4 min, cardiopulmonary bypass 96.1+/-48.3 min, and postclamping time (time between release of aortic clamp and the end of extracorporeal circulation) 22.1+/-41.3 min. The mean follow-up was 82.3+/-17.8 months. Follow-up was 97.6% complete. RESULTS: The hospital mortality was 5.9%. It was 1% when the duration of postclamping time was <15 min, 2.8% between 15 and 29 min, 13.2% between 30 and 44 min, and 26.9% >44 min. In the multivariate analysis, postclamping time, urgent surgery, and body mass index were statistically significant risk factors for hospital mortality. The late mortality was 17.1%. Cardiac-related mortality showed a linearized rate of 18.1% per 1000 patients-year. The Kaplan-Meier estimates for cardiac-related mortality was 75.0% at 10 years. Postclamping time, aortic valve gradient, age over 70 years, and BMI were statistically significant risk factors for cardiac-related late mortality. The incidence of paravalvular leak in the "Top-Hat" aortic prosthesis was 1.7% per 1000 patients-year. CONCLUSIONS: Using the CarboMedics supraannular prosthesis allows implantation of a larger prosthesis without increasing valve-related complications. Postclamping time appears as a strong predictor of both hospital mortality and late cardiac-related death.