Overview of mitral valve replacement versus mitral valve repair due to ischemic papillary muscle rupture: A meta-analysis inspired by a case report.

BACKGROUND: Papillary muscle rupture (PMR) is an infrequent but catastrophic complication after myocardial infarction (MI). Surgical procedure is considered the optimal treatment, despite high risk. However, the gold standard technique is still a major dilemma. Therefore, a meta-analysis was carried out to assess and provide an overview comparing mitral valve replacement (MVR) and mitral valve repair (MVr) for PMR post-MI. METHODS: A systematic literature search was performed. Data were extracted and verified using a standardized data extraction form. Meta-analysis was realized mainly using RevMan 5.4 software. RESULTS: From four observational studies 1640 patients were identified; 81% underwent MVR and 19% MVr. Operative mortality results were significantly higher in MVR group than the MVr group. MVR was performed under emergency conditions and patients admitted in cardiogenic shock or who required the use of mechanical cardiac support underwent MVR. MVr had shorter time of hospitalization and similar incidence of postoperative complications than MVR. No significant differences existed between the two procedures regarding cardiopulmonary bypass time. CONCLUSIONS: Mitral valve repair appears to be a viable alternative to MVR for post-MI PMR, given that it has lower operative mortality, shorter time of hospitalization and similar incidence of short-term postoperative complications than MVR. However, it needs to be pointed out that MVR was associated with the most critical clinical condition following PMR. There is uncertainty regarding the overall survival and improvement of the quality of life between the procedures. Nevertheless, further completed investigation is required.

A network meta-analysis of randomized trials and observational studies on left ventricular assist devices in adult patients with end-stage heart failure.

OBJECTIVES: The use of left ventricular assist devices (LVADs) is an approved treatment option for end-stage heart failure. Several devices have been developed over the years, including 2 newer ones (HeartMate 3 and HeartWare), but an overall comparative analysis has never been performed. We conducted a network meta-analysis of randomized trials on LVAD for adults with end-stage heart failure. METHODS: Pertinent studies were searched in several databases. Selected outcomes were extracted, including death, stroke and bleeding. Incident relative risks were computed with network meta-analysis with 95% confidence intervals (CIs) and P-scores (with highest values indicating the best therapy). RESULTS: Four randomized clinical trials and 4 observational studies were identified, totalling 2248 patients. Using HeartMate XVE/VE as the benchmark, all LVADs provided a significant better outcome for survival rate in comparison with medical therapy, without significant differences among newer LVADs. The relative risk for death was 0.79 (95% 0.60-1.04; P-score 0.89) for HeartMate II, 0.85 (95% CI 0.62-1.17; P-score 0.64) for HeartWare, 0.88 (95% CI 0.59-1.31; P-score 0.60) for HeartMate 3 and 1.48 (95% CI 1.21-1.80; P-score 0.01) for medical management. While appraising other outcomes, new generation devices (HeartMate 3 and HeartWare) proved better than older generation devices for bleeding, device thrombosis, hepatic dysfunction, renal dysfunction, respiratory dysfunction, right ventricular failure and sepsis with significant differences among them. CONCLUSIONS: In the management of end-stage heart failure, LVADs provided significant improvement in terms of survival rate compared to medical therapy, but no significant differences exist among LVADs. Despite the reduction of adverse events over time, further technological refinements will be crucial to improve this technology to better address decision-making and to improve clinical outcomes.

Residual SYNTAX score following coronary artery bypass grafting.

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

The impact of arterial cannulation strategy on operative outcomes in aortic surgery: evidence from a comprehensive meta-analysis of comparative studies on 4476 patients.

OBJECTIVES: There is a growing perception that peripheral cannulation through the femoral artery, by reversing the flow in the thoracoabdominal aorta, may increase the risk of retrograde brain embolization in aortic surgery. Central cannulation sites, including the right axillary artery, have been reported to improve operative outcomes by allowing antegrade blood flow. However, peripheral cannulation still remains largely used because a consensus for the routine use of central cannulation approaches has not been reached. METHODS: A meta-analysis of comparative studies reporting operative outcomes using central cannulation versus peripheral cannulation was performed. Pooled weighted incidence rates for end points of interest were obtained using an inverse variance model. RESULTS: A total of 4476 patients were included in the final analysis. Central cannulation was used in 2797 patients, and peripheral cannulation was used in 1679 patients. Central cannulation showed a protective effect on in-hospital mortality (risk ratio, 0.59; 95% confidence interval, 0.48-0.7; P < .001) and permanent neurologic deficit (risk ratio, 0.71; 95% confidence interval, 0.55-0.90; P = .005) when compared with peripheral cannulation. A trend toward an increased benefit in terms of reduced in-hospital mortality was observed when only the right axillary artery was used as the central cannulation approach (risk ratio, 0.35; 95% confidence interval, 0.22-0.55; P < .001; I(2) = 0%). CONCLUSIONS: Central cannulation was superior to peripheral cannulation in reducing in-hospital mortality and the incidence of permanent neurologic deficit. This superiority was particularly evident when the axillary artery was used for central cannulation.

Moderate chronic kidney disease and left ventricular hypertrophy after aortic valve replacement for aortic valve stenosis.

OBJECTIVE: Left ventricular hypertrophy regression is assumed to be one of the most important goals after aortic valve replacement for aortic stenosis. A moderate decrease in the glomerular filtration rate is associated with a significantly increased risk of left ventricular hypertrophy in hypertensive patients. The effect of moderate kidney disease on left ventricular hypertrophic remodeling in other conditions of chronic left ventricular pressure overload, such as aortic stenosis, remains unknown. Therefore we tested the hypothesis that moderate chronic kidney disease affects left ventricular mass regression in patients undergoing isolated aortic valve replacement for aortic stenosis. METHODS: In 157 patients with aortic stenosis, left ventricular mass regression was assessed at 18 months after aortic valve replacement. Among them, 73 (46%) had a moderate chronic kidney disease (glomerular filtration rate between 60 and 30 mL/min per 1.73 m(2)). Patients with severely impaired kidney function (glomerular filtration rate of <30 mL/min per 1.73 m(2)) were excluded. RESULTS: After surgical intervention, left ventricular mass was significantly lower from baseline value in both groups, but patients with moderate chronic kidney disease continued to show an increased left ventricular mass (61 +/- 18 vs 50 +/- 16 g/m(2.7), P = .0001). The baseline glomerular filtration rate was significantly related to left ventricular mass at 18 months after surgical intervention (beta = -0.17, r(2) = 0.45, P = .01) and left ventricular mass absolute (beta = 0.18, r(2) = 0.19, P = .03) and relative (beta = 0.20, r(2) = 0.21, P = .02) regression. These associations persisted after adjusting for confounding factors, including hypertension and patient-prosthesis mismatch. After a mean time of 34 +/- 12 months from surgical intervention, congestive heart failure symptoms developed mainly in subjects with moderate chronic kidney disease (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-3.9; P = .035). CONCLUSIONS: Patients with aortic stenosis with concomitant moderate chronic kidney disease present a less evident left ventricular mass regression after aortic valve replacement. Moreover, this condition is related to an increased occurrence of congestive heart failure after surgical intervention.

Cardiac troponin I concentrations during on-pump coronary artery surgery.

Perioperative myocardial infarction remains a frequent complication after coronary artery bypass grafting, and is associated with a poor prognosis. This retrospective study compared cardiac troponin I concentrations after on-pump bypass grafting in 2 groups of patients: 100 operated on using a single-clamp technique to perform anastomoses, and 80 operated on using a double-clamp technique. Postoperative cardiac troponin I levels were not significantly different between groups. It was concluded that the double-clamp technique did not reduce the incidence of myocardial infarction after elective on-pump coronary artery bypass grafting, and use of a single clamp is safe with no adverse effect on postoperative outcome.

Severe hypoxaemia after weaning from cardiopulmonary bypass: a case report.

Persistence of patent foramen ovale is frequent in adults and usually asymptomatic. We report the case of a patient in whom a patent foramen ovale was diagnosed after weaning from cardiopulmonary bypass and was not recognised preoperatively. Intraoperative transoesophageal echocardiography is pivotal for surgical decision-making and should be performed in all patients undergoing cardiac surgery.

Mild and moderate renal dysfunction: impact on short-term outcome.

BACKGROUND: Preoperative renal dysfunction is an important risk factor in cardiac surgery. Thus, the association between creatinine clearance (ClCr) and mechanical ventilation time and ICU length of stay, independent of other established preoperative risk indicators, was analyzed. METHODS: In our study, 156 consecutive patients underwent open-heart surgery at the Department of Cardiac Surgery, University Hospital St. Andrea, Rome, and were prospectively studied for the relation between the ClCr, using the formula develop by Cockroft and Gault, and ICU length of stay and mechanical ventilation time. The 156 patients were divided into two groups in relation of ClCr: group A (n=78) ClCr<70 ml/min; group B (n=78) ClCr>70 ml/min. RESULTS: In multivariate analysis, ICU length of stay was influenced by ClCr<70 ml/min, hypertension and COPD. ICU stay was median 48 h (range 24-72) in group A versus 24h (range 20.7-44) in group B (p=0.0001). In multivariate analysis, only ClCr<70 ml/min and EuroScore were associated with increasing VAM. VAM was median 8h (range 5.7-13.2) in group A versus 6h (range 4-10) in group B (p=0.001). CONCLUSIONS: Our study demonstrates that after short-term outcome follow-up, preoperative mild renal dysfunction is an independent predictor of ICU length of stay and mechanical ventilation time.

Clinical utility of tissue Doppler imaging in prediction of atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial systolic dysfunction in patients with coronary artery disease might influence the development of atrial fibrillation after coronary artery bypass grafting (CABG). Tissue Doppler imaging of the mitral annulus during atrial systole has proved to quantify, accurately, left atrial contractile function. Therefore, the aim of the present study was to investigate the correlation between preoperative left atrial dysfunction assessed by tissue Doppler and postoperative atrial fibrillation after CABG. METHODS: We studied a total of 96 patients (mean age 67 +/- 6 years; range, 55 to 81) undergoing CABG who were preoperatively in sinus rhythm. All patients underwent a preoperative transthoracic echocardiography with tissue Doppler evaluation. Until the day of discharge, all patients were monitored with continuous electrocardiographic telemetry. RESULTS: There were no hospital deaths. Postoperative atrial fibrillation was recorded in 24 of 96 patients (25%). Patients with postoperative atrial fibrillation were significantly older (70 +/- 6 vs 65 +/- 8 years; p = 0.006), had a preoperative larger left atrium diameter (38 +/- 5 vs 36 +/- 4 mm; p = 0.045), a larger left atrium area (13.2 +/- 3.4 vs 11.5 +/- 2.3 cm2; p = 0.007), and a lower peak atrial systolic mitral annular tissue Doppler velocity (10 +/- 3 vs 13 +/- 5 cm/second; p = 0.01). Stepwise logistic regression analysis showed that age 70 years or greater (p = 0.02; odds ratio [OR] 2.0), preoperative medication with beta-blockers (p = 0.04; OR 0.7), left atrium area 13 cm2 or greater (p = 0.02; OR 2.5), and peak atrial systolic mitral annular tissue Doppler velocity 9 cm/second or less (p = 0.03; OR 1.8) were independently related with the incidence of postoperative atrial fibrillation. CONCLUSIONS: Tissue Doppler is useful for assessing preoperative atrial dysfunction and predicting atrial fibrillation after CABG. Further studies are needed to confirm this finding.

Anterolateral papillary muscle rupture after weaning from cardiopulmonary bypass for coronary artery bypass grafting: once in a blue moon.

Complete rupture of the anterolateral papillary muscle after successful coronary artery bypass procedure is an extremely rare event. We have been able to detect the initial phase of this uncommon complication just after weaning from cardiopulmonary bypass using intraoperative transesophageal echocardiographic examination.

Emergency repair of coronary perforation following percutaneous transluminal coronary angioplasty failure: A high-risk choice?

Coronary perforation is a recognized hazard following cardiac catheterization and may lead to a catastrophic outcome. Prompt decision-making following diagnosis is of key importance. Whether to perform prolonged attempts at percutaneous repair or to promptly refer the patient for emergency surgery soon after diagnosis still remains a matter of debate. We report the case of a 78-year-old woman suffering from coronary artery perforation during left anterior descending coronary artery percutaneous transluminal coronary angioplasty-stenting, who underwent unsuccessful multiple prolonged attempts at percutaneous repair followed by subsequent successful emergency surgery.

Intensive hyperglycemia control reduces postoperative infections after open heart surgery.

BACKGROUND: Diabetes mellitus increases the risk of infections in patients undergoing cardiac surgery. We hypothesized that intensive perioperative hyperglycemia control by intravenous insulin infusion reduces postoperative infections in all patients undergoing open heart surgical procedures. METHODS: Sixty diabetics patients who underwent CABG operation (Group 1) were compared with fifty-five patients who underwent other cardiac surgery (Group 2) between January 2004 and March 2005. A continuous infusion of insulin was used in all these patients. RESULTS: There were no 30-day mortalities in either group. There was no difference in the incidence of infections between the two groups: in Group 1, 3 (5%) patients were diagnosed to have postoperative infection (superficial sternal wound infections in 1 (1.66%) and lung infection in 2 (3.33%) patients); postoperative infection occurred in only 2 patients (3.63%) in Group 2, 1 superficial sternal wound infections (1.81%) and 1 lung infection (1.81%). CONCLUSIONS: Our analysis indicates that continuous intravenous insulin infusion improves outcome and reduces postoperative infections in patients undergoing CABG as well as those undergoing other cardiac surgery procedures.

Indexed effective orifice area after mechanical aortic valve replacement does not affect left ventricular mass regression in elderly.

OBJECTIVE: After aortic valve replacement, the effects of a small functional prosthesis on the extent and pattern of regression of left ventricular hypertrophy and on clinical outcomes may be less significant in older patients with low cardiac output requirements. The objective of this study was therefore to determine whether patient-prosthesis mismatch affects left ventricular mass regression in the elderly. METHODS: The population studied was made up of 88 patients over 65 years of age with pure aortic stenosis who underwent mechanical aortic valve replacement. The effective orifice area index was calculated for each patient on the basis of the projected prosthesis in vivo effective orifice area. It was considered a continuous variable and influence of its entire range of values on the extent of left ventricular mass regression was analyzed in a multivariate prediction model. RESULTS: Even though, in the group with prosthesis-patient mismatch there was a trend for lower postoperative left ventricular mass index (115+/-24 g/m(2) vs 102+/-27 g/m(2), p=0.24) and postoperative peak trans-prosthetic gradients (32+/-9.8 mmHg vs 28.9+/-7.79 mmHg, p=0.35) these differences were not statistically significant. The prevalence of residual left ventricular hypertrophy at follow-up was 50% in the group with patient-prosthesis mismatch and 50% in the group without patient-prosthesis mismatch (p=0.83). In multivariate analysis the only factors associated with indexed left ventricular mass were the follow-up time (p=0.015, r(2)=0.22) and preoperative indexed left ventricular mass (p=0.0012, r(2)=0.11). CONCLUSIONS: The major finding of our study is that patient-prosthesis mismatch does not affect left ventricular mass regression in patients older than 65 with pure aortic stenosis who underwent mechanical aortic valve replacement. In older patients with low cardiac output requirements, even a small change in the valve effective orifice area after aortic valve replacement with modern efficient mechanical prosthesis, will result in a marked reduction of pressure gradient and this will be associated with a significant regression of left ventricular mass.

Effect of topic defibrillation on serum markers of myocardial damage.

Serum levels of cardiac enzymes and troponins after external cardioversion (ECV) for atrial defibrillation and atrial flutter, and after endocardiac cardioverter defibrillation by implantable cardioverter defibrillator (ICD), have been well investigated. The aim of this study was to assess the effects of topic defibrillation (TD), after cardiac surgery, on cardiac enzymes in patients with uncomplicated clinical course. Biochemical markers were analyzed prospectively for 20 patients after TD (group A) and for 20 patients that were not defibrillated (Control group). We obtained serum concentrations of cardiac Troponin I (cTnI), total creatine-kinase (CK), CK MB isoenzyme (CK-MB), Myoglobin (Myo) in both groups. The difference in cTnI plasma level and curve of raise was not statistically significant between the two groups, but there was a difference in the CK-MB and Myoglobin curve of raise between the two groups. Topic defibrillation does not influence the increase of cTnI, so a high cTnI should be correlated to myocardial damage and not to TD. In patients that received TD, it would be preferable to use cTnI as a marker of myocardial disease than CK-MB which is influenced by the TD.

Off-pump versus on-pump coronary artery bypass: does number of grafts performed represent a selection bias in comparative studies? Results from a matched cohort comparison.

BACKGROUND: Several retrospective studies comparing off-pump and on-pump coronary surgery and the largest randomized studies published to date showed a lower number of grafts performed in patients submitted to off-pump coronary artery bypass surgery (OPCAB). These findings bring about the question of the general applicability of the results. We eliminated the selection bias correlated with the number of grafts per patient by comparing the short-term outcomes of patients undergoing OPCAB and standard coronary artery bypass grafting (CABG) matched for number of grafts. METHODS: Eighty-seven consecutive patients undergoing OPCAB (group A) were selected from the database of our Institution during a 2-year period. Matching was performed by iterative selection prioritizing, in the following sequence: number of grafts, EuroSCORE, and age. A total of 87 patients operated upon with the on-pump technique represented the control group (group B). RESULTS: There were no significant differences in preoperative characteristics between the two groups. The number of grafts per patient was 2.2 +/- 0.5 in group A and 2.2 +/- 0.5 in group B. Early mortality did not differ between the two groups and it was 2.2% (2 patients) in group A and 3.4% (3 patients) in group B (p = NS). The incidence of myocardial infarction did not differ between the two groups. No patient in either group had stroke or coma. Five (5.7%) patients in group A and 7 (8.0%) patients in group B had atrial fibrillation (p = NS). CONCLUSIONS: We were unable to demonstrate any significant differences in short-term mortality or morbidity outcome between OPCAB and standard CABG patients Our findings suggest that excellent results can be obtained with both surgical approaches.

Left ventricular aneurysm repair: early survival.

BACKGROUND: The aim of this study was to evaluate the early survival in patients submitted to left ventricular (LV) repair and concomitant myocardial revascularization. METHODS: We retrospectively reviewed the records of 51 patients who were submitted to LV repair and concomitant myocardial revascularization between January 1998 and June 2003. Of 51 patients (44 males with a mean age of 60+/-9.2 years, and 7 females with a mean age of 61+/-6.5 years), 29 (56.9 %) were submitted to the McCarthy technique, 16 (31.3 %) to the technique that was described by Jatene and modified by Dor, and 6 (11.8%) to the Cooley technique (linear repair). The mean preoperative LV ejection fraction was 36.5+/-7.7 %, the mean preoperative LV end-diastolic diameter was 61.8+/-3.9 mm, the mean preoperative LV end-systolic diameter was 49.9+/-5.1 mm, the mean preoperative interventricular septal thickness was 9.7+/-1.7 mm, and finally, the mean posterior wall thickness was 8.9+/-1 mm. The mean follow-up was 30.7+/-23.4 months (range 11-82 months). RESULTS: One patient died during surgery (1.9%) and one early postoperatively (1.9%). The causes of death were respectively irreversible ventricular fibrillation and low cardiac output syndrome. The overall survival at follow-up was 98% (49 patients). One patient died during follow-up of myocardial infarction. At follow-up, all patients presented with improved clinical symptoms, and had a better mean NYHA functional class with respect to the preoperative value (3.3+/-0.3 vs 2.0+/-0.5, p < 0.05). Besides, the mean CCS angina class decreased in all patients (3.4+/-0.2 vs 1.9+/-0.3, p < 0.05). The average LV ejection fraction increased from 36.3+/-7.7 to 44.3+/-4.9% (p < 0.001), the average LV end-diastolic diameter decreased from 61.7+/-3.9 to 55.5+/-5.6 mm (p < 0.001), and the average LV end-systolic diameter decreased from 49.9+/-5.1 to 40.4+/-5.1 mm (p < 0.001). No statistically significant difference was found between the preoperative and postoperative data regarding the interventricular septal thickness (9.7+/-1.7 vs 10.3+/-1.6 mm, p = NS), and the posterior wall thickness (9.7+/-1 vs 8.8+/-1.3 mm, p = NS). CONCLUSIONS: LV aneurysm repair and concomitant myocardial revascularization may be performed with an acceptable surgical risk and a good early survival.

Disfunção aguda devido a uma trombose da prótese da válvula mitral mecânica / Acute dysfunction from thrombosis of a mechanical mitral valve prosthesis

Um homem de 64 anos recebeu uma prótese mecânica CarboMedics de 31 mm para refluxo mitral grave. Após quatro dias, o paciente apresentou-se com fadiga e dispnéia em repouso. Estudo do Doppler ecocardiografia transtorácica e transesofágica confirmaram uma disfunção na mobilidade do folheto da válvula protética devido à trombose e uma operação de emergência foi feita. O pós operatório transcorreu sem intercorrências. Este é um caso incomum de disfunção grave devido à trombose de uma prótese mitral mecânica em um paciente tomando anticoagulantes orais e calciparina

Reoperations in patients with patent left internal mammary artery.

In the past decade the rate of reoperative coronary bypass grafting has averaged 8%. In these patients adequate myocardial protection is often difficult because delivery of cardioplegia is frequently suboptimal when the internal mammary artery graft is patent. We describe a simple technique for performing cardiac reoperation in patients with a patent left internal mammary artery graft through a balloon catheter used for angioplasty and positioned in the left internal mammary artery graft. Our study included 3 patients and there were no operative deaths and complications.

Occluding clamp technique during coronary artery bypass grafting: single or double-clamp technique?

BACKGROUND: External manipulation of the diseased aorta during cardiac surgery is the most important mechanism leading to the detachment of atherosclerotic debris due, especially, to the use of aortic clamping. The aim of the present study was to determine the best occluding clamp technique to minimize the risk of postoperative cerebrovascular accidents in patients who undergo isolated coronary artery bypass grafting (CABG): single-clamp technique (SCT) or double-clamp technique (DCT)? METHODS: Two hundred and eighty-one consecutive patients undergoing isolated CABG in our center between January 2001 and December 2003 were enrolled. SCT was used in 145 cases and DCT was used in 136 cases. Postoperative adverse events were retrospectively compared between these two groups. RESULTS: The aortic cross-clamp times were longer for patients in the SCT group, whereas the mean cardiopulmonary bypass time was shorter in the DCT group. There were no differences between the two groups in terms of postoperative stroke (0.6% SCT vs 0.7% DCT, p = NS) and hospital mortality (1.3% SCT vs 1.4% DCT, p = NS). CONCLUSIONS: The results of this study suggest that, among patients who undergo CABG, there are no differences in neurologic outcome between those in whom DCT was used and those in whom SCT was employed.