Outcomes of Dialysis-Dependent Patients After Cardiac Operations in a Single-Center Experience of 483 Patients.

BACKGROUND: The aim of this study was to determine the preoperative predictors of in-hospital and medium-term mortality in patients with dialysis-dependent chronic renal failure (DD CRF) undergoing cardiac operations. METHODS: Between January 1996 and June 2014, 483 consecutive patients with DD CRF underwent cardiac surgical procedures. The mean age was 65 ± 11 years, and 32. 3% were women. Isolated coronary artery bypass grafting (CABG) or isolated valve operations were performed in 39.8% and 32.3%, of patients, respectively. Combined surgical procedures (CABG with valve operations) were necessary in 20.3% of patients. Endocarditis was an indication for surgical intervention in 11% of patients. Urgent or emergent operations were performed in 49.3% of patients. RESULTS: The in-hospital mortality was 15.3%. Postoperative respiratory failure, gastrointestinal complications, low cardiac output, stroke, and sepsis occurred in 25.7%, 12.4%, 11.8%, 5.6%, and 5.2% of patients, respectively. The independent predictors of in-hospital mortality were combined mitral and aortic valve pathologic conditions (odds ratio [OR], 3.7, 95% CI, 1. 5-9; p = 0.003), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.1-5.9; p = 0. 03), peripheral vascular disease (OR, 2.3; 95% CI, 1.04-4; p = 0.003), left ventricular ejection fraction (LVEF) <30% (OR, 2.9; 95% CI, 1.3-6. 4; p = 0.008), and active endocarditis (OR, 2.2; 95% CI, 1.04-4.6; p = 0.04). The estimated 2-, 4-, and 6-year survival was 50.1% ± 2%, 34.3% ± 2%, and 20.3% ± 2%, respectively. Previous cerebrovascular accident, active endocarditis, previous cardiac operations, and combined aortic/mitral valve pathologic conditions were independent predictors of medium-term mortality. CONCLUSIONS: Patients with DD CRF undergoing cardiac operations have high perioperative and medium-term mortality, particularly in the presence of combined aortic and mitral valve pathologic conditions, active endocarditis, and poor left ventricular function.

Intra-Aortic Balloon Pump Malposition Reduces Visceral Artery Perfusion in an Acute Animal Model.

Visceral artery perfusion can be potentially affected by intra-aortic balloon pump (IABP) catheters. We utilized an animal model to quantify the acute impact of a low balloon position on mesenteric artery perfusion. In six pigs (78 ± 7 kg), a 30-cc IABP was placed in the descending aorta in a transfemoral procedure. The celiac artery (CA) and the cranial mesenteric artery (CMA) were surgically dissected. Transit time blood flow was measured for (i) baseline, (ii) 1:1 augmentation with the balloon proximal to the visceral arteries, and (iii) 1:1 augmentation with the balloon covering the visceral arteries. Blood flow in the CMA and CA was reduced by 17 and 24%, respectively, when the balloon compromised visceral arteries compared with a position above the visceral arteries (flow in mL/min: CMA: (i) 1281 ± 512, (ii) 1389 ± 287, (iii) 1064 ± 276, P < 0.05 for 3 vs. 1 and 3 vs. 2; CA: (i) 885 ± 370, (ii) 819 ± 297, (iii) 673 ± 315; P < 0.05 for 3 vs. 1). The covering of visceral arteries by an IABP balloon causes a significant reduction of visceral artery perfusion; thus, the positioning of this device during implantation is critical for obtaining a satisfactory outcome.

The role of the heart team in complicated transcatheter aortic valve implantation: a 7-year single-centre experience.

OBJECTIVES: European guidelines recommend to perform transcatheter aortic valve implantation (TAVI) within a multidisciplinary heart team. However, there is a strong drive--despite existing guidelines--to perform TAVI outside of specialized centres. The aim of this study was to clarify the necessity of on-site cardiac surgery by providing a clear insight into the complications during/after TAVI that needed surgical management. METHODS: A total of 2287 (1523 transfemoral, 752 transapical and 12 transaortic) patients, with a mean age of 84.5 ± 5.3 years, and a mean log EuroSCORE of 21.7 ± 16.3, of which 205 were female (84%), underwent TAVI since February 2006 at our institution. All procedure-related complications that required surgical interventions, whether immediate or delayed but within the initial hospital stay, were recorded and retrospectively analysed. RESULTS: Out of this cohort, 245 (10.7%) patients required surgical treatment due to major complications. A total of 42 patients (1.8%) underwent conversion to full sternotomy and 27 (1.2%) were dependent on the short-term use of the heart-lung machine. Vascular complications with surgical intervention were seen in 85 patients (3.7%), 54 patients (2.4%) had to have a rethoracotomy within their initial stay and 15 (0.7%) required a cardiac reoperation. CONCLUSIONS: Severe complications during TAVI that can only be resolved surgically will continue to occur. Therefore, each TAVI procedure should be conducted or accompanied by a cardiac surgeon and an experienced team within a specialized centre.

Repair of the anterior mitral leaflet prolapse.

Repair of anterior mitral leaflet prolapse is one of the most challenging aspects in mitral valve repair surgery. In this review, we discuss the various techniques developed over the past three to four decades for the repair of anterior mitral leaflet prolapse, debate the pros and cons of each and compare their results, keeping reoperation for recurrent mitral regurgitation as the focal point of follow-up. At our center, chordal replacement with artificial expanded polytetrafluoroethylene sutures in the form of premeasured loops is the most commonly used technique for repair of anterior mitral leaflet prolapse for the past decade. We recommend and provide justification for the use of this technique, especially when mitral valve repair is performed through a minimally invasive approach. We believe that the trend towards a minimally invasive approach for mitral valve repair will exponentially increase in the next 5-10 years, at least until percutaneous techniques, if at all, become more reliable and safe.

Applying the Gender Lens to Risk Factors and Outcome after Adult Cardiac Surgery.

BACKGROUND: Applying the gender lens to risk factors and outcome after adult cardiac surgery is of major clinical interest, as the inclusion of sex and gender in research design and analysis may guarantee more comprehensive cardiovascular science and may consecutively result in a more effective surgical treatment as well as cost savings in cardiac surgery. METHODS: We have reviewed classical cardiovascular risk factors (diabetes, arterial hypertension, hyperlipidemia, smoking) according to a gender-based approach. Furthermore, we have examined comorbidities such as depression, renal insufficiency, and hormonal influences in regard to gender. Gender-sensitive economic aspects have been evaluated, surgical outcome has been analyzed, and cardiovascular research has been considered from a gender perspective. RESULTS: The influence of typical risk factors and outcome after cardiac surgery has been evaluated from a gender perspective, and the gender-specific distribution of these risk factors is reported on. The named comorbidities are listed. Economic aspects demonstrated a gender gap. Outcome after coronary and valvular surgeries as well as after heart transplantation are displayed in this regard. Results after postoperative use of intra-aortic balloon pump are shown. Gender-related aspects of clinical and biomedical cardiosurgical research are reported. CONCLUSIONS: Female gender has become an independent risk factor of survival after the majority of cardiosurgical procedures. Severely impaired left ventricular ejection fraction independently predicts survival in men, whereas age does in females.

Gender-dependent differences in patients undergoing tricuspid valve surgery.

OBJECTIVES: The proportion of women in tricuspid valve (TV) surgery is almost 60% and above, especially in redo surgery. Is there a different epidemiology for male or female patients regarding the incidence of TV regurgitation? Are there differences in the peri- and postoperative outcome in male and female patients? In these questions, we were interested in and investigated our database of patients with isolated TV surgery. METHODS: We present a retrospective analysis of 92 patients (37 men and 55 women) undergoing isolated TV surgery due to symptomatic severe tricuspid regurgitation and/or due to active endocarditis between May 1997 and August 2010. Mean age was 60.5 ± 15.8 years, mean log European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.1 ± 11.3%, 51.4% of the operations were redos (men: 27%, women: 65%, p < 0.001), 36% due to active endocarditis (men: 62%, women: 18%, p < 0.001). Follow-up was 95% complete with a mean duration of 34.2 ± 33.0 months. RESULTS: Overall 30-day mortality was 5.4% (men: 5.4% and women: 5.5%). Five-year survival was 70.2 ± 11.4 versus 76.3 ± 6.8% (p = 0.3); 5-year freedom from TV-related reoperation was 95.8 ± 4.1 versus 84.6 ± 8.5% for men and women (p = 0.4). There was no significant gender-dependent difference regarding the global postoperative outcome. In a binary logistic regression analysis with the dependent variable gender, the categories age, log EuroSCORE, endocarditis, previous cardiac surgery, and preoperative cardiac rhythm, an odds ratio of 0.17 for men regarding the factor endocarditis (95% confidence interval [CI]: 0.05 to 0.57; p = 0.004) was shown, as well as an odds ratio of 3.2 for women regarding the factor previous cardiac surgery (95% CI: 1.0 to 10.1; p = 0.04) and an odds ratio of 5.9 regarding the factor presence of a permanent pacemaker (95% CI: 1.4 to 24.7; p = 0.02). CONCLUSIONS: We were not able to find significant gender-dependent differences in the postoperative outcome after isolated TV surgery, but there seem to be demographic gender-dependent differences regarding the reasons for TV surgery, which could influence the treatment of patients.

Increased risk of dehiscence after tricuspid valve repair with rigid annuloplasty rings.

OBJECTIVES: Surgical management of tricuspid valve regurgitation mainly consists of tricuspid valve annuloplasty, usually performed with implantation of a rigid ring or a flexible band. METHODS: We performed a retrospective analysis on 820 patients who underwent tricuspid valve repair between March 2002 and July 2009 with either a flexible Cosgrove-Edwards band (n = 415; Edwards Lifesciences LLC, Irvine, Calif) or a rigid Carpentier-Edwards Classic annuloplasty ring (n = 405; Edwards Lifesciences). Mean patient age was 69.2 ± 9.5 years, 54.1% were female, and average logistic EuroSCORE was 13.3% ± 12.5%. Concomitant procedures were performed in 94.6% of patients (mitral valve surgery, 80.6%; aortic valve surgery, 28.2%; coronary artery bypass grafting, 24.5%; atrial fibrillation ablation, 44.5%). One fifth of the operations were reoperative procedures. Follow-up was 94% complete, with mean duration of 21.0 ± 19.0 months. RESULTS: Thirty-day mortality was 10.1% (Cosgrove-Edwards, 11.9%; Carpentier-Edwards, 8.4%), and 5-year survival was 62.4% (Carpentier-Edwards, 64.7%; Cosgrove-Edwards, 60.3%). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in tricuspid regurgitation grade from 2.3 ± 0.7 to 0.7 ± 0.7, and no differences between groups. Use of a Carpentier-Edwards ring, however, was associated with significantly higher risk of dehiscence (Carpentier-Edwards, 8.7%; Cosgrove-Edwards, 0.9%; P < .001), almost exclusively at the septal leaflet portion of the annulus. Multivariate analysis identified annuloplasty type as independently predicting ring dehiscence (odds ratio, 10.7; 95% confidence interval, 3.2-36.5; P < .001). Patients with annuloplasty dehiscence had more residual tricuspid regurgitation on predischarge echocardiography than did patients without dehiscence (1.4 ± 0.63 vs 0.7 ± 0.6; P < .001). Ten patients underwent reoperation for recurrent tricuspid regurgitation, 4 with ring dehiscence. Five-year freedom from reoperation was 95.3% (Cosgrove-Edwards, 97.7%; Carpentier-Edwards, 92.3%). CONCLUSIONS: Although both rigid and flexible systems provide acceptable early tricuspid valve repair results, use of a rigid ring increases risk of subsequent ring dehiscence.

Surgical management of aortic root abscess: a 13-year experience in 172 patients with 100% follow-up.

OBJECTIVE: The study objective was to evaluate the outcomes of surgery for active infective endocarditis with aortic root abscess formation. METHODS: Between July 1996 and June 2009, 1161 patients underwent operation for aortic valve endocarditis, of whom 172 had aortic root abscess. The infected valve was native in 96 patients and prosthetic in 76 patients. Patients' mean age (± standard deviation) and logistic EuroSCORE-predicted risk of mortality were 62 ± 13 years and 23.1% ± 26%, respectively. Surgery was emergent in 96 patients (58%). The abscess involved the aortic annulus in 90 patients (52%), the intervalvular fibrous body in 81 patients (47%), and the mitral annulus in 21 patients (12%). Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches, and valve replacement. Estimated mean follow-up was 4.0 ± 0.3 years (range, 0-8.2 years). RESULTS: Thirty-day mortality was 25% (n = 43) (prosthetic valve endocarditis vs native valve endocarditis, 35.5% vs 16.7%, P = .005). Independent predictors of mortality were sepsis (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.2-10.7), renal insufficiency (OR, 3.3; 95% CI, 1.1-9.5), concomitant coronary artery bypass grafting (OR, 2.8; 95% CI, 1.1-7.0), and prosthetic valve endocarditis (OR, 2.4; 95% CI, 1.1-5.6). Survival at 1 and 5 years was 55% ± 4% and 50% ± 4%, respectively, and predicted by concomitant mitral endocarditis (OR, 3.2; 95% CI, 1.3-8.2), sepsis (OR, 2.7; 95% CI, 1.6-4.5), renal insufficiency (OR, 1.9; 95% CI, 1.1-3.4), and age (OR, 1.05; 95% CI, 1.02-1.07). Endocarditis recurred in 15 patients (8.7%) at a mean of 1.8 ± 2.4 years postoperatively (39 days to 6 years). CONCLUSIONS: The surgical treatment of aortic root abscess remains a challenge with relatively high perioperative morbidity and mortality, although long-term survival is satisfactory.

Redo aortic valve surgery: Influence of prosthetic valve endocarditis on outcomes.

OBJECTIVE: Compared with reoperative aortic valve replacement for nonendocarditic causes, the contemporary risk and long-term outcomes of reoperation for aortic prosthetic valve endocarditis are ill-defined. METHODS: Between December 1994 and April 2008, 313 patients underwent reoperative aortic valve replacement, of whom 152 (48.6%) had prosthetic valve endocarditis. Mean follow-up was 6.5 ± 0.4 years and 97.4% complete. RESULTS: Patients with prosthetic valve endocarditis were older with a higher risk profile. The overall hospital mortality was 15.3% (n = 48) (prosthetic valve endocarditis vs nonendocarditis: 24.3%, n = 37, vs 6.8%, n = 11; P < .001). Independent predictors of perioperative mortality for prosthetic valve endocarditis were sepsis (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.0-21.0; P < .01), ejection fraction less than 30% (OR, 5.8; 95% CI, 1.3-25.0; P = .02), concomitant coronary artery bypass grafting (OR, 3.3; 95% CI, 1.1-9.8; P = .03), and aortic root abscess (OR, 2.7; 95% CI, 1.2-6.4; P = .02), and for the nonendocarditis group were concomitant coronary artery bypass grafting (OR, 8.1; 95% CI, 2.0-33.0; P < .01), and mitral valve surgery (OR, 4.8; 95% CI, 1.3-17.9; P = .02). The 1-, 3-, 5-, and 10-year survivals for patients with and without prosthetic valve endocarditis were 52% ± 4% versus 82% ± 3%, 43% ± 5% versus 73% ± 4%, 37% ± 5% versus 63% ± 5%, and 31% ± 7% versus 56% ± 8%, respectively (log rank < 0.001). Predictors of long-term mortality in prosthetic valve endocarditis were sepsis (OR, 3.1; 95% CI, 1.5-4.5; P < .01) and unstable preoperative status (OR, 1.8; 95% CI, 1.2-3.5; P = .04), whereas in nonendocarditis patients the only predictor was New York Heart Association class IV (OR, 2.5; 95% CI, 2.8-7.4; P < .01). Five-year actuarial freedom from endocarditis was 80% ± 0.3% versus 95% ± 0.6% (prosthetic valve endocarditis cersus nonendocarditis; P = .002). CONCLUSIONS: Despite contemporary therapy, reoperation for aortic prosthetic valve endocarditis is still associated with relatively high perioperative mortality and limited long-term survival.

Transapical aortic valve implantation in 100 consecutive patients: comparison to propensity-matched conventional aortic valve replacement.

AIMS: To evaluate the outcome of transapical aortic valve implantation (TA-AVI) in comparison to conventional surgery. METHODS AND RESULTS: One hundred consecutive high-risk patients with symptomatic aortic valve stenosis received TA-AVI using the Edwards SAPIEN pericardial xenograft between February 2006 and January 2008. Patient age was 82.7 +/- 5 years, 77 were females, logistic EuroSCORE predicted risk of mortality was 29.4 +/- 13% and Society Thoracic Surgeons score risk for mortality was 15.2 +/- 8.3%. Propensity score analysis was used to identify a control group of patients that underwent conventional aortic valve replacement (C-AVR). Transapical aortic valve implantation was performed successfully in 97 patients, whereas three patients required early conversion. There were no new onset neurological events in the TA-AVI group and early extubation was performed in 82 patients. Echocardiography revealed good valve function with low transvalvular gradients in all patients. Thirty-day survival was 90 +/- 3 vs. 85 +/- 4% for TA-AVI vs. C-AVR, and 1-year survival was 73 +/- 4 vs. 69 +/- 5% (P = 0.55). CONCLUSION: Transapical aortic valve implantation is a safe, minimally invasive, and off-pump technique to treat high-risk patients with aortic stenosis. Results of the initial 100 patients are good and compare favourably to conventional surgery.