Sleep-disordered breathing in patients undergoing transfemoral aortic valve implantation for severe aortic stenosis.

BACKGROUND: We examined the prevalence of sleep-disordered breathing (SDB) in patients with severe aortic valve stenosis (AS) and the impact of transfemoral aortic valve implantation (TAVI) on SDB. METHODS: 79 patients underwent cardiorespiratory polygraphy (PG) before TAVI (CoreValve™), 62 of them a second PG after the procedure. RESULTS: Forty-nine (62 %) patients had obstructive sleep apnea (OSA), 25 (32 %) central sleep apnea (CSA), and 5 (6 %) presented without significant SDB (apnea-hypopnea index (AHI) < 5/h). Among the 62 patients evaluated before and after TAVI, 36 (58 %) had OSA, 22 (36 %) CSA, and 4 patients (7 %) no SDB. AHI was significantly higher in CSA patients than in OSA patients (34.5 ± 18.3 vs. 18.0 ± 12.6/h, p < 0.001). Successful TAVI had a significant impact on CSA but not on OSA: CSA patients with optimal TAVI results experienced a significant reduction in central respiratory events (AHI 39.6 ± 19.6-23.1 ± 16.0/h, p = 0.035), while no changes were detected in OSA patients (AHI 18.8 ± 13.0-20.25 ± 13.4/h, p = 0.376). In contrast, in patients who developed at least moderate periprosthetic aortic regurgitation (AR > I), CSA increased significantly (AHI 26.3 ± 13.2-39.2 ± 18.4/h, p = 0.036), whereas no acute change was seen in patients with OSA (AHI 10.5 ± 7.8-12.5 ± 5.0/h, p = 0.5). CONCLUSION: OSA and CSA are prevalent in more than 90 % of patients undergoing TAVI for severe aortic valve stenosis. Successful TAVI had no significant impact on OSA but improved CSA. In case of an acute change from pressure overload (aortic stenosis) to acute volume overload (aortic regurgitation after TAVI), central, but not obstructive, sleep apnea deteriorated.

Balloon expandable sheath for transfemoral aortic valve implantation: a viable option for patients with challenging access.

BACKGROUND AND OBJECTIVES: Transcatheter aortic valve replacement (TAVR) via femoral access is a new option for patients with severe aortic valve stenosis considered to be at high risk for conventional open-heart surgery. This procedure requires peripheral arteries that are able to accommodate the large sheaths required for valve delivery. We present a series of patients with suboptimal vascular conditions, who received a self-expandable vascular sheath. METHODS AND RESULTS: From January 2009 to September 2011, a total of 96 patients (43% male) were treated with the 18F Medtronic CoreValve (Medtronic, Minneapolis, MN, USA). The patients' average age was 82.5 ± 4.6 years, and the mean EuroSCORE was 29%. In eight cases, vascular conditions were inadequate either due to advanced atherosclerotic disease (n = 5, 62.5%), or an arterial diameter ≤7 mm (n = 3, 37.5%). Instead of the standard 18F sheath, a balloon-expandable transfemoral introducer (SoloPath Introducer, Onset Medical Corporation, Irvine, CA, USA) was delivered and removed without complications in all but one (87.5%) patient. In the last case, rupture of the right femoral artery occurred after removal of the sheath with the need of vascular surgery. CONCLUSION: The SoloPath sheath is a feasible alternative to conventional sheaths for transfemoral TAVR patients with difficult femoral vascular access.

Surgical removal of occluder devices: complications and pitfalls.

Interventional closures of atrial septal defects (ASDs) and paravalvular leaks represent attractive treatment options to prevent surgical procedures. Nevertheless, a small number of complications or pitfalls remain after interventional closure of ASDs or paravalvular leaks that require surgical therapy. We report on 3 cases in which surgery was necessary after attempts to close a paravalvular leak. A mechanical valve prosthesis in the mitral position was explanted from a 73-year-old man because of increasing hemolysis and restriction of the motion of one leaflet by the occluder device. A 21-year-old woman with 3 previous surgeries for truncus arteriosus communis type 1 developed paravalvular leakage after replacements of the pulmonary and aortic valves. Although aortic insufficiency was reduced to grade I by placing 2 Amplatzer occluders, significant hemolysis developed. A 24-year-old woman had previously undergone 3 cardiac surgeries (commissurotomy at the age of 5 years for aortic stenosis, followed by aortic valve replacements at 13 and 14 years of age). The patient developed severe hemolysis after interventional closure. A redo aortic valve replacement was performed for the fourth time. As in the previous 2 cases, the surgery for this challenging case and the postoperative course went well. We also present 6 cases in which the occluder was explanted because of dislocation, thrombus formation, irritation of the aortic root, or systemic allergic reaction to the percutaneous occluder after initial closure of the ASD. The intra- and postoperative courses were uneventful in all cases. In summary, surgery for complications or pitfalls after interventional closure of paravalvular leaks or ASDs is challenging and carries a high risk in cases of paravalvular leaks. Nevertheless, the outcomes of the presented cases were uneventful. In the future, the development of a more suitable device technology may improve the results of interventional procedures, especially in cases of paravalvular leaks.

Valve replacement in octogenarians: arguments for an earlier surgical intervention.

BACKGROUND AND AIM OF THE STUDY: In octogenarians with symptomatic aortic valve stenosis (AS), aortic valve replacement (AVR) is frequently not performed in due time, because the prognostic benefit is underestimated, while perioperative morbidity and mortality are overestimated. The severely impaired prognosis and quality of life after myocardial decompensation then urges AVR with a significantly increased perioperative risk. METHODS: Between 2003 and 2006, all octogenarians with isolated symptomatic AS (indexed aortic valve opening area <0.5 cm2/m2) referred to the authors' unit were prospectively included in the survey. Among the 83 patients enrolled (51 women, 32 men; mean age 84 +/- 5.1 years), 38 patients (26 women, 12 men; mean age 84 +/- 2.3 years) had signs of chronic myocardial decompensation (dilated left ventricle and/or reduced left ventricular function; left ventricular ejection fraction (LVEF) 43 +/- 18% (range: 25-53%). These patients comprised group A. All other patients (group B) had normal left ventricular dimensions, a normal LVEF (>55%), and no clinical episodes of myocardial decompensation. All patients underwent AVR, while 23 (28%) underwent simultaneous coronary revascularization. RESULTS: In group A, the 30-day mortality rate was 5.3% (n = 2). Octogenarians without chronic myocardial decompensation had a lower 30-day mortality (1/45; 2.2%). The incidences of major postoperative complications (reversible acute renal failure, stroke, mechanical circulatory support) were significantly higher in group A (26.3% versus 8.9%, p < 0.05). During late follow up (mean 24.2 +/- 12.8 months), another four patients in group A (11.1%) and five in group B (11.4%) died. Octogenarians in group B had a significantly (p < 0.01) more favorable cumulative survival rate (87% versus 78% after 24 months; 81% versus 68% after 46 months). CONCLUSION: AVR can be performed in octogenarians with a low mortality and morbidity, but should not be postponed. The decision to perform for AVR may take into consideration any life-limiting comorbidities, but should be made independent of the patient's age.

Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: a multicenter analysis.

OBJECTIVES: Do prior percutaneous coronary interventions adversely affect the outcome of subsequent coronary artery bypass grafting? We investigated this effect on a multicenter basis. METHODS: Eight cardiac surgical centers provided outcome data of 37,140 consecutive patients who underwent isolated first-time coronary bypass grafting between January 2000 and December 2005. Twenty-two patient characteristics and outcome variables were retrieved. Three groups of patients were analysed for in-hospital mortality and in-hospital major adverse cardiac events: patients without a previous percutaneous coronary intervention, with 1 previous intervention, and with 2 or more previous percutaneous coronary interventions before bypass grafting. A total of 29,928 patients with complete information for prior percutaneous coronary intervention underwent final analysis. Unadjusted univariate and risk-adjusted multivariate logistic regression analysis as well as computed propensity score matching were performed, based on 14 major risk factors to correct for and minimize selection bias. RESULTS: A total of 10.3% of patients had 1 previous percutaneous coronary intervention, and 3.7% of patients had 2 or more previous interventions. Risk-adjusted multivariate logistic regression analysis revealed a significant association of 2 or more previous percutaneous coronary interventions with in-hospital mortality (odds ratio [OR], 2.0; confidence interval [CI], 1.4-3.0; P = .0005) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0013). After propensity score matching, conditional logistic regression analysis confirmed the results of adjusted analysis. A history of 2 or more previous percutaneous coronary interventions was significantly associated with in-hospital mortality (OR, 1.9; CI, 1.3-2.7; P = .0016) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0019). CONCLUSIONS: Multicenter analysis confirms that a history of multiple previous percutaneous coronary interventions increases in-hospital mortality and the incidence of major adverse cardiac events after subsequent coronary artery bypass grafting. Critical discussion of the treatment strategy in these patients is warranted.

Simultaneous aortic and mitral valve replacement in octogenarians: a viable option?

BACKGROUND: Few reliable data are available on clinical outcome of octogenarians undergoing simultaneous aortic and mitral valve replacement. METHODS: We performed a retrospective analysis of 55 patients aged 80 years and over with double valve replacement who were operated on at our institution between 2001 and 2005. Thirty-day mortality and 1-year survival were assessed. RESULTS: For most of the patients, stenosis was the cause of aortic valve surgery, whereas regurgitation was the cause of mitral valve replacement in the majority of patients. In one third of the patients, cardiac surgery had to be performed on an urgent/emergency basis. A large number of patients had concomitant diagnoses such as atrial fibrillation (73%), coronary artery disease (44%), renal insufficiency (29%), chronic obstructive pulmonary disease (20%), and diabetes mellitus (15%). In total, 16 patients (29%) died during follow-up. Survival rates at 30 days and 1 year were 91% and 71%, respectively. As determined by multivariable logistic regression analysis, Karnofsky performance status (hazard ratio: 0.899 per % increase; 95% confidence interval: 0.811 to 0.996; p = 0.043) and bypass time (hazard ratio: 1.062 per min; 95% confidence interval: 1.006 to 1.120; p = 0.028) were independent predictors of 30-day mortality. Beside these factors, additional independent predictors of 1-year mortality were preoperative stroke and postoperative intestinal failure (p = 0.008 and 0.003, respectively). CONCLUSIONS: Our data demonstrate that, for selected octogenarians, double valve replacement can be performed with acceptable outcome. A better performance status of the patients at the time of cardiac surgery will probably improve 1-year survival.

[Diabetes mellitus and heart failure - incidence and surgical therapy options]. / Diabetes mellitus und Herzinsuffizienz - Inzidenz und chirurgische Therapieoptionen.

The prevalence of diabetes mellitus in heart failure populations is close to 20% compared with 4-6% in control populations. Epidemiologic studies have demonstrated an increased risk of heart failure in diabetics. Experimental and clinical studies support the existence of a specific diabetic cardiomyopathy related to microangiopathy, metabolic factors or myocardial fibrosis. The knowledge of the diabetes status may help to define the optimal therapeutic strategy for heart failure patients. In ischemic cardiomyopathy the choice of the surgical treatment may differ according to diabetes status, coronary atherosclerosis and left ventricular function. At present, surgical revascularization techniques seem to be superior to interventional revascularization procedures. In the last decade a growing part of diabetics presenting severe heart failure underwent heart transplantation. Thereby, it was found that the survival rates of patients with uncomplicated diabetes mellitus and of nondiabetics did not differ. The survival rates in patients with severe and progressive form of diabetes mellitus are discussed controversially in the literature. Because of donor organ shortage each diabetic patient presenting severe heart failure should be evaluated to find the best therapy including permanent mechanical circulatory support ("destination therapy").

Significant obstruction of the right and left ventricular outflow tract in a patient with biventricular hypertrophic cardiomyopathy.

Echocardiography demonstrated pronounced asymmetric left ventricular (LV) hypertrophy and thickened right ventricular muscular components in a 54-year-old woman with a history of dyspnoea (NYHA III), and recurrent syncopes. Left ventricular outflow peak gradient was 80 mmHg at rest and 125 mmHg during Valsalva manoeuvre. Cardiac cine and gadolinium-enhanced T1 weighted magnetic resonance imaging (MRI) provided striking images of a right ventricular outflow tract obstruction and a markedly abnormal gadolinium uptake in the interventricular septum consistent with myocardial fibrosis. Right and left heart catherization, with simultaneous measurement of aortic and LV pressures revealed a 150 mmHg subaortic gradient and a 130 mmHg subpulmonic gradient at rest. Impediment to right ventricular (RV) outflow was due to massive hypertrophy of the crista supraventricularis with an 'hour-glass' deformity. A surgical intervention with LV septal myotomy-myectomy and RV ventriculotomy was performed successfully. Hypertrophic obstructive cardiomyopathy with significant RV and LV outflow tract obstruction is a very rare finding. Echocardiography and MRI can be used in combination for non-invasive evaluation of morphological and haemodynamic information because mechanisms of obstruction are different in each ventricle.

[Surgical management of aortic valve stenosis]. / Standardtherapie der Aortenklappenstenose. Indikation und Ergebnisse.

This paper gives an overview of the indications for surgical therapy of aortic valve stenosis. The current surgical management and the results of aortic valve replacement are outlined. The presented results of aortic valve replacement especially in elderly and high-risk patients compare favorably with other published data in respect to perioperative morbidity and mortality. All newly developed procedures for the treatment of aortic stenosis therefore will have to prove their superiority in future.

[Structural valve deterioration of aortic bioprostheses and reoperation in octogenarians. Results and risk factors for survival]. / Degeneration biologischer Aortenklappenprothesen im Senium. Ergebnisse und Risikofaktoren der operativen Therapie.

BACKGROUND: Due to increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, replacement of aortic valve prosthesis becomes necessary in a significant percentage of patients. However, reliable data on mortality and its risk factors in octogenarians after replacement of aortic bioprostheses are limited. PATIENTS AND METHODS: 56 patients aged > or = 80 years who underwent cardiac reoperation of a bioprosthesis due to structural valve deterioration at the authors' heart center between 1991 and 2004 were analyzed retrospectively. To assess predictors of 30-day and 3-year survival, uni- and multivariate Cox regression analyses were performed. RESULTS: 30-day, 1-year, 3-year, and 5-year survival rates were 81.1%, 71.3%, 67.5%, and 50.8%, respectively. Patients with reoperation had an estimated median survival of 5.0 years. Patients who survived their in-hospital stay had a very similar life expectancy compared with the general German population. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day and 3-year survival (p < 0.001). Postoperative New York Heart Association functional class improved markedly in the study cohort and the majority of survivors was able to live at home. As we cannot offer these patients an alternative effective medical therapy, octogenarians who need their aortic valve prosthesis to be replaced are left in a miserable condition with a poor prognosis, if surgery is denied. Therefore, considering that almost the same criteria are used for younger patients with the emphasis that surgery should not be delayed until they are highly symptomatic, reoperation of the aortic valve in this age group is justified. CONCLUSION: The data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who are in need of a replacement of their aortic valve prosthesis. Early as well as mid-term survival are predominantly influenced by unexpected postoperative complications.

Reoperation of the aortic valve in octogenarians.

BACKGROUND: Because of increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, cardiac reoperation becomes necessary in a significant percentage of patients. Reliable data on mortality and risk factors in octogenarians after replacement of aortic valve prostheses are scanty, however. METHODS: We retrospectively analyzed 71 patients aged 80 years and older who underwent cardiac reoperation of the aortic valve (69 bioprostheses, 2 mechanical prostheses) between 1991 and 2004 at our heart center. Survival rate of the study cohort was compared with a control group of octogenarians matched for age, sex, and year of aortic valve replacement. To assess predictors of 30-day survival and 3-year survival, we performed univariate and multivariate analyses. RESULTS: Survival rates at 30 days, 1 year, 3 years and 5 years were 83.6%, 76.1%, 70.8%, and 51.3%, respectively. Results did not differ significantly between the study cohort and the controls. Patients with reoperation had an estimated median survival of 5.6 years. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day survival (p = 0.020 and p = 0.015, respectively). Low cardiac output, intestinal failure, and diabetes mellitus were independent predictors of 3-year survival (p = 0.001 to 0.033). CONCLUSIONS: Our data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who have reoperation of the aortic valve prosthesis. Early and mid-term survival is predominantly influenced by unexpected postoperative complications and not by preoperative risk factors, with the exception of diabetes mellitus.

Tricuspid valve replacement: clinical long-term results for acquired isolated tricuspid valve regurgitation.

BACKGROUND AND AIM OF THE STUDY: Acquired isolated tricuspid valve insufficiency (TVI) is a rare condition, and tricuspid valve replacement (TVR) is reserved for those patients in whom operative repair is not possible. The long-term follow up of patients who underwent isolated TVR at the authors' institution was analyzed. METHODS: All patients (n = 107) who underwent TVR between January 1985 and December 2002 were identified from a clinical database. Among 87 multiple valve replacements, 20 consecutive patients (12 females, eight males; mean age 52.4 years) were encountered who underwent TVR for acquired isolated TVI. Preoperative and perioperative data were recorded retrospectively. The patients and/or their physicians were contacted directly to determine long-term outcome; the follow up was 100% complete. RESULTS: The mean follow up period was 40.8 months (range: 1-211 months). The cause of TVI was endocarditis (n = 6) or trauma (n = 1); two patients suffered from hypertrophic non-obstructive cardiomyopathy, and one patient had endomyocardial fibrosis. TVI was related to constrictive pericarditis (n = 1) and to prior heart transplantation (n = 3). Seven patients were in NYHA functional classes I/II, and 13 were in classes III/IV. TVR was performed with either a mechanical valve (n = 15) or a bioprosthesis (n = 5). One patient (5%) died perioperatively, and five (25%) died during the follow up period. Two patients underwent a redo-operation during follow up, one due to prosthetic endocarditis, and one after thrombosis of a mechanical prosthesis. There was no structural deterioration of biological prostheses, and no bleeding due to anticoagulation with mechanical prostheses. Among the surviving patients, 13 were in NYHA class I, and one was in class II/III at the time of follow up. CONCLUSION: Isolated TVR for acquired TVI is rarely performed. Among the present patients, perioperative mortality and morbidity were lower than previously reported in the literature. The long-term outcome appeared to be largely dependent on the etiology of the regurgitation.

[The impact of diabetes mellitus on the results of coronary artery bypass grafting with respect to left ventricular function]. / Der Einfluss des Diabetes mellitus auf koronarchirurgische Eingriffe unter besonderer Berücksichtigung der linksventrikulären Funktion.

BACKGROUND: Diabetes mellitus is not only an independent risk factor for the development of arteriosclerosis, but also a risk factor for the surgical and interventional treatment of coronary artery disease (CAD). PATIENTS AND METHODS: In 2003, a consecutive series of 2,142 patients underwent isolated coronary bypass grafting at the authors' institution, 567 of these suffering from diabetes mellitus. RESULTS: An analysis of the diabetic and nondiabetic patients revealed a more pronounced risk profile, a significantly reduced left ventricular function and a significantly poorer quality of the coronary arteries in the diabetic group. Perioperative mortality in both groups was not different. The incidence of wound infections, renal failure and neurologic complications was much higher in diabetic patients. CONCLUSION: From these findings it can be concluded that coronary artery bypass grafting in the current era is not associated with a higher perioperative mortality in diabetic patients despite their risk profile at baseline. The risk of wound infections and perioperative renal and neurologic complications is much higher in diabetic patients.

Determinants of mid- and long-term results in patients after surgical revascularization for ischemic cardiomyopathy.

BACKGROUND: The revascularization of patients suffering from ischemic cardiomyopathy is possible with acceptable perioperative mortality and morbidity. Many publications have discussed the problem of predicting myocardial viability, whereas the quality of the peripheral coronary vessels has been focused on less frequently. METHODS: We studied 908 consecutive patients with ischemic cardiomyopathy revascularized between January 1, 1988 and April 30, 2000. Death, recurrent heart failure, hospitalization due to cardiac causes, ventricular assist device implantation, heart transplantation, and ventricular arrhythmias were defined as adverse events. To analyze the importance of pre- and perioperative variables (state of the coronary arteries, myocardial viability, complete vs incomplete revascularization, urgency of the operation, previous operations, gender, diabetes, preoperative New York Heart Association class, age, number of grafts, and ischemic time), a proportional hazards model was used. RESULTS: The most important predictors of short- and long-term event-free survival were the quality of the coronary arteries, followed by myocardial viability, complete revascularization, number of bypass grafts, and an elective operation. CONCLUSIONS: The coronary vascular system can be described by means of a simple scoring system. A good or at least moderate coronary artery perfusing an area of dysfunctional yet viable myocardium is the main predictor of a successful perioperative course and an event-free survival. Patients with a poor coronary vasculature regardless of myocardial viability should not be considered suitable for revascularization.

The prognostic value of calcification and impaired valve motion in combined aortic stenosis and coronary artery disease.

BACKGROUND AND AIMS OF THE STUDY: Optimal management of patients with coronary artery disease and concomitant aortic valve stenosis remains a subject of controversy. In this retrospective study, an attempt was made to identify criteria indicating rapid progression of aortic valve stenosis in patients with coronary artery disease. METHODS: Between 1990 and 1999, 47 patients underwent aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) at the authors' institution. The postoperative data, including cardiac catheterization films, were reviewed. RESULTS: Aortic valve disease, mainly aortic stenosis, showed a rapid rate of progression. During a mean interval between CABG and AVR of 5.9 +/- 2.9 years, the mean peak-to-peak pressure gradient across the aortic valve rose from 16.1 +/- 13.8 to 61.4 +/- 23.9 mmHg in patients where presence of calcification and impaired aortic valve motion was found (66.0% of patients had calcified aortic valves; 72.3% had impaired valve motion) at the time of CABG; whereas in those without calcification and/or impaired leaflet motion a mean of 9.2 +/- 0.8 years elapsed before AVR became necessary. CONCLUSION: If a patient must undergo surgery for coronary artery disease, then AVR should be considered not only on the basis of hemodynamic criteria but also with regard to calcification of the aortic valve and its leaflet motion.