Operative and middle-term results of cardiac surgery in nonagenarians: a bridge toward routine practice.

BACKGROUND: Age >90 years represents in many centers an absolute contraindication to cardiac surgery. Nonagenarians are a rapidly growing subset of the population posing an expanding clinical problem. To provide helpful information in regard to this complex decision, we analyzed the operative and 5-year results of coronary and valvular surgical procedures in these patients. METHODS AND RESULTS: We retrospectively reviewed 127 patients aged >or=90 years who underwent cardiac surgery within our hospital group in the period 1998 to 2008. Kaplan-Meier and multiple logistic regression analyses were performed. A longer follow-up than most published studies and the largest series published thus far are presented. Mean age was 92 years (range, 90 to 103 years). Mean logistic EuroSCORE was 21.3+/-6.1. Sixty patients had valvular surgery (including 11 valve repairs), 49 patients had coronary artery bypass grafting, and 18 had valvular plus coronary artery bypass grafting surgery (55 left mammary artery grafts implanted). Forty-five patients (35.4%) were operated on nonelectively. Operative mortality was 13.4% (17 cases). Fifty-four patients (42.5%) had a complicated postoperative course. There were no statistically significant differences in the rate and type of complications between patient strata on the basis of type of surgery performed. Nonelective priority predicted a complicated postoperative course. Predictors of operative mortality were nonelective priority and previous myocardial infarction. Kaplan-Meier survival estimates at 5 years were comparable between patient groups on the basis of procedure performed. CONCLUSIONS: Although the rate of postoperative complications remains high, cardiac surgery in nonagenarians can achieve functional improvement at the price of considerable operative and follow-up mortality rates. Cardiac operations in these very elderly subjects are supported if appropriate selection is made and if the operation is performed earlier and electively. Our results should contribute to the development of guidelines for cardiac operations in nonagenarians.

RESTEM: a percutaneous coronary intervention 'real world' registry in the drug-eluting stent era.

Sirolimus-eluting stents (SESs) reduce the rate of in-stent restenosis in selected cases. Their performance in more complex patients and their impact on the final clinical outcome of these patients, however, remains uncertain. RESTEM Registry (REgistro delle PCI in era di STEnt Medicati), a prospective multicenter registry collecting all percutaneous coronary interventions (PCIs) performed over 20 months and monitored up to 2 years, includes 5524 consecutive patients treated with bare metal stent (BMS) (72%), sirolimus-eluting stent (SES) (15%), combined BMS+SES (4%), or other techniques (9%). The combination of death, acute myocardial infarction (AMI), unstable angina and revascularizations had been chosen as primary endpoint. One-year multivariate analysis shows no significant advantage of SES in combined clinical events, a slight benefit in primary endpoint [18.5 vs. 25.0% BMS=odds ratio (OR) 0.78) and revascularizations (13.6 vs. 20.4% BMS=OR 0.74], a consistent advantage when only target vessel revascularizations (TVRs) are considered (5.5 vs. 10.5% BMS=OR 0.52). The two-year adjusted results confirm a significant advantage of SES in TVR (8.3 vs. 13.7% BMS=OR 0.65), a slight benefit for revascularizations (18.3 vs. 25.6% BMS=OR 0.76), without reducing mortality and other clinical events; these data refute the benefit on primary endpoint observed at 12 months (25.8 vs. 32.4% BMS=OR 0.84). After analyzing events recorded during the first and second year follow-up periods separately, the incidence of many of them favors SES in the first year, yet appear independent of the technique utilized in the second. RESTEM results confirming SES's capacity to reduce TVR without reduction of other clinical events, suggest that this advantage is limited to the first year after PCI, and show no evidence of excess of deaths, AMIs and late thrombosis following SES implantation described in recent meta-analyses.

Acute aortic dissection: epidemiology and outcomes.

BACKGROUND: Little epidemiological information on acute aortic dissection (AAD) is available in the literature. The objective of the present study was to determine the incidence and mortality rates of AAD in the general population and to analyze its clinical features. METHODS: Data from the Emilia-Romagna regional database of hospital admissions was analyzed. Urgent admissions with the diagnosis of dissection of the aorta, dissection of the thoracic aorta and dissection of the thoracoabdominal aorta were selected. RESULTS: Between January 2000 and December 2008, 1499 Emilia-Romagna residents were hospitalized with a diagnosis of AAD. The patients were divided into three groups: Group A, 617 patients (41.2%) surgically treated for type A AAD; Group B, 93 complicated patients (6.2%) with type B AAD treated by endovascular stent-grafting and Group C, 789 patients (52.6%) suffering from any type of AAD medically treated. The overall annual incidence rate was 4.7%/100,000 people and was higher for men than for women (6.7% vs 2.9%).Two hundred ninety-six patients (19.8%) were 80 years of age or older.The overall in-hospital mortality rate was 27.7%, with mortality rates of 21.1%, 26.9% and 33% in Groups A, B and C, respectively. CONCLUSION: The incidence of AAD is not negligible and a notable rate of patients is ultra-octogenarian. A large number of patients with AAD had no surgery or interventional treatment. The results of surgical treatment for patients with type A dissection are acceptable but the results obtained in patients with complicated type B dissection who were treated with an endoprosthesis are dismal.

Air leaks following pulmonary resection for malignancy: risk factors, qualitative and quantitative analysis.

Air leaks are a common complication of pulmonary resection. The aims of this study were to analyze risk factors for postoperative air leak and to evaluate the role of air leak measurement in identifying patients at increased risk for cardiorespiratory morbidity and prolonged air leak. From March to December 2009, 142 consecutive patients underwent pulmonary resection for malignancy and were prospectively followed up. Preoperative and intraoperative risk factors for air leak were evaluated. Air leaks were qualitatively and quantitatively labeled twice daily. There were 52 (36.6%) patients who had an air leak on day 1, and 32 (22.5%) who had an air leak on day 2. Air leak was ≥180 ml/min in 12 (37.5%) of these patients. Independent predictors of air leak on day 2 included type of pulmonary resection, presence of adhesions, and incomplete fissures. Cardiorespiratory morbidity was significantly higher (34.4%) in patients who experienced air leak on day 2 than in those who did not (10.9%) (P=0.002). Nine (75%) out of 12 patients with air leak ≥180 ml/min on day 2 had prolonged air leak (greater than five days) (P=0.0001).

Short-term and long-term results of cardiac surgery in elderly and very elderly patients.

OBJECTIVE: Cardiac operations in elderly patients are increasingly frequent and imply major clinical, ethical, and economic issues. Operative and 5-year results of cardiac operations in patients aged 79 years or more are known in limited series, and a debate is ongoing on the appropriateness of selection of patients for surgery. METHODS: We retrospectively reviewed our experience in 6802 patients aged 79 years or more who had received a cardiac operation. Surgical candidates were selected according to functional status, crude operative risk, and social context and were managed according to a multimodality protocol. RESULTS: Mean age was 82 years and surgery was nonelective in 1613 cases (23.5%, 31 salvage). Procedures consisted of valve replacement (aortic, 2817; mitral, 532; and tricuspid, 2 cases), valve repair (aortic, 66; mitral, 532; and tricuspid, 232 cases), coronary bypass grafting (12,034 coronary vessels bypassed), and replacement of the thoracic aorta (ascending, 315; arch, 28 cases). Overall operative mortality was 3.4%. Nonelective presentation, need for aortic counterpulsation, cardiopulmonary bypass time, blood transfusion, depressed systolic function, and chronic lung disease predicted operative mortality. Five-year cumulative mortality was 7.5%. Poor systolic function, previous myocardial infarction, and combined coronary/mitral surgery predicted late mortality. The operative risk of nonagenarians operated on electively did not differ from that of risk-matched octogenarians. CONCLUSIONS: Cardiac surgery in elderly and very elderly patients can be performed with acceptable mortality provided that accurate selection and a multifactorial risk evaluation are adopted. Whenever possible, nonelective operations should be avoided and earlier surgery should be encouraged. Five-year survival and functional recovery are good.

Safety, efficacy and long-term durability of endovascular therapy for carotid artery disease: the tailored-Carotid Artery Stenting Experience of a single high-volume centre (tailored-CASE Registry).

AIMS: We aimed to determine the success, safety and long-term durability of carotid artery stenting (CAS) in stroke prevention for all-comers managed with mandatory neuroprotection and a tailored-approach to intervention. METHODS AND RESULTS: From our CAS registry (beginning July 1997) all procedures up to September 2007 with intention-to-treat by stenting under distal filter or proximal occlusion neuroprotection devices were analysed (N=1523; mean age 72 years [237 >or=80 years, 15.5%]). Indications included symptomatic stenoses >or=50% (366, 24.1%) and asymptomatic stenoses >or=80% (1157, 75.9%). CAS success was 99.6% and the 30-day all-stroke/death rate was 1.5% (minor stroke 11 [0.7%], major stroke 8 [0.5%], death 5 [0.3%]). The risk was 1.2% for asymptomatic patients and 2.7% for symptomatic patients (p=0.042). Regarding octogenarians this risk was 2.1% versus 1.5% for patients or=80 1.2%, symptomatic or=80 4.5%. The event free survival rates from all strokes or stroke-related deaths at eight years were 96% for asymptomatic and 92% for symptomatic patients. CONCLUSIONS: Results from this large cohort show that carotid stenting in a real-world setting is safe and efficacious, and durable in the long-term prevention of stroke.

[Coronary angioplasty in the real world: the RESTEM registry. Outcome of patients treated with sirolimus-eluting stents]. / L'angioplastica coronarica nel mondo reale: il registro RESTEM. Impatto degli stent a base di sirolimus sull'outcome dei pazienti.

BACKGROUND: RESTEM, a prospective multicenter registry collecting all percutaneous coronary interventions made over 20 months and monitored up to 2 years, had been performed to assess, in the real world, the impact of sirolimus-eluting stents (SES) versus bare metal stents (BMS) on patients' outcomes. METHODS: The registry includes 5524 consecutive patients treated with BMS (72%), SES (15%), BMS+SES (4%) or other techniques (9%). The combination of death, acute myocardial infarction, unstable angina and revascularization had been chosen as primary endpoint. RESULTS: The 2-year adjusted results confirm a significant advantage of SES in target vessel revascularization (8.3 vs 13.7%, odds ratio [OR] 0.66), a benefit for overall revascularizations (18.3 vs 25.6%, OR 0.76) without reducing mortality, other clinical events and primary endpoint, therefore denying the benefit on primary endpoint observed at 12 months (18.5 vs 25.0%, OR 0.68 at 1 year and 25.8 vs 32.4%, OR 0.84 at 2 years). CONCLUSIONS: RESTEM results confirm the SES capacity to reduce target vessel revascularization without decreasing other clinical events, suggest that this advantage is limited to the first 6 months after percutaneous coronary intervention, and show no evidence of excess of deaths, acute myocardial infarction and late thrombosis following SES implantation described in recent meta-analyses.