Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients.

OBJECTIVE: The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS: The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS: There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS: Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.

Does bilateral ITA grafting increase perioperative complications? Outcome of 4462 patients with bilateral versus 4204 patients with single ITA bypass.

OBJECTIVE: Superior patency of internal thoracic artery (ITA) grafting to saphenous veins is conclusive. The aim of the present study was to compare the early outcome of patients receiving either bilateral ITA (BITA) or single ITA (SITA) grafts and to identify risk factors for perioperative complications, such as obesity, diabetes mellitus, or advanced age. METHODS: All 8666 patients with isolated coronary artery bypass grafting (CABG, including emergent cases or redos) operated between January 1994 and June 2004 receiving either BITA (n=4462) or SITA (n=4204) grafting were analyzed retrospectively. Demographic data were comparable for both groups concerning mean age (65.3+/-9.4 years vs 64.9+/-9.3 years), range (35-89 years (p=0.05)), diabetes incidence (29.3% vs 2.6% (p=0.08)), dialysis-dependent renal failure (0.7% vs 0.6% (p=0.4)), preoperative ejection fraction (EF) mean (61.8% vs 61.2% (p=0.07)) but not for gender (80.4% vs 76.7% males (p=0.00)), body mass index (BMI) mean (27.2+/-3.6 vs 26.9+/-3.5 (p=0.00)), COPD (7.0% vs 8.5% (p=0.00)), and hyperlipidemia (78.3% vs 74.3% (p=0.00)). In the BITA group, right ITA (RITA) was directed preferentially to the left anterior descending artery (LAD), left ITA (LITA) to the lateral wall. In the SITA group, the LAD was revascularized with the left ITA. Additional bypasses were performed with saphenous vein grafts (SVG). RESULTS: The number of anastomoses was higher in the BITA group (3.8+/-0.9 vs 3.1+/-0.9 (p=0.00)); therefore, duration of surgery (mean: 189+/-46.3 min vs 164+/-46.2 min) and cross-clamp time (62.0+/-17.9 min vs 51.0+/-18.0 min) significantly prolonged (p=0.00). Incidence of rethoracotomy due to bleeding (2.9% vs 0.6%; p=0.00) or sternal refixation with (0.7% vs 0.2%; p=0.00) or without infection (1.4% vs 0.6%; p=0.00) was higher in the BITA group, strongly associated with diabetes mellitus and duration of surgery but not with BMI>27. Thirty-day mortality revealed 2.6% versus 3.2% (p=0.1) but was significantly lower for diabetic patients in the BITA group (3.1% vs 4.7%; p=0.00). CONCLUSIONS: CABG using both ITAs can be performed routinely with good clinical results and low mortality. Compared with single ITA grafting, sternal and bleeding complications were slightly increased. Diabetes mellitus, BITA grafting, duration of surgery but not obesity or COPD could be identified as independent risk factors for sternal complications. Dialysis-dependent renal failure, EF<30%, emergent cases, and the absence of BITA grafting were predictors for increased perioperative mortality.

The Mosaic bioprosthesis in the aortic position: seven years' results.

BACKGROUND AND AIM OF THE STUDY: The Mosaic bioprosthesis is a stented porcine aortic valve, which combines glutaraldehyde fixation with zero-pressure and root-pressure techniques and anti-mineralization treatment with amino-oleic acid for improved hemodynamics and tissue durability. The study aim was to collect intermediate-term data of the Mosaic bioprosthesis in the aortic position, the first device having been implanted in February 1994 at the authors' institution. METHODS: A total of 100 patients (49 females, 51 males) underwent aortic valve replacement with the Mosaic bioprosthesis between February 1994 and May 1999. Mean age at implant was 73.4 +/- 7.3 years. Concomitant procedures were performed in 40.0% of cases. Patients were followed up within 30 days postoperatively, after six months, and at annual intervals thereafter. Mean follow up was 3.8 years (range: 0.1-7.1 years); total follow up was 383.1 patient-years (pt-yr) and 100% complete. RESULTS: Early mortality (< or = 30 days) was 3.0%; late mortality was 4.6%/pt-yr, including a valve-related mortality of 0.6%/pt-yr. Freedom from event at seven years was 96.8 +/- 1.8% for thromboembolic events, 97.2 +/- 2.0% for thrombosed bioprosthesis, 96.6 +/- 2.6% for structural valve deterioration, 98.2 +/- 1.8% for nonstructural dysfunction, 95.9 +/- 2.0% for anti-thromboembolic hemorrhage, 98.9 +/- 1.1% for endocarditis, and 93.9 +/- 3.2% for reoperation/explant. After one year, the mean systolic pressure gradient was 15.3 +/- 6.7, 14.5 +/- 5.7, 12.7 +/- 4.1 and 12.9 +/- 4.8 mmHg for 21, 23, 25 and 27 mm valves respectively; the effective orifice area (EOA) was 1.4 +/- 0.4, 1.7 +/- 0.4, 1.8 +/- 0.4 and 2.6 +/- 0.4 cm2 for 21, 23, 25 and 27 mm valves respectively; and the EOA index was 0.8 +/- 0.3, 0.9 +/- 0.2, 0.9 +/- 0.2 and 1.3 +/- 0.1 cm2/m2 respectively. The mean left ventricular mass index was decreased significantly, from 159.7 +/- 56.8 g/m2 to 137.3 +/- 40.8 g/m2, for all valve sizes after one year. CONCLUSION: Clinical and hemodynamic performance of the Mosaic bioprosthesis was highly satisfactory during the first seven years after clinical introduction.

Quality of internal thoracic artery grafts after mediastinal irradiation.

BACKGROUND: With the increase of patients of advanced age requiring coronary artery bypass grafting (CABG), the number of those with previous mastectomy and irradiation of the chest increases proportionally. The question of whether mediastinal irradiation leads to relevant internal thoracic artery (ITA) graft damage remains unclear. The aim of the present study was to proof the quality of ITAs and to evaluate the early clinical outcome after using one or both ITAs in this specific population. METHODS: One hundred twenty-five patients (group A) with previous mastectomy or Hodgkin/non-Hodgkin disease and mediastinal irradiation operated on between January 1993 and September 2006 underwent CABG (n = 88) or CABG plus valve replacement (n = 37). Sixty-two patients received bilateral, 43 received unilateral ITAs, and 20 patients received veins. Postoperative complications and mortality were analyzed and compared with a propensity score pair-matched control group of 125 patients receiving CABG or CABG plus valve replacement within the same period (group B). A histomorphologic investigation was performed in 133 irradiated distal ITA segments and compared with a control group of 133 nonirradiated ITAs. RESULTS: Thirty-day mortality revealed 3.2% in group A versus 5.6% in group B. Sternal instabilities were more frequent in group A (3.2%) than in group B (0%). Mediastinitis occurred in 1.6% (group A) versus 1.6% (group B). Histomorphologic investigations did not identify any severe irradiation induced fibrosis or damage of ITA grafts. CONCLUSIONS: From the histologic point of view, there is no need for restrictions in use of ITA conduits after mediastinal irradiation. Compared with a control group, cardiac surgery was associated with a slightly enhanced incidence of sternal instabilities.