Effects of red-cell storage duration on patients undergoing cardiac surgery.

BACKGROUND: Some observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoing cardiac surgery may be especially vulnerable to the adverse effects of transfusion. METHODS: We conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge. RESULTS: The median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, -0.6 to 0.3; P=0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P=0.43); 28-day mortality was 4.4% and 5.3%, respectively (P=0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group. CONCLUSIONS: The duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.).

Transcatheter Aortic Valve Replacement as a Rescue Treatment for Prosthetic Valve Endocarditis.

A 74-year-old man with a history of bioprosthetic aortic valve replacement presented with acute severe aortic insufficiency and cardiogenic shock secondary to Diphtheroides and Enterococcus endocarditis. The patient was deemed to be not a surgical candidate by the multidisciplinary team and underwent rescue transcatheter aortic valve-in-valve replacement, resulting in complete recovery. (Level of Difficulty: Advanced.).

Racial Disparities and Outcomes After Left Ventricular Assist Device Implantation as Bridge to Transplantation or Destination Therapy.

OBJECTIVE: We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race. METHODS: Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival. RESULTS: A total of 158 patients who had LVADs as BTT (n = 63) and DT (n = 95) were studied. Of these, 56% (n = 89) were Caucasians, 35% (n = 55) were AA, and 9% (n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality. CONCLUSION: AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Multivessel off-pump revascularization in octogenarians: early and midterm outcomes.

BACKGROUND: Octogenarians are increasingly being referred for coronary artery revascularization. However, the prevalence of comorbid events and the propensity for neurologic dysfunction place octogenarians at higher risk for cardiopulmonary bypass-induced morbidity and mortality. Therefore, octogenarian patients represent a particularly attractive target for application of off-pump coronary artery bypass grafting. METHODS: From January 1999 to August 2001, 113 octogenarians had off-pump coronary artery bypass grafting. Their data were prospectively entered into the cardiac surgery database and analyzed retrospectively. Follow-up information was obtained through telephone survey. RESULTS: The mean age of the patients was 83 +/- 2.5 years, and the mean number of grafts per patient was 3.3 +/- 1. The most prevalent postoperative complication was atrial fibrillation (43%). Postoperative neurologic complications were seen in 5 patients (4%). There was one postoperative death (30-day mortality rate, 0.9%). The mean follow-up was 13.2 +/- 7 months and was complete for 90% of the patients. At the time of telephone survey, 85 (87%) of 98 patients were free from angina, and 91 (88%) were free from cardiac-related readmission. There were three late deaths. The majority of octogenarians (66%) reported that in retrospect, they would have the operation again. CONCLUSIONS: Off-pump multivessel revascularization in octogenarians is associated with excellent early and intermediate outcomes and provides a satisfactory quality of life.

Multivessel off-pump revascularization in patients with severe left ventricular dysfunction.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of multivessel beating heart revascularization in a high-risk group of patients with severe left ventricular dysfunction as well as to provide intermediate survival and quality of life data. METHODS: Our prospectively updated database was queried to extract all patients with left ventricular ejection fraction < or =30% who underwent beating heart revascularization. Standard demographics, clinical profiles and outcomes were collected. Outcomes were compared with Society of Thoracic Surgeons (STS) benchmarks for all coronary artery bypass grafting (CABG) patients. Telephone interviews were conducted and survival and quality of life data were tabulated. In addition, morbidity and mortality outcomes were compared with a concurrent cohort of patients with similarly impaired left ventricular function who underwent conventional coronary artery bypass. RESULTS: One hundred off-pump coronary artery bypass grafting patients were identified and follow-up was 93% complete in these patients. Mean age was 67+/-10.5 years and mean ejection fraction was 26+/-4%. Twenty-one percent were females. Balloon counterpulsation support was used liberally in the perioperative period. Patients received a mean of 3.5 grafts with 83% internal mammary artery use. Observed mortality was 3% with a predicted mortality of 5.3%. Observed to expected ratio was 0.56. Incidence of adverse events compared favorably with both that reported in the STS for all CABG patients regardless of left ventricular function, and also to a concurrent CABG cohort. One-year survival was 85%. Freedom from cardiac readmission was 88% and freedom from angina was 83%. No patient required repeat percutaneous or surgical intervention. CONCLUSIONS: We conclude that multivessel off-pump revascularization in patients with severe left ventricular dysfunction is a safe and effective alternative to conventional grafting. Long-term follow-up is mandatory to confirm these encouraging intermediate outcomes.

Is off-pump revascularization better for patients with non-dialysis-dependent renal insufficiency?

BACKGROUND: Renal dysfunction is a well-recognized complication following coronary artery bypass grafting (CABG). Coronary revascularization without cardiopulmonary bypass (CPB) has been shown to minimize renal injury in patients with normal preoperative renal function who undergo elective procedures. The purpose of this study was to define the effect of an off-pump revascularization strategy on the incidence of postoperative renal failure and survival of patients with preexisting renal dysfunction. METHODS: From January 1, 1999, to December 1, 2002, a total of 371 patients were identified as having a preoperative creatinine concentration greater than or equal to 1.5 mg/dL. This number included 291 patients who did not need hemodialysis or peritoneal dialysis to support renal function. These patients were subdivided into those undergoing traditional CABG with CPB (103 patients) and those undergoing off-pump revascularization (188 patients) whose demographic, operative, and outcome information was retrospectively reviewed and compared. RESULTS: The off-pump cohort was older than the on-pump cohort (70 +/- 9.6 versus 66 +/- 10.9 years; P =.002), had a lower prevalence of previous myocardial infarction (35% versus 50%; P =.008), and had a modestly higher mean left ventricular ejection fraction (0.47 +/- 0.01 versus 0.43 +/- 0.01; P =.017). Otherwise the groups were well matched. The mean preoperative serum creatinine and creatinine clearance values were not significantly different (1.8 +/- 0.5 versus 1.9 +/- 0.6 mg/dL [ P =.372] and 45.1 +/- 15.5 versus 46.8 +/- 17.2 mL/min [ P =.376] for the off-pump and on-pump cohorts, respectively). There was a significant reduction in postoperative renal failure (17% versus 9% of patients; P =.020) and need for new dialysis (10% versus 3% of patients; P =.022) when CPB was eliminated. Intermediate-term survival analysis revealed a survival benefit for the off-pump group (70% versus 57%) at 42 months, although this value did not reach statistical significance ( P =.143). CONCLUSION: The results of this study suggested that patients with preoperative non-dialysis-dependent renal insufficiency have more favorable outcome when revascularization is done off pump. Avoidance of CPB results in (1) a reduction in the incidence of postoperative renal failure; (2) a reduction in the need for new dialysis; and (3) improved in-hospital and midterm survival.

Multivessel off-pump revascularization in patients with significant left main coronary artery stenosis: early and midterm outcome analysis.

BACKGROUND: The presence of significant left main stenosis (> or =50%) has been considered a relative contraindication to the use of off-pump coronary artery bypass (OPCAB) stemming from well-documented hemodynamic perturbations during the displacement of the heart. We examined our experience with patients with critical left main stenosis (LMS) to assess the safety and feasibility of OPCAB in this subgroup. METHODS: Our prospectively updated database was queried to identify all patients with severe left main disease who underwent isolated coronary revascularization between January 1, 1999 and May 31, 2002. This query yielded 234 on-pump and 420 off-pump patients with significant LMS whose clinical information was retrospectively reviewed. RESULTS: The groups were well matched with regard to gender, left ventricular function, surgical priority, and severity of angina. The conventional coronary artery bypass (CABG) group was significantly younger than the OPCAB group and had a higher incidence of a previous myocardial infarction. Patients in the CABG cohort were more likely than OPCAB patients to remain ventilated after 24 hours, require placement of intraoperative or postoperative intraaortic balloon pump, or suffer from postoperative renal failure. There was a decrease in mortality (6.4% vs. 1.9%; p = 0.006) when CPB was eliminated. Intermediate term survival analysis revealed a significant survival benefit in the off-pump group (p = 0.007). CONCLUSIONS: Multivessel off-pump revascularization in patients with severe left main disease is a safe and effective alternative to conventional bypass grafting and conveys a survival benefit.