Transseptal approach versus left atrial approach to mitral valve: a propensity score matching study

Background: Many patients with mitral valve diseases need surgical procedures for the repair or replacement of their mitral valve. There is a great deal of controversy over the outcomes of the transseptal [TS] and left atrial [LA] approaches to the mitral valve. We sought to evaluate the outcomes of each approach more accurately by eliminating the possible biases in case selection and matching

Methods: This retrospective study included patients who had surgery for mitral valve diseases via either the TS approach or the LA approach between 2004 and 2011 in Tehran Heart Center. Patients with surgical approaches other than the TS and LA were excluded. To control for the confounding effects, a propensity score matching technique was applied and the patients were matched for 14 demographic and preoperative variables. After the selection of controls, the effect of the TS approach [163 patients] versus the LA approach [652 patients] on the outcomes was presented through odds ratio [OR] with 95% confidence intervals [CI]

Results: The mean age of the patients was 53.15 +/- 12.02 years in the TS group and 52.93 +/- 13.56 years in the LA group. Females comprised 119 [73.0%] patients in the TS group and 462 [70.9%] in the LA group. There was a significant association in the prevalence of new postoperative atrial fibrillation in the two groups [OR = 1.539, 95%CI: 1.072-2.210; p value = 0.019]. Temporary pacemaker placement had no statistically significant difference between the two groups [p value= 0.418]. The TS patients had significantly longer pump [p value < 0.001] and cross-clamp [p value < 0.001] times. The mortality rate was 4.1% [27 patients] in the LA group and 6.1% [10 patients] in the TS group [p value = 0.274]

Conclusion: In our study population, the TS approach was associated with higher pump and cross-clamp times as well as risk of postoperative atrial fibrillation, but it did not increase the rates of permanent pacemaker placement, re-operations, and mortality

Impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on mortality of coronary artery bypass grafting

There is controversy over the potential benefits/harms of the usage of angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs] as regards the postoperative mortality of coronary artery bypass grafting [CABG]. This study investigates the correlation between the in-hospital mortality of CABG and the preoperative administration of ACEI/ARB. Out of 10055 consecutive patients with isolated CABG from 2006 to 2009, 4664 [46.38%] patients received preoperative ACEI/ARB. Data were gathered from the Cardiac Surgery Registry of Tehran Heart Center. In-hospital mortality was defined as death within the same admission for surgery. Adjusted for confounders, multivariable logistic regression models were used to evaluate the impact of preoperative ACEI/ARB therapy on in-hospital death. The mean age of the patients was 60.04 +/- 9.51 years and 7364 [73.23%] were male. Eighty-seven [0.86%] patients expired within 30 days. Multivariate analysis revealed that the administration of ACEI/ARB significantly protected against in-hospital deaths in as much as there were 33 [0.70%] vs. 54 [1.0%] deaths in the ACEI/ARB positive and negative groups, respectively [OR: 0.628; p value = 0.09]. Patients without ACEI/ARB were more likely to have a higher global ejection fraction. Preoperative ACEI usage in patients undergoing CABG can be associated with decreased in-hospital mortality. Large-scale randomized clinical trials are suggested

Knowledge management in cardiac surgery: the second Tehran heart center adult cardiac surgery database report

The Adult Cardiac Surgery Databank [ACSD] of Tehran Heart Center was established in 2002 with a view to providing clinical prediction rules for outcomes of cardiac procedures, developing risk score systems, and devising clinical guidelines. This is a general analysis of the collected data. All the patients referred to Tehran Heart Center for any kind of heart surgery between 2002 and 2008 were included, and their demographic, medical, clinical, operative, and postoperative data were gathered. This report presents general information as well as in-hospital mortality rates regarding all the cardiac procedures performed in the above time period. There were 24959 procedures performed: 19663 [78.8%] isolated coronary artery bypass grafting surgeries [CABGs]; 1492 [6.0%] isolated valve surgeries; 1437 [5.8%] CABGs concomitant with other procedures; 832 [3.3%] CABGs combined with valve surgeries; 722 [2.9%] valve surgeries concomitant with other procedures; 545 [2.2%] surgeries other than CABG or valve surgery; and 267 [1.1%] CABGs concomitant with valve and other types of surgery. The overall mortality was 205 [1.04%], with the lowest mortality rate [0.47%] in the isolated CABGs and the highest [4.49%] in the CABGs concomitant with valve surgeries and other types of surgery. Meanwhile, the overall mortality rate was higher in the female patients than in the males [1.90% vs. 0.74%, respectively]. Isolated CABG was the most prevalent procedure at our center with the lowest mortality rate. However, the overall mortality was more prevalent in our female patients. This database can serve as a platform for the participation of the other countries in the region in the creation of a regional ACSD.

Determinant factors of renal failure after coronary artery bypass grafting with on-pump technique

The aim of the present study was to investigate the determinant factors of acute renal failure [ARF] after isolated on-pump coronary artery bypass grafting [CABG]. This was a retrospective study of 13, 315 adult patients who underwent isolated CABG with cardiopulmonary bypass [CPB] in Tehran Heart Center from May 2002 to May 2007. The exclusion criteria were age <18, concomitant cardiac and/or noncardiac surgical operations, history of renal failure before surgery, and chronic renal failure requiring dialysis. Preoperative and operative variables were measured, and a multivariate logistic regression model was constructed to identify the independent risk factors for developing renal failure after on-pump CABG. Of the 13,315 patients, 3,347 [25.4%] and 90,883 [74.6%] were females and males, respectively, with a mean age of 58.63 +/- 9.48 years. ARF was detected in 85 [0.6%] of the patients with isolated on-pump CABG. The mean age of the patients was 58.63 +/- 9.48 years, and 25.5% of them were female. The multivariate logistic regression analysis identified age [OR = 1.035; p = 0.002], female gender [OR = 1.622; p = 0.037], history of peripheral vascular disease [PVD] [OR = 2.579; p = 0.042], diabetes mellitus [OR = 1.918; p < 0.001], emergent and urgent surgery [OR = 1.744 and OR = 7.901, respectively; p = 0.003], CPB time >70 min [OR = 1.944; p = 0.007], and intra-aortic balloon pump [IABP] insertion [OR = 10.181; p < 0.001] as the independent risk factors for ARF. The data showed that age, female gender, positive history of diabetes and PVD, urgent and emergent surgery, CPB time >70 min, and need for IABP were the independent determinant factors of ARF after on-pump CABG

Effect of cardiac rehabilitation program on heart rate recovery after percutaneous coronary intervention and coronary artery bypass grafting

The objective of this study was to evaluate the effect of a hospital-based cardiac rehabilitation program on heart rate recovery [HRR] in patients who received percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]. Two hundred forty patients, who completed 24 sessions of a cardiac rehabilitation program [phase 2] after PCI [n=62] or CABG [n=178] at the rehabilitation department of Tehran Heart Center were included in the present study. Demographic and clinical characteristics and exercise capacity at baseline and at follow-up were compared between the two groups. The main outcome measurements were: Resting heart rate, peak heart rate, and HRR. All the patients showed significant improvements in heart rate parameters from the baseline to the last sessions. The profile of atherosclerotic risk factors [except for diabetes mellitus] was similar between the PCI and CABG subjects. After eight weeks of cardiac rehabilitation, HRR increased averagely about 17 and 21 bpm among the CABG and PCI patients, respectively [p=0.019]. The results of the present study were indicative of an increase in HRR over 1 minute in patients irrespective of their initial revascularization modality [i.e. PCI or CABG] after the completion of cardiac rehabilitation. Be that as it may, the PCI patients achieved greater improvement in HRR by comparison with the CABG patients

Coronary artery fistula from left circumflex to coronary

In this paper, we describe a case of an aneurysmal circumflex artery connected to the coronary sinus through a fistula in a 40-year-old man with a two-year history of palpitation and chest pain. We discussed surgical management for patients with coronary artery fistula [CAF], particularly for asymptomatic patients with a small left-to-right shunt

Early outcome of coronary artery bypass grafting in patients with severe left ventricular dysfunction

Left ventricular dysfunction is one of the most powerful predictors of early and late outcomes in patients who undergo coronary artery bypass grafting [CABG]. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay [LOS] after CABG in patients with an ejection fraction [EF] of 30% or less. Seven hundred seven patients who underwent CABG with EF 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. The thirty-day mortality rate [2.3% vs. 0.8%, P<0.0001], the mean of LOS [P<0.0001], and the mean of the length of ICU stay [P<0.0001] were higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the mean of NYHA score [P=0.0081], prolonged ventilation [P=0.0051], and renal failure [P=0.0606] were related to the 30-day mortality rate. Also, the prolonged LOS in these patients was correlated with the female gender [P=0.0018] and atrial fibrillation [P=0.0164]. Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with left ventricular dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital

Early outcome of coronary artery bypass grafting in patients less than 40 years old comparing with eldery patients

Age is one of the most important factors that have consistently emerged as the most potent predictors of mortality and morbidity after coronary artery bypass graft [CABG] surgery. However, early results of CABG in young patients in comparison with elderly ones have been different in previous surveys. The aim of this study was to compare shortterm mortality and morbidity in young versus older patients and evaluate the presence of risk factors and their influence on outcome in both groups. We conducted a retrospective database review of 13222 patients divided into two age groups: patients less than 40 years old [411 patients] and those older [12811 patients], who underwent CABG at Tehran Heart Center between January 2002 and January 2007. We also compared preoperative, operative, and postoperative characteristics between them and assessed the influence of the variables on the length of stay in hospital [LOS] in the two groups. Among postoperative complications, only atrial fibrillation [P<0.001] was more prevalent in the elderly group and other complications were similar. The thirty-day mortality rate was higher in the elderly group [1.1% vs. 0%, P=0.023]. Also, prolonged LOS [P<0.001] and ICU stay [P<0.001] were found more prevalent in the elderly group. Among the preoperative and postoperative variables, emergency surgery, diabetes mellitus, and previous myocardial infarction influenced the prolonged LOS in the young patients. Early mortality rate and prolonged length of stay in ICU and hospital were higher in the elderly than those in the young patients; however, other postoperative early complications were similar between the two groups

Role of Carotid Artery Screening Before Coronary Artery Bypass Graft Surgery

The incidence of stroke is 2.1-5.2% in bypass surgery patients with a mortality of 0-38%. This study was designed to evaluate the incidence of significant carotid artery stenosis and its related risk factors in c and idates for coronary artery bypass graft [CABG] surgery. 1045 consecutive c and idates for CABG underwent carotid artery Doppler examination in a prospective study. The relation of age, sex, smoking and diabetes as well as lipid profile and carotid stenosis was evaluated In 1045 CABG c and idates with the mean age of 60 years, the prevalence of significant carotid stenosis [>60%] was 6.9%. In the patients who aged 65 years and older, significant stenosis was 12.5%. Age of 50 years and above, female gender hypercholesterolemia and diabetes mellitus are independent risk factors for significant carotid stenosis. Significant carotid stenosis has an earlier beginning in our study. Cost effectiveness studies are recommended for revising the previous screening protocols

Methylenetetrahydrofolate Reductase [MTHFR] Gene C677T Polymorphism Is Associated with Coronary Atherosclerosis Disease in a Sample of Iranian Patients

Several studies showed that elevated plasma homocysteine level is a risk factor for coronary artery disease [CAD]. A common polymorphism C677T of methylenetetrahydrofolate reductase [MTHFR] gene is reported to be associated with decreased enzyme activity and increased blood homocysteine level. This study evaluated the association between C677T polymorphism and blood homocysteine level with CAD in 100 patients compared to 100 normal controls. Higher prevalence of the C677T polymorphism as well as elevated level in blood homosysteine were observed in Iranian CAD cases compared to the normal control. The C677T MTHFR common polymorphism was significantly associated with CAD, supported by a P value 0.032 and Chi-square equal to 6.87. The TT genotype of MTHFR gene was attributed to increased blood homocysteine level in patients compared to T/C and C/C genotypes in studied Iranian cases. This study shows the advantage of testing C677T polymorphism in affected patients as a risk factor for coronary artery disease