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

Diagnostic value of interferon-gamma assay in tuberculosis pericardial effusions: study on a cohort of Iranian patients

Tuberculosis pericarditis as a potentially fatal complication of tuberculosis requires effective diagnosis and treatment. We evaluated the efficacy of interferon-gamma [IFN-gamma] and adenosine deaminase [ADA] for diagnosing tuberculosis pericarditis in a cohort of Iranian patients presenting with pericarditis. We enrolled 38 patients with presentation of pericarditis. All patients underwent diagnostic and therapeutic pericardiostomy with drainage and biopsy. Adenosine deaminase and interferon-gamma levels were determined in pericardial fluid samples of all patients. Pericardial tissue samples were submitted for histopathologic and microbiologic studies. Polymerase chain reaction [PCR] was performed on all pericardial fluid samples to detect Mycobacterium tuberculosis. From 38 patients with pericarditis, 7 cases were diagnosed as having tuberculosis pericarditis [18.4%]. Mean concentration of interferon-gamma in tuberculosis group was significantly higher compared to non-tuberculosis group [69257 pg/l [range: 26600-148000] vs. 329 pg/l [range: 0-2200], P<0.000]. Receiver operating characteristic [ROC] curve showed a value of 14400 pg/l as the cutoff point with a sensitivity of 100% and specificity of 100% for diagnosing tuberculosis pericardial effusion. Adenosine deaminase was not found to be significantly higher in tuberculosis group in comparison with non-tuberculosis causes of pericardial effusion [35.7 [range: 9-69] vs. 36.03 [range: 8-420], P=0.28]. In this study interferon-gamma showed to be a valuable diagnostic test for detection of tuberculosis pericarditis among a cohort of Iranian patients. We suggest using interferon-gamma to diagnose tuberculosis pericarditis to make diagnose in case of suspicion. While in this study, adenosine deaminase measurement did not prove to have the characteristics of an accurate diagnostic test for tuberculosis pericarditis

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

Return to work following cardiac rehabilitation in patients undergoing cardiac procedures with an approach to patient's viewpoints and attitude

To estimate the rate of return to work [RTW] after cardiac rehabilitation and determine the relationship between RTW and clinical and socio-demographic factors with an approach to patient's attitude. Prospective follow-up study. Tehran Heart Center, Iran. Two hundred and forty six consecutive patients undergoing different types of cardiac procedures between May and September 2007 were studied. A checklist was completed for patients according to medical history and physical examination recorded in medical files. A complementary interview was also carried out by phone. Rate of RTW after cardiac rehabilitation and the relationship between RTW and clinical and socio-demographic factors. Two groups were matched for gender, age, occupation type and the type of cardiac procedures. Rehabilitated patients in comparison with control group had higher rates of RTW three month [55.4 Vs 26.2%] and eight months [94.7 Vs 81.0%] after the time of cardiac rehabilitation. Positive attitude toward RTW was observed more in rehabilitated patients three month and eight months after cardiac procedures. Cardiac rehabilitation programs [OR: 3.507, p = 0.027], preoperative functional class [OR: 6.541, p < 0.001], experience of regular physical activity at home before RTW [OR: 3.836, p = 0.004] and job support programs [OR: 4.050, p = 0.022] were main predictors for RTW eight months after cardiac procedures. Patients undergoing cardiac procedures benefit from cardiac rehabilitation to preserve work status. The need for appropriate supportive protocols can guarantee RTW after cardiac rehabilitation and improve patients' attitude toward continuing their jobs

Prosthetic valve endocarditis: early outcome following medical or surgical treatment

Prosthetic valve endocarditis [PVE] is an important cause of morbidity and mortality associated with heart valve replacement surgery. The aim of the present study was to describe the early outcome of treatment in patients with PVE in a single center. The data of all the episodes of PVE registered at our institution between 2002 and 2007 were collected and analyzed retrospectively. The patients were assessed using clinical criteria defined by Durack and colleagues [Duke criteria]. The analysis included a detailed study of hospital records. The continuous variables were expressed as mean +/- standard deviation, and the discrete variables were presented as percentages. Thirteen patients with PVE were diagnosed and treated at our center during the study period. In all the cases, mechanical prostheses were utilized. The patients' mean age was 46.9 +/- 12.8 years. Women made up 53.8% of all the cases. Early PVE was detected in 6 [46.2%] patients, and late PVE occurred in 7 [53.8%]. Eleven [84.6%] patients were treated with intravenous antimicrobial therapy, and the other two [15.4%] required surgical removal and replacement of the infected prosthesis in addition to antibiotic therapy. Blood cultures became positive in 46.2% of the patients. Mortality rate was 15.4% [2 patients]. It seems that in selected cases with PVE, i.e. in those who remain clinically stable and respond well to antimicrobial therapy, a cure could be achieved by antimicrobial treatment alone with acceptable morbidity and mortality risk

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

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