Results of new-generation balloon vs. self-expandable transcatheter heart valves for bicuspid aortic valve stenosis.

Background: Data comparing new-generation self-expandable (SEV, Evolut R/PRO) vs. balloon-expandable (BEV, SAPIEN 3/3Ultra) transcatheter heart valve replacement (TAVR) in bicuspid aortic valve stenosis (BAV) is limited. Our aim was to compare 30-day results of SEV and BEV implantations in patients with BAV. Methods: A total of 2009 patients underwent TAVR between April 2015 and June 2021 at our Centre. From our institutional registry, we identified 106 consecutive patients with BAV who underwent TAVR using SEV and BEV. Results: A 106 patients (n = 68 BEV; n = 38 SEV) were included. Mean age was 74.6 ± 8.8 years (BEV) vs.75.3 ± 8.7 years (SEV) (p = 0.670) and Society of Thoracic Surgeons score was 2.6 ± 1.9 (BEV) vs. 2.6 ± 1.6 (SEV) (p = 0.374), respectively. Device landing zone calcium volume (DLZ-CV) was 1168 ± 811 vs. 945 ± 850 mm3 (p = 0.192). Valve Academic Research Consortium (VARC)-3 device success at 30 days was similar (BEV 80.9% vs. SEV 86.8%; p = 0.433). More post-dilatations were performed in SEVs (23.5% BEV vs. 52.6% SEV; p = 0.002). Overall mean gradient at 30 days follow-up was 11.9 ± 4.6 mmHG (BEV) vs. 9.2 ± 3.0 mmHG (SEV) (p = 0.002). A mild-moderate degree of paravalvular leak (PVL) was detected more often in the SEV group (7.4% vs. 13.2%; p = 0.305). A trend towards higher rate of permanent pacemaker implantation was observed in SEV (11.8% vs. 23.7%; p = 0.109). Conclusions: Treatment of BAV revealed similar performance using BEV and SEV. In this retrospective cohort study, hemodynamics were more favorable with the SEV, although there was a trend toward more PVL and significantly more post-dilations.

Transcatheter aortic valve replacement in the management of aortic insufficiency secondary to left ventricular assist device implantation: a case report.

Background: Left ventricular assist device (LVAD) is considered either a destination therapy for patients with end-stage heart failure or heart transplantation bridging. LVAD implantation often causes aortic insufficiency (AI), which requires aortic valve repair. However, severe acute AI does not respond well to medication, and re-operation means higher risk to the patients; the most effective therapeutic strategies for LVAD-induced AI still need further exploration. In this report, we present the first described case of new-onset, severe LVAD-induced AI in China with a patient who underwent transcatheter aortic valve replacement (TAVR) and achieved significant improvement in functional capacity and symptoms with lower operation risk. Case Description: A 55-year-old male patient was diagnosed with dilated cardiomyopathy for 14 years. The effect of the medication gradually deteriorated, LVAD (HeartCon®) was implanted one year earlier. The patient complained of intermittent chest tightness for one week, which had been aggravated for two days before hospitalization. Echocardiographic findings revealed new-onset, severe LVAD-induced AI. TAVR was performed with a self-expandable stent-valve (TAV30, Vitaflow Liberty). Within minutes, the patient recovered with rapid disappearance of chest tightness and stable vital signs. Before discharge, the position of the artificial valve was fixed without incomplete closure nor thrombus attachment, yielding a left ventricular ejection fraction (LVEF) of 35%. The patient was hospitalized for 38 days, and followed up with outpatient treatment, the condition was stable until 19 June 2023. Conclusions: TAVR could be an effective, safe, and less invasive means of restoring ejection fraction for patients with a LVAD who develop severe AI.

Bioprosthetic Valve Fracturing: In vitro Testing of Edwards PERIMOUNT Model P 2900.

Background: Bioprosthetic valve fracturing (BVF) results in low gradients following valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). For the commonly used Edwards PERIMOUNT valve data from bench-testing are lacking to provide technical specifications for successful BVF during ViV-TAVR. Methods: Using four Perimount 19- and 21-mm valves, in-vitro high-pressure balloon valvuloplasty with the True Dilatation Balloon Valvuloplasty Catheter and Atlas Gold PTA Dilatation Catheter was performed to analyze balloon-oversizing and pressure-thresholds to successfully achieve BVF. Results: High-pressure balloons one millimeter larger than the labeled valve size and pressure rates of 20 atm (for Perimount 19-mm) and > 22 atm (for Perimount 21-mm) were required to achieve BVF. Caliper measurements demonstrated 2.5 mm (Perimount 19-mm) and 1.5 mm (Perimount 21-mm) enlarged inner prosthetic diameters after BVF. The Atlas TM Gold PTA Dilatation Catheter achieved BVF with the Perimount 21-mm, whereas the True TM Dilatation Balloon Valvuloplasty Catheter failed in the Perimount 21-mm either for balloon-rupture or pinhole-defect. Conclusion: Both 19-mm and 21-mm Perimount P 2900 are amendable to BVF, thereby increasing the inner prosthetic diameter. High-pressure balloons 1 mm larger than the labeled valves are essential for this purpose, and the Atlas Gold PTA Dilatation Catheter alone should ensure success in the 21-mm prosthetics.

Safety and efficacy of minimalist transcatheter aortic valve implantation using a new-generation balloon-expandable transcatheter heart valve in bicuspid and tricuspid aortic valves.

BACKGROUND: Bicuspid aortic valve may be associated with increased complications during transcatheter aortic valve implantation (TAVI). AIMS: Compare balloon-expandable transcatheter heart valve (THV) safety and efficacy in severe tricuspid (TAV) and bicuspid (BAV) aortic stenosis. METHODS: Transfemoral TAVI was performed in 743 patients (Jan 2014-June 2019) using the SAPIEN 3 THV. Aortic valve morphology was determined using computed tomography. Valve Academic Research Consortium-2 (VARC-2) derived safety and efficacy endpoints at 1 year were evaluated. RESULTS: BAV patients (n = 78), were younger (77 [72, 81] vs. 81 [78, 85] years, p < 0.001) with lower surgical risk (EuroSCORE II 2.96% vs. 4.51% p < 0.001). Bicuspid valves were more calcified (BAV 1308mm3, TAV 848mm3 p < 0.001) with more asymmetric calcification (BAV 63/78 (81%), TAV 239/665 (36%), p < 0.001). Device success (BAV 94%, TAV 90%, p = 0.45) and major vascular complications (BAV 6%, TAV 9%, p = 0.66) were comparable. At 1 year, there was a trend toward lower combined all-cause mortality and rehospitalization for congestive heart failure in BAV patients (BAV 7%, TAV 13%, p = 0.08) with significantly lower all-cause mortality in this cohort (BAV 1%, TAV 9%, p = 0.020). VARC-2 time-related valve safety (BAV 22%, TAV 20%, p = 0.60) was comparable; however, bioprosthetic valve thrombosis remained more common in BAV patients (BAV 7%, TAV 2%, p = 0.010, Hazard ratio 3.57 [95% confidence interval 1.26, 10.10]). After propensity score matching, only bioprosthetic valve thrombosis remained significantly different. CONCLUSIONS: Safety and efficacy of the SAPIEN 3 balloon-expandable THV in BAV is comparable with TAV. Higher rates of bioprosthetic valve thrombosis require further investigation.

Need for permanent pacemaker implantation following implantation of the rapid deployment valve in combined procedures: a single centre cohort study.

BACKGROUND: Rapid deployment aortic valves may interfere with the cardiac conduction system. We investigated the need for permanent pacemaker implantation (PPI) following the implantation of Edwards INTUITY valve (Edwards Lifesciences, Irvine, CA). METHODS: One hundred twenty patients underwent aortic valve replacement (AVR) with the INTUITY valve in a combined procedure at the German Heart Centre Munich between April 2016 and December 2019. Twenty-four patients with prior PPI or concomitant ablation procedures (24/120, 20%) were excluded. Patient-specific, procedural and post-procedural outcomes were assessed in the remaining 96 cases. RESULTS: AVR was successful in all cases. Seventy-four percent of the study population were men. Mean age was 69.5±7.6 years. EuroSCORE II was 3.2±2.9. Forty-six patients (46/96, 47.9%) presented with pre-operative conduction disorders, right bundle branch block (RBBB) (17/96, 17.7%) and first-degree or second degree atrio-ventricular block (AVB) (18/96, 18.8%), in particular. In total, 9 patients (9/96, 9.4%) underwent PPI. PPI was required in 3 patients (3/50, 6.0%) who did not have a pre-existing conduction disorder due to new high degree AVB. 6 patients with pre-operative conduction disorders (6/46, 13%) needed PPI. Timing of PPI was 5.2±1.5 days (median 5). Independent predictors of PPI were preoperative RBBB [odds ratio (OR) =4.554, P=0.049] and large valve size (#27) (OR =5.527, P=0.031). CONCLUSIONS: The analysis of the data collected enabled us to identify patient factors associated with higher risk for post-operative PPI following AVR with the INTUITY valve. Patient factors associated with post-operative PPI, were RBBB and large valve size. These patients should be closely monitored following the procedure, in particular.

Comparison of Self-Expanding Bioprostheses for Transcatheter Aortic Valve Replacement in Patients With Symptomatic Severe Aortic Stenosis: SCOPE 2 Randomized Clinical Trial.

BACKGROUND: Few randomized trials have compared bioprostheses for transcatheter aortic valve replacement, and no trials have compared bioprostheses with supra-annular design. The SCOPE 2 trial (Safety and Efficacy Comparison of Two TAVI Systems in a Prospective Randomized Evaluation 2) was designed to compare the clinical outcomes of the ACURATE neo and CoreValve Evolut bioprostheses for transcatheter aortic valve replacement. METHODS: SCOPE 2 was a randomized trial performed at 23 centers in 6 countries between April 2017 and April 2019. Patients ≥75 years old with an indication for transfemoral transcatheter aortic valve replacement as agreed by the heart team were randomly assigned to receive treatment with either the ACURATE neo (n=398) or the CoreValve Evolut bioprostheses (n=398). The primary end point, powered for noninferiority of the ACURATE neo bioprosthesis, was all-cause death or stroke at 1 year. The key secondary end point, powered for superiority of the ACURATE neo bioprosthesis, was new permanent pacemaker implantation at 30 days. RESULTS: Among 796 randomized patients (mean age, 83.2±4.3 years; mean Society of Thoracic Surgeons Predicted Risk of Mortality score, 4.6±2.9%), clinical follow-up information was available for 778 (98%) patients. Within 1 year, the primary end point occurred in 15.8% of patients in the ACURATE neo group and in 13.9% of patients in the CoreValve Evolut group (absolute risk difference, 1.8%, upper 1-sided 95% confidence limit, 6.1%; P=0.0549 for noninferiority). The 30-day rates of new permanent pacemaker implantation were 10.5% in the ACURATE neo group and 18.0% in the CoreValve Evolut group (absolute risk difference, -7.5% [95% CI, -12.4 to -2.60]; P=0.0027). No significant differences were observed in the components of the primary end point. Cardiac death at 30 days (2.8% versus 0.8%; P=0.03) and 1 year (8.4% versus 3.9%; P=0.01), and moderate or severe aortic regurgitation at 30 days (10% versus 3%; P=0.002) were significantly increased in the ACURATE neo group. CONCLUSIONS: Transfemoral transcatheter aortic valve replacement with the self-expanding ACURATE neo did not meet noninferiority compared with the self-expanding CoreValve Evolut in terms of all-cause death or stroke at 1 year, and it was associated with a lower incidence of new permanent pacemaker implantation. In secondary analyses, the ACURATE neo was associated with more moderate or severe aortic regurgitation at 30 days and cardiac death at 30 days and 1 year. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03192813.

Histological examination of explanted tissue-engineered bovine pericardium following heart valve repair.

OBJECTIVES: Our goal was to present histopathological findings of human explants of a tissue-engineered bovine pericardium CardioCel (Admedus Regen Pty Ltd, Malaga, WA, Australia) used for heart valve repair in patients with congenital and acquired heart valve disease. METHODS: Sixty patients underwent heart valve repair from May 2014 to November 2018 using CardioCel as a substitute for valve tissue. We identified 9 cases in which the CardioCel patch was explanted following valve repair and available for histomorphological analyses. CardioCel explants were evaluated histologically using haematoxylin and oeosin, Elastica van Gieson and immunohistochemical stains. RESULTS: The indications for explantation were related to the CardioCel patch in 6 patients. Median time between the implantation and explantation was 242 (range 3-1247) days. We demonstrated a characteristic remodelling pattern with superficial coating of the tissue-engineered bovine pericardium by granulation tissue composed of histiocytes, few lymphocytes and fibrin. We had 2 cases with a multifocal nodular disruption, fragmentation and sclerosis of the decellularized collagen matrix with focal calcification after 795 and 1247 days in situ. CONCLUSIONS: Our data suggest that the tissue-engineered CardioCel patch is initially tolerated in the valvular position in the majority of patients. However, we also experienced graft failures that showed degeneration with fragmentation of the collagen matrix and even 2 cases with focal calcification evident from the histopathological analysis. Further analyses of mid- and long-term performance are mandatory.

Aortic annulus sizing in stenotic bicommissural non-raphe-type bicuspid aortic valves: reconstructing a three-dimensional structure using only two hinge points.

Bicuspid aortic valve (BAV) anatomy is becoming an increasingly frequently encountered challenge in transcatheter aortic valve implantation (TAVI). Bicommissural non-raphe-type BAV (Sievers and Schmidtke Type 0) is composed morphologically of two aortic cusps with no raphe and is less common than the tricommissural or bicommissural raphe-type configurations. Precise annular sizing is a key step for successful TAVI in BAV. The challenge in bicommissural non-raphe-type BAV is that a three-dimensional structure has to be reconstructed using only two anatomical hinge points. For this reason, available software are limited when it comes to bicommissural non-raphe-type BAV. We propose that manual assessment of the aortic root in bicommissural non-raphe-type BAV using multi-planar reconstruction (MPR) software can be performed successfully by aligning the two available hinge points and measuring the smallest identifiable annular dimensions in the transverse plane (Fig. 1). We identified 12 patients with bicommissural non-raphe-type BAV undergoing TAVI between January 2013 and December 2017 in our high-volume institution. Our novel sizing strategy was employed prospectively in three patients-with good clinical outcomes-and evaluated retrospectively in the remainder (Table 1). No patient suffered a central major vascular complication or required new permanent pacemaker implantation. Device success occurred in all patients except one (post-procedural echocardiographic transvalvular gradient of 23 mmHg). In the retrospectively assessed cases, the novel annulus measure was concordant with the implanted THV size in 7 out of 9 procedures and, importantly, did not overestimate the annulus dimensions in any case. Furthermore, in two balloon-expandable THV cases the new measure may, in retrospect, have prompted consideration of a smaller implant size. To be noted, balloon sizing of the aortic annulus has additional value when selecting the valve size in BAV anatomy. Further prospective validation of this novel MDCT sizing technique is required.

Does Bilateral ITA Grafting Increase Perioperative Complications? Outcome of 6,476 Patients with Bilateral versus 5,020 Patients with Single ITA Bypass.

OBJECTIVES: Despite the superior patency of internal thoracic artery (ITA) grafting compared with saphenous veins, frequency of bilateral ITA (BITA) grafting in Europe is still approximately 10%. The aim of the present study was to compare the early outcome of patients receiving either BITA or single ITA (SITA) grafting. METHODS: A total of 11,496 patients with isolated coronary artery bypass grafting (CABG), operated between January 1996 and December 2012, were analyzed retrospectively; 0.6476 patients (mean age 65.2 years, 81.3% males) received BITA and 5,020 patients (mean age 66.6 years, 76.7% males) SITA grafting. Mean body mass index (BMI) was 27.2 versus 27.4, p = 0.017. Incidence of diabetes was 28.9 versus 28.4%, p = 0.08. Ejection fraction (EF) > 50 was 71.3% (BITA) versus 66.3% (SITA), p < 0.001. Elective operations were performed in 88.4% (BITA) versus 83.3% (SITA), and urgent/emergent surgery was necessary in 11.6% (BITA) versus 16.7% (SITA), p < 0.001. RESULTS: Number of grafts was 3.76 (BITA) versus 3.06, p < 0.001. Duration of surgery (194.4 vs. 180.4 minutes) as well as X-clamp time (60.4 vs. 51.7 minutes) was prolonged for BITA, p < 0.001. Perioperative infarction rate revealed 3.2% (BITA) versus 3.6%, p = 0.54. Frequency of rethoracotomy due to bleeding was higher in the BITA group (3.8 vs. 2.1%), p < 0.001. Sternal instabilities occurred in 2.3% (BITA) versus 2.2%, p = 0.749. Duration of mechanical ventilation < 12 hours was 74.6 versus 77.1%, p = 0.09 and duration of in-hospital stay was 10.5 versus 10.4 days, p = 0.68. Thirty-day mortality was 2.4% (BITA) versus 3.0%, p = 0.09. Multivariate analysis identified prolonged duration of surgery, BMI > 30, emergent operations, advanced age, and BITA grafting as predictor for sternal instabilities. EF < 30%, advanced age plus emergency were associated with increased 30-day mortality. CONCLUSION: CABG using BITA can be performed routinely with good clinical results and low mortality. Compared with SITA grafting, bleeding complications were enhanced.

"Blame it on the Comorbidities": A 5-Year Follow-Up of 53 Chronic Dialysis-Dependent Patients Who Underwent Cardiac Surgery.

Objectives This study evaluates midterm survival rates and risk factors for mortality of chronic dialysis-dependent patients undergoing cardiac surgery. Methods Fifty-three dialysis-dependent patients (34 males, aged 67 ± 12 years) with end-stage renal disease operated within March 2007 and May 2012 were analyzed retrospectively. Survival rates were calculated using Kaplan-Meier methods. Predictors of midterm survival were identified with multivariate Cox-regression analysis. Results Twenty-three patients received isolated coronary artery bypass graft surgery, 17 received isolated valve replacement, and 13 received combined procedures. Thirty-day mortality was 24.5% (n = 13). Follow-up was complete for 94.3% (n = 50). Survival rates at 1, 3, and 5 years were: 82, 50, and 17%, respectively. Neither age, gender, poor ejection fraction, emergency, ECC/X-clamp (cross-clamp) time, nor use of left internal thoracic artery or right internal thoracic artery had any influence on midterm survival. Causes of death within midterm follow-up period were related to cardiac events in 16% and neurological events in 16%. In the majority (47%), cause of death was associated with peripheral arterial disease (PAD).The only comorbidity, which could be identified as a significant risk factor, was PAD (p = 0.035). Five patients underwent successful renal transplantation within the follow-up period. Conclusion Although 30-day mortality in this high-risk patient population was increased, midterm survival rates were comparable to the results described in the literature. Cause of death within midterm follow-up period was mostly noncardiac related. Given the limited number of patients, predictors for enhanced 30-day mortality, such as preoperative myocardial infarction, prolonged extracorporeal circulation, operation time, and diabetes mellitus, did not have an influence on midterm survival.

Aortic Dissections Type A during Sexual Intercourse in Male Patients: Accident or Systematic Coincidence? Examination of 365 Patients with Acute Aortic Dissection within 20 Years.

OBJECTIVES: Physical exercise accompanied by arterial hypertension is known to trigger acute aortic dissections. As a booster effect, mental stress leads to aggravation of hypertensive crisis. The aim of the study was to evaluate whether stress factors during sexual intercourse play any role as a catalyst in patients with acute type A aortic dissections. Concerning this subject, only two case reports have been published. METHODS: A total of 365 patients with acute type A aortic dissections, operated between January 1993 and July 2014, were analyzed retrospectively. The main focus was to identify the provoking situation before onset of symptoms. A total of 247 patients were males and mean age was 60.2 years (range, 17.0-91.9 years). Of the total cohort, 86 patients (24%) were younger than 50 years (68 males) and 184 patients (50%) were younger than 60 years (149 males). RESULTS: The explicit trigger could not be determined in 24% of the patients. In majority of the patients, onset of symptoms occurred during physical exercises, such as sports or lifting of heavy weights (68%), without a significant difference between males and females. In only 8% of the patients, symptoms occurred at rest. In 0.9%, Marfan syndrome was evident. Eleven of 68 males < 50 years (16%) and 17 of 149 males < 60 years (11%) but none among females (p = 0.03) experienced sudden onset of symptoms during sexual intercourse. CONCLUSION: Combined physical and emotional stress during sexual intercourse seems to present a meaningful promoter effect for acute aortic dissections, especially in younger males, but not in females. Despite self-evidence of this phenomenon, frequency of this sensitive issue appears to be surprisingly high.

High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six Cases.

OBJECTIVES: To discuss the dilemma of adequate decision making in patients with intravenous drug abuse and recurrent valve prosthesis infections or in patients with positive HIV or hepatitis C status. Ethical, social, and economic considerations, not only in terms of technical feasibility but also in terms of unpromising results and aspects of resources, are discussed. Thoughts are presented about the legitimation of cardiac surgery centers refusing to perform surgery in high-risk patients with HIV or hepatitis C infections. METHODS: Presentation of six cases for discussion. Three patients were addicted to intravenous drugs and had recurrent prosthetic valve endocarditis, and the other three patients had either paravalvular leakage of a mitral valve prosthesis or acute aortic dissection or coronary artery disease. Five of these patients suffered from HIV/AIDS and infective hepatitis C. Four of these patients were refused by other centers due to high risk or a lack of capacity. RESULTS: All six patients were operated during 2013. Mortality was 17%. CONCLUSION: Decision making in noncompliant drug addicts with recurrent prosthesis infection and in HIV-positive patients leads beyond surgical challenges to ethical and economic considerations.

Novel thoughts on patient-prosthesis mismatch in aortic valve replacement: the rationale for the PAR I trial.

The hemodynamic performance of prosthetic tissue valves is influenced by valve design and valve-specific sizing strategies. Design determines the actual geometric opening area (GOA) of the prosthetic valve and sizing strategy its actual chosen size. Currently, hemodynamic performance is assessed by determining the effective orifice area (EOA; derived from the continuity equation by relating flow velocities with the area of the left ventricular outflow tract [LVOTA]). The question whether a valve is too small (patient-prosthesis mismatch [PPM]) is currently addressed by relating EOA to body surface area (EOA index [EOAi]). However, this relation may not be appropriate because the EOAi relates flow velocity to patient-specific anatomic parameters twice (i.e., LVOTA and body surface area). This potential confounder may explain the controversies regarding PPM. However, intuitively, leaving a gradient behind after aortic valve replacement cannot be irrelevant. PPM becomes even more relevant with transcatheter valve-in-valve implantation, where a second prosthesis is taking up inner space of a valve that may have already been too small initially. Thus, a reliable method to determine the presence of PPM is needed. The Prosthesis-to-Annulus Relation I (PAR I) trial is a German multicenter study assessing the relation between the prosthetic GOA and the LVOTA as a potentially new parameter for the prediction of hemodynamic outcome. The results may possibly guide future valve size selection and may allow prediction of functionally relevant PPM. Here, we will demonstrate the shortcomings of the currently applied EOAi for the assessment of hemodynamic relevance and present the rationale for the PARI trial, which recently started recruiting patients.

Applying the Gender Lens to Risk Factors and Outcome after Adult Cardiac Surgery.

BACKGROUND: Applying the gender lens to risk factors and outcome after adult cardiac surgery is of major clinical interest, as the inclusion of sex and gender in research design and analysis may guarantee more comprehensive cardiovascular science and may consecutively result in a more effective surgical treatment as well as cost savings in cardiac surgery. METHODS: We have reviewed classical cardiovascular risk factors (diabetes, arterial hypertension, hyperlipidemia, smoking) according to a gender-based approach. Furthermore, we have examined comorbidities such as depression, renal insufficiency, and hormonal influences in regard to gender. Gender-sensitive economic aspects have been evaluated, surgical outcome has been analyzed, and cardiovascular research has been considered from a gender perspective. RESULTS: The influence of typical risk factors and outcome after cardiac surgery has been evaluated from a gender perspective, and the gender-specific distribution of these risk factors is reported on. The named comorbidities are listed. Economic aspects demonstrated a gender gap. Outcome after coronary and valvular surgeries as well as after heart transplantation are displayed in this regard. Results after postoperative use of intra-aortic balloon pump are shown. Gender-related aspects of clinical and biomedical cardiosurgical research are reported. CONCLUSIONS: Female gender has become an independent risk factor of survival after the majority of cardiosurgical procedures. Severely impaired left ventricular ejection fraction independently predicts survival in men, whereas age does in females.

Performance of EuroSCORE II compared to EuroSCORE I in predicting operative and mid-term mortality of patients from a single center after combined coronary artery bypass grafting and aortic valve replacement.

OBJECTIVE: The performance comparison of the recently introduced European System for Cardiac Operative Risk Evaluation II in predicting operative as well as mid-term mortality, with its previous version in patients after combined aortic valve replacement and coronary artery bypass grafting surgery. METHODS: This retrospective analysis included 216 patients operated on at one institution from 01/1999 to 12/2005. Accuracy and calibration of EuroSCORE I and II were assessed by plotting the areas under the receiver operator curves and comparing observed and predicted mortalities. RESULTS: EuroSCORE II showed, regarding early mortality, a slightly higher discriminatory accuracy with an area under the receiver operator curve of 0.77, while additive and logistic EuroSCORE I areas were 0.749, 0.75, respectively. The highest specificity and sensitivity level was approached for EuroSCORE II at a predicted mortality of 4.4 %. Receiver operator curves concerning mid-term mortality revealed areas for additive, logistic EuroSCORE and EuroSCORE II of 0.745, 0.739 and 0.718 with the highest accuracy levels at predicted mortalities of 6.5, 6.48 and 3.88 %, respectively. Mean predicted mortalities by logistic EuroSCORE and EuroSCORE II were 8.35 and 3.99 %, respectively, while overall observed operative mortality was 6.3 %. In "high-risk" patients (EuroSCORE > 13), EuroSCORE II underestimated early and mid-term outcomes. CONCLUSIONS: Regarding operative mortality, EuroSCORE II showed in this study a slightly higher discriminatory accuracy than EuroSCORE I. There were no significant differences in the calibration of the two model versions in "low-" and "moderate-risk" patients regarding early as well as mid-term mortality. Analyses in larger patient populations will contribute to further model improvement.

Cardiac surgery in dialysis-dependent patients: impact of gender on early outcome in single-center experience with 204 consecutive cases.

BACKGROUND: This study evaluates the impact of gender in dialysis-dependent patients undergoing cardiac surgery. METHODS: We retrospectively identified 204 dialysis-dependent patients (68.6% male, aged 66.6 ± 9.9 years) with end-stage renal disease undergoing cardiac surgery and compared them to a propensity-score-pair-matched control collective. RESULTS: A 30-day mortality was 13.2% (14/106) for coronary artery bypass grafting (CABG), 19.3% (6/31) for aortic valve replacement (AVR), and 23.8% (16/67) for combined procedures. Postoperative chest tube output was significantly higher in men (1,007 ± 946 mL) versus women (687 ± 598 mL, p = 0.014). Compared with a propensity-score-pair-matched control collective of 204 patients, we identified significant differences in terms of 30-day mortality: overall mortality revealed 17.6 versus 4.6% (p = 0.0001), 13.2 versus 3.4% (p = 0.014) for CABG, 19.3 versus 0% (p = 0.051) for AVR, and 23.8 versus 9.1% (p = 0.02) for combined procedures. CONCLUSION: Multivariate analysis identified preoperative myocardial infarction, prolonged extracorporeal circulation time, operation time, and surgical reexploration as independent predictors of 30-day mortality. There was a higher occurrence of bleeding complications in men that remained significant even after correction for body surface area.