Quality of life 10 years after cardiac surgery in adults: a long-term follow-up study.

BACKGROUND: Quality of life (QoL) is a multifactorial concept that assesses physical and mental health. We prospectively studied the quality of life of patients undergoing coronary artery bypass graft (CABG) surgery using the Short-Form 36-item questionnaire (SF-36) up to 10 years after surgery. METHODS: Between January 2000 and December 2002, all patients undergoing elective isolated CABG in the cardiac & thoracic surgery department of a large university hospital in Eastern France underwent initial QoL evaluation with the SF-36. The same questionnaire was mailed to every patient annually (± 2 weeks around the date of surgery) up to 10 years after their operation. We recorded socio-demographic and clinical variables at inclusion. Predictors of impaired QoL at 10 years were identified by logistic regression. RESULTS: A total of 272 patients (213 men, 59 women) were enrolled; mean age at inclusion was 65 ± 10 years. At 10 years post-surgery, 81 patients had died (29.7%). The physical component summary (PCS) score was significantly higher at 5 years after surgery than at baseline (p < 0.01), and significantly lower at 10 years than at 5 years (p < 0.01), although there remained a significant difference between 10-year PCS and baseline score (p = 0.004). The mental component summary (MCS) score was significantly higher at 5 years than at the time of surgery (p < 0.001), and remained significantly higher compared to baseline at 10 years after surgery (p = 0.010). By multivariate analysis, diabetes and dypsnea were both associated with worse PCS at 10 years, while lower age was associated with better 10-year PCS. Only diabetes was associated with impaired MCS at 10 years. CONCLUSIONS: Cardiac surgery appears to durably and positively affect both physical and mental components of quality of life.

Exclusive Bilateral Internal Thoracic Artery Grafts for Myocardial Revascularization Requiring Four Anastomoses or More: Outcomes from a Single Center Experience.

Introduction Multivessel coronary artery bypass graft (CABG) with bilateral internal thoracic arteries (BITA) has only been uncommon and technically demanding. We describe our experience with BITA only CABGs requiring ≥ 4 anastomoses. Material and Methods The department's database was queried for patients undergoing isolated CABG with ≥ 4 anastomoses. The surgical technique included systematically a right internal thoracic artery (ITA) of left ITA Y graft. The multivariate model included variables with a p < 0.3 at univariate analysis. Results Between January 2006 and December 2009, 251 consecutive patients (71 ± 10 years) (on-pump: 130, off-pump: 121) had CABG with ≥ 4 anastomoses, representing 21% of total isolated CABGs for the same period; all patients received a totally arterial BITA only revascularization. Follow-up was 4.9 ± 1.6 years. Overall and cardiac cumulative survivals were 78 and 92%, respectively, at 5 years. The occurrence of any major postoperative complication was associated with overall and cardiac mortality (odds ratio [OR]: 3.6, 95% confidence interval [CI]: 1.3-9.9 and OR: 5.4, 95% CI: 1.3-21.9, respectively). Major sternal wound complication requiring surgical revision was not associated with impaired glucose control (n = 9; diabetics: 6/82, 7.3%; nondiabetics: 3/169, 1.8%, p = 0.06). Preoperative kidney failure was associated with incomplete revascularization (OR: 6.2; 95% CI: 1.2-33.5), that was unfailingly due to ungraftable right coronary artery targets. Discussion BITA only revascularization was a valuable and safe procedure, with favorable results in terms of morbidity and mortality at a 5 years' follow-up.

Relevance of Endothelial Cell-Specific Molecule 1 (Endocan) Plasma Levels for Predicting Pulmonary Infection after Cardiac Surgery in Chronic Kidney Disease Patients: The Endolung Pilot Study.

OBJECTIVES: This pilot study aimed to evaluate the relevance of endocan plasma levels for predicting pulmonary infection after cardiac surgery in patients with chronic kidney disease (CKD). METHODS: Serum collected in a previous prospective cohort study (from 166 patients with preoperative CKD who underwent cardiac surgery) was used. Five patients with postoperative pulmonary infection were compared with 15 randomly selected CKD patients with an uneventful outcome. Blood samples were tested at 4 time points (preoperatively and 6, 12, and 24 h after the end of surgery). Endocan, procalcitonin, and C-reactive protein plasma levels were compared between the two groups. RESULTS: At 6 h, the patients with pulmonary infection had significantly higher levels of endocan than the patients without pulmonary infection (24.2 ± 15.6 vs. 6.4 ± 3.2 ng/mL; p = 0.03). A receiver operating characteristic curve analysis showed 80% sensitivity and 100% specificity for endocan to predict pulmonary infection (area under the curve 0.84), with a cutoff value of 15.9 ng/mL. The time saved by assessment of the endocan dosage compared to a clinical diagnosis of pulmonary infection was 47 h. CONCLUSION: This pilot study showed that a specific study to assess the link between endocan plasma levels and pulmonary infection after cardiac surgery in CKD patients is of potential utility.

Validation of a Predictive Scoring System for Deep Sternal Wound Infection after Bilateral Internal Thoracic Artery Grafting in a Cohort of French Patients.

BACKGROUND: The Gatti score is a weighted scoring system based on risk factors for deep sternal wound infection (DSWI) that was created in an Italian center to predict DSWI risk after bilateral internal thoracic artery (BITA) grafting. No external evaluation based on validation samples derived from other surgical centers has been performed. The aim of this study is to perform this validation. PATIENTS AND METHODS: During 2015, BITA grafts were used as skeletonized conduits in all 255 consecutive patients with multi-vessel coronary disease who underwent isolated coronary bypass surgery at the Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France. Baseline characteristics, operative data, and immediate outcomes of every patient were collected prospectively. A DSWI risk score was assigned to each patient pre-operatively. The discrimination power of both models, pre-operative and combined, of the Gatti score was assessed with the calculation of the area under the receiver operating characteristic curve. RESULTS: Fourteen (5.5%) patients had DSWI. Major differences both as the baseline characteristics of patients and surgical techniques were found between this series and the original series from which the Gatti score was derived. The area under the receiver operating characteristic curve was 0.78 (95% confidence interval: 0.64-0.92) for the pre-operative model and 0.84 (95% confidence interval: 0.69-0.98) for the combined model. CONCLUSIONS: The Gatti score has proven to be effective even in a cohort of French patients despite major differences from the original Italian series. Multi-center validation studies must be performed before introducing the score into clinical practice.

Advantages of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography in detecting post cardiac surgery infections.

UNLABELLED: The 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) offers an excellent negative predictive value. Consequently, it is a reliable tool for excluding an infectious phenomenon in case of negativity. In case of persistent fever of unknown origin after cardiac surgery and in combination with other bacteriological examinations and medical imaging, we can rely on FDG-PET/CT to confirm or eliminate deep infections and prosthetic endocarditis. For this reason, FDG-PET/CT should be considered among the examinations to be performed in case of suspected infection after cardiac surgery. We have reported the case of a 76-year-old man who presented with a fever of unknown origin and recurrent septic shocks after a biological Bentall procedure combined with left anterior descending (LAD) coronary artery revascularization by the left internal thoracic artery. We performed a FDG-PET/CT which showed external iliac vein and right common femoral vein hyperfixation with infiltration of adjacent soft tissues, highly suspected to be an infectious process. LEARNING OBJECTIVE: The aim of this case report is to show that FDG-PET/CT, in combination with other bacteriological examinations and medical imaging, can be extremely helpful in detecting deep infectious sources, even during the early postoperative period.

Mid-term results of self-testing of the international normalized ratio in adults with a mechanical heart valve.

BACKGROUND: Commonly the frequency of international normalized ratio (INR) monitoring with a conventional laboratory test in stable patients is once a month. When using a dedicated personal device for INR assessment, the frequency may be increased to two or more times a month. OBJECTIVE: To show that INR assessed by self-measurement at home is reliable and feasible in the mid-term and improves medical care. PATIENTS AND METHODS: All patients in the study on INR self-measurement (clinical trial.gov: NCT00925197), conducted between 2004 and 2007, were re-contacted for mid-term follow-up. One hundred and seventy eight out of 192 patients who participated in the study answered a questionnaire. The average follow-up time was 4.2 years (±1) for the self-measurement group and 4.9 years (±1) for the laboratory-analyzed control group. RESULTS: Only 26 patients (group A) continued to use INR self-measurement to monitor treatment with vitamin K antagonists (VKA). The main reasons to stop INR self-measurement were its high cost and difficulty in obtaining strips. There were significantly fewer bleeding complications (p=0.04) and complications related to VKA (p=0.01) in self-measured patients compared to the control group. Feelings of security and quality of life were also significantly better (p=0.002) for self-measured patients. CONCLUSION: Many patients with a mechanical heart valve, who self-measured INR, continue to use this method for their follow-up because of its positive effects on their health and quality of life.

Comparison between three types of stented pericardial aortic valves (Trivalve trial): study protocol for a randomized controlled trial.

BACKGROUND: Aortic valve stenosis is one of the most common heart diseases in older patients. Nowadays, surgical aortic valve replacement is the 'gold standard' treatment for this pathology and the most implanted prostheses are biological ones. The three most implanted bovine bioprostheses are the Trifecta valve (St. Jude Medical, Minneapolis, MN, USA), the Mitroflow valve (Sorin Group, Saluggia, Italy), and the Carpentier-Edwards Magna Ease valve (Edwards Lifesciences, Irvine, CA, USA). We propose a randomized trial to objectively assess the hemodynamic performances of these bioprostheses. METHODS AND DESIGN: First, we will measure the aortic annulus diameter using CT-scan, echocardiography and by direct sizing in the operating room after native aortic valve resection. The accuracy of information, in terms of size and spatial dimensions of each bioprosthesis provided by manufacturers, will be checked. Their hemodynamic performances will be assessed postoperatively at the seventh day and the sixth month after surgery. DISCUSSION: This prospective controlled randomized trial aims to verify and compare the hemodynamic performances and the sizing of these three bioprostheses. The data obtained may help surgeons to choose the best suitable bioprosthesis according to each patient's morphological characteristics. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01522352.

Mid-term results of tricuspid annuloplasty with a three-dimensional remodelling ring.

OBJECTIVE: To assess the results of tricuspid annuloplasty performed with the Edwards MC3 remodeling ring. METHODS: From 2005 to 2007, 140 patients with tricuspid regurgitation (TR) secondary to left-sided valve disease (mean age 63.8 ± 11.6, permanent pacemaker in 7.8%, LVEF 56.4 ± 10.1%, LVEDD 54.1 ± 8 mm, SPAP 52.5 ± 14.4 mmHg) underwent tricuspid annuloplasty using the MC3 ring. Dilatation of the tricuspid annulus was present in all patients. Other concomitant mechanisms of TR (moderate leaflet prolapse, pacemaker wires, leaflets' retraction) were documented in 21 cases (15%). All patients underwent concomitant left-sided valve surgery. Ring size was between 28 and 32 in 84.3% of patients. RESULTS: Hospital mortality was 3.5% and actuarial survival at 3 years 94.8 ± 2.1%. Mean follow-up of the 135 hospital survivors was 22 ± 9.5 months (median 23 months). Echocardiography at hospital discharge documented no or mild TR in 119 patients (87%), moderate TR (2+/4+) in 15 (11%) and moderate-to-severe (3+/4+) in 1 patient (0.7%). At echocardiographic follow-up moderate TR was present in 14 patients (10.3%) and moderate-to-severe TR in 2 (1.4%). At 3 years freedom from TR ≥ 2+ was 88.1 ± 2.78% and freedom from TR ≥ 3+ was 94.3 ± 4.89. Predictors of TR ≥ 2+ at hospital discharge and at follow-up were preoperative LVEF (OR:0.8; p = 0.001 at discharge; HR:0.9; p = 0.003 at follow-up) and the presence of other mechanisms of TR besides annular dilatation (OR:10.8; p = 0.007 at discharge; HR:6.1; p = 0.003 at follow-up). CONCLUSION: Tricuspid annuloplasty with the MC3 ring provides satisfactory early results which remain stable at mid-term follow-up. The presence of other mechanisms besides annular dilatation leads to residual valve insufficiency after ring annuloplasty alone.

A new technique for vascular access management in transcatheter aortic valve implantation.

OBJECTIVES: To describe results from a novel percutaneous technique designed to minimize the risk of hemorrhage in the event of a major complication during transcatheter aortic valve implantation. BACKGROUND: Vascular access management is a major challenge in transfemoral TAVI due to the large introducer sheathes required. METHODS: Fifty-two pts underwent TAVI between November 2007 and March 2009. Of these, 37 received an Edwards-Sapien Valve (23 mm valve: 17/37; 26 mm valve: 20/37) whilst 15 patients received a CoreValve (26 mm valve: 6/15; 29 mm valve: 9/15). Using a crossover technique, the opposing femoral artery was cannulated with a 7Fr long sheath. This allowed contralateral passage of a balloon and inflation in the proximal iliac. The sheath was then removed and Prostar sutures tied in a dry field. Balloon optimization of the puncture site was performed as required. RESULTS: In three subjects, elective surgical repair was undertaken due to excessive femoral arterial calcification. In the remaining 49, the crossover technique was employed and closed with two Prostar devices (Edwards-Sapien) or one (CoreValve). There were serious "on-table" complications in seven patients, six due to the large introducer sheathes used in the TAVI procedure-iliac avulsion, two iliac dissections, iliac perforation, common femoral perforation and scrotal hematoma. All were repaired safely by combined surgical and endovascular techniques, using the crossover technique to ensure patient stability. All made a good recovery and were independently ambulant at discharge. CONCLUSION: Using crossover balloon inflation as an adjunct to Prostar closure may be helpful for managing TAVI vascular access sites.

Emergency transfemoral aortic valve-in-valve implantation with the balloon-expandable Edwards-Sapien valve.

The degeneration of a previously surgically implanted aortic bioprosthesis is an increasing etiology of aortic stenosis in the elderly, but reoperative surgery may present prohibitive risks. The feasibility of transcatheter aortic valve implantation into a conventional bioprosthesis (valve-in-valve concept) has been evaluated to decrease the reoperative risk for patients with a failed bioprosthesis. There have been several reports of valve-in-valve procedures using the self-expandable prosthesis CoreValve (Medtronic Inc.), whereas the feasibility of this procedure with the Sapien balloon expandable valve (Edwards Lifesciences Inc.) is still not well established. Here we report the case of a patient submitted to balloon-expandable aortic valve-in-valve implantation in an emergency setting to treat a severe aortic stenosis due to the premature failure of a surgical bioprosthesis.

Complete right atrial ablation with bipolar radiofrequency.

PURPOSE: Although it is deemed important, right atrial ablation is not considered feasible with bipolar radiofrequency alone. Normally, unipolar devices are used to complete the tricuspid connecting lines. We describe a simple technique to achieve a complete maze-like set of right ablations using a standard bipolar radiofrequency device. DESCRIPTION: Thirty-four patients underwent concomitant ablation with a right set of lines performed using bipolar radiofrequency only. The epicardium adjacent to the right atriotomy was entered and after separating the sulcus fat from the atrial wall, the deepest portion of the atrioventricular groove was developed bluntly with the scissors down to the tricuspid annulus. The tricuspid connecting lines were then performed with bipolar radiofrequency in an endo-epicardial fashion. EVALUATION: No ablation-related complications occurred. No patient died. Three patients required pacemaker implantation. At a mean follow-up of 8 +/- 5, 85% of the patients were free from arrhythmias. At 6 months 20 of 24 patients (83%) were in stable sinus rhythm. CONCLUSIONS: All the maze III right atrial ablations can be performed using a bipolar radiofrequency device alone. The procedure is safe and easily reproducible on a regular basis.

Heme oxygenase-1 expression in the left atrial myocardium of patients with chronic atrial fibrillation related to mitral valve disease: its regional relationship with structural remodeling.

Atrial fibrillation becomes a self-perpetuating arrhythmia as a consequence of electrophysiologic and structural remodeling involving the atrium. Oxidative stress may be a link between this rhythm disturbance and electrophysiologic remodeling. The aim of this study was to evaluate whether the heme oxygenase-1 (HO-1) marker of oxidative stress was more expressed in left atrial sites with stronger structural remodeling in patients affected by chronic atrial fibrillation (CAF) and mitral valve disease (MD). Myocardial samples were taken from the left atrial posterior wall (LAPW) and left atrial appendage (LAA) of 24 patients with CAF-MD in addition to 10 autopsy controls. The levels of HO-1 messenger RNA (mRNA) and HO-1 protein in each pathologic LAPW and LAA were quantified using reverse transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay. Furthermore, light microscopy was used to morphometrically evaluate the differential myocyte and interstitial changes in the same CAF-MD LAPW and LAA samples. In controls, HO-1 protein was quantified using enzyme-linked immunosorbent assay. Unlike controls, patients with CAF-MD had higher levels of HO-1 mRNA and its protein product, expressed as LAPW/LAA ratios, in the LAPW (2.18 +/- 1.18, P < .0001, and 1.55 +/- 0.67, P < .005), and their LAPW also showed greater histologic changes in myocytolytic myocytes (15.1% +/- 3.1% versus 6.9% +/- 3.3%, P < .0001), interstitial fibrosis (8.2% +/- 2.2% versus 2.8% +/- 1.2%, P < .0001), and capillary density (816 +/- 120 number/mm(2) versus 1114 +/- 188 number/mm(2); P < .05). In addition, markers of oxidative stress were immunohistochemically studied with antinitrotyrosine and anti-iNOS antibodies. In patients with CAF-MD, the inducible enzyme HO-1 is more expressed in the left atrial areas that show greater structural remodeling. This finding strongly suggests a pathogenetic relationship between oxidative stress and the degree of histologic change.

Complete left atrial ablation with bipolar radiofrequency.

OBJECTIVE: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. METHODS: An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device. RESULTS: All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250-442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245+/-50 euro vs 2403+/-17 euro; p<0.0001). CONCLUSIONS: Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.

Myocyte changes and their left atrial distribution in patients with chronic atrial fibrillation related to mitral valve disease.

It has been found that the pulmonary veins and adjacent left atrial posterior wall (LAPW) are deeply involved in both the initiation and maintenance of atrial fibrillation (AF), and the identification of these high-risk sites has aroused great interest in investigating their histopathologic substrate. We used light and conventional electron microscopy to evaluate the differential myocyte and interstitial changes in LAPW and left atrial appendage (LAA) samples from 28 patients with chronic AF undergoing mitral valve surgery and from 12 autoptic controls. There were always more myocytes with loss of sarcomeres in the LAPW than in the LAA (19.9% +/- 7.7% versus 8.2% +/- 5.0%; P < .0001), and the LAPW showed more marked immunohistochemical evidence of dedifferentiation, characterized by the reexpression of smooth muscle actin. In pathological left atria, myocyte diameter in the LAPW and LAA was comparable (19.0 +/- 1.5 versus 18.5 +/- 2.0 microm; not significant) but larger than in the controls (11.9 +/- 0.8 and 12.1 +/- 1.3 microm, respectively; P < .0001). A terminal deoxynucleotidyltransferase assay did not reveal any myocyte apoptosis. The LAPW also showed more interstitial fibrosis than the LAA (7.49% +/- 3.34% versus 2.80% +/- 1.35%; P < .0001). Ultrastructural examination confirmed the presence of myocyte myocytolysis in the perinuclear area and showed changes in mitochondrial shape. In conclusion, the LAPW in patients with chronic AF related to mitral valve disease seems to be a particular anatomical site in which major myocyte and interstitial changes are concentrated, whereas the LAA is more protected. This remodeling may increase the heterogeneity of LAPW electrical conduction, thus confirming this location as an elective target for the ablation treatment of AF.

The effect of concomitant radiofrequency ablation and surgical technique (repair versus replacement) on release of cardiac biomarkers during mitral valve surgery.

All patients undergoing heart surgery experience a certain amount of nonspecific myocardial injury documented by the release of cardiac biomarkers and associated with poor outcome. We investigated the role of unipolar radiofrequency ablation of atrial fibrillation on the release of cardiac biomarkers in 71 patients undergoing mitral valve surgery and concomitant left atrial ablation case-matched with 71 patients undergoing isolated mitral surgery. The study was powered to detect a 3 ng/mL difference. There was no difference between the 2 groups in terms of cardiac troponin I (10 +/- 5.3 versus 12 + 10.4 ng/mL; P = 0.7) or creatine kinase-MB (50 +/- 21.8 versus 57 +/- 62.0 ng/mL; P = 0.5) release. Postoperative peak cardiac troponin I levels had univariate associations with the duration of cardiopulmonary bypass (P = 0.002) and aortic cross-clamping (P = 0.001) and with the surgical technique (15 +/- 12 ng/mL for mitral valve replacement versus 9 +/- 4.8 for mitral valve repair; P = 0.0007) at univariate analysis. Mitral valve replacement was the only independent predictor of postoperative peak release of cardiac troponin I identified with multivariate analysis (P = 0.005). Radiofrequency ablation of atrial fibrillation does not significantly increase cardiac biomarker release compared with isolated mitral surgery; mitral valve repair is associated with less release of cardiac biomarkers compared with mitral valve replacement.