Long-term outcomes of aortic valve repair in over 500 consecutive patients: a single-center experience.

BACKGROUND: Over the last years, aortic valve repair has evolved from being a random and irreproducible procedure to a standardized technique yielding durable long­term results. AIMS: The aim of the study was to assess long­term outcomes of aortic valve repair and aortic valve sparing procedures. METHODS: We analyzed the outcomes of all consecutive patients who underwent aortic valve repair and/ or aortic valve sparing root replacement till the end of 2019. We assessed mortality, freedom from reoperation, and freedom from at least moderate aortic valve regurgitation. RESULTS: A total of 504 patients underwent aortic valve repair and/or aortic valve sparing root replacement over 17 years, including 452 (89.7%) elective and 52 (10.3%) emergency surgeries for acute type A aortic dissections. Median (interquartile range) age was 59 (35-66) years, 72.4% were male. Median follow­up time was 35 months. Estimated 5­year survival was 83%, and 10­year survival was 73%. In 452 patients after elective surgery, the estimated actuarial 5­year and 10­year survival was 86% and 75%, respectively. In patients after emergency surgery for acute type A aortic dissection, actuarial 5­year survival was 62%, and 10­year survival was 62%. Estimated 5- and 10­year freedom from reoperation was 96% and 87%, respectively. The comparison of both subgroups did not reveal differences (P = 0.42). Freedom from at least moderate aortic valve regurgitation was confirmed in 86.6% of patients. CONCLUSIONS: Aortic valve repair is a durable and effective surgical procedure associated with low early and late mortality. Aortic valve reconstruction in patients with acute type A aortic dissection yields good long­term results.

Restrictive Mitral Annuloplasty Does Not Limit Exercise Capacity.

BACKGROUND: Restrictive mitral annuloplasty is the preferred method of treating secondary mitral regurgitation. The use of small annuloplasty rings to reduce the high recurrence rates may result in mitral stenosis. METHODS: Thirty-six patients who underwent restrictive mitral annuloplasty with Carpentier-Edwards classic 26 size ring underwent exercise echocardiography and ergospirometry. Resting catecholamines and N-terminal pro brain natriuretic peptide (NT-proBNP) levels were measured. RESULTS: At the time of study, the median time from operation was 16.6 months (interquartile range, 8.5 to 43.3 months). Left ventricular end-systolic volume index (LVESVI) was 67 mL/m(2) (interquartile range, 25 to 92 mL/m(2)), and ejection fraction (EF) was 38.8% (interquartile range, 28.3% to 59.0%). Mitral gradients were higher at the leaflet tips than at the annular level. Continuous wave (CW) Doppler gradients at rest were 3.4 mmHg (interquartile range, 2.4 to 4.9 mmHg) mean and 9.5 mmHg (interquartile range, 7.0 to 14.7 mmHg) maximal. On exertion, they increased to 6.8 mmHg (interquartile range, 5.4 to 8.8 mmHg) (p = 0.001) and 19.7 mmHg (interquartile range, 12.8 to 23.3 mmHg) (p = 0.001), respectively. Maximal VO2 was 18.2 mL/kg/min (interquartile range, 16.3 to 21.5 mL/kg/min), VE/VCO2 slope was 31.1 (interquartile range, 26 to 34). Epinephrine level was 0.024 ng/mL (interquartile range, 0.0098 to 0.043 ng/mL), norepinephrine was 0.61 ng/mL (interquartile range, 0.41 to 0.95 ng/mL), and NT-proBNP was 303 pg/mL (interquartile range, 155 to 553 pg/mL). Maximal VO2 negatively correlated with resting norepinephrine level (r = -0.50, p = 0.003). VE/VCO2 slope positively correlated with NT-proBNP (r = 0.36, p = 0.004) and epinephrine (r = 0.36, p = 0.04) levels and with LV volumes (r = 0.51, p = 0.006) and was negatively correlated with LVEF (r = -0.52, p = 0.004). Neither maximal VO2 nor VE/VCO2 slope correlated with the highest mean (r = 0.24, p = 0.2, and r = -0.20, p = 0.3, respectively) and maximal (r = 0.13, p = 0.5, r = -0.20, p = 0.3, respectively) mitral gradients on exertion. CONCLUSIONS: Restrictive mitral annuloplasty for secondary mitral regurgitation does result in a degree of mitral stenosis; however, primary heart disease seems more important for patient's exercise performance than the mitral stenosis resulting from using an undersized ring.

Effects of preoperative aspirin in coronary artery bypass grafting: a double-blind, placebo-controlled, randomized trial.

OBJECTIVE: This trial was undertaken to determine the safety and efficacy of preoperative aspirin administration in a contemporary cardiac surgical practice setting. METHODS: This randomized, double-blind, parallel-group, single-center trial involved patients with stable coronary artery disease who were assigned to receive either 300 mg of aspirin or placebo the night before coronary bypass surgery. Using a random digit table, patients were allocated to receive the tablet from 1 of the 40 coded bottles containing either aspirin or placebo. Patients, surgeons, anesthetists, and investigators were all masked to treatment allocation. The primary safety end points were as follows: more than 750 mL of bleeding during the first postoperative 12 hours and more than 1000 mL of total discharge from the chest drains. The secondary efficacy end point was a composite of cardiovascular death, myocardial infarction, or repeat revascularization. RESULTS: A total of 390 patients were allocated to aspirin (387 analyzed) and 399 to placebo (396 analyzed). The follow-up median was 53 months. Fifty-four placebo recipients and 86 aspirin recipients bled more than 750 mL in the first 12 hours (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.25-2.63), while total chest drain discharge was above 1000 mL in 96 placebo and 131 aspirin recipients (OR, 1.60; 95% CI, 1.17-2.18). Preoperative aspirin decreased the long-term hazard of nonfatal coronary event (infarction or repeat revascularization)-hazard ratio (HR), 0.58 (95% CI, 0.33-0.99)--and tended to decrease the hazard of a major cardiac event (cardiovascular death, infarction, or repeat revascularization--HR, 0.65 [95% CI, 0.41-1.03]). CONCLUSIONS: Performing coronary grafts on aspirin is associated with increased postoperative bleeding but may decrease the long-term hazard of coronary events.

The new oral adenosine A1 receptor agonist capadenoson in male patients with stable angina.

BACKGROUND: Anti-ischaemic effect of A1 adenosine receptor agonists was shown in animal and preclinical studies. The present proof-of-concept study aimed at evaluation of the efficacy and safety of a new adenosine A1 receptor agonist capadenoson in patients with stable angina. METHODS: This was a randomized, double-blind, placebo-controlled, single dose-escalating, multicenter trial comparing the effect of capadenoson at 1, 2.5, 5, 10, and 20 mg versus placebo. For each dose step patients were randomized to receive single doses of either capadenoson or matching placebo in a 5:1 ratio. The primary efficacy variable was the absolute difference in heart rate (HR) at maximum comparable level of workload between baseline and post dose exercise tolerance test at maximum concentration of capadenoson. Capadenoson effect on total exercise time and time to 1-mm ST-segment depression were also measured. RESULTS: Sixty-two male patients with stable angina were enrolled in the study. There was a consistent trend for HR reduction at comparable maximum work load in active treatment groups, with significant differences against placebo for 10 and 20 mg (HR reduction by 12.2 and 6.8 beats per min, p = 0.0002 and p = 0.032, respectively). A statistically significant trend (p = 0.0003) for a reduction in HR with increasing doses of capadenoson was shown. Increases in total exercise time and time to 1-mm ST-segment depression were also observed. CONCLUSIONS: In patients with stable angina capadenoson lowers exercise HR at comparable maximum workload, which is associated with improved total exercise time and prolongation of time to ischaemia.

Cardiac myxoma - clinical presentation and long-term post-operative follow-up.

BACKGROUND: Myxoma is the commonest cardiac neoplasm. Due to varying symptomatology, its diagnosis can prove difficult. It is agreed to have an excellent prognosis. AIM: Assessing the clinical course in patients operated on due to cardiac myxoma in two departments of cardiac surgery over the course of a decade. METHODS: The medical records of patients operated on due to cardiac myxoma between 1999 and 2009 were analysed. The patients were then invited for an ambulatory visit, during which transthoracic and transoesophageal echocardiographic examinations were performed. RESULTS: There were 61 patients (47 females) with histologically confirmed myxoma operated upon. The commonest symptoms leading to diagnosis were heart failure (16 patients, 26%) and syncope (12 patients, 20%). There were five (8%) in-hospital deaths and two (3%) non-fatal strokes. Follow-up duration ranged between one and ten years (6.1 ± 3.2 years). Nine (15%) deaths occurred during follow-up. In four (7%) patients, myxoma recurred in the original location. Echocardiography performed at follow-up visit revealed one recurrence of myxoma, and minor pathologies in 20 patients. Patients who died perioperatively were significantly older compared to those who survived (69 ± 9.7 years vs 56 ± 13, p = 0.02). Patients who died during the follow-up were also significantly older than those who were alive at the time of the contact visit (65 ± 15 years vs 56 ± 12, p = 0.02). Death during follow-up occurred four times more often in males than females (36% vs 8.5%, p = 0.02). There were more deaths during the follow-up in patients whose initial presenting symptom was dyspnea: five deaths (31%) vs four deaths (9%, p = 0.04). The recurrence of myxoma was significantly more frequent in patients with a shorter duration of symptoms before the operation: 8.6 ± 15 weeks with relapse vs 33.9 ± 40 weeks without relapse (p = 0.04). CONCLUSIONS: Both, serious and benign events following myxoma excision are common. Clinical and echocardiographic surveillance should be implemented in all patients who undergo a myxoma operation.

Coronary artery bypass grafting in patients with relatively recent previous stent implantation: three years follow-up results.

BACKGROUND: An increasing number of patients who undergo coronary artery bypass grafting(CABG) have a history of coronary stent implantation. This study aims to assess perioperative and medium-term follow-up outcomes in patients in whom CABG was preceded by coronary stent implantation within two years before operation. METHODS: One hundred and sixty two patients undergoing CABG after previous stent placement (PCI + CABG group) were compared to 149 who had CABG without PCI in the past (CABG group). Clinical, angiographic and perioperative outcome data were compared. The three year follow-up comprised data on number of deaths and the presence of anginal symptoms. RESULTS: In both groups the extent of coronary artery disease was comparable, but more patients in the PCI + CABG group had a history of myocardial infarction. Perioperative outcome data did not differ between the groups except for a higher number of vessels considered infarct-related grafted in the CABG group. Patients operated on up to three months after PCI had more extensive coronary heart disease than those operated on later. They also had a significantly shorter operation time. This group also showed a trend towards less postoperative bleeding, less rethoracotomy and less low cardiac output syndrome. In a three year follow-up, 48 (30%) patients in the PCI + CABG group reported presence of angina compared to 28 (19%) in the CABG group (p = 0.04). CONCLUSIONS: Previous PCI does not significantly influence the CABG outcome. In mediumterm follow-up, freedom from anginal symptoms is less likely in patients in whom CABG was preceded by stent implantation.

Invasive treatment of coronary artery disease in octogenarians.

INTRODUCTION: There are many patients aged over 80 years among those hospitalised for coronary artery disease (CAD). The unanswered question is whether invasive treatment of such patients is effective and safe. AIM: To assess and compare one-year clinical outcomes after percutaneous coronary angioplasty (PTCA) and surgical coronary artery bypass grafting (CABG) in patients aged over 80 years and in younger patients. METHOD: There were 63 patients aged over 80 years suffering from CAD who underwent either PTCA or CABG. The control group consisted of 40 patients aged 60-65 years treated in the same way. Data on medical history, cardiovascular risk factors, and angiographic findings were analysed. The potential risks of the procedures, post-procedural complications as well as the clinical status at the end of one-year follow-up were evaluated. RESULTS: There were 24 surgical revascularisation procedures and 39 PCIs performed in the very old patients. Stable angina was found in 29 cases, unstable angina in 19 and acute myocardial infarction in 15 patients. There were three in-hospital deaths and 18 periprocedural complications were noted. During the one-year follow-up period six deaths occurred, persistent or recurrent angina was found in 11 patients after PCI and two after CABG. There were no deaths in the control group and the incidence of minor complications was similar to the senile group. In younger patients who underwent CABG, CCS class at one year was lower than in the very old ones. CONCLUSIONS: The invasive treatment of coronary artery disease in octogenarians is feasible with satisfactory results and acceptable procedural risks.

Effect of coronary artery bypass graft in patients with unstable angina on left ventricular remodelling in medium-term follow-up.

INTRODUCTION: Left ventricular remodelling is a process of change in size, shape, wall thickness and heart function, initiated by a noxious stimulus such as ischaemia. Methods of pharmacological and surgical inhibition or reversal of remodelling are being sought. AIM: To assess the influence of coronary artery bypass grafting on echocardiographic measures of left ventricular size and shape in medium-term follow-up. METHODS: In a group of 30 patients three echocardiographic examinations were performed: before CABG operation, 3 months after and 20 months after the operation. Left ventricular area and volumes as well as indices of sphericity, thinning and expansion were calculated. RESULTS: After the operation, left ventricular areas measured in short axis and in apical four-chamber view increased among patients with a history of myocardial infarction. Improvement in the sphericity index occurred after the operation in patients with a history of myocardial infarction in whom the ejection fraction before the operation was less than 50%. CONCLUSIONS: The left ventricular remodelling process progresses after coronary artery bypass grafting in patients with a history of myocardial infarction. Inhibition of remodelling may be expected in patients without myocardial infarction, with preserved left ventricular systolic function.

Left ventricular systolic function in myocardial infarction survivors treated with primary angioplasty, thrombolysis of angioplasty preceded by thrombolysis.

BACKGROUND: Acute myocardial infarction (AMI) may be treated with thrombolysis, primary angioplasty or a combination of both methods. Preservation of left ventricular systolic function is an important goal of treatment. AIM: To assess whether the mode of treatment of AMI influences left ventricular systolic function measured 6 months after AMI. METHODS: In a group of 108 patients who survived AMI, an echocardiographic examination was performed 6 months afterwards. Ejection fraction, wall motion score index, asynergy area index, infarcted wall motion score index and apical segments motion score index were measured. Patients were divided into three groups: those treated with thrombolysis only, treated with angioplasty or those who underwent angioplasty preceded by thrombolysis. RESULTS: Global left ventricular systolic function was similar in all three groups. Compared to the two remaining groups, the group treated with combined therapy had significantly worse indexes of infarcted wall motion score and apical segments motion score. This group also included a significantly higher number of patients with akinetic or dyskinetic apical segments. CONCLUSIONS: Echocardiographic examination of global left ventricular systolic function in MI survivors performed 6 months after AMI, reveals similar values regardless of the method used for AMI treatment. However, segmental systolic function in the area of infarcted wall and apical segments is significantly more altered in patients treated with angioplasty preceded by thrombolysis than in other analysed patients.