Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement.

BACKGROUND: Noninvasive measurement of myocardial contractility (end-systolic wall stress-adjusted change in left ventricular ejection fraction from rest to exercise [ΔLVEF - ΔESS]) predicts heart failure, subnormal LVEFrest, and sudden death in asymptomatic patients with chronic severe aortic regurgitation (AR). Here we assess the relation of preoperative ΔLVEF - ΔESS to survival after aortic valve replacement (AVR). METHODS: Patients who underwent AVR for chronic, isolated, pure severe AR (n = 66) were followed for 13.0 ± 6.4 event-free years. Preoperative ΔLVEF - ΔESS (from combined echocardiographic and radionuclide cineangiographic data) enabled cohort stratification into 3 terciles (-1 to -11% [normal or mild] contractility deficit, -12 to -16% [moderate], and ≤-17% [severe], identical with segregation in our earlier study) to relate preoperative contractility to postoperative survival and to age- and gender-matched US census data. RESULTS: Since AVR, 22 patients died (average annual risk [AAR] for all-cause mortality for the entire co hort = 3.15%). Preoperative ΔLVEF - ΔESS predicted postoperative survival (p = 0.009, log rank test). By contractility terciles, all-cause AARs were 1.44, 2.58, and 6.40%. Survival was lower than among US census comparators (p < 0.02), but the "mild" tercile was indistinguishable from census data (p = ns). By multivariable Cox regression, survival prediction by pre-AVR ΔLVEF - ΔESS was independent of, and superior to, prediction by age at surgery, gender, preoperative functional class, LVEFrest, LVEFexercise, change in LVEFrest to exercise, and LV diastolic or systolic dimensions (p ≤ 0.01, pre-AVR ΔLVEF - ΔESS vs. other covariates). CONCLUSION: In severe AR, preoperative contractility predicts post-AVR survival and may be prognostically superior to clinical, geometric and performance descriptors, potentially impacting on patient selection for surgery.

National trends in utilization and in-hospital outcomes of mechanical versus bioprosthetic aortic valve replacements.

OBJECTIVE: Substantial controversy surrounds the choice between a mechanical versus bioprosthetic prosthesis for aortic valve replacement (AVR), based on age. This study aims to investigate national trends and in-hospital outcomes of the 2 prosthesis choices. METHODS: All patients aged >18 years in the National Inpatient Sample who received an AVR between 1998 and 2011 were considered. Valve-type use was examined by patient, procedural, and hospital characteristics, after which we matched patients based on their propensity score for receiving a bioprosthetic valve and compared their in-hospital outcomes. RESULTS: Bioprosthetic valves comprised 53.3% of 767,375 implanted valves, an increase in use from 37.7% in the period 1998 to 2001 to 63.6% in the period 2007 to 2011. The median age was 74 years for patients receiving bioprosthetic valves, and 67 years for those receiving mechanical valves. Use of bioprosthetic valves increased across all age groups, most markedly in patients age 55 to 64 years. Compared with patients receiving mechanical valves, these patients had a higher incidence of renal disease (8.0% vs 4.2%), coronary artery disease (58.5% vs 50.5%), concomitant coronary artery bypass grafting (46.7% vs 41.9%), and having surgery in a high-volume (>250 cases per year) center (31.3% vs 18.5%). Patients receiving bioprosthetic valves had a higher occurrence of in-hospital complications (55.9% vs 48.6%), but lower in-hospital mortality (4.4% vs 4.9%) than patients receiving mechanical valves. This difference was confirmed in propensity-matched analyses (complications: 52.7% vs 51.5%; mortality: 4.3% vs 5.2%). CONCLUSIONS: Use of bioprosthetic valves in AVR increased dramatically from 1998 to 2011, particularly in patients age 55 to 64 years. Prosthesis selection varied significantly by facility, with low-volume facilities favoring mechanical valves. Aortic valve replacement with a bioprosthetic valve, compared with a mechanical valve, was associated with lower in-hospital mortality.

Preoperative hypothyroidism is a risk factor for postoperative atrial fibrillation in cardiac surgical patients.

BACKGROUND AND AIM: Although studies analyzing the effect of thyroid supplementation on postoperative morbidity and mortality from cardiac surgery have been inconclusive, they suggest a role in the prevention of postoperative atrial fibrillation. To further explore this relationship we conducted a retrospective study to determine whether abnormalities in routine preoperative thyroid function studies correlate with the incidence of postoperative atrial fibrillation. METHODS: From May 2004 until July 2011, 821 patients with complete thyroid function testing performed preoperatively underwent cardiac surgery. Preoperative, intraoperative, and postoperative laboratory, clinical and hemodynamic data including postoperative electrocardiogram monitoring were retrospectively evaluated. RESULTS: Mean age was 65.7 years and 36% (294) of patients were female. Mean preoperative ejection fraction was 48.6% and 18% (100) had clinical heart failure. Ninety percent (682) of patients were euthyroid and 10% (77) were hypothyroid. Atrial fibrillation occurred significantly more frequently in hypothyroid patients (33.4% vs. 22.5%; p = .033). In multivariable analysis, increasing thyroid stimulating hormone (TSH) level (OR: 1.11; CI: 1.01 to 1.22; p = .030) was an independent predictor of postoperative atrial fibrillation. Beta blocker use within 24 hours prior to operation was protective (OR: .54; CI: .35 to .83; p = .005). Length of stay was significantly longer in patients with postoperative atrial fibrillation (9.1 vs. 6.5 days; p < .001). CONCLUSIONS: In the current study, preoperative hypothyroidism was associated with postoperative atrial fibrillation. Further studies are warranted to delineate whether preoperative hypothyroidism is a useful biomarker for selecting patients most likely to benefit from preoperative thyroid supplementation in the prevention of postoperative atrial fibrillation.

Comparative effectiveness of robotic-assisted vs thoracoscopic lobectomy.

BACKGROUND: Robotic-assisted lobectomy is being offered increasingly to patients. However, little is known about its safety, complication profile, or effectiveness. METHODS: Patients undergoing lobectomy in in the United States from 2008 to 2011 were identified in the Nationwide Inpatient Sample. In-hospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted lobectomy were compared with those for patients undergoing thoracoscopic lobectomy. RESULTS: We identified 2,498 robotic-assisted and 37,595 thoracoscopic lobectomies performed from 2008 to 2011. The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy than for those undergoing thoracoscopic lobectomy (50.1% vs 45.2%, P < .05). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P < .05) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .05). The higher risk of iatrogenic bleeding complications persisted in multivariable analyses (adjusted OR, 2.64; 95% CI, 1.58-4.43). Robotic-assisted lobectomy costs significantly more than thoracoscopic lobectomy ($22,582 vs $17,874, P < .05). CONCLUSIONS: In this early experience with robotic surgery, robotic-assisted lobectomy was associated with a higher rate of intraoperative injury and bleeding than was thoracoscopic lobectomy, at a significantly higher cost.

Gastrointestinal complications after mitral valve surgery.

INTRODUCTION: Gastrointestinal (GI) complications are well-recognized risks of open heart surgery. However, open heart surgery comes in different shapes and sizes with widely varying pre-operative, intra-operative and post-operative pathologies. The aim of this study was to examine the etiology and risk factors for GI complications after mitral valve surgery. METHODS: A retrospective analysis of 565 patients who underwent mitral valve surgery from 2003-2005 was performed. Prospectively collected data included preoperative risk factors, cardiac status, intra-operative data, postoperative GI complications and mortality. Survival was analyzed using log-rank analysis. RESULTS: In this study population, 13 patients (2.3%) had 16 GI complications after mitral valve surgery resulting in an overall mortality of 0.7%. Complications included GI bleed (n = 9), cholecystitis (n = 3), perforated diverticulitis (n = 1) and ischemic bowel (n = 3). By univariate analysis, a history of hypertension, chronic renal insufficiency (CRI), hypercholesterolemia, myocardial infarction, congestive heart failure, cardiogenic shock, emergency valve surgery, coronary artery bypass surgery and preoperative vasopressor use were each associated with an increased incidence of GI complications (p <0.05). No increased incidence was seen in patients with atrial fibrillation. On multivariate analysis adjusted for age, cardiogenic shock (OR 8.1; 95% CI, 1.9-34.8), CRI (OR 8.1; 95% CI, 2.2-30.0) and vasopressor use (OR 6.5; 95% CI, 1.3-31.0) remained significant (p <0.02). Mean survival (3.2 vs. 5.4 years) was significantly lower (p <0.05) in those with GI complications. CONCLUSIONS: GI complications after mitral valve surgery are infrequent, with a higher incidence in those with cardiogenic shock, CRI or requiring vasopressors. Pre-operative hemodynamic instability may be a bellwether for potential GI complications and should be of more prominent concern in this cohort of patients.

Usefulness of preoperative exercise tolerance to predict late survival and symptom persistence after surgery for chronic nonischemic mitral regurgitation.

Exercise duration during exercise treadmill testing (ETT) predicts long-term outcome among asymptomatic patients with mitral regurgitation. However, the prognostic value of preoperative exercise duration in patients who undergo mitral valve surgery is unknown. We examined findings among 45 prospectively followed (average 9.2 ± 4.3 years) patients (aged 54.8 ± 12.0 years, 45% men) with chronic isolated severe MR who underwent ETT before mitral valve surgery to test the hypotheses that exercise duration predicts long-term postoperative survival and persistent symptoms within 2 years after operation. During follow-up, 11 patients died; of these, 8 had persistent symptoms. Among patients who exercised >7 minutes, average annual postoperative all-cause and cardiovascular mortality risks were 0.75% (both endpoints) versus 5.4% and 4.8%, respectively, versus those who exercised ≤7 minutes (p = 0.003 all-cause, p = 0.007 cardiovascular). Exercise duration predicted postoperative deaths (p <.02 all cause, p <.04 cardiovascular) even when analysis was adjusted for preoperative variations in age, gender, medications, history of atrial fibrillation, and peak exercise heart rates. Other ETT, echocardiographic, and clinical variables were not independently associated with these outcomes when exercise duration was considered in the analysis. Preoperative exercise duration also predicted postoperative (New York Heart Association functional class ≥II) symptom persistence (p = 0.012), whereas other ETT, echocardiographic and clinical variables did not (NS, all). In conclusion, among patients who undergo surgery for chronic nonischemic mitral regurgitation, preoperative exercise duration, unlike many commonly used descriptors, is useful for predicting postoperative mortality and symptom persistence. Future research should determine whether interventions to improve exercise tolerance before mitral valve surgery can modify these postoperative outcomes.

Nonischemic mitral regurgitation: prognostic value of nonsustained ventricular tachycardia after mitral valve surgery.

BACKGROUND: Nonsustained ventricular tachycardia (VT), frequent in unoperated severe mitral regurgitation (MR), confers mortality risk [sudden death (SD) and cardiac death (CD)]. The prognostic value of VT after mitral valve surgery (MVS) is unknown; we aimed to define this prognostic value and to assess its modulation by left (LV) and/or right (RV) ventricular ejection fraction (EF) for mortality after MVS. METHODS: In 57 patients (53% females, aged 58 ± 12 years) with severe MR prospectively followed before and after MVS, we performed 24-hour ambulatory electrocardiograms approximately annually. LVEF and RVEF were determined within 1 year after MVS by radionuclide cineangiography. RESULTS: During 9.52 ± 3.49 endpoint-free follow-up years, late postoperative CD occurred in 11 patients (7 SD, 4 heart failures). In univariable analysis, >1 VT episode after MVS predicted SD (p < 0.01) and CD (SD or heart failure; p < 0.04). Subnormal postoperative RVEF predicted CD (p < 0.04). When adjusted for preoperative age, gender, etiology or antiarrhythmics, both postoperative VT and RVEF predicted CD (p ≤ 0.05). When postoperative VT and RVEF were both in the multivariable model, only subnormal RVEF predicted CD (p < 0.04). Among those with normal RVEF, VT >1 episode predicted SD (p = 0.03). CONCLUSION: Postoperative VT and subnormal RVEF predict late postoperative deaths in nonischemic MR. Their assessment may aid patient management.

Low-dose spironolactone: effects on artery-to-artery vein grafts and percutaneous coronary intervention sites.

The efficacy of vein grafts used in coronary and peripheral artery bypass is limited by excessive hyperplasia and fibrosis that occur early after engraftment. In the present study, we sought to determine whether low-dose spironolactone alleviates maladaptive vein graft arterialization and alters intimal reaction to coronary artery stenting. Yorkshire pigs were randomized to treatment with oral spironolactone 25 mg daily or placebo. All animals underwent right carotid artery interposition grafting using a segment of external jugular vein and, 5 days later, underwent angiography of carotid and coronary arteries. At that time, a bare metal stent was placed in the left anterior descending artery and balloon angioplasty was performed on the circumflex coronary artery. Repeat carotid and coronary angiograms were performed before euthanasia and graft excision at 30 days. Angiography revealed that venous grafts of spironolactone-treated animals had lumen diameters twice the size of controls at 5 days, a finding that persisted at 30 days. However, neointima and total vessel wall areas also were 2- to 3-fold greater in spironolactone-treated animals, and there were no differences in vessel wall layer thicknesses or collagen and elastin densities. In the coronary circulation, there were no differences between treatment groups in any vessel wall parameters in either stented or unstented vessels. Taken together, these observations suggest that low-dose spironolactone may exert a novel protective effect on remodeling in venous arterial grafts that does not depend on the reduction of hyperplastic changes but may involve dilatation of the vessel wall.

Cardiac surgery in select nonagenarians: should we or shouldn't we?

BACKGROUND: Patients aged 90 years and older represent a rapidly growing subset of the population, many of whom are functionally limited by cardiovascular disease. Clinical decision making about cardiac surgical intervention in nonagenarians is hindered by a paucity of data examining survival outcomes in this population. METHODS: A consecutive series of nonagenarians who underwent cardiac operations between 1995 and 2004 were retrospectively reviewed. Data collection included baseline preoperative clinical status, intraoperative characteristics, and perioperative course. Area under the Kaplan-Meier survival estimate method was used to calculate mean survival. RESULTS: Cardiac surgical procedures were done in 49 patients (51% male); their mean age was 91.9 years (range, 90 to 97 years). Operative mortality was 8% (n = 4). Multivariate Cox proportional hazards models found preoperative chronic renal insufficiency (hazard ratio [HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p = 0.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00; p = 0.033) were independently associated with death. Overall mean survival was 5.1 +/- 0.5 years (median, 5.2 years). Quality of life outcomes were similar to that of two related norm-based populations based on age and disease process. CONCLUSIONS: Cardiac surgical procedures can be performed safely and with therapeutic benefit in carefully selected nonagenarians. We consider physiologic indicators, social factors, and patient preferences to be the main determinants in the patient selection process. Our results support the need for more proactive intervention in symptomatic nonagenarian patients as it relates to earlier consideration of elective, rather than emergency cardiac operations.

Improvement of outcomes after coronary artery bypass II: a randomized trial comparing intraoperative high versus customized mean arterial pressure.

BACKGROUND AND AIM OF THE STUDY: The objective of this randomized trial was to compare the efficacy of two strategies of hemodynamic management during cardiopulmonary bypass (CPB) on morbidity, mortality, cognitive complications and deterioration in functional status. METHODS: Patients scheduled to undergo primary elective CABG were eligible. In one group, mean arterial pressure target during CPB was 80 mmHg ("high" MAP group); in the other group, MAP target was determined by patients' pre-bypass MAP ("custom" MAP group). The principal outcomes were mortality, major neurologic or cardiac complications, cognitive complications or deterioration in functional status. RESULTS: Of 412 enrolled patients, 36% were women, with overall mean age of 64.7 +/- 12.3 years. Duration of bypass was identical for the two randomization groups. Overall complication rates were similar: 16.5% of the high group and 14.6% of the custom group experienced one or more neurologic, cardiac or cognitive complications. When only cardiac and neurologic morbidity and mortality were considered, the rates were 11.7% and 12.6%, in the high and custom groups, respectively. The aggregate outcome rate, including functional deterioration, was 31.6% in the high group and 29.6% in the custom group. CONCLUSIONS: There were no statistically significant differences between the high MAP group and the custom MAP group for the combined outcome of mortality cardiac, neurologic or cognitive complications, and deterioration in the quality of life.

Reoperations on the ascending aorta and aortic root in patients with previous cardiac surgery.

BACKGROUND: First time operations on the ascending aorta are performed with low mortality, few complications, and excellent long-term results. Reoperations for aortic pathology in patients with previous cardiac surgery carry significantly more risk. Technical issues during the procedure, as well as age, preoperative New York Heart Association class, and perioperative renal dysfunction, have been shown to contribute heavily to worse outcomes. We analyzed our results with aortic reoperations with the intent of further reducing surgical risk through alterations in surgical technique or patient selection. METHODS: From July 1997 until October 2005, 147 patients having previous cardiac surgery presented with aneurysm or dissection of the ascending aorta or root. Perioperative data were retrospectively analyzed. Morbidity, mortality, and risk factors for these events were calculated. RESULTS: Eight patients expired (5.4%) after their reoperation. Significant (p < 0.05) univariate risk factors for mortality included age greater than 75 years (< 0.001), previous coronary artery bypass grafting (CABG) (< 0.008), cardiopulmonary bypass greater than 240 minutes (< 0.01), need for intraaortic balloon pump support (< 0.001), need for new CABG (< 0.007), postoperative cerebrovascular accident (< 0.032), and tracheostomy (< 0.003). Age 75 years or older (p < 0.025) was the only significant variable for death by multivariate analysis. A majority of patients (n = 87, 60%) required circulatory arrest to complete their procedure. However, neither arch involvement nor type of aortic root procedure was predictive of perioperative mortality. CONCLUSIONS: Surgery on the ascending aorta and root in patients who have had previous cardiac surgery can be performed with low mortality. Advanced age and significant coronary disease may negatively influence surgical results.

Risk stratification of in-hospital mortality for coronary artery bypass graft surgery.

OBJECTIVES: The purpose of this research was to develop a risk index for in-hospital mortality for coronary artery bypass graft (CABG) surgery. BACKGROUND: Risk indexes for CABG surgery are used to assess patients' operative risk as well as to profile hospitals and surgeons. None has been developed using data from a population-based region in the U.S. for many years. METHODS: Data from New York's Cardiac Surgery Reporting System in 2002 were used to develop a statistical model that predicts mortality and to create a risk index based on a relatively small number of patient risk factors. The fit of the index was tested by applying it to another year (2003) of New York data and testing the correspondence of expected and observed mortality rates for each risk score in the index. RESULTS: The risk index contains a total of 10 risk factors (age, female gender, hemodynamic state, ejection fraction, pre-procedural myocardial infarction, chronic obstructive pulmonary disease, calcified ascending aorta, peripheral arterial disease, renal failure, and previous open heart operations). The score possible for each variable ranges from 0 to 5, and total risk scores possible range from 0 to 34. The highest score observed for any patient was 22, and 93% of the patients had scores of 8 or lower. When the risk index was applied to another year of New York data with a considerably lower mortality rate, the C-statistic was 0.782. CONCLUSIONS: The risk index appears to be a valuable tool for predicting patient risk when applied to another year of New York data. It should now be tested against other risk indexes in a variety of geographical regions.

Epicardial beating heart cryoablation using a novel argon-based cryoclamp and linear probe.

OBJECTIVE: Epicardial, beating heart cryoablation for the treatment of atrial fibrillation may be limited by heat from intracardiac blood flow. We therefore evaluated the ability to create cryolesions using an argon-based cryoclamp device, which temporarily occludes blood flow and facilitates transmurality. METHODS: Six mongrel dogs underwent sternotomy. A clamp employing a 10-cm argon-based linear cryoablation device was used epicardially to isolate the pulmonary veins and left atrial appendage. After clamping of lesions, the probe was removed from the cryoclamp device, and the remaining linear lesions, analogous to the Cox maze III, were performed. Pulmonary vein stenosis was evaluated with the use of magnetic resonance imaging. Left atrial function and pulmonary venous flow velocities were assessed with transesophageal echocardiography. Transmurality was confirmed both electrically and histologically. Animals were then put to death at 30 days. RESULTS: All acute and chronic cryoclamp lesions produced conduction block. There was no change in right (RPV) or left pulmonary vein (LPV) diameter on the basis of magnetic resonance imaging at baseline and at planned death (RPV-1, 19.6 +/- 2.9 mm vs 16.9 +/- 2.8 mm, P = .22; RPV-2, 13.2 +/- 2.0 mm vs 11.8 +/- 1.6 mm, P = .22; and LPV, 12.2 +/- 2.4 mm vs 11.2 +/- 1.9 mm, P = .30). Left atrial function and pulmonary venous flow velocities were unchanged. Tissue sections determined transmurality in 93% of cryoclamp lesions and 84% of linear ablations performed with the 10-cm malleable probe. CONCLUSIONS: Epicardial application of this cryoclamp device on the beating heart produced transmural lesions, which persisted 30 days. Linear epicardial cryoablation was not as effective as the cryoclamp device at producing consistent transmural lesions. This novel, versatile device may be useful in treating patients with atrial fibrillation on the beating heart without cardiopulmonary bypass.

No-clamp technique for valve repair or replacement in patients with a porcelain aorta.

BACKGROUND: Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure. METHODS: Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05. RESULTS: Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001). CONCLUSIONS: Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.

Surgical treatment of atrial fibrillation using argon-based cryoablation during concomitant cardiac procedures.

BACKGROUND: The development of ablative energy sources has simplified the surgical treatment of atrial fibrillation (AF) during concomitant cardiac procedures. We report our results using argon-based endocardial cryoablation for the treatment of AF in patients undergoing concomitant cardiac procedures. METHODS AND RESULTS: Sixty-three patients with AF who were undergoing concomitant cardiac procedures had the same left atrial endocardial lesion set using a flexible argon-based cryoablative device. Mean age was 65.1+/-1.3 years. Sixty-two percent had permanent AF, whereas 38% had paroxysmal AF. Mean duration of AF was 30.5+/-4.8 months. Mean left atrial diameter was 5.5+/-0.1 cm. Mean ejection fraction was 45+/-1.4%. All endocardial lesions were performed for 1 minute once tissue temperature reached -40 degrees C. Follow-up echocardiograms were obtained to determine freedom from AF. Kaplan-Meier analysis demonstrated an 88.5% freedom from AF rate at 12 months. Ablation time was 16.8+/-0.6 minutes. There were no in-hospital deaths and no strokes. Twelve patients (19%) required postoperative permanent pacemaker placement. CONCLUSIONS: Cryoablation using this flexible argon-based device for the treatment of AF during concomitant cardiac procedures was safe and effective, with 88.5% of patients free from AF at 12 months.

Long-term outcomes of coronary-artery bypass grafting versus stent implantation.

BACKGROUND: Several studies have compared outcomes for coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), but most were done before the availability of stenting, which has revolutionized the latter approach. METHODS: We used New York's cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. We determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients' severity of illness before revascularization. RESULTS: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implantation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal left anterior descending coronary artery and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the nonproximal left anterior descending coronary artery. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6 percent for subsequent PCI). CONCLUSIONS: For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting.

Comparison of open versus bedside percutaneous dilatational tracheostomy in the cardiothoracic surgical patient: outcomes and financial analysis.

BACKGROUND: The clinical and financial outcomes of a change in practice from traditional tracheostomy (open) to bedside percutaneous dilatational tracheostomies (PDT) was evaluated in patients who underwent cardiothoracic surgery. METHODS: During 3 years, 86 tracheostomies were performed in more than 4,000 patients who underwent cardiac surgery, 59 open and 27 PDT. A retrospective analysis was performed comparing clinical and financial outcomes of the two groups. RESULTS: There were no significant differences in demographics, medical histories, operations, or complications between open and PDT except the open group experienced more postoperative arrhythmias (70% [41 of 59] versus 44% [12 of 27], p < 0.05). Total savings associated with 1 year of PDT was $84,000, for a projected discounted savings of $283,000 during the study period. A sensitivity analysis of critical economic variables (number of tracheostomies per year, cost of operating room per minute, cost of intensive care unit bed per day) was included to evaluate the impact on cost savings. The net present value analysis, which discounts future savings by an appropriate interest rate, yielded a range of projected savings of PDT more than 5 years of $73,000 to $541,000 with a best estimate of $304,000 using figures established from our 3-year experience with PDT. Sensitivity analysis of the net present value for each critical variable was $227,000 per day of reduced intensive care unit length of stay, $180,000 per cost of operating room avoidance, $100,000 per intensive care unit bed cost per day, and $11,000 per additional tracheostomy per year. CONCLUSIONS: There were no significant clinical differences between open and PDT in cardiac surgery patients during the 3-year study period; however, PDT offered significant cost savings.

Cardiopulmonary bypass in patients with pre-existing coagulopathy.

Patients with pre-existing coagulopathies who undergo surgical interventions are at increased risk for bleeding complications. This risk is especially true in cardiac surgical procedures with cardiopulmonary bypass (CPB) because of the necessity for heparinization and the use of the extracorporeal circuits, which have destructive effects on most of the blood components. In this review, cases of cardiac surgeries in patients with certain pre-existing coagulopathies are summarized, which could shed a light on future managements of such patients undergoing cardiac procedures with CPB. Pre-existing coagulopathies include antithrombin III deficiency, heparin-induced thrombocytopenia, cancer, factor XII deficiency, hemophilia, idiopathic thrombocytopenic purpura, protein S deficiency, and drug-induced platelet inhibition. In summary, pre-existing coagulopathy in patients undergoing open-heart surgeries, if not recognized and appropriately managed, can cause serious complications. Management of patients undergoing cardiac procedures should include a routine coagulation work-up and a thorough past medical history examination. If any of the foregoing is abnormal, further evaluation is warranted. Proper diagnosis and management of the pre-existing coagulopathy disorders is of crucial importance to the surgical outcome and long-term morbidity.

Does cross-clamping the arch increase the risk of descending thoracic and thoracoabdominal aneurysm repair?

BACKGROUND: Descending thoracic and thoracoabdominal aortic aneurysms may arise in the distal aortic arch. Repair of these aneurysms has been associated with increased morbidity and operative mortality. Complex surgical and endovascular techniques have reduced the risks for this cohort. We examined outcomes utilizing an approach based on simple cross-clamping of the arch. METHODS: From July 1997 to January 2004, 272 consecutive patients had aneurysm repair through the left chest. Twenty-nine requiring profound hypothermic circulatory arrest (PHCA) were excluded. Two hundred and forty-three were divided into two groups: group I (n = 60) had distal arch involvement and required cross-clamping proximal to the left subclavian artery. Group II (n = 183) were cross-clamped distal to the subclavian. Adjuncts for neurologic and renal protection were utilized as needed. RESULTS: In-hospital mortality for all 243 patients was 3.7%. There was no difference in mortality between groups (I, 3.3% vs II, 3.8%). Group I patients also had similar rates of paraplegia (I, 0% vs II, 2.2%), stroke (I, 1.2% vs II ,1.1%), and renal failure (I, 1.7% vs II, 5.5%). Group I patients had significantly more recurrent nerve palsies (I, 33% vs II, 4.9%) although this did not translate into a higher incidence of respiratory failure. CONCLUSIONS: Repair of thoracic aneurysms arising in the distal arch can be repaired with a technique based on simple cross-clamping without an increase in mortality or major neurologic injury. Recurrent nerve palsy is much more common with this approach but is well-tolerated without increasing the need for tracheostomy.

Is the impact of hospital and surgeon volumes on the in-hospital mortality rate for coronary artery bypass graft surgery limited to patients at high risk?

BACKGROUND: Restriction of volume-based referral for CABG surgery to high-risk patients has been suggested, and earlier studies have reached different conclusions regarding volume-based referral for low-risk patients. METHODS AND RESULTS: Patients who underwent isolated CABG surgery in New York from 1997 through 1999 (n=57 150) were separated into low-risk and moderate-to-high-risk groups with a predicted probability of in-hospital death of 2% as the cutoff point. The provider volume-mortality relationship was examined for both groups. For annual hospital volume thresholds between 200 and 600 cases, the adjusted ORs of in-hospital mortality for high-volume to low-volume hospitals ranged from 0.45 to 0.77 and were all significant for the low-risk group; for the moderate-to-high-risk group, ORs ranged from 0.62 to 0.91, and most were significant. The number needed to treat at higher-volume hospitals to avoid 1 death was greater for the low-risk group (a range of 114 to 446 versus 37 to 184). As the annual surgeon volume threshold increased from 50 to 150 cases, the ORs for high- to low-volume surgeons increased from 0.43 to 0.74 for the low-risk group; for the moderate-to-high-risk group, ORs ranged from 0.79 to 0.86. Compared with patients treated by surgeons with volumes of <125 in hospitals with volumes of <600, patients treated by higher-volume surgeons in higher-volume hospitals had a significantly lower risk of death; in particular, the OR was 0.52 for the low-risk group. CONCLUSIONS: For both low-risk and moderate-to-high-risk patients, higher provider volume is associated with lower risk of death.