Coronary artery bypass grafting in patients with concomitant solid tumours: early and long-term results.

OBJECTIVES: Our goal was to analyse a consecutive series of patients with solid organ tumours undergoing coronary artery bypass grafting (CABG) by defining the risk factors for early and long-term outcomes. METHODS: Between 2005 and 2016, a consecutive series of 4079 patients underwent isolated CABG at our institution. Of 103 patients (2.5%) with active malignancy, we enrolled 82 patients (mean age 71 ± 7 years) with solid organ tumours, divided into 4 subgroups: lung (9 patients-11%), gastroenteric (16 patients-20%), urinary (48 patients-58%) and other solid tumours (9 patients-11%). A deterministic record linkage between the clinical database and the National Hospital Information System allowed identification of long-term survival rates and freedom from major adverse cardiovascular events (acute myocardial infarction, repeated admissions for percutaneous coronary intervention and heart failure). RESULTS: The most common forms of cancer were prostate, colon and carcinoma of the lung. Compared to patients without cancer, patients with neoplasms were significantly older and had a higher rate of comorbidities, without significant differences among the cancer subgroups. The 30-day mortality rate was significantly higher in patients with cancer compared to those without cancer (4.9% vs 1.8%). However, on logistic regression analysis, cancer was an independent risk factor for postoperative pulmonary dysfunction but not for in-hospital death. The median follow-up time was 58 ± 12 months. The overall 5-year survival rate was 60% [95% confidence interval (CI) 47-71%], with a dismal 32% (95% CI 5-65%) survival rate among patients who had lung tumours only. The 5-year freedom from major adverse cardiovascular events was 64% (95% CI 52-74%), without significant differences among subgroups, and was comparable to that of the non-cancer population. Resolution of coronary heart disease allowed safe cancer surgical resection in 80% of the population. CONCLUSIONS: Based on the results from the present study, CABG should not be denied to patients with solid organ tumours by claiming a worse prognosis or less graft durability. Further studies with larger numbers are warranted.

Giant pseudoaneurysm of the innominate artery late after surgical repair of type-A aortic dissection.

A 49-year-old man was admitted to our department 6 months after emergent surgery for type-A acute aortic dissection. A chest computed tomography-scan revealed a huge aneurysm originating from the proximal aortic arch, strongly adherent to the upper part of the sternum. Extracorporeal circulation was instituted first, and chest was reopened in circulatory arrest. The mass was a giant pseudoaneurysm originating from a laceration at the base of the innominate artery. Due to tissue fragility and complete distortion of the origin of right carotid and subclavian arteries, we performed an extra-anatomic ascending aorta-to-right carotid artery bypass, followed by Teflon-reinforced suture of the proximal artery stumps. The postoperative course was uneventful.

Is female sex an independent risk factor for early mortality in isolated coronary artery bypass graft? A propensity-matched analysis.

AIMS: Despite several studies reporting a higher mortality rate for women undergoing isolated coronary artery bypass graft (CABG) surgery, this issue has not been completely clarified. The aim of the current study was to determine if sex differences in CABG surgery affect adjusted operative results and operative mortality. METHODS: Between January 2005 and December 2012, 3756 consecutive patients (3009 men and 747 women) underwent isolated CABG at our institution. Women presented with older age, smaller BSA and higher rate of preoperative comorbidities. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups. RESULTS: The distribution of preoperative variables among matched pairs (553 patients in both groups) was, on average, equal. Propensity-matched women received a similar number of distal anastomoses (P = 0.56), had similar rate of left internal thoracic artery (LITA) graft (P = 0.73) and comparable extracorporeal circulation (P = 0.61) and aortic cross-clamp (P = 0.39) time as men. Postoperative complications were comparable in the two study groups with the exception of postoperative transfusion rate which was significantly higher in women (P = 0.01). However, operative mortality (3.8 vs. 2.7%; P = 0.20), perioperative acute myocardial infarction (P = 0.50) and stroke (P = 0.75) were not significantly different between the two groups. Interestingly, after adjustment for the other baseline characteristics, female patients with diabetes (P = 0.03), preoperative renal dysfunction (P = 0.07) and obesity (P = 0.07) exhibited a greater operative mortality rate compared with men with the same comorbidities. CONCLUSION: After adjustment for preoperative variables, female sex seems not to be an independent risk factor for early mortality in isolated CABG surgery. However, renal impairment, diabetes and obesity seem to play an important role in the operative risk profile of women undergoing isolated CABG.

Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study.

OBJECTIVES: Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS: A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS: A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS: Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Surgical ventricular restoration plus mitral valve repair in patients with ischaemic heart failure: risk factors for early and mid-term outcomes†.

OBJECTIVES: To assess the early and mid-term outcomes and related predictors in a consecutive series of patients who underwent surgical ventricular restoration (SVR) combined with additional mitral valve (MV) repair. METHODS: From January 2001 to October 2014, 626 patients underwent SVR; of these, 175 (28%, median age 65) had an additional MV repair. Anterior, inferior or diffuse remodelling was present in 124 (71%), 41 (23%) and 10 (6%) patients, respectively. The median ejection fraction was 30%, whereas mitral regurgitation grade was 3.3 ± 0.8. Multivariable logistic regression and Cox regression analyses were used to identify predictors of early and mid-term mortality. RESULTS: Operative death occurred in 25 patients (14.3%). Independent predictors of early mortality were age, creatinine and ejection fraction score [odds ratio (OR) = 5.1, 95% confidence interval (CI) 2.5-10.3], previous stroke (OR = 8.0, 95% CI 1.5-44), unstable angina (OR = 8.8, 95% CI 1.5-53) and diffuse remodelling (OR = 5.8, 95% CI 1.02-33). Average follow-up was 42 ± 37 months. The actuarial survival rate of the whole patient population at 3, 5 and 8 years was 72 ± 4, 65 ± 4 and 45 ± 6%, respectively. Risk factors for late mortality were preoperative creatinine (OR = 2.6, 95% CI 1.5-4.4), previous implantation of cardioverter defibrillator (OR = 4.7, 95% CI 1.6-5.8), whereas the absence of angina at the time of surgery emerged as protective factor (OR = 0.46, 95% CI 0.23-0.89). CONCLUSIONS: MV repair combined with SVR is a complex and challenging procedure that can be performed with acceptable early and mid-term results. Interestingly, angina features predict both early and late outcome, with unstable angina at the time of surgery being a predictor of poor early outcome and the absence of angina at surgery, a predictor of favourable outcome at mid-term follow-up.

Aortic valve decalcification for severe aortic valve stenosis in the elderly: medium-term results.

AIMS: To present the results of a novel technique of aortic valve decalcification (AVD) in a consecutive population of elderly patients with severe aortic valve stenosis (AVS) and small aortic annulus. METHODS: Between January 2008 and December 2012, a consecutive series of 34 patients (mean age 80 ±â€Š13 years) with severe AVS were operated on using AVD. They were compared with a matched population of 68 patients (mean age 82 ±â€Š7 years) submitted to aortic valve replacement (AVR) with bioprosthesis. The two groups were comparable for cardiac risk factors and admission symptoms. Preoperatively, all patients presented with severe AVS, small aortic annulus (19 mm) and preserved left ventricular function. RESULTS: Thirty-day mortality was 8.8 vs. 7.5% in the AVD and AVR groups, respectively (P = 0.88). Actuarial 2 and 5-year survival rates were 80 vs. 82% and 64 vs. 78% in the AVD and AVR groups, respectively (P = 0.27). Long-term valve-related events incidence was significantly higher in the AVD group (12%) compared with that in the AVR group (4%; P = 0.01). However, in the AVD group, patients with no or mild residual AR experienced 2 and 5 years of freedom from valve-related events, which is not significantly different from the patients submitted to the AVR group (P = 0.76). After AVD, a significant increase in the aortic valve area (from 0.8 to 1.9 cm) and a parallel reduction in the mean gradient (from 40 to 12 mmHg) was observed in all patients (P = 0.01). Postoperative aortic valve area (1.9 vs. 1.26 cm), as well as mean gradient (12 vs. 21 mmHg), were significantly better in the AVD group compared with that in the AVR group (P = 0.01). CONCLUSION: In this preliminary experience, AVD seems a good therapeutic option for elderly patients with severe AVS. Further studies with longer follow-up are needed in order to confirm these preliminary results and to ascertain the valve durability over time.

Long-term results of sequential vein coronary artery bypass grafting compared with totally arterial myocardial revascularization: a propensity score-matched follow-up study†.

OBJECTIVES: The aim of the study was to analyse the early and long-term outcomes of a consecutive series of patients who underwent sequential coronary artery bypass grafting (CABG) and to compare them with a matched population of totally arterial revascularized patients. METHODS: From January 1994 to December 1996, 209 patients underwent total arterial myocardial revascularization at our institution [arterial (ART) group]. In the same period, 2097 patients underwent CABG with left internal thoracic artery on left anterior descending and great saphenous vein on the right and circumflex branches sequentially [sequential vein (SV) group]. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups (209 vs 243 patients in the ART group and SV group, respectively). RESULTS: In-hospital mortality was 1% in the ART group and 0.4% in the SV group (P = 0.86). Mean follow-up was 14 ± 4 years. Long-term survival was comparable among the two study groups [actuarial 5- and 15-year survival rates were 97 vs 93% and 82 vs 79% in the ART group and the SV group, respectively (P = 0.29)]. At follow-up, recurrence of angina (17 vs 18%; P = 0.99), acute myocardial infarction (MI) (3 vs 5%; P = 0.72) and repeated percutaneous coronary intervention (19 vs 21%; P = 0.69) were similar in the ART group compared with the SV group. In the Cox regression analysis, type of revascularization was not an independent predictor of any long-term outcomes (death or major adverse cardiac events). In asymptomatic patients, exercise stress test at follow-up was comparable between the two groups (P = 0.14). CONCLUSIONS: Sequential vein CABG appears to have good early and long-term clinical outcomes. Also, early and long-term incidence of acute MI was not significantly higher in the SV group. However, further studies with a larger population are warranted in order to confirm the present results.

Surgical excision of cardiac myxomas: twenty years experience at a single institution.

BACKGROUND: Primary cardiac tumors are quite uncommon and myxomas constitute the major proportion among these masses. The present study summarizes our 20-year clinical experience with surgical resection of intracardiac myxomas. METHODS: Between January 1990 and December 2007, 98 patients (42 males, mean age 60.4±4.1 years) underwent complete excision of primary intracardiac myxoma. In 84 patients the origin site of the tumor was located in the left atrium, and the most common implant site was the interatrial septum. The most common symptom at admission was dyspnea, while systemic embolization was observed in 37 patients. Preoperative diagnosis was established in all patients by transthoracic echocardiography. All patients were operated through median sternotomy. RESULTS: Ninety-five patients (97%) survived the operation. Mean tumor dimension was 2.7±1.3 cm in largest diameter. According to the St. John Sutton classification (St. John Sutton MG, Mercier LA, Giuliani ER, et al. Atrial myxomas: a review of clinical experience in 40 patients. Mayo Clin Pro 1980;55:371-6), solid tumors were detected in 43 patients (44%), while a papillary myxoma was found in 55 patients (56%). The follow-up was 100% complete, and the mean time to last follow-up was 98±60 months. Of the 95 survivors, 3 patients (3%) died at a mean follow-up of 72±45 months after surgery. Actuarial survival was 98%, 98%, and 89% at 5, 10, and 15 years, respectively. One patient operated for left atrial myxoma resection showed a recurrence 68 months after the first surgery. CONCLUSIONS: Although cardiac myxomas carry the risk of severe systemic and cardiac symptoms, prompt surgical excision gives excellent early and long-term results.

Aortic valve replacement with 17-mm mechanical prostheses: is patient-prosthesis mismatch a relevant phenomenon?

BACKGROUND: We sought to evaluate the long-term performance of a consecutive cohort of patients implanted with a 17-mm bileaflet mechanical prosthesis. METHODS: Between January 1995 and December 2005, 78 patients (74 women, mean age=71±12 years) underwent aortic valve replacement with a 17-mm mechanical bileaflet prosthesis (Sorin Bicarbon-Slim and St. Jude Medical-HP). Preoperative mean body surface area and New York Heart Association class were 1.6±0.2 m2 and 2.6±0.8, respectively. Preoperative mean aortic annulus, indexed aortic valve area, and peak and mean gradients were 18±1.6 mm, 0.42 cm2/m2, 89±32 mm Hg, and 56±21 mm Hg, respectively. Patients were divided into two groups, according to the presence (group A, 29 patients) or absence of patient-prosthesis mismatch (group B, 49 patients). Patient-prosthesis mismatch was defined by an indexed effective orifice area less than 0.85 cm2/m2. RESULTS: Overall hospital mortality was 8.8%. Follow-up time averaged 86±44 months. Actuarial 5-year and 10-year survival rates were 83.7% and 65.3%, respectively. The mean postoperative New York Heart Association class was 1.3±0.6 (p<0.001). Overall indexed left ventricular mass decreased from 163±48 to 120±42 g/m2 (p<0.001), whereas average peak and mean prosthesis gradients were 28±9 mm Hg and 15±6 mm Hg, respectively (p<0.001). Early and long-term mortality were similar between the two groups as well as long-term hemodynamic performance (mean peak gradient was 28 mm Hg and 27 mm Hg in group A and B, respectively, not significant); left ventricular mass regression occurred similarly in both groups (indexed left ventricular mass at follow-up was 136±48 and 113±40 in group A and B, respectively; not significant). CONCLUSIONS: Selected patients with aortic stenosis experience satisfactory clinical improvement after aortic valve replacement with modern small-diameter bileaflet prostheses.

Tricuspid valve replacement with mechanical prostheses: long-term results.

BACKGROUND AND AIM OF THE STUDY: Historically, tricuspid valve replacement (TVR) has been associated with high mortality and morbidity, and current knowledge in the long-term outcome of TVR is limited. The study aim was to review the authors' experience from a consecutive series of patients. METHODS: Between January 1990 and December 2005, a total of 43 patients (seven males, 36 females; mean age 52 +/- 14 years) underwent TVR. The etiology was rheumatic in 33 patients (77%) and degenerative disease in 10 (22%). Thirty-six patients (84%) were in NYHA class III or IV. Thirty-four patients (79%) underwent redo procedures; all patients underwent TVR with a mechanical prosthesis. RESULTS: The overall operative mortality was 16% (n = 7). Of the 36 survivors, nine (25%) died during follow up. The Kaplan-Meier survival at 2.5, 5, and 10 years was 78%, 70%, and 58%, respectively. Five patients (14%) underwent reoperation during follow up (three for tricuspid valve thrombosis) and all five survived the reoperation. Freedom from reoperation at five and 10 years was 90% and 74%, respectively. On permutation test analysis, older age, liver congestion and redo surgery were found to be the major determinants of long-term mortality. CONCLUSION: TVR carries a higher short- and long-term mortality when compared to left-heart valve surgery. A timely referral before the development of end-stage cardiac impairment might determine a further improvement in outcome.

Chronic epigastric blood collection after coronary artery bypass grafting: case report.

A clinical case of epigastric pain 3 months after coronary artery bypass grafting (CABG) is presented. The CT finding of an abdominal mass with thick wall, internal horizontal by-gravity level and linear contrast enhancement at the border between the two different components was correctly interpreted for a chronic hematoma with separation of the formed blood elements from blood serum; in particular, the linear contrast enhancement was related to an artery-feeding vessel.