Usefulness of Balloon Aortic Valvuloplasty in the Management of Patients With Aortic Stenosis.

We aim to evaluate the contemporary role and outcomes of balloon aortic valvuloplasty (BAV), based on physician intent, for the management of severe aortic stenosis. This is a prospective, 2-center study of 100 consecutive high-risk patients with severe aortic stenosis who underwent BAV. Before BAV, physicians assigned intent as (1) bridge to decision (BTD); (2) therapeutic bridge to planned therapy; or (3) palliation. Patients in the BTD arm underwent clinical assessment at 30 days to determine eligibility for definitive valve therapy. All patients were followed up to 1 year, with outcomes measured including procedural complications, Kansas City Cardiomyopathy Questionnaires scores, 30-day and 1-year mortality, and definitive valve therapy. Enrolled patients had a mean age of 80.6 (±9.6) years, Society of Thoracic Surgeons predicted risk of mortality of 11.4% (±7.1%), and 91 (91.0%) patients had class III or IV New York Heart Association congestive heart failure. Intent in the 100 study patients was 76 BTD; 20 therapeutic bridge to planned therapy; and 4 palliation. Thirty-day mortality for all patients was 6 of 100 (6.0%), and 1-year mortality for all patients who received definitive valve therapy was 6 of 54 (11.1%). For patients surviving to 30 days, adjusted (by Society of Thoracic Surgeons predicted risk of mortality) Kansas City Cardiomyopathy Questionnaires scores were significantly improved from baseline for all patients and BTD patients. In conclusion, as a bridge to decision and treatment tool, BAV appears to have a valuable role in properly selecting and improving patients to undergo definitive valve replacement.

Prognostic Usefulness of Acute Kidney Injury After Transcatheter Aortic Valve Replacement.

Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) has been associated with increased postoperative morbidity and mortality. Long-term outcomes after TAVR with the Edwards SAPIEN valve in patients who develop AKI postoperatively are currently not well described. We retrospectively reviewed 384 consecutive patients undergoing TAVR at 2 institutions from August 2006 to April 2012. AKI was defined and staged according to Valve Academic Research Consortium-2 criteria. The incidence, multivariate predictors, and association of AKI with 3-year mortality were evaluated. Stage 1 AKI occurred in 24.0% of patients (92 of 384), stage 2 in 5.5% (21 of 384), and stage 3 in 8.1% (31 of 384). The overall operative mortality rate was 7.6%, with a mortality of 3.0% in patients with no kidney injury, 7.6% in stage 1, 23.8% in stage 2, and 32.3% in stage 3. The incidence of new postoperative dialysis was 3.1%. Survival at 3 years for no-AKI/stage 1/stage 2/stage 3 was 59.2 ± 3.3%, 43.4 ± 5.2%, 27.8 ± 10.0%, and 25.4 ± 7.9%, respectively. Logistic regression modeling for the combination of stage 2 or 3 AKI after surgery demonstrated that the last preoperative creatinine (for each 1 mg/dl increase, odds ratio = 3.23, 95% CI 1.83 to 5.69; p <0.001) and dye load (for each 10 ml increase, odds ratio = 1.04, 95% CI 1.01 to 1.08; p = 0.006) were significant predictors for AKI. In conclusion, AKI after TAVR is associated with increased postoperative and 3-year mortality. Significant multivariate predictors are potentially modifiable before the procedure.

Outcomes of Treatment of Nonagenarians With Severe Aortic Stenosis.

BACKGROUND: Because nonagenarians with aortic stenosis (AS) often present as frail with more comorbid conditions, long-term outcomes and quality of life are important treatment considerations. The aim of this report is to describe survival and functional outcomes of nonagenarians undergoing treatment for AS by surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). METHODS: This is a retrospective analysis of all patients aged 90 years or more undergoing treatment for AS between 2007 and 2013 at two centers. Outcomes were compared between SAVR and TAVR. Long-term survival was compared with an age- and sex-matched population from the Social Security Actuarial Life Table. RESULTS: In all, 110 patients underwent treatment for isolated AS (20 SAVR and 90 TAVR). Mean age was 91.85 ± 1.80 years, and 50.9% were female. The Society of Thoracic Surgeons mean predicted risk of mortality was 11.11% ± 5.74%. Operative mortality was 10.9% (10.0% SAVR; 11.1% TAVR); 2.7% of patients had a stroke. The TAVR patients were more likely to be discharged home (75.9% versus 55.6% for SAVR, p = 0.032). Mean follow-up was 1.8 ± 1.5 years, with a 1-year and 5-year survival of 78.7% and 45.3%, respectively, which approximated the US actuarial survival. There was a significant improvement in quality of life as measured by the Kansas City Cardiomyopathy Questionnaire at 1 year compared with baseline. CONCLUSIONS: Treatment of AS approximates natural life expectancy in select nonagenarians, with no significant difference in long-term survival between SAVR and TAVR. Importantly, patient quality of life improved at 1 year. With appropriate selection, nonagenarians with severe AS can benefit from treatment.

Does coronary artery bypass graft surgery improve survival among patients with end-stage renal disease?

BACKGROUND: Cardiovascular disease remains the most frequent cause of death for patients with end-stage renal disease. To determine the long-term benefit of surgical revascularization in this high-risk population, we studied our patients with ESRD having coronary artery bypass graft surgery (CABG), comparing the results of off-pump to on-pump revascularization. As a baseline reference group, we used dialysis patients with a diagnosis of coronary artery disease who did not have surgical revascularization or percutaneous coronary interventions. The control group data set was obtained from the United States Renal Data System. METHODS: From January 1995 through July 2003, 158 patients with end-stage renal disease who were on hemodialysis (excluding those in cardiogenic shock, needing resuscitation, and with emergent or salvage status) underwent CABG. Fifty-nine patients (37.3%) had off-pump revascularization, and 99 patients (62.7%) had bypass grafting utilizing extracorporeal circulation. Preoperative risk factors and operative results were analyzed, and longitudinal survival data obtained. RESULTS: The mean follow-up time was 39.1 months (median, 33.1) for the on-pump patients and 18.3 months (median, 14.7) for off-pump. The total number of anastomoses per off-pump patient was 2.4 +/- 1.0, and with cardiopulmonary bypass (CPB), it was 3.3 +/- 0.9 (p < 0.001). Patients revascularized off-pump had an operative mortality rate of 1.7%, whereas patients grafted using CPB had an operative mortality of 17.2% (p = 0.003). The predicted risk of mortality for the off-pump group (9.3% +/- 7.4%) was not statistically different from the on-pump cohort (9.1% +/- 7.7%, p = not significant). Logistic regression analysis indicates that CPB use was an independent risk factor for early death (p = 0.01, odds ratio = 13.6, 95% confidence interval: 1.7 to 110). Long-term follow-up demonstrated that the patients revascularized using CPB had improved survival compared with the off-pump patients and the control population. CONCLUSIONS: Off-pump CABG improves early mortality rate when compared with conventional revascularization. Despite a greater operative mortality, however, long-term survival is improved in the patients revascularized with CPB as compared with the off-pump cohort, suggesting possible advantages from a more complete revascularization in this population.

Experience with various surgical options for the treatment of atrial fibrillation.

BACKGROUND: New alternatives exist using various energy sources and lesion lines for the surgical treatment of atrial fibrillation (AF). The efficacy of these options compared to the cut-and-sew maze III procedure is unknown. METHODS: From August 1996 to August 2003, 79 patients have undergone a procedure for AF, with 70 patients currently more than 3 months postsurgery. The patients (58 continuous, 12 paroxysmal) underwent a surgical procedure for AF, lone AF (12) and with concomitant procedures (58). Techniques included cut and sew (23), bipolar radiofrequency (RF) (28) and unipolar-RF (10), and cryothermy (9). Lesions included maze III (46), pulmonary vein isolation (16), and pulmonary vein isolation plus mitral annular connecting line only (8). RESULTS: Follow-up was complete in 58 (83%) of 70 patients at a mean time of 595 +/- 750 days (range, 24-2530 days). The operative mortality was 0% in lone AF patients and 7.1% (5/70) in patients undergoing concomitant procedures. Need for perioperative pacemaker was 22.9%. Overall, normal sinus rhythm (NSR) was restored in 82.7% of patients, with success in 83.3% (10/12) lone procedures and 82.6% (38/46) concomitant procedures ( P = NS); the rate of continuous AF was 85.1% (40/47) and SR with paroxysmal fibrillation was 72.7% (8/11) ( P = NS). Traditional maze was successful in 80.6% (29/36) patients, pulmonary vein isolation was successful 93.3% (14/15), and left-sided maze in 71.4% (5/7) ( P = NS). Cut and sew procedures were successful in 88.2% (15/17), RF-bipolar in 84.0% (21/25), RFunipolar in 77.8% (7/9), and cryothermy in 71.4% (5/7) ( P = NS). Energy source, lesion set, AF duration, and lone/concomitant procedure were the factors subjected to logistic regression analysis. No factors were predictive of achieving postoperative NSR. CONCLUSIONS: Our early experience with newer surgical techniques employing different energy sources and fewer incision lines suggests that the success rate may approach the results obtained with traditional cut-and-sew Cox-maze III procedures.

First-year outcomes of beating heart coronary artery bypass grafting using proximal mechanical connectors.

BACKGROUND: To determine the extended results of mechanical connectors we compared the 1-year outcomes of patients having beating heart coronary artery bypass surgery with at least one sutured or mechanically connected proximal vein graft anastomosis. METHODS: From May 2001 to December 2001, 166 patients were identified as having undergone off-pump bypass grafting utilizing at least one St. Jude symmetry aortic connector (St Jude Medical Anastomotic Technology Group, St. Paul, MN). Follow-up for major adverse cardiac events (MACEs), which is defined as cardiac mortality, myocardial infarction, or revascularization of a previous target vessel, was obtained on 162 patients (97.6%). A control group of 159 patients was identified from a cohort of patients having beating heart surgery with one or more sutured proximal vein graft anastomosis in the preceding year. The MACE follow-ups were obtained in 136 patients (85.6%) by direct telephone contact. RESULTS: Patients with connectors showed an accelerated number of MACEs beginning approximately 180 days from the time of surgery and stabilizing at approximately 300 days. Logistic regression analysis identified the presence of diabetes as a significant preoperative risk factor predisposing patients to earlier onset of MACEs (p = 0.03) with an odds ratio of 2.9 (95% confidence interval, 1.1 to 7.6). Insulin dependent diabetics showed no differences between connector and control patients in the frequency or timing of MACEs. Connector patients using oral hypoglycemic agents demonstrated a significant deviation (p = 0.01) from a similar control population in the prevalence and timing of MACEs. CONCLUSIONS: Connector patients showed an increased incidence of early MACEs. These events were characterized by an increased requirement for early target vessel revascularization and were predominantly in noninsulin-dependent diabetics.