Aortic cross-clamp time correlates with mortality in the mini-mitral international registry.

OBJECTIVES: Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery. Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer. METHODS: We analysed the largest registry of mitral and/or tricuspid valve surgery patients (mini-mitral international registry (MMIR)) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015 to 2021, 7513 consecutive patients underwent mini-mitral and/or tricuspid valve surgery in 17 international Heart-Valve-Centres. Data were collected according to Mitral Valve Academic Research Consortium (MVARC) definitions and 6878 patients with 1 cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times. RESULTS: Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (Inpatient Quality Reporting (IQR): 0.80-2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional tricuspid valve surgery and 19% Atrial Fibrillation (AF)-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR: 107-173) and 85 min (IQR: 64-111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all P < 0.001). Age, low ejection fraction and emergent surgery were risk factors, but variables of 'increased complexity' (redo, endocarditis, concomitant procedures) were not. CONCLUSIONS: Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes.

Preoperative Pericardial Effusion is Associated with Low Cardiac Output Syndrome After Pericardiectomy for Constrictive Pericarditis.

BACKGROUND: Low cardiac output syndrome is the main cause of death after pericardiectomy. METHODS: Patients who underwent pericardiectomy for constrictive pericarditis from January 2009 to October 2020 at our hospital were included in the study. Histopathologic studies of pericardium tissue from every patient were performed. All survivors were followed up. RESULTS: Ninety-two consecutive patients underdoing pericardiectomy were included in the study. The incidence of postoperative low cardiac output syndrome was 10.7% (10/92). There were five operative deaths. Mortality and incidence of LCOS in the group with pericardial effusion were significantly higher than those in the group without pericardial effusion. Tuberculosis of the pericardium (60/92, 65.2%) was the most common histopathologic finding in this study. Both univariate and multivariate analyses showed that preoperative pericardial effusion is associated with increased rate of low cardiac output syndrome. Eighty-five survivors were in NYHA class I (85/87, 97.7%), and two were in class II (2/87, 2.3%) at the latest follow up. CONCLUSIONS: Preoperative pericardial effusion is associated with low cardiac output syndrome after pericardiectomy. Tuberculosis of the pericardium was the most common histopathologic finding in this study. For constrictive pericarditis caused by tuberculous bacteria, systematic antituberculosis drugs should be given. Preoperative pericardial effusion is associated with increased rate of low cardiac output syndrome. Perfect preoperative preparation is very important to reduce the incidence of postoperative low cardiac output syndrome and mortality. It is very important to use a large dose of diuretics with cardiotonic or vasopressor in a short time after the operation.

Use of Impella CP Device in Off-Pump Coronary Artery Bypass Graft Surgery.

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.

Pre-operative neutrophil-lymphocyte ratio predicts low cardiac output in children after cardiac surgery.

Neutrophil-lymphocyte ratio has been associated with clinical outcomes in several groups of cardiac patients, including patients with coronary artery disease, cardiac failure, and cardiac transplant recipients. We hypothesised that pre- and/or post-operative haematological cell counts are associated with clinical outcomes in children undergoing cardiac surgery for CHD. We performed a post hoc analysis of data collected as part of a prospective observational cohort study (n = 83, data available n = 47) of children evaluated for glucocorticoid receptor levels after cardiac surgery (July 2015-January 2016). The association of neutrophil-lymphocyte ratio with low cardiac output syndrome, time to inotrope free, and vasoactive-inotropic score was examined using proportional odds analysis, cox regression, and linear regression models, respectively. A majority (80%) of patients were infants (median/interquartile range 4.1/0.2-7.6 months) with conotruncal (36%) and left-sided obstructed lesions (28%). Two patients required mechanical circulatory support and three died. Higher pre-operative neutrophil-lymphocyte ratio was associated with higher cumulative odds of severe/moderate versus mild low cardiac output on post-operative day 1 (odds ratio 2.86; 95% confidence interval 1.18-6.93; p = 0.02). Pre-operative neutrophil-lymphocyte ratio was not significantly associated with time to inotrope free or vasoactive-inotrope score. Post-operative neutrophil-lymphocyte ratio was also not associated with outcomes. In children after congenital heart surgery, higher pre-operative neutrophil-lymphocyte ratio was associated with a higher chance of low cardiac output in the early post-operative period. Pre-operative neutrophil-lymphocyte ratio maybe a useful prognostic marker in children undergoing congenital heart surgery.

Perioperative management of critical right ventricular inflow obstruction from right atrial rhabdomyoma.

Rhabdomyoma is the most common cardiac tumor in infancy and commonly located in the ventricles causing outflow obstruction or arrhythmias. We report a rare pediatric (7 month old) case of a right atrial rhabdomyoma presenting with severe cyanosis and low cardiac output from significant tricuspid inflow obstruction with right to left shunt across a stretched patent foramen ovale. We present an emergency cardiac surgery for right atrial tumor resection, and the management of separating the patient with failing right ventricle from cardiopulmonary bypass using a Glenn shunt, since extracorporeal membrane oxygenation (ECMO) or nitric oxide was not available.

Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis.

BACKGROUND: Recent studies suggest that levosimendan does not provide mortality benefit in patients with low cardiac output syndrome undergoing cardiac surgery. These results conflict with previous findings. The aim of the current study is to assess whether levosimendan reduces postoperative mortality in patients with impaired left ventricular function (mean EF ≤ 40%) undergoing cardiac surgery. METHODS: We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library Database through November 20, 2017. Inclusion criteria were random allocation to treatment with at least one group receiving levosimendan and another group receiving placebo or other treatments and cardiac surgery patients with a left ventricular ejection fraction of 40% or less. The primary endpoint was postoperative mortality. Secondary outcomes were cardiac index, pulmonary capillary wedge pressure (PCWP), length of intensive care unit (ICU) stay, postoperative atrial fibrillation, and postoperative renal replacement therapy. We performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint. RESULTS: Data from 2,152 patients in 15 randomized clinical trials were analyzed. Pooled results demonstrated a reduction in postoperative mortality in the levosimendan group [RR = 0.53, 95% CI (0.38-0.73), I2 = 0]. However, the result of TSA showed that the conclusion may be a false positive. Secondary outcomes demonstrated that PCWP, postoperative renal replacement therapy, and length of ICU stay were significantly reduced. Cardiac index was greater in the levosimendan group. No difference was found in the rate of postoperative atrial fibrillation. CONCLUSIONS: Levosimendan reduces the rate of death and other adverse outcomes in patients with low ejection fraction who were undergoing cardiac surgery, but results remain inconclusive. More large-volume randomized clinical trials (RCTs) are warranted.

Intramural Left Coronary Artery in Truncus Arteriosus.

An intramural coronary artery in the setting of truncus arteriosus (common arterial trunk) is an uncommon association. Following an uneventful surgical repair, a neonate developed a low cardiac output state deteriorating into cardiac arrest shortly after arrival into the intensive care unit, requiring extracorporeal membrane oxygenation support. Echocardiography and angiography showed occlusion of the left coronary artery, prompting emergency surgical reexploration. A "slit-like" orifice with an intramural left coronary artery was successfully unroofed, allowing full recovery. Full definition of the proximal coronary anatomy beyond the orifices should be investigated preoperatively in truncus arteriosus, as a missed intramural segment could lead to significant morbidity or mortality.

What is the optimum method of weaning intra-aortic balloon pumps?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is weaning an intra-aortic balloon pump by volume superior to ratio reduction in terms of failure of weaning, inotropic support and haemodynamic parameters? A total of 667 papers were identified as a result of the search described below. Six papers were relevant to the question asked. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Little published evidence exists, although weaning by ratio is more common particularly in high-volume centres. The published data highlight the heterogeneity of weaning protocols not only between countries but also between hospitals in the same country. Current evidence is unable to establish any difference in clinical outcomes including mortality, reinsertion of intra-aortic balloon pumps and requirement for inotropic support between weaning by ratio, volume weaning and abrupt cessation. Despite this, the only randomized trial demonstrates improved haemodynamic profiles in those weaned by volume weaning. In addition, given the difficulty in obtaining clear clinical outcomes, N-terminal pro-brain natriuretic peptide and central venous oxygen saturation may be useful as surrogate markers for successful weaning.

[PECULIARITIES OF ANESTHESIA AND MECHANICAL VENTILATION IN CHILDREN WITH SURGICAL PATHOLOGY AND RELATED CONGENITAL HEART DEFECTS].

Unfortunately, last years there are more and more children with multiple malformations. Often in the intensive care unit appears children with problems requiring urgent surgical intervention. Congenital heart diseases (CHD) are often accompanying pathology. There are specific changes in hemodynamics in this category of children, which influence parameters of mechanical ventilation, leading sometimes to extremely undesirable consequences. Accordingly, this review deals with the features of anesthesia for various surgical interventions in children with severe (often uncorrected) accompanying CHD.

Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart Disease.

The purpose of this review is to discuss the management of the low cardiac output syndrome (LCOS) following surgery for congenital heart disease. The LCOS is a well-recognized, frequent post-operative complication with an accepted collection of hemodynamic and physiologic aberrations. Approximately 25% of children experience a decrease in cardiac index of less than 2 L/min/m2 within 6-18 hours after cardiac surgery. Post-operative strategies that may be used to manage patients as risk for or in a state of low cardiac output include the use of hemodynamic monitoring, enabling a timely and accurate assessment of cardiovascular function and tissue oxygenation; optimization of ventricular loading conditions; the judicious use of inotropic agents; an appreciation of and the utilization of positive pressure ventilation for circulatory support; and, in some circumstances, mechanical circulatory support. All interventions and strategies should culminate in improving the relationship between oxygen supply and demand, ensuring adequate tissue oxygenation.

Metabolic Uncoupling Following Cardiopulmonary Bypass.

OBJECTIVE: The objective of this study was to characterize the natural history of metabolic uncoupling (type B hyperlactemia and hyperglycemia) following cardiopulmonary bypass (CPB), and to determine the impact of insulin therapy on time to lactate normalization in patients without low cardiac output. DESIGN: The design used was a retrospective cohort study. SETTING: The study was set in a pediatric cardiac intensive care unit in a tertiary-care urban children's hospital. PATIENTS: All patients were aged ≤21 years admitted between 2007 and 2013 following cardiac surgery involving CPB with empiric intraoperative corticosteroids. ELIGIBILITY CRITERIA: simultaneous hyperlactemia (≥3.5 mEq/L) and hyperglycemia (≥200 mg/dL) within 48 hours after bypass. EXCLUSION CRITERIA: Exclusion criteria were evidence of low cardiac output state, diabetes or postoperative steroid administration. INTERVENTIONS: Characteristics were compared between those treated with insulin and those who were not (controls). OUTCOME MEASURES: Outcome measures used were time from admission to onset of hyperglycemia and hyperlactemia and time to resolution. Clinical outcomes included duration of mechanical ventilation, length of stay, unplanned readmission/reoperation, hypoglycemia and death. RESULTS: Of the 1345 patients receiving CPB, 132 (9.8%) met inclusion criteria. Seventy-eight (59%) were treated with insulin, leaving 54 controls. Patient characteristics, surgical complexity and time to onset of hyperglycemia and hyperlactemia were similar between groups. The insulin group had a shorter duration of hyperglycemia. There was no significant difference between groups in time to lactate normalization, ventilator days, length of stay, readmission and reoperation rates. Hypoglycemia (<60 mg/dL) occurred in three patients. CONCLUSIONS: In children with metabolic uncoupling after CPB, insulin use did not shorten the time to lactate normalization or alter clinical outcomes. These findings suggest that type B hyperlactemia with hyperglycemia after CPB will resolve spontaneously and does not warrant specific treatment.

Outcome of intracoronary shunt in off-pump coronary artery bypass surgery in patients with low cardiac output.

Patients with coronary artery disease and left ventricular dysfunction have high mortality with non surgical (medical) treatment. Coronary artery bypass grafting improves survival and the quality of life. Recently, revascularization without cardiopulmonary bypass has been presented as a viable alternative. The aim of this study was to survey the result of coronary artery bypass grafting with off pump technique using intracoronary shunt in patients with left ventricular ejection fraction≤ 25%. From January 2009 to December 2012, 86 patients with an ejection fraction ≤ 25% (58 males, 28 females) aged 41- 84 years (61.2 ± 3.1 yrs) underwent coronary artery bypass graft surgery with off-pump technique. Grafting was performed as needed with internal mammary artery and saphenous vein. We studied operative and postoperative data. Hospital Mortality was 2.32% (two patients). Postoperative complications were low. Total length of hospital stay was 7.2 days, length of ICU stay 2.1 days pulmonary complications 3.48% (three patients), postoperative bleeding 340, acute renal failure 1.16% (one patient) and left-ventricle ejection fraction before discharge was increased about 10% in these patients. Coronary artery bypass grafting without cardiopulmonary bypass with intracoronary shunt in patients with severe left ventricular dysfunction is valid and safe and has low mortality and morbidity.

Outcomes of extracorporeal life support for low cardiac output syndrome after major cardiac surgery.

OBJECTIVE: Extracorporeal life support (ECLS) is a widely accepted modality for the treatment of postoperative low cardiac output syndrome (LCOS) after major cardiac surgery by providing temporary circulatory support for the stunned myocardium. We sought to identify the factors that affect outcomes of ECLS for postoperative LCOS. METHODS: From 2005 to 2011, of a total of 9267 adult patients underwent major cardiac surgery, 93 patients (aged, 60.6 ± 13.8 years; 47 women) underwent ECLS to treat postoperative LCOS. RESULTS: Thirty-nine (41.9%) patients were weaned off ECLS successfully, and 1 patient underwent heart transplantation. A final total of 23 patients (24.3%), including 1 heart transplantation recipient, survived until the end of the follow-up period (median, 611 days; range, 125-2247 days). On logistic regression analysis, old age (P = .001), a high blood lactate level before ECLS initiation (P < .001), cardiopulmonary bypass weaning failure after surgery (P < .001), and postoperative bleeding (P = .012) were independent factors associated with mortality. In contrast, administration of anticoagulant nafamostat mesilate (P = .040) was found to be associated with improved outcomes of ECLS. When the predictive value of pre-ECLS blood lactate level for mortality was assessed using the receiver operating characteristic curve, the greatest accuracy was obtained at the cutoff value of 7.9 mmol/L, with 63% sensitivity and 68% specificity. CONCLUSIONS: High lactate level before ECLS is an independent predictor of mortality after ECLS, necessitating earlier ECLS implementations before profound lactic acidosis develops. Moreover, nafamostat mesilate should be considered as alternative to heparin to reduce the risk of bleeding in these high-risk patients.

How should I wean my next intra-aortic balloon pump? Differences between progressive volume weaning and rate weaning.

OBJECTIVE: Although the intra-aortic balloon pump is the most used ventricular assist device, no study has ever evaluated the best weaning method. We compared 2 different intra-aortic balloon pump weaning methods. METHODS: Thirty consecutive patients needing an intra-aortic balloon pump because of perioperative low-output cardiac syndrome were randomized to be weaned by ratio (4 consecutive hours of a 1:2 assisting ratio followed by 1 hour of a 1:3 ratio; group R) or by progressive volume deflation (10% of total volume every hour for 5 consecutive hours; 15 patients, group V). A duration of 5 hours was set a priori as the weaning duration. The weaning protocol was started when the cardiac index was greater than 2.5 L/min/m(2), the central venous pressure was 12 mm Hg or less, the blood lactate was less than 2.5 mmol/L, the mean arterial pressure was greater than 65 mm Hg, and the preserved urine output (≥1 mL/kg/hr) lasted for at least 5 consecutive hours before weaning. The cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure were registered at 9 points (T0, start; T1 to T5, the first 5 weaning hours; T6, 2 hours after withdrawal; T7, 12 hours after withdrawal; and T8, at intensive care unit discharge) using the pressure recording analytical method. The interval from intra-aortic balloon pump withdrawal to intensive care unit discharge, weaning failure, perioperative troponin I, and lactate (same points) were compared. RESULTS: All patients, except for 1 belonging to group R (P = 1.0), were successfully weaned. Group V had better preserved cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure (group*time P = .0001). Group R had worse cardiac index from T5 to T8 (P ≤ .0001), indexed systemic vascular resistance from T2 to T8 (P ≤ .004), cardiac cycle efficiency from T3 to T8 (P ≤ .001), central venous pressure from T4 to T8 (P ≤ .0001), and a longer interval from intra-aortic balloon pump withdrawal to intensive care unit discharge (P = .0001). The lactate level was lower in group V from T5 to T8 (P ≤ .027; group*time P = .001). CONCLUSIONS: Intra-aortic balloon pump weaning by volume deflation allowed better hemodynamic and metabolic parameters.

Levosimendan y mortalidad en pacientes con Síndrome de Bajo Gasto Cardíaco post cirugía cardiaca / Levosimendan and mortality in patients with Low Cardiac Output Syndrome after cardiac surgery

Objetivo: Determinar que el uso de Levosimendan disminuye la mortalidad hospitalaria en el síndrome de bajo gasto post cirugía cardíaca en pacientes adultos admitidos en el servicio de UCI del HNERM en el periodo 2009-2011. Material y Métodos: La presente investigación es de tipo Descriptivo, Analítico. La población está conformada por 63 pacientes adultos con síndrome de bajo gasto post cirugía cardíaca y que recibieron Levosimendan a una dosis continua de 0.1 mcg/kg/min en una solución glucosada al 5 por ciento. Resultados: La investigación concluye que hay una mejora estadísticamente significativa en la fracción de eyección, la media de la Fracción de eyección por ecografía preoperatoria por Simpson aumenta de 28.4 por ciento a 38.9 por ciento significativamente P<0.05, el 50 por ciento del total paciente mujeres con síndrome de bajo gasto cardíaco y con uso de Levosimendan tienen edad de 71 a 80 años. Asimismo se aprecia que del total de varones con síndrome de bajo gasto cardíaco y con uso de Levosimendan el 38.2 por ciento tiene edad de 61 a 70 años los pacientes en el preoperatorios el 63.5 por ciento presentan clase funcional III y el 36.5 por ciento presentan clase funcional IV, que del total de pacientes en el postoperatorios el 50.8 por ciento presentan clase funcional I y el 4.44 por ciento presentan clase funcional II. Se encontró que la media de la estancias hospitalaria es de 2.3 días. Los pacientes síndrome de Bajo Gasto Cardiaco Post Cirugía Cardíaca con el uso de levosimendan el 90.5 por ciento permanecen vivos y el 9.5 por ciento fallecieron en el posoperatorio temprano. Se encontró un índice cardíaco de 3.8. Conclusiones: Se observó que los pacientes posoperados de cirugía cardÍaca que cursaron con síndrome de bajo gasto cardíaco y que recibieron levosimendan, infusión continua de 0.1 mcg/kg/min presentaron una disminución en la mortalidad postoperatoria, asimismo hay una mejora estadísticamente significativa en la fracción de eyección.

Objective: To determine that the use of Levosimendan reduces the hospital mortality of patients whos present low cardiac output syndrome post cardiac surgery in adult patients admitted lo intensive care units in Care Edgardo Rebagliati Martins National Hospital in the period 2009-2011. Material and Methods: This research is of type Descriptive, Analytical. The population consists of 63 adult patients with low cardiac output post surgery syndrome and received Levosimendan a continuous dose of 0.1 mcg/kg/min in a 5 per cent glucose solution. Results: The study concludes that there are an statistically significant improvement in ejection fraction, the mean ejection fraction preoperative ultrasound by Simpson increases 28.4 per cent 38.9 per cent significantly P<0.05, and that 50 per cent of women patients with low cardiac output syndrome and use of Levosimendan are age 71 to 80 years. It also shows that the total number of en with low cardiac output syndrome and use of Levosimendan 38.2 per cent are age 61 to 70 years, also patients in the preoperative 63.5 per cent have functional class III and 36.5 per cent have functional class IV, which of all patients in the present 50.8 per cent postoperative class functional I and 44.4 per cent have functional class II. We found that the mean hospital stay is 2.3 days. Patients: Low Cardiac Outputs Syndrome Post Cardiac Surgery with the use of levosimendan 90.51 per cent remain alive and 9.5 per cent died in the early postoperative period. A cardiac index of 3.8 was found. Conclusions: It was observed that postoperative patients who have completed cardiac surgery with low cardiac output syndrome who received levosimendan, continuous infusion 0.1 mcg/kg/min showed a decrease in postoperative mortality, there is also a statistically significant improvement in ejection fraction.

Decrease of total antioxidative capacity in developed low cardiac output syndrome.

BACKGROUND: It has been known that cardiac surgery induces an oxidative stress. The persistent oxidative stress during reperfusion may lead to depressed myocardial function resulting in low cardiac output syndrome (LCOS) necessitating inotropic or intra-aortic balloon counterpulsation support. Total antioxidant capacity (TAC) is a measurement of oxidative stress in tissues. The purpose of this study was to examine the TAC differences during coronary artery bypass graft (CABG) operation in patients who have developed LCOS and who have not. MATERIAL AND METHODS: Seventy-nine patients were enrolled in the study. Central venous blood samples were obtained immediately before surgery, during operation, and at the end of surgery to assess TAC. Clinical data regarding patient demographics and operative outcomes were prospectively collected and entered into our clinical database. RESULTS: LCOS developed in 8 patients (10.12%). The TAC has decreased sharply in the LCOS patients compared with those who did not develop LCOS (P < 0.001) during operation. In addition, the receiver operating characteristic (ROC) area was 0.879. CONCLUSION: TAC has decreased during operation in a significant proportion of patients undergoing isolated CABG, and this is more prominent and serious and might be an independent variable in patients who have developed LCOS. This may be related to intraoperative misadventure or inadequate myocardial antioxidative protection. Routine measurement of the TAC during operation may provide information for assessment of the LCOS development.

Postcardiac transplant transcatheter core valve implantation for aortic insufficiency secondary to Impella device placement.

Conventional cardiac surgical procedures or transcatheter interventions after orthotopic heart transplantation are generally uncommon. We report the case of a 45-year-old woman who developed severe aortic insufficiency after insertion of a 5-L Impella device 16 weeks after heart transplantation. After joint evaluation by the transcatheter valve team, transcatheter aortic valve implantation was planned because of associated comorbid conditions. A 29-mm CoreValve prosthesis (Medtronic, Minneapolis, MN) was inserted percutaneously. At 6 months after prosthesis implantation, the patient was asymptomatic in New York Heart Association functional class II, and the echocardiogram showed a mean transvalvular gradient of 1 mm Hg, an aortic valve area of 1.5 cm2, and no paravalvular aortic insufficiency.

Comparison of risk scores to estimate perioperative mortality in aortic valve replacement surgery.

BACKGROUND: Transaortic valve implantation has recently been introduced as an alternative to aortic valve replacement (AVR) for high-risk patients with aortic stenosis. However, accurate assessment of surgical risk is critical for appropriate patient selection. We compared the accuracy of The Society of Thoracic Surgeons (STS) risk score, the European System for Cardiac Risk Evaluation (EuroSCORE), and the Veterans Administration (VA) risk score in predicting perioperative mortality after AVR. METHODS: We included 537 consecutive patients who underwent AVR for severe aortic stenosis at the Minneapolis VA Medical Center between 1997 and 2008. Observed and predicted perioperative (30-day) mortality rates were compared. Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic curves were performed to assess the performance of the scores. RESULTS: Perioperative mortality rate was 5.9% (n=32). Predicted mortality rates for the EuroSCORE, STS score, and VA score were 15.6%, 3.6%, and 6.7%, respectively (p=0.001). The EuroSCORE overestimated mortality in all patients, most notably among those with ejection fraction less than 35% (49% predicted versus 9% observed). The EuroSCORE had poor calibration (goodness-of-fit test p<0.008), whereas the STS and the VA scores were well calibrated. However, all three scores displayed good discrimination characteristics per the areas under the receiver operating characteristic curves: STS score 0.73 (95% confidence interval: 0.69 to 0.77); VA score 0.66 (95% confidence interval: 0.62 to 0.70); and EuroSCORE 0.68 (95% confidence interval: 0.64 to 0.72; p>0.05). CONCLUSIONS: The EuroSCORE substantially overestimates perioperative mortality risk in AVR, particularly in patients with low ejection fraction. These data have implications when deciding the appropriate intervention (transaortic valve implantation versus AVR) for high-risk aortic stenosis patients.

Myocardial protection during aortic surgery: comparison between Bretschneider-HTK and cold blood cardioplegia.

The ideal cardioplegic strategy in thoracic aorta operations requiring long cardiopulmonary bypass and cross-clamp time has not been established. Suboptimal myocardial protection may lead to myocardial damage and possible post-operative complications. We evaluate post-operative cardiac Troponin I (cTnI) release, low cardiac output syndrome (LCOS) and mortality, using a cold crystalloid single-dose intracellular or cold blood multidose cardioplegia in 112 elective or emergent thoracic aorta operation patients. Fifty-four patients (HTK group) received Custodiol® cardioplegic solution and 58 received cold blood cardioplegia (CB group). Cross-clamp time, cardiopulmonary bypass (CPB) time and cTnI peak release were similar in both groups. No differences were found for atrial and ventricular arrhythmias, inotropic support, LCOS and in-hospital mortality. Two-way ANOVA analysis revealed an interactive effect on cTnI peak (p=0.012) of cardioplegic solution type across the cross-clamp time quintile. In the fifth quintile, cross-clamp time patient (>160 min) cTnI peak value was higher in CB patients (p=0.044). HTK and CB cardioplegic solutions assure similar myocardial protection in patients undergoing thoracic aorta operations. In long cross-clamp times, the lower post-operative cTnI release detected using HTK may be indicative of a better myocardial protection in these extreme conditions.