Predictors of Permanent Pacemaker Implantation After Coronary Artery Bypass Grafting and Valve Surgery in Adult Patients in Current Surgical Era.

BACKGROUND: Permanent pacemaker (PPM) implantation after cardiac surgery is required in 0.4-6% of patients depending on cardiac surgery type. PPM implantation in the early postoperative period may reduce morbidity and postoperative hospital stay. We performed a retrospective review of electronic medical records of adult patients with coronary artery bypass grafting (CABG), valve surgery, or both, over a 3-year period. Our aim was to identify predictors of PPM requirements and PPM dependency on follow-up in the current surgical era. METHODS: After exclusion of patients with congenital heart disease, patients who already had a PPM or implantable cardioverter defibrillator (ICD), and patients with an indication for PPM or ICD before surgery, we identified 1,234 adult patients who underwent cardiac surgery between January 2007 and December 2009. A retrospective review of electronic medical records and pacemaker clinic data was performed. RESULTS: Patients' mean age was 46.65 ± 16 years, and 59% were males. CABG was performed in 575 (46.6%) cases, aortic valve replacement in 263 (21.3%), mitral valve replacement in 333 (27%), and tricuspid valve replacement in 76 patients (6.2%). Twenty patients (1.6%) required implantation of a PPM postoperatively. Indications for PPM implantation included complete atrioventricular (AV) block in 13 (65%), sick sinus syndrome in three (15%), and atrial fibrillation (AF) with a slow ventricular rate in four (20%). Predictors for PPM requirement by multivariate analysis were the presence of pulmonary hypertension (P-HTN), reoperation, and left bundle branch block (LBBB) (P < 0.05). Late follow-up was available in 18 patients, at 84.5 ± 30 months. Eleven patients (61%) were PPM dependent on long-term follow-up. CONCLUSIONS: Patients at high risk for PPM implantation after cardiac surgery include those with P-HTN, reoperation, and pre-existing LBBB. Of those receiving a PPM, about one-third will recover at least partially at long-term follow-up. We recommend preoperative assessment for risk of requiring postoperative PPM, to counsel patients about this risk and early PPM implantation in high-risk patients who are PPM dependent after surgery.

A high-volume heart transplantation center in an Islamic country.

Cardiac transplants are performed sporadically or not at all in the majority of predominantly Muslim countries in the Middle East. We examined our experience in 76 patients who underwent heart transplantation between January 2005 and May 2010 in our center in Saudi Arabia. Excluded were 50 transplants performed between 1989 and 2004, due to incomplete data. Primary outcomes were complications, 30-day and late mortality rates, and 1-year survival. The heart transplant activity between 2005 and 2010 (15.0 per year) was 4.5-fold higher than that between 1989 and 2004 (3.3 per year). There were 61 (80%) men and 15 (20%) women, with a mean age of 35 years (range, 13-57 years). The mean waiting list time was 64 days (range, 1-262 days), and hospital stay was 30 days (range, 12-166 days). Major complications were infection (10), low-grade rejection (9), reoperation for hemorrhage (8), and sternal dehiscence (2). The 30-day mortality was 7.8% (6/76). Actuarial survival was 87.4% at 1 year and 81.5% at 3 years. A hospital in a Muslim country can increase cardiac transplant activity with excellent 30-day mortality and early survival comparable to that in worldwide counterparts.

Determinants of short- and long-term outcomes following triple valve surgery.

BACKGROUND AND AIM OF THE STUDY: Triple valve surgery (3VS) is required in some cardiac disorders that simultaneously involve the aortic valve (AV), mitral valve (MV), and tricuspid valve (TCV). Herein are reported details of the authors' experience with 3VS, and their attempts to identify those factors associated with a poor clinical outcome. METHODS: The medical records of patients who underwent 3VS between 1985 and 2005 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after 3VS, namely death, valve reoperation, and survival without subsequent valve reoperation. RESULTS: A total of 206 consecutive patients (124 females, 82 males; median age 34 years; range: 12-82 years) underwent 3VS. The most common underlying pathology for all valves was rheumatic, followed by repair failure and prosthesis dysfunction for AV and MV, and functional regurgitation for TCV. In total, 72 patients (35.0%) had undergone prior valve surgery. At 3VS, the MV and AV were usually replaced (> 70%), whereas the TCV was usually repaired (91%). The operative mortality (prior to hospital discharge) was 11%, and 15-year survival 68%. At 15 years after 3VS, 21% of the patients had died, without subsequent valve reoperation, 50% had undergone valve reoperation, and 30% remained alive without valve reoperation. Baseline factors associated with early mortality after 3VS were older age at operation, TCV replacement, and the use of a mechanical MV during 3VS. A late risk of mortality was associated with poor left ventricular function and renal impairment at the time of the initial 3VS, and MV prosthesis prior to the initial 3VS. Younger age at 3VS and MV repair during the index 3VS were associated with a higher constant risk of valve reoperation, while female gender, MV prosthesis prior to index 3VS, MV replacement with a bioprosthesis during 3VS, and rheumatic TCV disease were associated with an increased late risk of valve reoperation. CONCLUSION: Both, primary and reoperative 3VS can be performed with acceptable operative mortality and long-term survival. However, patients continue to be at risk of valve reoperation, which steadily increases over time.

Pericardial adhesions simulating myocardial bridging.

A 48-year-old man with aortic valve disease was diagnosed to have myocardial bridging on preoperative coronary angiography. During surgical exploration, only pericardial adhesions were found, with a normal epicardial coronary course.

Seventeen years' clinical and echocardiographic follow up of mitral balloon valvuloplasty in 520 patients, and predictors of long-term outcome.

BACKGROUND AND AIM OF THE STUDY: Long-term echocardiographic follow up studies of mitral balloon valvuloplasty (MBV) are scarce. The study aim was to assess the long-term results (up to 17 years) of MBV and to identify predictors of restenosis and event-free survival. METHODS: The immediate and long-term clinical and echocardiographic results for 520 consecutive patients (mean age 31 +/- 11 years) who underwent successful MBV for severe mitral stenosis (MS) and were followed up for a mean of 7.3 +/- 4.35 years (range: 1 to 17 years) after MBV, were reported. RESULTS: Immediately after MBV, the mitral valve area (MVA) was increased from 0.92 +/- 0.17 to 1.96 +/- 0.29 cm2 (p < 0.0001). Restenosis occurred in 133 patients (25.6%), and was less frequent (16.7%) in patients with a low mitral echo score (MES < or = 8). Actuarial freedom from restenosis at 10, 15, and 17 years was 73 +/- 2%, 43 +/- 4%, and 23 +/- 6%, respectively, and was significantly higher in patients with MES < or = 8 (84 +/- 2%, 52 +/- 6%, and 36 +/- 9%, respectively; p < 0.001). Event-free survival (death, redo MBV, mitral valve replacement, NYHA class III or IV) at 10, 15, and 17 years was 82 +/- 2%, 45 +/- 5%, and 31 +/- 6% respectively, and was significantly higher for patients with MES < or = 8 (90 +/- 2%, 60 +/- 5%, and 51 +/- 8%, respectively; p < 0.001). Cox regression analysis identified MES > 8 (p < 0.0001) and post-procedure MVA (p = 0.044) as predictors of restenosis, and MES < or = 8 (p < 0.0001), age (p < 0.0001), and post-procedure MVA (p = 0.016) as predictors of event-free survival. CONCLUSION: MBV provides excellent long-term results for selected patients with MS. The long-term outcome of this procedure can be predicted from the baseline clinical and echocardiographic characteristics of the mitral valve.

Long-term results (up to 17 years) of pulmonary balloon valvuloplasty in adults and its effects on concomitant severe infundibular stenosis and tricuspid regurgitation.

BACKGROUND: Significant infundibular stenosis and significant tricuspid regurgitation (TR) occasionally result from severe pulmonary valve stenosis in adults, and these 2 conditions have an adverse impact on morbidity and mortality in patients who undergo corrective surgery. The goal of this study was (1) to evaluate the long-term (up to 17 years) outcome of pulmonary balloon valvuloplasty (PBV) in adults and (2) to determine the effect of successful PBV on severe infundibular stenosis and severe TR. METHODS: Pulmonary balloon valvuloplasty was performed in 90 consecutive patients (49 women, 41 men) of mean age 23 +/- 9 years (range 15-54 years) with congenital pulmonary valve stenosis. Clinical and echocardiographic assessment was performed 2 to 17 years (mean 10 +/- 3.9 years) after PBV. Repeat cardiac catheterization was performed 6 to 24 months after PBV in 43 patients who had concomitant moderate to severe infundibular stenosis (infundibular gradient > or = 30 mm Hg). RESULTS: There were no immediate or late deaths. The mean catheter peak pulmonary gradient (gradient between pulmonary artery and right ventricular body) before and immediately after PBV was 105 +/- 39 and 34 +/- 26 (P < .0001), respectively. The corresponding values for right ventricular pressure were 125 +/- 38 and 59 +/- 21 mm Hg (P < .0001), respectively. The infundibular gradient (in 43 patients) immediately after PBV was 42.9 +/- 24.8 (30-113) mm Hg, and it regressed at second catheterization to 13.5 +/- 8.3 mm Hg (P < .0001), whereas cardiac index improved from 2.68 +/- 0.73 to 3.1 +/- 0.4 L min(-1) m(-2) (P < .05). Doppler pulmonary gradient before PBV and at 1-year and long-term follow-up were 91 +/- 33 (range 36-200), 28 +/- 12 (range 10-60) (P < .0001), and 26 +/- 11 (range 7-60) mm Hg (P = .2), respectively. New mild pulmonary regurgitation was noted in 24 patients (28%) after PBV. Significant TR in 7 patients either regressed or disappeared after PBV. CONCLUSIONS: Long-term results of PBV in adults are excellent. Severe infundibular stenosis and severe TR regressed after successful PBV. Therefore, PBV should be considered as the treatment of choice for adult patients with valvular pulmonary stenosis even in the presence of severe infundibular stenosis or severe TR.

Up to 16 years follow-up of aortic valve reconstruction with pericardium: a stentless readily available cheap valve?

OBJECTIVE: There is lack of information regarding the long-term behavior of aortic valve reconstruction with pericardium (AoR). A 16-year follow-up is reported here. METHODS: Between 1988 and 1995, 92 consecutive patients had AoR with bovine (Group I, n=27) or glutaraldehyde-treated autologous pericardium (Group II, n=65). The mean age was 30 years (range 12-68). There were 65% males, 92% in sinus rhythm, 84% had rheumatic etiology and 36% had 'other valve' surgery. Mitral valve replacement with a mechanical prosthesis is a contraindication to the operation. RESULTS: Hospital mortality was 2%. The reconstructed aortic valve performed well with excellent hemodynamics. The mean follow-up interval was 10.5+/-4 years, range 9-16 years (longer for group I,12 versus 10 years) with 4% late deaths and seven patients lost to follow-up. Survival rate was 85+/-4%. There were no episodes of thromboembolism. Freedom from reoperation for the whole group was 68+/-5% at 10 years and 47+/-6% at 16 years. For group I, it was 68+/-9% at 10 years and 48+/-10% at 16 years, while for group II it was 72+/-6 and 45+/-8% at 10 and 15 years, respectively. Excluding endocarditis (one in group I and seven in group II) and 'other' reasons for reoperation (two in group I and three in group II), the freedom from structural valve degeneration (SVD) at 10 and 16 years was 78+/-1 and 55+/-10% for group I. For group II, it was 80+/-5% at 10 years and 58+/-9% at 15 years. The mean interval at which the valve degenerated was 8.8 years+/-3.6 and did not differ between the two groups. CONCLUSIONS: AoR is feasible with good hemodynamics, low mortality and thromboembolic rate. Its behavior at 10 years is comparable to that of stentless aortic valve bioprosthesis. It can be performed with either xenopericardium or glutaraldehyde-treated autologous pericardium, but the latter has the advantage of being inexpensive and readily available.