Severe prosthesis-patient mismatch after aortic valve replacement for aortic stenosis: Analysis of risk factors for early and long-term mortality.

BACKGROUND: Severe prosthesis-patient mismatch (PPM) is considered to further decrease survival compared to moderate PPM. This study aimed to assess the impact of severe PPM on survival after aortic valve replacement (AVR). METHODS: We retrospectively studied 2404 consecutive patients with PPM who underwent first-time AVR for pure stenosis between January 2003 and December 2014. Mismatch was moderate for indexed effective valve orifice >0.65 to <0.85cm2/m2 and severe for indexed effective valve orifice ≤0.65cm2/m2. Moderate mismatch occurred in 2165 patients (89%), and severe in 239 (11%) patients. Logistic multiple regression with bootstrapping and propensity score analyses were performed using 29 clinical and demographic data to assess the risk-adjusted impact of severe mismatch on mortality. The Cox proportional hazards model was constructed to process the long-term outcome. RESULTS: Early mortality was 2.3% (51/2165) in moderate mismatch group and 3.7% (9/239) in severe mismatch group (p=0.2). Mortality at 5 and 10 years, was 218/1470 (14.8%) and 252/585 (43.1%) for moderate mismatch and 43/198 (21.7%) and 61/105 (58.1%) for severe mismatch (p=0.02 and p=0.006). Multivariable predictors of late mortality were as follows: age ≥70 years, left ventricular ejection fraction ≤40%, indexed left ventricular mass >220g/m2 and concomitant coronary artery revascularization. After propensity score matching, conditional logistic regression analysis demonstrated no relationship between severe mismatch and increased mortality at 5 postoperative years (HR, 0.9; 95% CI, 0.7-1.6; p=0.06), whereas it was significant at 10 postoperative years (HR, 1.9; 95% CI, 1.2-2.5; p=0.03). During the follow-up, severe mismatch was associated with more frequent hospital readmissions for cardiac events (0.12 vs. 0.08 events/patient/year, p=0.007). CONCLUSIONS: Patients with severe mismatch had lower long-term survival and higher incidence of hospital readmissions for cardiac events. However, the effect of severe mismatch on outcome appeared mainly related to the preoperative risk profile of each patient.

Incremental value of anemia in cardiac surgical risk prediction with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II model.

BACKGROUND: Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations. METHODS: Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin <11.0 g/dL) in 593 patients (12.9%). The EuroSCORE II was used to evaluate predicted hospital death after operations. Logistic regression analysis for in-hospital death was performed including EuroSCORE II risk factors and anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI). RESULTS: Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p < 0.001) and also at multivariate analysis correcting for EuroSCORE II (p < 0.001). When anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p < 0.001), preserving the calibration with good concordance between predicted probabilities and outcome. CONCLUSIONS: Preoperative anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk.

Development and results of Puglia adult cardiac surgery registry.

AIMS: To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS: A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS: From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION: Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.

Risk stratification for in-hospital mortality after cardiac surgery: external validation of EuroSCORE II in a prospective regional registry.

OBJECTIVES: To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients. METHODS: Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed. RESULTS: Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of re-estimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality. CONCLUSIONS: This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.

Myocardial damage influences short- and mid-term survival after valve surgery: a prospective multicenter study.

OBJECTIVE: Myocardial damage occurs after valve surgery, but its prognostic implication has not been evaluated. The aim of the present study was to assess the influence of myocardial damage on mortality and morbidity in patients undergoing aortic surgery (AVS) and mitral valve surgery (MVS). METHODS: In a prospective multicenter study from the cardiac surgery registry of the Puglia region, cardiac troponin I (cTnI) was measured immediately after and the morning after the intervention in consecutive patients undergoing AVS or MVS. The percentile ranks of the cTnI peak values within each center were analyzed. RESULTS: Of 965 patients (age, 67±12 years; 45.5% women), 579 had undergone AVS and 386 MVS. cTnI release was significantly greater in the MVS group than in the AVS group and in the nonsurvivors than in the survivors in both groups. The cTnI cutoff with the greatest sensitivity and specificity (60th percentile for AVS and 91st for MVS) in predicting hospital mortality (2.6%) was also associated with a greater rate of postoperative complications and mortality within 3 months postoperatively (multivariate hazard ratio, 3.38; P=.005). Compared with the reference model, which included the multivariate predictors of hospital mortality (active endocarditis, New York Heart Association class III-IV, left ventricular ejection fraction≤30%, and cardiopulmonary bypass duration), the addition of cTnI greater than the cutoffs showed significant improvement in model performance (likelihood ratio test, P=.009; net reclassification improvement, 0.751; P<.001; integrated discrimination improvement, 0.048; P=.002; c-index 0.832 vs 0.838). CONCLUSIONS: An elevated postoperative cTnI level was an independent risk factor for mortality and morbidity. Measurement of the cTnI level improved the risk reclassification of patients undergoing AVS or MVS.

[Manual thrombus aspiration with the Export catheter during primary and rescue angioplasty. Predictors of failed myocardial reperfusion]. / Trombo-aspirazione manuale con catetere Export nell'angioplastica primaria e di salvataggio. Predittori di mancata riperfusione miocardica.

BACKGROUND: Manual thrombus aspiration seems to improve myocardial reperfusion after coronary angioplasty in patients with ST-elevation acute coronary syndrome. We sought to assess the independent variables of complete myocardial reperfusion after primary and rescue coronary angioplasty with use of the Export manual thrombus aspiration catheter. METHODS: Myocardial reperfusion were judged complete if ST-segment resolution were >70% at 60 min post-procedure ECG. Sixty-three consecutive patients undergoing primary (81%) or rescue angioplasty (19%) with use of the Export catheter were analyzed. RESULTS: Forty-three (68%) patients had a complete myocardial reperfusion and 20 (32%) patients did not. The independent predictors of failed myocardial reperfusion, at multivariate analysis, were: heart rate at hospital admission (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.01-1.09; p = 0.007), time to angioplasty >3 h (OR 6.07; 95% CI 1.31-27.97; p = 0.005), left anterior descending coronary artery involvement (OR 8.8; 95% CI 2.12-36.4; p = 0.003). CONCLUSIONS: The present study shows that in the setting of primary or rescue angioplasty with use of Export manual thrombus aspiration catheter, patients with high heart rate on admission, an ischemic time >3 h and left anterior descending coronary artery involvement are at higher risk of failed myocardial reperfusion.

[Cardiac metastasis of poorly differentiated adenocarcinoma of unknown primary site]. / Metastasi cardiache di adenocarcinoma poco differenziato a sede primitiva occulta.

The finding of intracardiac masses is very uncommon. In this patient the early clinical picture was characterized by neurologic signs and symptoms as mild forgetfulness, blurred vision, a sensation of imbalance, anorexia, weight loss. Brain magnetic resonance imaging showed multiple metastatic lesions, computed tomography of the chest, abdomen and pelvis showed intraatrial masses and whole body nuclear scanning evidenced bone lesion. It was not possible to find the primary tumor by other instrumental or laboratory exams. Transesophageal echocardiography showed a mass originating from interatrial septum, with atrial invasion and risk of embolization from the left atrium. The patient was transferred to the operating room for cardiac surgery, the mass at risk for embolization was resected and the specimen consisted of fibrous and fibrino-necrotic tissue infiltrated by poorly differentiated adenocarcinoma. The patient received brain and bone radiotherapy and chemotherapy with cisplatin and vinorelbin.