Effective Orifice Area during Exercise in Bileaflet Mechanical Valve Prostheses.

BACKGROUND: The aims of this study were to investigate the evolution of the transprosthetic pressure gradient and effective orifice area (EOA) during dynamic bicycle exercise in bileaflet mechanical heart valves and to explore the relationship with exercise capacity. METHODS: Patients with bileaflet aortic valve replacement (n = 23) and mitral valve replacement (MVR; n = 16) prospectively underwent symptom-limited supine bicycle exercise testing with Doppler echocardiography and respiratory gas analysis. Transprosthetic flow rate, peak and mean transprosthetic gradient, EOA, and systolic pulmonary artery pressure were assessed at different stages of exercise. RESULTS: EOA at rest, midexercise, and peak exercise was 1.66 ± 0.23, 1.56 ± 0.30, and 1.61 ± 0.28 cm2, respectively (P = .004), in aortic valve replacement patients and 1.40 ± 0.21, 1.46 ± 0.27, and 1.48 ± 0.25 cm2, respectively (P = .160), in MVR patients. During exercise, the mean transprosthetic gradient and the square of transprosthetic flow rate were strongly correlated (r = 0.65 [P < .001] and r = 0.84 [P < .001] for aortic valve replacement and MVR, respectively), conforming to fundamental hydraulic principles for fixed orifices. Indexed EOA at rest was correlated with exercise capacity in MVR patients only (Spearman ρ = 0.68, P = .004). In the latter group, systolic pulmonary artery pressures during exercise were strongly correlated with the peak transmitral gradient (ρ = 0.72, P < .001). CONCLUSIONS: In bileaflet mechanical valve prostheses, there is no clinically relevant increase in EOA during dynamic exercise. Transprosthetic gradients during exercise closely adhere to the fundamental pressure-flow relationship. Indexed EOA at rest is a strong predictor of exercise capacity in MVR patients. This should be taken into account in therapeutic decision making and prosthesis selection in young and dynamic patients.

Is the air in Toronto, Rochester, and Cleveland different from that in London, Monaco, Leiden, Genk, Milan, and New York?

The tricuspid valve has been recently referred to as the "forgotten valve," because one now realizes that tricuspid regurgitation is bad for the patient and that reoperation for progressive tricuspid regurgitation after a left-sided valvular correction still carries a high mortality risk. However, the indication for concomitant tricuspid valve repair during a mitral valve repair procedure is still controversial, as illustrated by the reaction of Dr T. David to the presentation of Dr Chikwe and colleagues at the 2015 American Association for Thoracic Surgery meeting. One of the explanations for these divergent opinions could be that tricuspid regurgitation grading is largely unreliable because of the dependence of the right ventricle on the preload and of the discrepancy between clinical and hemodynamic data. Therefore, we need a parameter that does not depend on preload. An annular dilation of 40 mm or 21 mm/m(2) has been proposed and validated by many authors. The preoperative functional class also plays a major role. Tricuspid regurgitation is a progressive disease, but the presence of a concomitant mitral valve disease may aggravate annular dilation; therefore, the earlier we operate on the mitral valve, the less frequently patients will require concomitant tricuspid valve repair.

Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering.

BACKGROUND: Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation might cause functional mitral stenosis, yet its clinical impact and underlying pathophysiological mechanisms remain debated. OBJECTIVES: The purpose of our study was to assess the hemodynamic and clinical impact of effective orifice area (EOA) after RMA and its relationship with diastolic anterior leaflet (AL) tethering at rest and during exercise. METHODS: Consecutive RMA patients (n = 39) underwent a symptom-limited supine bicycle exercise test with Doppler echocardiography and respiratory gas analysis. EOA, transmitral flow rate, mean transmitral gradient, and systolic pulmonary arterial pressure were assessed at different stages of exercise. AL opening angles were measured at rest and peak exercise. Mortality and heart failure readmission data were collected for at least 20 months after surgery. RESULTS: EOA and AL opening angle were 1.5 ± 0.4 cm(2) and 68 ± 10°, respectively, at rest (r = 0.4; p = 0.014). EOA increased significantly to 2.0 ± 0.5 cm(2) at peak exercise (p < 0.001), showing an improved correlation with AL opening angle (r = 0.6; p < 0.001). Indexed EOA (EOAi) at peak exercise was an independent predictor of exercise capacity (maximal oxygen uptake, p = 0.004) and was independently associated with freedom from all-cause mortality or hospital admission for heart failure (p = 0.034). Patients with exercise EOAi <0.9 cm(2)/m(2) (n = 14) compared with ≥0.9 cm(2)/m(2) (n = 25) had a significantly worse outcome (p = 0.048). In multivariate analysis, AL opening angle at peak exercise (p = 0.037) was the strongest predictor of exercise EOAi. CONCLUSIONS: In RMA patients, EOA increases during exercise despite fixed annular size. Diastolic AL tethering plays a key role in this dynamic process, with increasing AL opening during exercise being associated with higher exercise EOA. EOAi at peak exercise is a strong and independent predictor of exercise capacity and is associated with clinical outcome. Our findings stress the importance of maximizing AL opening by targeting the subvalvular apparatus in future repair algorithms for secondary mitral regurgitation.

The role of extracellular matrix in age-related conduction disorders: a forgotten player?

Cardiovascular aging is a physiological process gradually leading to structural degeneration and functional loss of all the cardiac and vascular components. Conduction system is also deeply influenced by the aging process with relevant reflexes in the clinical side. Age-related arrhythmias carry significant morbidity and mortality and represent a clinical and economical burden. An important and unjustly unrecognized actor in the pathophysiology of aging is represented by the extracellular matrix (ECM) that not only structurally supports the heart determining its mechanical and functional properties, but also sends a biological signaling regulating cellular function and maintaining tissue homeostasis. At the biophysical level, cardiac ECM exhibits a peculiar degree of anisotropy, which is among the main determinants of the conductive properties of the specialized electrical conduction system. Age-associated alterations of cardiac ECM are therefore able to profoundly affect the function of the conduction system with striking impact on the patient clinical conditions. This review will focus on the ECM changes that occur during aging in the heart conduction system and on their translation to the clinical scenario. Potential diagnostic and therapeutical perspectives arising from the knowledge on ECM age-associated alterations are further discussed.

Pulmonary homograft endocarditis and aortic autograft failure after Ross procedure: a double stentless bioprosthesis approach.

The case is reported of a 38-year-old male patient with pulmonary homograft acute infective endocarditis and aortic root dilation that occurred 13 years after a Ross procedure for bicuspid aortic valve regurgitation. Aortic and pulmonary root replacements were performed, using a Freestyle stentless aortic root bioprosthesis in both cases, with excellent hemodynamics on postoperative echocardiography. In addition, preoperative systemic septic embolization had occurred despite an absence of left-sided endocarditis, presumably due to an intrapulmonary shunt. This case report demonstrates the feasibility of a double stentless bioprosthesis approach, and stresses the need to remain vigilant for septic embolization even in isolated right-sided endocarditis.

Myectomy and mitral repair through the left atrium in hypertrophic obstructive cardiomyopathy: the preferred approach for contemporary surgical candidates?

OBJECTIVE: Patients with hypertrophic obstructive cardiomyopathy due to diffuse hypertrophy extending to or below the papillary muscles are poor candidates for alcohol septal ablation and suboptimal candidates for transaortic septal myectomy. In addition, the outflow obstruction is often aggravated by an abnormal mitral valve and subvalvular apparatus. METHODS: We performed transatrial myectomy in 12 patients with diffuse hypertrophy, who were highly symptomatic despite maximal medical therapy. All had at least moderate mitral regurgitation and systolic anterior motion. The anterior mitral leaflet (AML) was detached from commissure to commissure, allowing an easy myectomy through this AML toward the base of the anterior papillary muscle, with mobility fully restored. The abnormal chordae from the septum to the anterior papillary muscle and AML were divided. The continuity of this AML was restored with augmentation using an autologous pericardial patch. The height of the posterior mitral leaflet was reduced and the repair completed using an oversized annuloplasty ring. RESULTS: The peak intraventricular gradients decreased spectacularly from 98.8 ± 6.29 to 19.2 ± 13.4 mm Hg (P < .001), and the systolic anterior motion and mitral regurgitation disappeared. One patient died of left ventricular diastolic dysfunction. All other patients left the hospital in New York Heart Association class I or II. CONCLUSIONS: We believe that this technique is preferable for patients with hypertrophic obstructive cardiomyopathy and diffuse hypertrophy extending to the midportion of the left ventricle or beyond. It results in disappearance of outflow tract gradients and allows correction of the mitral valve abnormality.

Salvage extensive coronary thromboendarterectomy for a ruptured left anterior descending artery.

We describe a lifesaving emergent thromboendarterectomy of the entire left anterior descending artery in a 63-year old man. Four days earlier, he had undergone a coronary artery bypass grafting. The left anterior descending artery was not bypassed then due to severe diffuse disease and calcifications. After an uneventful recovery, syncope occurred during exercise. Emergency catheterization revealed patent grafts, but no flow over the left anterior descending artery. At rescue percutaneous coronary intervention, a perforation of the left anterior descending artery occurred, leading to cardiogenic shock. A successful thromboendarterectomy of the left anterior descending artery salvaged the patient's life.

Surgical patch angioplasty of the left main coronary artery.

Isolated ostial stenosis of the left main coronary artery (LMCA) is rare, occurring in <1% of the patients undergoing coronary angiography. Surgical patch angioplasty (SPA) offers an alternative to conventional coronary artery bypass grafting (CABG) in such cases and is advantageous in restoring more physiological myocardial perfusion, maintaining ostial patency and preserving conduit material. However, a number of early technical failures and high perioperative mortality have limited the generalized uptake of this procedure, and only recently have advances in myocardial protection and novel surgical approaches to the LMCA resulted in a resurgence of the technique. A systematic literature search identified 45 studies incorporating 478 patients undergoing SPA. A variety of patch materials were used, including the pericardium, saphenous vein and internal mammary and pulmonary arteries. Patients were followed up for a mean of 54.4 months. The 30-day mortality was 1.7% and cardiac specific mortality 3.3% at last follow-up. Encouragingly, 92.4% of reported cases (n = 182) showed complete angiographic patency at last follow-up. Our results indicate that SPA may be a viable alternative to CABG in the surgical management of isolated ostial LMCA stenosis. However, no randomized trials have been performed, and it is clear that careful patient selection is essential in minimizing morbidity and mortality in the short- and long-term. Further research is required to allow a direct comparison of SPA to techniques with a more substantial evidence base such as CABG and percutaneous coronary intervention, and to define the optimal patch graft material, elucidating that any beneficial effects arterial patches may have on long-term patency.

Management of mitral regurgitation during left ventricular reconstruction for ischemic heart failure.

OBJECTIVE: Remodeling of the left ventricle (LV) in ischemic cardiomyopathy frequently leads to functional mitral regurgitation (MR). The indication for correcting MR in patients undergoing LV reconstruction (LVR) is unclear. In this study, we evaluated our strategy of correcting MR≥grade 2+ by restrictive mitral annuloplasty (RMA) during LVR. METHODS: We studied 92 consecutive patients (76 men, mean age 61±10 years) who underwent LVR for ischemic heart failure (IHF). RMA was performed in all patients with MR≥grade 2+ on preoperative echocardiography and in patients who showed increased MR to ≥grade 2+ immediately after LVR. Patients were attributed to a RMA and no-RMA group, depending on whether or not concomitant RMA had been performed. Mean clinical and structured echocardiographic follow-up was 47±20 months and was 100% complete. RESULTS: In 38 out of 40 patients (95%) with preoperative MR≥grade 2+, concomitant RMA was planned and performed. In 17 out of 52 patients (33%) with MR

Augmentation of the posterior leaflet of the mitral valve.

The augmentation of mitral valve leaflets is mostly needed in rheumatic valve disease patients. The technical aspects of augmentation of the posterior leaflet by means of an autologous pericardial patch are described: the thickened and semi-rigid posterior leaflet is detached from the posterior annulus from commissure to commissure and augmented by an onlay patch of autologous pericardium which is incorporated using a continuous stitch-locked at each step-of Prolene or Pronova 5/0. The pitfall 'aortic cusp effect in diastole' is described as well as tips to prevent it.

Cardiac support device, restrictive mitral valve annuloplasty, and optimized medical treatment: a multimodality approach to nonischemic cardiomyopathy.

OBJECTIVE: Nonischemic dilated cardiomyopathy with functional mitral regurgitation carries a poor prognosis. Mitral valve surgery with implantation of a cardiac support device can treat mitral regurgitation and promote left ventricular reverse remodeling. This observational study evaluates clinical and echocardiographic outcomes of an individualized medico-surgical approach, focusing on mitral regurgitation recurrence and left ventricular reverse remodeling. METHODS: Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 ± 73 mL, ejection fraction 26% ± 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n = 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years' median follow-up. RESULTS: Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% ± 4%, 79% ± 5%, and 63% ± 7%. New York Heart Association class improved from 3.1 ± 0.4 to 2.0 ± 0.5 (P < .01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33% vs 18%; P = .007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% ± 8% vs 63% ± 11%; P = .067). CONCLUSIONS: An individualized medico-surgical approach to nonischemic cardiomyopathy combining restrictive mitral annuloplasty, cardiac support device implantation, and optimal medical management leads to favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling.

Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair.

OBJECTIVES: We hypothesize that concomitant tricuspid annuloplasty in patients with tricuspid annular dilatation who undergo mitral valve repair could prevent progression of tricuspid regurgitation and right ventricular remodeling. METHODS: In 2002, 80 patients underwent mitral valve repair. Concomitant tricuspid annuloplasty was performed in 13 patients with grade 3 or 4 tricuspid regurgitation. In 2004, 102 patients underwent mitral valve repair. Concomitant tricuspid annuloplasty was performed in 21 patients with grade 3 or 4 tricuspid regurgitation and in 43 patients with an echocardiographically determined tricuspid annular diameter of 40 mm or greater. Patients underwent transthoracic echocardiographic analysis preoperatively and at the 2-year follow-up. RESULTS: In the 2002 cohort right ventricular dimensions did not decrease (right ventricular long axis, 69 ± 7 vs 70 ± 8 mm; right ventricular short axis, 29 ± 7 vs 30 ± 7 mm); tricuspid regurgitation grade and gradient remained unchanged. In the 2004 cohort right ventricular reverse remodeling was observed (right ventricular long axis, 71 ± 6 vs 69 ± 9 mm; right ventricular short axis, 29 ± 5 vs 27 ± 5 mm; P < .0001); tricuspid regurgitation diminished (1.6 ± 1.0 vs 0.9 ± 0.6, P < .0001), and transtricuspid gradient decreased (28 ± 13 vs 23 ± 15 mm Hg, P = .021). Subanalysis of the 2002 cohort showed that in 23 patients without grade 3 or 4 tricuspid regurgitation but baseline tricuspid annular dilatation, the degree of tricuspid regurgitation was worse at the 2-year follow-up. Moreover, this caused right ventricular dilatation. Subanalysis of the 2004 cohort demonstrated reverse right ventricular remodeling and decreased tricuspid regurgitation in 43 patients with preoperative tricuspid annular dilatation who underwent tricuspid annuloplasty. CONCLUSIONS: Concomitant tricuspid annuloplasty during mitral valve repair should be considered in patients with tricuspid annular dilatation despite the absence of important tricuspid regurgitation at baseline because this improves echocardiographic outcome.

Clinical and functional effects of restrictive mitral annuloplasty at midterm follow-up in heart failure patients.

BACKGROUND: Restrictive mitral annuloplasty (RMA) is increasingly applied to treat functional mitral regurgitation in heart failure patients. Previous studies indicated beneficial clinical effects with low recurrence rates. However, the underlying pathophysiology is complex and outcome in terms of left ventricular function is not well known. We investigated chronic effects of RMA on ventricular function in relation to clinical outcome. METHODS: Heart failure patients (n = 11) with severe mitral regurgitation scheduled for RMA were analyzed at baseline (presurgery) and midterm follow-up by invasive pressure-volume loops, using conductance catheters. Clinical performance was evaluated by New York Heart Association class, quality-of-life-score, and 6-minute hall-walk-test. RESULTS: All patients were alive without recurrence of mitral regurgitation at follow-up (9.4 ± 4.1 months). Clinical parameters improved significantly (all p < 0.05). Global cardiac function, assessed by cardiac output, stroke volume, and stroke work did not change after RMA. Reverse remodeling was demonstrated by decreased end-systolic and end-diastolic volumes (16% and 11%, both p < 0.001). Systolic function improved, evidenced by increased ejection fraction (0.32 ± 0.05 to 0.36 ± 0.07, p = 0.001) and leftward shift of the end-systolic pressure-volume relation (ESV(100): 116 ± 43 to 74 ± 26 mL, p < 0.001). Diastolic function, however, demonstrated impairment by increased tau (69 ± 13 to 80 ± 14 ms, p < 0.001) and stiffness constant (0.022 ± 0.022 to 0.031 ± 0.028 mL(-1), p = 0.001). CONCLUSIONS: Restrictive mitral annuloplasty significantly improved clinical status without recurrence of mitral regurgitation at midterm follow-up in patients with heart failure. Hemodynamic analyses demonstrated significant reverse remodeling with unchanged global function and improved systolic function, but some signs of diastolic impairment. Overall, RMA appears an appropriate therapy for patients with dilated cardiomyopathy and functional mitral regurgitation.

Long-term effects of surgical ventricular restoration with additional restrictive mitral annuloplasty and/or coronary artery bypass grafting on left ventricular function: six-month follow-up by pressure-volume loops.

OBJECTIVES: Previous studies demonstrated beneficial short-term effects of surgical ventricular restoration on mechanical dyssynchrony and left ventricular function and improved midterm and long-term clinical parameters. However, long-term effects on systolic and diastolic left ventricular function are still largely unknown. METHODS: We studied 9 patients with ischemic dilated cardiomyopathy who underwent surgical ventricular restoration with additional restrictive mitral annuloplasty and/or coronary artery bypass grafting. Invasive hemodynamic measurements by conductance catheter (pressure-volume loops) were obtained before and 6 months after surgery. In addition, New York Heart Association classification, quality-of-life score, and 6-minute hall-walk test were assessed. RESULTS: At 6 months' follow-up, all patients were alive and clinically in improved condition: New York Heart Association class from 3.3 ± 0.5 to 1.4 ± 0.7, quality-of-life score from 46 ± 22 to 15 ± 15, and 6-minute hall-walk test from 302 ± 123 to 444 ± 78 m (all P < .01). Hemodynamic data showed improved cardiac output (4.8 ± 1.4 to 5.6 ± 1.1 L/min), stroke work (6.5 ± 1.9 to 7.1 ± 1.4 mm Hg · L; P = .05), and left ventricular ejection fraction (36% ± 10% to 46% ± 10%; P < .001). Left ventricular surgical remodeling was sustained at 6 months: end-diastolic volume decreased from 246 ± 70 to 180 ± 48 mL and end-systolic volume from 173 ± 77 to 103 ± 40 mL (both P < .001). Left ventricular dyssynchrony decreased from 29% ± 6% to 26% ± 3% (P < .001) and ineffective internal flow fraction decreased from 58% ± 30% to 42% ± 18% (P < .005). Early relaxation (Tau, minimal rate of pressure change) was unchanged, but diastolic stiffness constant increased from 0.012 ± 0.003 to 0.023 ± 0.007 mL(-1) (P < .001). CONCLUSIONS: Surgical ventricular restoration with additional restrictive mitral annuloplasty and/or coronary artery bypass grafting leads to sustained left ventricular volume reduction at 6 months' follow-up. We observed improved systolic function and unchanged early diastolic function but impaired passive diastolic properties. Clinical improvement, supported by decreased New York Heart Association class, improved quality-of-life score, and improved 6-minute hall-walk test may be related to improved systolic function, reduced mechanical dyssynchrony, and reduced wall stress.

Single-beat estimation of the left ventricular end-diastolic pressure-volume relationship in patients with heart failure.

AIMS: To test a method to predict the end-diastolic pressure-volume relationship (EDPVR) from a single beat in patients with heart failure. METHODS AND RESULTS: Patients (New York Heart Association class III-IV) scheduled for mitral annuloplasty (n=9) or ventricular restoration (n=10) and patients with normal left ventricular function undergoing coronary artery bypass grafting (n=12) were instrumented with pressure-conductance catheters to measure pressure-volume loops before and after surgery. Data obtained during vena cava occlusion provided directly measured EDPVRs. Baseline end-diastolic pressure (P(m)) and volume (V(m)) were used for single-beat prediction of EDPVRs. Root-mean-squared error (RMSE) between measured and predicted EDPVRs, was 2.79+/-0.21 mm Hg. Measured versus predicted end-diastolic volumes at pressure levels 5, 10, 15 and 20 mm Hg showed tight correlations (R(2)=0.69-0.97). Bland-Altman analyses indicated overestimation at 5 mm Hg (bias: pre-surgery 44 ml (95% CI 29 to 58 ml); post-surgery 35 ml (23 to 47 ml)) and underestimation at 20 mm Hg (bias: pre-surgery -57 ml (-80 to -34 ml); post-surgery -13 ml (-20 to -7.0 ml)). End-diastolic volumes were significantly different between groups and between conditions, but these differences were not dependent on the method (ie, measured versus predicted). RMSEs were not different between groups or conditions, nor dependent on V(m) or P(m), indicating that EDPVR prediction was equally accurate over a wide volume range. CONCLUSIONS: Single-beat EDPVRs obtained from hearts spanning a wide range of sizes and conditions accurately predicted directly measured EDPVRs with low RMSE. Single-beat EDPVR indices correlated well with directly measured values, but systematic biases were present at low and high pressures. The single-beat method facilitates less invasive EDPVR estimation, particularly when coupled with emerging non-invasive techniques to measure pressures and volumes.

Tranexamic acid and aprotinin in low- and intermediate-risk cardiac surgery: a non-sponsored, double-blind, randomised, placebo-controlled trial.

OBJECTIVE: Tranexamic acid has been suggested to be as effective as aprotinin in reducing blood loss and transfusion requirements after cardiac surgery. Previous studies directly comparing both antifibrinolytics focus on high-risk cardiac surgery patients only or suffer from methodological problems. We wanted to compare the effectiveness of tranexamic acid versus aprotinin in reducing postoperative blood loss and transfusion requirements in the patient group representing the majority of cardiac surgery patients: low- and intermediate-risk patients. METHODS: We conducted a non-sponsored, double-blind, randomised, placebo-controlled trial in which 298 patients scheduled for low- or intermediate-risk (mean logistic EuroSCORE 4.1) first-time heart surgery with use of cardiopulmonary bypass were randomised to receive either tranexamic acid, high-dose aprotinin, or placebo. All patients had preoperative normal renal function. End points of the study were monitored from the time of surgery until patient discharge. This trial was executed between June 2004 and October 2006. RESULTS: Both antifibrinolytics significantly reduced blood loss and transfusion requirements when compared with placebo. Aprotinin was about twice as effective as tranexamic acid in reducing total postoperative blood loss (estimated median difference 155 ml, 95% confidence interval (CI) 60-260; p < 0.001). Accordingly, aprotinin reduced packed red blood cell transfusions more than tranexamic acid, although the difference did not reach statistical significance. Only aprotinin significantly reduced the proportion of transfused patients when compared with placebo (mean difference -20.9%, 95% CI 7.3-33.5; p = 0.013), and only aprotinin completely abolished bleeding-related re-explorations (mean difference 6.8%, 95% CI 1.6-13.4%; p = 0.004). Neither antifibrinolytic agent increased the incidence of mortality (mean difference tranexamic acid -0.4%, 95% CI -4.6 to 4.4; p = 0.79, mean difference aprotinin -1.3%, 95% CI -6.2 to 3.5; p = 0.62) or other serious adverse events when compared with placebo. CONCLUSION: Aprotinin has clinically significant advantages over tranexamic acid in patients with normal renal function scheduled for low- or intermediate-risk cardiac surgery.

Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure.

OBJECTIVE: Advanced ischemic heart failure can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent heart failure have been identified, no plain predictor for identifying SVR patients with left ventricular damage beyond recovery is yet available. We tested echocardiographic wall motion score index (WMSI) as a predictor for mortality or poor functional result. METHODS: One hundred and one patients electively operated between April 2002 and April 2007 were included for analysis. All patients had advanced ischemic heart failure (NYHA-class>or=III and LVEFor=III) at 1-year follow-up were identified by univariable logistic regression analysis. Preoperatively, a 16-segment echocardiographic WMSI was calculated and receiver operating characteristic curve analysis was used to identify cut-off values for WMSI in predicting poor outcome. RESULTS: Early mortality was 9.9%, late mortality 6.6%. NYHA class improved from 3.2+/-0.4 to 1.5+/-0.7. At 1-year follow-up, 10 patients (12%) were in NYHA class III and the remaining patients were in NYHA class I or II (75 patients, 88%). WMSI was found to be the only statistically significant predictor for poor outcome (odds ratio 139, 95% confidence interval (CI) 17-1116, p<0.0001). The optimal cut-off value for WMSI in predicting mortality or poor functional result was 2.19 with a sensitivity and specificity of 82% (95% CI 81.5-82.5% and 81.4-82.6%). The area under the curve was 0.94 (95% CI 0.90-0.99). Positive and negative predictive values were 67% and 92% respectively (95% CI 66.4-67.6% and 91.4-92.6%). CONCLUSIONS: Sufficient residual remote myocardium is necessary to recover from a SVR procedure and to translate the surgically induced morphological changes into a functional improvement. Preoperative WMSI is a surrogate measure of residual remote myocardial function and is a promising tool for better patient selection to improve results after SVR procedures for advanced ischemic heart failure.