Mitral Repair vs Replacement for Degenerative Mitral Regurgitation in Patients Aged ≥65 Years.

BACKGROUND: The benefits of mitral valve repair vs replacement are well documented. However, survival benefits in the elderly population are more controversial. In this novel lifetime analysis, we hypothesize that survival benefits for valve repair vs replacement in the elderly are sustained throughout the patient's lifetime. METHODS: From January 1985 through December 2005, 663 patients, aged ≥65 years with myxomatous degenerative mitral valve disease underwent primary isolated mitral valve repair (n = 434) or replacement (n = 229). Propensity score matching was used to balance variables potentially related to outcome. RESULTS: Follow-up was complete in 99.1% of mitral repair and 99.6% of mitral replacement patients. In matched patients, perioperative mortality was 3.9% (9 of 229) for repair and 10.9% (25 of 229) for replacement (P = .004). Survival estimates (95% confidence limits) from 29-year follow-up for matched patients were 54.6% (48.0%, 61.1%) and 11.0% (6.8%, 15.2%) at 10 years and 20 years for repair patients, and 34.2% (27.7%, 40.7%) and 3.7% (1%, 6.4%) for replacement patients, respectively. Median survival (95% confidence limits) was 11.3 years (9.6, 12.2 years) for repair patients compared with 6.9 years (6.3, 8.0 years) for replacement patients (P < .001). CONCLUSIONS: This study demonstrates that although the elderly population is prone to multiple comorbidities, survival benefits of isolated mitral valve repair vs replacement are sustained throughout the patient's lifetime.

Long-Term Survival Benefits of Porcine versus Pericardial Bioprostheses in Elderly Patients Undergoing Isolated Aortic Valve Replacement: A 32-Year Study.

BACKGROUND: The elderly population is growing at an unprecedented rate. Aortic valve disease increases with age. Bioprostheses are the valves of choice for older patients; however, the optimal tissue valve remains undetermined. The purpose of this investigation was to perform a life-of-patient survival comparison of the prototypical porcine and pericardial prostheses in elderly patients. METHODS: The study population (N = 1480) consisted of patients 65 years of age and older who underwent isolated aortic valve replacement from 1990 through 2005 with a Carpentier-Edwards Porcine (n = 650) or Pericardial (n = 830) bioprosthesis. Propensity score-matched groups were created. RESULTS: Valve selection was not associated with operative mortality. Survival estimates at 10 years were better for Pericardial (41.8%; 95% CI: 37.9 to 45.7) than Porcine (32.6%; 95% CI: 28.8 to 36.3); and 5.2% (95% CI: 3.2 to 7.1) versus 2.0%; (95% CI: 0.8 to 3.2) at 20 years (p < 0.001). E-value analysis found minimal influence of unknown study confounders. Factors associated with long-term mortality were porcine valve (p < 0.001), age (p < 0.001), diabetes mellitus (p < 0.001), preop renal insufficiency (p < 0.001), peripheral artery disease (p = 0.011), congestive heart failure (p = 0.003), New York Heart Association Class III or IV (p = 0.004), surgical history-reoperation (p = 0.012), transient ischemic attack (p = 0.009), prolonged ventilation (p = 0.010), postop renal insufficiency (p < 0.001), and atrial fibrillation (p = 0.009). The indexed Effective Orifice Area (EOAi) was assessed and did not influence observed long-term survival differences. CONCLUSIONS: This unusual lifetime study provided substantial evidence for the superiority of the pericardial over the porcine bioprosthesis in the aortic position in elderly patients. It demonstrated enhanced long-term survival benefits for elderly patients without any increase in perioperative mortality. It is intended to inform future investigation into aortic valve design.

When should fractional flow reserve be performed to assess the significance of borderline coronary artery lesions: Derivation of a simplified scoring system.

OBJECTIVES: To derive a simplified scoring system (SSS) that can assist in selecting patients who would benefit from the application of fractional flow reserve (FFR). BACKGROUND: Angiographers base decisions to perform FFR on their interpretation of % diameter stenosis (DS), which is subject to variability. Recent studies have shown that the amount of myocardium at jeopardy is an important factor in determining the degree of hemodynamic compromise. METHODS: We conducted a retrospective multivariable analysis to identify independent predictors of hemodynamic compromise in 289 patients with 317 coronary vessels undergoing FFR. A SSS was derived using the odds ratios as a weighted factor. The receiver operator characteristics curve was used to identify the optimal cutoff (≥3) to discern a functionally significant lesion (FFR≤0.8). RESULTS: Male gender, left anterior descending artery apical wrap, disease proximal to lesion, minimal lumen diameter and % DS predicted abnormal FFR (≤0.8) and lesion location in the left circumflex predicted a normal FFR. Using a cutoff score of ≥3 on the SSS, a specificity of 90.4% (95% CI: 83.0-95.3) and a sensitivity of 38.0% (95% CI: 31.5-44.9) was generated with a positive predictive value of 89.0% (95% CI: 80.7%-94.6%) and negative predictive value of 41.6% (95% CI: 35.1%-48.3%). CONCLUSIONS: The decision to use FFR should be based not only on the % DS but also the size of the myocardial mass jeopardized. A score of ≥3 on the SSS should prompt further investigation with a pressure wire.

Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit.

BACKGROUND: Extensive evidence documents a survival benefit for bilateral internal mammary artery (BIMA) grafting compared with single internal mammary artery (SIMA) grafting for patients with advanced coronary artery disease. However, controversy continues to exist regarding the incremental benefit of broadly applied BIMA grafting in elderly patients. METHODS: Retrospective analysis was conducted of 4,503 consecutive isolated coronary artery bypass grafting operations (SIMA, n = 2,340 and BIMA, n = 2,163) performed from 1972 to 1994. Multivariate analysis was used to created propensity score-matched groups of SIMA (n = 1,063) and BIMA (n = 1,063) to compare patients 65 years of age and older, and 70 years of age and older (n = 612), with similar baseline characteristics. Survival status was obtained by periodic follow-up, query of the US National Death Index, and other Internet searches, and was 99.6% complete. RESULTS: The propensity score-matched groups experienced similar perioperative mortality and morbidity. Survival benefits were found for BIMA versus SIMA grafting across both age categories. Actuarial curves after 23,593 patient-years of follow-up (mean BIMA = 11.7 years; 6 weeks to 33.1 years; mean SIMA = 10.5 years; 6 weeks to 30.7 years) demonstrated improved long-term survival for BIMA versus SIMA patients at 12 years (51.0 ± 1.5% versus 39.0 ± 1.5%) and at 24 years (3.5 ± 0.7% versus 4.5 ± 0.7%; p < 0.001). Similarly, in matched groups of patients age 70 and older, overall survival was also enhanced with BIMA grafting (p = 0.005). CONCLUSIONS: Advanced age should not be a contraindication for BIMA grafting. Long-term follow-up clearly demonstrates that BIMA grafting when broadly applied in elderly patients results in improved long-term survival over SIMA grafting.

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study.

OBJECTIVE: To evaluate the perioperative and pathological outcomes associated with robot-assisted radical prostatectomy (RARP) in morbidly obese men. PATIENTS AND METHODS: Between January 2008 and March 2012, 3041 patients underwent RARP at our institution by a single surgeon (V.P.). In all, 44 patients were considered morbidly obese with a body mass index (BMI) of ≥40 kg/m(2) . A propensity score-matched analysis was conducted using multivariable analysis to identify comparable groups of patients with a BMI of ≥40 and <40 kg/m(2) . Perioperative, pathological outcomes and complications were compared between the two matched groups. RESULTS: There was no significant difference in operative time. However, the mean estimated blood loss was higher in morbidly obese patients, at a mean (sd) of 113 (41) vs 130 (27) mL (P = 0.049). Anastomosis was more difficult in morbidly obese patients (P = 0.001). There were no significant differences in laterality, ease of nerve sparing, or transfusion rate between the groups. There were no intraoperative complications in either group. Postoperative pathological outcomes were similar between the groups. Differences in positive surgical margins and ease of nerve sparing approached statistical significance (P = 0.097, P = 0.075 respectively). Postoperative complication rates, pain scores, length of stay and indwelling catheter duration were similar in the groups. CONCLUSIONS: RARP in morbidly obese patients is technically demanding. However, it can be accomplished with acceptable morbidity and resource use. In the hands of an experienced surgeon, it is a safe procedure and offers beneficial clinical outcomes.

Bilateral internal mammary artery grafting reverses the negative influence of gender on outcomes of coronary artery bypass grafting surgery.

OBJECTIVES: Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been clearly defined. METHODS: A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, [SIMA]; 1886 bilateral IMA, [BIMA]) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete. RESULTS: Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790). CONCLUSIONS: When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery.

Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30-year follow-up of propensity score-matched cohorts.

BACKGROUND: The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus SIMA grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. METHODS AND RESULTS: Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching with the propensity score was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years; mean, 8.9 years) determined long-term survival. There was no difference in operative mortality, sternal wound infection, or total complications between matched SIMA and BIMA groups (operative mortality, 10 of 414 [2.4%] versus 13 of 414 [3.1%]; P=0.279; sternal wound infection, 7 of 414 [1.7%] versus 13 of 414 [3.1%]; P=0.179); total complications, 71 of 414 [17.1%] versus 71 of 414 [17.1%]; P=1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival: SIMA, 9.8 years versus BIMA, 13.1 years; P=0.001). Use of BIMA was found to be associated with late survival on Cox regression (P=0.003). CONCLUSION: Compared with SIMA grafting, BIMA grafting in propensity score-matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality.

Detection of inadvertent catheter movement into the coronary sinus ostium or middle cardiac vein by real-time impedance monitoring prior to radiofrequency ablation in the right atrial posteroseptal region.

OBJECTIVE: The objective of this study was to evaluate the use of continuous catheter impedance monitoring prior to ablation to facilitate differentiation of the coronary sinus ostium (CSO) and the middle cardiac vein (MCV) from the right atrial posteroseptal region (RPS). BACKGROUND: Empiric observations have suggested that continuous catheter impedance monitoring could differentiate the CSO and MCV from the RPS region. Radiofrequency ablation in the MCV or coronary sinus has been associated with coronary artery injury. Differentiation of these areas may be difficult with either fluoroscopy or electrogram characteristics. METHODS AND RESULTS: Continuous impedance measurements using a 4-mm Navistar (Biosense Webster) ablation catheter were conducted in 17 consecutive patients undergoing ablation for supraventricular tachycardia. The average impedance value was recorded at the right atrial septum (RS) posterior to the bundle of His, the RPS region, within 1 cm inside the CSO and in the MCV. These areas were confirmed and demarcated with 3-D mapping and biplane fluoroscopy. A significant increase in impedance was observed between the CSO (X = 146.6 ± 24.8) and RPS [Formula: see text] regions (p < 0.001). Furthermore, a significant rise in impedance was seen between the MCV [Formula: see text] and RPS and CSO, respectively (p < 0.001). No significant change in impedance was found between the RS [Formula: see text] and RPS regions. CONCLUSIONS: Continuous impedance measurements during mapping can facilitate differentiation of catheter locations inside the CSO and MCV from extracoronary sinus regions. This may reduce the risk of inadvertent coronary artery damage during the ablation procedure.

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up.

OBJECTIVE: Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. METHODS: Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. RESULTS: There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). CONCLUSIONS: Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

Resource utilization in off-pump versus conventional coronary artery bypass grafting in a community hospital: a comparative analysis using propensity scoring.

BACKGROUND: At a time when cost containment in health care is under increased scrutiny, coronary artery bypass grafting remains the most widely performed cardiac surgical procedure in the world. This study compares 30-day mortality, morbidity, and resource use for off-pump coronary artery bypass (OPCAB) versus conventional coronary artery bypass (CCAB) revascularization. METHODS: From January 2000 through December 2008, 1003 patients underwent OPCAB grafting by a single surgeon (S.C.S.). Data were prospectively collected, entered into a Society of Thoracic Surgeons adult cardiac surgery database, and analyzed retrospectively. We used propensity-matching techniques to match this cohort to a group of 1003 patients who underwent CCAB. RESULTS: The hospital mortality rate was lower for the OPCAB patients than for the CCAB patients: 2.0% (20/1003) versus 2.8% (28/1003). Predictors of hospital mortality for the entire cohort included age (P = .001), cardiogenic shock (P = .001), congestive heart failure (P = .019), history of myocardial infarction (P = .001), and reoperation (P = .007). The overall incidence of morbidity was lower for the OPCAB patients (reoperation for bleeding, P = .011; prolonged ventilation, P = .035; stroke, P = .045; cardiac arrest, P = .004). OPCAB patients experienced significantly reduced procedure times (P = .001), postoperative ventilation times (P = .035), post-operative lengths of stay (P = .035), and blood product use (intraoperative, P = .001; postoperative, P = .001). CONCLUSION: These outcomes clearly demonstrate that OPCAB is a safe and effective procedure for myocardial revascularization. This retrospective, nonrandomized observational study has shown that the patients who underwent OPCAB had reduced morbidity and mortality, as well as decreased resource use, compared with those who underwent CCAB.

Location of the second internal mammary artery graft does not influence outcome of coronary artery bypass grafting.

BACKGROUND: Although the use of two internal mammary arteries (IMA) in coronary artery bypass graft surgery has been associated with improved patient survival and clinical status, the optimal use of the second IMA graft remains controversial. We, therefore, explored clinical outcomes in a large cohort of patients undergoing bilateral IMA grafting. METHODS: Between February 1972 and May 1994, 2,215 consecutive patients underwent bilateral IMA grafting. The second IMA was used to revascularize the left coronary system (LCS) in 1,479 and the right coronary system (RCS) in 736 patients. Propensity score optimal matching algorithm was used to create the matched LCS group (n=730) and RCS group (n=730). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8; 96.7% complete) was performed. Multivariable analyses were performed to determine correlates of operative mortality and late mortality. Patient clinical status and Short Form-36 scores of late survivors were compared. RESULTS: There was no difference in either operative mortality or late survival between LCS and RCS patients, in either unmatched or matched groups. Operative mortality unmatched was LCS 38 of 1,479 (2.6%) versus RCS 20 of 736 (2.7%; p=0.837). For matched groups, it was LCS 13 of 730 (1.8%) versus RCS 20 of 736 (2.7%; p=0.284). Median survival in unmatched patients was LCS 15.8 years versus RCS 16.1 years (p=0.803); for matched patients, it was LCS 16.1 years versus RCS 16.1 years (p=0.671). Site of second IMA was not associated with either operative mortality or late survival on multivariable analysis. At follow-up, both groups demonstrated excellent clinical outcomes, with 98.4% of LCS patients and 96.8% of RCS patients in Canadian Cardiovascular Society class I or II, and no significant difference in either the physical (p=0.142) or mental (p=0.542) health summary scores on the Short Form-36. CONCLUSIONS: Use of two IMA grafts demonstrates excellent long-term results with no demonstrable difference in outcome between RCS and LCS patients.

Eighteen-year follow-up demonstrates prolonged survival and enhanced quality of life for octogenarians after coronary artery bypass grafting.

OBJECTIVE: Octogenarians comprise the fastest growing population segment. Numerous reports have documented improved accomplishment of coronary artery bypass grafting in this high-risk cohort. But what is the quality of life after surgery, and how sustainable are the clinical benefits? METHODS: Sequential cross-sectional analyses were performed on 1062 consecutive patients 80 years old and older who underwent isolated on-pump coronary artery bypass grafting at a single institution from 1989 to 2001. After mean follow-up of 3.4 years (1 month-12.6 years), the Short Form 36 quality of life survey was administered to all survivors. Late follow-up for survival was performed after a mean 5.6 years (1 month-17.9 years). Multivariate analyses assessed risk factors associated with operative mortality, Short Form 36 self-assessment, and late survival. RESULTS: Mean age at operation was 83.1±2.8 years (range, 80-99 years). Overall in-hospital mortality was 9.7%, decreasing progressively to 2.2% during the course of the study. At midterm follow-up, 97.1% of patients were in Canadian Cardiovascular Society class I or II; Short Form 36 scores were comparable to age-adjusted norms in both physical and mental health summary scores. Actuarial survivals were 42.2%±1.5% at 7 years and 9.9%±1.4% at 14 years. Median survival was 5.9 years; 5.2 years for male patients and 6.7 for female patients (P=004). CONCLUSIONS: The risk of coronary artery bypass grafting for octogenarians now rivals that of a younger population. Midterm quality of life and long-term survival approach those of the general population.

Do Statins Reduce Atrial Fibrillation After Coronary Artery Bypass Grafting?

Background: Atrial Fibrillation (AF) is a common postoperative complication after coronary artery bypass grafting. There is contradictory evidence as to whether pre-operative statin use lowers the incidence of postoperative AF. This study aimed to assess whether pre operative statin therapy prevents the post-operative AF. Methods: In this retrospective cohort study we used a propensity score-matching analysis to evaluate the effect of preoperative treatment with statins on postoperative atrial fibrillation. There were 427 matched pairs of patients. Primary outcome was the incidence of postoperative AF. Secondary outcomes were 30 day mortality, stroke, myocardial infarction and length of hospital stay. Results: The incidence of postoperative AF was not different in the statin users compared with the nonusers (123, 28.1%, versus 127, 29.7%, respectively; p = 0.764). The 30 day mortality (6, 1.4%, versus 8, 1.9%; p = 0.590), stroke (10, 2.3%, versus 8, 1.9%; p = 0.634), myocardial infarction (2, 0.5%, versus 0, 0.0%; p = 0.499) and length of hospital stay in days (11.8 ± 9.0, versus 11.9 ± 9.3; p = 0.544) did not differ significantly between the two groups. Conclusions: In a propensity-matched cohort of patients undergoing coronary bypass surgery, we could not demonstrate that preoperative statins were protective for the development of post operative atrial fibrillation.

Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups.

BACKGROUND: The value of the left internal mammary artery (LIMA) graft is well established. However, the incremental value of a second IMA graft is controversial. Despite reports of improved survival with bilateral IMA (BIMA) grafting, the Society of Thoracic Surgeons reports its use in 4% of coronary artery bypass graft operations. We report the influence of BIMA vs SIMA grafting on hospital and late mortality in comparable groups. METHODS: Retrospective review was conducted of 4584 consecutive isolated coronary artery bypass graft operations (2369 SIMA and 2215 BIMA) performed from 1972 to 1994. The influence of the second IMA was assessed by multivariate analyses of risk factors associated with hospital and late mortality and by propensity score analysis that compares patients with similar baseline characteristics for receiving a second IMA graft. All patients were monitored clinically to assess outcomes. RESULTS: Hospital mortality was 4.5% for SIMA vs 2.6% for BIMA patients (p = 0.001). When stratified by propensity score to undergo BIMA grafting, no difference in hospital mortality was found. Multivariate analyses showed SIMA grafting was significantly associated with late but not hospital mortality. Survival curves after 52,572 patient-years of follow-up (mean, 11.5 years; range, 6 weeks to 32 years) demonstrated improved long-term survival for BIMA vs SIMA patients in all quintiles except those with the greatest propensity for SIMA, wherein late survival was comparable between groups. In matched groups, survival favored BIMA patients (p = 0.001). CONCLUSIONS: BIMA grafting offers a long-term survival advantage over SIMA grafting in propensity-matched groups.

Surgical management of aortic valve disease in the elderly: A retrospective comparative study of valve choice using propensity score analysis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve dysfunction is the most common form of valvular heart disease. As the population continues to age, a greater number of patients will become candidates for aortic valve replacement (AVR); hence, prosthetic valve choice becomes of paramount importance. METHODS: A retrospective analysis was conducted on 801 patients aged > or =65 years who underwent isolated AVR or AVR + coronary artery bypass grafting (CABG) between January 1989 and June 2003 with a Carpentier Edwards Perimount (CEP) pericardial bioprosthesis (n = 398) or a St. Jude Medical (SJM) mechanical valve (n = 403). The mean age of CEP patients was 74.5 years (range: 65-89 years), and of SJM patients 73.9 years (range: 65-90 years). The follow up was 96.2% and 96.5% complete for CEP and SJM patients, respectively. Propensity scoring was used to establish homogeneity of the groups and reduce bias. RESULTS: The operative mortality was 4.0% (n = 16) among CEP patients and 6.5% (n = 26) among SJM patients. Predictors of hospital mortality included: peripheral vascular disease (p = 0.018), surgical urgency (p = 0.010), preoperative intra-aortic balloon pump (IABP) (p = 0.010), intraoperative perfusion time (p = 0.046) and intraoperative IABP (p = 0.001). Postoperative morbidities were similar for the two groups. The mean follow up was 72.4 and 59.2 months for CEP and SJM patients, respectively. The five-year actuarial survival was 70.9 +/- 2.3% for CEP and 71.8 +/- 2.4% for SJM patients; at 10 years the actuarial survival was 32.6 +/- 3.3% and 38.2 +/- 3.8%, respectively. Freedom from reoperation for AVR, stroke and non-fatal myocardial infarction was 98.8% (159/161), 99.4% (160/161) and 99.4% (160/161), respectively, in CEP patients, and 100.0% (220/220), 97.7% (215/220) and 97.7% (215/220), respectively, in SJM patients (p = NS). Predictors of late death (>30 days) included chronic obstructive pulmonary disease (p = 0.001) and mechanical valve replacement (p = 0.001). CONCLUSION: In comparable elderly patients, the outcomes of CEP and SJM valves after AVR showed no significant differences in hospital morbidity, mortality, mid-term survival or late cardiac events. However, the cumulative risk of lifelong anticoagulation with a mechanical valve is a serious consideration that must be factored into the selection algorithm.

Routine use of the direct thrombin inhibitor bivalirudin for off-pump coronary artery bypass grafting is safe and effective.

Anticoagulation with unfractionated heparin has been the standard of care for more than a half-century for patients undergoing cardiac surgery. The risk of heparin-induced adverse reactions dictates the need for a safe and effective alternative, particularly in off-pump coronary artery bypass (OPCAB) surgery, an approach associated with a perioperative prothrombotic condition that may negatively influence graft patency. Between March 2003 and January 2005, 243 consecutive patients underwent OPCAB with bivalirudin (0.75 mg/kg bolus with 1.75 mg/kg per hour infusion). There were 171 men (70.4%) and 72 women (29.6%). The mean age was 64.9 +/- 10.9 years (age range 32-88 years). There were 147 patients (60.5%) with 3-vessel disease; 46 (18.9%) had substantial (>50%) stenosis of the left main coronary artery; 104 (42.8%) had a moderately reduced (0.30 to 0.50) ejection fraction; and 9 (3.7%) had a severely reduced (<0.30%) ejection fraction. Five patients (2.1%) required conversion to cardiopulmonary bypass and subsequently received heparin. Postoperative complications included perioperative myocardial infarction in 6 patients (2.5%), stroke in 3 (1.2%), prolonged ventilation in 4 (1.6%), reoperation for bleeding in 3 (1.2%), renal insufficiency in 14 (5.8%), atrial fibrillation in 26 (10.7%), low cardiac output in 3 (1.2%), and deep sternal infection in 1 (0.4%). Blood products were used in 117 patients (48.1%). The overall hospital mortality rate was 0.4% (1 of 243). Bivalirudin is a safe and effective anticoagulant that may be routinely used as an alternative to heparin and protamine in patients undergoing OPCAB. This is evidenced by low hospital mortality and morbidity rates. Further follow-up is warranted to discern the influence of bivalirudin on long-term clinical outcomes.

Minimally invasive surgical ablation of atrial fibrillation: the thoracoscopic box lesion approach.

BACKGROUND: Atrial fibrillation is the most common cardiac rhythm disturbance and is associated with increased morbidity and mortality. It is often found in association with structural heart disease; however, lone atrial fibrillation is not uncommon. Potentially, these patients are ideal candidates for a minimally invasive thoracoscopic approach for the surgical treatment of atrial fibrillation. METHODS: From August 2003 through February 2006, 100 drug-resistant symptomatic patients with lone atrial fibrillation underwent thoracoscopic off-pump closed-chest epicardial ablation using the FLEX 10 AFx Microwave Ablation System (Guidant, Indianapolis, IN, USA). There were 66 men (66.0%) and 34 women (34.0%), with a mean age of 60.9 +/- 9.8 (range 37-81) years. Mean duration of atrial fibrillation was 72.4 +/- 79.5 (range 6-480) months. Sixty-four patients (64.0% had paroxysmal, 11 (11.0%) had persistent and 25 (25.0%) had permanent atrial fibrillation. RESULTS: There were no hospital deaths. Postoperative in-hospital complications were minimal. Mean postoperative length of stay was 3.4 +/- 1.7 days. Cumulative follow-up was 2,106.3 (mean 23.1) patient months, with a maximum follow-up of 39.8 months. There were three late deaths (3.0%). In nine patients (9.0%), the thoracoscopic box lesion pulmonary vein isolation operation and subsequent electrophysiological intervention failed, and a Cox-Maze operation was performed. Follow-up was 100% complete, with 42.0% (37 of 88) patients in normal sinus rhythm. Two patients (2.3%) experienced a transient ischemic attack and two (2.3%) a cerebral vascular accident. Twenty-seven patients (30.7%) required electrophysiological intervention post procedure. Ten patients (11.4%) were on amiodarone and 48 (54.5%) were on coumadin at follow-up. CONCLUSION: Totally thoracoscopic surgical ablation for the treatment of atrial fibrillation is technically feasible and presents minimal risk to the patient. Clinical results with the application of microwave energy have been less than satisfactory, with no demonstrated electrical isolation of the pulmonary veins. Moreover, long-term relief from atrial fibrillation has not been achieved.

Angiographic and clinical outcomes of bivalirudin versus heparin in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

BACKGROUND: Heparin with adjunctive glycoprotein IIb/IIIa platelet receptor (GP IIb/IIIa) inhibitors has demonstrated its effectiveness in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, has recently been shown to be an effective alternative for patients undergoing elective PCI. OBJECTIVES: To assess the angiographic and clinical outcomes of adjunctive pharmacological strategies in a high-risk population presenting with ACS. METHODS: Of 891 consecutive PCI patients with ACS, 304 received bivalirudin (60.5% male, 68+/-11 years) and were compared with 283 who received heparin (58.7% male, 66+/-12 years). A 30-day major adverse cardiac event was defined as the occurrence of cardiac death, nonfatal myocardial infarction, urgent revascularization or major hemorrhage. RESULTS: Adjunctive GP IIb/IIIa inhibitors were used in 14.1% of the bivalirudin group and in 72.4% of the heparin group (P<0.010). The occurrence of Thrombolysis In Myocardial Infarction (TIMI) flow less than grade 3 was lower and the achievement of angiographic success was higher in the bivalirudin group than in the heparin group (5.2% versus 8.2%, 94.7% versus 89.7%, P=0.039 and P<0.010, respectively). There was no difference between groups in the incidence of bleeding events (bivalirudin 2.0% versus heparin 3.5%, P not significant) and in 30-day major adverse cardiac events (bivalirudin 8.3% versus heparin 5.7%, P=0.223). CONCLUSIONS: In the high-risk cohort undergoing PCI, bivalirudin with provisional GP IIb/IIIa inhibitors achieved better angiographic results. Although not powered to show a difference, and while acknowledging that a selection bias could have affected the data, the present study showed that bivalirudin may be as clinically effective and safe as heparin with adjunctive GP IIb/IIIa inhibitors.

Left atrial reduction enhances outcomes of modified maze procedure for permanent atrial fibrillation during concomitant mitral surgery.

BACKGROUND: Success of the maze procedure after mitral operations with large left atria and permanent atrial fibrillation remains suboptimal. Current technique variations tend to obscure the decision-making algorithm in these patients. A single energy-source approach for the surgical management of patients with large left atria and permanent atrial fibrillation is presented. METHODS: From January 2003 to July 2005, 71 consecutive drug-resistant patients with permanent atrial fibrillation and left atrial enlargement who required mitral valve surgery underwent aggressive left atrial reduction combined with left-sided only irrigated radiofrequency unipolar maze. Left atrial dimensions were measured by transesophageal echo anterior-to-posterior leading edge-to-edge standardized protocol. There were 39 men (54.9%) and 32 women (45.1%), and their mean age was 71.9 +/- 9.5 years. Mean duration of atrial fibrillation was 49.3 +/- 58.0 months. RESULTS: All patients underwent left atrial reduction with identical Cox-maze III pulmonary vein and appendage isolation including mitral annular connection, followed by appendage suture closure. Left atrial size was reduced from 6.7 +/- 1.2 cm to 4.3 +/- 0.6 cm (p = 0.001). Mitral valve repair was performed in 55 patients (76.1%) and replacement in 17 (23.9%). The 30-day mortality was 4.2% (3/71). Postoperative length of stay was 8.8 +/- 5.7 days, with 56 (82.4%) of 68 patients discharged in normal sinus rhythm. P-wave sinus rhythm was 93.8% between 7 and 12 months and 92.0% for patients with 1 year or more of follow-up. CONCLUSIONS: Left atrial reduction combined with a left atrial only single energy-source radiofrequency maze procedure is an effective treatment for patients with permanent atrial fibrillation undergoing concomitant mitral operations.