Long-term follow up of patients undergoing reoperative surgery with aortic or mitral valve replacement using a St. Jude Medical prosthesis.

BACKGROUND AND AIM OF THE STUDY: Between June 1978 and September 2002, a total of 440 reoperative open-heart patients (mean age 62 +/- 14 years; range: 18-91 years), following various primary cardiac operations, underwent single-valve replacement with the St. Jude Medical (SJM) heart valve. Of 241 patients having aortic replacement (AVR) and 199 mitral valve replacement (MVR), 86 (35%) and 42 (21%), respectively, underwent concomitant coronary artery bypass grafting. The study aim was to document patient survival and valve-related events in an experience extending up to 24 years after reoperative open-heart surgery with a single model cardiac valve prosthesis. METHODS: The Cardiac Surgical Associates Research Foundation (CSARF) has maintained an independent database of those patients with the SJM prosthesis since the world's first implant in October 1977. Patients were contacted by questionnaire and/or telephone between November 2002 and June 2003. The hospital course and valve-related events were verified by patient chart review and/or physician contact. RESULTS: Follow up was 94% complete, for a total of 3,114 patient-years (1,671 pt-yr after AVR; 1,443 pt-yr after MVR). The average follow up was 7 +/- 6 years (range: 0.1-24.3 years). The operative mortality was 9% (10% AVR, 8% MVR). Five deaths (13%) were valve-related. Freedom from all late mortality at 10 and 20 years, respectively, was 57% and 35% for AVR and 52% and 22% for MVR, and for valve-related mortality was 89% and 77% for AVR and 84% and 22% for MVR. Freedom from thromboembolic events at 10 and 20 years, respectively, was 93% and 93% after AVR and 92% and 81% after MVR; from anticoagulant-related hemorrhage it was 78% and 76% after AVR and 81% and 67% after MVR; and from reoperation it was 94% and 94% after AVR and 95% and 89% after MVR. CONCLUSION: Reoperative valve replacement carries a significant operative morbidity and mortality. Long-term results with the SJM valve demonstrated a durable prosthetic valve, excellent long-term patient survival, and freedom from valve-related events followed reoperative open-heart valve replacement surgery. However, the early postoperative period carried an increased risk for valve-related events.

Coronary artery bypass grafting with a minimized cardiopulmonary bypass circuit: a prospective, randomized trial.

OBJECTIVE: The study was designed to determine differences in blood loss and transfusion associated with a minimized cardiopulmonary bypass circuit versus a standard bypass circuit. METHODS: From February 2005 through April 2006, 199 patients were randomized to undergo coronary artery bypass grafting with a standard cardiopulmonary bypass circuit (Medtronic, Inc., Minneapolis, Minn) or a minimized bypass circuit, the Medtronic Resting Heart Circuit. Laboratory perimeters (hemoglobin and platelet count), were measured at baseline, after initiation of cardiopulmonary bypass, and on intensive care unit admission. Lowest values recorded were noted. Blood administration was controlled by study-specific protocol orders, (transfusion for hemoglobin <8mg%). Patient demographic data were retrieved from the Society of Thoracic Surgeons database. Blood product administration was recorded during hospital admission, and chest tube drainage as total output collected from operating room to discontinuation. Continuous variables were tested with a Wilcoxin rank test, and categoric variables with X(2) and Fisher's exact tests. RESULTS: Hematocrit, equivalent at baseline, was higher in minimized circuit cohort at lowest point during cariopulmonary bypass (31.5% +/- 3.9% vs. 25.5% +/- 3.7%), after protamine (31.6% +/- 3.9% vs 29.2% +/- 3.7%), and on intensive care unit arrival (35.2% +/- 4.1% vs 31.8% +/- 3.5%, P < .001). Similarly, platelet count was higher in minimized circuit group on intensive care unit arrival, as was lowest platelet count recorded (170 x 10(3) +/- 48 cells/mm(3) vs 107 x 10(3) +/- 28 cells/mm(3), P < .0001). Time to extubation was shorter in minimized circuit group (848 +/- 737 minutes vs. 526 +/- 282 minutes, (P < .01), and total chest tube drainage was lower (1124 +/- 647 mL vs. 506 +/- 214 mL, P < .01). Fewer red blood cells (148 vs 19 units) were given in minimized circuit group (P < .0001). CONCLUSIONS: A minimized cardiopulmonary bypass circuit provides less hemodilution, platelet consumption, chest tube output and lower post-operative blood loss than standard cardiopulmonary bypass. Red blood cell usage was also less. All differences are advantageous.

The St. Jude Medical cardiac valve prosthesis: long-term follow up of patients having double valve replacement.

BACKGROUND AND AIM OF THE STUDY: Between October 1977 and February 2002, a total of 343 patients (mean age 62 +/- 13 years; range: 19-91 years) underwent double valve replacement (DVR) with the St. Jude Medical (SJM) heart valve. Among the replacements, 337 (98%) were aortic and mitral in nature. Concomitant coronary artery bypass was performed in 73 patients (21%). METHODS: Cardiac Surgical Associates has maintained an independent database of patients undergoing valve replacement with the SJM prosthesis since the valve's first implantation in October 1977. Patients were contacted by questionnaire and/or telephone (94% complete) between November 2002 and June 2003. The patients' hospital course and valve-related events were verified by patient chart review and/or physician contact. RESULTS: Operative mortality was 8% (n = 29); mortality was valve-related in two cases. The mean follow up was 6.5 +/- 6.0 years (range: 1 month to 24 years); total follow up was 2,226 patient-years. Over 25 years, patient freedom from late mortality was 62%, and from valve-related mortality 78%. Freedom from thromboembolic events was 82% (93% from permanent defect), from bleeding events 76%, from endocarditis 98%, from valve thrombosis 99.9%, and from reoperation 98%. Six reoperations were carried out in five patients (2%), valve repair or replacement in five (2%), and suture closure of paravalvular leak in one patient (0.3%). There were no valve structural failures reported. CONCLUSION: The SJM valve has proven to be an effective and durable heart valve prosthesis. Over the long-term, the event rate is low and there is excellent freedom from reoperation in the double valve configuration.

Use of peripheral ultrafiltration in the postoperative cardiac surgery patient.

BACKGROUND: : After cardiac surgery, most patients have development of third-space fluid retention, commonly treated with diuretics. In some patients diuretics are ineffective. In this subset, a simplified system for ultrafiltration was used for fluid extraction. METHODS: : After obtaining permission from the institutional review board, the hospital charts of the first 30 patients having ultrafiltration were retrospectively reviewed to abstract data on fluid extraction and patient outcomes. Data are expressed as mean ± standard deviation. RESULTS: : From April 2004 through January 2006, 30 patients were selected for ultrafiltration. In one patient, adequate intravenous access could not be obtained. There were 11 female and 18 male (age, 69 ± 12 years) postoperative cardiac surgery patients. The mean ultrafiltration run was 10.5 ± 9 hours, resulting in fluid extraction of 3528 ± 2111 mL per run and 5596 ± 3870 mL per patient (11 patients had more than 1 run). Hospital stay was 9.4 ± 4.4 days. Three patients died unrelated to ultrafiltration. CONCLUSIONS: : Ultrafiltration as an alternative means of fluid extraction in postoperative cardiac surgery patients was effective and well tolerated.

Opposite trends in coronary artery and valve surgery in a large multisurgeon practice, 1979-1999.

BACKGROUND: Trends in coronary artery bypass (CAB) and valve operations (VO) may help predict the future of cardiac surgery in the context of changing case mix, shifting paradigms, emerging technology, and population demographics. METHODS: We retrospectively reviewed all 30,319 adult CAB and VO in our group from 1979 to 1999 according to specific procedures. RESULTS: Coronary artery bypass volumes peaked in 1996 at 1,895 cases, declining 15.3% to 1,605 cases in 1999 with a decrease in risk profile and percent reoperations and an increase in mean age and percent octogenarians, prior percutaneous coronary interventions (PCI), left internal mammary artery (LIMA) graft usage, off-pump technology usage, and hospital mortality of reoperations. Right internal mammary grafts were employed infrequently and radial artery grafts transiently. Overall VO volumes continued to increase 24.0% since 1996, from 470 to 583 cases with a decreased risk profile, increased mean age, and percent octogenarians and prior PCI. The percentage of mechanical valve implants decreased, while the percentage of various tissue solutions for valve disease increased. Limited access incisions and port-access were employed transiently with CAB and VO. CONCLUSIONS: Coronary artery bypass volumes are decreasing, with an increasing percentage of LIMA grafts and off-pump cases. Valve operation volumes are steadily increasing, with a decreasing percentage of mechanical valve implants, in favor of various tissue solutions.