LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery.

OBJECTIVES: Previous studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB). We reviewed the long-term outcomes up to 20 years, including overall survival and freedom from reintervention. METHODS: Consecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data. RESULTS: A total of 271 patients underwent an MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5-, 10-, 15- and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5%, respectively. Patients with single-vessel disease [left anterior descending artery (LAD) only] had significantly better survival compared to patients with multivessel disease (P = 0.0035). During long-term follow-up, there were no patients who required repeat revascularization of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardized mortality ratio, demonstrated that the rate of survival returned to that of the reference population (standardized mortality ratio = 0.94). CONCLUSIONS: MIDCAB is a safe and effective revascularization strategy which can be successfully performed in a carefully selected patient population with low morbidity and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year-matched counterparts within the normal population and hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.

Post-operative outcomes of inflammatory thoracic aortitis: a study of 41 patients from a cohort of 1119 surgical cases.

Aortitis is found in 2-12% of thoracic aortic aneurysm repair/replacement surgeries. Yet little is known about such patients' post-operative outcomes or the role of post-operative corticosteroids. The study was undertaken across three tertiary referral hospitals in Sydney, Australia. Prospectively collected data for all thoracic aortic repair/replacement patients between 2004 and 2018 was accessed from a national surgical registry and analysed. Histopathology records identified cases of inflammatory aortitis which were subclassified as clinically isolated aortitis (CIA), giant cell arteritis (GCA), Takayasu (TAK) or other aortitis. Between-group outcomes were compared utilising logistic and median regression analyses. Between 2004 and 2018, a total of 1119 thoracic aortic surgeries were performed of which 41 (3.7%) were inflammatory aortitis cases (66% CIA, 27% GCA, 5% TAK, 2% other). Eight out of 41 (20%) aortitis patients received post-operative corticosteroids. Compared to non-aortitis patients, the aortitis group was predominantly female (53.7% vs. 28.1%, p < 0.01), was older (mean 70 vs. 62 years, p < 0.01) and had higher prevalence of hypertension (82.9% vs. 67.1%, p = 0.03) and pre-operative immunosuppression (9.8% vs. 1.4%, p < 0.01). There was no difference (p > 0.05) between aortitis and non-aortitis groups for 30-day mortality (7.3% vs 6.5%), significant morbidity (14.6% vs. 22.4%), or infection (9.8% vs. 6.4%). Outcomes were similar for the non-corticosteroid-treated aortitis subgroup. Histologic evidence of inflammatory thoracic aortitis following surgery did not affect post-operative mortality or morbidity. Withholding corticosteroids did not adversely affect patient outcomes. These findings will assist rheumatologists and surgeons in the post-operative management of aortitis.

Should cardiac surgery be delayed in patients with uncorrected hypothyroidism?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'should cardiac surgery be delayed in patients with uncorrected hypothyroidism?' A total of 1412 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There was limited high-quality evidence with the majority of the studies being retrospective. One propensity-matched analysis and 6 cohort studies provided the evidence that there was no significant difference in the rate of major adverse cardiac events including mortality based on thyroid status. However, hypothyroidism and subclinical hypothyroidism were associated with higher rates of postoperative atrial fibrillation. Based on the available evidence, we conclude that cardiac surgery should not be delayed to allow achievement of euthyroid status.

'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?'

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?' Altogether more than 118 papers were found using the reported search, of which 4 represented the best evidence to answer the clinical question, which included 2 prospective cohort studies and 2 retrospective observational studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. There is a significant variation within the MIDCAB and TECAB techniques amongst the studies-including the experience of the surgeon, use of cardiopulmonary bypass, patient selection, and target vessel grafting strategies-highlighting the complexity of comparing these two minimally invasive procedures. Operative times were comparable across all studies, with TECAB patients having higher transfusions rates and conversion rates to either a median sternotomy or MIDCAB procedure. Overall safety was comparable between the two cohort groups, with similar length of stay and 30-day mortality. However, the TECAB group were more likely to require re-operation for bleeding and reintervention for early revascularisation with greater total hospital costs than the MIDCAB patients. Based on the available evidence, we conclude that TECAB is associated with a higher rate of transfusions, conversion to median sternotomy or MIDCAB, early graft failure and reintervention compared to the MIDCAB approach. We advise caution in adopting a TECAB approach.

In patients undergoing dialysis who require a valve replacement is a bioprosthetic valve superior to a mechanical prosthesis in terms of long-term survival and morbidity?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In [dialysis patients undergoing a valve replacement] is [a bioprosthetic valve superior to a mechanical prosthesis] for [long-term survival and morbidity]'. Altogether more than 501 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There was limited high-quality evidence with all studies being retrospective. One meta-analysis and four cohort studies provided the evidence that there was no significant difference in long-term survival based on prosthesis type. However, the majority of studies demonstrated a significantly higher rate of valve-related complications including bleeding and thromboembolism, and readmission to hospital in the mechanical valve prosthesis group, likely related to the requirement for long-term anticoagulation. We conclude that overall long-term survival in dialysis-dependent patients is poor. While prosthesis type does not play a significant contributing role to long-term survival, bioprosthetic valves were associated with significantly fewer valve-related complications. Based on the available evidence, a bioprosthetic valve may be more suitable in this high-risk group of patients as it may avoid the complications associated with long-term anticoagulation without any reduction in long-term survival.

Operative Results of Mitral Valve Repair and Replacement in Chronic Ischaemic Mitral Valve Regurgitation.

BACKGROUND: Ischaemic mitral regurgitation (IMR) carries significant morbidity and mortality. Surgical management includes coronary artery bypass surgery alone or concomitant with mitral valve repair or replacement. There is ongoing debate regarding the appropriate approach to the mitral valve in relation to long-term outcomes. This review examines our early and late follow-up, with operative and echocardiographic outcomes for mitral valve repair and mitral replacement for chronic IMR. METHODS: A retrospective review was performed on prospectively collected data of 119 consecutive patients who either underwent mitral repair (n=101) or mitral replacement (n=18) for chronic IMR at Prince Henry and The Prince of Wales hospitals in Sydney between 1999-2016. All patients had pre and postoperative transthoracic echocardiograms. Follow-up echocardiographic data was obtained from the most recent clinical appointment. Follow-up mortality outcomes were obtained with ethics approval from the Australian National Death Index (NDI). RESULTS: There was no statistical difference between cardiopulmonary bypass (CPB) time, cross-clamp time, time spent in intensive care unit (ICU) and time to discharge between cohorts. The replacement cohort was noted to have higher preoperative pulmonary artery (PA) pressures and a higher severity of IMR. Seven (7) deaths were in the mitral valve (MV) repair group within 30 days (6.9%) and three deaths in the MV replacement group within 30 days (16.7%). Echocardiographic follow-up was complete in 78% of the MV repair cohort at an average of 4.06±2.66 years, and 73% complete in the MV replacement cohort at an average of 6.09±4.3 years. Three (3) patients had prior MV repair before MV replacement early at days zero and 17, and late at 8 years respectively. Follow-up echocardiography showed mitral regurgitation (MR) in the mitral valve repair cohort as ≤ mild in 83.5% and ≤ trivial in 35.6%. In the MV replacement cohort MR ≤ mild in 100% and ≤ trivial in 82% with no moderate or severe MR. Preoperative tricuspid regurgitation (TR) and a flexible annuloplasty were predictive of an MR grade > mild in the repair cohort at discharge. Five-year (5-year) survival for the repair cohort was 85% with a mean follow-up time of 7.1±3.83 years. For the replacement cohort, five-year survival was 77.8% with a mean follow-up time of 5.35±1.54 years. CONCLUSIONS: Mitral valve repair and replacement for chronic IMR has acceptable mortality, reintervention rates and excellent postoperative echocardiographic degrees of IMR in this cohort. Further evaluation is required into quality of life post intervention for IMR and of preoperative predictive factors of significant MR postoperatively to help guide the appropriate choice of treatment. The presence of preoperative tricuspid regurgitation of moderate grade or higher, and the use of a flexible annuloplasty may indicate patients more likely to have a higher grade of MR at follow-up following mitral valve repair in patients with IMR.

Reduced efficacy of transcatheter and surgical revascularization in Takayasu arteritis.

A 55-year-old woman with newly diagnosed Takayasu arteritis was followed for 7 years, during which time she underwent bare metal stenting, drug eluting stenting and coronary bypass grafting for critical coronary and renal artery stenoses. Interventions were initially successful but restenosis occurred within 24 months for all modalities. In contrast, native vessel disease was largely stable after the introduction of immunosuppressive therapy. We advocate a conservative revascularization approach in Takayasu arteritis in the absence of critical end organ ischemia and early optimization of medical therapy.

Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes.

OBJECTIVE: This meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR). METHODS: Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints. RESULTS: Four randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR. CONCLUSIONS: In patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess long-term survival and freedom from reintervention.

Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Meta-Analysis of Clinical Outcomes and Cost-Effectiveness.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has emerged as a feasible alternative treatment to conventional surgical aortic valve replacement (AVR) for high-risk patients with aortic stenosis. The present systematic review aimed to assess the comparative clinical and cost-effectiveness outcomes of TAVI versus AVR, and meta-analyse standardized clinical endpoints. METHODS: An electronic search was conducted on 9 online databases to identify all relevant studies. Eligible studies had to report on either periprocedural mortality or incremental cost-effectiveness ratio (ICER) to be included for analysis. RESULTS: The systematic review identified 24 studies that reported on comparative clinical outcomes, including three randomized controlled trials and ten matched observational studies involving 7906 patients. Meta-analysis demonstrated no significant differences in regards to mortality, stroke, myocardial infarction or acute renal failure. Patients who underwent TAVI were more likely to experience major vascular complications or arrhythmias requiring permanent pacemaker insertion. Patients who underwent AVR were more likely to experience major bleeding. Eleven analyses from 7 economic studies reported on ICER. Six analyses defined TAVI to be low value, 2 analyses defined TAVI to be intermediate value, and three analyses defined TAVI to be high value. CONCLUSION: The present study demonstrated no significant differences in regards to mortality or stroke between the two therapeutic procedures. However, the cost-effectiveness and long-term efficacy of TAVI may require further investigation. Technological improvement and increased experience may broaden the clinical indication for TAVI for low-intermediate risk patients in the future.

A meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation.

BACKGROUND: The development of ischemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, there remains uncertainty regarding the optimal approach. The aim of the present study was to meta-analyze these two procedures, with mortality as the primary endpoint. METHODS: Seven databases were systematically searched for studies reporting peri-operative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analyzed according to pre-defined study selection criteria and clinical endpoints. RESULTS: Overall, 22 observational studies (n=3,815 patients) and one randomized controlled trial (n=251) were included. Meta-analysis demonstrated significantly reduced peri-operative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I(2)=0%; P<0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I(2)=0%; P=0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I(2)=46%; P<0.001) but the incidence of mitral valve re-operations were similar. CONCLUSIONS: In the present meta-analysis, MVr was associated with reduced peri-operative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. However, these findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention.

A meta-analysis of robotic vs. conventional mitral valve surgery.

OBJECTIVES: The present study is the first meta-analysis to compare the surgical outcomes of robotic vs. conventional mitral valve surgery in patients with degenerative mitral valve disease. METHODS: A systematic review of the literature was conducted to identify all relevant studies with comparative data on robotic vs. conventional mitral valve surgery. Predefined primary endpoints included mortality, stroke and reoperation for bleeding. Secondary endpoints included cross-clamp time, cardiopulmonary bypass time, length of hospitalization and duration of intensive care unit (ICU) stay. Echocardiographic outcomes were assessed when possible. RESULTS: Six relevant retrospective studies with comparative data for robotic vs. conventional mitral valve surgery were identified from the existing literature. Meta-analysis demonstrated a superior perioperative survival outcome for patients who underwent robotic surgery. Incidences of stroke and reoperation were not statistically different between the two treatment arms. Patients who underwent robotic surgery required a significantly longer period of cardiopulmonary bypass time and cross-clamp time. However, the lengths of hospitalization and ICU stay were not significantly different. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes in the majority of patients. CONCLUSIONS: Current evidence on comparative outcomes of robotic vs. conventional mitral surgery is limited, and results of the present meta-analysis should be interpreted with caution due to differing patient characteristics. However, it has been demonstrated that robotic mitral valve surgery can be safely performed by expert surgeons for selected patients. A successful robotic program is dependent on a specially trained team and a sufficient volume of referrals to attain and maintain safety.

Systematic review of percutaneous interventions for malignant pericardial effusion.

The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.