Background The effect of prosthesis–patient mismatch (PPM) on clinical outcomes after aortic valve replacement remains controversial. We evaluated effect of PPM on long-term clinical outcomes after ...isolated aortic valve replacement in patients with predominant aortic stenosis. Methods We analyzed data from patients with predominant aortic stenosis who underwent isolated aortic valve replacement between January 1995 and July 2010. The indexed effective orifice area, obtained by dividing the in vivo effective orifice area by the patient’s body surface area, was used to define PPM as clinically nonsignificant (group I, 224 patients), mild (group II, 52 patients), moderate (group III, 39 patients), and severe (group IV, 36 patients). Results Early survival was not significantly different among the groups, but overall survival was decreased gradually in group IV. Overall survival at 12 years was lower in group IV than in group I (92.8% ± 2.7% vs 67.0 ± 10.1, respectively; P = .001). Cardiac-related-death-free survival at 12 years was lower in patients with severe PPM. Left ventricular mass index decreased during the follow-up period in all groups. But left ventricular mass index was less decreased in group IV compared with groups I, II, and III. Age, severe PPM, and ejection fraction <40%, and New York Heart Association Functional Class IV were independent risk factors of overall survival on multivariate analysis. Severe PPM was an independent risk factor for cardiac-related death. Conclusions Severe PPM showed an adverse effect on long-term survival, and was an independent risk factor for cardiac-related death. In addition, patients with severe PPM showed less decreasing left ventricular mass index during follow-up.
Objective Prognostic implications of partial thrombosis of the residual aorta after repair of acute DeBakey type I aortic dissection have not been elucidated. We sought to analyze the impact of ...partial thrombosis on segmental growth rates, distal aortic reprocedures, and long-term survival. Methods A total of 118 consecutive patients (55% were male; mean age, 60 years) with acute DeBakey type I aortic dissection underwent surgical repair (1997–2007). The hospital mortality rate was 17.8%. Survivors underwent serial computed tomography scans. Segment-specific average rates of enlargement were analyzed. Distal reprocedures and patient survival were examined. Results Sixty-six patients had imaging data sufficient for growth rate calculations. The median diameters within 2 weeks after repair were as follows: aortic arch, 3.5 cm; descending aorta, 3.6 cm; and abdominal aorta, 2.4 cm. Subsequent growth rates were artic arch, 0.34 mm/y, descending aorta, 0.51 mm/y, and abdominal aorta, 0.35 mm/y. Partial thrombosis of the residual aorta predicted greater growth in the distal aorta ( P = .005). There were 13 distal aortic reprocedures (5 reoperations, 8 stent graft insertions) for 10 years, and reprocedure-free survival was 66%. Partial thrombosis ( P = .002) predicted greater risk of aorta-related reprocedures. Cox analysis revealed that estimated glomerular filtration rate less than 60 mL/min/1.73 m2 ( P = .030), reintubation ( P = .002), and partial thrombosis ( P = .023) were independent predictors for poor survival. Conclusion Partial thrombosis of the false lumen after repair of acute DeBakey type I aortic dissection, compared with complete patency or complete thrombosis, is a significant independent predictor of aortic enlargement, aorta-related reprocedures, and poor long-term survival.
To assess the effect of the extent of stent graft coverage and anatomic properties of aortic dissection on the outcomes of thoracic endovascular aortic repair (TEVAR) for complicated chronic type B ...aortic dissection (CCBAD) in terms of survival, reintervention, and false lumen thrombosis.
A retrospective analysis was performed of 71 patients who underwent TEVAR for CCBAD. Mean patient age was 54.7 years. Distal extent of stent graft coverage was categorized as short (≤ T7) or long (≥ T8) coverage. Indications of reintervention were categorized into three groups: proximal, alongside, and distal according to the anatomic relationship of the culprit lesion and the stent graft. Overall survival, reintervention-free survival, and extent of false lumen thrombosis were compared.
The technical success rate was 97.2%. The 1-year, 3-year, and 5-year overall survival rates were 97.1%, 88.9%, and 88.9%, and 1-year, 3-year, and 5-year reintervention-free survival rates were 80.7%, 73.8%, and 60.6%. There were no differences in overall survival, reintervention-free survival rates, and extent of false lumen thrombosis between the groups. In the short coverage group, distal reintervention was more frequent in patients with an abdominal aortic diameter ≥ 37 mm compared with patients with an abdominal aortic diameter < 37 mm (P = .005).
TEVAR was effective for CCBAD with a high technical success rate and low mortality. The extent of stent graft coverage did not make a difference in terms of survival and false lumen thrombosis. Reinterventions were more frequently performed in patients with a large baseline abdominal aortic diameter who were treated with short stent graft coverage, and so longer coverage is recommended in such patients.
The discrepancy between planimetered mitral valve area (MVA) and mean diastolic pressure gradient (MDPG) has not been studied extensively in patients with mitral stenosis. The purpose of the present ...study was to investigate differences in characteristics and outcomes after mitral valve replacement (MVR) between low- and high-MDPG groups in patients with very severe mitral stenosis (VSMS). The hypothesis was that the low-MDPG group would have different characteristics and would be associated with poor clinical outcomes after MVR.
In total, 140 patients who underwent isolated MVR because of pure VSMS (planimetered MVA ≤ 1.0 cm(2)) were retrospectively reviewed, and follow-up echocardiography was performed for ≥12 months after MVR. Patients were divided into two groups according to preoperative MDPG (low gradient LG, <10 mm Hg; high gradient HG, ≥10 mm Hg). Strain and strain rate analysis was performed using speckle-tracking echocardiography of the left ventricle before MVR in a subgroup of 56 patients.
There were 82 patients (59%) in the LG group and 58 patients (41%) in the HG group. The LG group was older and demonstrated a higher prevalence of female gender, diabetes mellitus, and atrial fibrillation (P < .05 for all). When comparing the LG and HG groups, the left atrial volume index was larger (105.1 ± 51.9 vs 87.8 ± 42.9 mL/m(2), P < .001), and strain rate during isovolumic relaxation of the left ventricle was lower (0.17 ± 0.08 vs 0.29 ± 0.09 sec(-1), P < .001) in the LG group. After MVR, the percentage left atrial volume index reduction after MVR was significantly smaller in the LG group (-29.9 ± 15.1% vs -43.5 ± 16.4%, P < .001). Persistent symptoms after MVR were more common in the LG group compared with the HG group (P = .004), even though preoperative functional class was similar between the groups.
Compared with those with HG VSMS, patients with LG VSMS were older, more often female, and more frequently had diabetes mellitus and atrial fibrillation. They also had greater impairment of isovolumic relaxation, less favorable left atrial reverse remodeling, and a greater risk for persistent symptoms after MVR. These data might suggest other concurrent mechanisms for left atrial enlargement and symptom development in LG VSMS, such as atrial fibrillation and diastolic dysfunction, as well as valvular stenosis.
Background The aim of this study was to evaluate the lung-protective effect of combined remote ischemic preconditioning (RIPCpre) and postconditioning (RIPCpost) in patients undergoing complex ...valvular heart surgery. Methods In this randomized, placebo-controlled, double-blind trial, 54 patients were assigned to an RIPCpre plus RIPCpost group or a control group (1:1). Patients in the RIPCpre plus RIPCpost group received three 10-min cycles of right-side lower-limb ischemia of 250 mm Hg at both 10 min after anesthetic induction and weaning from cardiopulmonary bypass. The primary end point was to compare postoperative Pa o2 /F io2 . Secondary end points were to compare pulmonary variables, incidence of acute lung injury, and inflammatory cytokines. Results In both groups, Pa o2 /F io2 at 24 h postoperation was significantly decreased compared with each corresponding baseline value. However, intergroup comparisons of pulmonary variables, including Pa o2 /F io2 and incidence of acute lung injury, revealed no significant differences. Serum levels of IL-6, IL-8, IL-10, and tumor necrosis factor-α were all significantly increased in both groups compared with each corresponding baseline value, without any significant intergroup differences. There were also no significant differences in transpulmonary gradient of IL-6, IL-10, and tumor necrosis factor-α between the groups. Conclusions RIPCpre plus RIPCpost as tested in this randomized controlled trial did not provide significant pulmonary benefit following complex valvular cardiac surgery. Trial registry ClinicalTrials.gov ; No.: NCT01427621 ; URL: www.clinicaltrials.gov
To investigate safety and efficacy of hybrid treatment for infected aortic and iliac aneurysms.
Between July 2007 and May 2011, hybrid treatment was performed in 6 male patients (mean age, 67.7 y; ...range, 57-76 y). Hybrid treatment consisted of extraanatomic bypass (EAB) and isolation of infected aneurysm with vascular plugs. Aneurysms were divided into primary and secondary infected aneurysms. Primary infected aneurysm refers to an aneurysm arising from bacterial infection of the native arterial wall; secondary infected aneurysm refers to infection involving an aneurysm that was previously treated with graft placement.
The infected aneurysm involved the infrarenal abdominal aorta in 4 patients and common iliac artery in 2 patients. Hybrid treatment was successful in all 6 patients. The 3 patients with primary infected aneurysms required only hybrid treatment, whereas infected graft excision and new graft interposition was performed in 2 of the 3 patients with secondary infected aneurysms. No 30-day mortality or complications were reported. During mean follow-up of 58.6 months (range, 32.6-75.8 months), 1 patient (17%) with a secondary infected aneurysm who did not undergo additional surgery died 32.6 months after hybrid treatment from hypovolemic shock secondary to recurrent aortoenteric fistula. Cumulative survival was 100%, 100%, 83%, and 83% at 3 months, 1 year, 3 years, and 5 years.
Hybrid treatment appears to be a stand-alone, curative treatment for primary infected aneurysms and serves as bridge therapy to subsequent surgery for secondary infected aneurysms.
Background Dual antiplatelet therapy with aspirin and clopidogrel is currently recommended in off-pump coronary artery bypass (OPCAB). However, no data exist concerning platelet reactivity on ...clopidogrel after OPCAB. The aim of this study was to assess the relationship between platelet reactivity and late major adverse cardiovascular events (MACEs) after OPCAB. Methods In this prospective, single-center, observational study, on-clopidogrel platelet reactivity was measured using a point-of-care assay (VerifyNow system; Accumetrics Inc, San Diego, CA) in 859 patients who underwent OPCAB with 1 or more vein grafts. The primary end point was late MACEs (30 days–1 year) including cardiac death, nonfatal myocardial infarction, and target vessel revascularization. Receiver operating characteristic curve analysis was used to estimate the cutoff value of P2Y12 reaction units (PRUs) for MACEs. Results The optimal cutoff value for posttreatment reactivity for the incidence of late MACEs was ≥188 PRU (area under the curve 0.72, 95% CI 0.68-0.75, P = .002). The incidence of late MACEs was significantly higher in the high platelet reactivity (HPR; ≥188 PRU) group than in the low platelet reactivity (<188 PRU) group (3.6% vs 1.4%, P = .040). Kaplan-Meier analysis revealed 1-year MACE-free survival rates of 98.4% ± 0.5% and 95.9% ± 1.3% in the low platelet reactivity and HPR groups, respectively ( P = .034). According to a Cox regression hazard model, HPR was an independent risk factor for late MACE-free survival (hazard ratio 3.51, 95% CI 1.27-9.69, P = .015). Conclusion High residual platelet reactivity after clopidogrel administration is strongly associated with 1-year MACE-free survival. Routine measurement of platelet reactivity and thorough monitoring of patients with HPR after OPCAB are warranted.
Background There are no clear guidelines in regard to optimal management of functional mitral regurgitation (MR) in patients undergoing aortic valve replacement (AVR). This study evaluated changes in ...functional MR and determined predictors of persistent MR after isolated AVR. Methods We retrospectively reviewed 118 consecutive patients with functional MR at the time of isolated AVR from January 2000 to December 2009. We collected preoperative and postoperative echocardiographic data to determine the degree of change in MR after AVR. Patients were divided into those without (n = 71) and those with persistent MR (n = 42). Late follow-up echocardiography was completed in 95% (113/118) of patients. The mean follow-up duration was 56.7 ± 35.3 months. Results Mitral regurgitation improved in 72% (81/113), was unchanged in 25% (28/113), and worsened in 3% (4/113) of patients. There were no differences in 10-year survival rates among groups based on preoperative MR status (grade I, 93.1%; grade II, 85.4%; grade III, 80%; p = 0.432). However, there was a significant difference in postoperative survival between patients without and with persistent MR (93.1% versus 77.8% respectively, p = 0.036). Predictors of persistent MR by univariate analysis included higher left ventricular ejection fraction (LVEF), higher right ventricular (RV) systolic pressure, decreased left ventricular end systolic dimension (LVESD), and decreased left ventricular end diastolic dimension (LVEDD). In multivariate analysis, only RV systolic pressure was identified as an independent risk factor predicting persistent MR ( p = 0.035; odds ratio OR, 1.037; confidence interval CI, 1.003 to 1.072). Conclusions Functional MR improved in most patients after AVR alone. Postoperative persistent MR affects long-term survival in functional MR. Preoperative RV systolic pressure is an independent risk factor predicting persistent MR.
Background Tissue Doppler imaging of systolic mitral annular velocity (Sm) has been shown to be able to detect early left ventricular (LV) dysfunction in the presence of chronic severe mitral ...regurgitation with normal left ventricular ejection fraction. We investigated the association of preoperative Sm with LV reverse remodeling after mitral valve surgery. Methods Patients with chronic severe organic mitral regurgitation exhibiting LV ejection fraction greater than 60% were enrolled. The LV reverse remodeling was defined as changes of LV mass index of 20% or greater postoperatively. The primary endpoints were to compare the changes of LV mass index in relation to the tertile distribution of the Sm and evaluate predictive value of the Sm for LV reverse remodeling. Results In all, 169 patients were analyzed. The changes of LV mass index in the first tertile was 25% (11% to 37) compared with 34% (19% to 43%) in the second tertile and 34% (26% to 47%) in the third tertile ( p = 0.003). On multivariate analysis, Sm was the only independent predictor of LV reverse remodeling (odds ratio 1.77, 95% confidence interval: 1.30 to 2.40, p < 0.001). The optimal cutoff value measured by receiver-operating characteristic curve analysis was 7 cm/s of Sm (area under the curve 0.721, 95% confidence interval: 0.64 to 0.80, p < 0.001). Conclusions In patients with severe mitral regurgitation exhibiting LV ejection fraction greater than 60%, surgery may be considered before the Sm is decreased below 7 cm/s to achieve favorable LV reverse remodeling.
PDF
