Background Increased life expectancy and younger patients’ desire to avoid lifelong anticoagulation requires a better understanding of bioprosthetic valve failure. This study evaluates risk factors ...associated with explantation for structural valve deterioration (SVD) in a long-term series of Carpentier-Edwards PERIMOUNT aortic valves (AV). Methods From June 1982 to January 2011, 12,569 patients underwent AV replacement with Edwards Lifesciences Carpentier-Edwards PERIMOUNT stented bovine pericardial prostheses, models 2700PM (n = 310) or 2700 (n = 12,259). Mean age was 71 ± 11 years (range, 18 to 98 years). 93% had native AV disease, 48% underwent concomitant coronary artery bypass grafting, and 26% had additional valve surgery. There were 81,706 patient-years of systematic follow-up data available for analysis. Demographics, intraoperative variables, and 27,386 echocardiographic records were used to identify risks for explant for SVD and assess longitudinal changes in transprosthesis gradients using time-varying covariable analyses. Results Three hundred fifty-four explants were performed, with 41% related to endocarditis and 44% to SVD. Actuarial estimates of explant for SVD at 10 and 20 years were 1.9% and 15% overall, respectively, and in patients younger than 60 years, 5.6% and 46%, respectively. Younger age ( p < 0.0001), lipid-lowering drugs ( p = 0.002), prosthesis–patient mismatch ( p = 0.001), and higher postoperative peak and mean AV gradients were associated with explant for SVD ( p < 0.0001). The effect of gradient on SVD was greatest in patients younger than 60 years. Conclusions Durability of the Carpentier-Edwards PERIMOUNT aortic valve is excellent even in younger patients. Explant for SVD is related to gradient at implantation, especially in younger patients. Strategies to reduce early postoperative AV gradients, such as root enlargement or more efficient prostheses, should be considered.
Contemporary mortality data for myectomy are well known to experts in dedicated HCM centers but may not have penetrated sufficiently into the practicing general cardiology community. ...this is an ...opportune time to tabulate the most recent operative mortality data from 5 major high-volume HCM myectomy centers in North America (Table 1). ...perceptions of HCM and myectomy have been contaminated by older obsolete published reports skewed to a grim portrayal of outcome, including high operative mortality (1,2). ...a contemporary understanding of the safety (and efficacy) (1,2) attributable to myectomy is crucial to assessing the role of surgery in the management armamentarium for this disease.
The recent success of continuous-flow circulatory support devices has led to the growing acceptance of these devices as a viable therapeutic option for end-stage heart failure patients who are not ...responsive to current pharmacologic and electrophysiologic therapies. This article defines and clarifies the major classification of these pumps as axial or centrifugal continuous-flow devices by discussing the difference in their inherent mechanics and describing how these features translate clinically to pump selection and patient management issues. Axial vs centrifugal pump and bearing design, theory of operation, hydrodynamic performance, and current vs flow relationships are discussed. A review of axial vs centrifugal physiology, pre-load and after-load sensitivity, flow pulsatility, and issues related to automatic physiologic control and suction prevention algorithms is offered. Reliability and biocompatibility of the two types of pumps are reviewed from the perspectives of mechanical wear, implant life, hemolysis, and pump deposition. Finally, a glimpse into the future of continuous-flow technologies is presented.
Objectives This study sought to determine the utility of quantitation of right ventricular (RV) function in predicting RV failure in patients undergoing left ventricular assist device (LVAD) ...implantation. Background Clinical evaluation alone seems insufficient for predicting RV failure, an important cause of morbidity and mortality after LVAD implantation. Methods Clinical, hemodynamic, and echocardiographic data were collected on 117 patients undergoing LVAD implantation. Standard pre-procedural echocardiographic RV measurements were supplemented by velocity vector imaging of RV free wall longitudinal strain. RV failure was defined as the need for placement of an RV assist device, or the use of inotropic agents for >14 days. Receiver operating characteristic curves were derived, with resampling to generate valid estimates of prediction accuracy. A net reclassification index was calculated for comparison of risk scores. Results RV failure occurred in 47 of 117 patients (40%). There was a significant difference in peak strain between patients with and without RV failure (–9.0% vs. –12.2%; p < 0.01). A peak strain cutoff of –9.6% predicted RV failure with 76% specificity and 68% sensitivity. In a multivariate logistic regression analysis including variables from the established Michigan RV risk score, peak strain remained an independent predictor of RV failure. RV strain was incremental to the Michigan risk score as a predictor of RV failure (area under the receiver operating characteristic curve: 0.77 vs. 0.66; p < 0.01). The net reclassification index with strain was +10.4%. Conclusions Reduced RV free wall peak longitudinal strain was associated with an increased risk for RV failure among patients undergoing LVAD implantation.
Abstract Objective To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. Methods From January 1995 to January ...2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). Results Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation ( P < . 05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities ( P < .0001). Conclusions These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.
Background Patients with hypertrophic cardiomyopathy (HCM) have exercise intolerance due to left ventricular outflow tract (LVOT) obstruction, mitral regurgitation, and left ventricular dysfunction. ...We sought to study predictors of outcomes in HCM patients undergoing cardiopulmonary stress testing (CPT). Methods We studied 1,005 HCM patients (50 ± 14 years, 64% men, 77% on β-blockers) who underwent CPT with echocardiography. Clinical, echocardiographic, and exercise variables (peak oxygen consumption VO2 and heart rate recovery HRR at first minute postexercise) were recorded. End point was a composite of death, appropriate defibrillator discharges, resuscitated sudden death, stroke, and heart failure admission. Results Mean left ventricular ejection fraction (LVEF), postexercise LVOT gradient, and peak VO2 were 62% ± 6%, 92 ± 51 mm Hg, and 21 ± 6 mL kg−1 min−1 , respectively. Despite 789 patients (78%) being in New York Heart Association classes I to II, only 8% achieved >100% age-gender predicted peak VO2 , whereas 77% and 15% achieved 50% to 100% and <50%, respectively. Left ventricular outflow tract gradient ≥30 mm Hg was observed in 83% patients, whereas 23% had abnormal HRR. More than 5.5 ± 4 years, there were 94 (9%) events; 511 (50%) patients underwent surgery for LVOT obstruction. Multivariable Cox proportional analysis demonstrated % age-gender predicted peak VO2 (hazard ratio HR 0.96 0.93-0.98), normal vs abnormal HRR (HR 0.48 0.32-0.73), higher LVEF (HR 0.96 0.93-0.98), surgery (0.53 0.33-0.83), and atrial fibrillation (HR 1.65 1.04-2.60) were associated with outcomes (all P < .05). Conclusions In HCM patients undergoing CPT, a higher % of achieved age-gender predicted VO2 and surgical relief of LVOT obstruction were associated with better outcomes, whereas abnormal HRR, atrial fibrillation, and lower LVEF were associated with worse outcomes.
Limited data exist regarding the outcome of atrial fibrillation (AF) surgery and catheter ablation in patients with hypertrophic cardiomyopathy (HCM).
The purpose of this study was to evaluate the ...safety and efficacy of nonpharmacologic treatment of AF in HCM.
One hundred forty-seven patients (46 female, age 55 ± 11 years, ejection fraction EF 58% ± 8%) with symptomatic paroxysmal (58%), persistent (31%), and long-standing persistent AF (11%) refractory to antiarrhythmic drugs who presented for their first catheter ablation (n = 79) or AF surgery (n = 68) were included.
After follow-up of 35 months (interquartile range 13, 60), 29% of patients who underwent catheter ablation and 51% of those who had undergone AF surgery had no documented recurrent atrial arrhythmia after a single procedure. Repeat ablation was performed in 55% of patients with recurrent arrhythmia in the catheter group and 24% in the surgery group, increasing the success rate to 39% and 53%, respectively, after 1 or more procedures. Predictors of success after the first procedure in a multivariable setting included higher baseline EF and male gender. Persistent or long-standing AF and log of AF duration were associated with lower success. Major complications occurred in 6% of the catheter ablation group and 18% of the AF surgery group. During follow-up, 16 patients died (9 in catheter group, 7 in surgery group) and 1 underwent heart replacement. Lower baseline EF and older age were independently associated with death.
Catheter ablation and AF surgery are associated with symptomatic improvement in HCM patients. However, long-term success is lower and complications are higher than previously reported.
Background Postoperative stroke is a devastating complication after aortic valve replacement (AVR). Our objective was to use a large national database to identify the incidence of and risk factors ...for stroke after AVR, as well as to determine incremental mortality, resource use, and cost of stroke. Methods We identified 360,437 patients who underwent isolated surgical AVR between 1998 and 2011 from the National Inpatient Sample (NIH) database. Mean age was 66 ± 32 years. Multivariable regression and propensity matching were used to identify risk factors and the effect of stroke on outcomes. Patients were stratified according to the Elixhauser comorbidity score (ECS) into low- (0–5), medium- (6–15), and high-risk (16+) categories. Results Stroke after AVR occurred in 5,092 (1.45%) patients. The incidence of stroke declined from 1.69% in 1999 to 0.94% in 2011 ( p < 0.001). Increasing age and higher comorbidities were the main predictors of stroke (each p < 0.001). The highest-volume centers (>200 AVRs/y) had the lowest rate of stroke (1.2%). After multivariable adjustment, high-volume centers had lower odds of stroke in medium-risk (odds ratio OR, 0.59; 95% confidence interval CI, 0.37–0.94) and high-risk patients (OR, 0.39; 95% CI, 0.22–0.68) compared with the lowest-volume centers. For low-risk patients, volume was not associated with stroke. Patients who experienced stroke were hospitalized for 4 days longer, had an average of $10,496 higher costs, and had 2.74 (95% CI, 1.97–3.80) times higher odds of in-hospital mortality compared with those who did not experience stroke (all p < 0.001). Conclusions The incidence of stroke after AVR has decreased but remains a significant cause of morbidity in medium- and high-risk patients. Superior outcomes can be achieved in medium- to high-risk patients at high-volume centers.
Background Septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM). However, it is being challenged by a less-invasive alternative: alcohol septal ablation. ...This study examined the clinical effectiveness and risks of isolated septal myectomy for HOCM. Methods From January 1994 to January 2005, 323 patients underwent isolated septal myectomy (mean age 50 ± 14 years, 53% male). Preoperative septal thickness was 2.3 ± 0.46 cm and peak left ventricular outflow tract (LVOT) gradient 68 ± 43 mm Hg. Effectiveness of myectomy was assessed by echocardiography, sudden death, and functional limitation, early risks by intraoperative and postoperative complications, and late risks by follow-up for HOMC-related reoperation, heart block, and all-cause mortality (mean 3.6 ± 2.8 years, 1,152 patient-years, 10% followed ≥8 years). Results Myectomy was effective, resulting in sustained decrease in septal thickness and LVOT gradient, absence of sudden death, and improved functional status. Early in-hospital morbidity was low, with no hospital deaths; two iatrogenic ventricular septal defects were repaired uneventfully, and 22 pacemakers were required for heart block. In the intermediate term, 10 patients required HOCM-related reoperations (4 redo myectomies, 6 mitral valve procedures), with 92% freedom from reoperation at eight years. Seventy-nine percent were free of pacemakers by 8 years, and survival was 90%, equivalent to that of the general population. Conclusions Isolated septal myectomy is effective in eliminating LVOT obstruction and sudden death and in improving functional status, with low operative morbidity and mortality. Few reoperations are required late and outcomes are excellent. It should be considered the treatment of choice for HOCM.
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