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.
...few data are available with regard to echocardiographically observed post-operative CP. ...the purpose of this study was to investigate the incidence and clinical course of CP observed on ...post-operative echocardiographic examination in patients who had undergone isolated coronary artery bypass graft (CABG) surgery. Because CABG is a traumatic procedure with intraoperative irritation to the pericardium by the physical manipulation of surgeons, this pericardial trauma and previously mentioned pericardial friction can possibly cause pericardial inflammation, which is enough to cause transient CP but not enough to cause constrictive pericarditis.
Abstract Background The purpose of this study was to examine the impact of previous percutaneous coronary intervention with stent on long-term outcomes after off-pump coronary artery bypass grafting ...(OPCAB). Methods Between January 2001 and December 2014, 1668 patients with triple-vessel disease undergoing OPCAB were reviewed and divided into two groups. The No-Stent group (n=1409) included patients who underwent OPCAB as a primary revascularization procedure and the Stent group (n=259) included patients with a history of percutaneous coronary intervention with stent. The mean follow-up duration was 5.32±3.39 years. Results After propensity score-matching, characteristics of both groups were comparable (n=259 in each group). In-hospital mortality (n=3 1.2% in both groups, p>0.999) was similar. The 14-year overall survival rate (75.6±6.6% in No-Stent group vs. 71.9±8.5% in Stent group, p=0.917) and freedom from major adverse cardiac and cerebrovascular events (MACCEs) rate (68.3±6.6% vs. 54.6±8.5%, p=0.239) were also similar. However, freedom from target vessel revascularization rate at 14-years was significantly higher in No-Stent group (97.2±1.7% vs. 76.9±6.5%, p<0.001). The independent risk factor for late target vessel revascularization was in-stent restenosis at OPCAB (HR: 3.355, 95% CI: 1.925-5.848, p<0.001) and also risk factor for MACCEs (HR: 1.645, 95% CI: 1.105-2.448, p=0.014). Conclusions Previous intracoronary stenting does not increase long-term mortality, but grafting to previously stented target vessels with in-stent restenosis increases the risk of repeat target vessel revascularization and MACCEs.
Background Second-generation drug-eluting stents (DESs) are known to have better safety and clinical outcomes compared with the first-generation DESs. We compared the clinical results of off-pump ...coronary artery bypass grafting (OPCAB) with percutaneous coronary intervention (PCI) using second-generation DESs. Methods The study enrolled 1,821 patients with triple-vessel or left main coronary disease, or both, who underwent OPCAB or PCI with second-generation DESs from 2008 to 2011. Major adverse cardiac and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and target vessel revascularization, were retrospectively compared between the two groups in a real-world and in a matched population (n = 1,294). Follow-up duration was 23.0 ± 13.0 months (range, 0 to 56 months). Results The postprocedural mortality rate was comparable between the two groups ( p = 0.384). The overall rate of MAACEs was 7.3% in the PCI group and 3.8% in the OPCAB group ( p = 0.001). The 3-year rate of freedom from MACCEs was 88.4% ± 1.5% in the PCI group and 94.9% ± 1.0% in the OPCAB group ( p < 0.001). In a matched population comparison, the 3-year rate of freedom from a MACCE was 87.5% ± 2.0% in the PCI group and 95.3% ± 1.2% in the OPCAB group ( p = 0.001). The determining factors were nonfatal myocardial infarction and target vessel revascularization. The OPCAB group showed a superior rate of freedom from MACCEs in the triple-vessel ( p = 0.008) and left main subset analysis ( p = 0.001). Conclusions The OPCAB showed superior outcomes in triple-vessel or left main disease, or both, compared with PCI in the second-generation DES era after 23 months of follow-up. Nonfatal myocardial infarction and target vessel revascularization were the determining factors. Longer follow-up with randomization will clarify our results.
Objectives The Carpentier rigid ring and the Duran flexible ring have been used for mitral valve repair. The Carpentier ring reduces mitral insufficiency very effectively, but it causes minor ...systolic dysfunction. Meanwhile, the Duran ring interferes less with the normal movements of the mitral annulus during the cardiac cycle than the Carpentier ring. Methods From January 1995 through August 2005, 363 patients underwent mitral valvuloplasty with annuloplasty rings. We chose the ring with randomization for mitral valve repair, and the data were collected prospectively. Seven patients who had undergone re-repair or replacement because of failure of initial repair confirmed by means of intraoperative transesophageal echocardiography were excluded in this study, and 356 patients were enrolled (Carpentier ring group, n = 186; Duran ring group, n = 170). Mean age was 49.4 years and 50.3 years for the Carpentier and Duran ring groups, respectively. There were no significant differences in age, sex, body surface area, or cause of mitral regurgitation between the 2 groups. Results There were 4 (1.1%) operative mortalities. The patients were followed up for 3 to 126 months (mean, 46.6 months), and total follow-up was 1368.2 patient-years. The left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and left atrial size were significantly decreased in both groups. However, there was no difference in the long-term echocardiographic results between the 2 groups. Overall actuarial survivals at 10 years were 85.9% ± 4.9% in the Carpentier ring group and 75.7% ± 7.2% in the Duran ring group, without a significant difference. Significant mitral regurgitation (grade ≥3) recurred in 23 patients (Carpentier ring group, 8; Duran ring group, 15). The 8-year freedom from recurrence of significant mitral regurgitation was 62.6% ± 19.0% in the Carpentier ring group and 55.5% ± 14.1% in the Duran ring group ( P = .172). Independent prognostic factors for recurrence of mitral regurgitation in logistic regression analysis were preoperative tricuspid regurgitation of grade 3 or greater and residual mitral regurgitation of grade 2 or greater at the 5th ∼ 7th postoperative days. Conclusions Mitral valvuloplasty favors the excellent surgical and long-term results in our prospective randomized study, regardless of the type of annuloplasty ring. There was no difference between the rigid and flexible rings in terms of left ventricular systolic function measured with echocardiography. It seems that timing of the operation before significant tricuspid regurgitation and precise mitral valve repair might prevent late recurrence of mitral regurgitation.
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.
Abstract Introduction Hypoxic hepatitis (HH) is commonly observed in out-of-hospital cardiac arrest (OHCA) survivors. The objective of this study was to investigate the incidence, clinical courses, ...and outcomes of as well as predisposing factors for HH in OHCA survivors. Methods The study was based on a registry of cardiac arrest cases from 2009 to 2012 at a tertiary university hospital. We assessed patients' serum aminotransferase levels on return of spontaneous circulation (ROSC) and at 6, 12, 24, 48, and 72 hours postarrest. Hypoxic hepatitis was defined as a rapid increase in serum aminotransferase that reached at least 20 times the upper limit of normal. The patients were classified into 2 groups: the HH group and the non-HH group; we then analyzed the outcomes of the HH group. Independent predisposing factors to HH in this cohort were identified. Results Of a total of 535 OHCA cases, 148 patients were enrolled in this study. Hypoxic hepatitis was identified in 13.5% (n = 20) of them. Serum aminotransferase rapidly increased in the first day after return of spontaneous circulation. Of the patients who developed HH, 5 (25%) survived to hospital discharge, and none of these individuals had good neurologic outcomes (Glasgow-Pittsburgh cerebral performance categories 1 and 2). Using multivariate logistic regression, we found that the no flow time was independent predictors of HH (odds ratio, 1.085 95% confidence interval, 1.027-1.146; P = .003). Conclusions Hypoxic hepatitis occurred frequently in survivors of OHCA. The no flow time was an independent risk factor for HH, which was significantly related to death and poor neurologic outcomes.
Background Recently, robotic technology in the surgical area has gained wide popularity. However, in the filed of head and neck surgery, the applications of robotic instruments are problematic owing ...to spatial and technical limitations. The authors performed robot-assisted endoscopic thyroid operations in consecutive thyroid tumor patients using the newly introduced da Vinci S surgical system. Herein the authors describe the technique used and its utility for the operative management of thyroid tumors. Methods From October 2007 to November 2008, 338 patients underwent robot-assisted endoscopic thyroid operations using a gasless, transaxillary approach. All procedures were successfully completed without conversion to an open procedure. Patient's clinicopathologic characteristics, operation types, operation times, the learning curve, and postoperative hospital stays and complications were evaluated. Results The mean patient age was 40 years (range, 16–69) and the male to female ratio was 1:16.8. Two hundred and thirty-four patients underwent less than total and 104 underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all malignant cases. Mean operation time was 144.0 minutes (range, 69–347) and mean postoperative hospital stay was 3.3 days (range, 2–7). No serious postoperative complication occurred; there were 3 cases of recurrent laryngeal nerve injury and 1 of Horner's syndrome. Conclusion Our technique of robotic thyroid surgery using a gasless, transaxillary approach is feasible and safe in selected patients with a benign or malignant thyroid tumor.
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