The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life ...(QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG.
The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) major adverse cardiac events (MACE) at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke major adverse cardiac and cerebrovascular events (MACCE), and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis.
A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 interquartile range (IQR), 0.9-2.3. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 IQR, 0.72-0.92 at baseline to 0.92 IQR, 0.82-1.00 at 1 year ( P <0.0001).
Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.
IntroductionSpain is one of the countries with the lowest rates of revascularisation and highest ratio of percutaneous coronary intervention (PCI) to coronary artery bypass grafting ...(CABG).ObjectivesTo investigate the changes and trends in the two revascularisation procedures between 1998 and 2017 in Spain.DesignRetrospective cohort study. Analysis of in-hospital outcomes.SettingMinimum basic data set from the Spanish National Department of Health: mandatory database collecting information of patients who are attended in the Spanish public National Health System.Participants603 976 patients who underwent isolated CABG or PCI in the Spanish National Health System. The study period was divided in four 5-year intervals. Patients with acute myocardial infarction on admission were excluded.Primary and secondary outcomesWe investigated the volume of procedures nationwide, the changes of the risk profile of patients and in-hospital mortality of both techniques.ResultsWe observed a 2.2-fold increase in the rate of any type of myocardial revascularisation per million inhabitants-year: 357 (1998) to 776 (2017). 93 682 (15.5%) had a coronary surgery. PCI to CABG ratio rose from 2.2 (1998–2002) to 8.1 (2013–2017). Charlson’s index increased by 0.8 for CABG and 1 for PCI. The median annual volume of PCI/hospital augmented from 136 to 232, while the volume of CABG was reduced from 137 to 74. In the two decades, we detected a significant reduction of CABG in-hospital mortality (6.5% vs 2.6%, p<0.001) and a small increase in PCI (1.2% vs 1.5%, p<0.001). Risk adjusted mortality rate was reduced for both CABG (1.51 vs 0.48, p<0.001), and PCI (1.42 vs 1.05, p<0.001).ConclusionWe detected a significant increase in the volume of revascularisations (particularly PCI) in Spain. Risk-adjusted in-hospital mortality was significantly reduced.
Surgical treatment of active prosthetic aortic valve endocarditis presents a challenge for cardiac surgeons because of tissue friability and destruction caused by infection. Sutureless prostheses, ...such as the Perceval S (LivaNova, Saluggia, Italy), have emerged as an option among the different surgical approaches for these complicated cases.
This study presents data from 9 patients who underwent aortic valve re-replacement with the Perceval S because of active prosthetic aortic valve endocarditis between January 2014 and August 2016. Hemodynamic performance (mean transprosthetic gradient and type of aortic regurgitation) was assessed intraoperatively after weaning from cardiopulmonary bypass, at discharge, and to 6 months postoperatively.
After weaning from cardiopulmonary bypass, cases 1 and 3 through 6 had no or trivial aortic regurgitation, cases 7 and 8 presented with trivial to mild regurgitation, case 9 showed mild intraprosthetic regurgitation, and case 2 had mild periprosthetic regurgitation. Cases 4 and 7 died of septic shock and multiorgan failure in the perioperative period. In the remaining patients, severity of aortic regurgitation maintained practically invariable at discharge compared with intraoperative results. These 7 patients did well at 6-month follow-up, with good clinical and hemodynamic performance of the Perceval S prosthesis. The median of mean transprosthetic gradient was 11 mm Hg (interquartile range: 10 to 12 mm Hg). Only patient 2 showed mild periprosthetic regurgitation; patient 9 showed mild intraprosthetic insufficiency, and the remaining patients had no or trivial regurgitation.
The sutureless Perceval S valve is a reasonable alternative for surgical treatment of prosthetic aortic valve endocarditis.
At some point in their lives, many people will require major heart surgery (MHS). Patients are generally older adults with various risk factors for infection. However, the incidence of infection ...after MHS is poorly known, as reported infection data are frequently biased due to different factors like the surgical procedure, postoperative timing, and infectious syndromes or etiologic agents, among others. In addition, most patient data are retrospectively obtained.
Data were prospectively collected regarding the incidence of all nosocomial infections produced from the time of surgery to hospital discharge in a cohort of 800 adults consecutively undergoing a MHS procedure.
During postoperative hospitalization, 124 of the 800 participants developed one or more infections (15.5%): during their ICU stay in 68 patients (54.8%), during their stay on the general ward post ICU in 50 (40.3%), and during their stay in both wards in 6 (4.8%). The most common infections were pneumonia (related or not to mechanical ventilation), surgical site and bloodstream. As etiological agents, 193 pathogens were isolated: mostly Gram-negative bacilli (54.4%), followed by Gram-positive bacteria (30%), viruses (4.6%) and fungi (1.5%). In our cohort, all-cause mortality was recorded in 33 participants (4.1%) and 9 infection-related deaths (1.1%) were produced. Among subjects who developed infections, overall mortality was 13.7% and in those who did not, this was only 2.3%.
Infection following MHS remains frequent and severe. Our data suggest that hospital-acquired infection studies should consider episodes of infection in all populations during their entire hospital stay and not only those related to specific clinical syndromes or acquired while the patient is in intensive care.
Background Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves ...dramatic clinical consequences. So far, only five cases have been described in the literature. Methods We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. Results We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). Conclusions Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patient's outcome, most often by means of an emergency revascularization strategy.
En la enfermedad reumática con afectación mitral, la insuficiencia es la forma de presentación más frecuente en gente joven. La posibilidad de reparación quirúrgica en la insuficiencia reumática ...depende fundamentalmente de factores anatómicos de la válvula, como son la flexibilidad del velo anterior y la presencia de lesiones calcificadas a nivel del aparato subvalvular, pero también de la experiencia del centro en reparación mitral compleja. Todo ello hace que esta patología infradiagnosticada haya quedado relegada a la sustitución protésica, ya que en muchos casos es remitida de forma tardía con una calcificación avanzada. Con el fin de desmitificar esta entidad, en el siguiente artículo abordaremos la insuficiencia mitral reumática y su tratamiento con las técnicas específicas reparadoras, así como la presentación de nuestra experiencia y una discusión de la patología con revisión de la literatura publicada hasta la fecha.
In rheumatic disease with mitral involvement, regurgitation is the most common form of presentation in young people. The possibility of surgical repair in rheumatic regurgitation depends on anatomical factors of the valve, such as the flexibility of the anterior leaflet and the presence of calcified lesions at the level of the subvalvular apparatus, but also on the experience of the center in complex mitral repair. All this means that this underdiagnosed pathology has been relegated to prosthetic replacement, since in many cases it is remitted late with advanced calcification. In order to demystify this entity, in the following article we will address rheumatic mitral regurgitation and its treatment with specific repair techniques, as well as the presentation of our experience and a discussion of the pathology with a review of the literature.
Colonization by Staphylococcus aureus is regularly assessed in patients undergoing major heart surgery (MHS). Despite pre-surgical decontamination attempts, a significant proportion of MHS patients ...remain colonized by S. aureus at the time of surgery. Nasal sampling can be improved by sampling extra-nasal areas. We evaluated whether processing lower respiratory tract (LRT) secretions enhanced the detection of S. aureus after MHS. Following a standard protocol, nasal swabs and LRT aspirates were obtained from all of the study patients at the time of surgery or in the immediate postoperative period. One swab was used for culture in the microbiology laboratory, and a second swab was used for the Xpert SA Nasal Complete assay. According to our definition of colonization (culture positive and/or PCR positive), 31 of 115 patients (26.9%) were colonized at the time of surgery. Among these, LRT samples only were positive in three patients (2.6% of the whole population and 9.7% of the carriers). The remaining 28 were either positive in the nasal sample or positive in both samples. The yield of the detection of colonization by S. aureus by including also LRT samples in patients undergoing MHS is limited and must be balanced with laboratory workload and demands on laboratory personnel. Trial registration: Clinical trials.gov NCT02640001.
Abstract Background Infective endocarditis (IE) is a severe complication associated with high mortality. Objectives To examine the clinical characteristics of IE in hemodialysis (HD) patients and to ...determine prognostic factors related to HD. Methods From January 2008 to April 2015, 2488 consecutive patients with definite IE were included. Clinical characteristics of IE patients on HD were compared with those of IE patients who were not on HD. Results A total of 126 patients (63% male, median age: 66 years; IQR: 54–74 years) with IE (5.1%) were on HD. Fifty-two patients died during hospitalization (41%) and 17 additional patients (14%) died during the first year. The rate of patients who underwent surgery during hospitalization was lower in HD patients (38 patients, 30%) than in non-HD patients (1177 patients, 50%; p < 0.001). Age > 70 years (OR: 4.1, 95% CI: 1.7–10), heart failure (OR: 3.3, 95% CI: 1.4–7-6), central nervous system (CNS) vascular events (OR: 6.7, 95% CI: 2.1–22) and septic shock (OR: 4.1, 95% CI: 1.4–12.1) were independently associated with fatal outcome in HD patients. Of the 38 patients who underwent surgery, 15 (39.5%) died during hospitalization. Conclusions HD patients with IE present a high mortality. Advanced age and complications, such as heart failure, CNS stroke or septic shock, are associated with mortality.
El riesgo que conlleva la sustitución de la válvula mitral en pacientes con insuficiencia valvular primaria se puede disminuir considerablemente con un procedimiento de reparación. Con independencia ...de la etiología de la insuficiencia mitral orgánica, la reparación valvular tiene una serie de beneficios, tales como menor mortalidad, mejor preservación de la función ventricular, menos complicaciones tromboembólicas y disminución del riesgo de endocarditis. También es de destacar que existen casos en los que la cirugía mínimamente invasiva de la válvula mitral se ha demostrado posible y eficaz, con baja mortalidad perioperativa y excelentes resultados a largo plazo. Con esta práctica, los pacientes se benefician de incisiones más pequeñas y de un período de rehabilitación más corto y menos doloroso.
En este caso clínico presentamos el de una paciente de 87 años con diagnóstico de endocarditis infecciosa de la válvula mitral y un perfil de elevado riesgo por alta fragilidad. Se describe la presentación clínica, el ecocardiograma, el microorganismo causante de la infección, el procedimiento quirúrgico y la evolución postoperatoria. Hasta el momento no se dispone de información previa sobre la reparación endoscópica de la válvula mitral en personas mayores de 80 años con afectación endocardítica.
The risk associated to mitral valve replacement in patients with primary mitral valve regurgitation can be significantly decreased by undertaking the lower risk mitral valve repair. Independent of the etiology of organic mitral regurgitation, mitral valve repair reports benefits in terms of lower hospital mortality, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis. Likewise, minimal access mitral valve surgery has already proved to be feasible and effective; low perioperative mortality and excellent long-term outcomes have been reported associated to this surgery. In the current era patients prefer smaller incisions and a shorter rehabilitation period.
In this report, we discuss the follow-up assessment of an 87-year-old female who presented mitral valve infective endocarditis and high risk profile for sternotomy. Clinical presentation, echocardiogram findings, infectious organism and surgical approach are described. To our knowledge there is no report on mitral valve repair in endoscopic setup for endocarditis in octogenarians.
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