Objective To investigate the influence of the availability of drug eluting stents (DES) on treatment choice (TC) among medical therapy (MT), coronary by-pass surgery (CABG) or percutaneous coronary ...interventions (PCI) and the consequent clinical outcomes in patients hospitalised because of coronary artery disease (CAD). Design Observational study comparing two cohorts hospitalised immediately before, and 3 years after DES availability. Setting Thirteen hospitals with cardiology facilities. Patients 2131 consecutive patients with at least one coronary stenosis >50% at coronary angiography (CA) after exclusion of those with acute myocardial infarction or previous CABG or associated relevant valvular disease. Main outcome measures Treatment choice after CA and 4-year clinical outcomes. Results TC among MT (27% vs 29.2%), PCI (58.6% vs 55.5%) and CABG (14.5% vs 15.3%) was similar in the DES and bare metal stent (BMS) periods (p = 0.51). At least one DES was implanted in 57% of patients treated with PCI in 2005. After 4 years, no difference in mortality (13.8% vs 13.2%, p = 0.72), hospital admissions for myocardial infarction (6.6% vs 5.2%, p = 0.26), stroke (2.2% vs 1.7%, p = 0.49) and further revascularisations (22.3% vs 19.7%, p = 0.25) were observed in patients enrolled in the DES and BMS periods. Only in patients with Syntax score 23–32 a significant change of TC (p = 0.0002) occurred in the DES versus BMS period: MT in 17.4% vs 31%, PCI in 62.2% vs 35.8%, CABG in 20.3% vs 33.2%, with similar 4-year combined end-point of mortality, stroke, myocardial infarction and further revascularisations (45.3% vs 34.2%, p = 0.087). Conclusions Three years after DES availability, the TC in patients with CAD has not changed significantly as well as the 4-year incidence of death, myocardial infarction, stroke and further revascularisations. In subgroup with Syntax score 23–32, a significant increase of indications to PCI was observed in the DES period, without any improvement of the 4-year clinical outcome.
Background. Results of valvular reoperations depend on extrinsic and patients’ intrinsic risk factors. New prosthetic substitutes continue to appear and the clinical effect is difficult to evaluate. ...Randomized studies are limited by patient selection and follow-up time. We followed the patient-centric outcome research applied to a large database of valvular operations.
Methods. Between January 1, 1970 and January 1, 1995 755 patients underwent one reoperation, 96 a second reoperation, and 12 a third reoperation. On January 1, 1996 a common closing date follow-up was obtained in 98.7% of reoperated patients. Multivariable analysis in the hazard domain was applied to obtain an upgradable model of survival that could be used for predictions and treatment comparison.
Results. Postoperative death hazard showed an early phase merging within 6 months with a constant low hazard phase. The survival proportion was 0.65 (70% CL, 0.63 to 0.67) at 5 years, 0.51 (70% CL, 0.49 to 0.53) at 10 years, 0.47 (range, 0.44 to 0.49) at 15 years, 0.42 (70% CL, 0.39 to 0.46) at 20 and 25 years. Significant incremental risk factors for early mortality were reoperative era 1970 to 1980 (hazard ratio = 2.8), reoperation number (hazard ratio = 1.9), heart penetration on surgery (hazard ratio = 7.6), emergent operation (hazard ratio = 5.8), urgent operation (hazard ratio = 2.1), prosthetic thrombosis (hazard ratio = 2.4), acute prosthetic endocarditis (hazard ratio = 3.0), acute endocarditis of the natural valve at antecedent operation (hazard ratio = 3.2), original floppy valve pathology (hazard ratio = 3.2), and mitroaortic replacement (hazard ratio = 5.7). Isolated mitral reoperation had a lower risk (hazard ratio = 0.5). Significant incremental risk factors for constant phase were: operative era (1970 to 1980) (hazard ratio = 2.0), congestive heart failure (hazard ratio = 2.6), reoperation on tricuspid valve after previous mitral insertion (hazard ratio = 4.9), reoperation for recurring dehiscence (hazard ratio = 4.6), double-valve procedure (hazard ratio = 1.6), coronary artery bypass graft (hazard ratio = 2.7), aortic root disease at original operation (hazard ratio = 2.1), older operative age (hazard ratio = 1.1). Use of bileaflet prosthesis was found to decrease significantly (
p = 0.0002) the death risk (hazard ratio = 0.2).
Conclusions. There is no late uprising hazard, and surviving patients remain exposed to a low risk of death (4% of patients per year). Considering simultaneously the confounding from operative age and operative era and the many concomitant risk factors, survival appears favorably influenced by use of bileaflet valves on reoperation.
OBJECTIVE: Patients with type B aortic dissection differ from patients with type A dissection in age, hypertension prevalence, indications andtiming of surgical treatment, yet reported long-term ...results have been rather similar (see Doroghazi et al. J Am Coll Cardiol 1984;3:1026-1034). METHODS: With the aim of comparing the post-surgical history, we have reviewed our results in 288 dissections, 213 type A and 75 type B, operated consecutively between 1 January 1970 and 31 November 1994. Follow-up was 100% complete. Empirical survival of both groups was interpolated with a fully parametric method and the shape and scale of the hazard function was investigated. RESULTS: Survival was not significantly different betweentype A and type B. Parametric survival was, respectively, 0.52% (70% C.L.: 0.48-0.55) vs. 0.56% (0.51-0.62) at 5 years, 0.44% (0.40-0.47) vs. 0.28%(0.23-0.25) at 10 years, 0.37% (0.33-0.41) vs. 0.25% (0.19-0.32) at 15 years, and 0.31% (0.26-0.35) vs. 0.24% (0.18-0.31) at 20 years. Following the high perioperative risk phase in type A dissection, the intermediate and late risk remains constant at a rate of 0.0033 events/month (3.9% patient-years (pt.-years)). By contrast, the postoperative course of type B dissection shows an intermediate risk phase between 4 and 10 years withan average linearized risk of 9.3% pt.-years and a peak of 20%. This determined lower survival rates (24 vs. 31% at 20 years, P = NS). CONCLUSIONS: We conclude that patients with type B dissection have a steeper postoperative death hazard as compared to type A dissection patients. Age confounding or late entry do not explain the difference. This could be possibly related to a greater propensity for expansion, higherrisk of malperfusion complications or to limitations of our current surgical treatment.
There is general agreement that left-sided elastomas must be removed to avoid systemic complications. Right-sided localization is less risky and surgical treatment is not agreed upon. We report a ...case of surgical resected fibroelastoma of the tricuspid valve and discuss the indications to surgery by reviewing the literature on the few reported cases. We feel that, if surgery is timely, the tumor can be resected, thus preserving the native valve. This provides an opportunity to prevent possible right-sided complications due to increasing tumor size and embolization.
The appropriateness of surgical correction of complete atrioventricular canal defect in patients with Down syndrome has been questioned on a cost-benefit basis. Our experience with nonselective ...correction of all patients with atrioventricular canal defects gave us the opportunity to evaluate the impact of Down syndrome on postoperative survival. Between January 1, 1975, and December 31, 1989, we operated on 94 patients with Down syndrome and on 127 genetically normal patients. One hundred thirty-four patients had partial or intermediate atrioventricular canal defect (28% Down patients) and 87 had complete atrioventricular canal defect (74% Down patients). Thirty-two patients died perioperatively and 10 patients died during the 15-year follow-up. The actuarial survival was 90% in the genetically normal patients and 57% in patients with Down syndrome (p < 0.0001). Nonetheless, when the confounding effects of pulmonary vascular resistance and the prevalence of more severe anatomic forms in patients with Down syndrome were eliminated with a multivariable analysis in the hazard domain, Down syndrome was not a significant independent incremental risk factor. This was verified by fitting parametric survival to actuarial survival graphically and by a testing of fit. Patients with Down syndrome underwent fewer reoperations and fared as well as or even better, on clinical and echocardiographic investigation, than their genetically normal counterparts. (J Thorac Cardiovasc Surg 1992;104:945-53)
Long-term results of mitral commissurotomy Scalia, Domenico; Rizzoli, Giulio; Campanile, Francesco ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/1993, Volume:
105, Issue:
4
Journal Article
Peer reviewed
Open access
Between January 1968 and December 1989, 280 patients underwent conservative surgical treatment for pure mitral stenosis. Closed commissurotomy was utilized in 134 patients, with a mean age of 38 ± 11 ...years and a mean valve area of 1.0 ± 0.29 cm2. Open commissurotomy was performed in 146 older patients (mean age 44 ± 11 years) with a mean valve area of 0.9 ± 0.3 cm2. The perioperative mortality was 3% in closed procedures and 3.4% in open procedures. Surviving patients were evaluated by questionnaires or phone interviews, and 129 patients were examined by two-dimensional echocardiography with the purpose of analyzing long-term results. Follow-up was 95% complete (Grunkemeier-Starr method), with a median of 18 years in patients with closed commissurotomy and 6.6 years in patients with open commissurotomy. The actuarial survival at 21 years was 60.8% (70% confidence limits 55% to 66%) in patients having closed commissurotomies and 60.6% (70% confidence limits 49% to 71%) at 22 years in patients having open commissurotomies. The “effective palliation” rate, defined by clinical and echocardiographic criteria, was 47% at 15 years and 15% at 20 years. We conclude that mitral commissurotomy is the procedure of choice in pure mitral valve stenosis and should be applied early. When performed in patients aged less than 40 years, a 78% (70% confidence limits 72% to 84%) survival at 18 years and 67% “effective palliation” at 15 years were observed. The closed valvotomy results of our study support the present trend toward use of percutaneous balloon valvotomy.
Reply to the Editor Rizzoli, Giulio; Mazzucco, Alessandro; Maizza, Filomena ...
The Journal of thoracic and cardiovascular surgery,
05/1994, Volume:
107, Issue:
5
Journal Article
Seventy-six hearts were studied having no direct communication between the right atrium and the ventricular mass. The different cardiac chamber combinations producing so-called "tricuspid atresia" ...were considered. The nature of the atrioventricular valve atresia, the morphology of the ventricular mass, the size and position of the interventricular communication, the ventriculoarterial connection, and the presence of subarterial outflow tract obstruction were all analyzed. The majority of cases were of the "classical" type, i.e., absent right atrioventricular connection with the left atrium connected to the left ventricle. In another group there was absence of the right atrioventricular connection but the left atrium drained into the morphologically right ventricle, which was left-sided. In a third group both atrial chambers connected with the ventricular mass but some structure, an imperforate valve or muscular partition, completely blocked the flow pathway through the right side of the heart. All the hearts described are candidates for the Fontan procedure with either an atrioventricular or an atriopulmonary conduit. The surgical options would not be affected by the observed variability at the atrioventricular junction but would be dictated by the feasibility of incorporating the subpulmonary ventricle within the pulmonary circulation.
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