The need for pacemaker implantation is a well-described complication of aortic valve replacement. Not so well described is the effect such an event has on long-term outcome. This study reviewed a ...21-year experience at the Mayo Clinic (Rochester, Minnesota) with aortic valve replacement to understand the influence of early postoperative pacemaker implantation on long-term mortality rates more clearly.
This study retrospectively reviewed the records of 5,842 patients without previous pacemaker implantation who underwent surgical aortic valve replacement from January 1993 through June 2014. The median age of these patients was 73 years (range, 65 to 79 years), the median ejection fraction was 62% (range, 53% to 68%), 3,853 patients were male (66%), and coronary artery bypass graft operation was performed in 2,553 (44%) of the patients studied. Early pacemaker implantation occurred in 146 patients (2.5%) within 30 days of surgical aortic valve replacement.
The median follow-up of patients was 11.1 years (range, 5.8 to 16.5 years), and all-cause mortality rates were 2.4% at 30 days, 6.4% at 1 year, 23.1% at 5 years, 48.3% at 10 years, and 67.9% at 15 years postoperatively. Early pacemaker implantation was associated with an increased risk of death after multivariable adjustment for baseline patients' characteristics (hazard ratio, 1.49; 95% confidence interval, 1.20, 1.84; p < 0.001).
Early pacemaker implantation as a complication of surgical aortic valve replacement is associated with an increased risk of long-term death. Valve replacement-related pacemaker implantation rates should be important considerations with respect to new valve replacement paradigms, especially in younger and lower-risk patients.
The RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification for acute kidney injury (AKI) was recently modified by the Acute Kidney Injury Network (AKIN). ...The two definition systems differ in several aspects, and it is not clearly determined which has the better clinical accuracy.
In a retrospective observational study we investigated 4,836 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from 2005 to 2007 at Mayo Clinic, Rochester, MN, USA. AKI was defined by RIFLE and AKIN criteria.
Significantly more patients were diagnosed as AKI by AKIN (26.3%) than by RIFLE (18.9%) criteria (P < 0.0001). Both definitions showed excellent association to outcome variables with worse outcome by increased severity of AKI (P < 0.001, all variables). Mortality was increased with an odds ratio (OR) of 4.5 (95% CI 3.6 to 5.6) for one class increase by RIFLE and an OR of 5.3 (95% CI 4.3 to 6.6) for one stage increase by AKIN. The multivariate model showed lower predictive ability of RIFLE for mortality. Patients classified as AKI in one but not in the other definition set were predominantly staged in the lowest AKI severity class (9.6% of patients in AKIN stage 1, 2.3% of patients in RIFLE class R). Potential misclassification of AKI is higher in AKIN, which is related to moving the 48-hour diagnostic window applied in AKIN criteria only. The greatest disagreement between both definition sets could be detected in patients with initial postoperative decrease of serum creatinine.
Modification of RIFLE by staging of all patients with acute renal replacement therapy (RRT) in the failure class F may improve predictive value. AKIN applied in patients undergoing cardiac surgery without correction of serum creatinine for fluid balance may lead to over-diagnosis of AKI (poor positive predictive value). Balancing limitations of both definition sets of AKI, we suggest application of the RIFLE criteria in patients undergoing cardiac surgery.
In patients with hypertrophic cardiomyopathy, obstruction of the left ventricular outflow tract can be relieved by surgical septal myectomy or alcohol septal ablation, but uncertainty remains ...regarding long-term results and comparative effectiveness of alcohol septal ablation. This study aims to compare short- and long-term outcomes of the 2 procedures.
Between December 1998 and September 2016, 2407 patients underwent septal myectomy and 211 patients underwent alcohol septal ablation at our institution. After 2:1 propensity score matching, the study cohort included 334 patients who underwent myectomy and 167 patients who underwent alcohol septal ablation.
Median (interquartile range) ages of patients in the myectomy and alcohol septal ablation groups were 65 (58-71) years and 64 (56-73) years (P = .9), respectively. After intervention, median resting left ventricular outflow tract gradient at predischarge transthoracic echocardiography was 0 (0-10) mm Hg in the myectomy group (n = 288) and 21 (10-60) mm Hg in the alcohol septal ablation group (n = 63) (P < .001, tested at baseline gradients of 30 and 50 mm Hg). There were no differences in survival between the 2 groups (risk of death for alcohol septal ablation vs myectomy, hazard ratio, 1.5; 95% confidence interval, 0.9-2.6; P = .1). Survival of patients undergoing septal myectomy was better than that of an age-, sex-, and race-matched US population (82% vs 75% at 12 years, P = .01). Reintervention for left ventricular outflow tract obstruction was more likely to occur in patients who received alcohol septal ablation (hazard ratio, 33.3; 95% confidence interval, 4.4-250.6; P < .001).
There were no differences in survival of patients undergoing myectomy or alcohol septal ablation, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing septal myectomy.
Objective A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) after mitral valve repair; however, predictors and long-term consequences remain unclear. ...Methods A study of 1705 patients with severe, degenerative mitral valve regurgitation and normal preoperative EF (>60%) undergoing mitral valve repair from 1993 to 2012 was performed. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of early postoperative LV dysfunction (EF < 50%) and long-term survival, respectively. Results Postoperative outcomes were comparable between patients; however, those with an EF of <50% (n = 314, 18.4%) had significantly greater enlargement in systolic dimension (left ventricular end-systolic diameter, −0.6 vs 4.3 mm; P < .001) and decrease in right ventricular systolic pressure (−2.7 vs −7.8 mm Hg; P < .001) immediately after repair. On longitudinal follow-up, early LV impairment persisted, with EF recovering to preoperative levels (>60%) in only one third of patients with postrepair EF <50% versus two thirds of those with an EF of ≥50% ( P < .001). The overall survival at 5, 10, and 15 years of follow-up was 95%, 85%, and 70.8%, respectively. Although early postoperative EF < 50% was not a significant determinant of late survival, when adjusting for older age (hazard ratio HR, 1.09), hypertension (HR, 1.38), New York Heart Association class III or IV (HR, 1.71), and preoperative atrial fibrillation (HR, 2.33), postoperative EF < 40% conferred a 70% increase in the hazard of late death (HR, 1.74; 95% confidence interval, 1.03-2.92; P = .037). A preoperative right ventricular systolic pressure >49 mm Hg and left ventricular end-systolic diameter >36 mm were independently associated with a 4.4- and 6.5-fold increased risk of developing a postoperative EF < 40% ( P < .001, for both). Conclusions De novo postoperative LV dysfunction is not uncommon in patients with “normal” preoperative EF undergoing mitral valve repair. LV dysfunction can persist, impairing recovery of LV size, function, and survival. The consideration of mitral repair before the onset of excessive LV dilation or pulmonary hypertension, even in those with preserved EF, seems warranted.
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to ...improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.
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