101,905 research outputs found
Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery
No full textObjective: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (>= 40 mm) prevents tricuspid regurgitation progression after mitral valve surgery.Methods: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (= 40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery.Results: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4%(1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n 15) versus 19%(n 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (>=+3) was present in 0% versus 28%(n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 +/- 8 mmHg vs 40 +/- 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 +/- 7mmvs 65 +/- 8 mm; P = .01; short axis: 33 +/- 4 mm vs 27 +/- 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 +/- 6 mm vs 70 +/- 7 mm; P = .08; short axis: 34 +/- 5 mm vs 33 +/- 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 +/- 23 m from baseline vs +75 +/- 35 m; P = .008).Conclusions: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes. (J Thorac Cardiovasc Surg 2012;143:632-8
Clinical utility of tissue Doppler imaging in prediction of atrial fibrillation after coronary artery bypass grafting
No full textBackground. Atrial systolic dysfunction in patients with coronary artery disease might influence the development of atrial fibrillation after coronary artery bypass grafting (CABG). Tissue Doppler imaging of the mitral annulus during atrial systole has proved to quantify, accurately, left atrial contractile function. Therefore, the aim of the present study was to investigate the correlation between preoperative left atrial dysfunction assessed by tissue Doppler and postoperative atrial fibrillation after CABG. Methods. We studied a total of 96 patients (mean age 67 +/- 6 years; range, 55 to 81) undergoing CABG who were preoperatively in sinus rhythm. All patients underwent a preoperative transthoracic echocardiography with tissue Doppler evaluation. Until the day of discharge, all patients were monitored with continuous electrocardiographic telemetry. Results. There were no hospital deaths. Postoperative atrial fibrillation was recorded in 24 of 96 patients (25%). Patients with postoperative atrial fibrillation were significantly older (70 +/- 6 vs 65 +/- 8 years; p = 0.006), had a preoperative larger left atrium diameter (38 +/- 5 vs 36 +/- 4 mm; p = 0.045), a larger left atrium area (13.2 +/- 3.4 vs 11.5 +/- 2.3 cm(2); p = 0.007), and a lower peak atrial systolic mitral annular tissue Doppler velocity (10 +/- 3 vs 13 +/- 5 cm/second; p = 0.01). Stepwise logistic regression analysis showed that age 70 years or greater (p = 0.02; odds ratio [OR] 2.0), preoperative medication with ss-blockers (p = 0.04; OR 0.7), left atrium area 13 cm(2) or greater (p = 0.02; OR 2.5), and peak atrial systolic mitral annular tissue Doppler velocity 9 cm/second or less (p = 0.03; OR 1.8) were independently related with the incidence of postoperative atrial fibrillation. Conclusions. Tissue Doppler is useful for assessing preoperative atrial dysfunction and predicting atrial fibrillation after CABG. Further studies are needed to confirm this finding
Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients
No full textObjective: Our objective was to determine whether the use of unilateral (u-ACP) or bilateral antegrade cerebral perfusion (b-ACP) results in different mortality and neurologic outcomes after complex aortic surgery.
Methods: PubMed, Embase, and the Cochrane Library were searched for studies reporting on postoperative mortality and permanent (PND) and temporary neurologic dysfunction (TND) in complex aortic surgery requiring circulatory arrest with antegrade cerebral protection. Analysis of heterogeneity was performed with the Cochrane Q statistic.
Results: Twenty-eight studies were analyzed for a total of 1894 patients receiving u-ACP versus 3206 receiving b-ACP. Pooled analysis showed similar rates of 30-day mortality (8.6% vs 9.2% for u-ACP and b-ACP, respectively; P = .78), PND (6.1% vs 6.5%; P = .80), and TND (7.1% vs 8.8%; P = .46). Age, sex, and cardiopulmonary bypass time did not influence effect size estimates. Higher rates of postoperative mortality and PND were among nonelective operations and for highest temperatures and duration of the circulatory arrest. The Egger test excluded publication bias for the outcomes investigated.
Conclusions: This meta-analysis shows that b-ACP and u-ACP have similar postoperative mortality and both PND and TND rates after circulatory arrest for complex aortic surgery
Surgical management of aortic root disease in Marfan syndrome: A systematic review and meta-analysis
No full textContext Surgical treatment of aortic root aneurysm in Marfan syndrome (MFS) patients.Objective To compare results of total root replacement versus valve-sparing aortic root replacement in MFS patients.Data Sources PubMed, Embase and Cochrane library were searched from January 1966 until February 2010 looking for papers reporting on aortic root operations in MFS patients. 530 studies were retrieved.Study Selection Finally, 11 publications were enrolled. Inclusion criteria were observational studies reporting valve-related morbidity and mortality after total root replacement (TTR) and/or valve-sparing root replacement (VSRR) in patients with MFS and study size n >= 30, reflecting the centre's experience.Data Extraction Data obtained from papers reporting both TRR and VSRR cohorts were analysed separately. In case of multiple publications, the most recent and complete report was selected. If the total number of patient-years was not provided, we calculated it by multiplying the number of hospital survivors with the mean follow-up duration of that study.Results Overall, 1385 patients were analysed (972 patients had TTR and 413 patients had VSRR). Reintervention rate was 0.3%/year (95% CI 0.1 to 0.5) versus 1.3%/year (95% CI 0.3 to 2.2) (p=0.02) and thromboembolic events rate was 0.7%/year (95% CI 0.5 to 0.9) versus 0.3%/year (95% CI 0.1 to 0.6) (p=0.01) after TRR and VSRR, respectively. When composite valve-related events were compared, no difference existed between the two surgical strategies (p=0.41). Among patients undergoing VSRR, reimplantation was associated with a reduced rate of reintervention compared with remodelling (0.7%/year vs 2.4%/year, p=0.02).Conclusions VSRR may represent a valuable option for patients with MFS with aortic aneurysm. However, this technique should be used with caution in patients with valve characteristics at risk for decreased durability
Moderate chronic kidney disease and left ventricular hypertrophy after aortic valve replacement for aortic valve stenosis.
No full textObjective: Left ventricular hypertrophy regression is assumed to be one of the most important goals after aortic valve replacement for aortic stenosis. A moderate decrease in the glomerular filtration rate is associated with a significantly increased risk of left ventricular hypertrophy in hypertensive patients. The effect of moderate kidney disease on left ventricular hypertrophic remodeling in other conditions of chronic left ventricular pressure overload, such as aortic stenosis, remains unknown. Therefore we tested the hypothesis that moderate chronic kidney disease affects left ventricular mass regression in patients undergoing isolated aortic valve replacement for aortic stenosis. Methods: In 157 patients with aortic stenosis, left ventricular mass regression was assessed at 18 months after aortic valve replacement. Among them, 73 (46%) had a moderate chronic kidney disease (glomerular filtration rate between 60 and 30 mL/min per 1.73 m2). Patients with severely impaired kidney function (glomerular filtration rate of<30 mL/min per 1.73 m2) were excluded. Results: After surgical intervention, left ventricular mass was significantly lower from baseline value in both groups, but patients with moderate chronic kidney disease continued to show an increased left ventricular mass (61 18 vs 50 16 g/m2.7, P 1⁄4 .0001). The baseline glomerular filtration rate was significantly related to left ventricular mass at 18 months after surgical intervention (b1⁄40.17, r2 1⁄4 0.45, P 1⁄4 .01) and left ventricular mass absolute (b 1⁄4 0.18, r2 1⁄4 0.19, P 1⁄4 .03) and relative (b 1⁄4 0.20, r2 1⁄4 0.21, P 1⁄4 .02) regression. These associations persisted after adjusting for confounding factors, including hypertension and patient–prosthesis mismatch. After a mean time of 34 12 months from surgical intervention, congestive heart failure symptoms developed mainly in subjects with moderate chronic kidney disease (adjusted hazard ratio, 1.9; 95%confidence interval, 1.2–3.9; P 1⁄4 .035). Conclusions: Patients with aortic stenosis with concomitant moderate chronic kidney disease present a less evident left ventricular mass regression after aortic valve replacement. Moreover, this condition is related to an increased occurrence of congestive heart failure after surgical intervention
Off-pump versus on-pump coronary artery bypass: Does number of grafts performed represent a selection bias in comparative studies? Results from a matched cohort comparison
No full textBackground: Several retrospective studies comparing off-pump and on-pump coronary surgery and the largest randomized studies published to date showed a lower number of grafts performed in patients submitted to off-pump coronary artery bypass surgery (OPCAB). These findings bring about the question of the general applicability of the results. We eliminated the selection bias correlated with the number of grafts per patient by comparing the short-term outcomes of patients undergoing OPCAB and standard coronary artery bypass grafting (CABG) matched for number of grafts. Methods: Eighty-seven consecutive patients undergoing OPCAB (group A) were selected from the database of our Institution during a 2-year period. Matching was performed by iterative selection prioritizing, in the following sequence: number of grafts, EuroSCORE, and age. A total of 87 patients operated upon with the on-pump technique represented the control group (group B). Results: There were no significant differences in preoperative characteristics between the two groups. The number of grafts per patient was 2.2 ± 0.5 in group A and 2.2 ± 0.5 in group B. Early mortality did not differ between the two groups and it was 2.2% (2 patients) in group A and 3.4% (3 patients) in group B (p = NS). The incidence of myocardial infarction did not differ between the two groups. No patient in either group had stroke or coma. Five (5.7%) patients in group A and 7 (8.0%) patients in group B had atrial fibrillation (p = NS). Conclusions: We were unable to demonstrate any significant differences in short-term mortality or morbidity outcome between OPCAB and standard CABG patients. Our findings suggest that excellent results can be obtained with both surgical approaches
Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system
No full textNeutrophil gelatinase-associated lipocalin (NGAL) has been implicated as an early predictive urinary biomarker of ischemic acute kidney injury (AKI). The aim of this study was to compare the effects of miniaturized cardiopulmonary bypass system (MCPB) vs. standard cardiopulmonary bypass system (SCPB) system on kidney tissue in patients undergoing myocardial revascularization using urinary NGAL levels as an early marker for renal injury. Sixty consecutive patients who underwent myocardial revascularization were studied prospectively. An SCPB was used in 30 patients (group A) and MCPB was used in 30 patients (group B). The SCPB group but not the MCPB group showed a significant NGAL concentration increase from preoperative during the 1st postoperative day (169.0+/-163.6 ng/ml in the SCPB group vs. 94.1+/-99.4 ng/ml in the MCPB group, P<0.05, respectively). Two patients in the SCPB group developed AKI and underwent renal replacement therapy; no patient in MCPB developed AKI. The MCPB system is safe in routine clinical use. Kidney function is better protected during MCPB as demonstrated by NGAL levels. NGAL represents an early biomarker of renal failure in patients undergoing cardiac surgery and the valuation of its concentration can aid in medical decision-making
Red blood cell distribution width predicts mortality after coronary artery bypass grafting
No full textINCIDENTAL FINDING OF INTERRUPTED AORTIC ARCH IN AN ADULT PATIENT UNDERGOING URGENT PERCUTANEOUS CORONARY INTERVENTION
No full textInterrupted Aortic Arch (IAA) is a rare congenital abnormality characterized by a complete
discontinuity of the aortic lumen, usually located after the origin of the left subclavian artery. IAA
is mainly diagnosed during childhood and has an extremely high mortality rate if left untreated.
Therefore, only a few cases have been diagnosed in adulthood. We report the case of a patient with
Non-ST Segment Elevation Myocardial Infarction (NSTEMI) and unknown IAA abnormality, who
underwent urgent percutaneous coronary angioplasty (PCI). It was not possible to reach ascending
aorta from the right radial artery because of the presence of tangled arteries connecting the prevertebral subclavian segment to the descending aorta. PCI was completed successfully through the
left radial artery. A post-procedural Angio-CT scan confirmed the Aortic Arch interruption. The
presented case highlights the crucial role of a multi-imaging modality approach for those patients
with such congenital abnormalities before undergoing PCI
Impact of prosthesis-patient mismatch on the regression of secondary mitral regurgitation after isolated aortic valve replacement with a bioprosthetic valve in patients with severe aortic stenosis
No full textBackground-Secondary mitral regurgitation (SMR) is generally reduced after isolated aortic valve replacement (AVR), but there is important interindividual variability in the magnitude of this reduction. Prosthesis-patient mismatch (PPM) may hinder normalization of left ventricular geometry and pressure overload following AVR, therefore we aimed to investigate the relationship between PPM and regression of SMR following AVR for aortic valve stenosis.Methods and Results-A total of 419 patients with AS who underwent isolated AVR at 2 institutions and presenting moderate SMR (mitral regurgitant volume 30 to 45 mL/beat) not considered for surgical correction were included in this study. Clinical and echocardiographic follow-up were completed at a median follow-up time of 37 months. PPM was defined as an indexed effective orifice area <= 0.85 cm(2)/m(2) and was found in 170/419 patients (40.6%). There were no significant differences in baseline and operative characteristics between patients with or without PPM. Patients with PPM had less regression of SMR following AVR compared with those with no PPM (change in mitral regurgitant volume: -11 +/- 4 versus -17 +/- 5 mL, respectively; P<0.0001). Variables significantly associated with postoperative change in mitral regurgitant volume on univariable analysis were entered in a multivariable linear regression model, which showed indexed effective orifice area (P<0.0001) and left atrial diameter (P=0.006) to be independently associated with mitral regurgitant volume improvement. Patients with PPM also had less postoperative improvement in 6-minute walking test distance (80 +/- 78 versus 42 +/- 41 m, P<0.0001).Conclusions-PPM is associated with lesser regression of SMR following AVR. This unfavorable effect was associated with worse functional capacity. These findings emphasize the importance of operative strategies aiming to prevent PPM in patients with aortic valve stenosis and concomitant SMR. (Circ Cardiovasc Imaging. 2012;5:36-42.
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