A Rastan

2014 ESC/EACTS Guidelines on myocardial revascularization The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Authors/Task Force members: Stephan Windecker* (ESC Chairperson) (Switzerland), Philippe Kolh* (EACTS Chairperson) (Belgium), Fernando Alfonso (Spain), Jean-Philippe Collet (France), Jochen Cremer (Germany), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Christian Hamm (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Switzerland), A. Pieter Kappetein (The Netherlands), Adnan Kastrati (Germany), Juhani Knuuti (Finland), Ulf Landmesser (Switzerland), Günther Laufer (Austria), Franz-Josef Neumann (Germany), Dimitrios J. Richter (Greece), Patrick Schauerte (Germany), Miguel Sousa Uva (Portugal), Giulio G. Stefanini (Switzerland), David Paul Taggart (UK), Lucia Torracca (Italy), Marco Valgimigli (Italy), William Wijns (Belgium), and Adam Witkowski (Poland).

Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

OBJECTIVE Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described. METHODS Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantation (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses. RESULTS Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% +/- 17.6%, logistic EuroSCORE was 21.6% +/- 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 +/- 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years. CONCLUSIONS Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.

Aortic Valve Replacement in Octogenarians: Utility of Risk Stratification With EuroSCORE

BACKGROUND With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification. METHODS All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete. RESULTS In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum. CONCLUSIONS Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Emergency coronary artery bypass graft surgery for acute coronary syndrome : Beating heart versus conventional cardioplegic cardiac arrest strategies

Background— Aim of this study was to compare the outcome of beating heart versus conventional coronary artery bypass graft (CABG) strategies in acute coronary syndromes for emergency indications. Methods and Results— 638 consecutive patients with acute coronary syndrome (ACS) receiving emergency CABG surgery via midline sternotomy from January 2000 to September 2005 were evaluated. Propensity score analysis was used to predict the probability of undergoing beating heart (BH) (n=240) versus cardioplegic cardiac arrest (CA) (n=398) strategies. Patients presented with stable hemodynamics (n=531) or in cardiogenic shock (CS) (n=107). Hospital and follow-up outcome was compared by propensity score adjusted multiregression analysis. BH included 116 on-pump and 124 off-pump (OPCAB) procedures. There was a propensity to operate CS patients on the beating heart (multivariate odds ratio [OR], 3.8; P=0.001). Under stable hemodynamics significant predictors for BH selection were logEuroSCORE >20% (OR, 2.05), creatinine >1.8 mg/dL (OR, 4.12), complicated percutaneous coronary intervention (OR, 1.88), ejection fraction <30% (OR, 2.64), whereas left main disease (OR, 0.68), circumflex artery (OR, 0.32), and 3-vessel disease (OR, 0.67) indicated preference for cardioplegic arrest. Time from skin incision to culprit lesion revascularization was significantly reduced in BH patients. BH surgery led to a significant benefit in terms of less drainage loss, less transfusion requirement, less inotropic support, shorter ventilation time, lower stroke rate, and shorter intensive care unit stay. In CS, BH was associated with lower incidence of stroke, inotropic support, acute renal failure, new atrial fibrillation and sternal wound healing complications. In CS patients, hospital mortality rate was reduced when using beating heart strategies (P=0.048). Overall survival, major adverse cerebral and cardiovascular event rate, and repeated revascularization was comparable during a 5-year follow-up. Conclusions— Beating heart strategies are associated with an improved hospital outcome and comparable long-term results for high-risk patients presenting acute coronary syndrome with or without CS.

Aortic valve calcium scoring is a predictor of significant paravalvular aortic insufficiency in transapical-aortic valve implantation‡

OBJECTIVE Transapical-aortic valve implantation (TA-AVI) has evolved as routine for selected high-risk patients. However, paravalvular leaks >1+ remain an unsolved issue using current generations of transcatheter valve devices. The purpose of this study was to investigate the impact of native aortic valve calcification on paravalvular leaks and outcomes using the Edwards SAPIEN™ prosthesis. METHODS One hundred and twenty consecutive patients (out of 307 TA-AVIs) with preoperative computed tomography aged 82.6 ± 6.2 years, 75.0% female were included. Implanted prosthetic valve sizes were 23 mm (n = 31) and 26 mm (n = 89), respectively. Mean logistic European System for Cardiac Operative Risk Evaluation-Score was 30.1 ± 15.5% and mean Society of Thoracic Surgeons-Score was 12.8 ± 7.9%. Electrocardiographic (ECG)-gated cardiac computed tomography allowed to quantify the amount of calcification of aortic valve leaflets using a scoring analogous to the Agatston calcium scoring of coronary arteries [Aortic Valve Calcium Scoring (AVCS)]. Paravalvular leaks were assessed intraoperatively by echocardiography and root angiography. RESULTS All valves were implanted successfully. The mean AVCS in patients without paravalvular leaks (n = 66) was 2704 ± 1510; with mild paravalvular leaks (n = 31) was 3804 ± 2739 (P = 0.05); and with moderate paravalvular leaks (n = 4) was 7387 ± 1044 (P = 0.002). There was a significant association between the AVCS and paravalvular leaks [odds ratio (OR; per AVCS of 1000), 11.38; 95% confidence interval (CI) 2.33-55.53; P = 0.001)] and a trend towards a higher incidence of new pacemaker implantation (OR 1.27; 95% CI 0.85-1.89; P = 0.26). No association was found to 30-day mortality, major cardiac events and stroke rate (OR 1.05; 95% CI 0.84-1.32; P = 0.68; OR 0.92; 95% CI 0.68-1.25; P = 0.57 and OR 0.90; 95% CI 0.41-1.96; P = 0.79, respectively). Overall 30-day mortality was 14.2%. CONCLUSION Severe native valve calcifications are predictive for postoperative relevant paravalvular leak. AVCS prior to TA-AVI might serve as an additional tool to reconsider the TAVI indication to reduce the risk of paravalvular leaks especially in so-called operable patients.

Transapical Aortic Valve Implantation

Background— Transapical aortic valve implantation has evolved to a reproducible therapeutic option for high-risk patients. The aim of the present study was to evaluate our learning experience over 4 years and to analyze outcome-related risk factors. Methods and Results— A total of 299 patients who received transapical aortic valve implantation between February 2006 and January 2010 with the Edwards SAPIEN transcatheter prosthesis were analyzed according to early experience (EE; patients 1 to 150) and recent experience (RE; patients 151 to 299). Patients consistently demonstrated high risk scores, and major perioperative parameters were comparable between the 2 groups. RE patients had a significantly higher logistic EuroSCORE (RE 33.2±17.2, EE 29.4±14; P=0.039) but a significantly lower STS (Society of Thoracic Surgeons) score (RE 11.4±7.5, EE 13.5±7.8; P=0.019). Use of contrast dye (EE 104±78 mL, RE 93±46 mL) and the need to perform a balloon redilation were significantly reduced in the RE group. Thirty-day mortality decreased from 11.3% to 6.0%, and 1-year mortality improved significantly from 30.7% (EE) to 21.5% in the RE patients (P=0.047). Multivariate logistic regression analysis revealed reduced vital capacity (<70%) and concomitant preoperative mitral regurgitation >1+ as the only independent predictors of 30-day mortality. Classic variables such as age, logistic EuroSCORE >30%, and STS score >15% failed to predict mortality. Conclusions— Recent results with transapical aortic valve implantation indicate a progressive improvement in outcomes despite an unchanged patient risk profile, which reflects a significant learning curve that includes a better understanding of optimal patient selection. Classic surgical risk factors fail to predict outcome, which indicates the need for new transapical aortic valve implantation–specific risk scores.

Complex coronary anatomy in coronary artery bypass graft surgery: Impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years

OBJECTIVE SYNTAX study compares outcomes of coronary artery bypass grafting with percutaneous coronary intervention in patients with 3-vessel and/or left main disease. Complexity of coronary artery disease was quantified by the SYNTAX score, which combines anatomic characteristics of each significant lesion. This study aims to clarify whether SYNTAX score affects the outcome of bypass grafting as defined by major adverse cerebrovascular and cardiac events (MACCE) and its components over a 2-year follow-up period. METHODS Of the 3075 patients enrolled in SYNTAX, 1541 underwent coronary artery bypass grafting (897 randomized controlled trial patients, and 644 registry patients). All patients undergoing bypass grafting were stratified according to their SYNTAX score into 3 tertiles: low (0-22), intermediate (22-32), and high (≥33) complexity. Clinical outcomes up to 2 years after allocation were determined for each group and further risk factor analysis was performed. RESULTS Registry patients had more complex disease than those in the randomized controlled trial (SYNTAX score: registry 37.8 ± 13.3 vs randomized 29.1 ± 11.4; P < .001). At 30 days, overall coronary bypass mortality was 0.9% (registry 0.6% vs randomized 1.2%). MACCE rate at 30 days was 4.4% (registry 3.4% vs randomized 5.2%). SYNTAX score did not significantly affect overall 2-year MACCE rate of 15.6% for low, 14.3% for medium, and 15.4% for high SYNTAX scores. Compared with randomized patients, registry patients had a lower rate of overall MACCE rate (registry 13.0% vs randomized 16.7%; P = .046) and repeat revascularization (4.7% vs 8.6%; P = .003), whereas other event rates were comparable. Risk factor analysis revealed left main disease (P = .049) and incomplete revascularization (P = .005) as predictive for adverse 2-year outcomes. CONCLUSIONS The outcome of coronary artery bypass grafting was excellent and independent from the SYNTAX score. Incomplete revascularization rather than degree of coronary complexity adversely affects late outcomes of coronary bypass.

Risk of acute kidney injury after minimally invasive transapical aortic valve implantation in 270 patients

OBJECTIVE Contrast agent is a potential risk factor for acute kidney injury (AKI). Little is known about the incidence of contrast-induced nephropathy (CIN) after trans-apical aortic valve implantation (TA-AVI) and on the impact of contrast exposure during preoperative computed tomography (CT) scan and cardiac catheterization. METHODS A total of 270 consecutive high-risk patients received TA-AVI for symptomatic aortic valve stenosis during a 3-year period. Different preoperative, peri-procedural, and postoperative variables were analyzed by uni- and multivariate logistic regression concerning incidence of early (<7 days) AKI and need for renal replacement therapy (RRT). Nine patients on chronic preoperative dialysis were excluded. RESULTS Mean age was 82 ± 5.8 years, 71% were female. LogEuroSCORE (European System for Cardiac Operative Risk Evaluation) and STS Score were 31.4 ± 15.6% and 12.1 ± 7.4%, respectively. Preoperative estimated glomerular filtration rate (eGFR) <60 ml min(-1) was present in 35.2%. CT scan and cardiac catheterization within 7 days before TA-AVI were performed in 43.7% and 20.3% of the patients and were associated with a mean contrast-agent exposition of 110 ± 21 ml for CT scans and 91 ± 65 ml for cardiac catheterization. Regarding the postoperative renal outcome, an improved or at least stable eGFR was seen in more than 50% of the patients. Intra-operative contrast-agent application was 99 ± 64 ml and correlated significantly to the development of postoperative AKI and need for RRT (p=0.013 and p=0.003). Postoperative RRT was required in 15.7%. Chronic renal insufficiency (odds ratio (OR)=6.8, p=0.025) and number of blood transfusions (OR=8.8, p=0.009) were independent risk factors for RRT. Postoperative AKI occurred in 16.1% and intra-operative contrast-agent burden >99 ml (OR=2.3, p=0.038), new thrombocytopenia (OR=4.4, p=0.005) and pathological leucocyte count (OR=2.8, p=0.009) were independent risk factors for this event. Early (within 1-7 days before TA-AVI) preoperative CT and cardiac catheterization did not significantly increase incidence of RRT or AKI. Short-term and long-term survival was explicitly lower in the AKI and in the RRT groups (p<0.001 each). CONCLUSIONS GFR improves after TA-AVI. Postoperative AKI and RRT depend on the amount of intra-operative contrast agent. These results strongly support the need for intra-operative tools to reduce contrast-agent exposition during TA-AVI.

Does Reasonable Incomplete Surgical Revascularization Affect Early or Long-Term Survival in Patients With Multivessel Coronary Artery Disease Receiving Left Internal Mammary Artery Bypass to Left Anterior Descending Artery?

Background— The objective was to evaluate the impact of complete revascularization (CR) versus reasonable incomplete surgical revascularization (IR) in others than left anterior descending artery territory on early and late survival in patients with multivessel coronary artery disease (CAD). Methods and Results— During a 7-year period, 8.806 consecutive patients with multivessel CAD affecting the proximal left anterior descending artery or left main stem underwent sternotomy for isolated coronary artery bypass grafting including left internal mammary artery–left anterior descending artery bypass. A total of 936 patients (10.6%) had IR of the circumflex or right coronary artery territory. IR was based on the traditional classification. Follow-up was 3.5±2.2 years. Patient groups were comparable regarding age (CR 67.1 versus IR 67.6 years), ejection fraction (57.2% versus 57.5%), and logEuroscore (4.5% versus 4.5%). Patients receiving IR presented with more complex CAD. Mean number of distal anastomoses was 3.0±0.8 CR versus 2.4±0.6 IR. Operation time (176 versus 187 minutes) and cross-clamp time (52 versus 56 minutes) were longer in the IR group (P<0.001). Hospital mortality was 3.3% CR versus 3.2% IR (P=0.520). Independent risk factors for hospital mortality were age, pulmonary hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and emergency indication, but not IR (P=0.922). Arterial revascularization was protective. Cumulative survival at 1-year was 93.1% CR versus 93.6% IR and at 5 years 82.2 CR versus 80.9% IR (P=0.457). Conclusions— In presence of left internal mammary artery-to-left anterior descending artery bypass, reasonable IR of the circumflex or right coronary artery territory did not adversely affect early or long-term survival in patients with multivessel CAD. In patients presenting with 1 poor target vessel; however, IR is a good therapeutic option and the benefit of CR should be balanced against the risks.

Transapical transcatheter aortic valve implantation using the JenaValve™ system: acute and 30-day results of the multicentre CE-mark study†

OBJECTIVES Transcatheter aortic valve implantation (TAVI) has shown promising results in patients with severe aortic stenosis (AS) at high risk for conventional heart surgery. The safety and efficacy of transapical aortic valve implantation using the JenaValve™, a second-generation TAVI device, were evaluated. The system consists of a tested porcine root valve mounted on a nitinol stent with feeler-guided positioning and clip fixation on the diseased leaflets. METHODS This multicentre, prospective, single-arm study, conducted at seven German sites, enrolled 73 patients (mean age 83.1 ± 3.9), European System for Cardiac Operative Risk Evaluation (EuroSCORE) (28.4 ± 6.5%) of whom 67 patients underwent elective TAVI. Three sizes were used for annular diameters up to 23 mm (n = 21), 25 mm (n = 31) and 27 mm (n = 15). Clinical and echocardiographic evaluations were performed at baseline, post-procedure, discharge and 30 days, and also at 3, 6 and 12 months. The primary endpoint was all-cause mortality at 30 days. Secondary endpoints were procedural success, major adverse cardiac and cerebrovascular events and echocardiographic performance. RESULTS TAVI with the JenaValve™ device was successful in 60 patients (procedural success rate 89.6%). The overall mortality at 30 days was 7.6%. Conversion to surgery was necessary in four patients (6%), two patients underwent valve-in-valve implantations (3%), one patient was withdrawn per protocol after conversion to TAVI using a balloon-expandable valve (1.5%) since the patient did not receive the study device. Perioperative stroke occurred in two cases (3%). Pacemaker implantation for new onset conduction disorders was necessary in six patients (9.1%). No ostial coronary obstructions were seen. Post-procedure TAVI resulted in favourable reduction of mean transvalvular gradients (40.6 ± 15.9 vs. 10.0 ± 7.2 mmHg, P < 0.0001) and increase in valve opening area (0.7 ± 0.2 vs. 1.7 ± 0.6 cm², P < 0.0001). The majority of successfully treated patients revealed no or minimal paravalvular aortic regurgitation (86.4%); none of the patients had severe post-procedural regurgitation (>2+). CONCLUSIONS Transapical JenaValve™ implantation was safe and effective in the treatment of severe AS in elderly patients at high risk for surgery. Active clip fixation on the native leaflets and anatomically correct feeler-guided positioning led to good functionality and prevented ostial coronary impairment. Implantation without the need for rapid pacing prevented haemodynamic compromise during valve implantation.