Annabelle Wood

Early and mid-term outcomes following surgical management of infective endocarditis with associated cerebral complications: a single centre experience

BACKGROUND Surgical management of patients with infective endocarditis (IE) who have suffered preoperative cerebrovascular complications remains controversial. This study evaluates the impact of timing from stroke to valvular surgery on the early and mid-term neurological sequelae, functional status and quality of life in this high-risk group of patients with IE. METHOD Data on 13/108 (12%) patients with IE who suffered cerebrovascular complications during the period 1998-2009 was prospectively collected. Mean follow-up was 37.2 months (100% complete). RESULTS Three of 13 (23%) suffered haemorrhagic stroke, 10/13 (77%) had embolic events (nine, stroke; one, TIA). The clinical diagnosis was made by a neurologist in 6/13 (46%) and confirmed in all by CT scan. Twelve of 13 had motor deficit involving MCA territory. Thirty-day mortality was 2/13 (one, cardiac; one, neurological) with no late deaths. The mean time from embolic stroke to surgery was 2.3 weeks (range 3-60 days). The reason for operating on eight patients in less than two weeks was heart failure in five, uncontrolled sepsis, AMI and TIA (one each). 2/8 (25%) suffered additional postoperative neurological events (one, brain death, one, new MCA stroke). On follow-up of the remaining eight patients with embolic events, five had improved neurology and three had stable neurology. The mean time to surgery from haemorrhagic stroke was 5.8 weeks (range 3-60 days). Deficit improved in two patients (<1 week, 1; >8 weeks, 1). On follow-up the NYHA class was I-II in 6/11 (56%). The EQ-5D questionnaire was used to assess quality of life. Mean index for the group was 0.67 using the US preference-weighted index score (SD 0.27). CONCLUSIONS Results regarding timing for haemorrhagic stroke cannot be defined from the small numbers. Timely surgical intervention (embolic greater than two weeks and preferably four weeks in absence of heart failure) is associated with acceptable neurological outcome, functional class and quality of life.

Contemporary results following surgical repair of acute type a aortic dissection (AAAD): a single centre experience.

OBJECTIVES The study aims to define predictors of neurological dysfunction, 30-day mortality, long-term survival and quality of life following repair of acute type A aortic dissection (AAAD). METHODS Between 2000 and 2008, 65 patients underwent repair of AAAD. Sixty-four pre-, intra- and post-operative variables were studied. Mean follow-up was 26.6 months. RESULTS The mean age was 61years; 60% were male and five had Marfans syndrome. At presentation, ischaemic ECG changes were seen in 45%, malperfusion syndrome in 59%, moderate-severe aortic regurgitation in 48% and tamponade in 16%. EF was <40% in 17%. There was a delay of >12hours between diagnosis and operation in 64%. Axillary cannulation was performed in 37%. Cerebral protection was by hypothermic arrest (HCA) alone (19%), HCA with retrograde cerebral perfusion (RCP) (11%), or HCA with antegrade cerebral perfusion (ACP) (46%). The procedure was performed on cross-clamp in 24%. Full arch replacement was performed in 14% and concomitant coronary artery grafting was performed in 11%. Post-operative neurological dysfunction was present in 33.8%. The only significant predictor of poor neurological outcome was full arch replacement (p=0.04) on univariate analysis. In-hospital OR 30 mortality was 23.53%. Significant predictors of mortality were low ejection fraction (p=0.017) and post-operative renal failure (p=0.012). Long-term survival was 70% at two years, 50% at five years and 25% at nine years. Functional outcomes and long-term quality of life were assessed in 69% of patients who were alive at last follow-up. Ninety percent of patients reported minimal limitation on functional scores. Quality of life was assessed using the EQ-5D questionnaire. Forty-eight percent of patients recorded full health with an overall mean index of 0.854 (where the best possible score is 1) using the US preference weighted index score. CONCLUSIONS Discharged patients have reasonable long-term survival and good quality of life.

Expression of fat mobilizing genes in human epicardial adipose tissue

BACKGROUND Epicardial adipose tissue (EAT) mass correlates with metabolic syndrome and coronary artery disease (CAD). However, little is known about the expression of genes involved in triglyceride (TG) storage and mobilization in EAT. We therefore analyzed the expression of genes involved in fat mobilization in EAT in comparison to subcutaneous abdominal adipose tissue (AAT) in CAD patients and in controls. METHODS EAT and AAT were obtained during coronary artery bypass graft (CABG) surgery from 16 CAD patients and from 14 non-CAD patients presenting for valve surgery. The state of atherosclerosis was assessed by angiography. RNA from tissues were extracted, reversibly transcribed and quantified by real time polymerase chain reaction (RT-PCR). The following genes were analyzed: perilipin-1 and -5 (PLIN1, PLIN5), lipoprotein lipase (LPL), hormone sensitive lipase (HSL), adipose triglyceride lipase (ATGL), comparative gene identification-58 (CIG-58), angiopoietin like protein 4 (ANGPTL4), in addition to interleukine-6 (IL-6), leptin (LEP) and adiponectin (ADPN). RESULTS A significant expression of all listed genes could be observed in EAT. The relative expression pattern of the 10 genes in EAT was comparable to the expression in AAT, yet there was a significantly higher overall expression in AAT. The expression of the listed genes was not different between CAD patients and controls. CONCLUSION It is suggested that the postulated difference in EAT volume between CAD patients and non-CAD patients is not caused by a differential mRNA expression of fat mobilizing genes. Further work on protein levels and enzyme activities will be necessary to get a complete picture.

Surgical management and mid-term outcomes of 108 patients with infective endocarditis.

This study evaluates the early and mid-term outcomes, predictors of mortality and morbidity and quality of life of patients operated for infective endocarditis. Data on 108 patients undergoing 113 surgical procedures during October 1998 to January 2010 was prospectively collected. NYHA Class was >III in 49 (43.4%) cases. Thirty-seven (33%) patients had isolated mitral valve procedures, 58 (51%) had aortic valve, two had tricuspid valve and 16 had multivalvular procedures. Active endocarditis was noted in 86 (76%) procedures, native valve endocarditis in 105 (93%) and prosthetic valve endocarditis in eight procedures. Logistic EuroSCORE at presentation was >14 in 18 (17%) patients. Staphylococcus aureus was the most common organism isolated. Follow-up was carried out in 76/85 (88.37%) of surviving patients, and the mean follow-up time was 37.2 months. Functional class and quality of life (using EQ-5D Health Questionnaire) were assessed by telephone interviews. NYHA Class on follow-up was I-II in 62/76 (83%). Multivariate predictor of 30-day mortality was peripheral vascular disease (p = 0.025) whilst multivariate predictors of long-term survival were male sex (p = 0.01), peripheral vascular disease (p = 0.02) and bypass time (p = 0.006). The overall survival was 87% at one year and 80% at five years. Thirty-three percent (25/76) patients reported a score reflecting full health. Optimal antibiotic therapy and timely surgical intervention were associated with improved functional class, quality of life and mid-term survival.

Does moderate tricuspid regurgitation require attention during mitral valve surgery

This study aims to determine whether tricuspid regurgitation (TR) ≥ 2+ requires attention during mitral valve surgery.

Surgical pulmonary embolectomy: mid-term outcomes

Despite the widespread use of venous thromboembolism (VTE) prophylaxis in hospitalized patients, pulmonary embolism continues to occur. Massive pulmonary embolism is associated with a high mortality. Surgical embolectomy has traditionally been reserved for cases with haemodynamic collapse or where thrombolysis is contraindicated or has failed.

Ischemic cardiomyopathy: midterm survival and its predictors:

Background: the aim of the study was to analyze all-cause mortality and predictors of long-term survival after myocardial revascularization for ischemic cardiomyopathy. Method: data of 101 patients (mean age, 63.86 years; age range, 30–85 years; 92% male), operated on with stable coronary artery disease and left ventricular ejection fraction <30% between April 2000 and June 2010, were analyzed. Results: operative mortality was 1.9% (2/101). There was a significant improvement in left ventricular ejection fraction from 25.99% ± 3.8% preoperatively to 34% ± 12% postoperatively (p < 0.0001). The mean duration of follow-up was 56.3 ± 33 months, and it was 97% complete (98/101). There were 18/96 (18.75%) late deaths. Overall actuarial survival at 1, 3, 5, and 10 years was 96%, 89%, 83% and 75%, respectively. Univariate predictors of late death were preoperative arrhythmia, cerebrovascular disease, peripheral vascular disease, and logistic EuroSCORE. Multivariate predictors of late death were cerebrovascular disease and preoperative arrhythmia. Conclusion: our study suggests that myocardial revascularization for ischemic cardiomyopathy improves left ventricular ejection fraction and is associated with favorable long-term survival. Patients with cerebrovascular disease and preoperative arrhythmias had poorer outcomes.