Egidio Varone

Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation §

BACKGROUND The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). METHODS From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with organic mitral or tricuspid valve disease were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/3+). No statistical difference was found between two groups concerning preoperative and operative variables. MV was repaired in 137 and replaced in 28 cases; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. RESULTS Thirty-day mortality was 6.7 (5.9% group A vs 7.9% group B, p=0.607). Five-year actuarial survival was 73.5% (66.6-80.4%); 88.2% (83.0-93.4%) group A versus 46.0% (33.7-58.3%) group B, p<0.001; the possibility to be alive in NYHA class I-II was 65.8% (58.4-73.2%); 78.4% (72.3-84.5%) group A versus 41.2% (29.1-53.3%) group B, p<0.001. Cox analysis confirmed the impact of untreated moderate-or-more FTR on 5-year survival (HR=3.1, 95% CI=1.8-5.1, p<0.001) and possibility to be alive in NYHA class I-II (HR=3.0, 95% CI=1.8-4.9, p<0.001). After a median interval time of 28 months (IQR=11-60), TR grade was echocardiographically assessed in 122 (79.2%) of 154 patients surviving the first month. In group A (87 patients), TR grade decreased significantly from 0.7+/-0.5 to 0.3+/-0.5 (p<0.001) in the early postoperative period. Then, it increased again to 0.6+/-0.7 at follow-up (p<0.001); no difference was found between preoperative and follow-up time (p=ns). In group B (35 cases), TR grade decreased significantly from 2.2+/-0.4 to 1.3+/-0.7 in the early postoperative period (p<0.001), but then increased again to 2.2+/-0.9 (p<0.001 vs postoperative value; p=0.838 vs preoperative value). Cox analysis confirmed that the progression of TR grade at follow-up is a risk factor for lower survival and possibility to be alive in NYHA class I-II. CONCLUSIONS Patients with untreated moderate-or-more FTR had survival and survival in NYHA class I-II lower than patients with untreated less-than-moderate FTR at 5-year follow-up.

Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.

OBJECTIVE This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. METHODS From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. RESULTS Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. CONCLUSIONS In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Echocardiographically based treatment of chronic ischemic mitral regurgitation

OBJECTIVES We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. METHODS From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm(2), and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. RESULTS Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm(2) to 2.3 ± 0.4 mm(2) (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm(2). Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P < .001), improving in 47, remaining unchanged in 63, and worsening in 7. CONCLUSIONS Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥ 10 mm(2) in 7.7% of cases, with no patients showing effective regurgitant orifice ≥ 20 mm(2)). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

Left ventricular surgical restoration for anteroseptal scars: Volume versus shape

OBJECTIVE We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target. METHODS From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V). RESULTS Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2). CONCLUSIONS When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest

OBJECTIVES To identify a safety threshold of deep hypothermic circulatory arrest (DHCA) duration; to determine which protection offers the best outcome and whether a 10-min period of cold perfusion (20°C) preceding rewarming can reduce neurological events (NE). METHODS From January 1988 to April 2009, 456 patients underwent aortic surgery using DHCA: for chronic disease in 239 and acute in 217. Cerebral protection was obtained by straight DHCA (sDHCA) in 69 cases, retrograde perfusion (RCP) in 198 and antegrade perfusion (ACP) in 189. In 247 subjects, a 10-min period of cold perfusion (20°C) preceded rewarming; in 209 rewarming was restarted without this preliminary. RESULTS Fifty-eight patients (13%) experienced NE. Twenty-two (5%) suffered temporary neurological dysfunction (TND) and 36 (8%) suffered stroke. DHCA duration >30 min was predictive for higher rate of NE (25.2% vs. 2.0%, P 0.001); after this value, only ACP was able to reduce incidence of NE (16.5% vs. 30.5%, P = 0.035). Cold reperfusion before rewarming significantly reduced incidence of NE (7.7% vs. 18.7%, P < 0.001) and extended the safe period to 40 min. Thirty-day mortality was 16.0%. Predictors of higher early mortality were acute aortic disease, longer DHCA, lack of ACP or prompt rewarming when DHCA >30 min and postoperative stroke. CONCLUSIONS sDHCA remains a safe and easy tool for cerebral protection when DHCA duration is expected to be less than 30 min. When aortic surgery requires a longer period, ACP should be instituted. Before rewarming, a 10-min period of cold perfusion significantly reduces incidence of NE.

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

BACKGROUND Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR. METHODS From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS<35 mmHg, N=224), mild-moderate (35≤sPAP<50 mmHg, N=159) and severe (sPAP≥50 mmHg, N=39). RESULTS Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild-moderate and severe PH (p=0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1-15.3, p=0.04) and New York Heart Association class III-IV (OR 14.9, 95% CI 1.8-117.8, p=0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6-4.9, p<0.0001), severe PH (HR 2.4, 95%CI 1.2-4.6 p=0.01), NHYA III-IV class (HR 2.3, 95% CI 1.3-4, p=0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6-3.1,p<0.0001) and age (HR 1.08, 95%CI 1.03-1.13, p=0.01). Five-year survival was 86%±3% with normal sPAP, 81%±4% with mild-moderate PH and 63±10% with severe PH (p<0.001). CONCLUSIONS In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival.

Mitral valve repair versus replacement in patients with ischaemic mitral regurgitation and depressed ejection fraction: risk factors for early and mid-term mortality †

OBJECTIVES Mitral valve (MV) surgery for ischaemic mitral regurgitation (IMR) in patients with depressed left ventricular ejection fraction (LVEF) is associated with poor outcomes. The optimal surgical strategy for IMR in these patients remains controversial. The objective of this study was to compare the early mortality and mid-term survival of MV repair versus MV replacement in patients with IMR and depressed LVEF undergoing coronary artery bypass grafting (CABG). METHODS A retrospective, observational, cohort study was undertaken of prospectively collected data on 126 consecutive CABG patients with IMR and LVEF <40% undergoing either MV repair (n = 98, 78%) or MV replacement (n = 28, 22%) between July 2002 and February 2011. RESULTS The overall mortality rate was 7.9% (n = 10). MV replacement was associated with a 4-fold increase in the risk of death compared with MV repair [17.9%, n = 5 vs 5.1%, n = 5; odds ratio (OR) 4.04, 95% confidence interval (CI) 1.08-15.1, P = 0.04]. However, after adjusting for preoperative risk factors, the type of surgical procedure was not an independent risk factor for early mortality (OR 0.1, 95% CI 0.01-31, P = 0.7). Multivariable analysis showed that preoperative LVEF (OR 0.8, 95% CI 0.6-0.9, P = 0.018), preoperative B-type natriuretic peptide (BNP) levels (OR 1.01, 95% CI 1-1.02, P = 0.025), preoperative left ventricle end-systolic diameter (OR 0.8, 95% CI 0.7-1.0, P = 0.05) and preoperative left atrial diameter (OR 1.3, 95% CI 1.0-1.6, P = 0.015) were independent risk factors of early mortality. At the median follow-up of 45 months (interquartile range 20-68 months), the mid-term survival rate was 74% in the MV repair group and 70% in the MV replacement group (P = 0.08). At follow-up, predictors of worse survival were BNP levels [hazard ratio (HR) 1.0, 95% CI 1.0-1.01, P = 0.047], preoperative renal failure (HR 4.6, 95% CI 1.1-20.3, P = 0.039) and preoperative atrial fibrillation (HR 3.3, 95% CI 1.1-10, P = 0.032). CONCLUSIONS MV repair in CABG patients with IMR and depressed LVEF is not superior to MV replacement with regard to operative early mortality and mid-term survival.

Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair

OBJECTIVE To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.

Routine versus selective coronary artery bypass for left main coronary artery revascularization: The appraise a customized strategy for left main revascularization (CUSTOMIZE) study

BACKGROUND Current guidelines recommend coronary artery bypass grafting (CABG) as the first choice of revascularization in patients with unprotected left main coronary artery (ULMCA) disease. We tested the hypothesis that a non guideline-driven approach to ULMCA revascularization which uses percutaneous coronary intervention (PCI) by default and CABG in selected patients may be as safe as the traditional guideline-driven approach. METHODS Between March 2002 and December 2008, PCI has been used as a default strategy for ULMCA revascularization in Center 1 (non guideline-driven [NGD] group), whereas CABG has been used as a default strategy in Center 2 (guideline-driven [GD] group). RESULTS A total of 838 patients with ULMCA disease were included. Of these 67.1% and 32.9% were treated in the NGD and GD groups, respectively. A significant higher risk of major adverse cardiac events (MACE) (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.10-2.33, p=0.014) and target vessel revascularization (HR 2.44, 95% CI 1.26-4.72, p=0.008) occurred at 24 months in the NGD group as compared with GD Group. Adjustment by means of propensity score did not result in substantial changes with regard to the subcomponent safety and efficacy endpoints. Conversely, the composite of MACE was no longer significant according to all types of statistical adjustment. CONCLUSIONS In a large registry of patients with ULMCA disease undergoing revascularization in current clinical practice, an approach based on PCI and the selective use of CABG gives results which are not inferior to those of a traditional approach guided by the current guidelines.

Mitral Valve Repair for Ischemic Mitral Regurgitation

Our aim was to evaluate midterm results in patients who underwent mitral valve repair (MVR) for ischermic mitral regurgitation (IMR) in our most recent experience. From March 2006 to March 2008, 105 patients underwent MVR for IMR. Mean IMR grade was 2.6 ± 1.1, with 46 patients having ≤2/4 and 59 ≥3/4. Five patients (4.8%) died within first month; Two-year freedom from death any cause was 85.5% ± 3.8, freedom from cardiac death was 88.7% ± 3.4. NYHA Class of the survivors was 1.3 ± 0.6, with 3 patients in NYHA Class III. Freedom from death any cause and NYHA Class III-IV was 78.6% ± 4.6. IMR grade decreased from 2.6 ± 1.1 to 0.1 ± 0.3 at the discharge and to 0.5 ± 0.3 after a mean of 7 ± 4 months, with no patient with IMR grade 3/4 or 4/4. MVR for IMR should be performed in patients with moderate-or-more IMR grade or when the MV is excessively dilated, to achieve good midterm results.