Eric Charbonneau

Permanent pacemaker implantation following isolated aortic valve replacement in a large cohort of elderly patients with severe aortic stenosis

Objectives To assess the incidence of conduction disturbances leading to permanent pacemaker implantation (PPI) following isolated aortic valve replacement (AVR) in a large cohort of elderly patients with severe symptomatic aortic stenosis, and to determine the predictive factors and prognostic value of PPI following AVR in such patients. Methods A total of 780 consecutive elderly patients (age 77±4 years, logistic EuroSCORE 10.4±8.5%, STS score 3.5±1.5%) with severe aortic stenosis and no previous pacemaker were analysed. Main outcome measures The incidence, clinical indications, timing and predictive factors of PPI within 30u2005days after AVR and their prognostic value were evaluated. Results Baseline ECG showed the presence of conduction abnormalities in 37.1% of the patients. Twenty-five patients (3.2%) needed PPI during the index hospitalisation due to the occurrence of complete atrioventricular block (2.6%) or severe bradycardia (0.6%). The presence of preprocedural left bundle branch block (OR 4.65, 95% CI 1.62 to 13.36, p=0.004) or right bundle branch block (OR 4.21, 95% CI 1.47 to 12.03, p=0.007) predicted the need for PPI after AVR. The need for PPI was associated with a longer hospital stay (p<0.0001). Thirty-day mortality rates were similar between patients with and without PPI (4% vs 3.2%, p=0.56). Survival rate at 5-year follow-up was 75%, with no differences between patients with and without PPI (p=0.12). Conclusions The need for PPI following isolated AVR in elderly patients with severe symptomatic aortic stenosis was low. Pre-existing bundle branch block predicted the need for PPI. PPI determined a longer hospital stay, but had no effect on acute and long-term mortality.

Completeness of Revascularization and Survival Among Octogenarians With Triple-Vessel Disease

BACKGROUNDnWe sought to determine the impact of the completeness of surgical revascularization among octogenarians with triple-vessel disease.nnnMETHODSnBetween 1992 and 2008, 476 consecutive patients aged 80 years or more who underwent primary isolated coronary artery bypass grafting (CABG) procedures were identified. Early and late survival were compared among patients who underwent complete revascularization (CR, n=391) and incomplete revascularization (IR, n=85). IR was present when 1 or more of the 3 main coronary arteries with 50% or greater stenosis that were identified preoperatively as a surgical target by the operating surgeon were not grafted. The mean follow-up was 5.4±3.0 years (maximum 15.3 years).nnnRESULTSnBaseline risk was similar between the 2 groups of patients. IR was more frequent in off-pump compared with on-pump CABG (34.9% versus 16.2%, respectively; p=0.002). The most common reason for IR was small or severely diseased arteries (87%). The incidence of postoperative myocardial infarction (MI) was similar in both groups (CR, 18.4% versus IR, 17.3%; p=0.81). In-hospital mortality was 7.2% among patients with CR and 4.7% among patients with IR (p=0.60). Three, 5-, and 8-year freedom from all-cause mortality among patients who underwent CR were 89.2%, 74.1%, and 54.3%, respectively, and were not significantly different from those patients who underwent IR (86.6%, 74.5%, and 49.4%, respectively) (p=0.40).nnnCONCLUSIONSnIn octogenarians with triple-vessel disease, a strategy of incomplete revascularization during CABG does not negatively impact early or long-term survival.

Reversible Circumflex Coronary Artery Occlusion During Percutaneous Transvenous Mitral Annuloplasty With the Viacor System

![Figure][1] nnA 68-year-old woman with severe functional mitral regurgitation was referred for a percutaneous transvenous mitral annuloplasty (PTMA) procedure. Multislice computed tomography was performed with 3-dimensional reconstruction and color rendering (A) . Three rods were inserted

Fatal Late Migration of Viacor Percutaneous Transvenous Mitral Annuloplasty Device Resulting in Distal Coronary Venous Perforation

We present the case of a patient with dilated ischemic cardiomyopathy and severe mitral regurgitation. Due to several comorbidities, he underwent percutaneous transvenous mitral annuloplasty. Postoperatively, he complained of atypical chest pain. He was treated for pericarditis and died suddenly 10 days after the procedure. Autopsy showed distal perforation of the anterior interventricular vein with migration of the device on the diaphragm.

Impact of the Radial Artery as an Additional Arterial Conduit During In-Situ Bilateral Internal Mammary Artery Grafting: A Propensity Score-Matched Study

BACKGROUNDnBilateral internal mammary artery (BIMA) grafting has been associated with improved long-term outcomes after CABG. We sought to evaluate the early results and long-term survival among coronary artery bypass graft patients who underwent in-situ BIMA grafting with the radial artery (RA) as an additional arterial conduit compared with those who underwent BIMA with additional saphenous vein graft (SVG).nnnMETHODSnBetween 1991 and 2013, 1,750 consecutive patients with triple-vessel disease or left main plus right coronary system disease underwent primary isolated in-situ BIMA grafting with at least one internal mammary artery to the left anterior descending artery. Patients were divided into a BIMA-RA group (n = 255) and BIMA-SVG group (n = 1,495). Propensity score matching was used to create two comparable cohorts: 249 BIMA-RA patients were one-to-one-matched to 249 BIMA-SVG patients. The date of death was obtained from provincial vital statistics. The median follow-up was 8 years.nnnRESULTSnThere was no difference in operative mortality between matched BIMA-RA and BIMA-SVG (0.8% versus 0.4%, respectively; p = 0.6). Five-year, 10-year, and 15-year survival rates were 98.3%, 92.0%, and 92.0%, respectively, among BIMA-RA patients, versus 96.5%, 93.0%, and 87.0% in the matched BIMA-SVG group (log rank p = 0.44). When we stratified the BIMA-RA patients into subgroups according to the severity of target artery stenosis, late survival was also similar among the BIMA-RA subgroups matched to BIMA-SVG patients (log rank p = 0.12).nnnCONCLUSIONSnThe use of the RA as an additional arterial graft in patients undergoing coronary artery bypass graft surgery with in-situ BIMA does not prolong late survival when compared with BIMA patients who received additional SVG.

Lessons learned from the use of 1,977 in-situ bilateral internal mammary arteries: a retrospective study

BackgroundWe sought to determine the early and long-term results of in-situ bilateral internal mammary artery (BIMA) grafting in patients undergoing coronary artery bypass graft surgery (CABG).MethodsBetween 1992 and 2011, 16,364 patients underwent primary isolated CABG involving at least one in-situ IMA at our institution. Among these, 1,977 patients underwent in-situ BIMA grafting: the right IMA was used to revascularize the right coronary artery system in 1,279, the circumflex system in 454 patients, and the left anterior descending (LAD) in 244. Logistic and Cox regression analyses were used to predict in-hospital mortality and cumulative late death.ResultsLate survival among BIMA patients was negatively and independently influenced by chronic obstructive pulmonary disease (hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.6-3.4, p = 0.0005), age (HR 1.2, 95% CI 1.1-1.3, p < 0.001), and mediastinitis (HR 2.1, 95% CI 1.1-4.2, p < 0.03). Gender, body mass index, diabetes, choice of target for the second (non-LAD) IMA, and conduit grafted to the LAD (RIMA vs. LIMA) did not influence late survival among BIMA patients. A BIMA grafting strategy was significantly beneficial for younger patients. However, it was not associated with superior late survival for patients aged 66 years and above at the time of CABG, and showed a trend to harm among octogenarians (HR 1.05, 95% CI 0.70-1.56, p = 0.80).ConclusionsFemale gender, non-insulin dependent diabetes, and the site of second IMA anastomosis did not influence early and long-term outcomes in patients undergoing CABG with in-situ BIMA grafting. The right and left IMAs are equally effective conduits for the LAD. However, advanced age, chronic obstructive pulmonary disease, and insulin-treated diabetes mellitus have a negative impact on late survival among patients with BIMA grafts.

Severe Upper Gastrointestinal Bleeding in Heartmate II Induced by Acquired von Willebrand Deficiency: Anticoagulation Management

Patients treated with continuous flow assist devices may have increased bleeding tendencies due to an induced high molecular weight von Willebrand factor (VWF) multimer deficiency. We report a patient supported with a HeartMate II (Thoratec, Pleasanton, CA) who developed severe gastrointestinal bleeding refractory to conventional therapy and needing a total of 60 transfusions. After documenting the lack of large VWF multimers, suggestive of a defective platelet function, the patient was switched from aspirin to warfarin therapy (target international normalized ratio between 1.5 and 2.0). Three days after changing the anticoagulant regimen, the patient stopped bleeding and required no further transfusion.

Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit?

OBJECTIVESnThe use of bilateral internal thoracic arteries (BITA) has been associated with improved long-term outcomes following coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the impact of BITA use on long-term survival among patients with low ejection fraction (EF) undergoing CABG.nnnMETHODSnBetween April 1991 and October 2011, 2035 consecutive patients underwent primary BITA grafting. Among them, there were 129 patients with left ventricular EF ≤40%. During the same time period, 1666 primary CABGs were performed using a single internal thoracic artery (SITA) in patients with EF ≤40%. A propensity score optimal matching algorithm was used to create the matched SITA and BITA groups (n = 111 in each group). Also, Cox regression multivariable analyses were performed to determine the independent risk factors for long-term mortality. The date of death was obtained from provincial vital statistics.nnnRESULTSnThere was no difference in operative mortality between matched BITA and SITA (n = 2, 1.8% vs n = 1, 0.9%, respectively, P = 0.6) groups. The mean follow-up was 8.6 ± 5.1 and 7.7 ± 5.5 years for BITA and SITA groups, respectively (P = 0.2). Five-, 10- and 15-year survival rates were 93.7, 77.5 and 59.0% in the matched BITA patients vs 82.8, 68.1 and 65.2% in the matched SITA patients (P = 0.3). In multivariate analysis, the independent risk factors for late mortality among hospital survivors were: insulin-dependent diabetes [adjusted hazard ratio (HR): 3.4, 95% confidence interval (CI): 1.4-8.4, P = 0.008], perioperative intra-aortic balloon pump insertion (HR: 3.2, 95% CI: 1.5-6.9, P = 0.004), postoperative deep sternal wound infection (HR: 7.4, 95% CI: 2.2-24.1, P = 0.001) and neurological complications (HR: 3.5, 95% CI: 1.4-8.4, P = 0.006). Choice of BITA versus SITA was not an independent predictor of long-term mortality (P = 0.3).nnnCONCLUSIONSnThe use of a second internal thoracic artery (ITA) does not prolong late survival in patients with low EF undergoing CABG compared with a propensity-matched group of SITA graft patients.

Risk factors of mortality after surgical correction of ventricular septal defect following myocardial infarction: Retrospective analysis and review of the literature

BACKGROUNDnRupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition.nnnMETHODSnWe review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. A retrospective study was performed on 34 consecutive patients who had undergone surgical repair for VSDs following AMI from December 1991 to July 2014. Preoperative, clinical and echocardiographic variables were studied by uni-and multivariate analyses.nnnRESULTSnMortality was analyzed for the entire group of patients. Mean age was 69 ± 7 years with 44% women. VSDs were anterior in 11 (32%) and posterior in 23 (68%) patients. A majority, 24 (71%) patients were in cardiogenic shock. Median interval from myocardial infarction to VSDs repair was 7 days. The 30 days operative mortality was 65%. Mortality within the posterior VSDs group was 74% and the anterior VSDs group was 46% (P=0.14). Concomitant coronary artery bypass graft (CABG) did not influence early or late survival. Multivariate analysis identified older age (HR=1.11, P=0.0001) and shorter time between AMI and surgery (HR=0.90, P=0.015) as independent predictors of 30-day and long-term mortality.nnnCONCLUSIONnIn conclusion, surgical repair of post-AMI VSDs carries a high operative mortality. An algorithm of treatment for the management of these patients is suggested.

Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation

BackgroundStudies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).MethodsUsing our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1–3xa0days) and late (1xa0year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments.ResultsFrom January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic timeu2009>u2009540xa0min (OR: 2.92 [95% CI, 1.28 – 7.05]; pu2009=u20090.01), and female gender (OR: 3.06 [95% CI, 1.42 – 6.89]; pu2009=u20090.004). At a median follow-up of 366xa0days [34–582xa0days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (changeu2009≥u20091 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 – 5.53]; pu2009=u20090.04).ConclusionsAfter primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.