Francis Wellens

The effect of completeness of revascularization on event-free survival at one year in the arts trial ☆

OBJECTIVES We sought to assess the relationship between completeness of revascularization and adverse events at one year in the ARTS (Arterial Revascularization Therapies Study) trial. BACKGROUND There is uncertainty to what extent degree of completeness of revascularization, using up-to-date techniques, influences medium-term outcome. METHODS After consensus between surgeon and cardiologist regarding the potential for equivalence in the completeness of revascularization, 1,205 patients with multivessel disease were randomly assigned to either bypass surgery or stent implantation. All baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization. RESULTS Of 1,205 patients randomized, 1,172 underwent the assigned treatment. Complete data for review were available in 1,143 patients (97.5%). Complete revascularization was achieved in 84.1% of the surgically treated patients and 70.5% of the angioplasty patients (p < 0.001). After one year, the stented angioplasty patients with incomplete revascularization showed a significantly lower event-free survival than stented patients with complete revascularization (i.e., freedom from death, myocardial infarction, cerebrovascular accident and repeat revascularization) (69.4% vs. 76.6%; p < 0.05). This difference was due to a higher incidence of subsequent bypass procedures (10.0% vs. 2.0%; p < 0.05). Conversely, at one year, bypass surgery patients with incomplete revascularization showed only a marginally lower event-free survival rate than those with complete revascularization (87.8% vs. 89.9%). CONCLUSIONS Complete revascularization was more frequently accomplished by bypass surgery than by stent implantation. One year after bypass, there was no significant difference in event-free survival between surgically treated patients with complete revascularization and those with incomplete revascularization, but patients randomized to stenting with incomplete revascularization had a greater need for subsequent bypass surgery.

Mitral valve surgery can now routinely be performed endoscopically.

Background—There is an increasing interest in minimally invasive cardiac surgery. Methods and Results—Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5±12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6±17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91±3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. Conclusions—Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

Myocardial Gene Expression in Heart Failure Patients Treated With Cardiac Resynchronization Therapy: Responders Versus Nonresponders

OBJECTIVES We studied whether functional improvement after cardiac resynchronization therapy (CRT) is associated with reversal of the heart failure (HF) gene program. BACKGROUND Cardiac resynchronization therapy improves exercise tolerance and survival in patients with advanced congestive HF and dyssynchrony. METHODS Twenty-four patients referred for CRT underwent left ventricular (LV) endomyocardial biopsies immediately before CRT implantation (baseline). In addition, 17 of them underwent LV endomyocardial biopsy procurement 4 months later (follow-up). In 6 control patients with normal LV function, LV biopsies were obtained at the time of coronary artery bypass grafting. The LV messenger ribonucleic acid (mRNA) levels of contractile and calcium regulatory genes were measured by quantitative real time polymerase chain reaction and normalized for glyceraldehyde 3-phosphate dehydrogenase (GAPDH). The HF patients showing an improvement in New York Heart Association (NYHA) functional class by >1 score and a relative increase in LV ejection fraction > or =25% at 4 months after CRT were considered as responders. RESULTS The HF patients were characterized by lower LV mRNA levels of alpha-myosin heavy chain (alpha-MHC), beta-myosin heavy chain (beta-MHC), sarcoplasmic reticulum calcium ATPase 2alpha (SERCA), phospholamban (PLN), and higher brain natriuretic peptide (BNP) mRNA levels as compared with control subjects. Responders to CRT (n = 11) showed an increase in LVEF (p < 0.001), a decrease in left ventricular end-diastolic diameter (p = 0.003), and NYHA functional class (p = 0.002), and a reduction in N-terminal proBNP levels (p = 0.032) as compared with baseline. This was associated with an increase in mRNA levels of alpha-MHC (p = 0.035), SERCA (p = 0.032), a decrease in BNP mRNA levels (p = 0.002), and an increase in the ratio of alpha-/beta-MHC (p = 0.018) and SERCA/PLN (p = 0.012). No significant changes in molecular profile were observed in nonresponders. CONCLUSIONS In HF patients with electromechanical cardiac dyssynchrony, functional improvement related to CRT is associated with favorable changes in established molecular markers of HF, including genes that regulate contractile function and pathologic hypertrophy.

Tricuspid valve replacement: Postoperative and long-term results ☆ ☆☆ ★

A series of 146 consecutive patients who underwent tricuspid valve replacement at the University Brugmann Hospital between 1967 and 1987 was reviewed. Mean age at operation was 51.4 years (+/- 12.1 years). Different types of prostheses were implanted including porcine and bovine pericardial bioprostheses and older and bileaflet mechanical valves. Most patients were severely disabled by their cardiac disease before operation, with 30.1% in New York Heart Association functional class III and 69.9% in class IV. Operative mortality and hospital mortality rates (30 days) were high (16.4%). Incremental risk factors for hospital death included icterus (p < 0.005), preoperative hepatomegaly (p = 0.012), and New York Heart Association functional class IV (p = 0.013). Multivariate analysis only selected preoperative icterus (p < 0.01) as being independently significantly related to hospital mortality. The hospital survivors were followed up for a median of 94 months. A complete follow-up was available for all patients except two for 30 months or more. At 30 months the only two significant parameters were the type of myocardial protection (p = 0.024) and the year of operation (before 1977 or after [precardioplegia era or after], p = 0.011). There were 70 late deaths during the entire follow-up period. The univariate (log-rank statistics) incremental risk factor for late death was the type of tricuspid prosthesis (Smeloff-Cutter and Kay-Shiley versus St. Jude Medical versus bioprosthesis) (p = 0.04). A trend was observed for the type of operative myocardial protection (normothermia and coronary perfusion) (p = 0.06) and preoperative New York Heart Association functional class IV (p = 0.055). Actuarial survival was 74% at 60 months and 23.4% at 180 months. Cumulative follow-up added up to 1015 patient-years. In a more detailed analysis of the effect on survival of the type of tricuspid prosthesis, a significant difference was observed between the bioprostheses and some older mechanical prostheses (Smeloff-Cutter and Kay-Shiley) (p = 0.04) but not between the bioprostheses and the bileaflet valves (p = 0.15). When the follow-up period was stratified according to less than 7 years and more than 7 years of follow-up, no difference was observed for the first period, but for the late follow-up the new mechanical prostheses did better than the bioprostheses (p = 0.05), suggesting a degradation of the bioprostheses after 7 years and favoring mechanical prostheses for those patients with a good long-term prognosis.

Deficient acceleration of left ventricular relaxation during exercise after heart transplantation.

BackgroundThe exercise-induced rise in left ventricular filling pressures after cardiac transplantation is considered to be the result of a blunted heart rate response, of elevated venous return, and of unfavorable passive late-diastolic properties of the cardiac allograft. In contrast to passive late-diastolic left ventricular properties, the effect of left ventricular relaxation on the exercise-induced rise in left ventricular filling pressures of the cardiac allograft has not yet been studied. In the present study, the response of left ventricular relaxation to exercise was investigated in transplant recipients and compared with left ventricular relaxation observed in normal control subjects exercised to the same heart rate. Moreover, the response of left ventricular relaxation of the cardiac allograft to β-adrenoreceptor stimulation, to reduced left ventricular afterload, and to increased myocardial activator calcium was investigated by infusion of dobutamine and of nitroprusside and by postextrasystolic potentiation Methods and ResultsTwenty-seven transplant recipients were studied 1 year (n = 17), 2 years (n = 7), 3 years (n =2), and 4 years (n = 1) after transplantation. All patients were free of rejection and of significant graft atherosclerosis at the time of study. Tip-micromanometer left ventricular pressure recordings and cardiac hemodynamics were obtained at rest, during supine bicycle exercise stress testing (n = 27), during dobutamine infusion at a heart rate matching the heart rate at peak exercise (n = 8), during nitroprusside infusion (n = 9), and after postextrasystolic potentiation (n = 10). Tip-micromanometer left ventricular pressure recordings were also obtained in a normal control group (n = 9) at rest and during supine bicycle exercise stress testing to a heart rate, which matched the heart rate of the transplant recipient group at peak exercise. Left ventricular relaxation rate was measured by calculation of a time constant of left ventricular pressure decay (T) derived from an exponential curve fit to the digitized tip-micromanometer left ventricular pressure signal. In the transplant recipients, exercise abbreviated T from 43±6 to 40±8 msec (p < 0.01) and caused a rise of left ventricular minimum diastolic pressure (LVMDP) from 5±2 to 9±6 mm Hg (p < 0.001). In normal control subjects, exercise induced a 2.5 times larger abbreviation of T (from 42±7 to 34±6 msec;p < 0.001) and a small drop in LVMDP from 5±2 to 4±3 mm Hg (p < 0.05). In the transplant recipients, the change in T (ΔT) from rest to exercise was variable ranging from an abbreviation, as observed in normal controls, to a prolongation and was significantly correlated with the change in RR interval (ARR) and the change in left ventricular end-diastolic pressure (ΔLVEDP) (ΔT=0.068ΔRR+0.58ΔLVEDP-2.2; r = 0.76; p < 0.001). In a first subset of transplant recipients (n = 8), dobutamine infusion resulted in a heart rate equal to the heart rate at peak exercise, a left ventricular end-diastolic pressure (8±7 mm Hg) lower than at peak exercise (22±6 mm Hg; p < 0.05) and a T value (32±9 msec), which was shorter than both resting value (44±5 msec;p < 0.005) and value observed at peak exercise (40±8 msec; p < 0.01). In a second subset of transplant recipients (n = 9), nitroprusside infusion and postextrasystolic potentiation resulted in a significant prolongation of T from 41±7 to 56±10 msec (p < 0.05) and a characteristic negative dP/dt upstroke pattern with downward convexity as previously observed in left ventricular hypertrophy ConclusionsExercise after cardiac transplantation resulted in a smaller acceleration of left ventricular relaxation than in a normal control group exercised to the same heart rate. These transplant recipients, who made the largest use of left ventricular preload reserve during exercise, showed least acceleration of left ventricular relaxation. This association between a rise of left ventricular end-diastolic pressure and slower left ventricular isovolumic relaxation was also evident in the individual transplant recipient from the slower isovolumic relaxation during exercise than during dobutamine infusion despite equal heart rates. After postextrasystolic potentiation during nitroprusside infusion, a slow left ventricular relaxation with downward convexity of the dP/dt signal was observed in the cardiac allograft. This finding suggests depressed function of the sarcoplasmic reticulum in left ventricular myocardium after transplantation, which could be related either to decreased adrenergic tone or to foregoing ischemic injury during organ retrieval or to hypertrophy caused by cyclosporine induced arterial hypertension.

Endoscopic Mitral and Tricuspid Valve Surgery After Previous Cardiac Surgery

Background— The purpose of this study was to evaluate the feasibility and effectiveness of a right video-assisted approach for atrioventricular valve disease after previous cardiac surgery. Methods and Results— Between December 1st 1997 and May 1st 2006, 80 adults (mean age 65±12 years; 56% female) underwent reoperative surgery using a video-assisted approach without rib spreading. Previous cardiac operations included mitral valve (39%), CABG (29%), congenital (10%), and other (23%). For 25% of patients, this was at least their third cardiac operation. Mean time to redo surgery was 15±12 years. Femoral vessel cannulation and endoaortic clamping were routinely used. Mean preoperative Euroscore was 9.0±2.7 (5 to 20) and predicted mortality was 16.0±14.2% (4 to 86). Median preoperative NYHA class was II and mean follow-up was 25±22 months. Lung adhesions necessitated sternotomy in 4 cases and cannulation problems in another patient. Total operative mortality was 3.8% (n=3), O/E for mortality being 0.24. Procedures were mitral valve repair (45%; n=36), replacement (50%; n=40) and tricuspid valve replacement (5%; n=4). Additional procedures were performed in 44% (n=35). Mean aortic crossclamp and procedure time were 92±37 and 267±64 minutes. Mean postoperative blood loss was 815±1083 mL. Postoperative morbidity included 2 strokes (2.5%). Mean hospital stay was 10.7±6.7 days. Survival at 1 and 4 years was 93.6±2.8% and 85.6±6.4%. There was 1 late reoperation at 5 years. Median NYHA class at follow-up was II. When comparing, all but 1 patient (98.8%) preferred their minimally invasive approach when considering perioperative pain, postoperative rehabilitation, and final esthetic result. Conclusions— Video-assisted minimal access correction of atrioventricular valve disease after previous cardiac surgery is not only feasible but had lower than predicted mortality and strong patient satisfaction. It should therefore be used more frequently in today’s practice.

Implantable Cardioverter-Defibrillator Therapy in Brugada Syndrome: A 20-Year Single-Center Experience

BACKGROUND Patients with Brugada syndrome and aborted sudden cardiac death or syncope have higher risks for ventricular arrhythmias (VAs) and should undergo implantable cardioverter-defibrillator (ICD) placement. Device-based management of asymptomatic patients is controversial. ICD therapy is associated with high rates of inappropriate shocks and device-related complications. OBJECTIVES The objective of this study was to investigate clinical features, management, and long-term follow-up of ICD therapy in patients with Brugada syndrome. METHODS Patients presenting with spontaneous or drug-induced Brugada type 1 electrocardiographic findings, who underwent ICD implantation and continuous follow-up at a single institution, were eligible for this study. RESULTS A total of 176 consecutive patients were included. During a mean follow-up period of 83.8 ± 57.3 months, spontaneous sustained VAs occurred in 30 patients (17%). Eight patients (4.5%) died. Appropriate ICD shocks occurred in 28 patients (15.9%), and 33 patients (18.7%) had inappropriate shocks. Electrical storm occurred in 4 subjects (2.3%). Twenty-eight patients (15.9%) experienced device-related complications. In multivariate Cox regression analysis, aborted sudden cardiac death and VA inducibility on electrophysiologic studies were independent predictors of appropriate shock occurrence. CONCLUSIONS ICD therapy was an effective strategy in Brugada syndrome, treating potentially lethal arrhythmias in 17% of patients during long-term follow-up. Appropriate shocks were significantly associated with the presence of aborted sudden cardiac death but also occurred in 13% of asymptomatic patients. Risk stratification by electrophysiologic study may identify asymptomatic patients at risk for arrhythmic events and could be helpful in investigating syncope not related to VAs. ICD placement is frequently associated with device-related complications, and rates of inappropriate shocks remain high regardless of careful device programming.

Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery

OBJECTIVE The surgical treatment of poststernotomy acute mediastinitis remains challenging. After disappointing results with a conservative management of post coronary artery bypass grafting (CABG) mediastinitis, we shifted towards a more aggressive surgical management. METHODS From March 1993 until December 1999, 32 patients (6 female/26 male), 0.5% of the total sternotomy population, were operated for mediastinitis, defined as wound and sternal dehiscence with medistinal pus and positive culture. Mean age was 66 years (32-79 years). Twenty-two patients (75%) underwent CABG and 16 patients were in New York Heart Association (NYHA) class III/IV. RESULTS We performed an omentoplasty in 11 patients, a pectoralis muscle flap associated with an omentoplasty in 20 patients. One patient had a bilateral pectoralis myoplasty. The reconstruction surgery occurred at an average of 11 days (6-26) after primary surgery. Twelve patients had a previous surgical drainage (1-3 surgical procedures) of the mediastinum. Hospital mortality was nine patients (28%). Seven of these patients (77%) were in NYHA IV with inotropic support. Five patients had to be reoperated on: four patients had a bilateral myoplasty after omentoplasty, one patient had an omentoplasty after a unilateral myoplasty. Late epigastric hernia was seen in three patients, two patients had wound revision and one had a retroperitoneal drainage for pancreatitis. There were no early or late flap failures. CONCLUSION In our experience, omental and pectoralis flaps for poststernotomy acute mediastinitis provides good outcome of our stable patients. We would be reluctant to use it as standard therapy in our unstable patients.

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience

BACKGROUND Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.

Hypertrophic Cardiomyopathy: Role of the Implantable Cardioverter-Defibrillator

OBJECTIVES We report the occurrence of cardiac events during long-term follow-up in patients with hypertrophic cardiomyopathy (HCM) after cardioverter-defibrillator implantation. BACKGROUND The identification of patients at high risk for sudden death and the prevention of recurrence of sudden death in HCM represents a difficult problem. METHODS We retrospectively analyzed the occurrence of cardiac events during follow-up of 13 patients with HCM who received an implantable cardioverter-defibrillator (ICD) because of aborted sudden death (n = 10) or sustained ventricular tachycardia (n = 3) (group I). Findings were compared with those in 215 patients with an ICD and other structural heart disease or idiopathic ventricular fibrillation (group II). RESULTS After a mean (+/-SD) follow-up period of 26+/-18 months, 2 of 13 patients in group I received appropriate shocks. The calculated cumulative incidence of shocks was 21% in group I and 66% in group II after 40 months (p < 0.05). We observed a low incidence of recurrence of ventricular tachycardia/fibrillation during follow-up in patients with HCM. No deaths occurred. CONCLUSIONS Our data suggest that ventricular tachyarrhythmias may not always be the primary mechanism of syncope and sudden death in patients with HCM. The ICD seems to have a less important impact on prognosis in patients with HCM than in patients with other etiologies of aborted sudden death.