Hyun Song

Long-Term Mortality After Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Surgery for the Treatment of Multivessel Coronary Artery Disease

Background— Although previous studies have compared the treatment effects of percutaneous coronary intervention and coronary artery bypass grafting (CABG), the long-term outcomes beyond 1 year among patients with multivessel coronary artery disease who underwent percutaneous coronary intervention with drug-eluting stents (DES) or CABG have not been evaluated. Methods and Results— Between January 2003 and December 2005, 3042 patients with multivessel disease underwent coronary implantation of DES (n=1547) or CABG (n=1495). The primary end point was all-cause mortality. In a crude analysis, the rate of long-term mortality was significantly higher in patients who underwent CABG than in those who underwent DES implantation (3-year unadjusted mortality rate, 7.0% for CABG versus 4.4% for percutaneous coronary intervention; P=0.01). However, after adjustment for baseline differences, the overall risks of death were similar among all patients (hazard ratio, 0.85; 95% confidence interval [CI], 0.56 to 1.30; P=0.45), diabetic patients (hazard ratio, 1.76; 95% CI, 0.82 to 3.78; P=0.15), and patients with compromised ventricular function (hazard ratio, 1.39; 95% CI, 0.41 to 4.65; P=0.60). In the anatomic subgroups, mortality benefit with DES implantation was noted in patients with 2-vessel disease with involvement of the nonproximal left anterior descending artery (hazard ratio, 0.23; 95% CI, 0.01 to 0.78; P=0.016). The rate of revascularization was significantly higher in the DES than in the CABG group (hazard ratio, 2.81; 95% CI, 2.11 to 3.75; P<0.001). Conclusions— For the treatment of multivessel coronary artery disease, percutaneous coronary intervention with DES implantation showed equivalent long-term mortality as CABG.

Long-term outcome of modified maze procedure combined with mitral valve surgery: Analysis of outcomes according to type of mitral valve surgery

OBJECTIVE Efficacy of the maze procedure for atrial fibrillation associated with advanced mitral disease not amenable to repair has not been determined. This study investigated whether type of mitral surgery affects maze outcome. METHODS From January 1999 to January 2007, a total of 435 patients underwent the maze procedure and concomitant mitral operation. Of these, 226 underwent mitral repair and 209 underwent mitral replacement. RESULTS Median follow-up was 40.6 months (0.4-111.3 months), with 25 deaths and 6 strokes. Nineteen patients did not regain normal sinus rhythm. There were no significant intergroup differences in survival, stroke incidence, or sinus rhythm restoration rate. Among 427 early survivors, 64 had late atrial fibrillation recurrence. Five-year atrial fibrillation-free rates were 80.9% + or - 3.7% in the repair group and 77.3% + or - 4.1% in the replacement group (P = .099). By multivariate analysis, age at surgery older than 60 years (P = .045), fine atrial fibrillation wave pattern (P = .033), and preoperative left atrial dimension greater than 60 mm (P = .019) were independent risk factors for atrial fibrillation recurrence, whereas type of mitral surgery was not (P = .573). Although transmitral A-wave prevalence did not differ significantly between groups beyond the early postoperative period, A-wave velocity was faster in the repair group through the entire postoperative period (P < .001). CONCLUSIONS Maze outcomes were acceptable regardless of type of mitral surgery. Late atrial fibrillation recurrence was mainly affected by age, unfavorable electrocardiographic characteristics of atrial fibrillation, and larger preoperative left atrial size.

Long-Term Outcomes of Mechanical Valve Replacement in Patients with Atrial Fibrillation: Impact of the Maze Procedure

Background— The long-term benefits of the maze procedure in patients with chronic atrial fibrillation undergoing mechanical valve replacement who already require lifelong anticoagulation remain unclear. Methods and Results— We evaluated adverse outcomes (death; thromboembolic events; composite of death, heart failure, or valve-related complications) in 569 patients with atrial fibrillation–associated valvular heart disease who underwent mechanical valve replacement with (n=317) or without (n=252) a concomitant maze procedure between 1999 and 2010. After adjustment for differences in baseline risk profiles, patients who had undergone the maze procedure were at similar risks of death (hazard ratio, 1.15; 95% confidence interval, 0.65–2.03; P=0.63) and the composite outcomes (hazard ratio, 0.82; 95% confidence interval, 0.50–1.34; P=0.42) but a significantly lower risk of thromboembolic events (hazard ratio, 0.29; 95% confidence interval, 0.12–0.73; P=0.008) compared with those who underwent valve replacement alone at a median follow-up of 63.6 months (range, 0.2–149.9 months). The effect of superior event-free survival by the concomitant maze procedure was notable in a low-risk EuroSCORE (0–3) subgroup (P=0.049), but it was insignificant in a high-risk EuroSCORE (≥4) subgroup (P=0.65). Furthermore, the combination of the maze procedure resulted in superior left ventricular (P<0.001) and tricuspid valvular functions (P<0.001) compared with valve replacement alone on echocardiographic assessments performed at a median of 52.7 months (range, 6.0–146.8 months) after surgery. Conclusion— Compared with valve replacement alone, the addition of the maze procedure was associated with a reduction in thromboembolic complications and improvements in hemodynamic performance in patients undergoing mechanical valve replacement, particularly in those with low risk of surgery.

Long-term outcomes of percutaneous mitral balloon valvuloplasty versus open cardiac surgery.

OBJECTIVES We sought to compare long-term outcomes between percutaneous mitral valvuloplasty and open heart surgery. METHODS The study evaluated 402 patients who underwent percutaneous mitral valvuloplasty and 159 patients who underwent open heart surgery between January 1, 1995, and December 31, 2000. The rates of cardiovascular death or repeated intervention (redo percutaneous mitral valvuloplasty or open heart surgery) were determined over a median follow-up of 109 months (mean + or - SD, 106 + or - 27). The therapeutic effects on adverse outcomes were estimated by the Cox proportional hazards model adjusting differences in the severity of illness before intervention. The effects of the cardiac rhythm and echocardiographic score were also tested. RESULTS The observed (unadjusted) event-free survival was similar for both groups, and the hazard ratio for the clinical events after percutaneous mitral valvuloplasty as compared with after open heart surgery was 1.510 (95% confidence interval, 0.914-2.496; P = .1079). However, the adjusted hazard ratio was 3.729 (95% confidence interval, 1.963-7.082; P < .0001), showing a higher event-free survival in the open heart surgery group. The adjusted hazard ratio after percutaneous mitral valvuloplasty as compared with after open heart surgery in patients with echocardiographic scores of 8 or more and atrial fibrillation were 5.348 (95% confidence interval, 2.504-11.422; P < .001) and 3.440 (95% confidence interval, 1.805-6.555; P = .0002), respectively, whereas the hazard ratio in patients with echocardiographic scores less than 8 and normal sinus rhythm did not show differences. CONCLUSIONS Open heart surgery was associated with a higher adjusted rate of long-term event-free survival than percutaneous mitral valvuloplasty. Patients with high echocardiographic scores or atrial fibrillation showed better outcomes after open heart surgery.

Echocardiographic and Clinical Characteristics of Aortic Regurgitation Because of Systemic Vasculitis

BACKGROUND Although systemic vasculitis has been described as one cause of aortic regurgitation (AR), clinical features of this disease entity have not been fully characterized. METHODS The clinical data of 153 consecutive patients (103 male), who underwent open-heart operation to correct predominant AR from January 1990 to December 2000 were retrospectively analyzed. RESULTS A total of 16 patients (10%) were found to have AR associated with systemic vasculitis; there were 9 patients with Takayasus arteritis (TA) and 7 with Behçets disease (BD). All patients with TA, but only 3 with BD, were female (P <.05). Echocardiography showed redundant motion of the elongated aortic cusp with the frequent periaortic echo-free space in BD, and characteristic motion limitation of thickened cusp with dilated and thickened aorta in TA. All patients with TA, but only 1 patient with BD, were given a diagnosis before operation (P <.05); the others underwent emergency operation to control acute AR of unknown etiology, and were given a correct diagnosis after detection of paravalvular leakage. In TA, paravalvular leakage developed in 1 patient (11%) and another died suddenly with chest pain. In BD, paravalvular leakage developed in 6 patients (86%) who needed repeated operation, and 2 died even after the third operation. The 2-year survival without clinical events (paravalvular leakage, repeated operation, or death) was 76 +/- 15% in TA and 14 +/- 13% in BD (P <.05). CONCLUSIONS TA and BD are 2 important causes of AR, and show different clinical features. A high rate of paravalvular leakage, especially in BD, warrants cautious systemic evaluations for the cause of AR, and characteristic echocardiographic findings seem to be helpful in the differential diagnosis.

Analysis of Recurrent Mitral Regurgitation after Mitral Valve Repair

Mitral valve repair was performed in 437 patients with mitral regurgitation from January 1994 to January 2002. The causes of mitral regurgitation were degenerative in 238 (54%), rheumatic in 134 (31%), and others in 65 (15%). The most frequently employed surgical techniques were ring annuloplasty in 417 (95%) cases, new chordae formation in 216 (50%), and quadrangular resection in 117 (27%). The mean follow-up was 29.04 ± 22.81 months. There were 5 (1.2%) early and 5 (1.2%) late deaths. The reoperation rate was 1.6% with 41 (9%) cases of recurrent mitral regurgitation. Of these 22 were procedure-related: incomplete repair in 13, discordant new chordal length in 7, suture dehiscence and leaflet perforation in 1 case each. There were 19 cases of valve related failures: progression of rheumatic disease in 18 and subacute infective endocarditis in 1. Valve-related failure strongly correlated with progression of rheumatic disease. As initial operative success was the prime determinant of repair durability, intraoperative repair assessment with transesophageal echocardiography was essential.

Unilateral Antegrade Selective Cerebral Perfusion in Aortic Surgery: Clinical Outcomes at Different Levels of Hypothermia

Although unilateral antegrade selective cerebral perfusion (UASCP) is considered a safe cerebral protection strategy during aortic surgery, an optimum temperature remains to be defined. This study compared outcomes in patients undergoing UASCP at either <24℃ or ≥24℃. Between 2000 and 2007, 104 consecutive patients underwent aortic surgery using UASCP. Patients were divided into two groups according to systemic temperature: group A comprised 64 patients undergoing deep hypothermia (<24℃); and group B comprised 40 patients undergoing moderate hypothermia (≥24℃). Both groups were similar in terms of the extent of aortic replacement and mean UASCP time. The total cardiopulmonary bypass time and aortic cross clamp time were longer in group A. Both groups were similar in terms of 30-day mortality rate (9.4% group A, 10.0% group B), and in terms of temporary (6.7% group A, 7.7% group B) and permanent (11.3% group A, 2.6% group B) neurological deficits. Multivariate analysis showed preoperative shock status was a risk factor for in-hospital mortality, and a preoperative history of a cerebral incident was a risk factor for permanent neurological deficit. UASCP under moderate hypothermia is a relatively safe and effective cerebral protective strategy during aortic surgery.

Mid-term follow up of patients using the St. Jude Medical Aortic Connector System for proximal vein graft in CABG.

The aortic connector system may reduce stroke during proximal venous anastomosis. However, the overall anastomotic patency rate has been generally reported to be low. From October 2002 to March 2004, 68 patients who received proximal anastomosis using the St. Jude Aortic Connector System were included in the study. There were 47 men and 21 women and their mean age was 65.68±6.68 yr old (52 to 85 yr). Grafts were evaluated by coronary angiography or multi-slice 16 channel 3-D CT at 6 days and at 6 months postoperatively. In the immediate postoperative period, no stenosis was observed by either angiography (n=22) or 3D CT (n=46). At 6-month postoperatively, we performed either angiography (n=7) or 3-D CT (n=52). Of these patients, 5 patients showed graft stenosis in the midportion, and 3 in the ostium. There were no stroke. Simple, and effective proximal anastomosis with good protection from cerebrovascular accident was achieved especially when calcification or atheromatous plaque was observed at the ascending aorta in the operation room. However, our mid term patency results raise concerns related to venous graft stenosis in the midportion. Therefore, longer follow up is recommended.