Joanna Chikwe

A propensity score-adjusted retrospective comparison of early and mid-term results of mitral valve repair versus replacement in octogenarians

AIMS Feasibility and efficacy of mitral repair in the elderly remain controversial. This study aims to compare outcomes of mitral repair and replacement in octogenarians. METHODS AND RESULTS We compared the outcomes of 322 consecutive octogenarian patients (mean age 82.6 ± 2.2 years) who underwent mitral repair (n = 227, 70%) or replacement (n = 95, 30%) at Mount Sinai Medical Center and Leipzig Herzzentrum between 1998 and 2008 using propensity score adjustment and univariate and multivariate analyses. Patients undergoing aortic valve replacement were excluded. Coronary bypass was performed in 47.5% (n = 153), and 31.1% (n = 100) required tricuspid repair. Propensity score adjustment yielded comparable groups. Thirty-day mortality in patients undergoing primary elective mitral repair for degenerative disease was 5.1% (2/39). Overall 90-day mortality was 18.9% (43/227) for repair compared with 31.6% (30/95) for replacement (P = 0.014). Pre-discharge echocardiography revealed less than moderate residual regurgitation in 99% of patients (231/232). Adjusted 1-, 3-, and 5-year survival for patients undergoing mitral repair was 71 ± 3, 61 ± 4, and 59 ± 4%, respectively, compared with 56 ± 5, 50 ± 6, and 45 ± 6% for patients undergoing mitral replacement (P = 0.046). Multivariate analysis demonstrated emergency surgery, previous myocardial infarction, concomitant coronary artery bypass surgery, and mitral replacement to be strong independent predictors of early mortality; mitral valve replacement was an independent predictor of reduced survival in degenerative patients. CONCLUSION Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.

Survival and Long-term Outcomes Following Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients Aged 50 to 69 Years

IMPORTANCE The choice between bioprosthetic and mechanical aortic valve replacement in younger patients is controversial because long-term survival and major morbidity are poorly characterized. OBJECTIVE To quantify survival and major morbidity in patients aged 50 to 69 years undergoing aortic valve replacement. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of 4253 patients aged 50 to 69 years who underwent primary isolated aortic valve replacement using bioprosthetic vs mechanical valves in New York State from 1997 through 2004, identified using the Statewide Planning and Research Cooperative System. Median follow-up time was 10.8 years (range, 0 to 16.9 years); the last follow-up date for mortality was November 30, 2013. Propensity matching yielded 1001 patient pairs. MAIN OUTCOMES AND MEASURES Primary outcome was all-cause mortality; secondary outcomes were stroke, reoperation, and major bleeding. RESULTS No differences in survival or stroke rates were observed in patients with bioprosthetic compared with mechanical valves. Actuarial 15-year survival was 60.6% (95% CI, 56.3%-64.9%) in the bioprosthesis group compared with 62.1% (95% CI, 58.2%-66.0%) in the mechanical prosthesis group (hazard ratio, 0.97 [95% CI, 0.83-1.14]). The 15-year cumulative incidence of stroke was 7.7% (95% CI, 5.7%-9.7%) in the bioprosthesis group and 8.6% (95% CI, 6.2%-11.0%) in the mechanical prosthesis group (hazard ratio, 1.04 [95% CI, 0.75-1.43). The 15-year cumulative incidence of reoperation was higher in the bioprosthesis group (12.1% [95% CI, 8.8%-15.4%] vs 6.9% [95% CI, 4.2%-9.6%]; hazard ratio, 0.52 [95% CI, 0.36-0.75]). The 15-year cumulative incidence of major bleeding was higher in the mechanical prosthesis group (13.0% [95% CI, 9.9%-16.1%] vs 6.6% [95% CI, 4.8%-8.4%]; hazard ratio, 1.75 [95% CI, 1.27-2.43]). The 30-day mortality rate was 18.7% after stroke, 9.0% after reoperation, and 13.2% after major bleeding. CONCLUSIONS AND RELEVANCE Among propensity-matched patients aged 50 to 69 years who underwent aortic valve replacement with bioprosthetic compared with mechanical valves, there was no significant difference in 15-year survival or stroke. Patients in the bioprosthetic valve group had a greater likelihood of reoperation but a lower likelihood of major bleeding. These findings suggest that bioprosthetic valves may be a reasonable choice in patients aged 50 to 69 years.

Excellent Early and Late Outcomes of Aortic Valve Replacement in People Aged 80 and Older

OBJECTIVES: To investigate early and late outcome of aortic valve replacement (AVR) in a large cohort of patients aged 80 and older.

Predictors and Early and Late Outcomes of Respiratory Failure in Contemporary Cardiac Surgery

BACKGROUND Respiratory failure (RF) is a serious complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, making prior investigations of RF after cardiac surgery less relevant to the current population. This study was designed to analyze the incidence, predictors of RF, and early and late outcomes following this complication in a large contemporary cardiac surgery population. METHODS We retrospectively analyzed prospectively collected data from the New York State Department of Health database including 5,798 patients undergoing cardiac surgery between January 1998 and December 2005. Patients with RF (intubation time > or = 72 h) were compared to patients without RF. RESULTS The incidence of RF was 9.1% (n = 529). The highest incidence of RF was observed following combined valve/coronary artery bypass graft (14.8%) and aortic procedures (13.5%). Multivariate analysis revealed preoperative and operative predictors of RF such as renal failure (odds ratio [OR], 2.3), aortic procedures (OR, 2.6), hemodynamic instability (OR, 3.2), and intraaortic balloon pump (OR, 2.6). The mortality rate following RF was 15.5% (n = 82), compared to 2.4% (n = 126) in the no-RF group (p < 0.001). Kaplan-Meier survival curves showed significantly poorer survival among RF patients (p < 0.001) compared to the no-RF group. CONCLUSION RF remains a serious and common complication following cardiac surgery, particularly in patients undergoing complex procedures. RF is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival. Future research efforts should focus on a more precise identification of patients at risk and the development of new treatment modalities that would potentially prevent the occurrence of this complication.

Bilateral internal mammary artery grafts, mortality and morbidity: an analysis of 1 526 360 coronary bypass operations

Objectives The objective of this study was to investigate the impact of bilateral internal mammary artery (BIMA) on early outcomes after coronary artery bypass grafting. Design Retrospective database analysis. Setting US hospitals. Patients 1 526 360 patients (mean age 65 years, 73% male) from the Nationwide Inpatient Sample from 2002–2008 who underwent isolated coronary artery bypass grafting with at least one internal mammary artery. Interventions Single versus BIMA bypass grafting. Main outcome measures Inhospital mortality, deep sternal wound infection (DSWI). Results The rate of BIMA use was 3.9%. Use of BIMA was independently associated with slightly lower inhospital mortality (unadjusted rate 1.1% vs 1.7%, adjusted OR 0.86, 95% CI 0.79 to 0.93). The DSWI rate was 1.4%. The independent predictors of DSWI were female gender (OR 1.06), congestive heart failure (OR 6.22), chronic pulmonary disease (OR 1.57), obesity (OR 1.17), diabetes mellitus (OR 1.04; OR 1.51 with chronic complication) and chronic renal failure (OR 2.13; OR 2.63 with dialysis). The use of BIMA was not an independent predictor of DSWI (OR 1.03, 95% CI 0.96 to 1.10). BIMA was associated with higher incidence of DSWI in patients with chronic complications of diabetes mellitus (OR 1.90, 95% CI 1.51 to 2.41). Conclusions BIMA grafting is associated with increased risk of DSWI only in patients with severe, chronic diabetes. The incremental morbidity and mortality of DSWI does not justify denial of BIMA in the majority of patients.

Can three-dimensional echocardiography accurately predict complexity of mitral valve repair?

OBJECTIVE Feasibility of mitral repair is a key factor in the decision to operate for mitral regurgitation. Repair feasibility is highly dependent on surgical experience and repair complexity. We sought an objective means of predicting complexity of repair using three-dimensional (3D) transoesophageal echocardiography. METHODS In a cohort of 786 patients who underwent mitral valve surgery between 2007 and 2010, 3D transoesophageal echocardiography was performed in 66 patients with mitral regurgitation prior to the institution of cardiopulmonary bypass. The surgeon reviewed the 2D echocardiographic images for all patients pre-operatively, but did not view the 3D echocardiographic quantitative data or volumetric analysis until after surgery. Repairs involving no or a single-segment leaflet resection, sliding-plasty, cleft closure, chordal or commissural repair techniques were classed as standard repairs. Complex repairs were defined as those involving bileaflet repair techniques, requiring multiple resections or patch augmentation. Disease aetiology included Barlows disease (n = 18), fibroelastic deficiency (n = 22), ischaemic (n = 5), endocarditis (n = 5), rheumatic (n = 2) and dilated cardiomyopathy (n = 2). RESULTS No patient required mitral replacement or had more than mild mitral regurgitation on pre-discharge echocardiography. Anterior and posterior leaflet areas, annular circumference, anterior and posterior leaflet angles, prolapse and tenting heights and volumes were most strongly predictive of repair complexity. As 21 of the 22 patients with bileaflet pathology and multisegment prolapse were complex repairs, we sought to develop a model predicting repair complexity in the remaining patients. The most predictive model with a c-statistic of 0.91 included three predictors: multisegment pathology, prolapsing height and posterior leaflet angle. After bootstrap validation, the revised c-statistic was 0.88. CONCLUSIONS 3D transoesophageal echocardiography provides an objective means of predicting mitral repair complexity in mitral regurgitation due to a range of aetiology.

Frailty: the missing element in predicting operative mortality.

Although age is an extensively documented independent risk factor for mortality, morbidity and decreased quality of life after cardiac surgery, it has also been demonstrated that excellent outcomes can be obtained after cardiac surgery in very elderly patients. The disparity between chronological and biological age that underlies these findings forms the focus of this review, which examines recent studies aiming to refine pre-operative risk stratification tools by using assessments of frailty and functional status.

Prosthetic valve selection for middle-aged patients with aortic stenosis

Choosing the optimal aortic valve prosthesis for middle-aged patients (late 40s to early 60s) with aortic stenosis presents a challenge. The available options all have substantial drawbacks that must be considered in the decision-making process. Current data indicate that there is little or no difference in survival between mechanical and bioprosthetic aortic valve replacement in middle-aged patients at 10–15 years after surgery. Patients who receive a mechanical valve replacement have an annual risk of major hemorrhagic or embolic events of 2–4% per year for life compared with about 1% per year for patients who have a bioprosthetic valve. However, bioprostheses are associated with an increasing risk of structural valve degeneration from 10 years postimplantation, and most patients will require reoperation if they survive much longer than a decade. The mortality risk associated with reoperation is similar to that of primary surgery for most patients, and does not seem to impact on the 15-year survival in this patient group. The Ross procedure, in which the aortic valve is replaced with a pulmonary autograft, can provide improved freedom from morbidity, but operative mortality is probably double that of isolated aortic valve replacement and most patients will require reoperation. Informed patient choice is the most important factor in deciding which valve to use, with biological valves increasingly favored over mechanical valves in middle-aged patients.

Predictors and Outcomes of Seizures After Cardiac Surgery: A Multivariable Analysis of 2,578 Patients

BACKGROUND Limited data exist regarding the epidemiology and prognosis of seizures in adults after cardiac surgery. The aim of this study was to define preoperative predictors of seizures and impact on postoperative outcomes. METHODS A prospective database of 2,578 consecutive adults who underwent cardiac surgery at a single institution between April 2007 and December 2009 was retrospectively analyzed to determine risk factors for postoperative seizures and prognostic impact. No patient received tranexamic acid or aprotinin. RESULTS Seizures occurred in 31 patients (1%) at a median of 2 days postoperatively (1 patient had a preoperative diagnosis of seizure disorder). Seizures were classified as generalized tonic-clonic (71%), simple/complex partial (26%), or status epilepticus (3%). Incidence differed according to procedure (coronary bypass 0.1%, isolated valve 1%, valve/coronary bypass 3%, aorta 5%; p <0.001). Patients who experienced seizures had nearly a fivefold higher operative mortality than patients who did not (29% versus 6%, p <0.001). Head computed tomography was performed in 26 patients (84%), of whom ischemic strokes were identified in 14 cases (53%). These were embolic in 9 patients (34%), and watershed in 3 (12%). Hemorrhagic strokes were observed in 2 patients (8%). The occurrence of a new postoperative stroke in seizure patients did not significantly increase the likelihood of in-hospital death. Thirteen patients (41%) were discharged without neurologic deficit. Multivariable logistic regression analysis identified three risk factors for seizure: deep hypothermic circulatory arrest, aortic calcification or atheroma, and critical preoperative state. CONCLUSIONS Seizures in adults after cardiac surgery are strong independent predictors of permanent neurologic deficit and increased operative mortality. Early head computed tomography may be indicated to identify treatable pathology.

Trends in Infective Endocarditis in California and New York State, 1998-2013

Importance Prophylaxis and treatment guidelines for infective endocarditis have changed substantially over the past decade. In the United States, few population-based studies have explored the contemporary epidemiology and outcomes of endocarditis. Objective To quantify trends in the incidence and etiologies of infective endocarditis in the United States. Design, Setting, and Participants Retrospective population epidemiology study of patients hospitalized with a first episode of endocarditis identified from mandatory state databases in California and New York State between January 1, 1998, and December 31, 2013. Exposure Infective endocarditis. Main Outcomes and Measures Outcomes were crude and standardized incidence of endocarditis and trends in patient characteristics and disease etiology. Trends in acquisition mode, organism, and mortality were analyzed. Results Among 75 829 patients with first episodes of endocarditis (mean [SD] age, 62.3 [18.9] years; 59.1% male), the standardized annual incidence was stable between 7.6 (95% CI, 7.4 to 7.9) and 7.8 (95% CI, 7.6 to 8.0) cases per 100 000 persons (annual percentage change [APC], −0.06%; 95% CI, −0.3% to 0.2%; P = .59). From 1998 through 2013, the proportion of patients with native-valve endocarditis decreased (from 74.5% to 68.4%; APC, −0.7%; 95% CI, −0.9% to −0.5%; P < .001). Prosthetic-valve endocarditis increased (from 12.0% to 13.8%; APC, 1.3%; 95% CI, 0.8% to 1.7%; P < .001), and cardiac device–related endocarditis increased (from 1.3% to 4.1%; APC, 8.8%; 95% CI, 7.8% to 9.9%; P < .001). The proportion of patients with health care–associated nosocomial endocarditis decreased (from 17.7% to 15.3%; APC, −1.0%; 95% CI, −1.4% to −0.7%; P < .001). The proportion of patients with health care–associated nonnosocomial endocarditis increased (from 32.1% to 35.9%; APC, 0.8%; 95% CI, 0.5% to 1.1%; P < .001). The incidence of oral streptococcal endocarditis did not increase (unadjusted: APC, −0.1%; 95% CI, −0.8% to 0.6%; P = .77; adjusted: APC, −1.3%; 95% CI, −1.8% to −0.7%; P < .001). Crude 90-day mortality was unchanged (from 23.9% to 24.2%; APC, −0.3%; 95% CI, −1.0% to 0.4%; P = .44); adjusted risk of 90-day mortality decreased (adjusted hazard ratio per year, 0.982; 95% CI, 0.978 to 0.986; P < .001). Conclusions and Relevance In California and New York State, the overall standardized incidence of infective endocarditis was stable from 1998 through 2013, with changes in patient characteristics and etiology over this time.