Nicholas Kang

Diagnosis of MI after CABG with high-sensitivity troponin T and new ECG or echocardiogram changes: relationship with mortality and validation of the universal definition of MI.

Aims: Criteria for diagnosing myocardial infarction (MI) after coronary artery bypass grafting (CABG) are controversial. Uncertainties remain around the optimal threshold for biomarker elevation and the need for associated criteria. There are no studies of high-sensitivity troponin (hs-TnT) after CABG. We assessed whether using hs-TnT to define MI after CABG was associated with 30-day and medium-term mortality and evaluated the utility of adding to the troponin criteria new Q-waves or imaging evidence of new wall motion abnormality as suggested in the Universal Definition of MI. Methods: Isolated CABG was performed in 818 patients from July 2010 to June 2012 and hs-TnT was measured 12–24 hours after CABG. Patients with rising baseline or missing troponins (n=258) were excluded. Thresholds of 140 ng/l (10-times 99th percentile upper reference limit) and 500 ng/l (10-times coefficient of variation of 10% for fourth-generation troponin T applied to hs-TnT) were prespecified. Results: Mean follow up was 1.8±0.6 years. On multivariate analyses, isolated hs-TnT rise >140 ng/l (n=360) or >500 ng/l (n=162) were not associated with mortality. Additional ECG and/or echocardiographic criteria plus hs-TnT >140 ng/l was associated with 30-day mortality (hazard ratio, HR, 4.92, 95% CI 1.34–18.1; p=0.017) and medium-term mortality (HR 3.44, 95% CI 1.13–10.5; p=0.030), whereas ECG and/or echocardiographic abnormalities with hs-TnT >500 ng/l was not (p=0.281 and p=0.123 for 30-day and medium-term mortality, respectively). Conclusions: A definition for MI following CABG using hs-TnT with a cut point of 10-times 99th percentile upper reference limit and ECG and/or echocardiographic criteria predicts 30-day and medium-term mortality. These findings validate the Third Universal Definition of type 5 MI.

Valvular repair or replacement for mitral endocarditis: 7-year cohort study.

Background A few studies have compared mitral valve repair and replacement in the setting of infective endocarditis, with varying results. We compared the characteristics and outcomes of mitral repair and replacement in endocarditis patients. Methods All patients undergoing mitral valve repair or replacement for active mitral endocarditis during 2005–2011 were included. Operative and follow-up mortality, composite morbidity, recurrent endocarditis, and redo operations were prespecified endpoints for analyses. Results There were 25 and 35 patients undergoing mitral valve repair and replacement, respectively. They were followed-up for 3.9 ± 2.5 years. Valve replacement patients were older (p = 0.029), had a higher prevalence of intracardiac abscess (p = 0.035), previous endocarditis (p = 0.036), atrial fibrillation (p = 0.001), worse renal function (p = 0.013), higher risk scores (p = 0.004–0.020), and longer operation times (p < 0.001). Repair and replacement had similar rates of operative mortality (4.0% vs. 8.6%, p = 0.634), composite morbidity (16.0% vs. 28.6%, p = 0.357), survival (p = 0.564), recurrent endocarditis (p = 0.081), and redo operations (p = 0.813). Independent predictors of operative mortality were preoperative inotropic or intraaortic balloon pump support. The independent predictor of mortality during follow-up was dialysis. Independent predictors of composite morbidity were intracardiac abscess and hypercholesterolemia. The independent predictor of recurrent endocarditis was previous endocarditis, and the independent predictor of redo operation was previous stroke. Conclusion Mitral valve replacement candidates had more baseline risk factors and higher raw rates of postoperative mortality and morbidity, which did not reach statistical significance.

Long-term Survival after Isolated Tricuspid Valve Replacement

BACKGROUND Isolated replacement of the tricuspid valve is rare, and the decision to operate is difficult. This study reviews the in-hospital mortality and long-term survival after tricuspid valve replacement in the absence of concomitant left sided valve surgery. It identifies predictors of poor outcome. METHODS All patients who underwent tricuspid valve replacement between January 1995 and December 2011 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. Logistic regression was used to identify predictors of early and late death. RESULTS Twenty-nine cases were identified. There were six in-hospital deaths (20.6%), and eight late deaths. Ascites was associated with in-hospital death (hazard ratio 16.96; p=0.0052). Higher dose of Frusemide was associated with late mortality (hazard ratio 1.157 per 20mg increase; p=0.0155). Frusemide dose and ascites were both significantly associated with death overall (p<0.01). Survival analysis estimated a 50% probability of surviving to 12.45 years. CONCLUSIONS Isolated tricuspid valve replacement has a high peri-operative risk. Long-term survival in this study was consistent with other reports. Ascites and higher doses of Frusemide were associated with poor outcomes.

Seven-year Cohort Study of Valvular Repair or Replacement for Active Mitral Endocarditis

of disease in the LAD was seen in 11% at 10 years, with a mean time to angiography of 7.3 years. Conclusion: The use of composite SV-IMA grafts in this group of patients provided good late survival and freedom from reintervention. Atheromatous disease in the venous segmentwasuncommondespite followupbeyond 15 years. The incidence of development of significant LAD disease after surgery for non-LAD double vessel disease was low. http://dx.doi.org/10.1016/j.hlc.2013.05.569