Pierre Pagé

Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery?

BACKGROUNDnAn apparent increase in the incidence of acute ascending aortic dissection following off-pump coronary artery bypass grafting (OPCAB) led us to assess retrospectively the rate and circumstances of this complication in our institution on a consecutive series of patients undergoing aortocoronary bypass performed with and without extracorporeal circulation (ECC).nnnMETHODSnA retrospective analysis of acute ascending aortic dissections complicating coronary artery bypass grafting surgery in 3,031 patients in our institution since April 1, 1995, was performed using the database of the Montreal Heart Institute.nnnRESULTSnThere was a greater frequency of hypertension in the OPCAB group. Iatrogenic acute aortic dissection occurred in 3 patients among 308 operated on without ECC (0.97%) and 1 patient among 2,723 operated on under ECC (0.04%). This difference was statistically significant (p < 0.00001).nnnCONCLUSIONSnThe risk of aortic dissection may be increased in OPCAB. Careful manipulation of the aorta with a single side-clamping and a control of the arterial pressure should be used to minimize aortic trauma. High-risk patients should undergo CABG without side-clamping of the aorta or CABG with ECC to prevent this redoubtable complication of myocardial revascularization.

Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis

BACKGROUNDnThe objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis.nnnMETHODSnA retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute.nnnRESULTSnSeventy-seven patients (57 men and 20 women, mean age 48 +/- 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 70% +/- 9%, 59% +/- 10%, and 55% +/- 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 45% +/- 10%, 40% +/- 10%, and 36% +/- 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% +/- 9% following aortic valve replacement and 79% +/- 9% following mitral valve replacement. Five-year survival for PVE averaged 66% +/- 12% following aortic valve replacement and 43% +/- 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2.nnnCONCLUSIONSnProsthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.

Tricuspid valve replacement: an analysis of 25 years of experience at a single center

BACKGROUNDnTricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial.nnnMETHODSnBetween 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15).nnnRESULTSnPatients with bioprosthetic tricuspid replacements averaged 53 +/- 13 years of age compared with 48 +/- 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% +/- 13% in the mechanical valve group and 56% +/- 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% +/- 9% in patients with mechanical valves and 97% +/- 3% in those with biologic valves (p = 0.2). CONCLUSIONS; Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.

Retrospective cohort analysis of 926 tricuspid valve surgeries: Clinical and hemodynamic outcomes with propensity score analysis

BACKGROUNDnThe objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence.nnnMETHODSnA retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women.nnnRESULTSnOperative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001).nnnCONCLUSIONnTricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes.

Experience with the 19-mm Carpentier-Edwards pericardial bioprosthesis in the elderly

BACKGROUNDnValve replacement in small aortic root remains a surgical challenge. The objective of this study was to compare results of the 19-mm bioprosthesis with those of larger prostheses in the elderly.nnnMETHODSnThe 443 patients, 70 years of age and older, who underwent aortic valve replacement with Carpentier-Edwards pericardial bioprostheses were reviewed.nnnRESULTSnThere were 93 patients with a mean age of 76+/-4 years with implantation of 19-mm prostheses and 350 patients with a mean age of 75+/-4 years with larger bioprostheses. Associated aortoplasty was performed in 10 patients (11%) with 19-mm bioprostheses and in 8 patients (2%) with larger bioprostheses (p = 0.001). There were 11 deaths (12%) within 30 days of surgery in patients with 19-mm prostheses and 22 deaths (6%) among those with larger prostheses (p = 0.1). The 7-year survival rate averaged 61%+/-7% in patients with 19-mm prostheses and 67%+/-4% in those with larger prostheses (p = 0.8). The 7-year freedom rates from all valve-related events averaged 96%+/-2% and 93%+/-2%, respectively (p = 0.6).nnnCONCLUSIONSnAortic valve replacement with the 19-mm Carpentier-Edwards pericardial bioprosthesis offers excellent midterm results in the elderly.

Cardioplegic arrest with l-arginine improves myocardial protection: results of a prospective randomized clinical trial

BACKGROUNDnBlood cardioplegic arrest remains the method of choice for myocardial protection. L-arginine has been suggested to improve protection through an increase in nitric oxide production.nnnMETHODSnA prospective, randomized, double-blinded clinical trial comparing standard blood cardioplegic solution to L-arginine-enriched solution (7.5 g/500 mL) enrolled 200 patients undergoing coronary artery bypass grafting. Clinical data and biochemical markers of ischemia were recorded. Warm blood cardioplegia (33 degrees C) was administered in 74% of patients and cold blood (20 degrees C) was used in 26% of patients. Both groups averaged three grafts per patient.nnnRESULTSnThere were two (2%) deaths in both groups. There were four (4%) myocardial infarctions (MI) in the control group and six (6%) infarctions in the L-arginine group (p = 0.5). For the 190 patients without MI, serum levels of troponin T averaged 0.40+/-0.43, 0.38+/-0.42, and 0.39+/-0.50 microg/L in control patients compared with 0.28+/-0.22, 0.24+/-0.18, and 0.27+/-0.20 microg/L in L-arginine patients, respectively, 12, 24 and 48 hours after coronary artery bypass grafting (p = 0.03). The cardiac index averaged 2.7+/-0.8 L x min(-1) x m(-2) in control patients and 2.9+/-0.7 L x min(-1) x m(-2) in arginine patients immediately after surgery (p = 0.09). Intensive care unit and hospital length of stay averaged 3.5+/-5 days and 7.3+/-6 days in control patients compared with 2.5+/-3 days and 6.1+/-4 days in arginine patients (p = 0.09).nnnCONCLUSIONSnL-arginine-supplemented blood cardioplegic solution is associated with reduced release of biochemical markers of myocardial damage, suggesting improved myocardial protection.

Long-Term Results With Triple Valve Surgery

BACKGROUNDnWhether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves.nnnMETHODSnAll 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed.nnnRESULTSnThirty patients averaging 62+/-10 years of age underwent primary triple valve surgery and 43 patients averaging 60+/-10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80%+/-7%, 75%+/-8%, and 41%+/-15%, and 70%+/-7%, 57%+/-9%, and 50%+/-10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87%+/-6% and 95%+/-3% in primary and reoperative patients, respectively, 5 years following surgery.nnnCONCLUSIONSnTriple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.

Aortic valve replacement with mechanical and biologic prostheses in middle-aged patients

Abstract Background . Mechanical prostheses are used in young patients and bioprostheses in the elderly because of the higher rate of structural failure of bioprostheses. The objective of the present study was to compare results after aortic valve replacement with mechanical (CarboMedics) and biologic (Carpentier-Edwards pericardial) in middle-aged patients. Methods . Five hundred twenty-one patients, aged between 55 and 65 years, who underwent aortic valve replacement with mechanical (n = 363) or biologic (n = 158) prostheses were reviewed. Results . The 10-year actuarial survival rate averaged 66% ± 6% in patients implanted with mechanical valves compared with 75% ± 4% in patients implanted with biologic valves ( p = 0.2). The 10-year freedom rate from thromboembolism, hemorrhage, and endocarditis averaged 92% ± 7%, 97% ± 2%, and 99% ± 1%, respectively, in patients with mechanical valves compared with 91% ± 3% ( p = 0.03), 99% ± 1% ( p = 0.4), and 95% ± 2% ( p = 0.01), respectively, in those with biologic valves. The 10-year freedom rate from all valve-related complications averaged 90% ± 7% and 83% ± 4%, respectively ( p = 0.01). Conclusions . The freedom rate from all valve-related complications was higher among patients with mechanical valves compared with biologic valves 10 years after aortic valve replacement in middle-aged patients.

Extraction of transvenous leads in the operating room versus electrophysiology laboratory: A comparative study

BACKGROUNDnAlthough risks and life-threatening complications associated with lead extraction are well characterized, practice patterns vary regarding whether procedures are performed in an operating room (OR) or electrophysiology (EP) laboratory with cardiothoracic surgical backup.nnnOBJECTIVEnOur objective was to compare procedural outcomes and complications associated with lead extraction in the OR vs. EP laboratory.nnnMETHODSnProspectively acquired data were pooled from 2 referral centers. Lead extraction procedures were performed between 2000 and 2010, encompassing a transition phase from the OR to EP laboratory. Analyses were conducted using generalized estimating equations.nnnRESULTSnA total of 1,364 leads (533 OR; 831 EP laboratory) were targeted in 684 consecutive procedures, 41.2% of which were in the OR. Laser sheaths and snares were used for 699 (51.2%) and 101 (7.4%) leads, respectively. Overall, 775 (93.1%) vs. 487 (91.4%) leads were completely extracted in the EP laboratory vs. OR [odds ratio 1.3, 95% confidence interval 0.9 to 2.1]. Complications occurred in 2.24% vs. 2.84%, respectively (P = .431). Two patients died because of superior vena caval lacerations (0.29%), 1 in each group. Rapid surgical intervention was helpful in 6 (0.9%) patients [4 OR (2 subclavian vein lacerations, 1 tricuspid valve laceration, 1 tamponade); 2 EP laboratory (tamponades)], with subsequently favorable outcomes. The only independent predictor of complications was older lead age [odds ratio 1.11 per year, 95% confidence interval 1.02 to 1.20].nnnCONCLUSIONnLead extraction in the EP laboratory with surgical backup is associated with a similarly low rate of complications and mortality as procedures performed in the OR.

Statin treatment equalizes long-term survival between patients with single and bilateral internal thoracic artery grafts.

BACKGROUNDnThe use of 2 internal thoracic artery (ITA) grafts increases survival 10 years after coronary artery bypass grafting (CABG) compared with single ITA grafting. Statin treatment was also shown to decrease development and progression of saphenous vein graft atherosclerosis. This study examined the effect of statin treatment on long-term survival after CABG.nnnMETHODSnOperative, survival, and pharmacologic data of 6655 patients who underwent CABG with ITAs between 1995 and 2007 in our institution were obtained.nnnRESULTSnPatients with bilateral ITA grafts had an average 10-year-survival rate of 83% +/- 2% compared with 67% +/-1% in patients with single ITA grafts (p = 0.0001). Statin treatment caused a significant decrease in the long-term risk of death among patients who underwent single ITA grafting (hazard ratio [HR], 0.735, p = 0.0001). However, statin treatment had no effect on the risk of long-term death among patients who underwent bilateral ITA grafting (HR, 1.053; p = 0.7806).nnnCONCLUSIONSnStatin treatment initiated early after grafting improved long-term survival in patients with a single ITA graft but not in those with bilateral ITA grafts. Survival of statin-treated patients with single ITA grafts was similar to bilateral ITA patients.