Piroze Davierwala

Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial

AIMS Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. METHODS AND RESULTS Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial. This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095). The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001). Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66). Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0-22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23-32) or high (≥ 33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization. Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints. CONCLUSION Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization. CLINICAL TRIAL REGISTRATION NCT00114972.

Redo Aortic Valve Surgery: Early and Late Outcomes

BACKGROUND Repeat aortic valve surgery (rAVS) is usually associated with an increased risk profile due to advanced patient age and comorbidities. We analyzed the current early and late results for isolated rAVS. METHODS One hundred fifty-five patients underwent isolated rAVS from November 1994 to April 2008, of which, 86 received isolated redo aortic valve surgery (rAVS without root) and 69 received aortic root replacement (rAVS with root) as the second operation. RESULTS Patient age was 58 ± 16 years; 23% were female. The indications for redo surgery were infective endocarditis (27.1%, n = 42), bioprosthetic structural valve dysfunction and degeneration (23.8%, n = 37), mechanical valve nonstructural dysfunction (7.2%, n = 11), paravalvular leak (18.1%, n = 28), aortic dissection (2.6%, n = 4), and aortic aneurysm (7.1%, n = 11). Early mortality was 4.5% (n = 7) for all patients (3.5% for rAVS without root and 5.8% for rAVS with root, p = 0.5). Left ventricular ejection fraction less than 0.30 (odds ratio 9.2, 95% confidence interval [CI] 1.1 to 80.3) and preoperative neurologic dysfunction (odds ratio 22.1, 95% CI 2.3 to 197.4) were found to be the independent predictors for in-hospital mortality according to multivariate analysis. Follow-up was 100% complete with a mean duration of 2.7 ± 2.8 years for all patients. Five-year and eight-year survival was 66% ± 5% and 61% ± 6% for all patients and did not significantly differ between surgical groups. Cox regression analysis revealed the following independent predictors of long-term survival: preoperative New York Heart Association functional class IV (hazard ratio 2.2, 95% CI 1.5 to 3.2, p < 0.01) and infective endocarditis (hazard ratio 2.2, 95% CI 1.4 to 3.1, p < 0.01). CONCLUSIONS Repeat isolated aortic valve surgery is associated with respectable outcomes. Follow-up results reveal good long-term survival for this group.

Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients.

OBJECTIVE To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE). METHODS From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis. RESULTS Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01). CONCLUSIONS Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.

Tricuspid valve repair in the presence of a permanent ventricular pacemaker lead.

OBJECTIVE Few studies have focussed on the outcomes of tricuspid valve (TV) repair in patients with a right ventricular permanent pacemaker lead (PPL) and tricuspid regurgitation (TR). METHODS Retrospective analysis of all patients with a PPL undergoing TV repair (annuloplasty ring in 83 patients and De Vega annuloplasty in 33 patients) between April 2001 and May 2008 (n=116) was performed. The mean patient age was 71 ± 8.8 years; 59.8% were female, and the average European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 16.4 ± 14.5%. Follow-up was 100% complete with a mean duration of 19.4 ± 20.3 months. RESULTS In addition to annular dilatation, leaflet injury secondary to PPL was observed in eight patients (7%). Isolated ring implantation or De Vega annuloplasty was performed in all patients, including five of the eight patients with leaflet injury. In the remaining three patients, the PPL was removed and an epicardial lead was implanted. A 30-day mortality was 14.6% and a 5-year survival 45% (95% confidence interval (CI): 29.4-61.6%). Four patients underwent TV re-operation resulting in a 5-year freedom of 93.4% from TV-related re-operation (95% CI: 88.2-97.7). Two of the four re-operated patients had PPL-related leaflet injury at the time of the initial operation and the PPL was left in situ. CONCLUSIONS Patients with a pre-existing PPL, who require TV surgery for significant TR, however without evidence of PPL-induced TR, can undergo TV repair without removal of the PPL. In patients with evidence of PPL-related TR, we suggest PPL removal followed by insertion of an epicardal or transcoronary sinus lead.

Double valve replacement and reconstruction of the intervalvular fibrous body in patients with active infective endocarditis

OBJECTIVES Destruction of the intervalvular fibrous body, though uncommon, occurs due to paravalvular abscess formation following active infective endocarditis. This warrants a highly complex operation involving radical surgical debridement of the intervalvular fibrous body, followed by double valve (aortic and mitral) replacement with patch reconstruction of the anterior mitral annulus, the left ventricular outflow tract and the left atrial roof. The objective of this study was to review the early and mid-term outcomes in patients undergoing this operation. METHODS A total of 25 patients underwent double valve replacement with reconstruction of the intervalvular fibrous body for extensive infective endocarditis between January 1999 and March 2012. The mean age was 64.3 ± 10.5 years. Most of the patients (60%) were in New York Heart Association Class III-IV, 12% and in cardiogenic shock. Associated comorbidities like acute renal insufficiency and cerebrovascular accidents were observed in 40 and 20% of patients, respectively. Twenty patients had previous heart valve surgeries. The logistic EuroSCORE predicted risk of mortality was 55.1 ± 22.9%. RESULTS Overall, 30-day mortality was 32%. Postoperative complications like low cardiac output, stroke and acute renal failure developed in 16, 28 and 56%, respectively. Thirty-two percent of patients required re-exploration for bleeding. Nine patients were alive at a mean follow-up of 406 days (0-8 years). The 2- and 5-year survivals were 37.0 ± 11.1 and 24.6 ± 12.5%, respectively. CONCLUSIONS Double valve replacement with reconstruction of the intervalvular fibrous body for infective endocarditis is a complex, technically challenging operation associated with high perioperative morbidity and mortality. Nevertheless, being the only option available for such complex disease, it should be performed in these patients who, otherwise, face 100% mortality.

Five years after the SYNTAX trial: what have we learnt?

Ever since the advent of percutaneous intervention (PCI) for the treatment of coronary artery disease (CAD), the optimal choice of therapy (PCI or coronary artery bypass grafting [CABG]) has always been disputed. Although previous multicentre randomized trials, like the ARTS I, MASS II and SoS trials for multivessel disease (MVD) have shown no compelling benefit in terms of 5-year allcause and cardiac mortality for CABG, they have consistently reported significantly greater rates of repeat revascularization for PCI [1–3]. Contrary to this, the 5-year follow-up results of the SYNTAX trial for the whole randomized cohort not only confirmed that CABG is associated with lower rates of repeat revascularization (13.7% for CABG vs 25.9% for PCI [P< 0.0001]), but also demonstrated a significant benefit in cardiac mortality (5.3% for CABG vs 9% for PCI [P< 0.003]), occurrence of major cardiac and cerebrovascular events (MACCEs; 26.9% for CABG vs 37.3% for PCI [P< 0.0001]) and myocardial infarction (MI; 3.8% for CABG vs 9.7% for PCI [P< 0.0001]) in patients undergoing CABG. The rates of allcause mortality and stroke, however, were not significantly different between groups [4]. What has made the SYNTAX trial exclusive from previous ones was that more than two-thirds of the patients (n= 3075, 71%) screened were recruited, either in the randomized (n= 1800) group, when eligible, or in the PCI and CABG nested registries (n= 1275), when not suitable for randomization, thus reflecting real-world practice [5]. As a result, the major criticism of previous trials, which was the exclusion of patients encountered in the ‘realworld scenario’, was overcome. The results of the SYNTAX trial are in accordance with the recently published ASCERT study, which is an analysis of large non-randomized observational data from the Society of Thoracic Surgeons and American College of Cardiology Foundation registries to evaluate the effectiveness of revascularization with CABG compared with PCI. The adjusted 4-year mortality was 16.4% in the CABG group and 20.8% in the PCI group (risk ratio, 0.79; 95% confidence interval, 0.76–0.82) [6]. Secondly, it is the largest trial that compared CABG using the latest techniques (arterial grafts) with PCI with drug-eluting stents (DESs). Thirdly, a heart-team approach, involving a local interventional cardiologist and a cardiothoracic surgeon supported by a study coordinator at each site, was applied to assess the suitability of patients for either treatment. Finally, it incorporated patients with complex CAD, including left main disease (LMD) and three-vessel disease (3VD), which formed two of the three predefined subgroups analysed. Since the primary clinical endpoint of the trial, which was freedom from MACCE at 1 year after allocation, failed to demonstrate non-inferiority of PCI to CABG, further subgroup analysis can only be considered observational and hypothesis-generating [7]. The 5-year MACCE rates were not significantly different between treatment groups (31.0% CABG vs 36.9% PCI; P= 0.12) in the overall LMD subgroup. In contrast, patients with 3VD and without LMD had 50% greater 5-year MACCE rates when treated with PCI compared with CABG (24.2% CABG vs 37.5% PCI; P< 0.001). Medically treated diabetic patients (third subgroup), who underwent CABG, also had lower 5-year MACCE rates (29.0% CABG vs 46.5% PCI; P< 0.001), which was comparable with the primary composite outcome of death from any cause, MI and stroke in diabetic patients included in the FREEDOM trial (18.7% CABG vs 26.6% PCI; P= 0.005) [8]. The trends of various outcomes of the SYNTAX trial are depicted in Tables 1 and 2. Notably, the composite outcome of death, MI and stroke achieved significance in favour of CABG for the first time at 5-year follow-up. This was chiefly driven by the significantly lower rates of cardiac death and MI in CABG-treated patients and the levelling out of the stroke rate between the two treatment groups at 5 years. This long-term benefit seen with CABG is due to the fundamental difference in the method of revascularization. Bypass grafts are anastomosed to coronary arteries distal to the lesions, thus rendering the complexity of the lesion inconsequential and providing an adequate buffer against the development of new lesions in the future. Since the source or inflow of bypass grafts is different from that of native coronary arteries, the development of new lesions proximal to the anastomoses is impertinent. In contrast, stents have to be deployed at the site of the lesion, which provides no protection against the progression or development of new disease, as the native coronary artery always remains the source of inflow. The CABG registry consisted of patients ineligible for PCI, i.e. usually those with highly complex or diffuse CAD. The MACCE (23.2%), all-cause death (12.6%), MI (3.8%) and repeat revascularization (6.7%) rates at 5 years in these patients were consistent with those in the randomized CABG arm. This would further enforce the fact that CABG results are not really dependent on the complexity of CAD anatomy. The PCI registry included patients who were considered to be at high risk for CABG, probably due to severe multiple comorbidities, poor ventricular function, etc. This probably explains the poorer outcomes (MACCE: 42.9%, all-cause death: 35.5% and death/stroke/MI: 35.3%) of patients in the PCI registry.

Impact of Expeditious Management of Perioperative Myocardial Ischemia in Patients Undergoing Isolated Coronary Artery Bypass Surgery

Background— To analyze the effect of immediate treatment of perioperative myocardial ischemia (PMI) because of early graft failure or incomplete revascularization in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods and Results— Between January 2004 and December 2010, 7461 patients underwent isolated CABG at our institution. All patients showing evidence of PMI (n=399; 5.3% of total) underwent emergent coronary angiography. A total of 900 grafts and 1061 distal anastomoses were examined. Two hundred fifty-five patients had 360 distal anastomoses compromised because of early graft failure or incomplete revascularization (ie, abnormal postoperative coronary angiogram). Revision CABG or percutaneous coronary intervention was performed in 130 (51.0%) and 34 (13.3%) patients with abnormal angiograms, respectively. Nonsurgical therapy was implemented in the remaining 91 patients (35.7%) with abnormal angiograms. One hundred forty-four patients had normal postoperative graft-related angiograms. In-hospital mortality was 7.3% and 2.9% in patients with and without PMI (P<0.001). In patients with PMI, in-hospital mortality was 9.4% and 3.5% in patients with abnormal and normal postoperative angiograms, respectively (P=0.03). Significant multivariable predictors of in-hospital mortality were hemodynamic deterioration, preangiography creatine kinase-MB isoenzyme rise >2× normal, and time interval between primary CABG and coronary angiography >30 hours. Five-year survival in patients without PMI (85.7±0.5%) was significantly better than those with PMI and abnormal angiograms (74.9±2.9%; P<0.001 log-rank). When in-hospital mortality was excluded, however, this difference in midterm survival disappeared (P=0.9). Conclusions— PMI is associated with increased in-hospital mortality in patients undergoing isolated CABG. Expeditious management of bypass graft failure results in similar midterm survival to nonischemic patients in hospital survivors.

Aortic arch reoperation in a single centre: early and late results in 57 consecutive patients

OBJECTIVES Aortic arch surgery following previous replacement of the ascending aorta has become more frequent due to the improved long-term survival of patients after the primary procedure and advances in the management of complex repeat cardiac procedures. We retrospectively analysed our results of redo aortic arch surgery. METHODS Between January 1995 and December 2011, a total of 1022 patients underwent surgery on the ascending aorta with or without involvement of the aortic arch. Of these, 57 patients (5%) underwent reoperations involving the aortic arch. Indications for repeat aortic arch surgery included arch aneurysm in 50%, residual aortic dissection with aneurysmal formation in 38%, and graft infection in 9% of patients. One patient (1%) underwent previous heart transplantation. Nine patients (16%) had Marfan syndrome. RESULTS Mean age was 55 ± 15 years and 23 patients (40%) were female. Logistic EuroSCORE-predicted risk of mortality was 38 ± 19%. The mean time interval between primary and redo surgery was 7.6 ± 7 years for aortic aneurysm and 4.4 ± 4 years in aortic dissection patients (P = 0.09). Total and partial arch replacements were performed in 52 and 47% of patients, respectively. Mean circulatory arrest time was 28.3 ± 22.1 min, with selective antegrade cerebral perfusion (SACP) utilized in 68% of patients. Overall incidence of stroke or transient neurological deficit was 15%. The 30-day mortality was 9% (n = 5). Multivariable logistic regression analysis revealed that previous type A aortic dissection was the only independent risk factor (OR 3.7, 95% CI 1.5-5.5, P = 0.01) for 30-day mortality. Mean survival was 5.5 ± 0.5 years, and estimated 5-year survival was 74.9 ± 0.6%. Survival of patients undergoing reoperation for residual aortic dissection was significantly worse compared with patients with aortic arch aneurysm (log-rank P = 0.016). CONCLUSIONS Aortic arch reoperation, although a technically complex operation, can be performed with acceptable mortality and morbidity. Patients with aortic dissection during their previous operation required repeat surgery significantly earlier when compared with patients with arch aneurysms, and had worse long-term survival.

Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses

OBJECTIVES To evaluate the early and long-term outcomes in patients undergoing complex aortic root reconstructions for complicated aortic root abscesses. METHODS A total of 1199 patients underwent aortic valve surgery for aortic valve endocarditis between July 1999 and June 2012. Of these, 150 patients, who underwent complex isolated aortic root operations for aortic root abscesses, were included in this study. Radical resection of the abscess was performed in all patients followed by an aortic root replacement (ARR) in 91 (61.7%) or an aortic valve replacement with patch reconstruction of the aortic root in 59 (39.3%) patients. Prosthetic valve endocarditis was observed in 74 patients (49.3%). Logistic regression analysis identified the predictors of 30-day mortality. Estimated mean follow-up was 7.0 ± 0.5 years (range 0-12.6 years). RESULTS Mean age was 62 ± 15 years and 87% (n = 130) were male. The majority of patients (91%; n = 137) underwent urgent or emergent surgery. Overall 30-day mortality was 19% (n = 29; ARR 21%; AVR 17%; P = 0.4). Postoperative low cardiac output, stroke and dialysis developed in 10.7, 4.7 and 25.3% of patients, respectively. Sepsis was the only independent predictor of 30-day mortality (odds ratio: 2.8; 95% confidence interval: 1.1-7.3; P = 0.03). The 1-, 5- and 10-year survival was 66 ± 5, 54 ± 5 and 51 ± 6%, respectively. Overall, 9% of surviving patients required a reoperation for recurrent endocarditis resulting in a 1-, 5- and 10-year freedom from reoperation of 93 ± 2, 91 ± 3 and 85 ± 5%, respectively, which was not influenced by surgical technique used (ARR vs AVR with patch reconstruction; log rank P = 0.9). CONCLUSIONS The surgical treatment of aortic root abscess is a challenging operation and is associated with a high early morbidity and mortality. However, the long-term survival and freedom from reoperation is satisfactory.

Role of Tricuspid Valve Repair for Moderate Tricuspid Regurgitation during Minimally Invasive Mitral Valve Surgery

BACKGROUND The aim of this study was to investigate the impact of short- and mid-term survival of tricuspid valve (TV) repair versus conservative therapy in patients with preoperative moderate functional tricuspid regurgitation (TR) undergoing minimally invasive mitral valve (MV) surgery. METHODS Between January 2002 and December 2009, a total of 430 patients with pure mitral regurgitation and concomitant moderate TR underwent minimally invasive MV surgery for mitral regurgitation at the Leipzig Heart Center without (n = 336; group A) and with (n = 94; group B) TV surgery. Mean age was 66.7 ± 10.3 years, mean LVEF was 58.0 ± 13.8%, and 206 patients (47.9%) were male. Average logEuroSCORE was 12.4 ± 11.4%. Follow-up was on average 4.6 ± 2.4 years and 97% completed. RESULTS Predischarge echocardiography showed no or mild TR in 51.1% of patients in group A versus 84.2% of patients in group B (p < 0.01). Overall 30-day mortality was 2.8% with no differences between both groups. Five-year survival was 82.9 ± 4.1% for patients with TV repair versus 85.0 ± 2.2% for patients without TV repair (p = 0.1) and it was 85.7 ± 3.3% in patients with moderate and more postoperative TR versus 90.1 ± 2.5% in patients with less than moderate postoperative TR (p = 0.08). Five-year freedom from TV-related reoperation was 98.8 ± 0.7% for patients in group A versus 98.9 ± 0.1% for patients in group B (p = 0.8). CONCLUSIONS Patients undergoing MV surgery with moderate functional TR do not experience increased perioperative complication rates when a concomitant TV repair is performed. Our observations, combined with those of other groups, support current recommendations to perform concomitant TV repair in such patients, particularly if tricuspid annular dilation is present.