Pyo-Won Park

Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis

Background— The optimal timing of surgical intervention remains controversial in asymptomatic patients with very severe aortic stenosis. We therefore compared the long-term results of early surgery and a conventional treatment strategy. Methods and Results— From 1996 to 2006, we prospectively included a total of 197 consecutive asymptomatic patients (99 men; age, 63±12 years) with very severe aortic stenosis. Patients were excluded if they had angina, syncope, exertional dyspnea, ejection fraction <0.50, significant mitral valve disease, or age >85 years. Very severe aortic stenosis was defined as a critical stenosis in the aortic valve area ≤0.75 cm2 accompanied by a peak aortic jet velocity ≥4.5 m/s or a mean transaortic pressure gradient ≥50 mm Hg on Doppler echocardiography. The primary end point was defined as the composite of operative mortality and cardiac death during follow-up. Early surgery was performed on 102 patients, and a conventional treatment strategy was used for 95 patients. There were no significant differences between the 2 groups in terms of age, gender, European System for Cardiac Operative Risk Evaluation score, or ejection fraction. During a median follow-up of 1501 days, the operated group had no operative mortalities, no cardiac deaths, and 3 noncardiac deaths; the conventional treatment group had 18 cardiac and 10 noncardiac deaths. The estimated actuarial 6-year cardiac and all-cause mortality rates were 0% and 2±1% in the operated group and 24±5% and 32±6% in the conventional treatment group, respectively (P<0.001), and for 57 propensity score-matched pairs, the risk of all-cause mortality was significantly lower in the operated group than in the conventional treatment group (hazard ratio, 0.135; 95% confidence interval, 0.030 to 0.597; P=0.008). Conclusions— Compared with the conventional treatment strategy, early surgery in patients with very severe aortic stenosis is associated with an improved long-term survival by decreasing cardiac mortality. Early surgery is therefore a therapeutic option to further improve clinical outcomes in asymptomatic patients with very severe aortic stenosis and low operative risk.

Early surgery versus conventional treatment for asymptomatic severe mitral regurgitation: a propensity analysis.

OBJECTIVES This study sought to compare long-term outcomes of early surgery with a conventional treatment strategy in asymptomatic patients with severe mitral regurgitation (MR). BACKGROUND The timing of surgery in asymptomatic severe MR remains controversial. METHODS From 1996 to 2009, 610 consecutive asymptomatic patients (364 men, 50 ± 14 years of age) with severe degenerative MR and preserved left ventricular function were evaluated prospectively. Early surgery was performed on 235 patients, and the conventional treatment strategy was chosen for 375 patients. We compared overall mortality, cardiac mortality, and cardiac events (operative mortality, cardiac mortality, repeat surgery, and urgent admission due to heart failure) between the 2 treatment strategies in the propensity score-matched cohort. RESULTS For the 207 propensity score-matched pairs, early surgery had a lower risk of cardiac mortality (hazard ratio [HR]: 0.109; 95% confidence interval [CI]: 0.014 to 0.836; p = 0.033) and cardiac events (HR: 0.216; 95% CI: 0.083 to 0.558; p = 0.002) than conventional treatment. On Cox proportional hazard model analysis, the risk of cardiac events was significantly lower in the early surgery group than in the conventional treatment group in patients aged 50 years of age and older (HR: 0.221; 95% CI: 0.086 to 0.567; p = 0.002), but not significantly different in those younger than 50 years of age (p = 0.20). CONCLUSIONS Compared with conservative management, early surgery is associated with significant long-term reductions of cardiac mortality and cardiac events in asymptomatic severe MR. These benefits were evident among patients age 50 years of age and older.

Plasma transforming growth factor β1 as a biochemical marker to predict the persistence of atrial fibrillation after the surgical maze procedure

OBJECTIVES The Cox maze procedure was developed as a surgical treatment for atrial fibrillation. However, atrial fibrillation recurs in some patients, and atrial remodeling in the form of fibrosis can lead to perpetuation of atrial fibrillation. To identify the predictor of the persistence of atrial fibrillation after the maze procedure using cryoablation, we evaluated the preoperative plasma transforming growth factor beta1. We also examined the correlations between plasma transforming growth factor beta1 levels and the degree of atrial fibrosis. METHODS Preoperative plasma transforming growth factor beta1 levels were measured in 86 consecutive patients (age, 54 +/- 12 years) who underwent both the open heart operation for valvular heart disease and the surgical maze procedure with cryoablation for persistent atrial fibrillation. We measured the degree of fibrosis from the tissue of the left atrium. RESULTS At 1 years follow-up, 10 of 86 patients had persistent atrial fibrillation. Patients with persistent atrial fibrillation had higher preoperative plasma transforming growth factor beta1 levels than the patients with sinus rhythm (0.44 +/- 0.29 vs 0.32 +/- 0.15 ng/mL, P = .03). Patients with persistent atrial fibrillation had higher mRNA expressions of collagen III and lower mRNA expressions of atrial natriuretic peptide than those with sinus rhythm, and the plasma transforming growth factor beta1 levels correlated with the degree of fibrosis in the left atrium (r = 0.497, P = .022). Multiple logistic regression analysis revealed that plasma transforming growth factor beta1 levels were independently associated with the postoperative persistence of atrial fibrillation at 1 years follow-up. CONCLUSIONS Preoperative plasma transforming growth factor beta1 levels could be used to predict the persistence of atrial fibrillation at 1 years follow-up after the surgical maze procedure by using cryoablation. Preoperative plasma transforming growth factor beta1 levels were correlated with the degree of fibrosis in the left atria of patients with mitral valvular heart disease.

Efficacy of the Maze Procedure for Atrial Fibrillation Associated with Atrial Septal Defect

Background Atrial fibrillation (AF) is a common complication in elderly patients with atrial septal defect (ASD). The purpose of this study was to examine the efficacy of the maze procedure in these patients. Materials and Methods Between February 2000 and May 2011, 46 patients underwent the maze procedure as a concomitant operation with ASD closure. Three patients who underwent a right-sided maze were excluded, and one patient was lost to follow-up. The mean follow-up duration was 3.2±2.5 years. Electrocardiography was performed 1 month, 3 months, 6 months, and 1 year after surgery, and checked annually after that. Results AF persisted in 4 patients after surgery. One year after surgery, among 38 patients, 55.3% remained in sinus rhythm without antiarrhythmic drugs. However, when including the patients who took antiarrhythmic drugs, 92.1% were in sinus rhythm. Freedom from AF recurrence at 3 months, 6 months, 1 year, 2 years, 3 years, and 5 years after surgery were 97.4±2.6, 94.4±3.8, 91.2±4.9, 87.8±5.8, 79.5±7.6, and 68.2±12.4, respectively. There was no early mortality after operation. Conclusion Concomitant treatment with the maze procedure and ASD closure is safe and effective for restoring the sinus rhythm.

N-terminal pro-B-type natriuretic peptide measurement is useful in predicting left ventricular hypertrophy regression after aortic valve replacement in patients with severe aortic stenosis

Background The predictive factors for early left ventricular hypertrophy (LVH) regression after aortic valve replacement (AVR) have not been fully elucidated. This study was conducted to investigate which preoperative parameters predict early LVH regression after AVR. Methods and results 87 consecutive patients who underwent AVR due to isolated severe aortic stenosis (AS) were analysed. Patients with ejection fraction <50% or concomitant coronary artery disease were excluded from the analysis. Preoperative evaluation including echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement was performed and midterm follow-up echocardiography was done at a median of 9 months after AVR. The presence of complete regression of LVH at the midterm follow-up was determined. In multivariate analysis, including preoperative echocardiographic parameters, only E/e′ ratio was associated with midterm LVH regression (OR 1.11, 95% CI 1.01 to 1.22; p=0.035). When preoperative NT-proBNP was added to the analysis, logNT-proBNP was found to be the single significant predictor of midterm LVH regression (OR 2.00, 95% CI 1.08 to 3.71; p=0.028). By receiver operating characteristic curve analysis, a cut-off value of 440 pg/mL for NT-proBNP yielded a sensitivity of 72% and a specificity of 77% for the prediction of LVH regression after AVR. Conclusions Preoperative NT-proBNP was an independent predictor for early LVH regression after AVR in patients with isolated severe AS.

Response to Letter Regarding Article, “Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis”

We are grateful to Meurin et al for their interest in our article,1 and for raising some concerns. They suggested that the results of our study should not help to justify operations for which real benefit is not proved. There were 3 main issues raised in their letter. First, a registry should not be used to compare 2 therapeutic strategies, because too many biases can be involved; patients in the conventional treatment group probably had serious extra cardiac disease more often, as suggested by a higher rate of noncardiac deaths. We have clearly acknowledged nonrandomized assignment of treatment strategies as the major …

323Changes of NT proBNP correlated with the regression of left ventricular hypertrophy in patients with aortic valve replacement

Eun-Seok Jeona,∗, Soo-Hyeon Yuna, hyun Mi Songa, Eun-Seon Jua, Sang Hoon Leea, Myeong-Chan Chob, Dong Ju Choi c, Jae-Joong Kimd, Kyu Hyung Ryue a Cardiac and Vascular Center, SamsungMedical Center, South Korea b Cardiology, Chungbuk National University Hospital, South Korea c Cardiology, Seoul National University Hospital, South Korea d Cardiology, Asan Medical Center, Ulsan Medical University, South Korea e Cardiovascular Center, Kunkook University Hospital, South Korea