Samer Kassem

EuroSCORE performance in valve surgery: a meta-analysis.

BACKGROUND The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to develop this score were valve procedures. We studied EuroSCORE performance in valve procedures. METHODS We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed. RESULTS A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval [CI], 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form. CONCLUSIONS The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered.

Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting: Single institution experience and meta-analysis

AIMS To assess EuroSCORE performance in predicting in-hospital mortality in on-pump coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB). METHODS AND RESULTS Additive and logistic EuroSCORE were computed for consecutive patients undergoing CABG (n = 3440, 75%) or OPCAB (n = 1140, 25%) at our hospital from 1999 to September 2007. The areas under the receiver operating characteristic (ROC) curves (AUCs) were used to describe performance and accuracy. No difference in performance between CABG and OPCAB and between additive and logistic EuroSCORE (additive EuroSCORE AUCs of 0.808 and 0.779 for CABG and OPCAB, respectively; logistic EuroSCORE AUCs of 0.813 and of 0.773 for CABG and OPCAB, respectively) was found, although a marked tendency to overpredict mortality by both models was evident. A meta-analysis of previously published data was done, and a total of eight studies representing 19 212 and 5461 patients undergoing CABG and OPCAB, respectively, met inclusion criteria. Meta-analysis confirmed similar performance of EuroSCORE in CABG and OPCAB: estimated AUCs were 0.767 and 0.766 for CABG and OPCAB, respectively, with an estimated difference of 0.001 (95% CI -0.061 to 0.063). CONCLUSION Additive and logistic EuroSCORE algorithms performed similarly, and cumulative evidence suggests comparable performance in CABG and OPCAB procedures; both risk models, however, significantly overestimated mortality.

Do statins improve outcomes and delay the progression of non-rheumatic calcific aortic stenosis?

Context It is not known whether statin treatment improves clinical outcomes and reduces aortic stenosis progression in non-rheumatic calcific aortic stenosis. Objective A meta-analysis of studies was performed comparing statin therapy with placebo or no treatment on outcomes and on aortic stenosis progression echocardiographic parameters. Data sources The authors searched Medline and Pubmed up to January 2010. Data extraction Two independent reviewers independently abstracted information on study design (prospective vs retrospective or randomised vs non-randomised), study and participant characteristics. Fixed and random effects models were used. A-priori subanalyses assessed the effect of statins on low-quality (retrospective or non-randomised) and on high-quality (prospective or randomised) studies separately. Results Meta-analysis identified 10 studies with a total of 3822 participants (2214 non-statin-treated and 1608 statin-treated); five studies were classified as prospective and five as retrospective; concerning randomisation, three trials were randomised whereas seven were not. No significant differences were found in all-cause mortality, cardiovascular mortality or in the need for aortic valve surgery. Lower-quality (retrospective or non-randomised) studies showed that, in statin-treated patients, the annual increase in peak aortic jet velocity and the annual decrease in aortic valve area were lower, but this was not confirmed by the analysis in high-quality (prospective or randomised) studies. Statins did not significantly affect the progression over time of peak and mean aortic gradient. Conclusions Currently available data do not support the use of statins to improve outcomes and to reduce disease progression in non-rheumatic calcific aortic valve stenosis.

Minimally invasive mitral valve repair as a routine approach in selected patients.

Objective To report our experience with minimally invasive mitral valve repair. Methods From 1999 to 2003, 104 patients underwent mitral valve repair through a right anterolateral minithoracotomy. Most of them were in New York Heart Association functional class I–II, had normal ejection fraction and were in sinus rhythm. Eighty-five patients suffered from severe mitral regurgitation due to degenerative disease (n = 82) or healed endocarditis (n = 3) and 19 patients had severe mitral stenosis. Sixty-two patients underwent edge-to-edge repair due to anterior/bileaflet prolapse, 23 had a quadrangular resection of the posterior leaflet and 19 a commissurotomy. Results No conversions to sternotomy were necessary. Mean cardiopulmonary bypass and aortic cross-clamp times were 75 ± 14 and 54 ± 8 min, respectively. Median mechanical ventilation and intensive care unit stay times were 6 and 13 h, respectively. No in-hospital deaths and no major postoperative complications occurred. At a mean follow-up of 27.4 ± 10.6 months, all patients but two were in New York Heart Association functional class I. The survival rate was 100% and freedom from reoperation was 95.2 ± 3.3% at 4 years. No or mild residual mitral regurgitation was detected at echocardiography in 100 patients (96%) and moderate insufficiency was found in two (1.9%). The degree of satisfaction in terms of cosmetic result and postoperative discomfort was very high. Conclusions Mitral valve repair can be effectively performed through a minimally invasive approach achieving excellent mid-term results and a high degree of patient satisfaction in terms of comfort, cosmetic result and prompt recovery. At our institution, this approach has now become the standard procedure for mitral valve disease in young and active patients.

Feasibility of pig and human-derived aortic valve interstitial cells seeding on fixative-free decellularized animal pericardium

Glutaraldehyde-fixed pericardium of animal origin is the elective material for the fabrication of bio-prosthetic valves for surgical replacement of insufficient/stenotic cardiac valves. However, the pericardial tissue employed to this aim undergoes severe calcification due to chronic inflammation resulting from a non-complete immunological compatibility of the animal-derived pericardial tissue resulting from failure to remove animal-derived xeno-antigens. In the mid/long-term, this leads to structural deterioration, mechanical failure, and prosthesis leaflets rupture, with consequent need for re-intervention. In the search for novel procedures to maximize biological compatibility of the pericardial tissue into immunocompetent background, we have recently devised a procedure to decellularize the human pericardium as an alternative to fixation with aldehydes. In the present contribution, we used this procedure to derive sheets of decellularized pig pericardium. The decellularized tissue was first tested for the presence of 1,3 α-galactose (αGal), one of the main xenoantigens involved in prosthetic valve rejection, as well as for mechanical tensile behavior and distensibility, and finally seeded with pig- and human-derived aortic valve interstitial cells. We demonstrate that the decellularization procedure removed the αGAL antigen, maintained the mechanical characteristics of the native pig pericardium, and ensured an efficient surface colonization of the tissue by animal- and human-derived aortic valve interstitial cells. This establishes, for the first time, the feasibility of fixative-free pericardial tissue seeding with valve competent cells for derivation of tissue engineered heart valve leaflets.

Papillary muscle-to-anterior annulus stitches: another technique to prevent systolic anterior motion after mitral valve repair.

From the Department of Cardiovascular Surgery, Centro Cardiologico Monzino I.R.C.C.S, Milan, Italy; and the Department of Cardiovascular Surgery, Damascus University Cardiovascular Hospital, Damascus, Syria. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Feb 7, 2011; revisions received March 17, 2011; accepted for publication March 28, 2011; available ahead of print May 2, 2011. Address for reprints: Samer Kassem,MD, Centro CardiologicoMonzino, Via Parea 4, 20138 Milan, Italy (E-mail: skassem@ccfm.it). J Thorac Cardiovasc Surg 2011;142:1278-81 0022-5223/

D-dimer is associated with arterial and venous coronary artery bypass graft occlusion

36.00 Copyright 2011 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2011.03.025

Saphenous vein cannulation in re-redo cardiac surgery.

Objective In this observational prospective study, we assessed the role of clinical variables and circulating biomarkers in graft occlusion at 18 months to identify a signature for graft occlusion. Methods A total of 330 patients undergoing primary elective coronary artery bypass grafting were enrolled. Blood collection for biomarker assessment was performed before surgery and discharge. Patients were then scheduled to undergo coronary computed tomography angiography at 18 months follow‐up, and 179 patients underwent coronary computed tomography angiography 18 ± 2 months postoperatively. Results There were 46 of 503 (9.1%) occluded grafts; of these, 29 (63%) were venous and 17 (37%) were arterial grafts; overall, 43 of 179 patients (24%) had at least 1 occluded graft. Logistic mixed effects model assessing independent factors associated with graft occlusion identified that lower D‐dimer levels at baseline (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.36‐4.89; P = .00) and total protein content at discharge (OR, 1.09; 95% CI, 1.01‐1.19; P = .028) were related to overall graft occlusion at follow‐up, along with an arterial graft other than the left internal thoracic artery (OR, 2.92; 95% CI, 1.24‐6.9; P = .078); moreover, a venous graft emerged was possibly associated with graft occlusion (OR, 1.51; 95% CI, 0.95‐2.39; P = .078). By separately analyzing saphenous vein and arterial grafts, D‐dimer levels (OR, 2.67; 95% CI, 1.15‐6.2; P = .022 and OR, 2.5; 95% CI, 1.01‐7.0; P = .05 for venous and arterial graft, respectively) were still associated with arterial and venous graft occlusion at follow‐up. Conclusions We identified D‐dimer as a biomarker associated with arterial and venous grafts occlusion. This may help stratify patients at risk of graft failure and identify new molecular targets to prevent this complication.

Acute Aortic Insufficiency due to Rupture of an Aortic Valve Commissure

Abstract  The widely used peripheral vein site of cannulation (i.e., the femoral vein) cannot always be employed in the setting of re‐redo procedures. We propose a safe and simple surgical technique for a femoral vein cannulation using the greater saphenous vein as the inflow tract for the venous drainage in the setting of redo cardiac surgery. (J Card Surg 2012;27:676‐677)

Coronary artery disease associated with severe mitral and tricuspid valve regurgitation after left pneumonectomy: report of a successful hybrid procedure

Myxomatous degeneration generally involves the atrioventricular valves (mitral and tricuspid). Rarely, it may affect the aortic or pulmonary valve. We report a case of an acute severe aortic insufficiency due to a rupture of a commissure of the aortic valve in a patient who had previously undergone mitral valve surgery for myxomatous mitral valve prolapse. doi: 10.1111/jocs.12276 (J Card Surg 2014;29:497–498)