Shahab Nozohoor

Transapical Versus Transfemoral Aortic Valve Implantation: A Comparison of Survival and Safety

BACKGROUND Transcatheter aortic valve implantation (TAVI) is a therapeutic option for high-risk patients with aortic stenosis. Procedural mortality remains high in comparison with conventional aortic valve replacement (AVR) because patients determined for TAVI are commonly denied conventional surgery. We aimed to evaluate access-related complications between the transfemoral (TF) and the transapical (TA) approach and to compare survival between TAVI and conventional AVR in propensity-score-matched patients. METHODS Between January 2008 and November 2009, 40 patients underwent TAVI (TF, n=10; TA, n=30) with the Edwards Sapien bioprosthesis (Edwards Lifesciences, Irvine, CA). Survival and postoperative complications were evaluated between the TF and the TA approach. A comparison of survival was made between the TAVI patients and propensity-score-matched patients undergoing conventional AVR. RESULTS Successful implantation rate was 92.5% (37 of 40). Thirty-day mortality was 5.0% (2 of 40), and the overall in-hospital mortality was 10.0% (4 of 40). Survival after TAVI was 77% at both 6 months and 1 year. Major vascular complications occurred in 3 of 10 patients (all in the TF group), and 3 of 40 patients (7.5%) suffered cerebrovascular events. A comparison of survival between TAVI and propensity score-matched conventional AVR patients showed no significant difference in either the TA group (p=0.73) or the TF group (p=0.59). CONCLUSIONS The vascular complications occurring when using the TF approach were probably related to a combination of a wide introducer sheath and heavily calcified femoral arteries in a high-risk population. No serious complications were encountered when using the TA approach. After propensity-score matching, survival with both the TA and TF approaches is similar to that after AVR.

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study

Abstract Aims Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. Methods and results All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012–13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72–120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53–1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72–120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04–2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56–0.92), P = 0.012]. Conclusion The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.

Negative-pressure wound therapy following cardiac surgery: bleeding complications and 30-day mortality in 176 patients with deep sternal wound infection

Negative-pressure wound therapy (NPWT) has been used for the treatment of deep sternal wound infection (DSWI) with promising results. However, questions have been raised regarding the potential risk of right ventricle (RV) rupture during treatment. In the present study, we evaluate our clinical experience of NPWT focusing on RV rupture and major bleeding complications and its potentially negative impact on 30-day mortality during an 11-year period. Serious bleeding complications during NPWT were reviewed for 176 patients treated for DSWI between January 1999 and April 2010. The 30-day mortality following DSWI was 1.1% (2/176). Four patients (2.3%) suffered bleeding from the RV rupture during NPWT of the sternal wound (two spontaneous and two debridement related). Furthermore, two patients had debridement-related bleedings from the venous bypass grafts during wound dressing change. The very low 30-day mortality (1.1%) following DSWI supports the use of NPWT. Overall, even if major bleeding complications may occur, the risk of RV rupture seems to be outweighed by the benefit of superior infection control. However, surgical experience is recommended when debriding sternal wounds and we recommend the use of a wound dressing, such as paraffin gauze, in order to protect the RV from direct contact with the polyurethane foam.

Erythropoietin and protection of renal function in cardiac surgery (the EPRICS Trial).

Background:To date, there are no known methods for preventing acute kidney injury after cardiac surgery. Increasing evidence suggests that erythropoietin has renal antiapoptotic and tissue protective effects. However, recent human studies have shown conflicting results. The authors aimed to study the effect of a single high-dose erythropoietin preoperatively on renal function after coronary artery bypass grafting in patients with preoperative impaired renal function. Methods:This single-center, randomized, double-blind, placebo-controlled study included 75 patients scheduled for coronary artery bypass grafting with preexisting renal impairment estimated glomerular filtration rate based on p-cystatin C (<60 and >15 ml/min). The patients either received a single high-dose erythropoietin (400 IU/kg) or placebo preoperatively. The primary endpoint was renal protection evaluated by p-cystatin C at the third postoperative day compared to the preoperative values. Incidence of acute kidney injury and other renal biomarker changes were among secondary endpoints. Results:There was no statistically significant difference on the third postoperative day for relative p-cystatin C level changes from baseline between the groups, 131 ± 31% (mean ± SD) for the study group and 125 ± 24% for the control group (P = 0.31; 95% CI, −0.6 to 20% for the difference). There were no statistically significant differences in other renal biomarkers or measures between the groups (p-neutrophil gelatinase–associated lipocalin, p-creatinine, p-urea, and estimated glomerular filtration rate). There were no other differences in outcome variables between the groups. Conclusion:Intravenous administration of a single high-dose (400 IU/kg) erythropoietin did not have a renal protective effect on patients with reduced kidney function undergoing coronary artery bypass surgery.

Influence of Prosthesis-Patient Mismatch on Diastolic Heart Failure After Aortic Valve Replacement

BACKGROUND Bioprostheses for supraannular placement have been developed to optimize the hemodynamic performance after aortic valve replacement. To evaluate the potential benefit of this design, we analyzed the influence of prosthesis-patient mismatch on diastolic function and left ventricular mass regression and evaluated the clinical performance of the Sorin Soprano and Medtronic Mosaic in the aortic position. METHODS A total of 372 patients underwent aortic valve replacement between July 2004 and February 2007, receiving either a Sorin Soprano (n = 235) or a Medtronic Mosaic (n = 137) prosthetic valve. Echocardiographic and clinical data were collected prospectively, and follow-up was performed in April 2007. Multivariate analyses were used to identify differences in hemodynamic performance, diastolic function, left ventricular mass regression, and predictors of impaired survival. Kaplan-Meier survival curves and log-rank tests were used to compare postoperative outcomes. RESULTS The 30-day mortality was 1.7% (4 of 235 patients) in the Sorin Soprano group and 2.9% (4 of 137 patients) in the Medtronic Mosaic group (p = 0.473). Neither prosthesis-patient mismatch nor type of prosthesis was a significant predictor of early or late mortality. Diastolic heart failure was a predictor of poor survival (p = 0.004); however, the recovery of diastolic function was not significantly influenced by prosthesis-patient mismatch. Neither moderate (indexed effective orifice area < 0.85 cm(2)/m(2)) nor severe (indexed effective orifice area < 0.65 cm(2)/m(2)) prosthesis-patient mismatch resulted in a significantly impaired left ventricular mass regression. CONCLUSIONS Prosthesis-patient mismatch was not an independent predictor of poor survival, impaired left ventricular mass regression, or recovery of diastolic function. The Sorin Soprano and the Medtronic Mosaic bioprostheses demonstrated comparable hemodynamic performance and excellent clinical outcome without signs of structural valve deterioration during follow-up.

Shrunken Pore Syndrome is associated with a sharp rise in mortality in patients undergoing elective coronary artery bypass grafting.

Abstract Shrunken Pore Syndrome was recently suggested for the pathophysiologic state in patients characterized by an estimation of their glomerular filtration rate (GFR) based upon cystatin  C, which is lower or equal to 60% of their estimated GFR based upon creatinine, i.e. when eGFRcystatin  C ≤ 60% of eGFRcreatinine. Not only the cystatin  C level, but also the levels of other low molecular mass proteins are increased in this condition. The preoperative plasma levels of cystatin  C and creatinine were measured in 1638 patients undergoing elective coronary artery bypass grafting. eGFRcystatin  C and eGFRcreatinine were calculated using two pairs of estimating equations, CAPA and LMrev, and CKD-EPIcystatin  C and CKD-EPIcreatinine, respectively. The Shrunken Pore Syndrome was present in 2.1% of the patients as defined by the CAPA and LMrev equations and in 5.7% of the patients as defined by the CKD-EPIcystatin  C and CKD-EPIcreatinine equations. The patients were studied over a median follow-up time of 3.5 years (2.0–5.0 years) and the mortality determined. Shrunken Pore Syndrome defined by both pairs of equations was a strong, independent, predictor of long-term mortality as evaluated by Cox analysis and as illustrated by Kaplan-Meier curves. Increased mortality was observed also for the subgroups of patients with GFR above or below 60 mL/min/1.73 m2. Changing the cut-off level from 60 to 70% for the CAPA and LMrev equations increased the number of patients with Shrunken Pore Syndrome to 6.5%, still displaying increased mortality.

Acute Kidney Injury Assessed by Cystatin C after Transcatheter Aortic Valve Implantation and Late Renal Dysfunction.

OBJECTIVE The aim of the present study was to evaluate acute kidney injury (AKI) with cystatin C following transcatheter aortic valve implantation (TAVI) and to assess the impact of postoperative AKI on outcome and late renal function. DESIGN A prospective study. SETTING Single, tertiary referral center. PARTICIPANTS Sixty-eight consecutive patients with severe aortic stenosis and advanced comorbidity. INTERVENTIONS Blood samples were collected on 4 occasions pre- and postoperatively to determine levels of s-creatinine and cystatin C. Additionally, a sample was collected at followup 12 months postoperatively for the determination of s-creatinine. MEASUREMENTS AND MAIN RESULTS The mean preoperative eGFR (s-creatinine) was 67±24 mL/min/1.73 m² compared to 45±21 mL/min/1.73 m² with eGFR (cystatin C) (p<0.001). Postoperative AKI was diagnosed in 25 patients (39%) with eGFR (cystatin C), compared to 21 patients (33%) with GFR (s-creatinine) and the RIFLE criteria. The 90-day mortality was 14.3% for the AKI+group and 2.3% for the AKI-group (p = 0.099). At 12 months followup, renal function remained impaired in patients with postoperative AKI and deteriorated in patients without. CONCLUSIONS The risk of postoperative AKI is considerable following TAVI, with an increased risk of early mortality for AKI+patients. Cystatin C may be a valuable adjunct to the established biomarker s-creatinine for preoperative risk assessment and for early postoperative diagnosis of AKI. The acute postoperative renal impairment in patients with AKI does not fully recover in the long term. There is a progressive renal impairment in both groups postoperatively, the etiology probably being multifactorial.

Postoperative Increase in B-Type Natriuretic Peptide Levels Predicts Adverse Outcome After Cardiac Surgery

OBJECTIVE To evaluate the prognostic implication of changes in postoperative B-type natriuretic peptide (BNP) concentrations in patients undergoing cardiopulmonary bypass for cardiac surgery. DESIGN A retrospective analysis of prospectively collected clinical data. SETTING Cardiothoracic surgery and an intensive care unit (ICU) in a university hospital. PARTICIPANTS The present study included a total of 407 consecutive patients undergoing cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS BNP concentrations were measured on admittance to the ICU (D0) and at day 1 after surgery. Patients were divided into quintiles according to their BNP level on admittance to the ICU. The predictive value of absolute changes in BNP levels during the first 24 hours postoperatively was analyzed with Kaplan-Meier estimates of survival and Cox multivariate proportional analysis. Prognostic factors for impaired midterm survival included elevation of the BNP level (HR, 7.3/ log10(x); 95% confidence interval, 1.8-29, p = 0.005). The BNP levels of patients undergoing isolated valve surgery or valve and concomitant CABG surgery were significantly higher (p = 0.012 and p = 0.032, respectively) than those undergoing isolated coronary artery bypass graft surgery. Patients in higher quintiles required ventilation for a longer time (p < 0.001), and prolonged inotropic support (p < 0.001). The mean plasma BNP concentration of 172 pg/mL (median, 64; interquartile range, 172) on arrival at the ICU had a sensitivity of 75% and a specificity of 74% for predicting 1-year mortality. CONCLUSIONS Elevated BNP levels on admittance to the ICU and postoperatively increasing BNP levels are associated with adverse postoperative outcome and are predictive of impaired late survival. Sequential postoperative BNP monitoring facilitates the early identification of patients at an increased risk of heart failure and may be used as an adjunct for clinical decision making and optimized patient management.

Diagnostic Yield and Efficacy of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in Mediastinal Lymphadenopathy.

Introduction:  Endobronchial ultrasound transbronchial needle aspiration (EBUS‐TBNA) is an emerging minimally invasive option for pathologic examination of intrathoracic lymphadenopathy as well as for staging lung cancer.

Polytetrafluoroethylene neochordae is noninferior to leaflet resection in repair of isolated posterior mitral leaflet prolapse: a multicentre study.

OBJECTIVES Resection techniques are the established method for posterior mitral valve leaflet repair in degenerative mitral valve disease. However, implantation of expanded polytetrafluoroethylene (ePTFE) neochordae is gaining acceptance. The aim of this study was to compare the durability and clinical outcome following mitral valve repair using ePTFE neochordae or leaflet resection. METHODS A retrospective study was conducted of 224 patients who had undergone isolated mitral valve repair for degenerative posterior mitral leaflet prolapse from 1998 to 2012 at two cardiothoracic centres, one in Sweden and one in Denmark. Follow-up was performed in February 2013 and was 100% complete for survival (1184 patient-years; mean 5.9 ± 3.9 years). Event rates were estimated with the Kaplan-Meier method. RESULTS The 30-day mortality rate was 0.5%. Repair was successful in 215 patients (96.0%). Leaflet resection was performed in 146 (72.6%), whereas 55 (27.4%) underwent ePTFE neochordae repair. All patients received an annuloplasty with a mean size of 33 ± 4 mm in the ePTFE group and 31 ± 3 mm in the resection group (P = 0.001). The 5-year survival rate was 98.2 ± 1.8% in the ePTFE group and 93.9 ± 2.1% in the resection group (P = 0.67). At 5 years, the rate of freedom from recurrent moderate or severe mitral regurgitation was 91.9 ± 5.5% in the ePTFE group and 95.8 ± 2.1% in the resection group (P = 0.20), and the rate of freedom from all-cause reoperation was 100% in the ePTFE group and 97.9 ± 1.2% in the resection group (P = 0.36). CONCLUSIONS ePTFE neochordae is noninferior to resection repair for posterior mitral leaflet prolapse. Both techniques have comparable early and mid-term postoperative outcomes with low mortality, and a low incidence of reoperation and recurrent mitral regurgitation.