Willis H. Williams

Outcomes and Long-Term Survival for Patients Undergoing Mitral Valve Repair Versus Replacement Effect of Age and Concomitant Coronary Artery Bypass Grafting

Background A paucity of literature is available on the effects of age and coronary artery bypass grafting (CABG) on the outcomes of patients undergoing mitral valve (MV) repair versus replacement. Methods and Results A matched study was performed using prospectively collected data from the Emory cardiovascular database from 1984 to 1997 comparing 625 MV repair patients with 625 MV replacement patients. Mean age was significantly higher in the replacement group (56±14 versus 55±14 years). Preoperative demographics and postoperative outcomes were similar between groups. Length of stay (LOS) was significantly less in the repair group (9.5±9.4 versus 12.3±13.1 days). In‐hospital mortality was significantly less in the repair group (4.3% versus 6.9%), and overall 10‐year survival was significantly higher in the repair group (62% versus 46%). Ten‐year survival of patients <60 years of age was significantly higher in repair patients (81% versus 55%) but similar in patients ≥60 years of age (33% versus 36%, respectively). Ten‐year survival of MV repair without CABG was significantly higher compared with MV replacement patients (74% versus 51%) but similar to patients with concomitant CABG (28% versus 34%, respectively). Independent predictors of long‐term mortality included increasing age, urgent/emergent status, female sex, diabetes mellitus, increasing weight, heart failure, decreasing ejection fraction, concomitant CABG, and MV replacement. Conclusions Mitral valve repair has reduced LOS and improved in‐hospital and 10‐year survival. However, in the present series, MV repair does not provide significant long‐term survival benefit over MV replacement in patients older than 60 years of age or those requiring concomitant CABG. (Circulation. 2003;108:298‐304.)

One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction

BACKGROUND Surgical repair of obstructive lesions of the right ventricular outflow tract (RVOT) in children commonly creates pulmonary valve incompetence that may eventually require pulmonary valve replacement (PVR). We reviewed our experience with PVR late after RVOT reconstruction. METHODS We performed 100 PVRs in 93 children 1.1 months to 22.4 years (median 8) after RVOT reconstruction. Children with right ventricular to pulmonary artery conduits and primary PVRs were excluded. Age at PVR was 4.5 months to 27.9 years (median 9.5 years). Initial diagnosis was tetralogy of Fallot and variants, 62; critical pulmonary stenosis, 15; pulmonary atresia with intact ventricular septum, 7; and others, 9. Eleven patients had a redo PVR. A total of 62 PVRs were homografts; 38 were porcine valves. RESULTS There was one early death. On follow-up of 5 months to 12.4 years (mean 4.9 years) there were no late deaths although 1 child underwent cardiac transplantation. Actuarial freedom from redo PVR at 8 years was 100% for porcine valves but 70% for homograft valves (p = 0.17). For children younger than 3 years at PVR, freedom from reoperation was 76% at 1 year and 39% at 8 years compared with freedom from redo PVR at 8 years of 100% for children older than 3 years. On latest echocardiogram 97% of porcine valves had mild or no pulmonary regurgitation compared with 72% of homograft valves. CONCLUSIONS PVR after RVOT reconstruction can be performed with low risk. Porcine valves may be superior to homograft valves although this advantage may be due to older age at time of PVR.

Off-Pump and On-Pump Coronary Artery Bypass Grafting Are Associated With Similar Graft Patency, Myocardial Ischemia, and Freedom From Reintervention: Long-Term Follow-Up of a Randomized Trial

BACKGROUND The Surgical Management of Arterial Revascularization Therapies trial was conceived to rigorously compare completeness of revascularization, clinical outcomes and resource utilization in unselected patients referred for elective, primary coronary artery bypass grafting randomly assigned to undergo off-pump (OPCAB) or conventional on-pump coronary artery bypass grafting using cardiopulmonary bypass (CPB). The goal of this follow-up study was to compare long-term survival, graft patency, myocardial ischemia, and clinical outcomes among survivors who volunteered to return for clinical evaluation and imaging studies. METHODS Two hundred unselected patients with multivessel coronary artery disease were randomly assigned to OPCAB or CPB coronary artery bypass grafting between March 2000 and August 2001. All-cause mortality was determined by individual patient contact and referencing the Social Security Death Master File. Of 140 survivors, 87 volunteered to return after a minimum of 6.8 years (maximum, 8.4 years; mean, 7.5 years) for assessment of graft patency (computed tomographic angiography) and myocardial ischemia (cardiac positron emission tomography and 12-lead electrocardiogram). Age at follow-up ranged from 38 to 90 years (mean, 68 years). RESULTS There were 26 deaths from all causes among OPCAB patients and 31 among CPB patients as of March 30, 2009. Graft patency was similar between groups among 622 grafts assessed by angiography before hospital discharge (99% OPCAB versus 97.7% CPB; p=0.22, Fishers exact test), among 511 grafts assessed by angiography at 1 year (93.6% OPCAB versus 95.8% CPB; p=0.33), and among 190 grafts assessed by computed tomographic angiography at late follow-up (76% OPCAB versus 83.5% CPB; p=0.44). Twelve of 34 OPCAB (35.3%) and 16 of 39 CPB patients (41.0%) had any ischemia on positron emission tomography scanning (p=0.62). Four OPCAB patients (11.8%) and 9 CPB patients (23.1%) had an ischemic region in excess of 10% of myocardium (p=0.21). At late follow-up, recurrent angina had occurred in 11 of 43 (25.6%) OPCAB patients and 5 of 44 (11.4%) CPB patients (p=0.09). Percutaneous reintervention had been performed at the discretion of blinded local cardiologists in 1 of 43 (2.3%) OPCAB patients and 1 of 44 (2.3%) CPB patients (p=1.0). No patient in either group has undergone repeat CABG. CONCLUSIONS In this randomized trial, off-pump and on-pump coronary artery bypass grafting were associated with similar early and late graft patency, incidence of recurrent or residual myocardial ischemia, need for reintervention, and long-term survival.

Valve replacement in patients on chronic renal dialysis: implications for valve prosthesis selection

BACKGROUND Reports are sparse describing heart valve replacement in patients with end-stage renal disease. This review assesses a 15-year experience and outcomes after valve replacement in patients on chronic preoperative renal dialysis. METHODS A computerized database, hospital records, and telephone contact provided outcome data for patients on chronic dialysis undergoing valve replacement between March 22, 1985, and October 13, 2000, in two hospitals. RESULTS Seventy-two patients underwent 95 valve procedures (74 operations). Ages ranged from 23 years to 84 years (mean, 57 years). Fifty-five aortic, 30 mitral, and 3 tricuspid valve replacements and 7 valvuloplasties were performed. Six of the 74 procedures were reoperative valve replacements. In the 46 patients with reliable long-term (greater than 30 days) follow-up data, significant bleeding or stroke was documented in 17 of 34 patients with a mechanical valve and 1 of 12 patients with a bioprosthetic valve. Overall survival (including two operative deaths) was 72.8% at 3 months, 65.4% at 6 months, 60.5% at 1 year, 39.8% at 2 years, 28.5% at 3 years, and 15.9% at 6 years (Kaplan-Meier). Type of valve implanted did not influence early and late survival. CONCLUSIONS In this series of patients on chronic dialysis, survival appears to justify valve replacement. However, the sixfold higher incidence of late bleeding or stroke in patients on dialysis with a mechanical valve requiring warfarin suggests that bioprosthetic valves are the valve substitute of choice in patients on chronic dialysis.

Follow-up of surgical correction of vascular anomalies causing tracheobronchial compression

SummaryBetween January 1977 and January 1990, 44 patients with symptomatic vascular rings/slings required surgical intervention at this center. Nineteen patients had double aortic arch (group I); 13 patients had vascular ring consisting of right aortic arch, anomalous origin of the left subclavian artery, and ligamentum arteriosus (group II); eight patients had innominate artery compression (group III); and four patients had pulmonary artery sling (group IV). Three patients had complex congenital heart defect and died secondary to it and are excluded from the study. Follow-up was obtained on 31 patients (76%). The follow-up period ranged from 0.4 years to 10.9 years, with a mean of 3.6 years. Seventy percent of the overall group were asymptomatic, and 30% of patients continued to have upper and lower respiratory symptoms on late follow-up. One third of patients in groups I and II, who underwent surgical repair, continue to have symptoms. Patients who have persistent symptoms should be further evaluated with PFTs, MRI, and bronchoscopy, and may benefit from aortopexy. Patients with innominate artery compression and pulmonary artery sling do well soon after surgery with relief of most of their symptoms.

Effects of Dual-Chamber Pacing for Pediatric Patients With Hypertrophic Obstructive Cardiomyopathy

OBJECTIVES The effects of both temporary and permanent dual-chamber pacing (DCP) were evaluated in symptomatic pediatric patients with hypertrophic obstructive cardiomyopathy (HOCM) unresponsive to medications. BACKGROUND Permanent DCP pacing can reduce left ventricular outflow tract (LVOT) gradient and relieve symptoms in adult patients with HOCM. METHODS Ten patients (mean [+/-SD] age 11.1 +/- 6 years, range 1 to 17.5) with HOCM and a Doppler LVOT gradient > or = 40 mm Hg were studied. The seven patients showing hemodynamic improvement during temporary pacing at cardiac catheterization underwent surgical implantation of a permanent DCP system. The effects of permanent pacing were evaluated using a questionnaire, Doppler evaluation, treadmill testing and repeat cardiac catheterization. RESULTS At initial cardiac catheterization, three patients failed to respond to temporary pacing (inadequate pace capture in two; congenital mitral valve abnormality in one). The remaining seven patients (70%, 95% confidence interval 38.0% to 91.7%, mean age 13 +/- years, range 4 to 17.5) showed a significant reduction (p < 0.05) in LVOT gradient, left ventricular systolic pressure and pulmonary capillary wedge pressure. After pacemaker implantation, these seven patients reported a significant reduction in dyspnea on exertion and exercise intolerance. Serial Doppler evaluation showed a significant reduction in LVOT gradient. Follow-up catheterization at 23 +/- 4 months in six patients (one patient declined restudy) showed a persistent decrease in LVOT gradient (53 +/- 13 vs. 16 +/- 11 mm Hg), left ventricular systolic pressure (149 +/- 16 vs. 108 +/- 14 mm Hg) and pulmonary capillary wedge pressure (18 +/- 2 vs. 12 +/- 4 mm Hg) versus preimplantation values. CONCLUSIONS Permanent DCP is an effective therapy for selected pediatric patients with HOCM. Rapid atrial rates and intrinsic atrioventricular conduction, as well as congenital mitral valve abnormalities, may preclude effective pacing in certain patients.

Is preoperative fibrinogen predictive for postoperative bleeding after coronary artery bypass grafting surgery

In their article, Karlsson and colleagues stated that preoperative fibrinogen concentrations provide information about postoperative bleeding volume and transfusion requirements after on-pump coronary artery bypass grafting (CABG) surgery. This is an intriguing observation, but it generates some debate. The authors included 170 patients undergoing primary CABG surgery with cardiopulmonary bypass in a prospective and observational study. A total of 26 (15%) of the patients received allogeneic red blood cell (RBC) transfusion, and total blood loss over 12 hours after surgery was between 110 and 2085 mL. The correlation between preoperative fibrinogen and postoperative bleeding is somewhat surprising since we rather expected a correlation between postoperative fibrinogen level and postoperative bleeding. However, the authors did not present these data. In particular, volume replacement therapy and surgical and transfusion practice differ among institutions. The author’s conclusion may not be simply inferred to other clinical settings. Thus we conducted a post hoc analysis of 197 patients who underwent primary CABG surgery from March 2000 to August 2001. The patients were randomly assigned to off-pump and conventional on-pump surgery. Because statistical analyses showed no difference in postoperative chest tube drainage between groups, we considered a potential influence of fibrinogen as a predictor of bleeding in a single cohort. The preoperative fibrinogen level ranged from 1.8 to 9.3 mg/mL, but all patients had levels above the lower normal range (1.6 mg/mL). Postoperative mediastinal drainage ranged from 170 to 2340 mL over 12 hours and from 185 to 3885 mL over 24 hours. Forty-one (21%) patients received postoperative RBC transfusions. In both respects, the data from our patients were comparable to those of the study by Karlsson and colleagues. Postoperative fibrinogen levels ranged from 1.2 to 6.4 mg/mL. There was no correlation between preoperative fibrinogen levels and 24-hour blood loss (r = -0.100; p = 0.170) or postoperative number of transfused units of RBCs (r = 0.122; p = 0.083), but a weak correlation between postoperative fibrinogen levels and 24-hour blood loss (r = -0.154; p = 0.032) or postoperative number of transfused units of RBCs (r = -0.164; p = 0.022). Multiple linear regression analysis examining the covariates sex, off-pump versus on-pump, age, preoperative platelet count, and preoperative fibrinogen level revealed no independent variable associated with postoperative blood loss. For further analysis, we defined chest tube drainage 1000 mL or more/24 hours as clinically relevant blood loss. Receiver operator characteristics curves were used, and the optimal fibrinogen cutoff of 2.0 mg/mL was chosen to predict postoperative bleeding. In case of postoperative fibrinogen level of less than 2 mg/mL, 17 (42%) of 41 patients had 24-hour blood loss of 1000 mL or more compared to 35 (22%) of 156 patients with a fibrinogen of 2 mg/mL or more (c = 0.013). The odds ratio for bleeding with lower fibrinogen was 2.48 (95% confidence interval, 1.20-5.14). In conclusion, we found no correlation between preoperative fibrinogen concentrations and postoperative bleeding in patients undergoing primary on-pump and off-pump CABG surgery. The predictive value of preoperative fibrinogen concentration for bleeding remains a controversial topic as already discussed by the authors. The threshold concentration at 1 mg/mL for fibrinogen replacement has been suggested by international guidelines, but our data indicate that there was a lower risk of bleeding when postoperative fibrinogen levels were maintained over 2 mg/mL in primary coronary bypass surgery. The correlation between “low fibrinogen” and “bleeding” suggested in the study by Karlsson and colleagues and ours may not directly prove the causality because of relatively small sample sizes and retrospective nature. Additional large-scale studies involving more complex cardiac surgery are necessary to determine the threshold concentration of fibrinogen with regard to the risk of severe postoperative bleeding.

Heparin anticoagulation in patients undergoing off-pump and on-pump coronary bypass surgery

PurposeThe authors analyzed the coagulation data of patients who underwent on-pump coronary artery bypass graft (CABG) or off-pump coronary artery bypass surgery (OPCAB) in a randomized prospective trial.MethodsCABG and OPCAB patients received heparin anticoagulation at 400 U·kg−1, and 180 U·kg−1 plus 3000 U every 30 min, respectively. In addition, OPCAB patients received a rectal aspirin, 650 mg, during the procedure. Perioperative coagulation test results (platelet count, fibrinogen, prothrombin time, partial thromboplastin time [PTT], activated clotting time [ACT], and thromboelastography [TEG; Haemoscope] were collected from CABG (n = 99) and OPCAB (n = 98) patients. Residual heparin activity after protamine was measured, using an anti-activated factor X (Xa) assay, in 10 patients from each group.ResultsOur study showed that the current anticoagulation regimen in the OPCAB patients achieved a peak ACT of 445 ± 73 s, and it preserved platelet counts and fibrinogen levels. A residual heparin effect was detected, with residual anti-Xa heparin activity of 0.2 U·ml−1 up to 2 h after surgery in the OPCAB group. Despite the residual anticoagulation, the OPCAB group had a similar TEG index of native blood, postoperative chest tube drainage, and non-erythrocyte transfusion rate as compared with the CABG group.ConclusionWe have shown that the heparin anticoagulation regimen in OPCAB patients does not lead to an immediate hypercoagulable state. Total doses of heparin and protamine were lower in the OPCAB group compared with the CABG group, and there was a residual heparin effect on TEG and PTT in the early postoperative period in the OPCAB group.

Esmolol as an adjunct in the treatment of systemic hypertension after operative repair of coarctation of the aorta

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Neurocognitive and neuroanatomic changes after off-pump versus on-pump coronary artery bypass grafting: Long-term follow-up of a randomized trial

OBJECTIVE It is unknown whether avoidance of cardiopulmonary bypass during coronary artery bypass grafting affects cerebral injury or long-term neuropsychological function. METHODS Two hundred unselected patients were randomized to off-pump coronary artery bypass or on-pump coronary artery bypass grafting between March 2000 and August 2001. One hundred sixty-eight patients had early postoperative brain magnetic resonance imaging. Eighty-seven returned after a mean of 7.5 years of follow-up; 67 had repeat magnetic resonance imaging, and 76 had neuropsychological testing. RESULTS There were 26 deaths among patients undergoing off-pump coronary artery bypass and 31 among patients undergoing cardiopulmonary bypass as of March 2009. Seventy-six patients (41 undergoing cardiopulmonary bypass and 35 undergoing off-pump coronary artery bypass) had neuropsychological testing at late follow-up. Groups were similar in age, sex, depression, and IQ. Patients undergoing off-pump coronary artery bypass showed better attention, performing better at tracking and mentally manipulating information (P =.011). Patients undergoing off-pump coronary artery bypass demonstrated better cognitive reasoning and made fewer errors in reasoning (P = .05); they also showed a trend toward better verbal learning (P = .064). There were no domains in which patients undergoing cardiopulmonary bypass outperformed those undergoing off-pump coronary artery bypass. Early magnetic resonance imaging in 168 patients showed no significant differences between groups in temporal or frontal lobe atrophy, subcortical white matter lesions, or acute infarctions. There were no significant differences between groups in atrophy over time or new subcortical white matter lesions or infarctions. Acute perioperative cerebral infarctions were more common and atrophy more progressive during follow-up among diabetic than nondiabetic patients. CONCLUSIONS After a mean of 7.5 years of follow-up, patients undergoing off-pump coronary artery bypass performed better than those undergoing cardiopulmonary bypass in several neuropsychological domains; these differences were small and of uncertain clinical importance. Early brain magnetic resonance imaging showed no significant differences in acute cerebral infarctions between the off-pump coronary artery bypass and cardiopulmonary bypass groups.