Do hospitals with low mortality rates in coronary artery bypass also perform well in valve replacement?

BACKGROUND: While hospital performance in coronary artery bypass graft (CABG) surgery is reported widely, patients may find it difficult to learn about their hospital's performance in heart valve replacement. We sought to determine if a hospital's performance in CABG is correlated to its performance in heart valve replacement. METHODS: We studied operative mortality after CABG, aortic valve replacement (AVR), and mitral valve replacement (MVR) using the 1994 to 1999 national Medicare database. After excluding any hospital that did not perform at least 50 CABGs and 20 valve replacements per year we examined the correlation between hospital mortality in CABG and hospital mortality in AVR and MVR using least-squares simple linear regression models. Operative mortality was adjusted for patient characteristics using logistic regression models. RESULTS: A total of 684 hospitals performed 817,606 isolated CABGs, 142,488 AVRs (54% with concomitant CABG), and 61,252 MVRs (45% with concomitant CABG). Hospital mortality rates with AVR ranged from 6.0% to 13.0% between hospitals in the lowest and highest, respectively, 10th percentile of CABG performance. Similarly hospital mortality rates with MVR ranged from 10.1% to 20.5% in the lowest and highest respectively, 10th percentile of CABG performance. Adjusted mortality rates for both AVR and MVR were closely correlated with isolated CABG mortality rates (correlation coefficients 0.592 and 0.538, respectively; p = 0.001 for both correlations). In stratified analyses these correlations persisted regardless of whether valve replacement was performed with or without concomitant CABG or whether valve replacement was performed in a high- or low-volume hospital. CONCLUSIONS: Hospital mortality rates with CABG are closely correlated with mortality rates with valve replacement. These findings suggest that shared processes and systems of care are important determinants of performance in cardiac surgery.     

Concomitant Mitral Regurgitation in Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis: A Systematic Review

Background: Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging.Methods: A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR.Results: A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%.Conclusion: This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.     

Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery

BACKGROUND: Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. METHODS: Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. RESULTS: Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29-2.09) and MVR patients (OR 2.21, 95% CI 1.48-3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93-1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. CONCLUSIONS: Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.     

Management of aortic valve disease during aortic surgery

BACKGROUND: Outcomes and resource utilization of patients undergoing mitral valve replacement (MVR) with or without concomitant coronary artery bypass grafting (CABG) were reviewed. METHODS: Data for 1,844 patients undergoing isolated primary MVR at Emory University Hospitals between 1980 and 1997 were recorded prospectively in a computerized database. RESULTS: The four groups included patients undergoing elective MVR with (n = 360) or without CABG (n = 1332) and urgent/emergent MVR with (n = 66) or without CABG (n = 86). Length of stay was significantly higher in patients undergoing elective MVR with CABG (15 days) than in those without CABG (11 days) but was not significantly different in patients undergoing urgent/emergent MVR with CABG (17 days) than in those without CABG (19 days). In-hospital mortality was significantly higher for patients undergoing elective (14%) or urgent/emergent (41%) MVR with CABG than in those undergoing MVR without CABG (elective:6%; urgent/emergent:20%). The 19-year survival rate was 32% for patients undergoing elective MVR with CABG compared with 51% for those without CABG and 28% for patients undergoing urgent/emergent MVR with CABG compared with 46% for those without CABG. Multivariate correlates of long-term mortality included older age, concomitant CABG, and urgent/emergent status. Hospital costs were significantly higher for patients undergoing elective MVR with ($33,216) than for those without ($23,890) CABG. No significant difference in cost were noted between patients undergoing urgent/emergent MVR with ($40,535) and without ($31,981) CABG. CONCLUSIONS: The addition of CABG or urgent/emergent status to patients undergoing MVR significantly increases morbidity, mortality, and costs. Careful scrutiny of the benefits versus resource utilization is required for patients undergoing high risk MVR.     

Management of mild to moderate aortic valve disease during coronary artery bypass grafting.

OBJECTIVE: The long term survival of patients with mild to moderate aortic valve disease who do not have valve replacement at the time of coronary artery bypass grafting (CABG) is unknown. Therefore we have reviewed our experience with such patients. METHODS: We reviewed the medical records of consecutive patients between June 1978 and December 1996, and identified 40 patients with mild to moderate aortic valve disease, who underwent CABG, without valve replacement (study group). Mean preoperative aortic gradient was 34 mmHg and mean intraoperative gradient 20 mmHg. Eleven patients underwent valve inspection, and an equal number, underwent valve repair. The records of 61 other patients with severe aortic valve disease, who underwent concomitant aortic valve replacement (AVR) and CABG (control group), were also reviewed. RESULTS: Survival was significantly better in the control group. Eleven patients (27.5%) in the study group underwent reoperation for AVR, with no operative mortality. Multivariate analysis confirmed valve replacement at initial CABG to be the only predictor of survival (beta=0.586,P=0.038) Preoperative gradient <40 mmHg, intraoperative gradient <20 mmHg, age over 70, sex, aortic stenosis and valve pathology did not predict survival in the study group. CONCLUSION: Patients with mild to moderate aortic valve disease undergoing coronary artery bypass grafting may be best served by valve replacement, rather than repair, inspection or no procedure.     

Impact of dialysis in patients undergoing bioprosthetic aortic valve replacement

 Open in a separate windowOBJECTIVESTo determine the incidence of bioprosthetic structural valve deterioration in dialysis patients undergoing aortic valve replacement compared to that in patients without dialysis.METHODSThis single-centre retrospective observational study included 1159 patients who underwent aortic valve replacement using bioprosthetic valves for aortic stenosis and/or regurgitation at our institution between 2007 and 2017 [patients with dialysis (group D, n = 134, 12%) or without dialysis (group N, n = 1025, 88%)]. To adjust for potential differences between groups in terms of initial preoperative characteristics or selection bias, a propensity score analysis was conducted. The final sample that was used in the comparison included 258 patients, as follows: 129 patients with dialysis (group D) and 129 patients without dialysis (group N). The cumulative incidences of all-cause death, cardiac death and moderate or severe structural valve deterioration were estimated using the Kaplan–Meier method.RESULTSOperative mortality was significantly higher in group D than group N (9% vs 0%, P = 0.001). Kaplan–Meier analysis revealed that in group D, the incidence was significantly higher for all-cause death (P < 0.001, 50% vs 18% at 5 years), cardiac death (P = 0.001, 18% vs 5% at 5 years) and moderate or severe structural valve deterioration (P < 0.001, 29% vs 5% at 5 years) compared with group N.CONCLUSIONSThe incidence of structural valve deterioration in dialysis patients undergoing aortic valve replacement was higher than that in patients without dialysis. Bioprosthetic valves should be carefully selected in dialysis patients undergoing aortic valve replacement.     

Open heart surgery in the elderly

Of 3254 open heart surgical cases performed since 1972, 126 patients (3.9%) were 70 years of age or older. The mean age was 72 years, the oldest being 82. Sixty-seven per cent were male. The following procedures were performed: coronary artery bypass grafting (CABG) 51, aortic valve replacement (AVR) 44, AVR + CABG 16, mitral valve replacement (MVR) 3, MVR + CABG 6, MVR + AVR 4, and other, 2. Of those undergoing CABG, 33% came from the Coronary Care Unit and 24% had left main coronary artery stenosis. There was one peri-operative death (2.0%). Of those undergoing AVR, 43% had coronary artery disease and 13% triple vessel disease. Operative mortality for AVR, and AVR + CABG was 11.4% (5/44) and 18.8% (3/16), respectively. Twenty-six per cent of operative survivors had significant postoperative complications (excluding atrial arrhythmias). The postoperative hospital stay for CABG, AVR and other cases was 11, 13 and 16 days, respectively. Seven year survival of all patients was 61.2 +/- 6.5% (+/- 1 SE) and for AVR +/- CABG was 51.5 +/- 8.6%. Five year survival for CABG was 83.9 +/- 6.3%. We conclude that, in selected cases, CABG can be performed safely in the elderly. Although valvular and combined surgery may result in significant morbidity and mortality, the satisfactory long term results in survivors justifies surgery in this group of patients.     

Combined mitral valve and coronary artery surgery

During the past 10 years, 50 patients underwent combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) at our clinic, with additional aortic valve replacement (AVR) in six cases. The early mortality was 8%. During the first half of the study period this mortality was 4/11 patients, but in the second half it was 0/39. All six patients with CABG + MVR + AVR survived the operation. Adverse factors were found to be advanced functional impairment, female sex, concomitant untreated aortic valvulopathy and elevated pulmonary vascular resistance. All 46 patients who survived the operation were followed up for a mean period of 31 months, and during that time there were nine deaths. The survival rate was 54% after 3 years and 40% after 5 years. Most of the patients had improved by at least one functional class. The good results in this series probably were attributable to improvements in surgical procedure (introduction of cold potassium cardioplegia) and in postoperative management (intra-aortic balloon pumping).     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

Mortality after mitral regurgitation surgery: importance of clinical and echocardiographic variables.

OBJECTIVES: The management of patients with mitral regurgitation (MR) constitutes a challenge due to its heterogeneity in terms of etiology and possible treatment strategies. In the present study, we sought to describe the importance of preoperative echocardiographic and clinical variables in relation to outcome 5 years after surgical treatment of MR. METHODS: The echocardiographic reports (transthoracic) from 298 patients were analyzed and the anatomic lesions were classified into one of three main groups (functional, organic degenerated with hypermobile valve or organic degenerated without hypermobility). 5-year cumulative survival was compared with the expected survival in an age- and gender-matched normal population. Risk functions were determined with a Poisson regression model. RESULTS: Operative mortality was 4.4%, with higher mortality in patients with concomitant coronary artery bypass grafting (CABG) (7.6 vs. 2.2%, P=0.03). Survival after 5 years was 65% in patients with concomitant CABG, compared with the expected 86% (P<0.001), 70 vs. 88% (P<0.001) in patients with preoperative NYHA class III/IV, while survival in patients with NYHA class I/II did not differ from the expected (90 vs. 90%, P=0.56). In patients with a hypermobile valve without CABG, postoperative survival did not differ from the expected (91 vs. 89%, P=0.92). The estimated risk ratio for death, repair versus prosthesis, was 0.57 (95% confidence interval 0.32-1.00, P=0.05). CONCLUSIONS: The present study shows that it is possible, using transthoracic echocardiography and clinical data, to identify patients with an excellent outcome. The adverse effects of severe symptomatology and replacement compared with repair are demonstrated. The findings encourage early intervention before severe symptoms occur, especially if repair is possible.     

Trend in morbidity and mortality in surgical aortic valve replacement: a retrospective,observational, single-centre study

Open in a separate window OBJECTIVESContinuous improvement in the management of patients undergoing surgical aortic valve replacement (SAVR) may have considerably enhanced surgical outcomes including in-hospital mortality and perioperative complications. We aimed to analyse in-hospital mortality and morbidity trends in patients undergoing SAVR in a single centre to provide insights for future benchmarking for transcatheter aortic valve implantation indications.METHODSThis was a retrospective study of prospectively collected data from patients undergoing either isolated SAVR or combined with coronary artery bypass grafting (CABG) at the Bristol Heart Institute, UK, from January 2000 to December 2017. Baseline characteristics were extracted and analysed across 3 different eras (2000–2005, 2006–2011 and 2012–2017). Risk-adjusted time trend was obtained from univariate and multivariate logistic regression including all baseline characteristics.RESULTSA total of 2719 patients (63.2%) underwent isolated SAVR, and 1581 (36.8%) underwent combined CABG and SAVR during the study period. For patients undergoing SAVR, in-hospital mortality decreased from 2.9% in 2000–2005 to 0.7% in 2012–2017 (risk-adjusted time trend 0.0001). Hospital mortality in patients aged 75–79 and ≥80 years decreased from 5.6% and 5.3% to 0.4% and 2.2%, respectively. Mortality after combined SAVR and CABG did not significantly decrease (from 3.9% in 2000–2005 to 3.5% in 2012–2017; risk-adjusted time trend = 0.62). However, in patients aged ≥80 years, index hospitalization mortality showed a decreasing non-significant trend from 9.8% to 4.8%.CONCLUSIONSOur findings support the hypothesis that mortality and morbidity rates following SAVR have significantly improved over the years, including for patients at high risk.     

慢性中重度缺血陛二尖瓣关闭不全的外科治疗及中期随访

目的 比较二尖瓣成形术和瓣膜置换术治疗慢性中重度缺血性二尖瓣关闭不全的手术效果及中期随访结果 .方法 自2002年6月至2008年5月,83例慢性缺血性二尖瓣关闭不全(中度35例,重度48例)接受冠状动脉旁路移植术同期行二尖瓣成形术或二尖瓣置换术.男49例,女34例;年龄51～77岁,平均(59.3±7.5)岁.43例二尖瓣成形术包括使用Dacron补片条或自体心包条环缩后瓣环21例,交界处环缩9例,后叶矩形切除9例,St.Jude成形环环缩4例.40例二尖瓣置换术包括机械瓣28例,生物瓣12例.结果 住院死亡3例,二尖瓣成形术组和二尖瓣置换术组住院死亡分别占2.3%(1/43例)、5.0%(2/40例),差异无统计学意义(P>0.05).术后瓣膜置换组机械通气时间长于二尖瓣成形组(P<0.05),二尖瓣成形组术后6例残余轻度二尖瓣反流(P<0.05)但不影响心功能,两组其他住院并发症无统计学差异(P>0.05).76例通过门诊或电话随访,随访3～60个月,平均(20.2±4.9)个月.随访期间二尖瓣成形术7例轻度二尖瓣反流.瓣膜置换组人工瓣功能均良好,3例出现抗凝相关并发症.随访远期死亡7例,冠状动脉旁路移植术同期二尖瓣成形术和二尖瓣置换术5年生存率分别为90%和61%.结论 对于慢性中重度缺血性二尖瓣关闭不全病人,二尖瓣成形术后近期和远期效果好,可作为优先选择的术式.     

Nine years' experience with the Bj?rk-Shiley prosthetic valve: early and late results of 932 valve replacements

Between November, 1970, and December, 1977, 932 consecutive patients received the standard Bj?rk-Shiley prosthesis. Operative mortality was 4.6% for aortic valve replacement (AVR; N = 364), 5.1% for mitral valve replacement (MVR; N = 313); 11.3% for multiple valve replacement (N = 194), and 13.7% for valve replacement combined with coronary artery bypass grafting (CABG; N = 51). Factors influencing hospital mortality included type of valve replacement, age at operation, whether the valve replacement was done as an emergency, and year of implantation. Complete follow-up (mean, 3.7 years) was achieved in 95% of the survivors. Actuarial survival was 82% for AVR patients at 8 years, 83% for MVR patients at 7 years, 72% for multiple valve replacement patients at 7 years, and 76% for those who had valve replacement with CABG at 3 years. No significant difference in late survival was found between patients with mitral insufficiency alone (p greater than 0.2) or aortic insufficiency alone (p greater than 0.9) and those with stenotic lesions only. Thromboembolic complications occurred at an incidence of 1.17% per patient-year, and Dicumarol-induced hemorrhages occurred at an incidence of 2.11% per patient-year. Twelve out of 13 patients survived operation for prosthetic valve thrombosis, indicating that this complication is not as catastrophic as many believe. The incidence of reoperation in anticoagulated patients was 0.63% per patient-year. All of these results are compared with data from the recent literature.     

Combined valve replacement and myocardial revascularization

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with greater than 70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p less than 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement and CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early results of mitral valve replacement.

Early results of mitral valve replacement were reviewed in 336 unselected patients, 261 without and 75 with concomitant coronary artery bypass grafting (MVR and MVR + CABG groups). Early (less than 30 days) mortality was 7% in the MVR and 16% in the MVR + CABG group, with cardiac failure as the dominant cause. In multivariate analysis, the variables most strongly related to early mortality were congestive heart failure, diabetes and previous cardiac surgery in the MVR group and congestive heart failure in MVR + CABG. In the cases with fatal outcome the incidence of peroperative technical complications was 32% at MVR and 17% at MVR + CABG. The incidence of myocardial injury was 21% and 35% in the respective groups, and the early mortality in these cases was 19% vs 23%. Half of all fatal cases showed signs of peroperative myocardial injury. Multivariate analysis showed factors independently related to myocardial injury to be year of surgery and aortic cross-clamp time in MVR and previous cardiac surgery in MVR + CABG. Operation before cardiac reserves are reduced, optimal peroperative myocardial preservation and avoidance of technical errors should improve results of MVR.     

Risks of mitral valve replacement and mitral valve replacement with coronary artery bypass

One hundred thirty consecutive patients who underwent mitral valve replacement (MVR) or MVR with coronary artery bypass grafting (CABG) using cold crystalloid cardioplegic solution were analyzed to determine operative mortality and risk factors. Twenty-eight patients had mitral stenosis (MS), 37 had mitral regurgitation (MR), 37 had mixed MS and MR, 23 had MR with coronary artery disease (CAD), and 5 had MS with CAD. Preoperative pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index were not different among groups, but patients with MR and CAD had a significantly higher left ventricular end-diastolic pressure (LVEDP) and a significantly lower ejection fraction than other groups. Mortality was 7.1% for patients with MS, 5.4% for MR, 8.1% for mixed MS and MR, 0 for MS with CAD, and 21.7% for MR and CAD. Overall mortality was 9.2%. Eleven patients had emergency operations for cardiogenic shock with a mortality of 45%. Nineteen additional patients in New York Heart Association (NYHA) Functional Class IV had MVR or MVR plus CABG with a mortality of 26%. Sixteen patients required intraaortic balloon pump assistance, and 9 survived. Four patients with MR and CAD required the left ventricular assist device, and 3 survived. Excluding patients who had emergency operations, overall mortality was 5.8%. Excluding patients who had emergency operations and patients in NYHA Functional Class IV, overall mortality was 2%. Factors associated with death were cardiogenic shock, NYHA Class IV, LVEDP greater than 15 mm Hg (16% mortality), and age greater than 60 years (15% mortality).     

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

 Open in a separate windowOBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.     

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BackgroundRecent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase.MethodsPatients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score–matched analyses were used to compare patients with and without mitral intervention.ResultsA total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; P_trend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; P_trend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5).ConclusionsConsistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.     

Late Echocardiographic and Clinical Outcomes after Mitral Valve Repair for Degenerative Disease

Abstract   Background and aim of the study: Mitral valve repair is the procedure of choice for severe degenerative mitral regurgitation (MR). The objective of this study was to review prospectively gathered echocardiographic and clinical results with mitral valve repair for degenerative disease. Methods: Between May 1995 and July 2004, 403 patients underwent mitral valve repair for degenerative disease (mean age 63 ± 12 years, 72% males). Concomitant procedures included CABG (29%), radiofrequency left-sided maze procedure (8%), aortic valve replacement (6%), and tricuspid valve repair (4%). Results: Thirty-day mortality was 0.4% for patients with isolated mitral valve repair and 5.1% for patients with mitral valve repair and concomitant procedure (p = 0.003). Five-year survival was higher for isolated mitral valve repair compared to mitral valve repair with a combined procedure (92 ± 2% vs. 76 ± 5%; p < 0.001). Pulmonary artery pressure and left atrial and left ventricular end-diastolic diameters were significantly improved following mitral valve repair (all p ≤ 0.005) and this was sustained afterward. The freedom from severe (3+ or 4+) and moderate-severe (2+, 3+, or 4+) MR was 95% and 77% at 5 years, respectively, whereas the freedom from reoperation was 96 ± 1% at 5 years. Significant predictors of moderate-severe MR recurrence were cardiac dilatation, anterior leaflet prolapse, and concomitant procedure, whereas mitral valve disease amenable to posterior leaflet resection had a lower risk of MR recurrence. Conclusions: Excellent clinical outcomes can be obtained using standard techniques of mitral valve repair of the degenerative valve. MR recurrence is low but nonnegligible, emphasizing the necessity for long-term postoperative echocardiographic follow-up in these patients. (J Card Surg 2010;25:9-15)     

Risks of combined surgical treatment of acquired heart valve defects and coronary heart disease

In the past years the number of patients with combined treatment of the heart valves and coronary arteries rised as well as the patients age did. In 1980-1987 the rate of patients with aortic valve replacement and simultaneous aorto-coronary bypass was 10.9% in those who underwent aortic valve replacement and 2.9% in those who had aorto-coronary bypass operation. Since 1988 the ratios changed to 18.2% and 4.9%. For the calculation of the operative risk of the combined operative treatment (AVR + CABG, MVR + CABG) we compared these groups with those patients with isolated operations (MVR, AVR, CABG). We studied all patients during 1980 and July 1989. The hospital mortality of combined procedures was significantly increased. The mortality among female patients was higher as compared to the male group. The age of patients treated by the combined procedures was higher as compared to the isolated procedures. The mean age of the patients which died was severely increased as compared to the isolated procedures. However, in the combined procedures this increase was not as pronounced as in the isolated groups. Patients with combined procedures had a higher NYHA class. The risk factors of the combined procedures were comparable to isolated CABG.