Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in Northern New England

BACKGROUND: Predicting risk for aortic and mitral valve surgery is important both for informed consent of patients and objective review of surgical outcomes. Development of reliable prediction rules requires large data sets with appropriate risk factors that are available before surgery. METHODS: Data from eight Northern New England Medical Centers in the period January 1991 through December 2001 were analyzed on 8943 heart valve surgery patients aged 30 years and older. There were 5793 cases of aortic valve replacement and 3150 cases of mitral valve surgery (repair or replacement). Logistic regression was used to examine the relationship between risk factors and in-hospital mortality. RESULTS: In the multivariable analysis, 11 variables in the aortic model (older age, lower body surface area, prior cardiac operation, elevated creatinine, prior stroke, New York Heart Association [NYHA] class IV, congestive heart failure [CHF], atrial fibrillation, acuity, year of surgery, and concomitant coronary artery bypass grafting) and 10 variables in the mitral model (female sex, older age, diabetes, coronary artery disease, prior cerebrovascular accident, elevated creatinine, NYHA class IV, CHF, acuity, and valve replacement) remained independent predictors of the outcome. The mathematical models were highly significant predictors of the outcome, in-hospital mortality, and the results are in general agreement with those of others. The area under the receiver operating characteristic curve for the aortic model was 0.75 (95% confidence interval [CI], 0.72 to 0.77), and for the mitral model, 0.79 (95% CI, 0.76 to 0.81). The goodness-of-fit statistic for the aortic model was chi(2) [8 df] = 11.88, p = 0.157, and for the mitral model it was chi(2) [8 df] = 5.45, p = 0.708. CONCLUSIONS: We present results and methods for use in day-to-day practice to calculate patient-specific in-hospital mortality after aortic and mitral valve surgery, by the logistic equation for each model or a simple scoring system with a look-up table for mortality rate.     

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

BackgroundAs many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR.MethodsThe Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ² tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI.ResultsA total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level.ConclusionsTEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.     

Evolving experience with thoracoabdominal aortic aneurysm repair at a single institution

Fifty-seven patients underwent repair of atherosclerotic thoracoabdominal aortic aneurysms between 1978 and 1990. Five patients had urgent surgery for rupture. The 30-day operative mortality rate for the entire group was 18% (10 patients). Before July 1987, 19 patients (group 1) were operated on by use of a technique previously described. In these earlier patients the peritoneum was routinely entered, the diaphragm was divided radially, and no heparin was given. Among patients in group 1 there was a 30-day operative mortality rate of 42% (8 patients), and morbidity included myocardial infarction 4 (21%), respiratory failure 9 (47%), renal failure 12 (63%), bleeding requiring reoperation 4 (21%), and intestinal ischemia 3 (16%). Since July 1987 a standardized approach to all elective thoracoabdominal aortic aneurysms has been used in 38 patients (group 2). This method uses a left thoracoabdominal incision, circumferential division of the hemidiaphragm, retronephric totally extraperitoneal aortic exposure, single lung anesthesia, full heparinization, the graft inclusion technique, and liberal use of visceral endarterectomy. Patients in group 2 sustained a 30-day operative mortality rate of 5% (2 patients) and morbidity included myocardial infarction 2 (5%), respiratory failure 10 (26%), renal failure 11 (29%), bleeding requiring reoperation 1 (3%), paraplegia 6 (16%), and paraparesis 4 (11%). Modern surgery for repair of thoracoabdominal aortic aneurysm results in acceptably low operative mortality rates. Spinal cord ischemia remains an unresolved source of morbidity.     

再次肝移植术后早期与死亡率相关的危险因素分析

目的 探讨再次肝移植术后早期与死亡率相关的独立危险因素.方法 回顾性分析2004年1月至2007年12月间的36例再次肝移植的资料.根据再次肝移植术后早期(术后3个月内)的转归,将患者分为死亡组和存活组.收集两组患者术前及术中常用的15项临床或实验室指标作为可能影响死亡率的危险因素进行单因素分析,将有统计学意义的危险因素再进行Logistic回归分析,筛选出与术后早期死亡率相关的独立危险因素.结果 再次肝移植术后早期死亡率为25%(9/36),死亡原因为:严重感染5例(55.6%),急性肾功能衰竭2例(22.2%),心肌梗死和脑出血各1例(各11.1%).经单因素分析显示,死亡组和存活组间术前肌酐水平、终末期肝病模型评分、感染、重症监护室(ICU)监护时间、机械通气时间以及再次肝移植的手术时间和术中出血量的差异有统计学意义(P<0.05),Logistic多元回归分析显示,术前ICU监护时间和术中出血量是术后早期与死亡率相关的独立危险因素.结论 再次肝移植术前ICU监护时间和术中出血量与术后早期死亡率密切相关.     

Factors associated with mortality in patients new to haemodialysis.

BACKGROUND: Patients receiving dialysis therapy for end-stage kidney failure have a high cardiovascular mortality that can only be partially explained by traditional risk factors. METHODS: This study was a post hoc analysis of a prospectively gathered data set from a randomized trial comparing outcomes in new haemodialysis patients treated with sevelamer or calcium-containing phosphate binders. Patients were followed from the time of enrollment until death or censor on 31 December 2005. Median follow-up was 3.6 years. Demographics, cardiovascular risk factors, laboratory data, medication use and severity of vascular calcification were available at baseline and over the first 18 months of dialysis. RESULTS: Baseline predictors of mortality included age, creatinine, heart rate, iPTH, C-reactive protein (CRP), coronary and aortic calcium scores and the presence of aortic valve calcification. Over the first 18 months, averages of diastolic blood pressure, BUN, creatinine, albumin, phosphorus, iPTH and CRP were all significantly different between survivors and non-survivors. A stepwise multivariable adjusted Cox regression model demonstrated that low BUN and albumin and high CRP along with the use of calcium-containing phosphate binders (rather than sevelamer) were the strongest predictors of mortality in patients new to haemodialysis. CONCLUSIONS: These findings suggest that non-traditional risk factors, such as inflammation and malnutrition measured during the first 18 months of dialysis, are important determinates of survival in new dialysis patients. In addition, the unique risk factor for dialysis patients, the use of calcium-containing phosphate binders, was associated with a higher mortality rate in patients new to dialysis.     

Determinants of operative mortality for patients undergoing aortic valve replacement. Discriminant analysis of 1,479 operations

The influence of 35 preoperative and intraoperative characteristics on operative mortality risk after 1,479 isolated aortic valve replacement procedures (1967 to 1981) was investigated utilizing univariate and multivariate logistic regression analyses. Mean age at operation was 58 +/- 13 years; 72% of patients were men. Physiology was classified as aortic stenosis (58%), regurgitation (30%), or both (9%). The overall operative mortality rate was 7% +/- 1%, but there were substantial differences in operative mortality rates among physiological subgroups (aortic regurgitation, 10% +/- 2%; aortic stenosis, 6% +/- 1%; stenosis/regurgitation, 5% +/- 2%). Independent determinants of operative mortality rate in the entire group were advanced New York Heart Association functional class, renal dysfunction, physiological subgroup, atrial fibrillation, and older age. In the aortic regurgitation subgroup, functional class, atrial fibrillation, and operative year were independent predictors. In the aortic stenosis subgroup, the significant determinants were functional class, renal dysfunction, age, prosthetic valve dysfunction, and absence of angina. Concomitant coronary bypass grafting, previous operation, endocarditis, and ascending aortic replacement had no independent predictive effect on operative mortality rate. Thus, the early results of aortic valve replacement can be related to several specific variables describing the functional and physiological status of the patient. Operative mortality rate is not independently related to previous operation or concomitant operative procedures. Specific differences in risk factors exist among the various physiological subgroups, probably reflecting the pathophysiology of the different hemodynamic lesions. This information should provide for a more rational approach to aortic valve replacement, at least in terms of early risk/benefit deliberations.     

Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs

BackgroundOperative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution.MethodsAll AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed.ResultsWe had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more.ConclusionsOSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.     

Clinical, hemodynamic, and angiographic predictors of operative mortality in patients undergoing single valve replacement. Veterans Administration Cooperative Study on Valvular Heart Disease

Preoperative characteristics of 964 patients in the Veterans Administration Cooperative Study on Valvular Heart Disease undergoing single valve replacement were examined to determine predictors of operative mortality. The operative mortality rate was 8.3% in 661 patients having isolated aortic valve disease and 7.5% in 239 patients having isolated mitral valve disease, but 12.5% in 64 patients with multivalve disease undergoing single valve replacement. For the aortic valve replacement subgroup, three-vessel coronary artery disease, left ventricular systolic pressure, prior cardiac operation, body surface area, and cardiac index were related to operative mortality. In the mitral valve replacement group, there was a strong association of operative mortality with advanced age, exertional dizziness, reduced cardiac index, left ventricular contraction grade, ST segment depression on the resting electrocardiogram, and pleural effusion. The risk of operative death for an individual patient undergoing aortic or mitral valve replacement may be estimated with the use of independent risk factors.     

Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery

Introduction

Preoperatively elevated serum creatinine (SCr) is considered an independent risk factor for morbidity and mortality after cardiac surgery. The aim of this study was to apply the Kidney Disease Improving Global Outcomes classification for acute kidney injury in a population of patients with preoperatively elevated serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to evaluate the acute worsening of renal function as a predictor of 30-day mortality.

Methods

This was a single-center retrospective study that included patients from the Postoperative Cardiac Surgery Intensive Care Unit of the Hospital de Base, São José do Rio Preto Medical School. Demographics, type of surgery, laboratory data and pre, peri and postoperative data were obtained from a prospectively collected database. From January 2003 to June 2013, 2,878 patients underwent cardiac surgery, either coronary artery bypass grafting or cardiac valve surgery, at the Hospital de Base of São José do Rio Preto Medical School. Out of those, 918 showed elevated preoperative serum creatinine, with SCr > 1.30 mg/dL for men and > 1.00 mg/dL for women. Five hundred and forty nine patients (60%) undergoing coronary artery bypass grafting and 369 patients (40%) undergoing cardiac valve surgery. A Multivariate Cox Proportional Hazard Model (stepwise) was used to assess the relationship between AKI and mortality at 30 days.

Results

Out of the 918 patients studied, 391 (43%) had postoperative AKI: 318 (35%) had Kidney Disease Improving Global Outcomes stage 1, 27 (2.9%) had Kidney Disease Improving Global Outcomes stage 2, and 46 (5.0%) had Kidney Disease Improving Global Outcomes stage 3. Patients in every stage of acute kidney injury showed progressive increase in EuroSCORE values, 30-day mortality ratescardiopulmonary bypass duration, and intensive care length of stay. Among patients classified as Kidney Disease Improving Global Outcomes stage 3, 76% required dialysis with a 30-day mortality of 66%. The Cox proportional hazards model showed that the hazard ratio for 30-day mortality was 4.8 for Kidney Disease Improving Global Outcomes stage 1 patients, 13.5 for Kidney Disease Improving Global Outcomes stage 2 patients, and 20.8 for Kidney Disease Improving Global Outcomes stage 3 patients (P<0.001 for all). Subgroup analyses (coronary artery bypass grafting and cardiac valve surgery) had similar results.

Conclusion

In this population, acute kidney injury based on the Kidney Disease Improving Global Outcomes criteria was a powerful predictor of 30-day mortality in patients with elevated preoperative serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery).     

Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis

Background: Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO₂) was therefore investigated after cardiac surgery. Methods: Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5‐year period in the southeast region of Sweden (n=396). SvO₂ was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO₂ in relation to post‐operative mortality related to cardiac failure and all‐cause mortality within 30 days was performed. Results: The area under the curve (AUC) was 0.97 (95% CI 0.96–1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53–0.99) for all‐cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO₂ 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all‐cause mortality was SvO₂ 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post‐operative morbidity was also markedly increased in patients with a low SvO₂. Conclusion: SvO₂, on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post‐operative mortality related to cardiac failure and a fairly good AUC for all‐cause mortality, with an excellent negative predictive value.     

Predictors of outcome in a multicenter port-access valve registry

BACKGROUND: The aim of this study was to examine the predictors of outcome in patients undergoing isolated valve operation using port-access techniques. METHODS: Logistic regression analysis was performed in a prospective, multi-institutional registry of patients undergoing isolated aortic valve replacement (AVR, n = 252), mitral repair (MVP, n = 491), or mitral replacement (MVR, n = 568) using port-access techniques from 1997 to 1999. RESULTS: Endoaortic balloon occlusion was used in 2% (AVR), 93% (MVP), and 90% (MVR) of cases. Conversion to full sternotomy occurred in 3.8% of all cases. For all patients, early mortality was 50 of 1,311 (3.8%) and onset of new atrial fibrillation occurred in 140 of 1,311 (11%) patients. The determinants of 30-day mortality were redo, age, and MVR or AVR. The determinants of reoperation for bleeding were age, reoperation, and MVR. Age was a predictor for stroke, and age and low or medium volume center were predictors of new atrial fibrillation. CONCLUSIONS: Excellent short-term results can be obtained using port-access techniques in isolated mitral or aortic valve operations. Patient outcome is not related to institutional case volume, and the primary determinants of outcome after port-access valve procedures are generally patient-related factors.     

Early and late results of aortic root replacement with antibiotic-sterilized aortic homograft

Between November 1972 and November 1986, 108 patients aged 5 to 73 years had complete replacement of the aortic root with an aortic homograft into which the coronary arteries were implanted. The main indications were (1) a tunnel type of aortic obstruction involving a hypoplastic ring, (2) a para-aortic annular abscess, (3) prosthetic valve dysfunction, mainly a previous aortic homograft, and (4) aortic stenosis with a small aortic anulus. Eighty-four patients (78%) had previous aortic valve operations. Concomitant cardiac procedures were done in 34 patients (32%). The 30-day mortality rate was 14% (15 patients). The cumulative follow-up period was 180.3 patient-years. The late mortality rate was 6.1% per patient-year (11 patients). The patients were not given anticoagulants postoperatively, but the entire group has been completely free from thromboembolism. The actuarial 5-year survival rate including operative deaths was 72%. The freedom from valve-related death at 5 years after operation is 86% and freedom from reoperation at 5 years is 96%. The use of homografts for replacement of the aortic valve and root in patients with complex lesions affecting these structures has shown encouraging early and late results, with regard to both survival and valve performance.     

Acute type A dissection: conservative methods provide consistently low mortality

BACKGROUND: A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database. METHODS: Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear. RESULTS: Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively. CONCLUSIONS: Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative "pathology-oriented" approach helps to achieve this aim.     

Quality control for cardiac surgery in the Veterans Administration

The volume of cardiac surgical procedures and the 30-day mortality associated with them were reviewed for the total experience of 72 Veterans Administration medical centers over a 10-year period (1975 to 1984). The total number of cardiopulmonary bypass operations increased from 3,074 in 1975 to 6,455 in 1984, whereas operative mortality declined from 8.3 to 4.7%. Operative mortality associated with isolated valve replacement operations declined from 10.9 to 5.9%. Aortocoronary vein bypass operations, which increased in number from 1,679 to 4,988 over the 10-year period, were associated with an operative mortality of 4.7% in 1975 and 3.6% in 1984. The extent of the patient's disease accounted for most of the operative mortality, but problems related to the adequacy of myocardial protection and the surgical technique were also important factors. These data were compared with similar comprehensive statistics compiled by the New York State Department of Health over a five-year period (1979-1983). Operative mortality rates were quite similar for aortocoronary bypass procedures, mitral valve replacements, and total cardiac operations. However, operative mortality for aortic valve procedures was higher among the Veterans Administration hospitals. In the future, if operative risk factors are clearly defined, a more meaningful comparison of operative mortality among ongoing reviews, such as those being carried out by the Veterans Administration and by New York State, could be used to establish standards of performance for cardiac surgery.     

Reoperations on the Aortic Valve Combined with Replacement of the Ascending Aorta

ABSTRACT Objective: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. Patients and Methods: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. Results: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%± 4% for patients who had composite replacement of the aortic valve and ascending aorta. Conclusions: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Reoperations on the aortic valve combined with replacement of the ascending aorta

OBJECTIVE: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. PATIENTS AND METHODS: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. RESULTS: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%+/-4% for patients who had composite replacement of the aortic valve and ascending aorta. CONCLUSIONS: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Outcome analysis for prediction of intraaortic balloon pump support failure and long-term survival in high-risk patients undergoing mitral valve surgery

The outcome predictors of intra-aortic balloon pump (IABP) in patients who undergo mitral valve surgery remain unknown. This study aimed to retrospectively review valvular surgery in patients who received an IABP to identify the predictors of failure of IABP support and anticipate the necessary therapy. This retrospective observational study recruited a total of 157 consecutive patients who underwent open-heart mitral valve surgery with IABP implantation intraoperatively or postoperatively. Univariate and multivariate logistic regression analyses were performed to identify the risk factors attributed to 30-day mortality. Follow-up data of survivors were collected to investigate the effect of IABP support to evaluate long-term outcomes. The overall 30-day mortality was 35.7% (56 patients). The following factors that contributed to 30-day mortality included sepsis (P < .001, OR: 5.627, 95%CI: 2.422-11.683); IABP implantation postoperatively rather than intraoperatively (P = .001, OR: 6.395, 95%CI: 2.085-19.511); right heart failure (P = .042, OR: 3.419, 95%CI: 1.225-12.257); and lack of subvalvular apparatus preservation (P = .033, OR: 3.710, 95%CI: 1.094-13.167). Furthermore, follow-up data of these patients showed an estimation of 5-year and 10-year survival rates of 58.9% and 35.7%, respectively. Patients with intraoperative IABP demonstrated better long-term survival outcomes when compared to those with postoperative IABP (χ² = 4.291, P = .038). In summary, this study distinguished the preoperative predictors of 30-day mortality of IABP-support in mitral valve surgery patients. These results indicated that early intervention with IABP should be taken into consideration in case of hemodynamic instability in critically ill patients undergoing mitral valve surgery.     

Aortic root surgery does not increase the operative risk of acute type A aortic dissection

Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 (P = NS). By multivariate analysis, preoperative shock (P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias (P = 0.002, OR = 4.62), and packed red blood cell transfusion (P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.     

儿童心瓣膜病的外科治疗

目的 报告儿童心瓣膜手术的经验。方法 ８７儿童心瓣膜病变患者,男５８例,女２９例,年龄４～１４岁,平均年龄１０．２岁。其中二尖瓣置换术３６例,主动脉置换术１３例,二尖瓣和主动脉瓣双瓣膜置换术６例,主动脉瓣成形术１３例,二尖瓣成形术１９例,所用心瓣膜均为机械瓣。同期处理三尖瓣关闭不全４１全,室间隔缺损２３例,房间隔缺损９例,佛氏窦瘤破裂８例,动脉导管未闭３例。结果 术后早期并发症包括：低心排血量综合