Biomedical subjects

Jeevanantham Rajeswaran

Publications and source records attributed to Jeevanantham Rajeswaran.

At least 19 recordsLinked to original sources

PubMed2006

Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation?

BACKGROUND: It is unknown whether pulmonary vein isolation or a complete Cox-Maze procedure is needed to ablate paroxysmal atrial fibrillation in patients with mitral valve disease. Our objective was to assess the impact of different surgical treatments for this arrhythmia in patients undergoing mitral valve surgery. METHODS: From July 1993 to January 2004, 152 patients underwent combined surgical treatment of paroxysmal atrial fibrillation and mitral valve disease. Ablation procedures included pulmonary vein isolation alone (n = 31, 20%), pulmonary vein isolation with left atrial connecting lesions (n = 80, 53%), and Cox-Maze (n = 41, 27%). The latter had longer durations of atrial fibrillation than the former (p < 0.0001). Rhythm documented on 1,225 postoperative electrocardiograms was used to estimate prevalence of, and risk factors for, atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 22% at 2 weeks and declined to 9% at 1 year. Risk factors included older age (p = 0.09), larger left atrium (p = 0.05), and rheumatic (p = 0.003) and degenerative etiologies (p = 0.03). Freedom from ablation failure was 84% at one year. Ablation procedure did not affect prevalence of atrial fibrillation or incidence of ablation failure. CONCLUSIONS: Pulmonary vein isolation alone may be adequate treatment for patients with paroxysmal atrial fibrillation undergoing mitral valve surgery, particularly when it is of short duration. A randomized trial is necessary to examine this strategy, especially in patients with longer duration of paroxysmal atrial fibrillation.

Aged↗

PubMed2006

Mitral valve surgery in the adult Marfan syndrome patient.

BACKGROUND: Because mitral valve dysfunction in adults with Marfan syndrome is poorly characterized, this study compares mitral valve pathophysiology and morphology with that of myxomatous mitral disease, documents types of mitral valve operations, and assesses long-term survival and durability of mitral valve surgery in Marfan patients. METHODS: From May 1975 to June 2000, 27 adults with Marfan syndrome underwent mitral valve surgery. Their valve pathophysiology and morphology was compared with that of 119 patients with myxomatous mitral disease undergoing surgery from September 1995 to March 1999. Survival and repair durability were assessed at follow-up. RESULTS: Compared with myxomatous disease patients, Marfan patients had less posterior leaflet prolapse (44% versus 70%, p = 0.01), more bileaflet (44% versus 28%, p = 0.09) and anterior leaflet prolapse (11% versus 3%, p = 0.07), and presented earlier for surgery (age 41 +/- 12 years versus 57 +/- 13, p < 0.0001). Marfan patients had longer and thinner leaflets. Mitral valve repair was performed less frequently in Marfan (16 of 27, 59%) than myxomatous disease patients (112 of 119, 94%). There were no hospital deaths; at 10 years, survival was 80% and freedom from reoperation 96%, with only 1 reoperation among the 16 repairs. CONCLUSIONS: Mitral valve pathophysiology and morphology differ between Marfan and myxomatous mitral valve diseases. Valve repair in Marfan patients is durable and gives acceptable long-term results, even in adults who present with advanced mitral valve pathology. With increasing use of the modified David reimplantation operation and sparing of the aortic valve, mitral valve repair is a greater imperative, particularly since we have not had to reoperate on any Marfan patients with reimplantations.

Adult↗

PubMed2006

Surgery for permanent atrial fibrillation: impact of patient factors and lesion set.

BACKGROUND: Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. METHODS: From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. CONCLUSIONS: This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

Adult↗

PubMed2006

Tracheostomy after cardiovascular surgery: an assessment of long-term outcome.

OBJECTIVE: To ascertain long-term survival, identify risk factors for death, and document complications of tracheostomy after cardiovascular surgery. METHODS: Between January 1, 1998, and September 1, 2001, 188 (1.4%) of 13,191 patients undergoing cardiovascular surgery had tracheostomy for respiratory failure 5 to 79 days (median, 14 days) after surgery. Factors associated with mortality were identified in the hazard function domain, and mode of death and complications of tracheostomy were determined by follow-up. RESULTS: Survival was 75%, 50%, and 31% at 30 days, 3 months, and 2 years, respectively. The most important risk factors for death were older age (P = .004) and variables representing deteriorating hemodynamic (P < .0001), respiratory (P < .0001), and renal (P = .0001) function between the index cardiovascular operation and tracheostomy. The mode of death was isolated respiratory failure in only 21 (16%) of 130 patients, but multisystem organ failure in 71 (55%). Follow-up of 58 survivors identified voice complaints in 13 (24%), tracheal stenosis in 5 (9.2%), and permanent tracheostomy in 3 (6%). CONCLUSIONS: Only one third of patients undergoing tracheostomy after cardiovascular surgery survive, because it is used primarily in those with deteriorating function of multiple organ systems. Although tracheostomy may enhance patient comfort and simplify nursing care, selection algorithms need to be developed if survival is the goal of the intervention.

Cardiovascular Diseases↗

PubMed2006

Thromboembolism after pneumonectomy for malignancy: an independent marker of poor outcome.

OBJECTIVE: Because venous thromboembolism results in important postoperative morbidity and mortality after pneumonectomy for malignancy, we sought to determine its prevalence, location, management, timing, and risk factors. We also evaluated short- and long-term outcomes of patients in whom venous thromboembolism developed compared with those of patients in whom it did not. METHODS: Between January 1990 and January 2001, 336 patients underwent pneumonectomy for malignancy. Patients were considered to have venous thromboembolism if they were identified as having deep vein thrombosis or pulmonary embolus through chart review, including pulmonary imaging studies. All patients were managed with anticoagulation or anticoagulation plus thrombolysis. RESULTS: Twenty-five (7.4%) patients had postoperative venous thromboembolism, with peak incidence 7 days after the operation; most had already been discharged from the hospital. Higher pack-years of smoking was associated with increased risk, as well as with earlier occurrence of venous thromboembolism (P < .04). Survival was 55% at 6 months and 13% at 18 months; mode of death was cancer in 14 (61%) of 23, respiratory failure in 4 (17%) of 23, multisystem organ failure in 3 (13%) of 23, myocardial infarction in 1 (4.4%) of 23, and uncertain in 1 (4.4%) of 23. Low preoperative forced vital capacity was predictive of poor long-term survival (P = .02). Patients with venous thromboembolism had substantially lower survival than predicted from competing-risks analysis of survival without venous thromboembolism (13% vs 60% at 18 months), and this difference persisted after censoring for deaths directly attributable to venous thromboembolism. CONCLUSIONS: Venous thromboembolism is surprisingly common after pneumonectomy for malignancy and portends poor survival. Improved screening and better prophylaxis might prevent this complication and enhance outcome.

Female↗

PubMed2006

Magnesium as a neuroprotectant in cardiac surgery: a randomized clinical trial.

OBJECTIVE: We sought to evaluate magnesium as a neuroprotectant in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: From February 2002 to September 2003, 350 patients undergoing elective coronary artery bypass grafting, valve surgery, or both were enrolled in a randomized, blinded, placebo-controlled trial to receive either magnesium sulfate to increase plasma levels 1(1/2) to 2 times normal during cardiopulmonary bypass (n = 174) or no intervention (n = 176). Neurologic function, neuropsychologic function, and depression were assessed preoperatively, at 24 and 96 hours after extubation (neurologic) and at 3 months (neuropsychologic, depression). Neurologic scores were analyzed using ordinal longitudinal methods, and neuropsychologic and depression inventory data were summarized by principal component analysis, followed by linear regression analysis using component scores as response variables. RESULTS: Seven (2%) patients had a postoperative stroke, 2 (1%) in the magnesium and 5 (3%) in the placebo group (P = .4). Neurologic score was worse postoperatively in both groups (P < .0001); however, magnesium group patients performed better than placebo group patients (P = .0001), who had prolonged declines in short-term memory and reemergence of primitive reflexes. Three-month neuropsychologic performance and depression inventory score were generally better than preoperatively, with few differences between groups (P > .6); however, older age (P = .0006), previous stroke (P = .003), and lower education level (P = .0007) were associated with worse performance. CONCLUSIONS: Magnesium administration is safe and improves short-term postoperative neurologic function after cardiac surgery, particularly in preserving short-term memory and cortical control over brainstem functions. However, by 3 months, other factors and not administration of magnesium influence neuropsychologic and depression inventory performance.

Aged↗

PubMed2005

Transfusion increases the risk of postoperative infection after cardiovascular surgery.

BACKGROUND: Because of the immunomodulatory effects of transfusion, we attempted to identify factors associated with blood product use and determine the association of transfusion quantity with postoperative infection. STUDY DESIGN: We studied total perioperative transfusion of blood products for 15,592 cardiovascular operations performed from July 1998 to May 2003. Infection end points were septicemia/bacteremia (n=351, 2.2%) and superficial (n=353, 2.3%) and deep (n=212, 1.4%) sternal wound infections. Factors associated with blood product administration were used to form balancing scores to adjust for differences in patient characteristics among those receiving and not receiving blood products. RESULTS: Fifty-five percent of patients received packed red blood cells (RBC), 21% received platelets, 13% got fresh frozen plasma (FFP), and 3% got cryoprecipitate. Factors associated with RBC use included older age, female gender, higher New York Heart Association class, lower hematocrit, reoperation, and longer cardiopulmonary bypass time--all indicative of higher-risk patients. The more RBC units transfused, the higher was the occurrence of septicemia/bacteremia (p < 0.0001) and superficial (p=0.0007) and deep (p < 0.0001) sternal wound infection. Use of FFP (septicemia/bacteremia) and platelets (septicemia/bacteremia and deep sternal wound infection) mitigated against this association only slightly. CONCLUSIONS: Blood products tended to be used in the sickest patients. But after accounting for this, risk of infection increased incrementally with each unit of blood transfused. Although cause and effect cannot be established, results suggested that blood product transfusion is an independent risk factor for postoperative infection in cardiac surgical patients, blood products are more likely to be used in the sickest patients, and no amount of blood loss treated by transfusion is innocuous.

Aged↗

PubMed2005

The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation.

OBJECTIVES: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in patients undergoing mitral valve surgery, and new approaches to atrial fibrillation ablation must be compared with it. Therefore, we sought to determine the time-related prevalence of atrial fibrillation and its risk factors after combined Cox maze and mitral valve surgery. METHODS: From November 1991 through January 2004, 263 patients (mean left atrial diameter, 5.8 +/- 1.2 cm) underwent combined mitral valve surgery (repair in 71%) and a cut-and-sew Cox maze procedure for atrial fibrillation (permanent, 74%; persistent, 7%; paroxysmal, 16%). Rhythm documented on 2367 postoperative electrocardiograms was used to estimate the prevalence of atrial fibrillation across time. RESULTS: Hospital mortality was 1.9%. Postoperative atrial fibrillation prevalence peaked at 36% at 2 weeks, decreasing to 21% at 5 years. Risk factors for higher postoperative atrial fibrillation prevalence varied with time and included longer duration of preoperative atrial fibrillation (P = .003), larger left atrial diameter (P = .01), older age (P = .0002), and higher left ventricular mass index (P = .02). CONCLUSIONS: In some patients undergoing mitral valve surgery and a Cox maze procedure, atrial fibrillation recurs over time, mandating close, long-term follow-up of heart rhythm. Earlier operation and left atrial size reduction should be considered to improve results in selected patients.

Atrial Fibrillation↗

PubMed2005

Importance of moderate ischemic mitral regurgitation.

BACKGROUND: The importance of moderate ischemic mitral regurgitation in patients presenting for coronary artery bypass grafting (CABG) is controversial. Therefore, we tracked the course of unrepaired moderate ischemic mitral regurgitation after CABG surgery alone, identified factors associated with worsening postoperative ischemic mitral regurgitation, and assessed the impact of unrepaired moderate ischemic mitral regurgitation on survival. METHODS: From 1980 to 2000, 467 patients with moderate ischemic mitral regurgitation underwent CABG alone. The course of unrepaired mitral regurgitation was estimated by a longitudinal analysis of 267 follow-up echocardiograms from 156 patients. The survival impact of moderate ischemic mitral regurgitation was determined among propensity-matched patients with and without ischemic mitral regurgitation. RESULTS: Mitral regurgitation was dynamic early postoperatively. Immediately postoperatively, it was absent or mild in 73% and severe in 6%; by 6 weeks, these figures were 40% and 22%, respectively. The course of postoperative mitral regurgitation was not associated with the preoperative extent of coronary artery disease or left ventricular dysfunction. Five-year survival of matched bypass patients without ischemic mitral regurgitation was 85% compared with 73% for patients with moderate ischemic mitral regurgitation (p = 0.003). CONCLUSIONS: Moderate ischemic mitral regurgitation does not reliably resolve with CABG surgery alone and is associated with reduced survival. Therefore, a mitral valve procedure may be warranted for such patients presenting for CABG. A randomized trial comparing strategies of revascularization with mitral valve repair and revascularization alone is required to determine optimal treatment.

Adult↗

PubMed2005

Can we predict long-term survival after pulmonary metastasectomy for renal cell carcinoma?

BACKGROUND: The purpose of this study is to identify factors associated with time-related survival after pulmonary metastasectomy for renal cell carcinoma and to confirm the safety of metastasectomy. METHODS: From January 1986 to July 2001, 417 patients were diagnosed with pulmonary metastases from renal cell carcinoma; 92 underwent pulmonary metastasectomy. Median disease-free interval after nephrectomy was 3.0 years. Half the patients had 1 or 2 pulmonary nodules; 37% had 5 or more. Median size of the largest nodule (pulmonary metastasis) was 15 mm. Complete resection was obtained in 63 patients (68%). Twenty-nine patients received preoperative immunotherapy. Multivariable hazard function analysis was used to identify continuous, ordinal, and true dichotomous risk factors. RESULTS PREDICTORS: The strongest risk factor for time-related mortality was incomplete resection. Five-year survival was 8% for incomplete and 45% for complete resection. Other risk factors included the following continuous and ordinal variables: larger nodule size (p = 0.0001), increasing number of involved lymph nodes (p = 0.01), and decreased preoperative 1-second forced expiratory volume (p = 0.02). Immunotherapy did not improve survival. For completely resected patients, shorter disease-free interval was a risk factor (p = 0.01). Fewer pulmonary nodules predicted higher probability of complete resection (p < 0.0001). SAFETY: No operative deaths occurred. Nine patients (10%) experienced a total of 12 complications, with persistent air leak and atrial arrhythmia accounting for 5 (42%). CONCLUSIONS: Because pulmonary metastasectomy for renal cell carcinoma is safe, survival depends on complete resection of pulmonary disease and adequate pulmonary reserve. Preoperative determination of resectability is thus critical, and computed chest tomography and mediastinoscopy are valuable tools for optimizing patient selection.

Carcinoma, Renal Cell↗

PubMed2005

Ischemic versus degenerative mitral regurgitation: does etiology affect survival?

BACKGROUND: Ischemic mitral regurgitation (MR) is associated with poor survival and degenerative MR with excellent survival. We hypothesized that in some patients with degenerative MR requiring concomitant coronary artery bypass grafting (CABG), ischemic disease would dominate prognosis, resulting in survival as poor as in patients with ischemic MR. Thus, we (1) determined survival impact of etiology (degenerative vs ischemic) after combined mitral valve repair and CABG and (2) explored survival differences within etiology groups. METHODS: From 1985 to 2003, 710 patients underwent mitral valve repair for degenerative MR and concomitant CABG (two diseases); 400 patients had mitral annuloplasty and CABG for functional ischemic MR (one disease). Patients were propensity-matched on demography, symptoms, comorbidities, coronary artery disease, and left ventricular function. Survival was compared between matched groups and within groups. RESULTS: Compared with patients with degenerative MR, those with ischemic MR had more extensive coronary artery disease, worse ventricular function, more comorbidities, and more symptoms (p < 0.05). Unadjusted 5-year survivals were 64% and 82% for patients with ischemic and degenerative MR, respectively. However, 123 ischemic and degenerative MR matched pairs had equivalently poor 5-year survival (p > 0.9), 66% and 65%, respectively. Among patients with degenerative MR, survival varied widely, depending largely on ischemic burden and extent of left ventricular dysfunction. CONCLUSIONS: The large survival discrepancy between patients with ischemic and degenerative MR is attributable to differences in patient profile, particularly extent of ischemic disease and left ventricular dysfunction. Thus, ischemic and degenerative MR patients with equivalent characteristics have equivalently poor survival.

Aged↗

PubMed2005

Surgical ablation of atrial fibrillation with bipolar radiofrequency as the primary modality.

OBJECTIVES: In studying cardiac surgical patients undergoing atrial fibrillation ablation with bipolar radiofrequency, we sought to (1) quantify the time-related prevalence of atrial fibrillation postoperatively and identify its risk factors and (2) determine time-related ablation failure and its risk factors. METHODS: From November 2001 to January 2004, 513 patients underwent atrial fibrillation ablation (bipolar radiofrequency alone or with cryothermy) and other cardiac operations. Rhythm documented on 3495 postoperative electrocardiograms was used to estimate the prevalence of and risk factors for atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at about 1 month, decreased to 13% at 6 months, and gradually increased thereafter. Risk factors associated with increased prevalence varied by time period and included older age ( P = .004) for early occurrence, lesion set in permanent atrial fibrillation ( P = .02) for late occurrence, and larger left atrial diameter ( P = .02) and permanent atrial fibrillation ( P < .0001) for occurrence across the entire time span. Freedom from ablation failure was 72% at 12 months. Risk factors for ablation failure included lesion set in permanent atrial fibrillation ( P = .001), longer duration of atrial fibrillation ( P = .01), and larger left atrial diameter ( P = .03). CONCLUSIONS: Bipolar radiofrequency enables extension of ablation to most cardiac surgical patients with atrial fibrillation. Recurrence is influenced by the type and duration of atrial fibrillation, choice of lesion set in permanent atrial fibrillation, and left atrial size. Early operation, careful choice of lesion set, and left atrial reduction might enhance results.

Aged↗

PubMed2004

Cannulation of the axillary artery with a side graft reduces morbidity.

BACKGROUND: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it. METHODS: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score. RESULTS: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002). CONCLUSIONS: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.

Adolescent↗

PubMed2004

Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings.

BACKGROUND: Complex mitral regurgitation (MR) jets can make repair challenging; edge-to-edge (Alfieri) repair augments the repertoire of repair techniques. Objectives of this study were to demonstrate causes of MR amenable to edge-to-edge repair and to determine safety, obstructive potential, and durability of edge-to-edge repair. METHODS: From January 1997 to October 2001, 224 patients underwent Alfieri repair. Indications included ischemic cardiomyopathy (n = 143, 64%), myxomatous disease (n = 31, 14%), dilated cardiomyopathy (n = 27, 12%), and hypertrophic obstructive cardiomyopathy (n = 14, 6%). Concomitant ring annuloplasty was performed in 188 patients (84%). Two additional patients had takedown of an Alfieri repair in the operating room for obstruction. Preoperative MR was 4+ in 109 patients (50%) and 3+ in 65 (30%). Postoperative and follow-up mitral gradient and return of MR were assessed using 396 transthoracic echocardiograms and longitudinal analyses. RESULTS: Hospital mortality was 2% (5 of 224). Mitral valve mean gradient was low (3.7 mm Hg) and nonprogressive (p = 0.7), although peak gradient rose slightly, from mean 8.4 to 10.0 mm Hg (p = 0.01). During the first 3 postoperative months, absence of MR declined to 40%, and prevalence of 3+ MR increased to 14%, then rose slowly thereafter. Fourteen patients--12 within 2 years--underwent mitral valve reoperation, none for stenosis; 7 patients--6 within 2 years--underwent heart transplantation. CONCLUSIONS: Alfieri mitral repair can be used in a variety of settings with a low risk of creating mitral stenosis. However, in ischemic MR, steadily increasing prevalence of moderately severe and severe regurgitation after edge-to-edge repair suggests other techniques are needed.

Aged↗

PubMed2004

Does the arterial cannulation site for circulatory arrest influence stroke risk?

BACKGROUND: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest. METHODS: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression. RESULTS: Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs). CONCLUSIONS: Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Aged↗

PubMed2004

Aortic dissection after previous cardiovascular surgery.

BACKGROUND: Risk of repairing aortic dissection after previous cardiovascular surgery has not been described clearly. This study assesses early and late outcomes of such reoperations. METHODS: From January 1, 1990, to January 1, 2002, 108 patients with prior cardiovascular surgery (isolated coronary artery bypass grafting, 51%; isolated valve surgery, 21%; aortic aneurysm repair, 24%; and combinations of these in the remainder) underwent reoperation for aortic dissection (emergency operation for acute dissection in 24%). Mean age was 63 +/- 13 years, and 85% were men. The interval since prior surgery ranged from 10 days to 22 years (median, 3.8 years). This was the third operation for 8%. Ascending aortic repair with or without aortic arch or descending aortic repair was performed in 40%, aortic valve replacement (n = 15) or repair (n = 17) with ascending aortic repair in 30%, aortic root replacement with or without aortic arch or descending aortic repair in 30%, and aortic arch with or without descending aortic repair in 1%. Circulatory arrest was used in 78%, with retrograde brain perfusion in 58%. RESULTS: Hospital mortality was 6%, stroke 4%, renal failure 2%, and respiratory failure 7%. Survival at 30 days and 1, 3, 5, and 7 years was 93%, 85%, 74%, 63%, and 53%, respectively. Aortic reoperation was performed in 7 patients, with freedom from this event at 30 days and 1, 3, 5, and 7 years of 98%, 95%, 93%, 91%, and 89%., respectively CONCLUSIONS: Aortic dissection after cardiovascular surgery is rare and can be managed with acceptable operative risks and good long-term survival. Need for subsequent aortic reoperation is uncommon.

Aged↗

PubMed2004

Tricuspid valve repair: durability and risk factors for failure.

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.

Aged↗

PubMed2004

HLA sensitization in ventricular assist device recipients: does type of device make a difference?

BACKGROUND: We sought to (1) characterize the temporal pattern of T-cell panel reactive antibody during ventricular assist device support, (2) identify predictors of higher T-cell panel reactive antibody during ventricular assist device support, and (3) determine whether device type remained a predictor after accounting for nonrandom device selection. METHODS: Between December 1991 and August 2000, 239 patients received implantable ventricular assist devices, of whom 231 had T-cell panel reactive antibody measured. Panel reactive antibody was measured before implantation of the assist device, approximately 2 weeks after device implantation, irregularly thereafter depending on clinical events and length of support, and at transplantation. Longitudinal mixed modeling was used to characterize the temporal pattern of sensitization and its predictors during ventricular assist device support. To account for nonrandom factors in device selection when comparing HeartMate (Thermo Cardiosystems, Inc, Woburn, Mass) and Novacor (Baxter Healthcare Corp, Novacor Div, Oakland, Calif) devices, we propensity-matched patients according to baseline characteristics. RESULTS: T-cell panel reactive antibody increased rapidly after implantation of the ventricular assist device and then immediately began to decrease. Predictors of higher T-cell panel reactive antibody during support with the assist device were a shorter interval from device implantation to T-cell panel reactive antibody measurement (P <.0001), female sex (P =.0004), younger age (P =.01), higher T-cell panel reactive antibody before device implantation (P =.03), more perioperative red blood cell transfusions (P =.006), and an earlier date of device implantation (P =.001). In matched patients, device type was not a predictor of higher T-cell panel reactive antibody during ventricular assist device support (P =.8). CONCLUSIONS: HLA sensitization during ventricular assist device support is not constant but increases rapidly at implantation and then decreases. This temporal pattern of sensitization is influenced by patient factors and not by the type of device.

Adult↗