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Biomedical subjects

Joseph F Sabik

Publications and source records attributed to Joseph F Sabik.

At least 19 recordsLinked to original sources
PubMed2006

Occurrence and risk factors for reintervention after coronary artery bypass grafting.

BACKGROUND: Reintervention after coronary artery bypass grafting (CABG) is common. We sought to determine its occurrence and identify patient characteristics and operative techniques that influence the need or bias for reintervention. METHODS AND RESULTS: From 1971 to 1998, 48,758 patients underwent primary isolated CABG, and 1000 patients per year were actively followed-up every 5 years (n =26,927). A multivariable time-related analysis was performed to model freedom from first coronary reintervention (either reoperation or percutaneous coronary intervention) and identify patient and operative characteristics associated with first reintervention. A total of 3997 patients underwent coronary reintervention, percutaneous in 1638 and reoperation in 2359. Freedom from reintervention was 99%, 96%, 88%, 73%, 60%, and 46% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reintervention (hazard function) demonstrated a short, rapidly declining early phase followed by a longer, slow-rising late phase. Patient variables increasing the likelihood of coronary reintervention included younger age (P<0.0001), higher triglycerides (P=0.002), lower high-density lipoprotein (P=0.006), diabetes mellitus (P<0.0001), and more extensive coronary artery disease (P=0.0005). Increasing extent of arterial grafting performed at primary operation decreased the likelihood of coronary reintervention (P<0.0001). CONCLUSIONS: Reintervention after primary CABG is common. Risk factors for arteriosclerosis and type of bypass conduit influence the need or bias for repeat coronary therapy. Aggressive post-CABG risk factor reduction and extensive arterial grafting at primary operation should decrease coronary reinterventions.

Age Factors↗
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

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

Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery?

OBJECTIVE: To determine whether adding right internal thoracic artery to previous left internal thoracic artery bypass at reoperation increases deep sternal wound infection and hospital mortality, particularly in diabetic patients. METHODS: Reoperations (n = 2875; 2381 men) in patients with previous left internal thoracic artery bypass were performed between January 1990 and January 2003; 1939 (67%) had no repeat internal thoracic artery grafting, 923 (32%) received an additional right internal thoracic artery graft, and 13 (0.5%) had bilateral internal thoracic artery grafting with reuse of the left internal thoracic artery. Of the patients, 352 (12%) were insulin-treated and 590 (21%) non-insulin-treated diabetics. Multivariable logistic regression analysis was used to identify preoperative variables associated with right versus non-right internal thoracic artery use in diabetics and nondiabetics and to formulate propensity models. Propensity scores were used for matching and adjusted multivariable analyses of deep wound infection and hospital mortality. RESULTS: Deep wound infection occurred in 3.0% (7/230) of diabetics receiving right internal thoracic artery grafts, 2.2% (5/230) of propensity-matched diabetics receiving non-right internal thoracic artery grafts (P = .6), in 1.1% (6/538) of nondiabetics receiving right internal thoracic artery grafts, and in 1.0% (5/538) of matched non-diabetic patients receiving non-right internal thoracic artery grafts (P = .8). Corresponding hospital mortality in these matched groups was 1.7% (4/230) versus 6.1% (14/230) for diabetics (P = .02) and 2.6% (14/538) versus 3.5% (19/538) for nondiabetics (P = .4). Risk factors for deep wound infection included higher weight (P = .0003), higher New York Heart Association functional class (P = .03), and less severe left anterior descending disease (P = .03). Risk factors for death were (P < .02) emergency operation, mitral valve replacement, and greater number of saphenous vein grafts. CONCLUSIONS: Use of the right internal thoracic artery for reoperations does not increase the risk of deep wound infections in diabetics or nondiabetics and does not increase mortality.

Aged↗
PubMed2005

Influence of patient characteristics and arterial grafts on freedom from coronary reoperation.

OBJECTIVE: Arteriosclerosis is a progressive disease, and many patients require repeat coronary intervention after coronary artery bypass grafting. We sought to identify patient characteristics and operative factors that predict the need for or bias toward reoperative coronary artery bypass grafting. METHODS: From 1971 to 1998, 48,758 patients underwent primary isolated coronary artery bypass grafting, and 1000 per year were followed every 5 years (n = 26,927). A multivariable time-related analysis was performed to model freedom from coronary reoperation and to identify patient and operative variables associated with occurrence of coronary reoperation. RESULTS: Freedoms from reoperative coronary artery bypass grafting were 99.6%, 98.4%, 93%, 82%, 72%, and 65% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reoperation (hazard function) demonstrated a short, rapidly declining early phase, followed by a long, slow-rising late phase. Patient variables that increased the likelihood of coronary reoperation included younger age (P < .0001), higher total cholesterol (P = .0004) and triglyceride levels (P = .0005), lower high-density lipoprotein (P = .0002) level, diabetes mellitus (P < .0001), and more extensive coronary artery disease (P = .01). Increasing extent of arterial grafting performed at primary coronary artery bypass grafting decreased occurrence of coronary reoperation (P < .0001). CONCLUSION: Patient factors associated with arteriosclerosis progression and type of bypass conduit influence the need for or bias toward repeat coronary artery bypass grafting. Aggressive patient risk-factor reduction and extensive arterial coronary revascularization at primary coronary artery bypass grafting should result in fewer coronary reoperations.

Coronary Artery Bypass↗
PubMed2005

Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.

BACKGROUND: We sought to compare saphenous vein and internal thoracic artery graft patency by coronary system. METHODS: From 1972 to 1999, 50,278 patients underwent primary coronary surgery; subsequently, 4,333 had angiography of 2,121 internal thoracic artery and 8,733 saphenous vein grafts. Longitudinal analysis was used to model graft occlusion and identify risk factors. Using the model, patency was calculated twice for each graft and compared first as if an internal thoracic artery, and second as if a saphenous vein, were used. RESULTS: Unadjusted 1-, 5-, and 10-year patency was 93%, 88%, and 90% for internal thoracic arteries and 78%, 65%, and 57% for saphenous veins. At 10 years, internal thoracic arteries were more likely than saphenous veins to be patent to left anterior descending in 99.1% of cases, to diagonals in 98.3%, to circumflex in 98.3%, to posterior descending artery in 98.5%, and to right coronary arteries in 82.5%. For right coronary arteries, saphenous vein patency was equivalent to or better than internal thoracic artery patency early after surgery. However, by 10 years, internal thoracic artery patency was better in right coronary arteries with 70% stenosis or greater. At all times after surgery and all levels of clinically important coronary stenosis, internal thoracic artery patency surpassed saphenous vein patency in grafts to the left anterior descending, diagonal, circumflex, and posterior descending arteries. CONCLUSIONS: Internal thoracic arteries demonstrate better patency than saphenous veins except when grafting moderately stenosed right coronary arteries. When bypassing right coronary arteries with less than 70% stenosis, saphenous veins may be a better choice.

Coronary Angiography↗
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

Is reoperation still a risk factor in coronary artery bypass surgery?

BACKGROUND: Hospital mortality for reoperative coronary artery bypass grafting (CABG) is approaching that of primary CABG. This raises two questions: (1) has experience neutralized the risk of reoperation attributable to its greater difficulty, or (2) has experience neutralized the risk attributable to the higher-risk profile of reoperative patients?. METHODS: From 1990 to 2003, 21,568 CABG procedures were performed, of which 4,518 (21%) were reoperations: 3,919 first, 552 second, 43 third, 3 fourth, and 1 fifth. Reoperative patients had a higher-risk profile than primary patients, with more vascular disease, left ventricular dysfunction, and coronary artery disease (all p < 0.0001). Logistic regression was used to identify factors associated with hospital death and to develop a propensity score for reoperation, which was used to (1) adjust multivariable analyses of death and (2) compare outcomes in matched patients. RESULTS: Hospital mortality was 4.3% (168 of 3,919) for first reoperation, 5.1% (28 of 552) for second, and 6.4% (3 of 47) for third or more, compared with 1.5% (263 of 17,050) for primary operations. Risk of both primary and reoperative CABG decreased with experience (p > 0.0002); however, reoperative risk fell markedly in the mid-1990s. In both the overall and matched-pairs analyses, reoperation was a risk factor before 1997 (p < or = 0.008), but not after (p = 0.2). Reoperation within 1 year of previous CABG increased risk (p < 0.0001). Risk attributable to left ventricular dysfunction decreased with experience (p = 0.05). CONCLUSIONS: Hospital mortality for reoperative CABG has been consistently higher than for primary operation, but this difference has narrowed considerably. Patient characteristics, not reoperation itself, now have greater influence.

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↗
PubMed2005

Coregistered MR imaging myocardial viability maps and multi-detector row CT coronary angiography displays for surgical revascularization planning: initial experience.

PURPOSE: To evaluate assignment of left ventricular (LV) myocardial segments to coronary arterial territories by using coregistered magnetic resonance (MR) imaging and multi-detector row computed tomography (CT) displays; to assess the accuracy of coregistered displays in determining the distribution of clinically important coronary artery disease (CAD) and regional effect of CAD on LV myocardium in patients with chronic ischemic heart disease (CIHD); and to determine the utility of coregistered displays in optimizing surgical revascularization planning. MATERIALS AND METHODS: This study was HIPAA compliant and was approved by the local Institutional Review Board, with waiver of informed consent. Twenty-six patients (19 men, seven women; age, 56 years +/- 12 [+/- standard deviation]) with CIHD underwent MR imaging assessment of myocardial viability and multi-detector row CT assessment of CAD on the same day. For coregistration, a population-based LV model was fit to each data set separately; models were then registered spatially. For data analysis, correspondence between coregistered displays and the 17-segment LV model for assessment of CIHD was evaluated, accuracy of using coregistered displays to evaluate the extent of CAD and myocardial disease was assessed, and utility of coregistered displays in optimizing surgical revascularization planning was determined. RESULTS: Coronary assignment for coregistered displays and the 17-segment LV model differed in 17% of myocardial segments. For the majority of patients, three segments (midanterolateral [62%], apical lateral [73%], and apical inferior [58%]) were discordant. Segments were supplied by the left anterior descending artery, a diagonal branch, or a ramus intermedius with diagonal distribution in all but one case. Coregistered displays were deemed concordant with selective coronary angiography and alternate myocardial imaging in all cases. Overall, surgical planning was potentially enhanced in 83% of cases because, compared with alternate imaging modalities, coregistered displays were believed to demonstrate the relationship between coronary arteries and underlying myocardial tissue more definitively and efficiently (for patients in whom surgery was performed) or more correctly and comprehensively (for a presumably better-tailored surgery). CONCLUSION: Assessment of CIHD can be improved by using coregistered displays that directly relate the condition of LV myocardium to the anatomy of the coronary arteries in individual patients.

Contrast Media↗
PubMed2004

Bipolar radiofrequency to ablate atrial fibrillation in patients undergoing mitral valve surgery.

BACKGROUND: Atrial fibrillation (AF) affects 30% to 50% of patients undergoing mitral valve surgery. The optimum treatment of AF in these patients is unclear. The purpose of this study was to describe initial clinical experience using a bipolar radiofrequency clamp to facilitate AF ablation in patients undergoing mitral valve surgery. METHODS: From November 2001 through March 2003 a bipolar radiofrequency clamp was used to facilitate AF ablation in 108 patients undergoing mitral valve surgery. Preoperative AF was paroxysmal in 25%, persistent in 26%, and permanent in 49% of the patients. All patients underwent bilateral pulmonary vein isolation performed with the bipolar radiofrequency clamp and excision or exclusion of the left atrial appendage. Most patients had connecting lesions between the right and left pulmonary veins and between the left atrial appendage and the left pulmonary veins. Novel statistical methods were used to create a plot of the prevalence of AF versus time after surgery. RESULTS: Mean time required for AF ablation was 17+/-4 minutes (range, 9-28 minutes). All patients left the operating room with sinus rhythm or with atrial or atrioventricular pacing for an underlying nodal rhythm. Perioperative AF was common, affecting 64% of patients. At discharge, 33% of patients were in AF or atrial flutter. By 3 months postoperatively, the predicted prevalence of AF or atrial flutter was 15%. There were no device-related complications. CONCLUSIONS: Bipolar radiofrequency facilitates rapid and safe AF ablation in patients with mitral valve disease. Perioperative AF is common and should be treated aggressively. By 3 months postoperatively, 85% of patients are free of AF or atrial flutter. Continued follow-up is necessary to document late results of this strategy.

Absorptiometry, Photon↗
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

Elephant trunk procedure: newer indications and uses.

BACKGROUND: The elephant trunk procedure is used for extensive aortic aneurysms. We evaluated its safety, newer indications, and influence of second-stage completion on survival. METHODS: Records were reviewed for 94 consecutive patients (age 67 +/- 11 years, 47% men) who underwent the procedure between November 1990 and February 2003. The trunk was implanted as an extension of the ascending aorta and arch graft in 83 of 94 (88.3%) patients, distal arch graft in 8 of 94 (8.5%) patients, and in 3 distal to the left subclavian artery (3 of 94 patients [3.2%]). Aortic dissection was present in 37 (39.4%) patients and Marfan syndrome was present in 7 (7.4%). Twenty-three were reoperations (24.5%). In 9 patients, the trunk procedure was adjunctive in preparation for the second operation. In 15 patients, the anastomosis was completed between the left subclavian and common carotid arteries. Coronary artery bypass was performed in 36 (38.4%) and aortic valve operation in 55 (58.5%; 20 root sparing repairs, 16 composite grafts and 19 replacements) patients. RESULTS: There were two early 30-day in-hospital deaths (2.1%) and 5 permanent strokes (5.3%). Eleven died before the second-stage procedure. Forty-seven (57%) underwent second-stage procedures; 40 by thoracotomy and 7 by stent graft insertion, including 2 thoracoabdominal aneurysm repairs with visceral bypasses before stent grafting with 4 early deaths (8.5%). Five-year survival was 34% without a second-stage procedure versus 75% 3-year survival with it. CONCLUSIONS: With a current total of 142 elephant trunk procedures, we found it is safe and should be used more with initial cardiac surgery before descending or thoracoabdominal aorta repair.

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

The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.

BACKGROUND: To compare survival of patients receiving bilateral internal thoracic artery grafts and single internal thoracic artery grafts more than 20 postoperative years, assess magnitude of benefit, and identify predictors of benefit. METHODS: From cohorts of 8123 patients receiving single internal thoracic artery grafts and 2001 receiving bilateral internal thoracic artery grafts during primary isolated bypass operations for multivessel coronary disease between 1971 and 1989, we identified 1152 propensity-matched pairs. Mean follow-up of survivors was 16.5 years, with 51 patients followed for 20 years or more. Hazard function methodology was used to identify risk factors for mortality, compare survival, and assess magnitude of benefit. RESULTS: Comparison of the matched pairs showed survival of the bilateral internal thoracic artery and single internal thoracic artery groups at 7, 10, 15, and 20 years was 89% versus 87%, 81% versus 78%, 67% versus 58%, and 50% versus 37%, respectively (p < 0.0001). Divergence of bilateral internal thoracic artery and single internal thoracic artery hazard function curves continued to widen through 20 postoperative years. At 20 years, bilateral internal thoracic artery grafting was predicted to produce worse survival in 2.8% of patients, a survival advantage of less than 5% in 12.9%, greater than 10% in 52%, and greater than 15% in 7.6%. Combinations of cardiac and noncardiac descriptors were used to define higher and lower risk patient subsets. Advanced age, abnormal left ventricular function and noncardiac risk factors decreased overall survival but the incremental benefit of bilateral internal thoracic artery grafting persisted. CONCLUSIONS: Bilateral internal thoracic artery grafting produces improved survival compared with single internal thoracic artery grafting during the second postoperative decade, and the magnitude of that benefit increases through 20 postoperative years.

Coronary Disease↗
PubMed2004

In vivo short-term Doppler hemodynamic profiles of 189 Carpentier-Edwards Perimount pericardial bioprosthetic valves in the mitral position.

We sought to determine the hemodynamic performance of the Carpentier-Edwards Perimount pericardial valve in the mitral position. We reviewed the Doppler echocardiographic data on 189 patients (110 women; 68 +/- 12 years of age) who were implanted with this valve (7.6 days +/- 13 postoperatively) at our institution between September 2000 and May 2002. The average ejection fraction was 47%. For all valves, the peak velocity was 1.9 +/- 0.3 m/s, peak gradient was 15 +/- 4.8 mm Hg, and mean gradient was 5.8 +/- 2 mm Hg. The pressure half-time was 93 +/- 24 milliseconds, with a calculated effective orifice area of 2.5 +/- 0.6 cm2. The average effective orifice area by continuity equation (83 valves) was 1.5 +/- 0.5 cm2. The mitral regurgitation was graded mild or less in 97.5% of all valves. This is the largest series establishing the favorable hemodynamic behavior of the different sizes of a new Perimount mitral valve, and the reported data could serve as a reference.

Adult↗