Background: This study aimed to verify the external validation of a contemporary nomogram in predicting long-term survival after an isolated coronary artery bypass with bilateral internal thoracic artery grafting (CABG-BITA). Methods: Consecutive patients who underwent CABG-BITA at a single center were included in the study. All the predictors of the original risk score (age, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic renal failure, old myocardial infarction, ejection fraction, intra-aortic balloon pump and peripheral arterial disease) were available for analysis. Results: Among the 2846 consecutive patients, a total of 1176 (41.3%) deaths were recorded during the 31,383 patient years of follow-up. The median EuroSCORE II was 2.35, and the median follow-up was 11.1 years. The risk score showed 72.7% overall discriminatory ability as measured by Harrell's concordance statistic. It showed satisfactory calibration at 10, 15 and 20 years of follow-up. The risk score showed a time-varying nonlinear effect, and accordingly, adjusted long-term survival predictions were calculated. There were subgroups (scores < 50 points) with favorable 20-year survival rates ranging from 77% to 60%. Higher risk subgroups (scores > 90 points) showed poor 20-year survival rates ranging from 22% to 4%. Conclusions: The validated risk score represents a useful algorithm for the detection of patients who could benefit after CABG-BITA with respect to long-term survival. Although further multi-center studies are required worldwide to reveal the usefulness of this score in the clinical setting, its wide adoption may act as a motivation for cardiac surgeons resulting in higher numbers of CABG-BITA procedures.

Objective: Risk algorithms for the prediction of long-term survival after coronary artery bypass grafting (CABG) do not include the use of bilateral internal thoracic artery (BITA) grafting among the independent predictors. We sought to reveal the superiority of BITA grafting in the long-term outcome through the lenses of an existing bedside risk score (BRS). Methods: This study analyzed data from 5,666 consecutive patients undergoing isolated (n = 4,715 -BITA = 2,792) and combined (n = 951 -BITA = 246) CABG. The mean follow-up period was 10.3 years (interquartile range, 9.9 years). All the predictors of an existing BRS were available for analysis (age, body mass index, ejection fraction, unstable hemodynamic state, left main disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, malignant ventricular arrhythmia, chronic obstruc-tive pulmonary disease, diabetes, and previous heart surgery). Furthermore, a modified BRS was con-structed taking into account the use of BITA grafting and combined CABG. Results: The good discriminatory ability and satisfactory calibration of the BRS was confirmed in the isolated CABG subgroup. The modified BRS showed improved discriminatory ability and similar cali-bration. It showed a time-varying coefficient, and accordingly, we calculated the adjusted survival pre-dictions up to 20 years after isolated and combined CABG with or without BITA grafting. Patients with BITA grafting in the low-risk quartile showed 68.4% and 65.5% predicted survival rates at 20 years in the isolated and combined CABG subgroups, respectively, versus the survival rates of 56.4% and 52.8% observed among patients without BITA grafting. Conclusion: The modified BRS is a useful simplified algorithm for clinicians in choosing treatment intervention for severe isolated or combined coronary artery disease. We clearly demonstrated the su-periority of BITA grafting in long-term survival throughout the entire range of the modified BRS. (c) 2021 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Intravenous leiomyomatosis with intracardiac extension is a rare condition characterized by extensive growth of a benign uterine mass that extends into the venous system through uterine channels and then into the cardiac chambers. A variety of presentations exist; cure relies on complete surgical resection. Extensive abdominal dissection, cardiopulmonary bypass (with or without circulatory arrest), and removal of the intracaval component are required. However, because of the rarity and variety of presentation, exact preferred management has not been well defined. A specific case, followed by a comprehensive literature review, helps delineate the specific decision making necessary for mass removal.

AIMS:The aim of this study was to assess the papillary muscle strain as a contributor to recurrent mitral regurgitation (MR) after mitral valve repair for fibroelastic deficiency.METHODS AND RESULTS:Sixty-four patients with isolated posterior mitral valve prolapse and severe MR referred for surgery were prospectively recruited between 2008 and 2012. Two- and three-dimensional echocardiography and speckle tracking were performed in all patients. The longitudinal strain of the anterolateral (AL) and posteromedial (PM) papillary muscles was individually calculated as well as the global longitudinal strain of both papillary muscles was measured before and after mitral repair and normalized to left ventricle end-diastolic volume. Eight patients (12.5%) had at least moderate MR 6 months after mitral repair. The longitudinal strain of the AL (preop -4.94 ± 2.2 vs. postop -3.28 ± 1.3, P < 0.001) and the PM papillary muscles (preop -12.64 ± 5.3 vs. postop -4.12 ± 6.77, P < 0.001) as well as the global strain of both papillary muscles (preop -7.59 ± 3.48 vs. postop -1.07 ± 6, P < 0.001) were all reduced after surgical repair. The longitudinal strain of the PM papillary muscle was the strongest predictor of recurrent MR (when less than or equal to -14.78). The global preoperative papillary muscle strain was also a determinant of recurrent MR when the global strain was greater than -9.05% (area under the curve: 0.895, sensitivity: 100%, and specificity: 76.8%).CONCLUSIONS:Patients with isolated posterior mitral leaflet prolapse are less likely having any residual MR post repair when the global papillary muscle strain of both papillary muscles is close or equal to zero. Strain of the papillary muscles may be an important determinant in predicting residual MR in patients who undergo mitral valve repair.

Toumpoulis, Ioannis K. MD; Lozos, Vasileios A. MD; Agrogiannis, Georgios MD; Chamogeorgakis, Themistokles P. MD; Rizos, Ioannis K. MD; Patsouris, Efstratios S. MD; Anagnostopoulos, Constantine E. MD; Rokkas, Chris K. MD Author Information

Background: Potassium adenosine triphosphate (K-ATP) channel openers have been involved in the enhancement of ischemic tolerance in various tissues. The purpose of the present study is to evaluate the effects of aprikalim, a specific KATP channel opener, on spinal cord ischemic injury.Methods: Fifty-four rabbits were randomly assigned to three groups: group 1 (n - 18, sham operation), group 2 (n = 18, 30 min of normothermic aortic cross-clamping) and group 3 (n = 18, aprikalim 100 mu g/kg was administered 15 min before 30 min of normothermic aortic cross-clamping). Neurologic evaluation was performed according to the modified Tarlov scale. Six animals from each group were sacrificed at 24, 48 and 168 h postoperatively. The lumbar spinal cords were harvested and examined histologically. The motor neurons were counted and the histologic lesions were scored (0-3, 3: normal).Results: Group 3 (aprikalim group) had better Tarlov scores compared to group 2 at all-time points (P < 0.025). The histologic changes were proportional to the Tarlov scores and group 3 had better functional outcome as compared to group 2 at 168 h (number of neurons: 21.2 +/- 4.9 vs. 8.0 +/- 2.7, P < 0.001 and histologic score: 1.67 +/- 1.03 vs. 0.50 +/- 0.55, P = 0.03). Although aprikalim exhibited improved effect on clinical and histologic neurologic outcome when compared to normothermic spinal cord ischemia, animals in group 3 had worse Tarlov score, reduced number of motor neurons and worse histologic score when compared to group 1 (sham operation) at 168 h (P = 0.003, P = 0.001 and P = 0.019 respectively).Conclusion: Aprikalim reduces the severity of spinal cord ischemic injury in a rabbit model of spinal cord ischemia. (C) 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Background: Abdominal aortic aneurysm (AAA) is a common and lethal disease. AAAs are associated with atherosclerosis, chronic inflammation, and extracellular matrix degradation. The aim of this study was to determine whether treatment with simvastatin can influence the development of experimental aortic aneurysms in a rabbit model.Materials and Methods: A total of 76 rabbits were randomized in four groups: in group I (n = 12), where the abdominal aortas were exposed to 0.9% NaCl, and in group II (n = 24), group III (n = 24) and group IV (n = 18), where the aortas were exposed to CaCl2 0.5 mol/L for 15 minutes after laparotomy. Group III received 2 mg/kg simvastatin daily starting 7 days before laparotomy, and in group IV, the daily treatment with simvastatin started 7 days after laparotomy. Animals were sacrificed at intervals of first, second, third, and fourth week to obtain measurements of aortic diameter and histological examination. Moreover, immunohistochemistry was used in order to examine the relative distribution of matrix metalloproteinases (MMPs) 2 and 9 (MMP-2 and MMP-9, respectively) and tissue inhibitor 1 of MMPs within the aortic aneurysms.Results: The increase of aortic diameter in animals of group I ranged from 4.6% to 7.6%; in group II, from 41% to 85% (P < 0.001 vs. group I); in group III, from 9% to 18% (group II vs. group III, P < 0.001); and in group IV; from 36% to 38%. Moreover, aortic specimens of group II presented a statistically significant increase in MMP-2 and MMP-9 immunoexpression compared with other groups (I, III, IV) (P < 0.05 for all comparisons), with the exception of animals of group IV at the end of second week. Immunoreactivity of tissue inhibitor 1 of MMPs was not statistically different among groups II, III, and IV.Conclusions: Simvastatin may prove clinically significant in suppressing the development and expansion of AAAs and, thereby, in reducing the risk of rupture and the need for repair.

Introduction: In this study, we examined the longitudinal strain of primary papillary muscles (anterolateral and posteromedial) of the mitral valve and the left ventricle (LV) before and after repa...

Mechanical and biological prostheses are valid options when aortic valve replacement is necessary. The Ross procedure is also an alternative solution, especially for young patients. We describe the case of a young patient with congenital aortic stenosis and bicuspid aortic valve who presented with dyspnea on exertion. An open commissurotomy was performed, and within 8 months the patient developed recurrent symptoms of severe aortic stenosis. He underwent redo sternotomy and a Ross-Konno procedure with an uneventful recovery.

Cox's widely used semi-parametric proportional hazards (PH) regression model places restrictions on the possible shapes of the hazard function. Models based on the first hitting time (FHT) of a stochastic process are among the alternatives and have the attractive feature of being based on a model of the underlying process. We review and compare the PH model and an FHT model based on a Wiener process which leads to an inverse Gaussian (IG) regression model. This particular model can also represent a “cured fraction” or long-term survivors. A case study of survival after coronary artery bypass grafting is used to examine the interpretation of the IG model, especially in relation to covariates that affect both of its parameters.

AIM:Prolonged cardio-pulmonary bypass (CPB) time, usually necessary for reoperations, is known to increase mortality in coronary bypass procedures and aortic reoperations. We investigated if prolonged CPB time and arch reconstruction in reoperations of the thoracic aorta affect in-hospital outcome.METHODS:Twenty-nine patients underwent reoperations on the thoracic aorta. The reoperations performed were aortic root replacement with composite graft without aortic arch involvement in ten patients, isolated ascending aorta replacement in six patients, aortic arch replacement as a primary procedure in two patients, and aortic arch in conjunction with ascending or descending aorta replacement in 11 patients.RESULTS:Fourteen patients had aortic reoperation with deep hypothermic circulatory arrest (DHCA) and 15 without DHCA. The in-hospital mortality rate was 13.8%. The use deep hypothermic circulatory arrest or CPB time did not affect early outcome. Previous coronary artery bypass procedure was independent predictor of in-hospital mortality. Seven patients required re-exploration for bleeding. One patient suffered from stroke and finally five patients had prolonged ventilation, two requiring tracheostomy. There have been no deaths in the follow-up period. None of the patients has required repeat surgical intervention on the heart or the aorta.CONCLUSION:The use of DHCA or prolonged CPB time do not affect early outcome in reoperations of the thoracic aorta.

We examined the effects of extracoronary artery disease on postoperative complications, 30-day mortality, and long-term mortality after coronary artery bypass grafting (CABG). We reviewed 4766 patients who underwent CABG at a single institution between 1992 and 2008. Preoperative and intraoperative risk factors and postoperative complications were collected prospectively for our state cardiac surgery database. Long-term survival data (mean follow-up 8.3 years) were obtained from the National Death Index. Risk factors for postoperative complications and 30-day mortality were determined by multivariate logistic regression analysis and predictors for long-term mortality were determined by multivariate Cox regression analysis. Risk-adjusted Kaplan-Meier curves were constructed and compared using the log-rank test. Of all patients undergoing CABG, 513 patients (10.8%) had carotid artery disease and 563 patients (11.8%) had peripheral vascular disease (PVD). Just 162 patients (3.4%) had both conditions. Postoperative complications occurred in 11.0%, with the most common complication being respiratory failure. After adjusting for other risk factors, PVD remained an independent predictor for postoperative complications (OR 1.42, 95% CI 1.10-1.82, p = 0.008), but carotid disease did not. Thirty-day mortality overall was 7.3%; neither carotid disease nor PVD were associated with increased 30-day mortality after adjusting for other risk factors. After ten years, survival for patients without carotid disease or PVD was 70%; survival was 42% for those with carotid disease and 38% for those with PVD. After risk-adjustment, both carotid disease (HR 1.19, 95% CI 1.04-1.36, p = 0.01) and PVD (HR 1.41, 95% CI 1.24-1.61, p < 0.001) remained independent predictors of long-term mortality. While neither carotid disease nor PVD were associated with 30-day mortality, both were independent predictors of long-term mortality after CABG. Only PVD was associated with increased postoperative complications.

Background. Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination.Methods. We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index.Results. There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p = 0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively (p = 0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively.Conclusions. Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival.

Aim. The study investigated the release of cardiac Troponin I (cTnI) levels in heart valve surgery and in coronary artery bypass grafting (CABG). The aims of the research were 1) to evaluate the ability of cTnI to detect the myocardial damage; and 2) to demonstrate possible causative factors of the cTnI release after valve surgery.Methods. A prospective, single-center study. Ninety consecutive patients were operated on for different types of cardiac surgery; 45 patients underwent cardiac valve surgery - The VALVE group. 45 patients underwent CABG surgery - the CABG group. CTnI levels were measured preoperatively, on the day of operation and the 7 days postoperatively. The diagnosis of damaged myocardium classically performed through the measurement of cTnI, twelve-lead electrocardiograms (ECG) and echocardiographics according to the protocol of the study.Results. Although more elevated cTnI release was noticed in valve group early after operation, no occurrence of cardiac events was found in that group. Statistically significant occurrence of cardiac events was found in CABG group (P=0.015). No relationship was shown between the peak of cTnI and the presence of cardiac events in valve group. A statistically significant correlation was observed between cardiac events and peak cTnI in CABG group (P=0.05). Possible correlations were investigated between the peak of cTnI and perioperative parameters in both two groups.Conclusion. The absence of cardiac events and the association of valve surgery with higher early release of cTnI compared to CABG suggest that the type of surgery strongly affects the induction of myocardial damage.

Background: Prior studies have demonstrated the deleterious effect of peripheral vascular disease (PVD) on long-term mortality after cardiac surgery. In this study we attempted to determine the effect of PVD on the short-term events of in-hospital postoperative complications, prolonged length-of-stay, and in-hospital mortality, in addition to long-term mortality. Methods: We studied 7160 patients who underwent cardiac surgery at a single institution between 1992 and 2008. Preoperative and intraoperative risk factors, including demographic information, medical comorbidities, hemodynamic status, need for emergent operation, and procedures performed, were collected prospectively for our state cardiac surgery database. Postoperative complications were also submitted to the database and included myocardial infarction, renal failure, respiratory failure, stroke, bleeding requiring a reoperation, deep sternal wound infection, sepsis, and gastrointestinal bleeding. Long-term survival data (mean follow-up 7.6 years) were obtained from the National Death Index. Independent predictors for in-hospital postoperative complications and prolonged length of stay were determined by multivariate logistic regression analysis and predictors for long-term mortality were determined by multivariate Cox regression analysis. Risk-adjusted Kaplan-Meier curves were constructed and compared using the log-rank test. Results: Seven hundred and forty-six patients (10.4%) were diagnosed with PVD, defined as significant disease in the aorta, iliac, femoral, or popliteal arteries, prior to cardiac surgery. Of those patients, 22% had a postoperative complication, with the most common complications being respiratory failure requiring 72 hours or more of mechanical ventilation (12% of patients) and stroke (6%). After risk adjustment, PVD remained an independent risk factor for complications (OR 1.5, 95%CI 1.2-1.8, p<0.001). See Table for the list of significant risk factors for postoperative complications identified in multivariate analysis. Length of stay for patients with PVD was longer than average, with 30% over thirteen days, the fourth quartile for length of stay in all patients. After adjusting for preoperative and intraoperative risk factors and postoperative complications, PVD remained an independent predictor of prolonged length-of-stay (OR 1.5, 95%CI 1.2-1.8, p<0.001). Finally, PVD was an independent predictor of long-term mortality (HR 1.4, 95%CI 1.2-1.5, p<0.001) after adjusting for all other factors. See Figure for risk-adjusted Kaplan-Meier curves. PVD was not an independent predictor of in-hospital mortality. Conclusions: We note a significant effect of PVD on short-term complications and prolonged hospital stay after cardiac surgery, in addition to its effect on long-term mortality. Our results showed no effect of PVD on in-hospital mortality, which is consistent with prior published studies. View Large Image Figure Viewer

Background— The molecular mechanisms leading to ascending thoracic aortic aneurysms (ATAAs) remain unknown. We hypothesized that alterations in expression levels of specific fibrillar collagens occur during the aneurysmal process. Methods— Surgical samples from ascending aortas from patients with degenerative ATAAs were subdivided by aneurysm diameter: small, 5 to 6 cm; medium, 6 to 7 cm; and large, greater than 7 cm; and compared with nonaneurysmal aortas (mean diameter, 2.3 cm). Results— Histology, immunofluorescence, and electron microscopy demonstrated greater disorganization of extracellular matrix constituents in ATAAs as compared with control with an increase in collagen α 1(XI) within regions of cystic medial degenerative lesions. Real-time quantitative reverse transcription-polymerase

Aim. Patients with depressed left ventricular function are more susceptible to develop postoperative complications after cardiac surgery. The aim of the present study was to examine the effect of severe left ventricular dysfunction on the activation of systemic inflammatory reaction during and after coronary artery bypass grafting (CABG).Methods. Clinical prospective study; 32 selected patients underwent CABG; 16 patients had depressed left ventricular function before the operation (low ejection fraction [EF] <30%) - Low EF group (study group). Sixteen patients had normal left ventricular function (normal EF, >50%) - Normal EF group (control group). The levels of inflammatory mediators TNF-alpha IL-6, IL-8 and IL-10 were measured preoperatively, during and after cardiopulmonary bypass (CPB) and 24 hours postoperatively.Results. Higher levels of almost all of inflammatory mediators were detected in patients with depressed left ventricular function compared with patients of normal EF group. IL-6 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.039) and after the administration of protamine (P=0.02). IL-8 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.05), 30 min after the start of CPB (P=0.02), after the administration of protamine (P=0.015) and 24 hours after the end of the operation (P=0.05). No statistically significant differences were demonstrated between the 2 groups of study relative to TNF-alpha and IL-10.Conclusion. A greater activation of systemic inflammatory reaction occurred in patients with depressed left ventricular function than in patients with normal cardiac function when they underwent CABG with extracorporeal circulation.

A middle-aged male patient with progressive right ventricular heart failure due to pulmonary thromboembolism causing pulmonary hypertension was referred for evaluation of a mobile right ventricular mass. The mass originated from the pulmonary valve and was removed in surgery. Pathological assessment showed that the mass was a thrombus located on the pulmonary valve. Echocardiographic images before surgery as well as images of the removed mass and its histology, are presented to describe this very rare cause of pulmonary thromboembolism.

BACKGROUND AND AIM OF THE STUDY Patients with heart valve surgery may have a periprocedural mortality extending up to one year after surgery. The study aim was to determine independent predictors for in-hospital and long-term mortality after heart valve surgery. METHODS A total of 1,376 consecutive patients who underwent isolated or combined heart valve surgery at a single institution was studied. Multivariate logistic regression analysis was used to determine independent predictors for in-hospital mortality. Long-term survival data (mean follow up 5.6 years) were obtained from the National Death Index. Multivariate Cox regression analysis was used to determine independent predictors for long-term mortality. All available preoperative, intraoperative and postoperative risk factors were included in these analyses. RESULTS The mean EuroSCORE was 6.2 +/- 3.7. There were 86 (6.3%) in-hospital and 550 (40.0%) late deaths. Eleven independent predictors were determined for in-hospital mortality, and 13 for long-term mortality. There were six common independent predictors (preoperative dialysis, total bypass time, intraoperative stroke, postoperative sepsis and/or endocarditis, renal and respiratory failure). Unique independent predictors for in-hospital mortality included intra-aortic balloon pump, preoperative endocarditis, intravenous use of nitroglycerine, bleeding requiring reoperation and gastrointestinal complications. The model for in-hospital mortality showed acceptable calibration (Lemeshow-Hosmer, p = 0.629) and excellent discriminatory ability (C statistic 0.88). Unique independent predictors for long-term mortality included age, ejection fraction, stroke prior to surgery, hemodynamic instability, chronic obstructive pulmonary disease and deep sternal wound infection. CONCLUSION Independent predictors were determined for early and long-term mortality after heart valve surgery. The prevention of postoperative complications may be a key element for increased early and long-term survival in these patients.