BACKGROUND: Among patients with coronary artery disease (CAD), around 25% have multisite artery disease (MSAD). Patients with CAD and MSAD are at higher risk of peri-operative and long-term cardiovascular events. Whether off-pump coronary bypass grafting (CABG) can improve their prognosis is unknown. We aimed to assess the benefits of off- vs. on-pump cardiac surgery in patients undergoing CABG, according to coexistence of extra-cardiac artery disease. METHODS: Between April 1998 and September 2008, 1221 patients undergoing CABG without any other intervention were enrolled. Overall death and major cardiovascular events were recorded at 1-month and during long-term follow-up. A propensity score (PS), derived from all relevant variables (P<0.25) associated with on-pump as compared to off-pump CABG, and representing the likelihood for each individual patient to receive off-pump CABG, was calculated. RESULTS: MSAD was observed in 279 patients (23%). Off-pump CABG was performed in 208 (17%) patients. The median follow-up was 7.6 years. The 10-year mortality was significantly lower in off- vs. on-pump CABG group (74 +/- 4% vs. 68 +/- 2%, P=0.024). In patients with MSAD, there was a trend for better survival for off- vs. on-pump CABG (63 +/- 8% vs. 50 +/- 4%, P=0.078). After adjustment for PS, we found no further difference between on- and off-pump CABG both in the whole cohort (HR=1.30, P.10), as well as in MSAD patients (HR=1.51, P=0.14). CONCLUSIONS: Patients with MSAD receiving CABG are at worst prognostic than those with isolated CAD. In these patients, we found no significant difference in the long-term mortality and cardiovascular events between on- and off-pump CABG.

Objective: To assess the performance of transthoracic echocardiographic parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting, and to assess its incremental prognostic value as compared to the Society of Thoracic Surgeons (STS) score. Materials and methods: We prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalised for coronary artery bypass grafting. Preoperative transthoracic echocardiography was performed for each patient. The primary endpoint was 30-day mortality or major morbidity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. The secondary endpoint was prolonged hospitalisation for over 14 days. Results: A total of 172 patients was included (mean age 66.1±10.2 years, 12.2% were women). The primary endpoint occurred in 33 patients (19.2%), and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary endpoint were an increased left atrial volume (>31 mL/m²; odds ratio (OR) 3.55, 95% confidence interval (CI) 1.38–9.12; P=0.004) and a decreased tricuspid annular plane systolic excursion (<20 mm; OR 3.45, 95% CI 1.47–8.21; P=0.008). The predictive value of the multivariate model increased when the two echocardiographic parameters were added to the STS score (area under the curve 0.598 vs. 0.695, P=0.001; integrated discrimination improvement 7.44%). Conclusion: In patients undergoing coronary artery bypass grafting, preoperative assessment of left atrial size and tricuspid annular plane systolic excursion should be performed systematically, as it provides additional prognostic information to the STS score.

Objective: To report our experience in aortic valve replacement with the Mitroflow (Sorin, Vancouver, Canada) aortic bioprosthesis.Methods: We retrospectively reviewed all patients who underwent aortic valve replacement with a Mitroflow bioprosthesis at our institution from January 1994 to December 2011. No exclusion criteria were retained. Patients were followed yearly. Echocardiography follow-up was performed systematically before the hospital discharge and annually by patients' cardiologists.Results: Seven hundred twenty-eight patients (mean age, 76 +/- 6 years; range, 33-91 years) underwent aortic valve replacement with Mitroflow 12A or LX model and were included in this analysis. 30-day mortality for nonemergent isolated aortic valve replacement was 5.5%. Eight patients (1%) underwent reoperation for structural valve deterioration (SVD) and 30 patients (5.8%) presented echocardiographic signs of SVD. Actuarial freedom from reoperation for SVD was 99% +/- 0.5% and 95% +/- 5% at 10 and 15 years. Actuarial freedom from echocardiographic signs of SVD was 77% +/- 5% and 56% +/- 11% at 10 and 15 years, respectively. At the univariate analysis, only the mean gradient at discharge (P = .0200), the prevalence of size 19 (P = .0273), and severe patient-prosthesis mismatch (P = .0384) were significantly different in patients developing SVD at follow-up. Freedom from echocardiographic signs of SVD at 8 years were 88% +/- 4% and 64% +/- 13% in patients with a Mitroflow > 19 and Mitroflow 19, respectively (log-rank test, P = .0056; Wilcoxon test, P = .0589).Conclusions: Overall outcomes were satisfactory. However the risk of early SVD seems higher for the Mitroflow size 19. This size should be reserved for applications when annulus enlargement is risky or there is an anatomic contraindication to sutureless or stentless valve.

Long-term survival and risk of reoperation in "non-Marfan syndrome" patients with a long life expectancy who undergo emergency surgery for acute type A aortic dissection (aTAAD) are not well known. To analyse survival, risk of reoperation and quality of life in this population. From 1990 to 2010, all patients aged ≤ 50 years and not affected by Marfan syndrome, who underwent emergency surgery for aTAAD at two institutions, were included in this analysis. Patients were categorized into four groups according to the extension of the aortic replacement: SUPRACORONARY, ROOT, ARCH and EXTENSIVE. Sixty-six patients (mean age 45 ± 4 years; range 34–50 years) were considered eligible for this analysis. Overall in-hospital mortality was 24% (16/66 patients); and 25%, 23%, 20.5% and 43% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Mean follow-up among survivors was 10.5 ± 7.2 years (range: 0.1–24.7 years). Overall 10-year survival was 55 ± 6%; and 75 ± 12%, 69 ± 13%, 47 ± 8% and 28 ± 17% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Overall freedom from reoperation on the aorta was 73 ± 7.5%; and 40 ± 20%, 75 ± 21%, 78 ± 8% and 100% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. In our experience, patients who underwent isolated supracoronary ascending aorta or root replacement showed the most satisfactory late survival. However, because the risk of reoperation is low when the replacement is extended to the root, our data suggest that root replacement could represent a good compromise between operative mortality and long-term survival. Les résultats à très long terme après chirurgie pour dissection aortique aiguë de type A chez le patient avec une longue espérance de vie non atteint du syndrome de Marfan sont peu connus. Nous analysons la survie et le risque de réintervention dans cette population. Nous avons analysé rétrospectivement tous les patients âgés de moins de 50 ans, non atteints du syndrome de Marfan et opérés d'une dissection aortique aiguë de type A dans deux hôpitaux, entre 1990 et 2010. Les patients ont été repartis en 4 groupes selon l'extension du remplacement aortique : SUS-CORONAIRE, RACINE (étendu que à la racine), ARCHE (étendu que à l'arche) et ETENDU (de la racine à l'arche). Soixante-six patients (âge moyen : 45 ± 4 ans; de 34 à 50 ans) ont été inclus dans cette analyse. La mortalité hospitalière globale était de 24 % (16/66 patients) et de 25 %, 23 %, 20,5 % et 43 % dans les groupes SUS-CORONAIRE, RACINE, ARCHE et ETENDU, respectivement. Le suivi moyen parmi les survivants était de 10,5 ± 7,2 ans (de 0,1 à 24,7 ans). La survie à 10 ans (mortalité hospitalière incluse) était de 55 ± 6 %, 75 ± 12 %, 69 ± 13 %, 47 ± 8 % et 28 ± 17 %, dans les groupes SUS-CORONAIRE, RACINE, ARCHE et ETENDU, respectivement. La liberté d'une réintervention sur l'aorte à 10 ans était de 73 ± 7,5 %, 40 ± 20 %, 75 ± 21 %, 78 ± 8 %, dans les groupes SUS-CORONAIRE, RACINE, ARCHE et ETENDU, respectivement. Dans notre série, les patients qui ont bénéficié d'un remplacement de l'aorte sus-coronaire ou d'un remplacement de la racine aortique présentent la meilleure survie au long terme. Toutefois, puisque le risque de réintervention est faible après remplacement de la racine aortique, nos données suggèrent que le remplacement de la racine aortique semble être un bon compromis entre la mortalité hospitalière et la survie au long terme.

BACKGROUND:Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) have worse outcome compared with those with normal flow. Furthermore, prosthesis-patient mismatch (PPM) after aortic valve replacement is a predictor of reduced survival. However, the prevalence and prognostic impact of PPM in patients with PLF-AS are unknown. We aimed to analyze the prevalence and long-term survival of PPM in patients with PLF-AS. METHODS AND RESULTS:Between 2000 and 2010, 677 patients with severe AS, preserved left ventricular ejection fraction, and aortic valve replacement were included (74±8 years; 42% women; aortic valve area, 0.69±0.16 cm(2)). A PLF (indexed stroke volume ≤35 mL/m(2)) was found in 26%, and after aortic valve replacement, 54% of patients had PPM, defined as an indexed effective orifice area ≤0.85 cm(2)/m(2). The combined presence of PLF and PPM was found in 15%. Compared with patients with noPLF/noPPM, those with PLF/PPM were significantly older, with more comorbidities. They also received smaller and biological bioprosthesis more often (all P<0.01). Although early mortality was not significantly different between groups, the 10-year survival rate was significantly reduced in case of PLF/PPM compared with noPLF/noPPM (38±9% versus 70±5%; P=0.002), even after multivariable adjustment (hazard ratio, 2.58; 95% confidence interval, 1.5-4.45; P=0.0007). CONCLUSIONS:In this large catheterization-based study, the coexistence of PLF-AS before surgery and PPM after surgery is associated with the poorest outcome.

Purpose: Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) (indexed stroke volume< 35ml/m2) despite preserved left ventricular ejection fraction >50%, have worse outcome compared to those with AS but normal flow. Moreover, Prosthesis-Patient Mismatch (PPM) (indexed prosthetic valve effective orifice area< 0.85cm2/m2) after aortic valve replacement (AVR) is a predictor of higher mortality. However, the impact of PPM in patients with PLFAS on long-term survival is unknown. Our aim was to analyze the prevalence and the impact on long-term survival of PPM in patients with PLFAS. Methods: 667 consecutive patients (age 74±8 years, 42% female, AVA 0.69±0.16 cm2) with preserved LVEF who underwent AVR for severe AS at our institution between 2000 and 2010 were included in this study. Patients were divided into 4 groups according to the presence/absence of PLF at cardiac catheterization and presence/absence of PPM following AVR and we compared short and long-term survival between these groups. Results: Among the 667 patients, 26% had PLFAS and PPM occurred in 54% of patients after AVR. Compared to patients with no PLF & no PPM (36% of the total cohort), those with PLF & PPM (15%) were significantly older, with more comorbidities. The 30-day mortality did not differ between the PLF- PPM and no-PLF-no PPM group. The 10-yr survival rate was significantly reduced in the PLF-PPM (37±9%) group compared to no PLF-no PPM (70±5%; p=0.003). In multivariate analysis adjusting for all predictors of survival, concomitant presence of PLF & PPM was an independent predictor of survival (HR= 2.68 95% CI: 1.5-4.4; p=0.0003) 10-year survival according to PPM/PLF 10-year survival according to PPM/PLF Conclusion: In this catheterization-based study, patients with PLF and PPM have worse outcome when compared to those without these 2 conditions.

Background: Previous studies have shown patients with severe AS and paradoxical low flow (PLF) (indexed stroke volume (SVi) ≤ 35 mL/m 2 and preserved LVEF (≥ 50%) have worse outcome compared to those with severe AS but a normal flow. Moreover, Prosthesis-Patient Mismatch (PPM) after aortic valve replacement (AVR) is a predictor of higher mortality. However, the prevalence and impact of PPM in patients with PLF-AS on survival is unknown. Aim: was to analyze prevalence and impact on long-term survival of PPM in patients with PLF-AS. Methods and results: Between 2000 and 2010, 1407 patients had cardiac catheterization at our institution for preoperative evaluation of AS severity and coronary artery disease. After exclusion of those with significant other valvular heart disease and/or LVEF 2 and mean gradient 49±16 mmHg). 26% of patients had PLF-AS. After AVR, 54% of patients had at least moderate PPM, whereas 15% had simultaneous PLF and PPM. Compared to patients with noPLF/noPPM, those with PLF/PPM were significantly older, with more comorbidities. LVEF, SVi and pulmonary arterial pressures were also significantly deteriorated in the group PLF/PPM (all p Conclusion: This large catheterization-based study shows patients with PLF-AS and post operative PPM have worse outcome, compared to those with noPLF/noPPM. Patients with PLF-AS are at an advanced stage of their disease and every effort should be made to prevent the occurrence of PPM in patients with PLF-AS despite their apparently preserved LVEF.

Background. The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations.Methods. Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6 +/- 2.8 years).Results. The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p < 0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p < 0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years.Conclusions. Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed. (C) 2013 by The Society of Thoracic Surgeons

PURPOSETo describe the clinical presentation and echocardiographic findings associated with localized tamponade after open-heart surgery.METHODSRetrospective analysis of a case series with a surgically proven diagnosis.RESULTSAmong 23 patients with surgically proven localized cardiac tamponade after elective open-heart surgery, 5 patients (22%) died in the ICU from multiorgan failure. At the time of diagnosis (median delay: 2 days; range: 0-8 days), shock was present in 19 patients, 8 of them being hypotensive. Transthoracic echocardiography (TTE) depicted the localized cardiac tamponade in 3 of 4 examined patients, whereas transesophageal echocardiography (TEE) was always conclusive. The right atrium was primarily involved, solely (n = 11) or with the right ventricle (n = 5), whereas the left cardiac cavities were less frequently compressed (left atrium: n = 6, left ventricle: n = 1). The free wall curvature of the involved cardiac chamber was consistently inverted, and blood flow turbulences were depicted in 12 patients. Surgical removal of the compressive hematoma improved the clinical status of 18 patients (78%) who were discharged from the hospital.CONCLUSIONSince localized tamponade complicating open-heart surgery has various, non-specific clinical presentations and TTE is not diagnostic, indications of TEE must be liberal in this setting to prompt diagnosis and surgical reoperation.

In the new (2007) universal definition for myocardial infarction (MI), the type-5 corresponded to MI after coronary revascularization, with cardiac enzymes release >5x normal values (N) required after coronary artery bypass graft (CABG) surgery. However, data on long-term prognosis of patients with post-operative troponin release are scarce. We followed up 826 consecutive patients operated for CABG between 1998 and 2002 in our institution. Post-operative troponin Ic (Tr-Ic) release has been systematically monitored. The primary outcome was total mortality. The secondary outcome was composite and combined: death, acute coronary syndrome, stroke, coronary or peripheral revascularization. Among the 693 men and 133 women (age 66.1 ± 9.3 yrs), post-operative Tr-Ic peak >5xN, >10xN and >20xN were at 54.8%, 29.6% and 15.6%, respectively. During the follow-up period (6.5 ± 2.7 yrs), 146 (17.6%) deceased, and 302 (36.6%) met the composite outcome. Only the survival curves of those with Tr-Ic peak >10xN were significantly poorer than those without type-5 MI (Figure). Adjusted for age, sex, use of beta-blockers and statins, CVD risk factors, NYHA stage, LVEF <40%, number of bypasses, on/off-pump surgery, atrial fibrillation, peripheral artery or chronic kidney disease, only Tr-Ic >20xN was associated with mortality, and Tr-Ic >10xN was predictive for the composite outcome (table). This series with the longest follow-up ever published confirms the prognostic value of troponin release after CABG. However, the current type-5 MI definition after CABG is not specific enough to stratify the long-term post-operative prognosis. Higher thresholds are mandatory.Table-Post-CABG troponin and long-term prognosis (abstract 327).Empty CellMortalityComposite endpointTr-Ic peakHR (95%CI)pHR (95%CI)p< 5xNrefref5 to <10 xN1.02 (0.65–1.61)ns1.14 (0.84–1.55)ns10 to <20 xN1.33 (0.78–2.26)ns1.45 (1.02–2.07)0.0420 xN1.81 (1.14–2.88)0.011.38 (1.00–1.94)0.05Download : Download full-size imageFigure - Survival according to post-CABG troponin Table-Post-CABG troponin and long-term prognosis (abstract 327). Figure - Survival according to post-CABG troponin

Techniques and armamentarium for intentional replantation have varied throughout the years with no universally accepted clinical treatment guidelines. A wide range of success rates has been reported, and accordingly, this treatment method has often been regarded as a treatment of last resort. However, recent studies have shown more consistent success rates as high as 88% to 95%. In light of these new studies, intentional replantation may now be considered a more commonly accepted treatment modality. The purpose of this review was to critically examine reported techniques for intentional replantation.A search of the literature on intentional replantation techniques was performed using electronic databases including PubMed, Medline, and Scopus. A total of 3183 articles were generated and screened for relevance based on defined inclusion and exclusion criteria. Subsequently, 27 studies were included for critical review of technique.There has been an evolution in technique for intentional replantation over the decades.Numerous aspects of the procedure exhibit variations, whereas other aspects exhibit considerable consistency. Few studies reported techniques consistent with modern endodontic surgical principles.

Heart rate (HR) predicts mortality and cardiovascular events in the general population and in patients with coronary artery disease. However, little evidence is available for patients after coronary revascularization. The aim of this study was to assess the prognostic value of ambulatory postoperative HR after coronary artery bypass grafting. Data from a prospective cohort study enrolling patients who underwent nonurgent coronary artery bypass grafting from 1998 to 2002 were analyzed. Baseline postoperative HR was measured 2 months after surgery, and patients were followed annually thereafter. The primary outcome was all-cause mortality. The secondary outcome combined any of the following events: death, nonfatal acute coronary syndromes, stroke or transient ischemic attack, secondary coronary revascularization, or vascular surgery. Seven hundred ninety-four patients (mean age 65.8 ± 9.3 years) were eligible for follow-up, predominantly men (84.1%). The mean follow-up duration was 3.2 ± 1.3 years, during which 40 patients (5.0%) died. In the univariate analysis, HR >90 beats/min was significantly associated with all outcomes. After adjustments for major confounding factors and the use of β blockers, postoperative HR >90 beats/min remained significantly associated with the secondary outcome (hazard ratio 2.26, 95% confidence interval 1.04 to 4.91, p = 0.04). Association of postoperative HR >90 beats/min with all-cause mortality was only borderline in the multivariate analysis (hazard ratio 3.57, 95% confidence interval 0.90 to 14.17, p = 0.07), because of the limited sample population size. In conclusion, postoperative HR >90 beats/min may be associated with poor prognoses in patients with coronary artery disease, even after surgical revascularization.

Background Plasma concentrations of sFlt-1, the soluble form of the vascular endothelial growth factor receptor (VEGF), markedly increase during coronary artery bypass graft (CABG) surgery with extracorporeal circulation (ECC). We investigated if plasma sFlt-1 values might be related to the occurrence of surgical complications after CABG. Methods Plasma samples were collected from the radial artery catheter before vascular cannulation and after opening the chest, at the end of ECC just before clamp release, after cross release, after weaning from ECC, at the 6 th and 24 th post-operative hour. Thirty one patients were investigated. The presence of cardiovascular, haematological and respiratory dysfunctions was prospectively assessed. Plasma sFlt-1 levels were measured with commercially ELISA kits. Results Among the 31 investigated patients, 15 had uneventful surgery. Patients with and without complications had similar pre-operative plasma sFlt-1 levels. Lowered plasma sFlt-1 levels were observed at the end of ECC in patients with haematological (p = 0.001, ANOVA) or cardiovascular (p = 0.006) impairments, but not with respiratory ones (p = 0.053), as compared to patients with uneventful surgery. Conclusion These results identify an association between specific post-CABG complication and the lower release of sFlt-1 during ECC. sFlt-1-induced VEGF neutralisation might, thus, be beneficial to reduce the development of post-operative adverse effects after CABG.

BACKGROUND AND OBJECTIVE Amniotic membranes are used with success in ophthalmology to treat corneal wounds and ulcers. In this pilot study, we attempt to assess the tolerance of amniotic membranes in the management of resistant venous and/or arterial vascular ulcers. MATERIAL AND METHODS We prospectively included 8 patients, 7 males and 1 female, mean age 69.5+/- 9.6 years, with venous and/or arterial ulcers resistant after 6 months with usual medical care and/or after revascularisation failure. Amniotic membranes were applied on a weekly basis with the fetal side on the ulcer, covered by a secondary bandage. The primary end-point was evaluation of tolerance of amniotic membranes on vascular ulcers. The secondary end-points were a >50% reduction of ulcer's area, a significant (P< or =0.05) improvement of pain visual scale score and the quality of life assessed by the SF-36 questionnaire. RESULTS Tolerance was excellent in all cases. We observed no adverse effect. We observed complete healing at weeks 19 and 26 for 2 patients and a >50% reduction of ulcer area at weeks 26, 31 and 32 for 3 patients. A sixth patient had an ulcer area reduction <50% and the 2 remaining showed no improvement. A significant improvement was noticed for visual pain scale and the health feeling dimension in the SF-36 questionnaire. No adverse effect or amputation requirement was noted. CONCLUSION These preliminary results are encouraging and require a larger confirmatory study. Further studies are required to clarify the action mode of this therapeutic option.