Background. The port access (PA) approach for valvular heart surgery is widely used, but few studies evaluating outcomes compared with the sternotomy approach have been performed.

OBJECTIVES:This study analyzed the differences in clinical presentation, etiology, and hospital outcome between Hispanic and non-Hispanic patients who underwent surgical correction of mitral valve disease at a large urban medical center.DESIGN:All adult patients undergoing isolated mitral valve repair or replacement surgery at two hospitals between 1993 and 2003 were studied. Patients were grouped according to ethnicity as reported to the New York State Cardiac Surgery Reporting System. Preoperative variables compared included age, congestive heart failure (CHF), etiology, and pertinent medical and surgical histories, while perioperative variables included type of operation, mortality, and hospital complications.RESULTS:A total of 1683 patients (135 Hispanic,1548 non-Hispanic) underwent mitral valve surgery. Hispanic patients were younger (48.3+/-16.0 vs 59.7+/-15.9 years, P<.001) and had higher incidences of CHF (48.9% vs 35.3%, P=.002), endocarditis (8.9% vs 5.0%, P=.05), and rheumatic disease (12.6% vs 5.4%, P<.001). Non-Hispanic patients had a higher incidence of degenerative disease (68.0% vs 54.8%, P<.01). No differences in hospital mortality (Hispanic 5.9% vs 5.3%, P=.76) or perioperative complications were observed between the two groups, although Hispanic patients were less likely to undergo mitral valve repair than mitral valve replacement (35.6% vs 61.2%, P<.001).CONCLUSIONS:In the urban population studied, Hispanic patients presented for mitral valve surgery at a younger age and with a higher prevalence of CHF and rheumatic disease. Public health strategies to prevent rheumatic fever among Hispanics are needed, and improved screening might facilitate earlier referral for Hispanic patients, increasing the potential for benefitting from mitral valve repair.

BACKGROUND:Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution's surgical results in this target population.METHODS:From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index.RESULTS:The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 (p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease (p = 0.019; OR, 2.14), and peripheral vascular disease (p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age (p < 0.001), previous cardiac operations (p < 0.014; OR, 1.51), renal failure (p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease (p < 0.007; OR, 1.30) were predictors of worse survival.CONCLUSIONS:Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points.

BACKGROUND:Disparities associated with race, particularly African-American race, in access to medical and surgical care for patients with cardiac disease have previously been documented. The purpose of this study was to determine the presentation, etiology, and hospital outcome differences between African-American patients and white patients with regard to surgically corrected mitral valve disease.METHODS:All 1,425 adult patients who underwent first time, isolated mitral valvuloplasty or mitral valve replacement by the same group of surgeons at New York University Medical Center and Bellevue Hospital Center between 1993 and 2003 were studied.RESULTS:African Americans (n = 123, 8.6%) were significantly younger (45.6 +/- 14.4 versus 60.5 +/- 15.3 years) and had significantly higher incidences of diabetes mellitus, renal failure, congestive heart failure, endocarditis, and rheumatic mitral disease; whereas whites (n = 1,302, 91.4%) more commonly had degenerative mitral disease. African Americans were less likely to undergo mitral valvuloplasty. There were no significant differences in the incidences of postoperative complications or hospital mortality (2.4% African American versus 5.1% white, p = 0.19).CONCLUSIONS:African Americans present for mitral valve surgery at a significantly younger age than whites and with higher incidences of many risk factors. Whether presentation at a significantly earlier age in African Americans is a result of failures in primary care or an enhanced susceptibility to the process of mitral disease and comorbidities remains to be determined. African Americans were less likely to undergo mitral valvuloplasty, which may have an effect on long-term outcome. Improved screening in this racial group will facilitate earlier referral, increasing the potential for mitral valvuloplasty.

Value of intraoperative pleural lavage in staging non-small cell lung cancer OE

Is it important to examine gender differences in the epidemiology and outcome of severe heart failure?OE

Derivaux, Christopher C. MD; Pintucci, Giuseppe Ph.D.; Yu, Pay-Jen BS; Silver, Eric BS; Seghezzi, Graziano MS; Grossi, Eugene A. MD; Steinberg, Bryan M. MD; Baumann, Gregory F. Ph.D.; Colvin, Stephen B. MD; Mignatti, Paolo MD; Galloway, Aubrey C. MD Author Information

Background. This study attempts to confirm favorable results with mitral valve reconstruction (MVP) in patients greater than or equal to 70 years of age and to examine complication rates by actual analysis.Methods. Between June of 1980 and December of 1997, 278 patients 70 years of age or older (mean, 75.2 years; range, 70 to 87 years) underwent MVP for mitral regurgitation. Most involved insertion of an annuloplasty ring. Concomitant procedures were performed in 72.3%, and 55.0% required coronary revascularization.Results. For isolated MVP, the in-hospital mortality rate was 6.5% and 17.0% when combined with coronary revascularization. The mortality rate when combined with another valve procedure was 13.2%. The 5-year freedom from late cardiac death was 100% in the isolated MVP group and 79.7% for MVP with a concomitant procedure (p = 0.006). Complications were analyzed using actual (cumulative incidence) analysis to eliminate the competing risk of noncardiac death. Mean NYHA class improved from 3.32 to 1.71 postoperatively. Repair failure was rare, with a 5-year freedom from reoperation of 91.2%.Conclusions. These findings confirm the favorable outcome of MVP in elderly patients. Late repair failures are rare; comorbid disease is an important predictor of outcome.

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two, crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five, Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization), Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%), In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA.

Between 6/79 and 6/93 a total of 560 patients with mitral insufficiency had Carpentier type mitral valve reconstruction with ring annuloplasty. The primary etiology of mitral disease was degenerative in 46%, rheumatic in 21%, ischemic in 18% and other in 15%. Concomitant cardiac procedures were performed in 283 patients (51%). Hospital mortality was 5.9% 133/560) overall and 2.5% (7/277) for isolated mitral reconstruction. Multivariate analysis revealed that NYHA classification, age, and associated coronary disease were significant predictors of increased operative risk. Late clinical and echocardiographic follow-up (f/u) was 98% complete, with a mean f/u interval of 3.5 years (range 1 month-14 years; total f/u 1,977 patient-years). Actuarial freedom from complications at 5 and 10 years was as follows: thromboembolic = 93% &86%, anticoagulant = 97% & 97%, endocarditis = 97%& 95%, reoperation = 90% & 83%; survival from all cardiac death was 85% & 77%, Pulmonary artery pressure, concomitant cardiac procedures, and associated coronary disease were predictive of late cardiac death by Cox regression analysis. Ten year freedom from reoperation was significantly better in nonrheumatic (90%) than in rheumatic patients (67%, p l 0.001). These data demonstrate durable long-term results and a continued low risk of late complications after mitral valve reconstruction using Carpentier techniques. This experience suggests that mitral valve reconstruction should be considered the procedure of choice for nonrheumatic patients with mitral valve insufficiency.

Neointimal hyperplasia limits the long-term patency of saphenous vein grafts (SVGs), but is notably absent from most internal mammary artery (IMA) grafts. Basic fibroblast growth factor (bFGF) is a local endothelial and vascular smooth muscle mitogen known to be involved in the pathogenesis of neointimal hyperplasia. This study used an animal model to compare the number of available high-affinity (HAR) and low-affinity (LAR) bFGF receptors in SVGs and IMA grafts and to determine whether distention injury causes an increase in receptor availability. The IMA and SVG specimens were harvested from 12 dogs and distended at 25 or 200 mm Hg for 15 minutes, and then the bFGF receptor uptake was measured in them using iodine 125-labeled bFGF. In the IMA conduits distended at low pressure, there were 2.54 +/- 0.10 (mean +/- standard error of the mean) HARs per mm(2) of intimal surface area available and 5.19 +/- 0.40 LARs per mm(2). High-pressure distention significantly (p < 0.001) increased the number of available HARs to 5.06 +/- 0.27 per mm(2) and of LARs to 7.27 +/- 0.042 per mm(2). At low pressure, the SVGs had significantly (p < 0.001) more HARs (9.14 +/- 0.84 per mm(2)) and LARs (18.2 +/- 0.57 per mm(2)) available than did the IMA conduits, and high pressure significantly (p < 0.001) increased the number of HARs available in SVGs to 24.1 +/- 2.43 per mm(2) and the number of LARs to 44.7 +/- 2.34 per mm(2). These results demonstrate that there is a significantly higher number of available bFGF receptors per unit of surface area in dog SVGs than IMA grafts. High-pressure distention further increases the differences in the number of available bFGF receptors between SVGs and IMA grafts (p < 0.001). These findings suggest a newly recognized mechanism that may contribute to the increased intimal hyperplasia found in implanted SVGs but not IMAs.

Diaphragmatic paralysis developed in an adult after a cardiac operation. The patient suffered from recurrent fevers and could not be weaned from mechanical ventilatory support. Diaphragmatic plication was performed and enabled rapid and sustained weaning from respiratory support.

Diaphragmatic paralysis developed in an adult after a cardiac operation. The patient suffered from recurrent fevers and could not be weaned from mechanical ventilatory support. Diaphragmatic plication was performed and enabled rapid and sustained weaning from respiratory support.

A wide variety of carotid shunts are available for use in extracranial carotid surgery. Since it is commonly assumed that when properly positioned all shunts are equal in ability to protect the brain from cerebral ischemia, the choice of shunt is usually based on handling characteristics. However, after an intraoperative stroke occurred in a patient, we compared shunt flow rates using a simple and reproducible method of measurement. A mock circuit was created using a saline-filled fluid reservoir connected to the particular shunt being tested via 1/2-inch tubing. Hydrostatic pressure across the shunt was varied by changing the height of the reservoir, and the flow was collected over 30-second intervals. Multiple flow rate measurements were performed for each shunt with pressure gradients varying from 25 to 150 cm H2O. The data show significant hemodynamic differences among commercially available carotid shunts. A pressure gradient of 75 cm H2O produced a 2.8-fold variation in the amount of fluid delivered by various shunts. Minimal cerebral blood flow requirements and the possibility of underperfusion require that the surgeon consider such data in choosing an appropriate carotid shunt.

Cardiac disease continues to be the leading cause of morbidity and mortality following peripheral vascular surgical procedures. Although the mechanism of sudden myocardial infarction remains elusive, many possibilities exist. The role of catecholamines is intriguing in view of the evidence that beta-adrenergic blockers reduce cardiac morbidity and mortality in vascular surgical patients. To ascertain whether the plasma catecholamine levels rise significantly during abdominal aortic aneurysm repair, serial determinations of plasma epinephrine and norepinephrine levels were performed in 18 patients. Epinephrine levels rose significantly from preoperative baseline values both during the operation and postoperatively, and norepinephrine levels rose significantly at 24 hours postoperatively. Although only one patient studied developed a myocardial infarction, the finding that patients undergoing aortic surgery uniformly experienced abnormally high serum catecholamine levels supports other evidence that perioperative myocardial ischemic events have a hormonal component.