Almanac 2012 adult cardiac surgery: The national
society journals present selected research that has
driven recent advances in clinical cardiologyq
UHSM, Southmoor Road, Manchester M23 9LT, United Kingdom
Mitral valve surgery;
Aortic valve surgery;
Minimally invasive surgery;
Off pump surgery
years, including the current evidence base for surgical revascularisation and the use of off-pump
surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in con-
ventional aortic valve surgery are described alongside the outcomes of clinical trials and registries
for transcatheter aortic valve implantation, and the introduction of less invasive and novel
approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also
considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
ª 2012 Egyptian Society of Cardiology. Production and hosting by Elsevier B.V. All rights reserved.
This review covers the important publications in adult cardiac surgery in the last few
10. Transcatheter valve insertion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coronary artery surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coronary artery surgery or PCI for angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ESC/EACTS revascularisation guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is off pump coronary artery surgery safe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is endoscopic vein harvesting safe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Should bilateral internal mammary artery grafts be used for coronary artery surgery?. . . . . . . . . . . . . . . . . . . . . . . .
Coronary artery surgery for heart failure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aortic valve surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E-mail address: email@example.com
qThe article was first published in Heart 2012;98:1412-17 and is
republished with permission.
Peer review under responsibility of Egyptian Society of Cardiology.
Production and hosting by Elsevier
The Egyptian Heart Journal (2013) 65, 43–50
Egyptian Society of Cardiology
The Egyptian Heart Journal
1110-2608 ª 2012 Egyptian Society of Cardiology. Production and hosting by Elsevier B.V. All rights reserved.
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mitral valve surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Risk modelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiac surgery remains an important treatment option for
many patients with coronary artery disease, valvular heart dis-
ease and heart failure. Coronary artery remains the common-
est operation undertaken in most centres, but its proportion is
decreasing in the UK.1More patients are undergoing mitral
and aortic valve procedures, both by conventional and novel
approaches including smaller incisions for conventional sur-
gery and the insertion of new devices using catheter-based de-
vices. This article will summarise publications from recent
years that are having an impact on the practice of cardiac
2. Coronary artery surgery
There are marked changes in patients coming for coronary ar-
tery surgery over time that have been shown clearly from the
analyses of large series from the USA and UK. A report from
the Society for Thoracic Surgeons (STS) database has de-
scribed the increasing risk profile of patients coming to surgery
with fewer smokers, more patients with diabetes and more use
of the left internal mammary artery (LIMA) as a bypass con-
duit. Overall, there has been a significant decline in postoper-
ative mortality and morbidity.2Similar trends have been
reported in the UK from the national adult cardiac surgery
database, where there has been a greater than 50% reduction
in risk adjusted mortality since 2000, again with increasing risk
profiles, and more use of the internal mammary artery.1,3
However, despite some evidence for their efficacy, off-pump
surgery and multiple grafts have not become widespread.1
3. Coronary artery surgery or PCI for angina
The major contemporary randomised clinical trial to inform
decision making in patients with multi-vessel coronary artery
disease is the Synergy between PCI with Taxus and Cardiac
Surgery (SYNTAX) trial. The study randomised 1800 patients
with previously treated three vessel or left main coronary ar-
tery disease or both in 85 sites in 17 countries across Europe
and the USA. The 1-year results were published in 2009, show-
ing that the percutaneous coronary intervention (PCI) group
had higher rates of the combined end point of major adverse
cardiac or cerebrovascular events and failed to achieve the pre-
defined end point of non-inferiority.4This difference was dri-
ven by a high rate of repeat revascularisation in the PCI
group (13.5% PCI, 5.9% coronary artery bypass grafting
(CABG)). The 1-year rates of death or myocardial infarction
(MI) were not different between the groups. These differences
persist over longer follow-up with 3-year MACCE rates (death
stroke, MI or repeat revascularisation) being higher in the PCI
group (28%) than the CABG group (20%), again driven
mainly by repeat revascularisation, but there was no difference
in the primary safety end point or the incidence of stroke. On
subgroup analysis, there was no difference in major adverse
events in the patients with left main stem (LMS) stenosis,
but outcomes were worse following PCI in the three vessel sub-
group.5Analysis of outcomes based on procedural risk from
the syntax score has shown at 4 years that the curves are
diverging overall, but with no difference in the low risk pa-
In line with the data from SYNTAX, a large registry-based
study from the USA linked the ACCF National Cardiovascu-
lar registry and the STS adult cardiac surgery database to the
Medicare and Medicaid registries and used propensity scoring
to match patients who were 65 years or older undergoing PCI
and CABG. Four years after intervention there was a mortal-
ity advantage in the CABG group, which persisted in the
While the late outcomes of most higher risk patients with
multi-vessel coronary artery disease seem to be better with
CABG, in both randomised and registry-based studies, the
outcome following intervention for LMS stenosis is not so
clear cut, certainly during early follow-up. In a meta-analysis
of patients with unprotected LMS stenosis analysing 2905 pa-
tients from eight clinical studies, there was no significant differ-
ence between the two groups with respect to mortality or a
composite end point of death, MI or stroke at 1 year.7Another
meta-analysis of 3773 patients looking out to 3 years gave sim-
ilar findings.8Analysis of the left main subgroup of the SYN-
TAX study also showed no difference up to 3 years.5,9More
recently, the Premier of Randomised Comparison of Bypass
Surgery versus Angioplasty using Sirolimus-Eluting Stent in
Patients with Coronary Artery Disease trial has reported re-
sults of 300 patients in each arm to 2 years, and showed PCI
to be non-inferior, but the authors accept that the non-inferi-
ority margin was wide, leaving open the need for further stud-
ies.10Similar findings have also been detected in a smaller
study.11To understand better the safety and efficacy of the
place of PCI for LMS stenosis, the Evaluation of Xience Prime
versus Coronary Artery Bypass Surgery for Effectiveness of
Left Main Revascularisation trial is ongoing in patients with
LMS disease and syntax scores of #32.12,13
4. ESC/EACTS revascularisation guidelines
The European Society for Cardiology and European Associa-
tion of Cardiothoracic Surgery published guidelines for revas-
cularisation in 2010 that were developed by a balanced writing
team of interventional cardiologists, non-interventional cardi-
ologists and surgeons. The guidelines recommend decision
making through an appropriately configured ‘heart team’
and suggest that surgery is the better option for revascularisa-
tion for the majority of anatomical forms of coronary artery
disease.14Data published since the guidelines were released,
including later analyses of the SYNTAX trial, have further
reinforced the evidence on which the guidelines are based. Po-
tential implications of these recommendations have been re-
ported,15,16but detailed analyses of any changes in practice
are not yet available.
5. Is off pump coronary artery surgery safe?
Controversy remains surrounding the relative benefits of
undertaking coronary artery surgery with or without the car-
diopulmonary bypass machine.17,18In the UK, around 20%
of cases are undertaken off pump but there are conflicting data
about safety and longer-term outcomes.1
Concern was raised from the ROOBY trial in which 2203
patients undergoing CABG were randomised to surgery on
or off pump. There was no significant difference in 30-day
mortality, but there were a higher proportion of patients
receiving fewer grafts than planned in the off-pump group.
Of concern, there was a significantly worse 1-year composite
end point of death, repeat revascularisation or non-fatal MI
and poorer graft patency in the off-pump group.19Critics of
the study have commented that the trial enrolled low risk, male
patients who would be the least likely to benefit from avoiding
cardiopulmonary bypass, the surgeons were inexperienced and
there was a high (12%) rate of intraoperative conversion to by-
pass surgery.20Furthermore, endoscopic vein harvesting was
associated with worse outcomes at 1 year in the study (see fur-
ther below).21In addition, Moller et al. have reported random-
ised trial data on 341 high risk (EuroSCORE > 5) patients
with three vessel disease undergoing surgery on- or off-pump
in the Best Bypass Surgery trial. There was no significant dif-
ference in the primary outcome of adverse cardiac and cerebro-
vascular events during a median follow-up of 3.7 years,
although all cause mortality was higher in the off-pump
More reassuring data have recently been published from the
MASS 3 trial with 5-year follow-up from a single centre
with no difference in a composite end point of death, MI or
further revascularisation between the groups and from
the CORONARY study, which randomised 4752 patients to
on- or off- pump and showed no significant difference in 30-
day mortality or the incidence of MI, stroke and renal fail-
ure.23,24Later outcome data from this study are awaited with
There has also been a meta-analysis of 35 propensity score
studies on 123137 patients undergoing on- or off-pump sur-
gery. This suggested that off-pump surgery was superior for
short-term mortality and other outcomes.25In a single centre
study of 14766 patients reported by Puskas et al. there was
no difference in operative mortality in the lowest risk quartile
but increasing benefit for higher risk patients, which supports
the argument used by critics of the findings of the ROOBY
study.26Similar findings have been reported on 349 survivors
of two randomised studies comparing on- and off-pump sur-
gery in which 199 patients had graft patency assessed, and in
299 patients health-related quality of life, with no difference
seen between the groups at 6–8 years.27
While the benefits or otherwise of off-pump surgery are not
yet clearly defined, there remains interest in optimising out-
comes from on-pump surgery by refining bypass techniques.
For example, a recent trial has drawn attention to how the
brain might be protected by using a minimal extracorporeal
circulation.28In this randomised comparison of minimal ver-
sus conventional extracorporeal circulation, the minimal cir-
cuit was associated with improved cerebral perfusion during
cardiopulmonary bypass and improved neurocognitive perfor-
mance on direct testing at discharge, with evidence of sustained
effects at 3 and 14 months. The data suggest that some of the
advantages proposed by off-pump enthusiasts, particularly
cerebral protection, might be achieved by modifying on-pump
6. Is endoscopic vein harvesting safe?
In line with other moves towards less invasive surgery, there
has been a significant move towards harvesting the long saphe-
nous vein through minimally invasive, including endoscopic,
approaches but there remains some concern over safety. As de-
scribed previously, a subgroup analysis of the ROOBY trial
suggested that endoscopic vein harvesting was associated with
worse outcomes.21A secondary analysis of patients from the
PREVENT IV trial at 3 years of follow-up also showed worse
outcomes for patients undergoing endoscopic harvesting, but
this finding has not been confirmed in other observational
7. Should bilateral internal mammary artery grafts be used for
coronary artery surgery?
It is generally accepted that using the LIMA graft to the left
anterior descending coronary artery is associated with better
inhospital mortality, long-term survival and freedom from an-
gina, and a number of observers suggest that if one mammary
is good, two would be better. Despite this, <10% of coronary
artery operations in the UK receive both internal mammary
arteries.1To address this, the ART trial is a large randomised
study, which has now reported 1-year data on 1554 patients
receiving a single LIMA graft and 1548 receiving bilateral
mammary arteries (BIMA). It has been powered to look at sur-
vival at 10 years. The 1-year data show no mortality difference
between the groups but there was a three times increase in the
rate of sternal wound reconstruction in the BIMA group.32In
view of our understanding of the timing of vein graft failure it
would have been surprising to see any benefit from BIMA
grafting at this stage. Further supportive evidence for the ben-
eficial effect of BIMA has been shown from a single centre pro-
pensity matched study of 928 BIMA versus 928 LIMA and
saphenous vein grafts reporting to 17 years with a survival
benefit of 10% at 10 years and 18% at 15 years.33
There has been great interest in the use of the radial artery
as a conduit for coronary artery bypass surgery, with enthusi-
asts recommending its use, either alongside both internal mam-
mary arteries for a total arterial grafting approach or in
addition to a single mammary artery, to improve long-term
outcomes. However, a randomised study of 733 patients com-
paring radial artery grafts to saphenous veins has recently
shown similar graft patency at 1 year (both 89%).34Of con-
cern, the radial artery was associated with a higher incidence
of vasospasm in this study and the saphenous vein had better
outcomes in diabetic patients. Further concern has been raised
Almanac 2012 adult cardiac surgery: The national society journals45
from a study using CT scanning to assess graft patency.35
However, there remains a number of reports claiming good
late patency rates.36–38
Most of the studies looking at comparative outcomes of dif-
ferent surgical strategies have relied on late outcomes, with
mortality being most important, and these data are obviously
difficult to collect and they only provide useful information
many years ‘after the event’. To help provide useful and more
timely differential data, some workers have been looking at
techniques to assess preoperative risk other than clinical out-
comes such as per-operative injury to the left ventricular myo-
cardium. This is hard to quantify and was the subject of a
recent study from Oxford in which 40 patients underwent car-
diac MR before and after CABG with the serial assessment of
troponin I (TnI).39TnI correlated closely with the mass of new
cardiac MR necrosis (r 0.83, p < 0.001), with sensitivity and
specificity values of 75% and 87%, making it a robust means
of diagnosing this type of MI.
Alongside analyses of ways to optimise operative surgical
strategy, there is also an increasing focus on non-mortality
postoperative outcomes and pathways. For example, a study
has examined the implications of postoperative anaemia in a
retrospective analysis of 2553 CABG patients included in the
IMAGINE trial.40They showed that postoperative anaemia
sustained for >50 days is associated with an increased inci-
dence of cardiovascular events during the first 3 months. The
researchers also found that ACE inhibition slowed recovery
from postoperative anaemia and increased the incidence of
cardiovascular events after CABG, although the mechanism
and therapeutic implication of this observation is not clear.
It has also become increasingly accepted that formal cardiac
rehabilitation is beneficial to enhance recovery after CABG
surgery, with an emphasis being placed on exercise pro-
grammes. While the best means of delivering these pro-
grammes are unclear, a Canadian study favoured a home-
based strategy based on a 6-year follow-up of patients ran-
domised to hospital versus telephone-monitored home-based
8. Coronary artery surgery for heart failure?
The STICH trial has showed that there is no difference in
survival between patients with heart failure and poor left ven-
tricular function, randomised to either medical therapy or
medical therapy plus CABG. In a subset of this study in
which myocardial viability was assessed, the presence of via-
ble myocardium was associated with better survival overall,
but this was not significant after adjusting for other baseline
variables.42,43Taken at face value these are profound findings
for the practice of coronary artery surgery and are at odds
with many physicians’ and surgeons’ preconceptions, but
some observers have questioned whether the findings of the
trial are valid because of difficulties in trial recruitment lead-
ing to changes in trial design after instigation alongside a
crossover rate of 17% to CABG, therefore underestimating
the benefits of surgery and suggesting that CABG should still
be considered if CAD is severe and viable myocardium is
seen.44For example, a recent propensity matched study of
CABG versus medical therapy in these patients (designed to
mimic the STICH trial inclusion) showed a clear survival
advantage of CABG at 10 years.45
9. Aortic valve surgery
The practice of aortic valve surgery is changing. In the USA,
an analysis of 108 687 isolated aortic valve replacement
(AVR) patients from 1997 to 2006 was reported in 2009.46
Morbidity and mortality have fallen despite gradual increases
in patient age and overall risk profile, alongside an increase in
biological valve use. Similar trends have been seen in the UK
with a report of 41227 patients between 2004 and 2009 with
an overall inhospital mortality of 4.1%. The annual number
increased by 20%, with significant increases in the mean age
of patients with aortic stenosis, octogenarians, the proportion
of high-risk patients and again those receiving biological valves
(which is almost certainly influenced by surgeons’ views of bet-
ter longevity of modern biological valves and the promise of a
transcatheter valve solution for subsequent valve failure).47
Over this time, inhospital mortality decreased from 4.4% to
3.7%.48While transcatheter valve insertion (TAVI) (see below)
is having an impact on valve surgery, in contrast to just erod-
ing the numbers of conventional valve operations, it has been
reported that starting a TAVI service may increase overall aor-
tic valve interventions, including those for conventional
There remains some controversy about the timing of sur-
gery in asymptomatic aortic stenosis (see parallels with mitral
valve repair below). Some work is being produced suggesting
benefits from earlier intervention but other observers have
published data suggesting benefits and safety of the watchful
10. Transcatheter valve insertion
The major change in the treatment of patients with aortic ste-
nosis in recent years has been the advent of TAVI, which has
now been shown to be a good option for the treatment of some
patients with aortic stenosis. The Partner study Cohort A trial
of 358 patients who were not considered suitable for conven-
tional AVR showed that TAVI decreased the rate of mortality
at 1 year (from 51% to 31%) and reduced cardiac symptoms
compared with conventional treatment.54The 2-year results
have also been reported showing persistent survival advantage,
but a high rate of stroke in the TAVI group, due to more
ischaemic strokes in the first 30 days after the procedure and
more haemorrhagic events thereafter. The rate of rehospitali-
sation was 35% in the TAVI group and 72% in the conven-
tional group. Quality of life studies on these patients using
the Kansas City Cardiomyopathy Questionnaire and the SF-
12 showed significant benefits in the TAVI group going out
to 1 year.55An economic analysis of these data demonstrated
an incremental cost per life-year gained that was well within
the acceptable range.56
TAVI has also been shown to be comparable with conven-
tional aortic valve surgery. In the Partner study Cohort B, 699
patients with severe aortic stenosis who were deemed to be of
high risk were randomised to TAVI or conventional surgery.57
There was no significant difference in mortality rates at
30 days (3.4% TAVI and 6.5% conventional surgery) or 1 year
(24.2% TAVI, 26.8% conventional surgery). Two-year data
have also been reported, again showing no difference in mor-
tality rates.58Procedural complication rates were different be-
tween the groups, with major vascular complications being
46 B. Bridgewater
more common in the TAVI patients and bleeding and new on-
set atrial fibrillation (AF) more common in conventional sur-
gery. A number of large registry studies have also confirmed
acceptable procedural and longer-term outcomes.59–63
Transcatheter aortic valves are now being inserted in
increasing numbers through the femoral artery, trans-apically
directly via the left ventricle and through the aortic ap-
proach.64–66In response to potential benefits from less invasive
approaches, there has also been increasing interest in conduct-
ing ‘conventional’ surgery through a variety of smaller inci-
sions including mini-sternotomy, para-sternotomy, transverse
sternotomy, and right anterior thoracotomy. Various studies
including single centre experiences and meta-analyses have
shown that it can be applied safely in expert centres.67,68
Alongside less invasive approaches, to minimise insertion times
and allow easier valve implantation through small incisions,
various novel aortic valves are being developed and tested
which have ‘sutureless’ implantation techniques.69,70
A final word on aortic valve surgery and TAVI is that there
are now consensus statements produced about the practice of
TAVI and to understand better how to achieve optimal out-
comes from conventional AVR, health service research studies
have shown that the outcomes of surgery are better for higher
risk patients under high volume surgeons, which lay down a
challenge for the configuration of surgical services for these
11. Mitral valve surgery
The major advances in understanding of mitral valve surgery
in recent years are related to mitral valve repair. It is now well
accepted that repair is a better option than replacement for
most patients with degenerative mitral valve disease, and that
inhospital and later mortality outcomes are dependent on the
degree of symptoms and left ventricular dysfunction at the
time of surgery. Evidence from the UK suggests that many pa-
tients are still being referred late in the disease process with
47% of patients having NYHA class 3 or 4 symptoms and
31% of people displaying left ventricular (LV) ejection frac-
tions of <50% at the time of surgery.1
Surgical treatment for mitral valve disease is changing over
time, and a report on 58370 patients with isolated mitral regur-
gitation from the STS database in the 8 years to December
2007 showed a progressive adoption of mitral repair rather
than replacement from 51% to 69%. There was also a decrease
in the use of mechanical rather than biological valves over that
time from 68% to 37% (and there are similar data from the
UK).1,73This, of course, indicates that one in three patients
with severe MR undergo a valve replacement, and this remains
a concern from the perspective of health service delivery.74
The major controversy around patients with severe MR is
around the timing of surgery. There are no randomised trial
data to support early surgery or ‘watchful waiting’ and so
the evidence is derived from observation studies. In 2005, Enri-
quez-Sarano and colleagues from the Mayo Clinic reported an
observational study on 456 patients with symptomatic organic
mitral regurgitation, showing that patients with an effective
regurgitant orifice area of >40 mm2had a survival at 5 years
that was lower than expected.75On this basis, they recom-
mended mitral valve repair for patients with genuinely severe
mitral regurgitation, purely on the basis of symptoms, irrespec-
tive of left ventricular size or function. Similar findings have
been reported from Korea on 447 consecutive asymptomatic
patients undergoing early surgery or conventional treatment
strategy with early surgery associated with improved long-term
event rates by decreasing cardiac mortality and congestive
heart failure hospitalisation.76A further observational study
of 192 patients followed up for 8.5 years, divided into an early
surgery and a conservative group, also showed better out-
comes in the conservative group.77
Conversely, Rosenhek et al. have reported outcomes on 132
patients and only intervened at the time of onset of symptoms,
left ventricular impairment or significant LV dilatation accord-
ing to the accepted guidelines of the time of onset of symp-
toms, left ventricularimpairment
dilatation.78,79Overall, late outcomes were excellent, and only
a third of the patients required surgery during then follow-up
period of 5 years, but it is obviously important that if this
strategy is followed, then follow-up must be robust and
Guidance from the American College of Cardiology/Amer-
ican Heart Association from 2006 suggests that early surgery
should be considered for asymptomatic patients at low proce-
dural risk in ‘experienced centres’ as long as the likelihood of
successful repair is >90%.80An attempt has been made from
a UK consensus study to describe the criteria associated with
an experienced centre.81However, if one comes from a surgical
epidemiologal approach there must be some concern about an
overall early surgery strategy for these patients.74In a report of
13614 patients with mitral regurgitation undergoing surgery
from the STS database there was a marked variation in the
overall volumes per year, and higher volume centres showed
higher rates of valve repair and lower risk adjusted mortality.82
Again from the STS database in an analysis of 28507 patients
undergoing isolated mitral valve surgery with or without tri-
cuspid valve or concomitant AF surgery under 1088 surgeons,
the mean rate of repair by surgeons was only 41%. The median
annual number of operation was five (1–166) and increasing
surgeon volume was independently associated with increased
probability of repair.83The consensus-based opinion study
from the UK has suggested that hospitals should be undertak-
ing more than 50 mitral repair operations each year to get opti-
mal outcomes, and individual surgeons should be doing more
than 25. It seems that many hospitals and surgeons fall short
of this. Offering an early surgical strategy in the absence of
assurance about high repair rates and excellent durability of
repair procedures may not be in the patients’ best interests.
There have been some developments in the techniques of
mitral valve repair with a move towards more use of artificial
chordae tendinae and preservation of leaflet tissue rather than
resection and the increasing use of less invasive techniques.84–
89While there are a growing number of reports suggesting the
safety of minimally invasive approaches, there is significant
anecdotal reporting of the concern about these techniques
and their safety.
There are also developments in catheter-based treatments
of mitral regurgitation, and the Endovascular valve edge to
edge repair (EVEREST 2) trial has reported the outcomes of
78 patients at high risk from conventional surgery having an
‘edge to edge’ treatment with the ‘MitralClip’ showing a proce-
dural mortality of 7.7% with a reduction in MR in most pa-
tients with an improvement in clinical symptoms in three-
fourths of the patients.90
Almanac 2012 adult cardiac surgery: The national society journals 47
12. Risk modelling
The assessment of operative risk in cardiac surgery is impor-
tant to guide decision making (e.g., conventional surgery or
TAVI for patients with aortic stenosis), support informed con-
sent and for governance and public reporting of hospital and
surgeon mortality rates. The STS scores were published in
2009 after analysing data from the STS database, with models
published for coronary artery surgery, valve surgery and com-
bined coronary and valve surgery. These model a standard set
of outcomes for all procedures including mortality, stroke,
reoperation, renal failure, deep sternal wound infection, pro-
longed ventilation, composite major morbidity, prolonged
length of stay and short length of stay.91–94
More recently, it has been accepted that the EuroSCORE is
no longer suitable for contemporary practice and the Euro-
SCORE 2 has been published.95,96Unlike the STS models,
which are procedure specific, the EuroSCORE 2 is a generic
model covering all cardiac surgery, which have some potential
strengths and weaknesses. It was derived from a patient popu-
lation of 22381 consecutive patients undergoing major cardiac
surgery in 154 hospitals in 43 countries over a 12-week period
(May 2010 to July 2010). The fields required to derive the score
have been updated from the previous model and include creat-
inine clearance, modifications to the categorisation of LV ejec-
tion fraction and introduction of a limited mobility field.96,97
The ‘weight of intervention’ is also dealt with differently from
the original EuroSCORE model. The developers report good
discrimination and calibration and it is likely that this model
will be widely adopted, but will require robust external valida-
tion. There remains debate about the derivation and use of this
type of model.98
B.B. wrote the manuscript.
Provenance and peer review
Commissioned; internally peer reviewed.
1. Bridgewater B, Kinsman R, Walton P, et al. Demonstrating
quality:The Sixth National
Report. Henley-on Thames: Dendrite Clinical Systems Ltd; 2009.
2. ElBardissi AW, Aranki SF, Sheng S, et al. Trends in isolated
coronary artery bypass grafting: an analysis of the Society of
Thoracic Surgeons adult cardiac surgery database. J Thorac
Cardiovasc Surg 2012;143:273–81.
3. Bridgewater B. Cardiac registers: the adult cardiac surgery
register. Heart 2010;96:1441–3.
4. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous
coronary intervention versus coronary-artery bypass grafting for
severe coronary artery disease. N Engl J Med 2009;360:961–72.
5. Kappetein AP, Feldman TE, Mack MJ, et al. Comparison of
coronary bypass surgery with drug-eluting stenting for the
treatment of left main and/or three-vessel disease: 3-year follow-
up of the SYNTAX trial. Eur Heart J 2011;32:2125–34.
6. Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Compar-
ative effectiveness of revascularization strategies. N Engl J Med
7. Lee MS, Yang T, Dhoot J, et al. Meta-analysis of clinical studies
comparing coronary artery bypass grafting with percutaneous
coronary intervention and drug-eluting stents in patients with
unprotected left main coronary artery narrowings. Am J Cardiol
8. Naik H, White AJ, Chakravarty T, et al. A meta-analysis of 3,773
patients treated with percutaneous coronary intervention or
surgery for unprotected left main coronary artery stenosis. JACC
Cardiovasc Interv 2009;2:739–47.
9. Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in
patients with de novo left main disease treated with either
Synergy Between Percutaneous Coronary Intervention with
TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation
10. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents
versus bypass surgery for left main coronary artery disease. N Engl
J Med 2011;364:1718–27.
11. Boudriot E, Thiele H, Walther T, et al. Randomized comparison
of percutaneous coronary intervention with sirolimus-eluting
stents versus coronary artery bypass grafting in unprotected
left main stem stenosis. J Am Coll Cardiol 2011;57:538–45.
12. Capodanno D, Tamburino C. Unraveling the EXCEL: promises
and challenges of the next trial of left main percutaneous coronary
intervention. Int J Cardiol 2012;156:1–3.
13. Capodanno D, Caggegi A, Capranzano P, et al. Validating the
EXCEL hypothesis: a propensity score matched 3-year compar-
ison of percutaneous coronary intervention versus coronary artery
bypass graft in left main patients with SYNTAX score </=32.
Catheter Cardiovasc Interv 2011;77:936–43.
14. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial
revascularization. Eur Heart J 2010;31:2501–55.
15. Ribichini F, Taggart D. Implications of new ESC/EACTS
guidelines on myocardial revascularisation for patients with
multi-vessel coronary artery disease. Eur J Cardiothorac Surg
16. Taggart DP, Boyle R, de Belder MA, et al. The 2010 ESC/EACTS
guidelineson myocardial revascularisation.
17. Falk V, Taggart DP. NICE guidance for off-pump CABG: turn
off the pump. Heart 2011;97:1731–3.
18. Pepper JR. NICE guidance for off-pump CABG: keep the pump
primed. Heart 2011;97:1728–30.
19. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-
pump coronary-artery bypass surgery. N Engl J Med 2009;361:
20. Puskas JD, Mack MJ, Smith CR. On-pump versus off-pump
CABG. N Engl J Med 2010;362:851, author reply 53–4.
21. Zenati MA, Shroyer AL, Collins JF, et al. Impact of endoscopic
versus open saphenous vein harvest technique on late coronary
artery bypass grafting patient outcomes in the ROOBY (Ran-
domized On/Off Bypass) Trial. J Thorac Cardiovasc Surg
22. Moller CH, Perko MJ, Lund JT, et al. Three-year follow-up in a
subset of high-risk patients randomly assigned to off-pump versus
on-pump coronary artery bypass surgery: the Best Bypass Surgery
trial. Heart 2011;97:907–13.
23. Hueb W, Lopes NH, Pereira AC, et al. Five-year follow-up of a
randomized comparison between off-pump and on-pump stable
multivessel coronary artery bypass grafting The MASS III Trial.
Circulation 2010;122(Suppl. 11):S48–52.
48 B. Bridgewater
24. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-
pump coronary-artery bypass grafting at 30 days. N Engl J Med
25. Kuss O, von Salviati B, Borgermann J. Off-pump versus on-pump
coronary artery bypass grafting: a systematic review and meta-
analysis of propensity score analyses. J Thorac Cardiovasc Surg
2010;140:829–35, 35 e1–13.
26. Puskas JD, Thourani VH, Kilgo P, et al. Off-pump coronary
artery bypass disproportionately benefits high-risk patients. Ann
Thorac Surg 2009;88:1142–7.
27. Angelini GD, Culliford L, Smith DK, et al. Effects of on-and off-
pump coronary artery surgery on graft patency, survival, and
health-related quality of life: long-term follow-up of 2 randomized
controlled trials. J Thorac Cardiovasc Surg 2009;137:295–303.
28. Anastasiadis K, Argiriadou H, Kosmidis MH, et al. Neurocog-
nitive outcome after coronary artery bypass surgery using minimal
versus conventional extracorporeal circulation: a randomised
controlled pilot study. Heart 2011;97:1082–8.
29. Lopes RD, Hafley GE, Allen KB, et al. Endoscopic versus open
vein-graft harvesting in coronary-artery bypass surgery. N Engl J
30. Grant SW, Grayson AD, Zacharias J, et al. What is the impact of
endoscopic vein harvesting on clinical outcomes following coro-
nary artery bypass graft surgery? Heart 2012;98:604.
31. Ouzounian M, Hassan A, Buth KJ, et al. Impact of endoscopic
versus open saphenous vein harvest techniques on outcomes
after coronary artery bypass grafting. Ann Thorac Surg 2010;89:
32. Taggart DP, Altman DG, Gray AM, et al. Randomized trial to
compare bilateral vs. single internal mammary coronary artery
bypass grafting: 1-year results of the Arterial Revascularisation
Trial (ART). Eur Heart J 2010;31:2470–81.
33. Grau JB, Ferrari G, Mak AW, et al. Propensity matched analysis
of bilateral internal mammary artery versus single left internal
mammary artery grafting at 17-year follow-up: validation of a
contemporary surgical experience. Eur J Cardiothorac Surg
2012;41:770–5, discussion 76.
34. Goldman S, Sethi GK, Holman W, et al. Radial artery grafts vs
saphenous vein grafts in coronary artery bypass surgery: a
randomized trial. JAMA 2011;305:167–74.
35. Levisman JM, Budoff MJ, Karlsberg RP. Long-term coro-
nary artery graft patency as evaluated by 64-slice coronary
36. Achouh P, Boutekadjirt R, Toledano D, et al. Long-term (5- to
20-year) patency of the radial artery for coronary bypass grafting.
J Thorac Cardiovasc Surg 2010;140:73–9, 79 e1–2.
37. Hayward PA, Buxton BF. The Radial Artery Patency and Clinical
Outcomes trial: design, intermediate term results and future
direction. Heart Lung Circ 2011;20:187–92.
38. Hayward PA, Gordon IR, Hare DL, et al. Comparable patencies
of the radial artery and right internal thoracic artery or saphenous
vein beyond 5 years: results from the Radial Artery Patency and
Clinical Outcomes trial. J Thorac Cardiovasc Surg 2010;139:60–5,
39. Pegg TJ, Maunsell Z, Karamitsos TD, et al. Utility of cardiac
biomarkers for the diagnosis of type V myocardial infarction after
coronary artery bypass grafting: insights from serial cardiac MRI.
40. Westenbrink BD, Kleijn L, de Boer RA, et al. Sustained postop-
erative anaemia is associated with an impaired outcome after
coronary artery bypass graft surgery: insights from the IMAGINE
trial. Heart 2011;97:1590–6.
41. Smith KM, McKelvie RS, Thorpe KE, et al. Six-year follow-up of
a randomised controlled trial examining hospital versus home-
based exercise training after coronary artery bypass graft surgery.
Coron Artery Dis
42. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass
surgery in patients with left ventricular dysfunction. N Engl J Med
43. Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and
survival in ischemic left ventricular dysfunction. N Engl J Med
44. Mack MJ. Coronary artery disease: how should the STICH trial
results affect clinical practice? Nat Rev Cardiol 2011;8:427–8.
45. Velazquez EJ, Williams JB, Yow E, et al. Long-term survival of
patients with ischemic cardiomyopathy treated by coronary artery
bypass grafting versus medical therapy. Ann Thorac Surg
46. Brown JM, O’Brien SM, Wu C, et al. Isolated aortic valve
replacement in North America comprising 108,687 patients in 10
years: changes in risks, valve types, and outcomes in the Society of
Thoracic Surgeons National Database. J Thorac Cardiovasc Surg
47. Cockburn J, Trivedi U, Hildick-Smith D. Transaortic transcath-
eter aortic valve implantation within a previous bioprosthetic
48. Dunning J, Gao H, Chambers J, et al. Aortic valve surgery:
marked increases in volume and significant decreases in mechan-
ical valve usedan analysis of 41,227 patients over 5 years from the
Society for Cardiothoracic Surgery in Great Britain and Ireland
National database. J Thorac Cardiovasc Surg 2011;142(776–82):e3.
49. Grant SW, Devbhandari MP, Grayson AD, et al. What is the
impact of providing a transcatheter aortic valve implantation
service on conventional aortic valve surgical activity: patient
risk factors and outcomes in the first 2 years. Heart 2010;96:
50. Kang DH, Park SJ, Rim JH, et al. Early surgery versus
conventional treatment in asymptomatic very severe aortic steno-
sis. Circulation 2010;121:1502–9.
51. Brown ML, Pellikka PA, Schaff HV, et al. The benefits of early
valve replacement in asymptomatic patients with severe aortic
stenosis. J Thorac Cardiovasc Surg 2008;135:308–15.
52. Le Tourneau T, Pellikka PA, Brown ML, et al. Clinical outcome
of asymptomatic severe aortic stenosis with medical and surgical
management: importance of STS score at diagnosis. Ann Thorac
53. Avakian SD, Grinberg M, Ramires JA, et al. Outcome of adults
54. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve
implantation for aortic stenosis in patients who cannot undergo
surgery. N Engl J Med 2010;363:1597–607.
55. Reynolds MR, Magnuson EA, Lei Y, et al. Health-related quality
of life after transcatheter aortic valve replacement in inoperable
patients with severeaortic
56. Reynolds MR, Magnuson EA, Wang K, et al. Cost-effectiveness
of transcatheter aortic valve replacement compared with standard
care among inoperable patients with severe aortic stenosis: results
from the placement of aortic transcatheter valves (PARTNER)
trial (Cohort B). Circulation 2012;125:1102–9.
57. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus
surgical aortic-valve replacement in high-risk patients. N Engl J
58. Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes
after transcatheter or surgical aortic-valve replacement. N Engl J
59. Moat NE, Ludman P, de Belder MA, et al. Long-term outcomes
after transcatheter aortic valve implantation in high-risk patients
with severe aortic stenosis: the U.K. TAVI (United Kingdom
Transcatheter Aortic Valve Implantation) Registry. J Am Coll
Catheter Cardiovasc Interv
Almanac 2012 adult cardiac surgery: The national society journals 49
60. Zahn R, Gerckens U, Grube E, et al. Transcatheter aortic valve
implantation: first results from a multi-centre real-world registry.
Eur Heart J 2011;32:198–204.
61. Lefevre T, Kappetein AP, Wolner E, et al. One year follow-up of
the multi-centre European PARTNER transcatheter heart valve
study. Eur Heart J 2011;32:148–57.
62. Gilard M, Eltchaninoff H, Iung B, et al. Registry of transcatheter
aortic-valve implantation in high-risk patients. N Engl J Med
63. Ussia GP, Barbanti M, Colombo A, et al. Impact of coronary
artery disease in elderly patients undergoing transcatheter aortic
valve implantation: insight from the Italian CoreValve Registry.
Int J Cardiol Published Online First: 27 March 2012.
64. Eltchaninoff H, Durand E, Borz B, et al. Prospective analysis of
30-day safety and performance of transfemoral transcatheter
aortic valve implantation with Edwards SAPIEN XT versus
SAPIEN prostheses. Arch Cardiovasc Dis 2012;105:132–40.
65. Bapat V, Khawaja MZ, Attia R, et al. Transaortic Transcatheter
Aortic valve implantation using Edwards Sapien valve: a novel
approach. Catheter Cardiovasc Interv 2012;79:733–40.
66. Litzler PY, Borz B, Smail H, et al. Transapical aortic valve
implantation in Rouen: four years’ experience with the Edwards
transcatheter prosthesis. Arch Cardiovasc Dis 2012;105:141–5.
67. Murtuza B, Pepper JR, Stanbridge RD, et al. Minimal access
aortic valve replacement: is it worth it? Ann Thorac Surg
68. Brown ML, McKellar SH, Sundt TM, et al. Ministernotomy
versus conventional sternotomy for aortic valve replacement: a
systematic review and meta-analysis. J Thorac Cardiovasc Surg
69. Zannis K, Folliguet T, Laborde F. New sutureless aortic valve
prosthesis: another tool in less invasive aortic valve replacement.
Curr Opin Cardiol 2012;27:125–9.
70. Folliguet TA, Laborde F, Zannis K, et al. Sutureless perceval
aortic valve replacement: results of two European centers. Ann
Thorac Surg 2012;93:1483–8.
71. Holmes Jr DR, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/
SCAI/STS expert consensus document on transcatheter aortic
valve replacement. J Am Coll Cardiol 2012;59:1200–54.
72. Dewey TM, Herbert MA, Ryan WH, et al. Influence of surgeon
volume on outcomes with aortic valve replacement. Ann Thorac
Surg 2012;93:1107–12, discussion 12–3.
73. Gammie JS, Sheng S, Griffith BP, et al. Trends in mitral valve
surgery in the United States: results from the Society of thoracic
surgeons adult cardiac surgery database. Ann Thorac Surg
2009;87:1431–7, discussion 37–9.
74. Anyanwu AC, Bridgewater B, Adams DH. The lottery of mitral
valve repair surgery. Heart 2010;96:1964–7.
75. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al.
Quantitative determinants of the outcome of asymptomatic mitral
regurgitation. N Engl J Med 2005;352:875–83.
76. Kang DH, Kim JH, Rim JH, et al. Comparison of early surgery
versus conventional treatment in asymptomatic severe mitral
regurgitation. Circulation 2009;119:797–804.
77. Montant P, Chenot F, Robert A, et al. Long-term survival in
asymptomatic patients with severe degenerative mitral regurgita-
tion: a propensity score-based comparison between an early
surgical strategy and a conservative treatment approach. J Thorac
Cardiovasc Surg 2009;138:1339–48.
78. Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful
waiting in asymptomatic severe mitral regurgitation. Circulation
79. Rosenhek R. Watchful waiting for severe mitral regurgitation.
Semin Thorac Cardiovasc Surg 2011;23:203–8.
80. Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006
guidelines for the management of patients with valvular heart
disease: a report of the American College of Cardiology/American
heart Association Task Force on practice guidelines (writing
committee to revise the 1998 guidelines for the management of
patients with valvular heart disease): developed in collaboration
with the Society of cardiovascular Anesthesiologists: endorsed by
the Society for cardiovascular angiography and interventions
and the Society of thoracic surgeons. Circulation 2006;114:
81. Bridgewater B, Hooper T, Munsch C, et al. Mitral repair best
practice. Proposed standards. Heart 2006;92:939–44.
82. Bolling SF, Li S, O’Brien SM, et al. Predictors of mitral valve
repair: clinical and surgeon factors. Ann Thorac Surg 2010;90:
1904–11, discussion 12.
83. Gammie JS, O’Brien SM, Griffith BP, et al. Influence of hospital
procedural volume on care process and mortality for patients
undergoing elective surgery for mitral regurgitation. Circulation
84. Perier P, Hohenberger W, Lakew F, et al. Toward a new
paradigm for the reconstruction of posterior leaflet prolapse:
midterm results of the ‘‘respect rather than resect’’ approach. Ann
Thorac Surg 2008;86:718–25, discussion 18–25.
85. Gammie JS, Bartlett ST, Griffith BP. Small-incision mitral valve
repair: safe, durable, and approaching perfection. Ann Surg
86. Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain
Memorial Paper for adult cardiac surgery. Less-invasive mitral
valve operations: trends and outcomes from the Society of thoracic
surgeons adult cardiac surgery database. Ann Thorac Surg
2010;90:1401–8, 10 e1; discussion 08–10.
87. Modi P, Hassan A, Chitwood Jr WR. Minimally invasive mitral
valve surgery: a systematic review and meta-analysis. Eur J
Cardiothorac Surg 2008;34:943–52.
88. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus
conventional open mitral valve surgery: a meta-analysis and
systematic review. Innovations (Phila) 2011;6:84–103.
89. Iribarne A, Russo MJ, Easterwood R, et al. Minimally invasive
versus sternotomy approach for mitral valve surgery: a propensity
analysis. Ann Thorac Surg 2010;90:1471–7, discussion 77–8.
90. Whitlow PL, Feldman T, Pedersen WR, et al. Acute and 12-
month results with catheter-based mitral valve leaflet repair: the
EVEREST II (Endovascular Valve Edge-to-Edge Repair) High
Risk Study. J Am Coll Cardiol 2012;59:130–9.
91. Shahian DM, Edwards FH. The Society of Thoracic Surgeons
2008 cardiac surgery risk models: introduction. Ann Thorac Surg
92. O’Brien SM, Shahian DM, Filardo G, et al. The Society of
Thoracic Surgeons 2008 cardiac surgery risk models: part 2––
isolated valve surgery. Ann Thorac Surg 2009;88(Suppl. 1):S23–42.
93. Shahian DM, O’Brien SM, Filardo G, et al. The Society of
Thoracic Surgeons 2008 cardiac surgery risk models: part 3––valve
plus coronary artery bypass grafting surgery. Ann Thorac Surg
94. Shahian DM, O’Brien SM, Filardo G, et al. The Society of
Thoracic Surgeons 2008 cardiac surgery risk models: part 1––
coronary artery bypass grafting surgery. Ann Thorac Surg
95. Choong CK, Sergeant P, Nashef SA, et al. The EuroSCORE risk
stratification system in the current era: how accurate is it and what
should be done if it is inaccurate? Eur J Cardiothorac Surg
96. Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J
Cardiothorac Surg 2012;41:734–44, discussion 44–5.
97. Miceli A, Bruno VD, Capoun R, et al. Mild renal dysfunction in
patients undergoing cardiac surgery as a new risk factor for
EuroSCORE. Heart 2011;97:362–5.
98. Sergeant P, Meuris B, Pettinari M. EuroSCORE II illum qui est
gravitates magni observe. Eur J Cardiothorac Surg 2012;41:
50 B. Bridgewater