[Show abstract][Hide abstract] ABSTRACT: To review our experience with sutureless aortic valve replacement (AVR) in the setting of concomitant mitral valve (MV) surgery and discuss the technical considerations.
Journal of Thoracic and Cardiovascular Surgery 10/2014; 148(4):1354-9. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Following the approval of transcatheter aortic valve replacement (TAVR) for high-risk and inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs have been initiated. Contemporary outcomes from these newly-initiated centers remain unknown.
In March 2013, our institution was authorized by the Quebec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT transcatheter heart valve. In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium-2 guidelines.
From April 2013 to January 2014, 30 consecutive high-risk (n=16; 53.3%) or inoperable (n=14; 46.7%) patients (mean age 84.6, mean Society of Thoracic Surgery score 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intra-procedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, with no death at 30 days. Disabling stroke occurred in one (3.3%) patient 48 hours after THV implantation. Major vascular complication and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 [1, 3] days with eight (26.7%) patients discharged within 24 hours post-procedure.
Excellent outcomes can be achieved in newly initiated, relatively low-volume centers, which compare favorably to previously published large series. Important considerations include appropriate team-training, rigorous patient-screening, use of multimodality imaging techniques, a heart-team approach, constant integration of lessons learned from larger published experiences and maintaining a recommended minimum volume of 25 cases/year.
The Canadian journal of cardiology 08/2014; · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: With improved durability of contemporary bioprostheses, surgeons are now recommending biologic valves in younger patients. However, long-term outcomes of patients younger than 60 years old undergoing biologic aortic valve implantation are not well known.
From November 1991 to March 2011, 144 patients less than 60 years old underwent aortic valve replacement (AVR) with Carpentier-Edwards pericardial valves (Edwards Lifesciences, Irvine, CA). Mean follow-up was 10 ± 4 years. Outcomes were reported according to published guidelines.
Seventy-five percent of patients were male, with a mean age of 51 ± 9 years. Actuarial survival rates including early deaths were 89% ± 3%, 79% ± 4%, and 57% ± 6% after 5, 10, and 15 years of follow-up, respectively. Survival of patients was comparatively lower than a gender- and age-matched general population at all time points. The freedom from major adverse cardiac events (myocardial infarction, heart failure, hemorrhage, thromboembolic event, and endocarditis) was 89% ± 3%, 87% ± 3%, and 75% ± 6% at 5, 10, and 15 years after surgery. The freedom rate from prosthetic valve dysfunction was 97% ± 2%, 84% ± 4%, and 57% ± 6% at 5, 10, and 15 years after surgery. Patients with a diagnosis of structural valve deterioration (29 of 37, 78%) underwent reoperation 11 ± 5 years after the initial valve replacement with no perioperative mortality.
In patients younger than 60 years undergoing AVR, the Carpentier-Edwards Perimount bioprosthesis provided satisfactory clinical outcomes. However, late survival was inferior to an age- and gender-matched population. Structural valve deterioration and the need for reintervention were common late after implantation, but reoperation for prosthetic valve dysfunction was associated with a very low risk of mortality.
The Annals of thoracic surgery 03/2014; · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation (TAVI) is an accepted alternative treatment for severe symptomatic aortic stenosis in high-risk and inoperable patients. Femoral or transapical accesses are commonly used. We report our initial clinical experience with TAVI using the left-axillary artery approach.
A single-center, retrospective study of patients undergoing transaxillary TAVI between January 2010 and December 2012 was performed. Procedural success was defined as successful device implantation with reduction in the mean aortic gradient and without need for conversion to open-heart surgery. Short-term echocardiographic follow-up was obtained in all patients.
A total of 18 consecutive patients with severe aortic stenosis who were not candidates for surgical replacement underwent transaxillary TAVI. Mean age was 81.1 ± 7.3 years and 14 patients (78%) were male. Median logistic European System for Cardiac Operative Risk Evaluation was 8.5% (range, 1.5% to 54.1%). Procedural success was obtained in 17 out of 18 patients (94%). There was no in-hospital or 30-day mortality. One major bleeding complication in the form of an upper gastrointestinal bleeding was observed. No stroke or major vascular complication was reported. Postoperative implantation of a permanent pacemaker was performed in 7 patients (39%). At a mean follow-up of 326 ± 213 days, mean aortic gradient was 10.8 ± 4.8 mm Hg. Mean aortic valve area was 1.7 ± 0.4 cm(2) and aortic insufficiency grade was mild or less in all but 1 patient, who showed moderate regurgitation.
The transaxillary approach for TAVI is associated with high procedural success and low rates of stroke, vascular, or bleeding complications. This approach is an appealing alternative to the commonly used transfemoral and transapical TAVI.
The Annals of thoracic surgery 01/2014; · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to determine long-term survival and clinical outcomes after elective isolated mechanical aortic valve replacement in young adults.
A clinical observational study was conducted in a cohort of 450 consecutive adults less than 65 years of age who had undergone elective isolated mechanical aortic valve replacement (AVR) between 1997 and 2006. Patients who had undergone previous cardiac surgery, and those undergoing concomitant procedures or urgent surgery were excluded. Follow-up was 93.3% complete with a mean follow-up of 9.1 ± 3.5 years. The primary end point was survival. Life table analyses were used to determine age- and gender-matched general population survival. Secondary end points were reoperation and valve-related complications.
Overall actuarial survival at 1, 5, and 10 years was 98% ± 1%, 95% ± 1%, and 87% ± 1%, respectively, which was lower than expected in the age- and gender-matched general population in Quebec. Actuarial freedom from prosthetic valve dysfunction was 99% ± 0.4%, 95% ± 1%, and 91% ± 1% at 1, 5, and 10 years, respectively. Actuarial freedom from valve reintervention was 98% ± 1%, 96% ± 1%, and 94% ± 1% at 1, 5 and 10 years, respectively. Actuarial survival free from reoperation at 10 years was 82% ± 2%. Actuarial freedom from major hemorrhage was 98% ± 1%, 96% ± 1%, and 90% ± 2% at 1, 5, and 10 years, respectively.
In young adults undergoing elective isolated mechanical AVR, survival remains suboptimal compared with an age- and gender-matched general population. Furthermore, there is a low but constant hazard of prosthetic valve reintervention after mechanical AVR.
The Journal of thoracic and cardiovascular surgery 12/2013; · 3.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The CarboMedics mechanical prosthesis (CarboMedics Inc, Austin, TX) has been used for mitral and aortic valve replacement for more than 20 years in our institution. This study describes the long-term survival of patients with this prosthesis as well as the valve-related events.
Between June 1988 and May 2010, 3,297 patients underwent either single aortic valve replacement (AVR) (2,242 patients) or mitral valve replacement (MVR) (1,055 patients) with the CarboMedics mechanical valve prosthesis. They were followed annually for valve-related complications at the Montreal Heart Institute valve clinic.
Operative mortality was 4% with AVR and 7% with MVR. Total follow-up was 23,671 patient-years (range, 1 month to 21 years; average, 7.5 ± 5.3 years). At 20 years, patient freedom from late mortality was 43.2% in the AVR group and 40.9% in the MVR group. Freedom from valve-related mortality was 78.3% for AVR and 74.6% for MVR. Freedom from thromboembolic event was 91.6% for AVR and 88.5% for MVR. Freedom from reoperation was 89.2% for AVR and 80.3% for MVR. Freedom from bleeding event was 89.5% for AVR and 88% for MVR. Freedom from endocarditis was 97.3% for both AVR and MVR. Freedom from valve thrombosis was 98.9% for AVR and 91.4% for MVR. There was no structural valve failure in our cohort.
The CarboMedics valve is an effective and durable mechanical valve prosthesis with a low event rate and no structural failure at 20 years.
The Annals of thoracic surgery 11/2013; · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The femoral artery has been the traditional approach for implantation of the Impella left ventricular assist device. We describe the case of a young man with toxic (cocaine-related) cardiomyopathy, severe left ventricular dysfunction, and moderate mitral insufficiency who received a transfemoral Impella left ventricular assist device that was relocated to the right axillary artery due to uncontrolled femoral access bleeding. The patient immediately stabilized post-implantation and was successfully bridged to a full recovery 6 days later.
[Show abstract][Hide abstract] ABSTRACT: The impact of a transvalvular pacemaker lead on the progression of tricuspid regurgitation (TR) after tricuspid valve (TV) repair has not been clearly demonstrated. The aim of this study was to evaluate the presence of a transvalvular pacemaker lead as a risk factor for TR after TV repair in a large patient cohort.
A retrospective review included 791 patients who underwent TV repair at our institution from 1977 to 2008. All patients bearing a transvenous pacemaker implanted either preoperatively or within 30 days of surgery were categorized in the "PACE" group (n = 176), the remaining patients were categorized in the "NO PACE" group (n = 615).
Mean age was 61 ± 11 years, and 575 patients (73%) were female. Mean follow-up was 5.8 ± 5.5 years. Operative mortality was 13%. At discharge, TR severity was 3+ or greater in 10% and 15% of patients in the PACE and NO PACE groups, respectively (p = 0.19). Multivariate analysis using a Cox regression model identified the presence of a transvenous pacemaker as an independent risk factor for recurrence of TR 2+ or greater (hazard ratio [HR] 1.60, p = 0.008) and TR 3+ or greater (HR 1.47, p = 0.046) at last follow-up. The presence of a transvenous pacemaker was also a significant independent predictor of late mortality (HR 2.12, p = 0.02).
In patients undergoing tricuspid valve surgery, the presence of a transvenous pacemaker implanted either preoperatively or within 30 days of surgery is associated with a significantly increased risk of persistent or recurrent TR at late follow-up.
The Annals of thoracic surgery 07/2013; · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Functional ischemic mitral regurgitation (FIMR) increases mortality independently of the baseline characteristics and ventricular function. The effect of treating FIMR with annuloplasty is unclear when mitral regurgitation is moderate. Myocardial revascularization alone has been shown to improve mitral valve function.
We randomized 31 patients with moderate (grade 2-4) FIMR to receive either coronary artery bypass grafting (CABG) alone or CABG plus downsizing mitral ring annuloplasty. The patients were followed up for clinical outcomes and echocardiographic assessment of mitral valve function and left ventricular dimensions at 3 and 12 months. Clinical improvement was assessed using the Minnesota quality-of-life questionnaire, 6-minute walk test, and brain natriuretic peptide levels.
The clinical course was similar in the 2 groups of patients during the study period. FIMR was perfectly corrected intraoperatively in the ring group. Echocardiographic follow-up at 3 months showed no difference in the FIMR grade between the 2 groups (66% less than grade 2 in the CABG alone and 86% in the CABG plus ring group; P = .316). The improvement in the CABG alone group was even more marked at 12 months (85% less than grade 2 in the CABG group and 85% in the CABG plus ring group). The left ventricular ejection fraction was significantly better at 3 months in the CABG alone group, although at 12 months, the left ventricular ejection fraction in the 2 groups had improved similarly.
Although initially effective at reducing moderate FIMR, the addition of a ring did not change the clinical course after CABG surgery. At 12 months, no echocardiographic difference was found in terms of residual mitral regurgitation, left ventricular dimensions and function, or clinical outcomes.
The Journal of thoracic and cardiovascular surgery 07/2013; · 3.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The Carpentier-Edwards pericardial valve was designed to minimize structural valve deterioration. Excellent durability and low incidence of valve-related complications have been reported. The objective of the present study was to analyze clinical results after 25 years of experience with this valve implanted in the aortic position. The effect of patient age at the time of surgery was also evaluated. METHODS: This is a retrospective cohort study of 2,405 patients from November 1981 to March 2011. Primary outcomes of interest were survival and freedom from major adverse effects such as thromboembolic, endocarditis, and reoperation. RESULTS: Sixty percent were male, with a mean age of 71 ± 9 years old. Actuarial survival rates including early deaths averaged 78% ± 2%, 55% ± 2%, and 16 % ± 2% after 5, 10, and 20 years of follow-up, respectively. The freedom rate of valve reoperation for prosthesis dysfunction and all other causes averaged 98 % ± 0.2%, 96% ± 1%, and 67% ± 4% at 5, 10, and 20 years. Patients younger than 60 years of age had a 15-year survival averaging 54% ± 5% compared with patients aged between 60 and 70 years of age averaging 46% ± 3% and with patients older than 70 years of age averaging 28% ± 3% (p = 0.001). Survival at 5, 10, and 20 years for patients who had concomitant CABG [coronary artery bypass grafting] were 78% ± 1%, 55% ± 2%, and 9% ± 3% compared with no concomitant CABG (84% ± 1%, 62% ± 2%, and 22% ± 3% (p < 0.001)). CONCLUSIONS: Carpentier-Edwards pericardial valve implantation in the aortic position is secure and durable. The effects of age influence reoperation rate and survival as well as a concomitant coronary artery bypass procedure.
The Annals of thoracic surgery 05/2013; · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES
Mediastinal drainage following cardiac surgery with traditional large-bore plastic tubes can be painful and cumbersome. This study was designed to determine whether prolonged drainage (5 days) with a silastic tube decreased the incidence of significant pericardial effusion and tamponade following aortic or valvular surgery.METHODS
One hundred and fifty patients undergoing valvular or aortic surgery in a tertiary cardiac surgery institution were randomized to receive a conventional mediastinal tube plus a silastic Blake drain (n = 75), or two conventional tubes (n = 75). Conventional drains were removed on postoperative day (POD) 1, while Blake drains were removed on POD 5. The primary end-point was the combined incidence of significant pericardial effusion (≥15 mm) or tamponade through POD 5. Secondary end-points included total mediastinal drainage, postoperative atrial fibrillation (AF) and pain.RESULTSAnalysis was performed for 67 patients in the Blake group and 73 in the conventional group. There was no difference between the two groups in the combined end-point of significant effusion or tamponade (7.4 vs 8.3%, P = 0.74), or in the incidence of AF (47 vs 46%, P = 0.89). Mean 24-h drainage was greater in the Blake group than in the conventional group (749 ± 444 ml vs 645 ± 618 ml, P < 0.01). Overall incidence of significant pericardial effusion at 30 days was 12.1% (n = 17), with 5% (n = 7) requiring drainage. The Blake group had a numerically lower incidence of effusion requiring drainage at POD 30 (3.0 vs 6.8%, P = 0.44). Postoperative pain was similar between groups.CONCLUSIONS
In patients undergoing ascending aortic or valvular surgery, prolonged drainage with silastic tubes is safe and does not increase postoperative pain. There was no difference between the Blake and conventional drains with regard to significant pericardial effusion or tamponade in this cohort; however, this conclusion is limited by the low overall incidence of the primary outcome in this cohort.
Interactive Cardiovascular and Thoracic Surgery 04/2013; · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a case of an elderly male with significant comorbidities and a dominant aberrant left vertebral artery originating on an aneurysmal aortic arch. The patient underwent a successful staged hybrid procedure with aortic arch debranching and left vertebral artery transposition onto the left common carotid artery, followed by endovascular aneurysmal repair.
Journal of Cardiac Surgery 01/2013; · 1.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To address the clinical consequences related to chest tube clogging, a novel chest drainage apparatus, the PleuraFlow Active Tube Clearance System (Clear Catheter Systems, Bend, OR), was developed. The aim of this world's first clinical experience study was to follow clinicians using the PleuraFlow system to assess usability issues and potential areas of improvement in the heart surgery setting.
A user preference study was conducted to assess how specified users (surgeons, nurses, and intensive care physicians) used the PleuraFlow system to achieve specified goals in an efficient manner. Data were collected from patient charts and by a questionnaire that they had filled.
All the surgeons (n = 7) noted that the device was not any more difficult to insert than a conventional chest tube and was easy to assemble and use. There were no reports of malfunction or complications related to the installation or use of the system. A majority, 77% (24/31), of nurses felt that the device was more time efficient than stripping, milking, or tapping the chest tubes to keep them open. A majority (16/19, 84%) of the PleuraFlow chest tubes and guide tubes were removed together in one piece within 1 day of surgery (on postoperative day 1).
Overall, the physicians and nurses rated the PleuraFlow system positively for its ability to be incorporated into the postoperative workflow of managing the drainage of patients after heart surgery. This device may be useful to allow caregivers to be certain that chest tubes are functioning in the early hours after surgery, when active bleeding is resolving and when complications from undrained blood can ensue.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 09/2012; 7(5):354-8.
[Show abstract][Hide abstract] ABSTRACT: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence.
A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women.
Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001).
Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes.
American heart journal 05/2012; 163(5):851-858.e1. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P = 0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P = 0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.
Interactive Cardiovascular and Thoracic Surgery 01/2012; 14(4):452-6. · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Statin therapy prior to coronary artery bypass surgery (CABG) has been shown to prevent perioperative events such as myocardial infarction and perioperative death. The effect of statin therapy as a preventive treatment to decrease the stroke risk unrelated to cardiac surgery is also documented. In the setting of CABG, we have found no studies reporting a preventive effect of statin therapy on neurologic outcome.
We analyzed 6,813 patients treated by CABG surgery at our institution between 1995 and 2005 for which complete medication history including all drugs taken before and after surgery was available. We analyzed the risk factors for postoperative stroke using a multiple logistic regression analysis, more specifically looking at the effect of preoperative treatment with statin, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors, alone or in combination.
At 30 days postoperative, 94 patients suffered a new documented stroke (1.4%). Hypertension, carotid disease, diabetes, and age were all associated with a greater risk of postoperative stroke. When analyzing the four groups of drug therapy, none of the medications alone affected the stroke rate. However, upon multivariable analysis the combination of statin and β-blockers gave an odds ratio of 0.377, suggesting a strong protective effect.
Beta-blockers combined with statin confer a protective effect for stroke after CABG.
The Annals of thoracic surgery 03/2011; 91(3):654-9. · 3.45 Impact Factor