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Impact of Patient Prosthesis Mismatch on Short And Long-Term Mortality Outcomes After Aortic Valve Replacement
year prior to conduit replacement was 49 and 64 mm Hg respectively. Of the 24 patients that were alive with good follow up, 7 still had their original conduit, 16 are on their second conduit with a median conduit age of 7.9 years (range 1.5–13.8 years) and one has had a third conduit implanted. Discussion: Survival in neonates undergoing repair of truncus arteriosus is comparable with published results from older cohorts. Surgery is indicated in the first month of life principally to avoid the development of heart failure and to avoid interval morbidity and mortality. Conduit longevity is related to the choice of material and its size. Valved and un-valved synthetic grafts had a longer freedom from operation than homografts and porcine aortic roots. A simple tube graft showed good long term results and may be preferable to a homograft as the first conduit. The loss of valve function in the early post-operative period may be less important than the development of early mixed stenosis and regurgitation, in a lifetime of right ventricular to pulmonary artery connections. doi:10.1016/j.hlc.2010.04.097 Short Presentation
493
Abstracts of the ASCTS 2008 Annual Scientific Meeting
Results: Among the variably located VSDs, the RCC was prolapsed in all cases, whereas 51.6% also had a noncoronary cusp prolapse. Prior to surgery, there was no AR in 9.1%, trivial in 29.6%, mild in 25.8% and moderate in 35.5%. VSD repair was performed by direct closure (48.1%) and with a patch (51.9%). Additionally, 8 patients had aortic valve repair because of rupture or gross aneurysm formation of sinus of Valsalva. Following surgery, there was significant improvement in all of the following indices. Index PI R/L N/L CH
From 1.34 1.34 1.20 6.57
± ± ± ±
0.29 0.17 0.20 2.21
To 1.20 1.23 1.14 7.57
p ± ± ± ±
0.15 0.17 0.17 2.58
0.031 0.0025 0.032 0.01
The degree of AR improved in 51.6% but remained unchanged in the rest. These changes were identical between two methods of VSD closure. Discussion: Risk adjusted outcomes of Aortic Valve Repair still fall shorter in comparison with the success story of Mitral Valve Repair. Opportunities to study and follow the aortic valve anatomy closely might bring aortic valve repair within our grasp one day.
19 Impact of Surgical Closure of VSD With Prolapsed Aortic Valve on Aortic Cusp Deformity Indices Assessed By 2DTrans-Thoracic Echocardiography Prashant Joshi, Martin Wong, Vaishali Londhe, KH Sim Introduction: Aortic Valve Prolapse (AVP), as a complication or an aberration is often associated with Oriental sub-aortic VSD. Various Aortic Cusp Deformity Indices are used to quantify the severity of AVP [1]. Even though early closure of VSD is believed to prevent the progression of AR [2], its impact on these indices is not known. Objectives: (1) To evaluate the changes in various cusp deformity indices before and after surgical closure. (2) To assess the effect of repair on degree of AR and (3) to determine if method of VSD closure has any impact on the outcome. Methods: Retrospective review of 57 cases of VSD closure (mean age 13.11 + 10.77 years) performed for the indication of AVP. Immediately before and at a median age of one year after surgery, following indices were obtained by trans-thoracic 2D-echo. Aortic Cusp Prolapse Index (PI), Right Coronary Cusp Imbalance Index (R/L), Non-Coronary Cusp Imbalance Index (N/L), Aortic Cusp Coaptation Height (CH), and the severity of AR.
References [1] Tomita H. Severity Indices of RCC prolapse and AR complicating VSD. Circ J 2004. [2] Sim EKW, et al. Outcome of surgical closure of doubly committed subarterial ventricular septal defect. Ann Thorac Surg 1999;67:736–8.
doi:10.1016/j.hlc.2010.04.098 Short Presentation 20 Impact of Patient Prosthesis Mismatch on Short And Long-Term Mortality Outcomes After Aortic Valve Replacement Waleed A. Ahmed, Rob Baker, John Knight Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia Background: It is still controversial in literatures whether patient prosthesis mismatch is a real predictor of poor short and long term mortality outcome after Aortic valve replacement surgery. Objective: The aim of this study was to evaluate the impact of patient prosthesis mismatch (PPM) and additional risk factors (including age and left ventricular function) on mortality outcome after aortic valve replacement (AVR). Methods: We analysed prospectively collected data of 427 consecutive patients undergoing mechanical and tissue AVR between January 1996 and December 2005. The valve indexed effective orifice area (IEOA) was estimated
ABSTRACTS
Heart, Lung and Circulation 2010;19:483–510
494
Heart, Lung and Circulation 2010;19:483–510
Abstracts of the ASCTS 2008 Annual Scientific Meeting
ABSTRACTS
for each valve prosthesis implanted. PPM was defined as ≤0.75 cm2 per m2 body surface area (BSA) Patients were divided into two groups, Group 1 with IEOA >0.75 cm2 per m2 BSA and Group 2, with IEOA ≤0.75 cm2 per m2 BSA. Short and long outcomes of the two groups were assessed using univariate (Fisher’s exact test) and multivariate logistic regression analysis, as well as survival analysis (Kaplan–Meier). Results: Group 1 contained 324 (75.8%) patients with group 2 having 103 patients (24.2%). In-hospital mortality was similar between the two groups (1.2% vs 1%) p < 0.65, and the hazard model suggested no differences in long term survival in relation to IEAO. PPM was not independently predictive of short or long term mortality. Further analysis revealed an increased risk of mortality after AVR was associated with patient age (p < 0.001, HR 1.04), renal impairment (p < 0.001, HR 2.9), left ventricular dysfunction (p < 0.05) and urgent surgery (p < 0.001, HR 1.09). Conclusion: PPM was present in a quarter of patients undergoing AVR in this cohort. Whilst factors such as age and renal impairment were predictors of adverse outcome, PPM had no significant impact on short or long term mortality following AVR.
respectively. Mean lengths of ICU stay and hospital stay were 50.0 versus 63.7 h (p = 0.26) and 8.4 versus 11.2 days (p = 0.057) in the prophylaxis and control groups respectively. The incidence of new-onset heart block requiring temporary pacing was similar in both groups ((5 of 151 (3.3%) and 6 of 153 (3.9%)). Postoperative cerebrovascular event rates were reduced in the prophylaxis group to 0.7% (one transient ischaemic attack) versus 4.7% (7 permanent strokes) in the control group (p = 0.06). Conclusions: The use of prophylactic oral amiodarone in a pre- and peri-operative setting may have some benefits in reducing both the incidence and impact of atrial fibrillation with trends towards reduced length of hospital stay in patients undergoing cardiac surgery. Its relation to a reduced incidence of disabling stroke is not clear.
doi:10.1016/j.hlc.2010.04.099
Massimo Massetti
Short Presentation
Cardiac Surgery, University Hospital CHU CAEN, France
21 Efficacy of Peri-Operative Amiodarone in Prevention of Atrial Fibrillation Following Adult Cardiac Surgery Jim Dimitriou, Philip Hayward, Rinaldo Bellomo, N. Seevanayagam, George Matalanis Austin Hospital, United States Background: Atrial fibrillation (AF) is the commonest complication after adult cardiac surgery with an incidence reported around 25% (range 5–65%). It has been associated with increased length of hospital stay as well as increased mortality and morbidity. The aim of this ongoing study is to determine the efficacy of pre- and peri-operative amiodarone in the prevention of post-operative AF after adult cardiac surgery. Methods: Retrospective case note review which compared 151 patients operated during a five month period from February 08 to June 08, all of whom received amiodarone pre- and post-operatively, with a historical control group of 153 consecutive patients operated during a comparable five month period Aug 06 to Dec 06, who received amiodarone as treatment only when AF occurred. Prophylactic amiodarone was given as 10 mg/kg/day orally for six days pre-operatively, by infusion on the day of surgery and orally for six days post-operatively. Results: Post-operative atrial fibrillation occurred in 24 of 151 pts (15.9%) in the prophylactic amiodarone group and 32 of 153 (20.9%) in the control group (p = 0.21). Thirtyday mortality was comparable with 4 deaths (2.6%) versus 5 deaths (3.3%) in the prophylaxis and control groups
doi:10.1016/j.hlc.2010.04.100 Short Presentation 22 Resuscitation from Prolonged Cardiac Arrest Using Portable ECC
Introduction: Survival of patients after prolonged cardiac arrest or refractory cardiogenic shock is still inadequate. Medical progress during the last 20 years did not change the prognostic evolution of these patients. The support of circulatory and respiratory function with mechanical devices can be an alternative to conventional therapy for patients who do not respond to cardiopulmonary cerebral resuscitation. Historical experience with Extra Corporeal Life Support resuscitation for decompensated acute heart failure has shown that patient prognosis can be increased significantly and has demonstrated the rationale of the portable extracorporeal circulation as a rescue therapy. During the 1980s and early 1990s, significant progress in cardiopulmonary by-pass technology made portable by-pass systems easy to use even in non cardiac surgery environment. Main improvements include miniaturisation, heparin-coated circuits, longer durability of oxygenators and increased hardware performance. The rationale for using an emergent portable by-pass is to provide in a timely fashion, temporary circulatory and respiratory support to the vital organs of a patient suffering from refractory cardiac and/or respiratory failure. The key to improving organ recovery is to achieve early restoration of circulation. One additional benefit is to support therapeutic synergies like hypothermia and new pharmacological medications. This innovative approach placing patients at the center of a multidisciplinary network is the rationale of a resuscitation program organised transversally across the emergency department for the out-of-hospital interventions, the intensive care units, the cardiology and cardiac surgery departments, and the neurology and neurosurgery departments.
493
Abstracts of the ASCTS 2008 Annual Scientific Meeting
Results: Among the variably located VSDs, the RCC was prolapsed in all cases, whereas 51.6% also had a noncoronary cusp prolapse. Prior to surgery, there was no AR in 9.1%, trivial in 29.6%, mild in 25.8% and moderate in 35.5%. VSD repair was performed by direct closure (48.1%) and with a patch (51.9%). Additionally, 8 patients had aortic valve repair because of rupture or gross aneurysm formation of sinus of Valsalva. Following surgery, there was significant improvement in all of the following indices. Index PI R/L N/L CH
From 1.34 1.34 1.20 6.57
± ± ± ±
0.29 0.17 0.20 2.21
To 1.20 1.23 1.14 7.57
p ± ± ± ±
0.15 0.17 0.17 2.58
0.031 0.0025 0.032 0.01
The degree of AR improved in 51.6% but remained unchanged in the rest. These changes were identical between two methods of VSD closure. Discussion: Risk adjusted outcomes of Aortic Valve Repair still fall shorter in comparison with the success story of Mitral Valve Repair. Opportunities to study and follow the aortic valve anatomy closely might bring aortic valve repair within our grasp one day.
19 Impact of Surgical Closure of VSD With Prolapsed Aortic Valve on Aortic Cusp Deformity Indices Assessed By 2DTrans-Thoracic Echocardiography Prashant Joshi, Martin Wong, Vaishali Londhe, KH Sim Introduction: Aortic Valve Prolapse (AVP), as a complication or an aberration is often associated with Oriental sub-aortic VSD. Various Aortic Cusp Deformity Indices are used to quantify the severity of AVP [1]. Even though early closure of VSD is believed to prevent the progression of AR [2], its impact on these indices is not known. Objectives: (1) To evaluate the changes in various cusp deformity indices before and after surgical closure. (2) To assess the effect of repair on degree of AR and (3) to determine if method of VSD closure has any impact on the outcome. Methods: Retrospective review of 57 cases of VSD closure (mean age 13.11 + 10.77 years) performed for the indication of AVP. Immediately before and at a median age of one year after surgery, following indices were obtained by trans-thoracic 2D-echo. Aortic Cusp Prolapse Index (PI), Right Coronary Cusp Imbalance Index (R/L), Non-Coronary Cusp Imbalance Index (N/L), Aortic Cusp Coaptation Height (CH), and the severity of AR.
References [1] Tomita H. Severity Indices of RCC prolapse and AR complicating VSD. Circ J 2004. [2] Sim EKW, et al. Outcome of surgical closure of doubly committed subarterial ventricular septal defect. Ann Thorac Surg 1999;67:736–8.
doi:10.1016/j.hlc.2010.04.098 Short Presentation 20 Impact of Patient Prosthesis Mismatch on Short And Long-Term Mortality Outcomes After Aortic Valve Replacement Waleed A. Ahmed, Rob Baker, John Knight Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia Background: It is still controversial in literatures whether patient prosthesis mismatch is a real predictor of poor short and long term mortality outcome after Aortic valve replacement surgery. Objective: The aim of this study was to evaluate the impact of patient prosthesis mismatch (PPM) and additional risk factors (including age and left ventricular function) on mortality outcome after aortic valve replacement (AVR). Methods: We analysed prospectively collected data of 427 consecutive patients undergoing mechanical and tissue AVR between January 1996 and December 2005. The valve indexed effective orifice area (IEOA) was estimated
ABSTRACTS
Heart, Lung and Circulation 2010;19:483–510
494
Heart, Lung and Circulation 2010;19:483–510
Abstracts of the ASCTS 2008 Annual Scientific Meeting
ABSTRACTS
for each valve prosthesis implanted. PPM was defined as ≤0.75 cm2 per m2 body surface area (BSA) Patients were divided into two groups, Group 1 with IEOA >0.75 cm2 per m2 BSA and Group 2, with IEOA ≤0.75 cm2 per m2 BSA. Short and long outcomes of the two groups were assessed using univariate (Fisher’s exact test) and multivariate logistic regression analysis, as well as survival analysis (Kaplan–Meier). Results: Group 1 contained 324 (75.8%) patients with group 2 having 103 patients (24.2%). In-hospital mortality was similar between the two groups (1.2% vs 1%) p < 0.65, and the hazard model suggested no differences in long term survival in relation to IEAO. PPM was not independently predictive of short or long term mortality. Further analysis revealed an increased risk of mortality after AVR was associated with patient age (p < 0.001, HR 1.04), renal impairment (p < 0.001, HR 2.9), left ventricular dysfunction (p < 0.05) and urgent surgery (p < 0.001, HR 1.09). Conclusion: PPM was present in a quarter of patients undergoing AVR in this cohort. Whilst factors such as age and renal impairment were predictors of adverse outcome, PPM had no significant impact on short or long term mortality following AVR.
respectively. Mean lengths of ICU stay and hospital stay were 50.0 versus 63.7 h (p = 0.26) and 8.4 versus 11.2 days (p = 0.057) in the prophylaxis and control groups respectively. The incidence of new-onset heart block requiring temporary pacing was similar in both groups ((5 of 151 (3.3%) and 6 of 153 (3.9%)). Postoperative cerebrovascular event rates were reduced in the prophylaxis group to 0.7% (one transient ischaemic attack) versus 4.7% (7 permanent strokes) in the control group (p = 0.06). Conclusions: The use of prophylactic oral amiodarone in a pre- and peri-operative setting may have some benefits in reducing both the incidence and impact of atrial fibrillation with trends towards reduced length of hospital stay in patients undergoing cardiac surgery. Its relation to a reduced incidence of disabling stroke is not clear.
doi:10.1016/j.hlc.2010.04.099
Massimo Massetti
Short Presentation
Cardiac Surgery, University Hospital CHU CAEN, France
21 Efficacy of Peri-Operative Amiodarone in Prevention of Atrial Fibrillation Following Adult Cardiac Surgery Jim Dimitriou, Philip Hayward, Rinaldo Bellomo, N. Seevanayagam, George Matalanis Austin Hospital, United States Background: Atrial fibrillation (AF) is the commonest complication after adult cardiac surgery with an incidence reported around 25% (range 5–65%). It has been associated with increased length of hospital stay as well as increased mortality and morbidity. The aim of this ongoing study is to determine the efficacy of pre- and peri-operative amiodarone in the prevention of post-operative AF after adult cardiac surgery. Methods: Retrospective case note review which compared 151 patients operated during a five month period from February 08 to June 08, all of whom received amiodarone pre- and post-operatively, with a historical control group of 153 consecutive patients operated during a comparable five month period Aug 06 to Dec 06, who received amiodarone as treatment only when AF occurred. Prophylactic amiodarone was given as 10 mg/kg/day orally for six days pre-operatively, by infusion on the day of surgery and orally for six days post-operatively. Results: Post-operative atrial fibrillation occurred in 24 of 151 pts (15.9%) in the prophylactic amiodarone group and 32 of 153 (20.9%) in the control group (p = 0.21). Thirtyday mortality was comparable with 4 deaths (2.6%) versus 5 deaths (3.3%) in the prophylaxis and control groups
doi:10.1016/j.hlc.2010.04.100 Short Presentation 22 Resuscitation from Prolonged Cardiac Arrest Using Portable ECC
Introduction: Survival of patients after prolonged cardiac arrest or refractory cardiogenic shock is still inadequate. Medical progress during the last 20 years did not change the prognostic evolution of these patients. The support of circulatory and respiratory function with mechanical devices can be an alternative to conventional therapy for patients who do not respond to cardiopulmonary cerebral resuscitation. Historical experience with Extra Corporeal Life Support resuscitation for decompensated acute heart failure has shown that patient prognosis can be increased significantly and has demonstrated the rationale of the portable extracorporeal circulation as a rescue therapy. During the 1980s and early 1990s, significant progress in cardiopulmonary by-pass technology made portable by-pass systems easy to use even in non cardiac surgery environment. Main improvements include miniaturisation, heparin-coated circuits, longer durability of oxygenators and increased hardware performance. The rationale for using an emergent portable by-pass is to provide in a timely fashion, temporary circulatory and respiratory support to the vital organs of a patient suffering from refractory cardiac and/or respiratory failure. The key to improving organ recovery is to achieve early restoration of circulation. One additional benefit is to support therapeutic synergies like hypothermia and new pharmacological medications. This innovative approach placing patients at the center of a multidisciplinary network is the rationale of a resuscitation program organised transversally across the emergency department for the out-of-hospital interventions, the intensive care units, the cardiology and cardiac surgery departments, and the neurology and neurosurgery departments.