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Utility of high-sensitivity troponins after combined aortic valve replacement and coronary artery bypass grafting towards defining myocardial infarction
Abstract
and provide a competent aortic valve with relief of left ventricular outflow tract obstruction (LVOTO). Optimum management is not so straightforward in adults. Methods: Between 1995 and 2014, 17 adults of mean age 34.9 years (18 - 57) with hypoplastic aortic annulus (AA) measuring 20 mm or less, and mean aortic valve/LVOT gradient of 61 mm Hg (30 - 70) presented for surgery. Results: 8 patients with mean LVOT/AA diameter 19.6 mm (18 - 20) underwent an inclusion cylinder type Ross procedure (RP). 9 patients with more severe LVOT/AA obstruction, mean diameter of LVOT/AA of 17.4 mm (16 - 19) underwent mechanical aortic valve replacement (AVR) with standard Konno type aortoventriculoplasty. There was zero early and late mortality, no re-operations were required, with mean follow up of 7.6 years (1 - 20). Last echo shows residual mean gradient across LVOT/AA of 6 mm Hg (2 - 12) after RP, and 13.2 mm (6 - 22) after mechanical AVR/Konno. Summary: In adults, the RP is a good alternative for mild to moderate aortic root hypoplasia, however for cases with severe obstruction, a Ross/Konno is not possible with the same method of autologous support used in a non-Konno RP, and this could be expected to impact on late durability and the need for further intervention, in a group that have already undergone multiple procedures in childhood. Both methods lead to excellent early and late results. http://dx.doi.org/10.1016/j.hlc.2015.06.706 704 Utility of high-sensitivity troponins after combined aortic valve replacement and coronary artery bypass grafting towards defining myocardial infarction T. Wang 1,∗ , R. Stewart 1 , D. Choi 1 , S. Harrmos 1 , G. Gamble 2 , T. Ramanathan 1 , H. White 1 1 Green
Lane Cardiovascular Service, Auckland City Hospital, New Zealand 2 Department of Medicine, University of Auckland, New Zealand Background: The Universal Definition for type 5 myocardial infarction (MI) applies to coronary artery bypass grafting (CABG), while perioperative MIs for other cardiac surgeries are not specifically defined. Our previous studies found isolated aortic valve replacement (AVR) to have higher troponin rises than CABG. We assessed whether post-operative high-sensitivity troponin (hs-TnT) at pre-specified thresholds, with or without concurrent ischaemic changes on ECG or echocardiogram, predicted mortality and morbidity after AVR+CABG. Methods: Patients undergoing AVR+CABG during July 2010-December 2012 were identified (n=167), and hs-TnT routinely measured 12-24 hours post-operatively. We prespecified 140ng/L(10 times 99th percentile upper reference limit (URL)), 500ng/L(10 times coefficient of variation of 10% for 4th generation troponin T applied to hs-TnT) as cutpoints for analyses, excluding patients with unstable elevated preoperative troponins (n=26).
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Results: Amongst 141 patients, median hs-TnT was 690ng/L, with 141 (100%) having post-operative hsTnT>140ng/L and 95 (67.4%) >500ng/L, while 27 (19.1%) had new ECG or echocardiographic changes. C-statistics and 95% confidence interval for operative mortality were hsTnT alone 0.711 (0.576-0.845), ECG and/or echocardiographic changes alone 0.730 (0.527-0.932) and combination with hsTnT>500ng/L threshold 0.764 (0.559-0.968). In multivariate analyses, the MI criteria to independently and most strongly predict operative mortality was hs-TnT>500ng/L+ECG and/or echocardiographic changes odds ratio 15.9 (95% confidence interval 2.33-109); and for mortality during follow-up the same criteria hazards ratio 7.05 (2.40-20.7). Conclusion: Hs-TnT>500ng/L+ECG and/or echocardiographic criteria was strongly prognostic of short and long-term mortality after AVR+CABG. Our findings suggest higher hsTnT threshold for defining MI after AVR+CABG than isolated CABG is more appropriate. http://dx.doi.org/10.1016/j.hlc.2015.06.707 705 Validation of 30-day mortality data in the ANZSCTS database through successful linkage with the national death index database L. Tran 1,∗ , C. Ayres 1 , N. Marrow 1 , D. Dahya 1 , G. Shardey 2 , C. Reid 1 1 Centre
of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Australia 2 Cabrini Health Malvern, Melbourne, Australia Objective: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) National Cardiac Surgery Database Program was linked to the Australian Institute of Health and Welfare’s National Death Index (NDI) Database. The objective of this study is to evaluate the accuracy of the ANZSCTS database 30-day mortality data and the successfulness of linkage. Methods: A total of 73,434 cases between 2001-2013 were submitted to the NDI for probabilistic matching using patient name, date of birth, and sex. Clerical review post linkage was required to accept or reject potential matches. Matches with a weighting >40 were considered high-weighted matches and <20 were low-weighted matches. The ANZSCTS Database mortality date (at 30 days) was compared to NDI date of death to ascertain 30-day mortality data accuracy. Results: The NDI matched 42,897/73,434 (58.4%) records successfully. These were subjected to clerical review where 5,504 (12.8%) high-weighted matches were automatically accepted. Low-weighted matches (N=28,507, 66.5%) were automatically rejected. Analyses of the remaining cases resulted in another 6,510 records (15.2%) to be accepted. The overall acceptance rate was 28.0% (N=12,014). The ANZSCTS database had 1,960 30-day mortality records, of which 1,918 were matched (relative sensitivity=97.9%). Comparatively, the STS Database in the USA had a relative sensitivity of 90.4%.
and provide a competent aortic valve with relief of left ventricular outflow tract obstruction (LVOTO). Optimum management is not so straightforward in adults. Methods: Between 1995 and 2014, 17 adults of mean age 34.9 years (18 - 57) with hypoplastic aortic annulus (AA) measuring 20 mm or less, and mean aortic valve/LVOT gradient of 61 mm Hg (30 - 70) presented for surgery. Results: 8 patients with mean LVOT/AA diameter 19.6 mm (18 - 20) underwent an inclusion cylinder type Ross procedure (RP). 9 patients with more severe LVOT/AA obstruction, mean diameter of LVOT/AA of 17.4 mm (16 - 19) underwent mechanical aortic valve replacement (AVR) with standard Konno type aortoventriculoplasty. There was zero early and late mortality, no re-operations were required, with mean follow up of 7.6 years (1 - 20). Last echo shows residual mean gradient across LVOT/AA of 6 mm Hg (2 - 12) after RP, and 13.2 mm (6 - 22) after mechanical AVR/Konno. Summary: In adults, the RP is a good alternative for mild to moderate aortic root hypoplasia, however for cases with severe obstruction, a Ross/Konno is not possible with the same method of autologous support used in a non-Konno RP, and this could be expected to impact on late durability and the need for further intervention, in a group that have already undergone multiple procedures in childhood. Both methods lead to excellent early and late results. http://dx.doi.org/10.1016/j.hlc.2015.06.706 704 Utility of high-sensitivity troponins after combined aortic valve replacement and coronary artery bypass grafting towards defining myocardial infarction T. Wang 1,∗ , R. Stewart 1 , D. Choi 1 , S. Harrmos 1 , G. Gamble 2 , T. Ramanathan 1 , H. White 1 1 Green
Lane Cardiovascular Service, Auckland City Hospital, New Zealand 2 Department of Medicine, University of Auckland, New Zealand Background: The Universal Definition for type 5 myocardial infarction (MI) applies to coronary artery bypass grafting (CABG), while perioperative MIs for other cardiac surgeries are not specifically defined. Our previous studies found isolated aortic valve replacement (AVR) to have higher troponin rises than CABG. We assessed whether post-operative high-sensitivity troponin (hs-TnT) at pre-specified thresholds, with or without concurrent ischaemic changes on ECG or echocardiogram, predicted mortality and morbidity after AVR+CABG. Methods: Patients undergoing AVR+CABG during July 2010-December 2012 were identified (n=167), and hs-TnT routinely measured 12-24 hours post-operatively. We prespecified 140ng/L(10 times 99th percentile upper reference limit (URL)), 500ng/L(10 times coefficient of variation of 10% for 4th generation troponin T applied to hs-TnT) as cutpoints for analyses, excluding patients with unstable elevated preoperative troponins (n=26).
S417
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Results: Amongst 141 patients, median hs-TnT was 690ng/L, with 141 (100%) having post-operative hsTnT>140ng/L and 95 (67.4%) >500ng/L, while 27 (19.1%) had new ECG or echocardiographic changes. C-statistics and 95% confidence interval for operative mortality were hsTnT alone 0.711 (0.576-0.845), ECG and/or echocardiographic changes alone 0.730 (0.527-0.932) and combination with hsTnT>500ng/L threshold 0.764 (0.559-0.968). In multivariate analyses, the MI criteria to independently and most strongly predict operative mortality was hs-TnT>500ng/L+ECG and/or echocardiographic changes odds ratio 15.9 (95% confidence interval 2.33-109); and for mortality during follow-up the same criteria hazards ratio 7.05 (2.40-20.7). Conclusion: Hs-TnT>500ng/L+ECG and/or echocardiographic criteria was strongly prognostic of short and long-term mortality after AVR+CABG. Our findings suggest higher hsTnT threshold for defining MI after AVR+CABG than isolated CABG is more appropriate. http://dx.doi.org/10.1016/j.hlc.2015.06.707 705 Validation of 30-day mortality data in the ANZSCTS database through successful linkage with the national death index database L. Tran 1,∗ , C. Ayres 1 , N. Marrow 1 , D. Dahya 1 , G. Shardey 2 , C. Reid 1 1 Centre
of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Australia 2 Cabrini Health Malvern, Melbourne, Australia Objective: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) National Cardiac Surgery Database Program was linked to the Australian Institute of Health and Welfare’s National Death Index (NDI) Database. The objective of this study is to evaluate the accuracy of the ANZSCTS database 30-day mortality data and the successfulness of linkage. Methods: A total of 73,434 cases between 2001-2013 were submitted to the NDI for probabilistic matching using patient name, date of birth, and sex. Clerical review post linkage was required to accept or reject potential matches. Matches with a weighting >40 were considered high-weighted matches and <20 were low-weighted matches. The ANZSCTS Database mortality date (at 30 days) was compared to NDI date of death to ascertain 30-day mortality data accuracy. Results: The NDI matched 42,897/73,434 (58.4%) records successfully. These were subjected to clerical review where 5,504 (12.8%) high-weighted matches were automatically accepted. Low-weighted matches (N=28,507, 66.5%) were automatically rejected. Analyses of the remaining cases resulted in another 6,510 records (15.2%) to be accepted. The overall acceptance rate was 28.0% (N=12,014). The ANZSCTS database had 1,960 30-day mortality records, of which 1,918 were matched (relative sensitivity=97.9%). Comparatively, the STS Database in the USA had a relative sensitivity of 90.4%.