Mohammad Bashar Izzat Loay S. Kabbani, Gianni D. Angelni
Minimal-access and Minimally invasive Cardiac Surgery
Recent Advances in Surgery-23, Year-2000, Pg. 85
Median sternotomy has remained the standard approach for most open-heart procedures because it provides easy exposure of the entire heart and allows for the various cardiopulmonary by pass and myocardial protection techniques.
It is fitting at the beginning to define minimally-invasive and minimal access surgical techniques.
Minimizing the invasiveness of surgery implies reducing the peri-operative morbidity defined by measures of clinical outcome in comparison to conventional techniques.
Extracorporeal circulation is another significant cause of patient morbidity. Hence avoiding the use of cardiopulmonary bypass, regardless of the type of surgical incision, is another minimally invasive approach in cardiac surgery.
Currently employed minimal-access approaches to heart operations can be broadly classified into: [I] direct-vision techniques through limited incisions; and [ii] video-assisted approaches using endoscopic methods.
At present, the partial stenotomy incision is the most commonly used minimal-access approach for intra-cardiac operations.
It has many of the advantages of median sternotomy, the incision is easily opened and closed, provides excellent access, allows for standard cardiopulmonary bypass techniques and can be easily converted to full sternotomy in troublesome techniques and can be easily converted full sternotomy in troublesome cases.
With a upper partial sternotomy, the sternum is split from the sternal notch to the level of the third intercostal space.
Alternatively, a lower partial sternotomy incision can be used, dividing the sternum from the xiphoid process up the level of the second rib, and terminating the sternal split into the left 2nd intercostal space.
Minimizing access has been advantageous in clinical experience. For the surgeon, opening and closing the chest is easier and faster, and mediastinal blood loss is significantly reduced.
These patients resume normal activities earlier than those who undergo the conventional operation.
Postoperative pain is also reported to be reduced, both in hospital and after discharge.
Thistlewaite PA, Tarazi RY, Giordano FJ, et al [Univ of California, San Deigo]
Surgical Management of Spontaneous Left Main Coronary Artery Dissection
Ann Thorac Surg 66: 258-260, 1998
Spontaneous coronary artery dissection is a rare cause of ischemic heart disease and sudden death. It occurs predominantly in healthy, young women in the third trimester of pregnancy or in the early postpartum period. Cardiac risk factors are usually absent. Early recognition is essential because coronary artery bypass grafting may be life saving. Woman, 34, 12 weeks postpartum,was first seen after 18 hours of chest pain, with acute anterior wall myocardial infarction. Cardiac catheterization revealed a dissection of the left coronary artery extending into the left anterior descending artery. She underwent urgent bypass grafting, with bluish hemorrhage noticed over the left main coronary artery and distal left descending coronary artery, at operation. She was discharged on the sixth postoperative day. Transthoracic echocardiography after two months, indicated improvement in both wall motion and ejection fraction.
Most cases of primary coronary dissection occur in peripartum women without known cardiovascular risk factors. Young patients seen with acute ischemic symptoms should be considered for urgent angiography. If left main coronary artery dissection is detected, bypass grafting is safe and effective. Rapid diagnosis and surgical intervention are lifesaving.
Mannheimer C, Eliasson T, Augustinsson LE, et al [ Ostra Hosp, Sahlgrens Hosp, Gothenberg, Sweden]
Electrical Stimulation Versus Coronary Artery Bypass Surgery in Severe Angina Pectoris : The ESBY Study
Circulation 97: 1157-1163. 1998
Since 1985, epidural spinal cord stimulation [SCS] has been used to treat intractable angina pectoris. This randomized, prospective trial compared the results of coronary artery bypass grafting [CABG] with those of SCS in patients accepted for CABG who had increased risk of surgical complications and a lack of prognostic benefits from CABG.
The study group consisted of 51 patients who were randomized to CABG and 53 patients who were randomized to SCS from January 1992 to March 1995. CABG and SCS were compared with an intention to treat design. The primary end points were symptoms and myocardial ischemia. Secondary end points included mortality and morbidity. Clinical outcome was recorded on a questionnaire after exercise testing.
The stimulation equipment was implanted under local anesthesia, and the electrode positioned so that the patient felt a prickling sensation in the anginal pain region. The electrode tip was placed at T1 and T2, and the pulse generator was placed subcutaneously in a pouch below the left costal arch. The pulse generator was telemetrically programmed with 2 stimulation strengths, the stronger for anginal pain and the weaker for prophylactic treatment. The prophylactic treatment was used for two hours four times daily.
Both CABG and SCS provided symptom relief to the patients. The CABG group had increased exercise capacity, less S-T segment depression, and an increase in the rate-pressure product. There were seven deaths in the CABG group, and 1 death in the SCS group, during the follow-up. Mortality was lower in the SCS group, as was the cerebrovascular morbidity.
In conclusion, the authors state the limitations of the study in the small samples, short follow-up, and inability to blind the patients or physicians, In patients with an increased risk of surgery and no prognostic benefits from the same, SCS may be a good therapeutic alternative to CABG. SCS did provide symptomatic relief in patients with intractable angina pectoris.
Horvath KA [Northwestern Univ,Chicago]
Thoracoscopic Transmyocardial Laser Revascularization
Ann Thorac Surg 65: 1439-1440, 1998
Transmyocardial laser revascularization has been used for more than 6 years to treat patients with end-stage coronary artery disease, who are not amenable to conventional coronary artery revascularization techniques and who suffer severe refractory angina. The operative approach for these has been through an 18 to 20 cm anterior thoracotomy. The author describes a minimally invasive technique for transmyocardial laser revascularization. Woman, 67, with 2 previous myocardial infarctions, who had been treated with angioplasty and stenting, was seen with a third myocardial infarction. A repeat angiography revealed that stents were open and that there was little change in her diffusely diseased coronary arteries. She experienced significant substernal chest pressure that was refractory to medical treatment. Dual-isotope perfusion scanning revealed a large area of reversible ischemia. Under general anesthesia, a thoracoscopic port was placed in her fifth intercostal space along the mid-axillary line. The pericardium was opened and retracted so that the carbon dioxide hand piece could be introduced through the fifth intercostal space incision. An additional 4 cm. Incision was made in the fourth intercostal space at the mid-clavicular line, under thoracoscopic guidance, to allow introduction of the laser and to create channels anteriorly and laterally close to the base of the heart. A single chest tube was placed through the fifth intercostal space incision. The procedure was completed in 65 minutes and the patient was extubated in the operating room. The postoperative course was unremarkable. The patient was discharged on the third postoperative day. She has been monitored for 8 months and has had no recurrence of angina. Follow-up perfusion scans revealed improved perfusion in the laser treated area.
Thoracoscopic transmyocardial laser revascularization is a minimally invasive method for achieving transmural revascularization.
Alessandrini F, Gaudino M, Glieca F, et al [Catholic Univ, Rome; - R-Calai – Hosp, Gualdo, Italy]
Lesions of the Target Vessel During Minimally Invasive Myocardial Revascularization
Ann Thorac Surg 64: 1349-1353, 1997
Minimally invasive coronary artery bypass grafting is a recent addition to cardiac surgery. The incidence of surgically induced distal target vessel stenosis in patients who undergo this procedure was studied.
Postoperative Doppler evaluation of mammary artery flow was performed in 55 patients who had minimally invasive coronary artery bypass grafting.
In the first 35 patients, 3 had mammary artery occlusion, anastomotic stenosis, or stenosis of the target artery [ the left anterior descending artery]. In two more patients, late angiography detected stenosis of the anterior descending artery.
Thus surgically induced stenosis is a major disadvantage of minimally invasive coronary artery bypass grafting. It is a procedure that may transform the treatment of coronary artery disease, but improvements need to be made in the technique as well as in anticoagulant and antiplatelet therapy, before this procedure can be used in clinical practice with confidence.
Gundry SR, Romano MA, Shattuck OH, et al [ Loma Linda Univ, Calif.]
Seven Year follow-up of Coronary Artery Bypasses Performed with and Without Cardiopulmonary Bypass
J Thorac Cardiovasc Surg 115: 1273-1278, 1998
To decrease the morbidity and hospitalization associated with coronary artery bypass grafting [CABG] by cardiopulmonary bypass [CPB], surgeons revascularize the beating heart [BH] without CPB. Patients treated by the same surgeons, by both the techniques, were compared and long-term survival and intervention-free outcomes were assessed.
Between June 1989 and July 1990, 112 patients had CABG with CPB and 107 patients had CABG on the beating heart [CABG on BH], at the hands of three surgeons. The average age and risk factors were identical for the two groups. Patients undergoing CABG with CPB had an average of 3.2 grafts vs 2.4 grafts in the other group.
At a seven year follow-up 79% of the former group and 80% of the latter group were alive. Cardiac deaths occurred in 9% in the former group vs 12% of the latter. However, 16% of patients who had CABG with CPB, required catheterization for their symptoms as against 30% of patients who had CABG on BH. Angioplasty or secondary CABG was required in 7% of the former as against 20% of the latter group.
Thus patients with CABG on BH had twice as many requiring repeat investigations and thrice as many interventions as compared to the patients who had CABG under CPB.
Pick AW, Orszulak TA, Anderson BJ, et al [Mayo Clinic, Rochester, Minn]
Single Versus Bilateral Internal Mammary Artery Grafts : 10-Year Out-come Analysis
Ann Thorac Surg 64: 599-605, 1997
The use of the left internal mammary artery [IMA] to bypass the left anterior descending coronary artery has been associated with superior graft patency, reduced cardiac events and enhanced survival, so some surgical groups have begun using both IMAs for revascularization. To determine whether use of both IMAs confers further advantage to patients at bypass surgery, a group of patients with bilateral IMA [BIMA] bypass procedures was compared to a group of single IMA [SIMA] bypass procedures. Beginning in January 1984 and continuing for 24 months, 160 patients with multivessel disease had coronary revascularization procedures with BIMA grafts plus saphenous venous grafts, and 160 patients had saphenous grafts alone. During an extended time to May 1986, a matched group of 161 patients with a SIMA grafts plus supplementary saphenous venous grafts, operated on by the same surgeon were identified. The three groups of patients were matched for gender, preoperative angina, priority status, extent of coronary artery disease, left ventricular function, and number of distal anastomoses. Diabetes was more common in the SIMA group. Operative mortality was 0.6% for the SIMA group and nil for the BIMA group.
The average follow-up of 10 years, revealed lower late cardiac mortality in the BIMA group; survivals at 10 years were 75% for the SIMA group vs 85% for the BIMA group. Diabetes, age, and lower ejection fractions were the main factors responsible for late cardiac deaths in all the patients.
Bilateral internal artery grafts were associated with reduced risk of angina recurrence, late myocardial infarction, and other late cardiac events after revascularization. Larger studies are suggested to confirm the findings.
Tatoulis J, Buxton BF, Fuller JA [Univ of Melbourne, Australia]
Results of 1454 Free Right Internal Thoracic Artery – To- Coronary Artery Grafts
Ann Thorac Surg 64: 1263-1269, 1997
To overcome anatomic limitations of pedicled right internal thoracic artery-to-coronary graft, its use as a free graft [FRITA] was studied. A ten-year experience of 1454 consecutive patients who had planned FRITA-to-coronary artery graft as a part of coronary revascularization is described.
The patients had an average age of 59. Eight percent had non-insulin-dependent diabetes and 0.5% had insulin-dependent diabetes. Decreased left ventricular ejection fraction was present in 12%, and unstable angina in 9.9%. In eleven patients, FRITA was the only graft. There was an average of 3.3 distal anastomoses per patient. Bypass time was about 69 minutes and aortic clamp time about 49 minutes.
Operative mortality was 0.9%, stroke occurred in 1%; and myocardiac infarct in 1.3% of the patients. Complications included sternal infection in 1.2%, and reoperation for hemorrhage in 1.6%. Survival at 5 years was 96% and at 7 years 94%. In 71 patients followed up for an average of 42 months, FRITA was widely patent in 67, displayed a string sign in 3, and occlusion in 1.
The right internal thoracic artery can be safely and successfully used as a free graft for myocardial revascularization. Short and long term results were similar to those of single thoracic artery grafting.
Edwards FH, Carey JS, Grover FL, et al [Univ of Florida, Jacksonville; Torrance Med Ctr, California; Univ of Colorado, Denver]
Impact of Gender on Coronary Bypass Operative Mortality
Ann Thorac Surg 66: 125-131, 1998
Women appear to have higher mortality after coronary artery bypass surgery, than men; with most studies reporting womens mortality as twice that of men.
To discover the reasons for higher mortality in women, 344,913 patients [ 97,153 women] who had coronary artery bypass surgery, were reviewed. A variety of risk factors such as age, first operation, renal failure, morbid obesity, myocardial infarction, diabetes, triple vessel disease, race, cardiomegaly, diuretic therapy, hypertension, and body surface area, were considered and compared among men and women.
A significantly larger mortality was found among women, for every risk factor considered, as compared to equally matched men, in the low-and medium risk patients; but in the high-risk patients there were no differences in mortality in the men and women.
Thus except in high risk cases, gender is an independent risk factor in coronary artery bypass surgery.
Gill IS, FitzGibbon GM, Higginson LAJ, et al [ Univ of Ottawa, Ontario, Canada]
Minimally Invasive Coronary Artery Bypass: A study with Early Qualitative Angiographic Follow-up
Ann Thorac Surg 64: 710-714, 1997
Minimally invasive direct coronary artery bypass grafting [MIDCABG] has advantages over conventional coronary operations involving cardiopulmonary bypass and cardioplegic arrest, but the technical accuracy of distal anastomosis on a beating heart, has been questioned. A consecutive series of selected patients undergoing MIDCABG were analyzed.
Between January and October 1996, 25 patients had MIDCABG on the beating heart performed at the University of Ottawa Heart Institute. Transit time ultrasonic flows were monitored for the final 8 patients in the series, after completion of the anastomoses. A postoperative angiogram was performed for all patients within 6 hours. Patients had follow-up visits at 2 weeks, 6 weeks, and 3 months. Follow-up was 100% and ranged from 15 days to 11 months.
Graft patency was 97.5%; one internal thoracic artery was damaged; there was no mortality. There were no perioperative myocardial infarcts. All patients remained symptom free. Of the 26 anastomoses evaluated, 81% were grade A, and 19% grade B. For comparison, 96% of the anastomoses created by the same surgeon, on an arrested heart, were grade A.
Thus in the small selected group of patients, MIDCABG on the beating heart was performed effectively and safely. The development of sophisticated devices and instruments could continue to improve results.
Gu YG, Mariani MA, van Overen W, et al [Univ Hosp, Gronigen, The Netherlands]
Reduction of the Inflammatory Response in Patients Undergoing Minimally Invasive Coronary Artery Bypass Grafting
Ann Thorac Surg 65: 420-424, 1998
The induction of a systemic inflammatory response caused by cardiopulmonary bypass [CPB] is an important disadvantage of coronary artery bypass grafting [CABG]. Minimally invasive CABG [MICABG] performed through a small anterolateral thoracotomy without CPB, can reduce postoperative morbidity, though the mechanism for this is unclear. The clinical and subclinical indicators of inflammatory response in patients undergoing MICABG vs CABG under CPB, were asessed.
The study included 62 consecutive patients undergoing surgery for isolated stenosis of the left anterior descending artery. One group was randomized to undergo MICABG and the other to undergo CABG with CPB. Inflammation-associated clinical morbidity was compared between the two groups. In 10 patients in each group, subclinical markers of the inflammatory response were measured: leucocyte elastase, platelet betathromoglobulin, and complement C3a.
The MICABG had shorter duration of surgery, 104 minutes vs 140 minutes; less blood loss, 312 vs 788 mls; shorter duration of ventilatory support, 7.7 vs 12.9 hours; and a shorter hospital stay, 4.4 vs 7.7 days. The inflammatory markers increased significantly in CABG under CPB group, but remained unchanged from baseline to completion of bypass grafting, in the MICABG.
Thus MICABG is superior in every respect to CABG with CPB for stenosis of one coronary artery.
Weintraub WS, Stein B, Kosinski A, et al [Emory Univ, Atlanta Ga]
Outcome of Coronary Bypass Surgery Versus Coronary Angioplasty in Diabetic Patients with Multivessel Coronary Artery Disease
J Am Coll Cardiol 31: 10-19, 1998
There is concern about revascularization in patients with diabetes and multi-vessel coronary artery disease because long-term event rates are higher than in patients without diabetes.
Data were obtained retrospectively for 2639 diabetic patients with multivessel coronary artery disease; 834 patients had percutaneous transluminal coronary angioplasty and 1805 patients had coronary artery bypass graft surgery. The mean follow-up was 5 years. Follow-up data were obtained in 96% of the patients. There were more in-hospital deaths and more Q wave myocardial infarcts after bypass surgery. After coronary artery angioplasty, 5 year survival rate was 78% and 10 year survival rate was 45%, versus 76% and 48% respectively for bypass surgery. For patients on insulin, with angioplasty, survival rates for angioplasty for 5 years and 10 years were 72% and 31%; and the same for bypass surgery were 70% and 48% respectively. In both groups, older age, lower left ventricular ejection fractions, heart failure, hypertension, and requirement of insulin in diabetics, were associated with higher long-term mortality.
Thus in patients with diabetes and multi-vessel coronary artery disease, there was a high rate of adverse events with angioplasty as compared to bypass surgery.
MY Rady, T Ryan, NJ Starr
Perioperative Determinants of Morbidity and Mortality in Elderly Patients Undergoing Cardiac Surgery
Crit Care Med 26: 225-235. 1998
Whether cardiac surgery is appropriate for patients older than 75 years is debatable. The frequency of, the identification of pre-intra-and peri – and postoperative morbidity and mortality, factors that predict such outcomes and the impact on ICU resources were investigated.
Cardiovascular surgery was performed on 8501 patients [1157 aged over 75 years and above] over 30 months. Incidence of cardiac dysfunction, cardiac arrhythmias, pulmonary dysfunction, protracted weaning from ventilator support, renal dysfunction, gastrointestinal dysfunction, hepatic dysfunction, coagulopathy, nosocomial infection and neurological dysfunction were documented.
Overall morbidity in-patients over 75 years or older was 54% and mortality 8%. Mortality rates for elective cardiac surgery and emergency cardiac surgery in younger patients were 1.5% and 5% as compared to 3% and 11% in patients 75 years and older.
Operative factors related to mortality were emergency surgery, reoperation, other procedures, return to operating room for re-exploration, cardiopulmonary by pass time, aortic cross clamp time, circulatory arrest time, total operating time and transfusions of red blood cells, platelets and fresh frozen plasma. Perioperative factors related to mortality were history of heart failure, myocardial infarction, cardiac shock, intra-aortic balloon pump, disturbances in hematocrit, blood urea nitrogen, and creatinine and, serum albumin. Over all patients over 75 years needed care for 6859 ICU days [21.5%]; non survivors needed care for 2032 ICU days and survivors with multiple morbidities used 5903 ICU days.
Peri-operative predictors of morbidity and mortality in patients 75 years and older resulted in a disproportionate requirements for ICU resources. To improve outcome in such patients we need to concentrate on proper preoperative criteria, improvement in surgical techniques, preoperative therapy to improve visceral ischemia and prevention of anemia.
S Borzak, JE Tisdale, NB Amin, et al (Wayne State Univ, Detroit)
Atrial Fibrillation After Bypass Surgery: Does the Arrhythmia or the Characteristics of the Patients Prolong Hospital Stay ?
Chest 113: 1489-1491, 1998.
After coronary artery bypass surgery, atrial fibrillation (AF) or flutter is common and it is associated with clinical instability and stroke. AF is commoner in old patients and in those who have chronic obstructive lung disease (COPD). It is advisable to reverse AF as early as possible to prevent the complications of AF itself.
Fang WC, Helm RE, Kreiger KH, et al [Univ. of Massachusetts, Worcester, Cornell Univ, New York; North Shore Univ. Hosp., Manhasset, NY]
Impact of Minimum Hematocrit During Cardiopulmonary Bypass on Mortality in Patients Undergoing Coronary Artery Surgery
Circulation 96 [suppl II] : II-194-II-199, 1997
Over the years variety of measures have been used to reduce the need for blood transfusion during coronary artery bypass grafting [CABG]. The hematocrit commonly falls to a low level in patients undergoing cardiopulmonary bypass [CPB] and there is a debate over the minimum safe hematocrit level during this procedure. The mortality effect of the minimum hematocrit level achieved during CPB was investigated.
The analysis included 1638 sequential patients undergoing CABG over 42 months. Patients requiring valve replacement or other concurrent surgical procedures were excluded.
Minimum hematocrit levels reached during PCB was analyzed, along with 31 preoperative risk factors for effect on postoperative mortality.
The initial multiple logistic regression model identified 8 preoperative risk factors as independent predictors of postoperative mortality: shock, renal failure, ventricular arrhythmia, previous open heart surgery, IV nitroglycerine administration, congestive heart failure, aortoiliac disease, and older age. In a further model, minimum hematocrit during CPB was independently associated with mortality risk.
With adjustment for other factors, patients with minimum hematocrit of 14% or below had an increased probability of risk-adjusted mortality With high risk patients, minimum hematocrit of 17% or lower had significantly higher risk of postoperative mortality.
Thus extent to which hematocrit falls during CPB is an independent risk factor for postoperative mortality.
Bonnati J, Hangler H, Hormann C, et al [ Univ of Innsbruck, Austria]
Myocardial Damage After Minimally Invasive Coronary Artery Bypass Grafting on the Beating Heart
Ann Thorac Surg 66: 1093-1096, 1998
Previous studies have reported a 2% to 6% rate of perioperative myocardial infarction in-patients undergoing conventional coronary artery bypass grafting. When troponins and other sensitive marker proteins are used, these rates rise even higher. There is little information about the rate of perioperative myocardial infarction or about above marker protein release in patients undergoing minimally invasive direct coronary artery bypass grafting [MIDCABG] on the beating heart. Cardiac troponin I was used to determine the rate of myocardial damage in patients undergoing MISCABG.
The study included 15 consecutive patients undergoing MIDCABG via minithoracotomy. There were 11 men and 4 women, with mean age of 60. Intra and postoperative monitoring was carried out with ECG, transthoracic and transesophageal echocardiography and measurement of creatine kinase – MB mass concentration and cardiac troponin I.
One patient had severe myocardial ischemia and ventricular fibrillation and died. Of the survivors, 44% had evidence of myocardial ischemia; another 21% had reversible signs of myocardial ischemia. In 2 of the 4 patients in the latter group, angiography showed patholoy in the bypass graft or the target vessel.
Subclinical myocardial damage is common in MIDCABG on the beating heart and can be detected by serial measurement of troponin I, which could serve as the gold standard for diagnosis of myocardial damage. Increased troponin I is an indication for repeat angiography.
Khan JH, McElhinney DB, Hall TS, et al [ Univ of California, San Francisco]
Cardiac Valve Surgery in Octogenarians : Improving Quality of Life and Functional Status
Arch Surg 133 : 887-893, 1998
Open heart surgery can be performed on octogenarians with acceptable mortality but significant morbidity, but no studies have assessed the resulting quality of life and functional status of such patients. Factors that may predict survival, performance status, and medical resources use were retrospectively reviewed.
Between June 1987 and May 1995, medical records of 61 patients [14 women], aged 80 to 89 years, who underwent cardiac valve surgery, were reviewed, and patients were interviewed on telephone. Patients were followed up for 30 months. They had a variety of co-morbid conditions, and all were symptomatic at surgery. Functional status and Karnofsky status were assessed at discharge and at 3 months.
Patients underwent aortic valve replacement [n=47], mitral valve replacement and /or repair [n=14] and coronary artery bypass grafting with other procedures [n=27]. Seven patients [11.4%] died perioperatively, and 20 patients [37%] experienced significant postoperative complications. Hospital stay for those with complications was 25 days versus 12 days for the rest. Of the 54 survivors, 15 were discharged to nursing homes, 9 of them for functional disabilities. There were 12 late deaths. The remaining 42 survivors had 18 hospital re-admissions. Actuarial survivals were 85% at 1 year and 66% at 5 years. Patients with postoperative complications had longer hospital stay and decreased actuarial survival. One months after discharge, New York Heart Association classification had improved a median of two classes; Karnofsky performance had improved to a median of 80%, from a preoperative level of 30%. Results were similar at 8 months.
Heart valve replacement in octogenarians is safe, improves symptoms and functional status, and enhances quality of life but more resources are used, and recovery is complicated and delayed.
Kirsch M, Guesnier L, LeBesnerais P, et al [Hospital Henri Mondor, Creteil, France]
Cardiac Operations in Octogenarians : Perioperative Risk Factors for Death and Impaired Autonomy
Ann Thorac Surg 66: 60-67, 1998
With the aging of the population, cardiac surgeons are more frequently performing surgery on older, higher-risk patients. Records of 191 consecutive patients, aged 80 years or older, who underwent cardiac surgery were reviewed to identify risk factors for early and late postoperative mortality, impaired function, and reduced quality of life.
Between January 1, 1991 and December 31, 1996, 191 patients [ 98 men] aged 80 to 91 years, in New York Heart Association class III or IV and a mean left ventricular ejection fraction of 0.55, underwent aortic valve replacement [n=110], coronary artery bypass [n=47], combined aortic valve replacement and coronary bypass grafting [ n=26], mitral valve replacement [n=5] and other procedures [n=3].
The mean postoperative stay was 6 days, and the mean hospital stay was 9.5 days. Complications occurred in 132 patients [91%]; and included cardiovascular in 82.6%, pulmonary in 32.5% , stroke in 9.4%, intra-abdominal complications requiring surgery in 2.1%, renal failure in 12.0%, and infection in 10%. The in -hospital mortality was 16.2%. Actuarial survivals at 1,3 and 5 years were 79.2%, 74.9% and 56.2% respectively. The over-all mortality rate was 31.0%. The most common causes of death were heart related. In those with in-hospital deaths, preoperative pulmonary hypertension and low left ventricular ejection fractions, were independent predictors of mortality. In those with late deaths, predictors of mortality were female sex and combined aortic valve and coronary artery bypass surgery.
At follow-up, 129 patients [63.6% ] were completely autonomous. Subjective quality of life assessments revealed 83% were satisfied, 8.5% were somewhat satisfied and 7.8% were dissatisfied.
Thus outcome after cardiac surgery in octogenarians is satisfactory, with majority continuing long-term autonomy and satisfactory quality of life.
Sollano JA, Rose EA, Williams DL. et al [Columbia Univ, New York]
Cost-Effectiveness of Coronary Artery By-pass Surgery in Octogenarians
Ann Surg 228; 297-306, 1998
Survival, quality of life, and economic outcomes are important issues to evaluate when considering the efficacy and cost effectiveness of coronary artery bypass graft [CABG] in octogenarians. Results of a retrospective relative effectiveness, and cost effectiveness analysis of CABG surgery versus medical management in octogenarians were studied.
Two cohorts of patients with significant multi-vessel coronary artery disease, treated by CABG [n=176; 57% male, aged 80 to 90 years] or by medical management [n=48; 75% male, aged 80 to 89 years], were compared, at Columbia Presbyterian Medical Center between 1992 and 1996. Medically managed patients were reasonable surgical candidates. End points were health outcomes, cost, and cost effectiveness.
Surgically and medically managed patients were followed up for 38 and 31 months respectively and 3 year survivals were 80% and 64% respectively. Perioperative mortality was 6.8%. A subgroup of patients, who had refused surgery and were medically managed, had a ten-month survival rate of 50%. The costs for surgical group were $ 41348 as against $ 12467 for those managed medically and $ 15232 for those refusing surgery and opting for medical treatment. The costs when adjusted for quality of life gained, worked out almost same for the two groups.
Thus CABG in octogenarians is cost effective and increases quality of life.
Zamora R, Rao PS, Llyod TR, et al [ Univ of Arizona, Tucson; St. Louis Univ; Univ. of Michigan, Ann Arbor]
Intermediate-Term Results of Phase 1 Food and Drug Administration Trials of Buttoned Device Occlusion of Secundum Atrial Septal Defects
J Am Coll Cardiol 31: 674-676, 1998
Only short-term follow-up studies have investigated the buttoned device used for transcatheter occlusion of secundum atrial septal defects, and the device has been shown to be safe, feasible, and effective. The intermediate-term results of the multi-institutional trial of the button device were evaluated.
Forty-six patients who had successful implantation of the device were prospectively studied and evaluated at 1,6, 12 months and yearly thereafter. Follow-up lasted from 51 to 68 months, with the mean of 60.8 months. The patients were evaluated for history, physical examination, chest radiograph, electrocardiogram, and Doppler echocardiography. The patients ranged in age from 1 to 62 years [mean age 4 years] and in weight from 10 to 105 kgms [mean weight 18 kgms].
The patients had stretched atrial septal defects in which the sizes were 14 mms [plus/minus 4 mms] left to right shunts and 10 mms [plus/minus 3 mms] right to left shunts. Effective occlusion had occurred in 45 of the 46 patients [ 98%], and complete closure in 34 patients [74%]. There was an incidence of residual shunts of 65% at 1 month after implantation, which decreased to 27% at follow-up; all of these were described as trivial. Reintervention for significant residual defects occurred in only 2 patients [4%]; there were no incidents of endocarditis or thromboembolism in the entire follow-up.
In 98% of patients who had the atrial septal device inserted, it provided effective closure for upto 5.5 years; during follow-up the incidence of residual shunts decreased, and no instances of endocarditis or thromboembolism were observed.
Hershberger RE[ Health Sciences Univ, Portland Ore]
Clinical Outcomes, Quality of Life, and Cost Outcomes, After Cardiac Transplantation
Am J Med Sci 314: 129-138, 1997
Improving survival is the most compelling reason for cardiac transplantation in patients with advanced heart failure, particularly those dependant on intravenous inotropic support or mechanical assistance. This procedure, however, is not curative; rather, it remains a treatment modality requiring indefinite immunosuppression and ongoing care. The cost of cardiac transplantation was also investigated.
Primarily cardiac transplantation should be considered because it improves survival. For patients with advanced disease treated with enalapril, the mortality was 40% at 1 year. Patients with Class III or IV heart failure at initial evaluation, had a 1-year mortality rate of 16%. Survival for cardiac transplantation at 1 year was 81.8%.
Improved quality of life has been found after heart transplantation in most studies, with less total symptom distress, better health perception, better overall functional status, and more satisfaction with life. The most common area of disability after transplantation was work-related. Employment rates varied from 32% to 50% after transplantation.
At the time of this study in 1998, cost of heart transplantation from date of transplant to date of discharge, was about $ 91,600. Only 2500 hearts are available for transplantation per year; although 40,000 patients await donors; this affects cost outcomes. A median waiting period of 122 days for a heart transplant, results in patients getting sicker, thus further raising the cost of transplantation. The left ventricular assist device [LVAD] has become the most advanced technology to bridge the gap to cardiac transplantation, with the cost ranging from $ 30,000 to $ 60,000.
DeRose JJ, Jr, Umana JP, Argenziano M, et al [ Columbia Univ, New York]
Implantable Left Ventricular Assist Devices Provide an Excellent Out-patient Bridge to Transplantation and Recovery
J Am Coll Cardiol 30 : 1773-1777, 1997
The limited donor pool makes heart transplantation available for only 2500 patients every year. Left ventricular assist devices [ LVADs] have been successfully used as a bridge to transplantation for 10 years. Recent experience with out-patient LVAD support demonstrates the possibilities and limitations of long-term out-patient mechanical circulatory assistance.
Thirty-two patients underwent implantation of the Thermo Cardiosystem Heartmate vented electric LVAD during 1993 and 1994. This device is powered by batteries worn on shoulder holsters and is operated by a belt-mounted system controller that allows unrestricted patient ambulation and hospital discharge.
Mean duration of LVAD support was 122 days [ range 3 to 605 days]. The survival rate to transplantation or explantation was 78%. Nineteen patients were discharged from hospital at a mean postoperative time of 41 days [ range 17 to 68 days]. Out-patient support time was a mean of 108 days [ range 2 to 466 days]. Because of early transplantation, four patients were not available to participate in the discharge program. At final follow-up, three patients were awaiting discharge. The complication rate in the series was similar to an earlier series of 52 patients with a pneumatic LVAD.
Outpatient LVAD support is safe and offers improved quality of life for patients awaiting heart transplantation. Wearable and totally implantable LVADs should be evaluated as permanent treatment options in patients who are not candidates for heart transplantation.
Johnson D, Perrault H, Vobecky SJ, et al [ Ste-Justine Hospital, Montreal; McGill Univ, Montreal]
Influence of the Postoperative Period and Surgical Procedure on Ambulatory Blood Pressure -Determination of Hypertension Load After Successful Surgical Repair of Coarctation of the Aorta
Eur Heart J 19: 638-646, 1998
The monitoring of blood pressure after surgical correction of coarctation of the aorta is usually performed using a sphygmomanometer. Ten to 40% of patients who undergo an apparently successful repair of coarctation of aorta have hypertension 10 to 20 years later. The hypertension load was quantified using 24-hour ambulatory blood pressure monitoring in patients less than 10 years and more than 10 years after surgery. The type of surgical repair was also assessed.
Ambulatory blood pressure recordings were taken using an Accutracker II monitor every 30 minutes in the daytime and every one hour at night. Patients were grouped in two groups according to the period elapsed after surgery. Group 1 less than 10 years and Group 2 more than 10 years after surgery. A group of healthy adolescents were used as a control group. Of the twenty-one patients 12 had end-to-end anastomosis and 9 left subclavian artery angioplasty for correction of the coarctation.
Compared with the controls all operated cases showed higher day and night systolic and diastolic blood pressures. Daytime systolic hypertension occurred in 20% in Group 1 and in 49% in Group 2. There was no diastolic hypertension. There were also no differences in blood pressure recordings in the two types of operation.
Patients undergoing repair for coarctation of aorta develop hypertension with time and need constant monitoring.
Stefanadis CI, Stratos CG, Lambrou SG, et al (Athens Univ, Greece; All India Inst of Med Sciences, New Delhi, India; Onassis Cardiac Surgery Ctr, Athens, Greece, et al)
Retrograde Nontransseptal Balloon Mitral Valvuloplasty: Immediate Results and Intermediate Long-term Outcome In 441 Cases – A Multi-Center Experience
J Am Coll Cardiol 32:1009-1016, 1998
Retrograde nontransseptal balloon mitral valvuloplasty (RNBMV) is a purely transarterial technique that was created with the goal of avoiding complications related to transseptal catheterization. The immediate and long-term results of RNBMV were assessed in 4 cooperating centers in Greece and India.
Between 1988 and 1996, RNBMV was attempted by independent operators in 441 cases (320 females and 121 males) with mitral stenosis. All patients first underwent preoperative workup that included evaluation of clinical status and echocardiographic examination. Mean follow-up after RNBMV was 3.5 years.
Of 438 patients with completed procedures, 338 patients had technically successful procedures (increase in mitral valve area of 1.5 sq. cm or greater and final mitral regurgitation of grade 2 or below). Unfavourable predictors of immediate outcome were pre-procedural mitral regurgitation and prior surgical mitral commissurotomy. There were no occurrences of cardiac perforation, cardiac tamponade, or embolic events. Complications included death (0.5%) severe mitral regurgitation (3.4%) and injury of the femoral artery (1.1%).
Event-free survival rates (freedom from cardiac death, mitral valve surgery, repeat valvuloplasty, and symptoms on NYHA class higher than II) for follow-up years 1, 2, 4, and 9, respectively were 100%, 96.9%, 89.8%, and 75.5%.
This multicenter experience suggests RNBMV is a safe and effective approach to the treatment of symptomatic mitral stenosis.
Reddy VM, McElhinney DB, Sagrado T, et al (Univ of California, San Francisco)
Results of 102 Cases of Complete Repair of Congenital Heart Defects in Patients Weighing 700 to 2500 Grams
J Thorac Cardiovasc Surg 117: 324-331, 1999
Low birth weight (< 2500 g) is a risk factor for poor outcome in corrective surgery for many congenital heart defects. Mere supportive therapy is often associated with severe morbidity.
During a 7-year period, 102 low birth weight infants, with a correctable congenital heart defect underwent complete repair at a median age of 16 days. The most common defects were ventricular septal defect, tetralogy of Fallot and transposition complexes.
There were 10 (10%) early deaths. Cardiac failure caused 4 deaths; there were 1 case each of multiorgan failure, arrhythmia, sepsis, idiopathic coronary intimal necrosis, foot gangrene, and pulmonary hemorrhage.
Surviving infants were hospitalized for a median of 19 days and received mechanical ventilation for a median of 5 days. Complete follow-up (median 30 months) was available for 88 of 90 early survivors.
Eight late deaths occurred and 8 others underwent 10 interventions. No survivors had clinical evidence of neurological abnormalities.
Thus even complex heart defects can be successfully corrected when surgery is performed early in low birth weight infants. There is also evidence that such infants experience better growth after early rather than later repair.