Faculty Bibliography

BACKGROUND: Few studies have reported population-based outcomes for aortic valve replacement patients. METHODS: Patients with severe aortic valve stenosis who underwent aortic valve replacement with or without concomitant coronary artery bypass graft surgery from January 1, 2003, to December 31, 2005, were included in the study. Statistical models were developed to identify significant risk factors for mortality, to compare survival for patients with and without selected risk factors, and to compare survival to an age- and sex-matched group from US life tables. RESULTS: There was total of 6,369 patients in the study. The in-hospital and 30-day mortality rates were 3.97% for aortic valve replacement and 5.69% for aortic valve replacement with concomitant coronary artery bypass graft surgery. Significant risk factors for 30-month mortality included concomitant coronary artery bypass graft surgery, advancing age, lower body surface area, emergency status, low ejection fraction, congestive heart failure, previous heart surgery, and several comorbidities. The 64.3% of patients with isolated aortic valve replacement who had neither congestive heart failure, ejection fraction less than 0.40, acute myocardial infarction less than 24 hours, nor hemodynamic instability had a risk-adjusted survival of 89.9% compared with the 90.0% survival rate of the age- and sex-matched general population (p = 0.28). CONCLUSIONS: For the large number of patients without high-risk conditions, the 30-month survival is essentially as high as that of an age- and sex-matched group of the US population.

The c-Met proto-oncogene encodes a receptor tyrosine kinase (TK) that promotes invasive tumor growth and metastasis. Recent studies show that the presence of c-Met gene amplification is predictive for selective c-Met TK inhibitors in gastric cancer and lung cancer. In this study, we utilized a highly quantitative PCR/ligase detection reaction technique to quantify c-Met gene copy number in primary colorectal cancer (CRC) (N=247), liver metastases (N=147), and paired normal tissues. We identified no differences in c-Met gene copy number between normal colonic mucosa and liver tissue. However, mean c-Met gene copy number was significantly elevated in CRC compared with normal mucosa (P<0.001), and in liver metastases compared with normal liver (P<0.001). Furthermore, a significant increase in c-Met was seen in liver metastases compared with primary CRC (P<0.0001). c-Met gene amplification was observed in 2% (3/177) of localized cancers, 9% (6/70) of cancers with distant metastases (P<0.02), and 18% (25/147) of liver metastases (P<0.01). Among patients treated by liver resection, there was a trend toward poorer 3-year survival in association with c-Met gene amplification (P=0.07). Slight increases in c-Met copy number can be detected in localized CRCs, but gene amplification is largely restricted to Stage IV primary cancers and liver metastases. c-Met gene amplification is linked to metastatic progression, and is a viable target for a significant subset of advanced CRC.

BACKGROUND: Numerous studies have compared the outcomes of two competing interventions for multivessel coronary artery disease: coronary-artery bypass grafting (CABG) and coronary stenting. However, little information has become available since the introduction of drug-eluting stents. METHODS: We identified patients with multivessel disease who received drug-eluting stents or underwent CABG in New York State between October 1, 2003, and December 31, 2004, and we compared adverse outcomes (death, death or myocardial infarction, or repeat revascularization) through December 31, 2005, after adjustment for differences in baseline risk factors among the patients. RESULTS: In comparison with treatment with a drug-eluting stent, CABG was associated with lower 18-month rates of death and of death or myocardial infarction both for patients with three-vessel disease and for patients with two-vessel disease. Among patients with three-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.80 (95% confidence interval [CI], 0.65 to 0.97) and the adjusted survival rate was 94.0% versus 92.7% (P=0.03); the adjusted hazard ratio for death or myocardial infarction was 0.75 (95% CI, 0.63 to 0.89) and the adjusted rate of survival free from myocardial infarction was 92.1% versus 89.7% (P<0.001). Among patients with two-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.71 (95% CI, 0.57 to 0.89) and the adjusted survival rate was 96.0% versus 94.6% (P=0.003); the adjusted hazard ratio for death or myocardial infarction was 0.71 (95% CI, 0.59 to 0.87) and the adjusted rate of survival free from myocardial infarction was 94.5% versus 92.5% (P<0.001). Patients undergoing CABG also had lower rates of repeat revascularization. CONCLUSIONS: For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization

BACKGROUND: Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution's surgical results in this target population. METHODS: From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index. RESULTS: The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 (p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease (p = 0.019; OR, 2.14), and peripheral vascular disease (p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age (p < 0.001), previous cardiac operations (p < 0.014; OR, 1.51), renal failure (p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease (p < 0.007; OR, 1.30) were predictors of worse survival. CONCLUSIONS: Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points

BACKGROUND: Off-pump coronary artery bypass graft surgery (OPCAB) has been performed for many years, but its use is increasing in frequency, and it remains an open question whether OPCAB is associated with better outcomes than on-pump coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS: New York State patients who underwent either OPCAB with median sternotomy (13 889 patients) or on-pump CABG surgery (35 941 patients) between 2001 and 2004 were followed up via New York databases. Short- and long-term outcomes were compared after adjustment for patient risk factors and after patients were matched on the basis of significant predictors of type of CABG surgery. OPCAB had a significantly lower inpatient/30-day mortality rate (adjusted OR 0.81, 95% confidence interval [CI] 0.68 to 0.97), lower rates for 2 perioperative complications (stroke: adjusted OR 0.70, 95% CI 0.57 to 0.86; respiratory failure: adjusted OR 0.80, 95% CI 0.68 to 0.93), and a higher rate of unplanned operation in the same admission (adjusted OR 1.47, 95% CI 1.01 to 2.15). In the matched samples, no difference existed in 3-year mortality (hazard ratio 1.08, 95% CI 0.96 to 1.22), but OPCAB patients had higher rates of subsequent revascularization (hazard ratio 1.55, 95% CI 1.33 to 1.80). The 3-year OPCAB and on-pump survival rates for matched patients were 89.4% and 90.1%, respectively (P=0.20). For freedom from subsequent revascularization, the respective rates were 89.9% and 93.6% (P<0.0001). CONCLUSIONS: OPCAB is associated with lower in-hospital mortality and complication rates than on-pump CABG, but long-term outcomes are comparable, except for freedom from revascularization, which favors on-pump CABG