Faculty Bibliography

BACKGROUND: Patients with reduced ventricular function undergoing aortic valve replacement have increased operative risks, but the impact of valvular pathophysiology and other risk factors has not been clearly defined. METHODS: From June 1992 through June 2002, 1,402 consecutive patients underwent isolated aortic valve surgery with or without coronary artery bypass grafting; of these patients, 416 had an ejection fraction less than 40% and are the subject of this report. These patients (mean age, 68.6) had severe stenosis (62.5%), severe regurgitation (30.3%), or mixed disease (7.2%). Aortic valve replacement plus coronary artery bypass grafting was performed in 48.4% of patients, and 27% had previous cardiac surgery. Follow-up included echocardiography and survival analysis. RESULTS: Hospital mortality was 10.1% (42 of 416), with no difference between aortic stenosis (9.6%) and regurgitation (11.1%). Multivariate analysis revealed that age (p = 0.002) and renal disease (odds ratio = 4.2; 95% confidence interval, 1.9 to 9.3; p = 0.001) were independently associated predictors of mortality. Valvular pathophysiology had no impact on mortality. Peripheral vascular disease, multivessel coronary disease, and renal disease were associated risks for any postoperative complication. Peripheral vascular disease (odds ratio = 12.3, p = 0.02), history of cerebrovascular disease (odds ratio = 4.8, p = 0.038), and diabetes (odds ratio = 2.7, p = 0.04) were associated risks for stroke. The ejection fraction was more than 40% in 52% of the patients who had postoperative echocardiography (mean follow-up, 6 months). Actuarial survival revealed no difference between pathophysiologic groups. CONCLUSIONS: Aortic valve surgery in patients with impaired ventricular function carries an acceptable operative risk that can be stratified by age and comorbidities. The type of valvular pathophysiology does not significantly affect mortality

OBJECTIVE: Although minimally invasive aortic valve replacement (MIAVR) has recently become popular, additional outcome evaluation is required. This study analyzed a single institutional experience with MIAVR with respect to hospital morbidity and mortality. METHODS: Between 12/96 and 06/02, 482 consecutive patients at a single institution underwent MIAVR, including concomitant procedures in 123 pts: 55 multiple valves, 18 CABGs, 21 myomectomies, and 29 other procedures. These patients (mean age 65 yrs; range 15-94) had severe stenosis (58.9%), severe insufficiency (33.0%), or mixed disease (8.1%). Thirty-three percent had a previous MI, 13.3% had a previous cardiac operation, and 17.3% were >80 years old. Right anterior minithoracotomy was performed in 87.3%. Ascending aortic cannulation was used in 68% of the patients while direct external cross clamping was used in 97% of cases. RESULTS: Hospital mortality was 6.2% (30/482) overall and 5.3% (19/359) for isolated AVR. Mean aortic crossclamp and cardiopulmonary bypass times were 87 and 122 min, respectively. Postoperative complications included stroke in 2.3% (11/482) and 82.5% of patients were free from any complications. Neither aortic dissection nor mediastinitis was observed. Univariant analysis demonstrated that female gender, renal failure, CHF, and age >80 years were risk factors for mortality. Multivariable analysis revealed that age and CHF were independently associated with increased risk of mortality (p<0.05). CONCLUSIONS: These results demonstrate that MIAVR is a safe procedure, with low morbidity and acceptable perioperative mortality, and may be used routinely in a large series of patients

BACKGROUND: This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data. METHODS: Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561 patients had isolated mitral valve operations (375 repairs, 186 replacements). Mean age was 58.3 years (range, 14 to 96 years; 30.1% > 70 years), and 15.4% of patients had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21%, with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%. RESULTS: Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours, and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%); there was no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency. CONCLUSIONS: This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations