Faculty Bibliography

BACKGROUND: The surgical treatment of mitral valve regurgitation (MR) at the time of aortic valve replacement (AVR) remains controversial. The purpose of this study was to evaluate the change in severity of MR following isolated AVR, and to determine survival benefit. METHODS: Between 1991 and 2001, 250 patients underwent isolated AVR; 196 patients had concomitant functional MR. Follow-up transthoracic echocardiography (TTE) was available on 107 patients, with a median of 818 +/- 752 days. Aortic valve was stenotic in 77 and regurgitant in 30 patients. RESULTS: Mean age was 67 +/- 15 years and 57 (53%) were male. Preoperative MR was trivial (1+) in 27 (25%), mild (2+) in 44 (41%), moderate (3+) in 29 (27%), and severe (4+) in 7 (7%). At follow-up TTE, MR improved by 1 or 2 grades in 48 patients (45%). Of patients with preoperative 2+ MR, 19 (43%) improved, 16 (36%) remained unchanged, and 9 (21%) worsened. Although some patients with preoperative 3+ MR exhibited improvement, 11 (38%) remained with moderate-to-severe MR. Of those with a preoperative MR of 4+, 3 (71%) improved, and 4 remained with 3-4+ MR. For patients with preoperative 1 to 2+ MR, survival at 3 years was 98% compared to 78% for those with 3 to 4+ MR (p = 0.038). CONCLUSION: Functional MR does not always improve after isolated AVR. Survival is lower for patients with preoperative 3 to 4+ MR. Moderate-to-severe MR should be repaired at the time of aortic valve surgery.

BACKGROUND: Patients with acute right ventricular (RV) failure after cardiotomy have a poor prognosis. We evaluated the surgical and long-term outcomes of patients with isolated RV failure that required right ventricular assist device (RVAD) support. METHODS: Between 1991 and 2002, a total of 30 patients received RVAD support for isolated RV dysfunction. We evaluated survival, duration of mechanical support, post-RVAD hemodynamics, and RV function. RESULTS: Right ventricular failure developed in patients after coronary artery bypass surgery alone or combined with valve surgery (12 patients), valvular surgery (5), ascending aortic replacement (6), heart transplantation (3), and pulmonary endarterectomy (4). Mean age was 58 +/- 15 years, and 17 (57%) were women. Surgery was emergent in 5 (73%) patients. Centrifugal pumps were used in 21, extra corporeal membrane oxygenation in 8, and as Abiomed pump in 1 patient. Overall, 17 (57%) patients died while receiving assist device support, 3 of sepsis, 2 of stroke, and 12 of inability to wean from the device. We successfully weaned RVAD support in 13 (43%) patients, with a median duration of support of 5 days (range, 2-8 days). Ten survived to hospital discharge. After RVAD removal, mean pulmonary artery pressure was 25.1 +/- 6.5 mmHg, cardiac output was 4.8 +/- 2.0 liters, and central venous pressure was 16.5 +/- 3.7 mmHg. Echocardiogram after RVAD removal showed normal RV function in 2 patients and in 11 patients demonstrated improvement. CONCLUSION: After cardiotomy, patients with RV failure who require mechanical support continue to have increased mortality. For patients successfully weaned from the RVAD, residual RV dysfunction is compatible with survival. More liberal use of RV mechanical support may be indicated for patients with acute RV failure.

OBJECTIVE: End-stage heart failure has been associated with high mortality in the absence of transplantation. We evaluated the outcome of patients receiving optimal medical therapy who were removed from the cardiac transplant waiting list to determine survival and predictors of mortality. METHODS: We performed a retrospective review of 27 patients removed from the cardiac transplant waiting list from 1999 to 2001 at our institution. RESULTS: Mean age was 53 +/- 11 years; 16 of the patients were male. Status was IB in 3 cases and II in 24. Median time on the list was 32 months, and median follow-up was 2.9 years. Patients were removed from the transplant list because of either clinical improvement (group A, n = 18) or deterioration (group B, n = 9). In group A, 13 patients had improved functional status and 10 were in New York Heart Association class 1 or 2; 16 had improved echocardiographic left ventricular function. Survivals at 3 years were 100% in group A and 44% in group B (P <.01). CONCLUSION: Patients with end-stage heart failure who have clinical response to medical therapy have excellent 3-year survival. These data suggest the necessity of close evaluation of patients waiting for transplantation, with a low threshold for inactivation if persistent clinical improvement is observed

Recombinant human B-type natriuretic peptide (BNP) is a promising new agent in the management of heart failure. The pharmacologic properties of BNP make it desirable to use in a subset of patients after cardiac surgical operations. Among these therapeutic potentials is the effect on markedly reducing pulmonary vascular resistance and central venous pressure with mild systemic vasodilatation. In addition, BNP directly effects the kidneys to promote natriuresis. We believe this agent to be useful in the treatment of the postcardiac surgery patients with left ventricular dysfunction and mild to moderate renal insufficiency. This report summarizes our experience in 2 patients.

Right ventricular dysfunction after myocardial infarction is associated with high morbidity and mortality. If optimal medical management is ineffective, early consideration should be given to right-sided temporary mechanical assistance.

OBJECTIVES: This study was undertaken to identify management strategies that maximize survival of patients with stage III non-small cell lung cancer and metachronous brain metastases and to determine whether any apparent improved survival was due to treatment or simply to patient selection. METHODS: Treatment evaluations of both primary non-small cell lung cancer and brain metastases were performed in 91 patients. Optimal treatment was identified by multivariable analysis. Propensity scoring and multivariable analysis were used to separate treatment benefit from patient selection. RESULTS: Risk-unadjusted median, 12-, and 24-month survivals were 5.2 months, 22%, and 10%, respectively. Younger age (P =.006), good performance status (P =.003), stage IIIA (P =.001), lung resection (P =.02), no other systemic metastases at time of diagnosis of brain metastases (P =.02), and either metastasectomy (P <.001) or stereotactic radiosurgery (P <.001) predicted best survival. However, metastasectomy or stereotactic radiosurgery was more common after lung resection (P =.02) and in patients with good performance status (P =.006), no other systemic metastases at time of diagnosis of brain metastases (P =.01), and fewer brain metastases (P <.001), suggesting that the patients with the best risk profile were selected for aggressive therapy of both lung primary and brain metastases. Despite this selection, analysis of propensity-matched patients demonstrated the benefit of lung resection and metastasectomy or stereotactic radiosurgery (P <.001). CONCLUSIONS: Younger patients with resected stage IIIA non-small cell lung cancer who have isolated metachronous brain metastases and good performance status do best when treated with metastasectomy or stereotactic radiosurgery. This survival benefit is a brain treatment effect, not the result of selecting the best patients for aggressive therapy.