Research

The Freestyle Aortic Bioprosthesis: A Systematic Review

by

Sherrah AG, Edelman JJ, Thomas SR, Brady PW, Wilson MK, Jeremy RW, Bannon PG, Vallely MP

Heart Lung Circ 2014 Dec;23(12):1110-1117

PMID: 25047283

Abstract

BACKGROUND: The Medtronic Freestyle bioprosthesis (FSB) provides an alternative to other prostheses for both aortic valve and aortic root surgery. This paper is a systematic review of the post-operative outcomes in patients with aortic valve and/or aortic root disease following FSB implantation.

METHODS: Electronic databases were searched for primary analysis, prospective randomised studies comparing the FSB with an alternative aortic prosthesis were included. Additionally, case series that included data for at least 100 individual operated patients were used for secondary analysis.

RESULTS: Among three identified randomised studies, 199 FSB cases were compared with homografts, and stented and an alternative stentless bioprosthesis. The FSB showed comparable hospital mortality (4.5% vs 5.3%) and eight-year actuarial survival (80±5.0% versus 77±6.0%) with the homograft (respectively) and comparable reduction in left ventricular mass index relative to other prosthesis types. Over 6000 individual patients were included in the selected 15 case series. Weighted mean operative mortality, neurological event rate and five-year actuarial survival was 5.2%, 5.5% and 77.8%, respectively.

CONCLUSION: The FSB performed comparably against alternative prostheses regarding in-hospital mortality, long-term survival and reduction in left ventricular mass index. Included case series demonstrated robust post-operative outcomes in both the short and long term.

Should clopidogrel be discontinued before coronary artery bypass grafting for patients with acute coronary syndrome? A systematic review and meta-analysis

by

Cao C, Indraratna P, Ang SC, Manganas C, Park J, Bannon PG, Yan TD

J. Thorac. Cardiovasc. Surg. 2014 Dec;148(6):3092-8

PMID: 24954178

Abstract

OBJECTIVE: Patients presenting with acute coronary syndrome (ACS) are treated with dual antiplatelet agents, including aspirin and clopidogrel, to prevent mortality and recurrent ischemia. However, those who require coronary artery bypass grafting (CABG) could have increased postoperative bleeding and bleeding-related adverse outcomes. The current guidelines on clinical management differ significantly. The present meta-analysis examined the evidence for clopidogrel in the treatment of patients presenting with ACS requiring CABG, with a focus on the timing of medication cessation before surgery.

METHODS: A systematic review of 9 electronic databases was performed to identify all relevant studies with comparable outcomes for patients with ACS treated with clopidogrel before CABG. The endpoints included reoperation, major bleeding, mortality, and a composite endpoint of mortality and recurrent myocardial infarction.

RESULTS: Five relevant studies were identified according to the predefined selection criteria. Patients who had received clopidogrel had a significantly lower incidence of composite endpoints than those who had not. However, patients who underwent CABG < 5 days after the last dose of clopidogrel had a significantly greater incidence of reoperation, major bleeding, and combined adverse outcomes than those who had had a washout period >5 days.

CONCLUSIONS: The results from the present meta-analysis suggest that patients who present with ACS should be treated with dual antiplatelet therapy, including clopidogrel. However, for patients subsequently referred for CABG, a minimum washout period of 5 days should be observed to minimize perioperative bleeding and bleeding-related complications, unless emergency indications exist. These results differ from those of previous studies and guidelines.

Prognostic coronary surgery in a case of malignant mesothelioma previously managed with trimodality treatment

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Dhurandhar V, Robinson BM, McCaughan BC, Bulliard C, Bannon PG

Heart Lung Circ 2014 Oct;23(10):e198-201

PMID: 24996387

Abstract

We report a case of malignant pleural mesothelioma treated with trimodality treatment. At three years after the extrapleural pneumonectomy, coronary artery revascularisation surgery for NSTEMI was performed in view of favourable long term prognostic and survival outcome. Five years following pleuropneumonectomy there is no clinical or radiological evidence of mesothelioma and the patient remains free of cardiac symptoms.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

by

Seco M, Forrest P, Jackson SA, Martinez G, Andvik S, Bannon PG, Ng M, Fraser JF, Wilson MK, Vallely MP

Heart Lung Circ 2014 Oct;23(10):957-62

PMID: 24954708

Abstract

BACKGROUND: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently.

METHOD: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE.

RESULTS: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue.

CONCLUSIONS: Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.

Geriatric cardiac surgery: chronology vs. biology

by

Seco M, Edelman JJ, Forrest P, Ng M, Wilson MK, Fraser J, Bannon PG, Vallely MP

Heart Lung Circ 2014 Sep;23(9):794-801

PMID: 24851829

Abstract

Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their “chronological age”, without considering the patient’s true “biological age”.

Minimally invasive mitral valve surgery using single dose antegrade Custodiol cardioplegia

by

Matzelle SJ, Murphy MJ, Weightman WM, Gibbs NM, Edelman JJ, Passage J

Heart Lung Circ 2014 Sep;23(9):863-8

PMID: 24767979

Abstract

OBJECTIVE: Our unit began a minimally invasive mitral surgery (MIMS) program utilising antegrade Custodiol solution as the sole cardioplegia. The aim of this paper is to report our results of this program.

PATIENTS/METHODS: Early clinical outcomes were identified and assessed for the first consecutive 100 MIMS patients with comparisons made to a historical group operated via a sternotomy (n=113). The efficacy of myocardial protection was assessed using surrogate outcomes of myocardial protection with serial sodium concentrations also analysed.

RESULTS: Six hours postoperatively 12 patients required inotropic support. Peak troponin-I in the first 24 hours was 5.1 (0.8-40 μg/L [median(range)]. Sodium levels decreased following administration of Custodiol but by six hours postoperatively the sodium had returned to greater than 130 mmol/L in all but five patients. Blood transfusion was smaller in the MIMS versus historical group (RBC 17% vs. 65%). MIMS patients had a shorter duration of ventilation, hospital stay and one-year mortality rate (0%).

CONCLUSIONS: In this series of patients undergoing MIMS, single dose antegrade Custodiol offers satisfactory and safe myocardial protection. Early clinical outcomes were also satisfactory. Whilst our findings are observational, they nevertheless support the use of this less invasive approach to mitral surgery using single dose Custodiol for myocardial protection.

A meta-analysis of endoscopic versus conventional open radial artery harvesting for coronary artery bypass graft surgery

by

Cao C, Tian DH, Ang SC, Peeceeyen S, Allan J, Fu B, Yan TD

Innovations (Phila) 2014 Jul-Aug;9(4):269-75

PMID: 25084252

Abstract

OBJECTIVE: The radial artery has been demonstrated to provide superior long-term patency outcomes compared with saphenous veins for selected patients who undergo coronary artery bypass graft surgery. Recently, endoscopic radial artery harvesting has been popularized to improve cosmetic and perioperative outcomes. However, concerns have been raised regarding the effects on long-term survival and graft patency of this relatively novel technique. The present meta-analysis aimed to assess the safety and the efficacy of endoscopic radial artery harvesting versus the conventional open approach.

METHODS: A systematic review of the current literature was performed on five electronic databases. All comparative studies on endoscopic versus open radial artery harvesting were included for analysis. Primary endpoints included mortality and recurrent myocardial infarction. Secondary endpoints included graft patency, wound infection, hematoma formation, and paresthesia.

RESULTS: Twelve studies involving 3314 patients were included for meta-analysis according to predefined selection criteria. There were no statistically significant differences in overall mortality, recurrent myocardial infarction, or graft patency between the two surgical techniques. However, patients who underwent endoscopic harvesting were found to have significantly lower incidences of wound infection, hematoma formation, and paresthesia.

CONCLUSIONS: Current literature on endoscopic harvesting of the radial artery for coronary artery bypass graft surgery is limited by relatively short follow-up periods as well as differences in patient selection and surgical techniques. In addition, there are currently no randomized controlled trials to provide robust clinical data. However, the available evidence suggests that the endoscopic approach is associated with superior perioperative outcomes without clear evidence demonstrating compromised patency or survival outcomes.

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