Biomedical subjects

Daniel G Swistel

Publications and source records attributed to Daniel G Swistel.

At least 19 recordsLinked to original sources

PubMed2006

Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: are women different from men?

OBJECTIVE: The long-term mortality of coronary artery bypass grafting in women in not certain. The purpose of this study was to determine and compare risk factors for long-term mortality in women and men undergoing coronary artery bypass grafting. METHODS: Between 1992 and 2002, 3760 consecutive patients (2598 men and 1162 women) underwent isolated coronary artery bypass grafting. Long-term survival data were obtained from the National Death Index (mean follow-up, 5.1 +/- 3.2 years). Multivariable Cox regression analysis was performed, including 64 preoperative, intraoperative, and postoperative factors separately in women and men. RESULTS: There were no differences in in-hospital mortality (2.7% in men vs 2.9% in women, P = .639) and 5-year survival (82.0% +/- 0.8% in men vs 81.1% +/- 1.3% in women, P = .293). After adjustment for all independent predictors of long-term mortality, female sex was an independent predictor of improved 5-year survival (hazard ratio, 0.82; 95% confidence interval, 0.71-0.96; P = .014). Twenty-one independent predictors for long-term mortality were determined in men, whereas only 12 were determined in women. There were 9 common risk factors (age, ejection fraction, diabetes mellitus, > or =2 arterial grafts, postoperative myocardial infarction, deep sternal wound infection, sepsis and/or endocarditis, gastrointestinal complications, and respiratory failure); however, their weights were different between women and men. Malignant ventricular arrhythmias, calcified aorta, and preoperative renal failure were independent predictors only in women. Emergency operation, previous cardiac operation, peripheral vascular disease, left ventricular hypertrophy, current and past congestive heart failure, chronic obstructive pulmonary disease, body mass index of greater than 29, preoperative dialysis, thrombolysis within 7 days before coronary artery bypass grafting, intraoperative stroke, and postoperative renal failure were independent predictors only in men. CONCLUSIONS: Despite equality between sexes in early outcome and superiority of female sex in long-term survival, there were 3 independent predictors for long-term mortality after coronary artery bypass grafting unique for women compared with 12 for men. Clinical decision making and follow-up should not be influenced by stereotypes but by specific findings.

Aged↗

PubMed2006

Does bilateral internal thoracic artery grafting increase long-term survival of diabetic patients?

BACKGROUND: The purpose of the present study was to determine whether long-term survival in diabetic patients increased after bilateral internal thoracic artery (BITA) coronary bypass compared with matched patients with single internal thoracic artery (SITA) coronary bypass. METHODS: The propensity for BITA was determined using logistic regression analysis and each BITA patient was matched with one SITA patient. Between January 1992 and March 2002, 980 matched diabetic patients (490 BITA versus 490 SITA) underwent coronary artery bypass surgery. Long-term survival data were obtained from the National Death Index (mean follow-up, 4.7 +/- 3.0 years). Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. RESULTS: Multivariate Cox regression analysis determined that BITA grafting had no significant effect on long-term survival (hazard ratio 0.89, 95% confidence interval: 0.69 to 1.14, p = 0.343). There were no differences in 30-day mortality (3.9% for BITA versus 3.7%, p = 0.999) and major postoperative complications except for length of stay (11.4 days for BITA versus 12.7 days, p < 0.001). Five-year survival rate was 79.9% in the BITA group and 75.7% in the SITA group (p = 0.252). There was no difference in 5-year survival rate between matched patients younger than 60 or from 70 to 79 years old. However, BITA patients aged 60 to 69 years had better 5-year survival rates (84.1% versus 71.0%, p = 0.0196), whereas the opposite was observed in patients aged more than 79 years (5-year survival for BITA 43.1% versus 70.0%, p = 0.016). CONCLUSIONS: Bilateral internal thoracic artery grafting had no significant effect on long-term survival for diabetic patients, but it may increase long-term survival in patients aged 60 to 69 years, whereas SITA grafting may be beneficial for patients more than 79 years old.

Age Factors↗

PubMed2006

Resection, Plication, Release--the RPR procedure for obstructive hypertrophic cardiomyopathy.

OBJECTIVE: The surgical management of left ventricular outflow tract (LVOT) obstruction secondary to hypertrophic cardiomyopathy (HCM) has classically consisted of a septal myectomy. To address inconsistent results the extended myectomy or resection (R) and papillary muscle release (R) have been described. Our group introduced a novel addition to the surgical management consisting of an anterior mitral leaflet plication (P). We call the procedure resection - plication- release for repair of complex HCM pathology - the RPR operation. We investigated the mid-term results of all our patients undergoing surgical management for simple and complex HCM pathology. METHODS: Forty-two patients have undergone surgery for HCM at our hospital center since we began to look critically at the pathophysiology. Patients received either an extended myectomy alone, a myectomy plus either papillary muscle release or mitral leaflet plication, or the total RPR procedure. Pre and post-operative transesophageal echocardiograms were obtained in all patients to assess LVOT gradient, adequacy of resection and degree of mitral insufficiency. Subsequently, all patients had a trans-thoracic echocardiogram at a mean follow-up period of 3.4 +/- 3.1 years (range, 0.5 to 7). RESULTS: Twenty-one patients underwent the full RPR procedure; thirteen received portions of the procedure and only seven underwent myectomy alone (including three with concomitant mitral valve replacement (MVR) for insufficiency unrelated to their obstructive pathology). One patient had an isolated MVR as primary therapy for HCM management. The average age was 56 +/-14 years. The preoperative LVOT obstruction gradient was 137 +/- 45 mm Hg and reduced to 10 +/- 17 mm Hg post-operatively. All patients had mitral insufficiency pre-operatively, grade 3.1 on average (scale 0-4), and reduced post-operatively to trivial, grade 0.2. During the follow-up period, LVOT gradient remained low at 6 +/- 14 mm Hg, and mitral insufficiency remained trivial, grade 0.4 (All p values <0.0001). There were no hospital deaths and overall, no need for reoperations. CONCLUSIONS: Hypertrophic cardiomyopathy patients often present with wide anatomic variation. When these variations are understood, the operative approach should be directed to correct or ameliorate those specific aspects, termed simple or complex pathophysiology. Durable long-term results can be achieved in all patients when the mitral valve pathology is appreciated and appropriately repaired, along with a properly located and adequately sized septal myectomy.

Cardiac Surgical Procedures↗

PubMed2006

Long-term prognosis of hypertrophic cardiomyopathy after surgery.

Hypertrophic cardiomyopathy is a heterogeneous disease with both medical and surgical treatment options. Patients who are symptomatic with a left ventricular outflow tract (LVOT) gradient of >50 mm Hg are referred for septal myectomy. A review of both early and recent literature of outcomes of surgical therapy was performed. Specialized centers referred large numbers of patients for septal myectomy were the focus. Overall improvement in symptoms, morbidity, mortality, and long-term survival were reviewed. Over the past 40 years, surgical therapy has shown consistent improvement in symptoms and reduction of LVOT gradient for patients with hypertrophic cardiomyopathy. Furthermore, there has been a significant decrease in both morbidity and mortality for septal myectomy with improved techniques in the field of cardiac surgery and better understanding of the pathophysiology of the disease process. Surgical resection of the septum for hypertrophic cardiomyopathy is a safe, reproducible, and effective procedure for symptomatic patients with a significant LVOT obstruction.

Cardiac Surgical Procedures↗

PubMed2005

Does EuroSCORE predict length of stay and specific postoperative complications after coronary artery bypass grafting?

BACKGROUND: To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after coronary artery bypass grafting (CABG). METHODS: Data on 3760 consecutive patients with CABG were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, prolonged length of stay (>12 days) and major postoperative complications (stroke, myocardial infarction, sternal infection, bleeding, sepsis and/or endocarditis, gastrointestinal complications, renal and respiratory failure). A C statistic (receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: In-hospital mortality was 2.7%, and 13.7% of patients had one or more major complications. EuroSCORE showed very good discriminatory ability in predicting renal failure (C statistic: 0.80) and good discriminatory ability in predicting in-hospital mortality (C statistic: 0.75), sepsis and/or endocarditis (C statistic: 0.72) and prolonged length of stay (C statistic: 0.71). There were no differences in terms of the discriminatory ability between standard and logistic EuroSCORE. Standard EuroSCORE showed good calibration (Hosmer-Lemeshow: P>0.05) in predicting these outcomes except for postoperative length of stay, while logistic EuroSCORE showed good calibration only in predicting renal failure. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also prolonged length of stay and specific postoperative complications such as renal failure and sepsis and/or endocarditis after CABG. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.

Aged↗

PubMed2005

The impact of preoperative thrombolysis on long-term survival after coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) is frequently used after thrombolytic therapy. However, there is little information regarding long-term survival in this setting. The purpose of the present study was to compare the long-term survival of patients subjected to CABG after thrombolysis to those without thrombolysis. METHODS AND RESULTS: We studied 3760 consecutive patients with isolated CABG between 1992 and 2002. CABG patients without thrombolysis were compared with those who were treated with thrombolysis within 7 days before CABG. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for thrombolysis was determined by logistic regression analysis, and each patient with thrombolysis was then matched to 5 patients without thrombolysis. One hundred ninety-six patients (5.2%) were treated with thrombolysis. Patients with thrombolysis were more likely to be male, younger, and with higher rates of unstable angina, emergency operation, recent or transmural myocardial infarction, preoperative intraaortic balloon pump, hemodynamic instability, shock, intravenous nitroglycerine, left-ventricular hypertrophy, sustained ventricular arrhythmia, and higher EuroSCORE. There were no differences in early outcome between matched groups, but the 5-year actuarial survival was higher in patients with thrombolysis (90.3+/-2.2% versus 78.5+/-1.6%; P=0.0007). After adjustment for all factors, the hazard ratio of long-term mortality for patients with thrombolysis was 0.54 (95% CI, 0.36 to 0.81; P=0.003) and, if deaths during the first 12 months were excluded, 0.46 (95% CI, 0.27 to 0.76; P=0.003). CONCLUSIONS: Patients subjected to CABG within 7 days after thrombolysis demonstrated increased long-term survival.

Aged↗

PubMed2005

Risk factors for sepsis and endocarditis and long-term survival following coronary artery bypass grafting.

We sought to determine risk factors for sepsis and/or endocarditis (S/E) and to identify their impact on long-term survival after coronary artery bypass grafting (CABG). We studied 3760 consecutive patients who underwent isolated CABG from 1992 to 2002. Patients with CABG without S/E were compared with those who developed S/E. Long-term survival data (mean follow-up 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for S/E was determined by logistic regression analysis and each patient with S/E was matched to one patient without S/E. Thirty-six patients (0.96%) developed S/E. Independent predictors for S/E were increased age (odds ratio [OR] 1.05 per year, 95% Confidence interval [95% CI] 1.00-1.09; p = 0.040) and the development of other major complications after CABG such as deep sternal wound infection (OR 30.80, 95% CI 9.50-99.82; p < 0.001), gastrointestinal complications (OR 19.48, 95% CI 7.14-53.18; p < 0.001), renal failure (OR 15.18, 95% CI 4.42-52.06; p < 0.001), intraoperative stroke (OR 13.11, 95% CI 4.81-35.69; p < 0.001) and respiratory failure (OR 12.95, 95% CI 5.69-29.45; p < 0.001). After adjustment for pre-, intra- and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with S/E was 3.33 (95% CI 2.17-5.10; p < 0.001). There was no difference in 30-day mortality between matched groups (25.0% vs. 19.4% in patients without S/E, p = 0.778), however patients without S/E had better 5-year survival rate (52.7 +/- 8.7% vs. 16.2 +/- 6.2%; p = 0.0004). We have identified risk factors for S/E following CABG and we found that there was increased mortality in patients with S/E during a 10-year follow-up period.

Aged↗

PubMed2005

EuroSCORE predicts long-term mortality after heart valve surgery.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is the most rigorously evaluated scoring system in cardiac surgery. We sought to evaluate the performance of EuroSCORE in the prediction of long-term mortality in patients undergoing heart valve surgery. METHODS: Medical records of patients with isolated or combined heart valve surgery, who were discharged alive (n = 1035), were retrospectively reviewed. Their operative surgical risks were calculated according to EuroSCORE model (standard and logistic). Long-term survival data (mean follow-up 4.5 +/- 3.1 years) were obtained from the National Death Index. Kaplan-Meier curves of the quartiles of standard and logistic EuroSCORE were plotted. RESULTS: The estimated 5-year survival rates of the quartiles in the standard and logistic EuroSCORE model were: 90.0% +/- 2.3%, 85.1% +/- 2.3%, 64.8% +/- 3.3%, and 55.1% +/- 3.7% (p < 0.0001, log-rank test with adjustment for trend) and 90.4% +/- 2.2%, 86.4% +/- 2.5%, 66.9% +/- 3.3%, and 56.1% +/- 3.3% (p < 0.0001, log-rank test with adjustment for trend) respectively. The odds of death in the highest-risk quartile were 7.46- and 7.82-fold higher than the odds of death in the lowest-risk quartile for standard and logistic EuroSCORE respectively. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also long-term mortality in the whole context of heart valve surgery. This outcome can be predicted using the standard EuroSCORE, which is very simple and easy in its calculation.

Aged↗

PubMed2005

Beyond extended myectomy for hypertrophic cardiomyopathy: the resection-plication-release (RPR) repair.

BACKGROUND: Extended myectomy for left ventricular outflow tract obstruction (LVOTO) due to hypertrophic cardiomyopathy (HCM) has good long-term results. In addition to the midseptal resection (R) for HCM, our group has introduced a novel variation in anterior leaflet plication (P) and release (R) of papillary muscle attachments. We sought to investigate the medium-term success of this three-step repair that addresses all aspects of complex HCM pathology. METHODS: Nineteen patients underwent resection-plication-release repair for complex HCM pathology. Transesophageal echocardiography was performed on all patients preoperatively and postoperatively to assess adequacy of resection, left ventricular outflow tract gradients, and mitral valve function. All patients underwent transthoracic outpatient echocardiography at a mean follow-up of 2.4 +/- 2.1 years (range, 0.5 to 6). RESULTS: The average age of the patients was 57 +/- 14 years. The preoperative peak LVOTO was 137 +/- 45 mm Hg. The average degree of mitral regurgitation was 3.1. The average length of stay was 7.5 +/- 3.3 days. There were no readmissions or deaths in the group. Initial postoperative transesophageal echocardiography demonstrated marked reduction in LVOTO to 10 +/- 17 mm Hg (p < 0.0001) and significant improvement in mitral regurgitation to 0.2 (p < 0.0001). In follow-up, the LVOT gradient remained low at 6 +/- 14 (p > 0.0001) and mitral regurgitation remained insignificant at 0.4 (p < 0.0001). CONCLUSIONS: Anterior leaflet plication and papillary muscle release are logical adjuncts to septal resection in the treatment of the complicated pathophysiology of obstructive HCM. Durable long-term results can be achieved with an aggressive approach to mitral valve pathology in conjunction with extended myectomy.

Adult↗

PubMed2005

Does EuroSCORE predict length of stay and specific postoperative complications after cardiac surgery?

OBJECTIVE: To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after cardiac surgery. METHODS: Data on 5051 consecutive patients (isolated [74.4%] or combined coronary artery bypass grafting [11.1%], valve surgery [12.0%] and thoracic aortic surgery [2.5%]) were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, 3-month mortality, prolonged length of stay (>12 days) and major postoperative complications (intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, re-exploration for bleeding, sepsis and/or endocarditis, gastrointestinal complications, postoperative renal failure and respiratory failure). A C statistic (or the area under the receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: In-hospital mortality was 3.9% and 16.1% of patients had one or more major complications. Standard EuroSCORE showed very good discriminatory ability and good calibration in predicting in-hospital mortality (C statistic: 0.76, Hosmer-Lemeshow: P=0.449) and postoperative renal failure (C statistic: 0.79, Hosmer-Lemeshow: P=0.089) and good discriminatory ability in predicting sepsis and/or endocarditis (C statistic: 0.74, Hosmer-Lemeshow: P=0.653), 3-month mortality (C statistic: 0.73, Hosmer-Lemeshow: P=0.097), prolonged length of stay (C statistic: 0.71, Hosmer-Lemeshow: P=0.051) and respiratory failure (C statistic: 0.71, Hosmer-Lemeshow: P=0.714). There were no differences in terms of the discriminatory ability in predicting these outcomes between standard and logistic EuroSCORE. However, logistic EuroSCORE showed no calibration (Hosmer-Lemeshow: P<0.05) except for sepsis and/or endocarditis (Hosmer-Lemeshow: P=0.078). EuroSCORE was unable to predict other major complications such as intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, gastrointestinal complications and re-exploration for bleeding. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also 3-month mortality, prolonged length of stay and specific postoperative complications such as renal failure, sepsis and/or endocarditis and respiratory failure in the whole context of cardiac surgery. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.

Aged↗

PubMed2005

Preoperative prediction of long-term survival after coronary artery bypass grafting in patients with low left ventricular ejection fraction.

OBJECTIVE: We aimed to develop multivariable models of preoperative risk factors that predict long-term survival after coronary artery bypass grafting in patients with ejection fraction 25% or less. METHODS: We retrospectively evaluated 544 consecutive patients with ejection fraction 25% or less who underwent coronary artery bypass grafting from 1992 to 2002 at a single institution. Long-term survival data (mean follow-up 4.1 years) were obtained from the National Death Index. Multivariable Cox regression analysis was performed to construct a predictive score for long-term mortality. A split-sample approach was also used building a model on a training group (n = 360); this model was then tested on a separate validation group (n = 184). RESULTS: From the entire database, the predictive score was calculated according to the following equation: 0.430(if past congestive heart failure) + 0.049(age in years) + 0.507(if peripheral vascular disease) + 0.580(if emergency operation) + 0.366(if chronic obstructive pulmonary disease). The 5-year survivals of the predictive score quartiles were 82.3%, 78.2%, 65.5%, and 45.5% (P < .0001). The model based on the training group had four independent predictors for long-term mortality (the same as the listed equation except for past congestive heart failure). The 5-year survival rates of the quartiles were 90.1%, 75.4%, 64.3%, and 49.2% in the training group (P < .0001) and 77.4%, 71.2%, 65.8%, and 45.5% in the validation group (P = .0001). CONCLUSION: Coronary artery bypass grafting in patients with severe ischemic cardiomyopathy achieves satisfactory midterm and long-term survival in selected patients. This new score, which is based on long-term data from a large number of patients, may aid clinicians in selecting therapeutic interventions for patients with ischemic cardiomyopathy.

Aged↗

PubMed2005

The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting.

OBJECTIVES: To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG). BACKGROUND: DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality. METHODS: We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI. RESULTS: DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 +/- 2.4% vs 50.8.6 +/- 8.5% [mean +/- SE]; p = 0.0007 between matched groups). CONCLUSIONS: We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.

Aged↗

PubMed2005

Does leukofiltration reduce pulmonary infections in CABG patients? A prospective, randomized study with early results and mid-term survival.

BACKGROUND: We present the first prospective randomized study of primary coronary artery bypass grafting (CABG) patients who were analyzed for postoperative infections after undergoing blood and/or blood product transfusion (BBPT) with a Pall Purecell leukoreducing filter. METHODS AND RESULTS: One hundred and four patients were enrolled between March 1998 and March 1999. Seventy-two of the patients received BBPT (average 5.6 units BBPT/filter patient and 5.6 units/control patient). Three patients who had CABG without extracorporeal circulation or mixed transfusions of filtered and unfiltered BBPT were excluded. The remaining 69 transfused patients (38 filtered, 31 control) were analyzed and the incidence of culture proven infections was recorded. Mid-term survival data were obtained from the National Death Index and Kaplan-Meier survival plots were constructed. All patients were stratified and matched according to the EuroSCORE.Thirty-day mortality was 2.6% and 3.2% for the filtered and control patients, respectively. There were 5 cases of culture proven infections in 38 filtered patients (13.2%) and 8 in 31 controls (25.8%), P = 0.224. No pulmonary tract infections were recorded in the filter group vs. 4 (12.9%) in controls, P = 0.048. Reduced length for mechanical ventilation (16.3 hours vs. 57.8, P = 0.103), length of stay (9.1 vs. 10.8 days, P = 0.685), as well as increased 50-month actuarial survival, (45.5 vs. 42.3 months, P=0.695) in filtered vs. control, respectively, were recorded. CONCLUSIONS: The use of leukoreduced BBPT reduced the incidence of pulmonary tract infections in patients undergoing CABG.

Blood Transfusion↗

PubMed2004

Antegrade endovascular repair of a coarctation-associated aneurysm through an upper hemi-sternotomy.

Late aneurysm formation is a well-described complication after surgical correction of aortic coarctation. Endovascular repair of such aneurysms avoids the morbidity of conventional reoperative thoracic surgery. We describe a unique case of antegrade endovascular repair of a distal coarctation-associated aneurysm with vascular access acquired through the aortic arch by an upper hemi-sternotomy.

Aged↗

PubMed2004

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing: the posterior approach.

Patients with congestive heart failure and altered interventricular conduction enjoy improvements in quality of life and ventricular function after successful resynchronization therapy with biventricular pacing. Technical limitations owing to individual coronary sinus and coronary venous anatomy result in a 10% to 15% failure rate of left ventricular (LV) lead placement through percutaneous approaches. To provide a minimally invasive option for these patients with LV lead failures, we developed a technique of endoscopic, epicardial LV lead implantation with the use of the da Vinci robotic system. The surgical approach targets the posterolateral wall through a novel posterior approach.

Cardiac Pacing, Artificial↗

PubMed2004

European system for cardiac operative risk evaluation predicts long-term survival in patients with coronary artery bypass grafting.

OBJECTIVE: To evaluate the accuracy of predicting long-term mortality in patients with coronary artery bypass grafting (CABG) by using the European system for cardiac operative risk evaluation (EuroSCORE). METHODS: Medical records of patients with CABG (n=3760) between January 1992 and March 2002 were retrospectively reviewed and their predicted surgical risk was calculated according to the standard (study A) and logistic (study B) EuroSCORE. In study A the patients were divided into six groups: 0-2 (n=610), 3-5 (n=1479), 6-8 (n=1099), 9-11 (n=452), 12-14 (n=103) and >14 (n=17). In study B the patients were divided into seven groups: 0.00-2.00 (n=447), 2.01-5.00 (n=1190), 5.01-10.00 (n=890), 10.01-20.00 (n=686), 20.01-30.00 (n=234), 30.01-60.00 (n=254) and >60.00 (n=59). Long-term survival was obtained by the National Death Index and Kaplan-Meier curves were constructed and compared employing the log-rank test. Multivariate Cox regression analysis was performed in order to control for pre, intra and postoperative factors and adjusted hazard ratios were calculated for standard and logistic EuroSCORE groups. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the EuroSCORE. RESULTS: In study A there were differences among the six groups in 30-day mortality (0.7%, 1.0%, 3.1%, 4.6%, 13.6% and 23.5%; P<0.001), in major complications (8.5%, 10.4%, 16.2%, 20.4%, 31.1% and 35.3%; P<0.001) as well as in actuarial long-term survival (86.2%, 79.6%, 53.6%, 37.9%, 24.9% and 0% from EuroSCORE 0-2 to >14; P<0.001). In study B there were differences among the seven groups in 30-day mortality (0.9%, 1.1%, 1.2%, 3.6%, 3.4%, 8.7% and 15.3%; P<0.001), major complications (8.5%, 10.1%, 12.1%, 18.4%, 16.2%, 26.0% and 30.5%; P<0.001) as well as in actuarial long-term survival (89.5%, 79.9%, 66.9%, 51.0%, 40.3%, 38.4% and 13.7% from EuroSCORE 0.00-2.00 to >60.00; P<0.001). Multivariate Cox regression analysis confirmed that EuroSCORE (standard or logistic) was a statistically significant predictor for long-term mortality, while the area under the ROC curve was 0.72 for either standard or logistic EuroSCORE. CONCLUSION: The predicted surgical risk in CABG patients as calculated by standard or logistic EuroSCORE is a strong predictor for long-term survival in addition to predicting operative survival for which it was originally designed.

Coronary Artery Bypass↗

PubMed2004

Early and midterm outcome after off-pump coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: The purpose of this study was to define the early outcome and the potential for midterm survival in patients with left ventricular dysfunction (LVD) who undergo off-pump coronary artery bypass (OPCAB) and to compare these results with those of conventional coronary artery bypass grafting (CABG). METHODS: Medical records of patients with LVD (n = 732) between January 1998 and March 2002 were retrospectively reviewed. There were 523 patients with moderate LVD (ejection fraction, 30%-50%; 463 CABG versus 60 OPCAB) and 209 patients with severe LVD (ejection fraction, < 30%; 136 CABG versus 73 OPCAB). Midterm survival data (mean follow-up, 2.3 years) were obtained from the National Death Index. Groups were compared by multivariate Cox proportional hazard models, and Kaplan-Meier curves were plotted. RESULTS: CABG patients had lower European System for Cardiac Operative Risk Evaluation values (5.3 versus 7.2 and 8.0 versus 9.6 in moderate and severe LVD subgroups, respectively; P < .001). There were no differences (OPCAB versus CABG) in 30-day mortality (3.3% versus 1.9%, moderate LVD group, P = .366; 6.8% versus 4.4%, severe LVD group, P = .521), length of stay (9.3 versus 8.6 days, moderate LVD group, P = .683; 11.9 versus 11.8 days, severe LVD group, P = .423), and postoperative complications (13.3% versus 11.0%, moderate LVD group, P = 0.663; 16.4% versus 20.6%, severe LVD group, P = .581). Successful coronary bypass in patients with severe LVD was associated with 68.2% and 66.2% actuarial 48-month survival rates for the CABG and OPCAB patients, respectively (P = .336), and these rates rose to 86.0% and 82.9% in patients with moderate LVD (P = .121). When CABG patients with moderate LVD were considered the reference group, the adjusted hazard ratio of OPCAB patients with moderate LVD for midterm mortality was 1.32 (95% confidence interval, 0.61-2.87; P = .481). CABG and OPCAB patients with severe LVD had the same adjusted hazard ratio of 1.86, and this figure was statistically significant compared with the value for the reference group (P = .011 and P = .039, respectively). CONCLUSIONS: Patients with LVD can derive midterm benefit from coronary bypass. OPCAB in higher-risk patients had early and midterm outcomes similar to those of CABG.

Aged↗

PubMed2003

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing.

OBJECTIVES: Ventricular resynchronization might be achieved in a minimally invasive fashion using a robotically assisted, direct left ventricular (LV) epicardial approach. BACKGROUND: Approximately 10% of patients undergoing biventricular pacemaker insertion have a failure of coronary sinus (CS) cannulation. Rescue therapy for these patients currently is limited to standard open surgical techniques. METHODS: Ten patients with congestive heart failure (New York Heart Association class 3.4 +/- 0.5) and a widened QRS complex (184 +/- 31 ms) underwent robotic LV lead placement after failed CS cannulation. Mean patient age was 71 +/- 12 years, LV ejection fraction (EF) was 12 +/- 6%, and LV end-diastolic diameter was 7.1 +/- 1.3 cm. Three patients had previous cardiac surgery, and five patients had a prior device implanted. RESULTS: Nineteen epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.0 +/- 0.5 V at 0.5 ms, R-wave was 18.6 +/- 8.6 mV, and impedance was 1,143 +/- 261 ohms at 0.5 V. Complications included an intraoperative LV injury and a postoperative pneumonia. Improvements in exercise tolerance (8 of 10 patients), EF (19 +/- 13%, p = 0.04), and QRS duration (152 +/- 21 ms, p = 0.006) have been noted at three to six months follow-up. Lead thresholds have remained unchanged (2.1 +/- 1.4 V at 0.5 ms, p = NS), and a significant drop in impedance (310 +/- 59 ohms, p < 0.001) has been measured. CONCLUSIONS: Robotic LV lead placement is an effective and novel technique which can be used for ventricular resynchronization therapy in patients with no other minimally invasive options for biventricular pacing.

Aged↗