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Background: Bioprosthetic surgical mitral valve replacement (SMVR) remains an important treatment option in the era of transcatheter valve interventions. We present 10-year clinical outcomes of Medicare beneficiaries undergoing SMVR with a contemporary low-profile mitral porcine valve., Methods: This is a single-arm observational study using Medicare fee-for-service claims data. De-identified patients undergoing SMVR with the Epic™ Mitral valve (Abbott, Minnesota, USA) in the United States between 1/1/2008-12/31/2019 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality, heart failure (HF) re-hospitalization, and mitral valve reintervention (surgical or transcatheter valve-in-valve) were evaluated at 10-years using the Kaplan Meier method., Results: Among 75,739 Medicare beneficiaries undergoing SMVR during the study period, 14,015 were implanted with the Epic™ Mitral valve, of which 76.5% (10,720) had underlying HF. Mean age was 74±8 years. Survival at 10-years in patients without preoperative HF was 40.4% (95% CI 37.4%-43.4%) compared to 25.4% (95% CI 23.8%-27.0%) for patients with HF (p < 0.001). The 10-year freedom from HF rehospitalization was 51.3% (95% CI 49.4%-53.1%). Freedom from mitral valve reintervention was 91.4% (95% CI 89.7%-92.7%) at 10 years., Conclusions: This real-world nationwide study of Medicare beneficiaries receiving the Epic™ Mitral valve demonstrates >90% freedom from all-cause valve reintervention and >50% freedom from HF rehospitalization at 10-years post-implant. Long-term survival and HF rehospitalization in this population with mitral valve disease undergoing SMVR was found to be impacted by underlying HF., (Copyright © 2024. Published by Elsevier Inc.)

Background: The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting., Methods: Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support., Results: The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p<0.001) and a higher incidence of congestive heart failure (35% versus 17%, p<0.01) and acute myocardial infarction (37% versus 17%, p<0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0+/-10.5 versus 6.0+/-3.7 days, p<0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy., Conclusions: Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.

Background: A new emphasis has been directed toward "off-pump" coronary artery bypass grafting to avoid the morbidity of cardiopulmonary bypass and further reduce the postoperative hospital length of stay. With the intent of achieving a hospital discharge for "on-pump" coronary artery bypass grafting procedures comparable with the same procedures "off pump," we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day., Methods: The cases of 104 consecutive patients who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass were retrospectively reviewed. A rapid-recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthesia protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early extubation as well as a mild state of negative fluid balance and to ensure absence of postoperative bleeding and a safe transfer from the intensive care unit to a monitored floor. On the second postoperative day, chest drains were discontinued, and aggressive ambulation therapy was instituted. If at 72 hours postoperatively the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge home was planned., Results: The 30-day mortality rate for the entire group was 1.9%. The average postoperative hospital length of stay for the entire series was 4.8 +/- 2.4 days. Of the 102 survivors, 30 patients (29%) were discharged within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Patients in group 1 were younger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of an intraaortic balloon pump preoperatively (13% versus 35%). Group 1 patients also had almost no complications and a lower readmission rate (3.3% versus 6.9%)., Conclusions: With the application of a rapid-recovery protocol to patients undergoing "on-pump" coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe for patients who have minimal comorbid conditions.

Background: Rapid recovery protocols after coronary artery bypass grafting have been applied successfully to young patients with normal ventricular function. However, the success of such protocols when applied to the elderly population has not been thoroughly validated, and at some centers there is still reluctance in allowing elderly patients to be discharged early from the hospital., Methods: One hundred fifty-two consecutive younger patients (< 70 years) were compared retrospectively with 167 consecutive elderly patients (> or = 70 years) who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass. A rapid recovery protocol emphasizing an anesthetic protocol for early extubation, reduced cardiopulmonary bypass time, and perioperative administration of corticosteroids and thyroid hormone was applied to all patients. The protocol also emphasized early identification and management of postoperative atrial fibrillation, a proactive negative fluid balance, rapid return of bowel function, mobilization of the patient, and aggressive use of the intraaortic balloon pump preoperatively., Results: The 30-day mortality rate for the younger group of patients was 3.3% (Parsonnet risk 7.2 +/- 6.2), compared with 4.2% (Parsonnet risk, 17.7 +/- 6.8) for the elderly group of patients. There were no statistically significant differences in the 30-day mortality rates or postoperative complications between the elderly and younger patient groups. Rapid recovery with discharge before the fifth postoperative day was achieved in 19% of the elderly, in comparison with 48% of the younger patients (p < 0.001). The younger patients were discharged earlier after operation than the older patients (5.7 +/- 5.2 versus 8.0 +/- 8.5 days; p < 0.01)., Conclusions: Application of the rapid recovery protocol helped expedite recovery for all patients regardless of age, acuity of illness, or associated conditions. Although younger patients had a significantly shorter postoperative length of hospital stay, older patients performed well and are suitable candidates for rapid recovery protocols.