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Background: Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve., Methods: After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin., Results: Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, -0.07%; 95% CI, -3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding., Conclusions: Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525)., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Learning curves and skill attrition with aging have been reported to impair outcomes in select surgical subspecialties, but their role in complex cardiac surgery remains unknown., Methods: From 1986 to 2019, 2314 patients underwent reoperative cardiac surgery: coronary artery bypass grafting (n = 543), valve (n = 1527), or combined coronary artery bypass grafting and valve (n = 244). Thirty-four different surgeons in practice between 1 and 39 years were included. Standardized mortality ratio (observed-to-expected) was determined for all surgeons in each post-training year of experience., Results: Risk-adjusted cumulative sum change-point analysis was used to define five distinct career phases: 0 to 4 years, 5 to 8 years, 9 to 17 years, 18 to 28 years, and 29 to 39 years. With 5 to 8 years and 18 to 28 years of experience, standardized mortality ratio was near unity (0.95 and 1.05, respectively) and lowest with 9 to 17 years of experience (0.78, P = .03). In the youngest experience group (0 to 4 years), observed and expected mortality were both highest, and standardized mortality ratio was elevated at 1.29, which approached statistical significance (P = .059). In the oldest experience group (29 to 39 years), expected mortality was low compared with most other groups but observed mortality increased, yielding a significantly elevated standardized mortality ratio at 1.53 (P = .032)., Conclusions: Standardized mortality ratios with reoperative cardiac surgery were highest early and late in a surgeon's career and lowest in mid career. As surgeons gain experience, outcomes improve through the first two career decades, then stabilize in the third decade before declining in the fourth decade., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to investigate the progression of uncorrected mild aortic insufficiency and its impact on survival and functional status after left ventricular assist device implantation., Methods: We retrospectively reviewed 694 consecutive patients who underwent implantation of a continuous-flow left ventricular assist device between January 2006 and March 2018. Pre-left ventricular assist device transthoracic echocardiography identified 111 patients with mild aortic insufficiency and 493 patients with trace or no aortic insufficiency. To adjust for differences in preoperative factors, propensity score matching was used, resulting in 101 matched patients in each of the mild aortic insufficiency and no aortic insufficiency groups., Results: Although both groups showed similar survival (P = .58), the mild aortic insufficiency group experienced higher incidence of readmission caused by heart failure (hazard ratio, 2.62; 95% confidence interval, 1.42-4.69; P < .01). By using the mixed effect model, pre-left ventricular assist device mild aortic insufficiency was a significant risk factor for both moderate or greater aortic insufficiency and worsening New York Heart Association functional status (P < .01)., Conclusions: Patients with uncorrected mild aortic insufficiency had a higher risk of progression to moderate or greater aortic insufficiency after left ventricular assist device implantation with worse functional status and higher incidence of readmission caused by heart failure compared with patients without aortic insufficiency. Further investigations into the safety and efficacy of concomitant aortic valve procedures for mild aortic insufficiency at the time of left ventricular assist device implant are warranted to improve patients' quality of life, considering the longer left ventricular assist device use as destination therapy and bridge to transplant with the new US heart allocation system., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical ablation (SA) for atrial fibrillation (AF) concomitant to mitral valve repair/replacement (MVRR) improves longitudinal sinus rhythm. However, the risk of adding SA remains a clinical question. This study examined whether the addition of contemporary SA for AF has an impact on operative outcomes., Methods: The study cohort included 88,765 MVRR patients with or without SA, coronary artery bypass grafting (CABG), septal defect, and tricuspid repair in The Society of Thoracic Surgeons Database between 2011 and 2014. Group 1 did not have AF (No-AF) and did not receive SA (No-SA); group 2 had No-AF immediately preoperatively but received SA; group 3 had AF but No-SA; and group 4 had AF with SA. Groups 3 and 4 were stratified into paroxysmal versus nonparoxysmal AF. With the use of logistic regression, with group 1 as reference, risk-adjusted odds ratios (OR) for mortality were compared for SA performance, AF type, and SA technique., Results: Group 3 had higher age, New York Heart Association class, redo operations, and unadjusted mortality than group 4. Relative to group 1, group 3 had an OR for mortality of 1.15 (95% confidence interval: 1.04 to 1.27, p < 0.01). OR increments were similar for paroxysmal and nonparoxysmal AF. In group 4, concomitant SA was independently associated with lower AF-related relative risk (OR 1.08), to a level that was not different from group 1 (p = 0.13). Observed treatment effects were equivalent for paroxysmal and nonparoxysmal AF and across all levels of baseline risk., Conclusions: For patients with AF at the time of mitral operation, the performance of SA seems associated with a lower risk-adjusted operative mortality compared with patients who do not undergo ablation., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine the incidence and clinical significance of postoperative delirium (PD) in patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR)., Method: Between 2010 and 2013, 427 patients underwent TAVR (n = 168) or SAVR (n = 259) and were screened for PD using the Confusion Assessment Method for the Intensive Care Unit. The incidence of PD in both treatment groups was determined and its association with morbidity and mortality was retrospectively compared., Results: PD occurred in 135 patients (32%) with a similar incidence between SAVR (33% [86 out of 259]) and TAVR (29% [49 out of 168]) (P = .40). TAVR by transfemoral approach had the lowest incidence of PD compared with SAVR (18% vs 33%; P = .025) or TAVR when performed by alternative access techniques (18% vs 35%; P = .02). Delirium was associated with longer initial intensive care unit stay (70 vs 27 hours), intensive care unit readmission (10% [14 out of 135] vs 2% [6 out of 292]), and longer hospital stay (8 vs 6 days) (P < .001 for all). PD was associated with increased mortality at 30 days (7% vs 1%; P < .001) and 1 year (21% vs 8%; P < .001). After multivariable adjustment, PD remained associated with increased 1-year mortality (hazard ratio, 3.02; 95% confidence interval, 1.75-5.23; P < .001). There was no interaction between PD and aortic valve replacement approach with respect to 1-year mortality (P = .12). Among propensity-matched patients (n = 170), SAVR-treated patients had a higher incidence of PD than TAVR-treated patients (51% vs 29%; P = .004)., Conclusions: PD occurs commonly after SAVR and TAVR and is associated with increased morbidity and mortality. Given the high incidence of PD and its associated adverse outcomes, further studies are needed to minimize PD and potentially improve patient outcomes., Competing Interests: Statement All other authors have nothing to disclose with regard to commercial support., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the role of preoperative pulmonary function tests (PFTs) in patients with aortic stenosis (AS) evaluated for aortic valve replacement (AVR), and to evaluate the association between lung disease and mortality in specific subgroups., Methods: Between 2008 and 2013, 535 patients with preoperative PFTs underwent AVR (transcatheter AVR [TAVR], n = 246; surgical AVR [SAVR], n = 289). The severity of lung disease determined by the Society of Thoracic Surgeons (STS) definition was evaluated in those with and without a clinical suspicion for lung disease (smoking, inhaled steroids/bronchodilators, or home oxygen). The association between lung disease and 1-year mortality was evaluated., Results: Of the 186 patients (35%) without suspected lung disease, 39 (21%) had moderate/severe lung disease by PFT analysis. Among all patients, 1-year mortality was 12% in those with no lung disease, 17% in those with no mild lung disease, 22% in those with moderate lung disease, and 31% in those with severe lung disease (P < .001, log-rank test). After adjustment, moderate/severe lung disease was associated with increased 1-year mortality (adjusted hazard ratio, 2.07; 95% confidence interval, 1.30-3.29; P = .002); this association was not altered by smoking history, suspicion of lung disease, New York Heart Association class, or AVR type (interaction P value nonsignificant for all)., Conclusions: In patients with AS evaluated for AVR, the STS risk score is significantly influenced by the severity of lung disease, which is determined predominantly by PFT results. Even when lung disease is not suspected, PFTs are abnormal in many patients undergoing AVR. Moderate/severe lung disease, diagnosed predominantly by PFTs, is an independent predictor of mortality after SAVR or TAVR. Collectively, these findings suggest that PFTs should be a routine part of the risk stratification of patients considered for AVR., Competing Interests: Statement R.J.D. has received educational funding from Edwards Lifesciences. A.Z. is a consultant for Edwards Lifesciences. B.R.L. receives grants and personal fees from Roche Diagnostics. All other authors have nothing to disclose with regard to commercial support., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The need to perform an additional atriotomy is a major concern that keeps many surgeons from performing an extended left atrial lesion set in patients with atrial fibrillation during procedures such as aortic valve replacement. This does result either in a suboptimal lesion set or even in ignoring the rhythm disorder, leaving the patient exposed to an increased risk of stroke and possible hemodynamic compromises. This report describes a technique how pulmonary vein isolation, an isolation of the posterior left atrial wall and an anterior mitral annular line, which substitutes for the mitral isthmus line in order to prevent perimitral atrial flutter, can be performed during aortic valve replacement without the need for an atriotomy. This technique allows for an optimal time management by minimizing additional cardiopulmonary bypass-time and cross-clamp-time; however, its equivalent efficacy in successfully treating atrial fibrillation compared to the left atrial Maze IV ablation pattern needs to be revealed in future trials., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: In heart failure populations without aortic stenosis (AS), the prognostic utility of multiple biomarkers in addition to clinical factors has been demonstrated. We aimed to determine whether multiple biomarkers of cardiovascular stress are associated with mortality in patients with AS undergoing aortic valve replacement (AVR) independent of clinical factors., Methods: From a prospective registry of patients with AS, 345 participants who were referred for and treated with AVR (transcatheter (n=183) or surgical (n=162)) were included. Eight biomarkers were measured on blood samples obtained prior to AVR: growth differentiation factor 15 (GDF15), soluble ST2 (sST2), amino-terminal pro-B-type natriuretic peptide (NTproBNP), galectin-3, high-sensitivity cardiac troponin T, myeloperoxidase, high-sensitivity C reactive protein and monocyte chemotactic protein-1. Biomarkers were evaluated based on median value (high vs low) in a Cox proportional hazards model for all-cause mortality and a parsimonious group of biomarkers selected. Mean follow-up was 1.9±1.2 years; 91 patients died., Results: Three biomarkers (GDF15, sST2 and NTproBNP) were retained in the model. One-year mortality was 5%, 12%, 18% and 33% for patients with 0 (n=79), 1 (n=96), 2 (n=87) and 3 (n=83) biomarkers elevated, respectively (p<0.001). After adjustment for the Society of Thoracic Surgeons (STS) risk score, a greater number of elevated biomarkers was associated with increased mortality (referent: 0 elevated): 1 elevated (HR 1.47, 95% CI 0.60 to 3.63, p=0.40), 2 elevated (HR 2.89, 95% CI 1.24 to 6.74, p=0.014) and 3 elevated (HR 4.59, 95% CI 1.97 to 10.71, p<0.001). Among patients at intermediate or high surgical risk (STS score ≥4), 1-year and 2-year mortality rates were 34% and 43% for patients with three biomarkers elevated versus 4% and 4% for patients with 0 biomarkers elevated. When added to the STS score, the number of biomarkers elevated provided a category-free net reclassification improvement of 64% at 1 year (p<0.001). The association between a greater number of elevated biomarkers and increased mortality after valve replacement was similar in the transcatheter and surgical AVR populations., Conclusions: These findings demonstrate the potential utility of multiple biomarkers to aid in risk stratification of patients with AS. Further studies are needed to evaluate their utility in clinical decision-making in specific AS populations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: This study sought to clarify the clinical and echocardiographic prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR)., Background: The clinical significance of cardiac biomarker elevation after TAVR remains unclear., Methods: Patients treated with TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial were divided into tertiles (T1, T2, T3) based on the difference between the values on post-procedure day 1 and the baseline values of 2 cardiac biomarkers: cardiac troponin I (ΔcTnI); and creatine kinase-myocardial band (ΔCK-MB) fraction. Patients were stratified according to their access route: transfemoral (TF) (n = 1,840) or transapical (TA) (n = 1,173)., Results: At 30 days after TF-TAVR, patients in the highest tertile (T3) of cardiac biomarker elevation had a higher rate of all-cause mortality (ΔcTnI: T3: 5.4% vs. T1: 0.5%, p = 0.006; ΔCK-MB: T3: 5.7% vs. T1: 0.9%, p = 0.006) and cardiovascular mortality (ΔcTnI: T3: 4.9% vs. T1: 0.5%, p = 0.01; ΔCK-MB: T3: 3.9% vs. T1: 0.5%, p = 0.02). At 1 year, only patients in the highest CK-MB tertile had higher rates of all-cause (25.4% vs. 16.8%, p = 0.02) and cardiovascular (10.3% vs. 5.0%) mortality. Multivariable analysis demonstrated that greater release of cardiac biomarkers was independently associated with increased mortality in the TF population. After TA-TAVR, being in the highest tertile of cardiac biomarker elevation had no influence on clinical and echocardiographic outcomes at 30 days and 1 year., Conclusions: After TF-TAVR, a greater degree of myocardial injury was associated with higher rates of 30-day all-cause and cardiovascular mortality. At 1 year, being in the highest tertile of ΔCK-MB was correlated with a higher rate of all-cause and cardiac mortality. Finally, the level of myocardial injury after TA-TAVR had no impact on clinical and echocardiographic outcomes., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to study the outcomes of redo-mitral valve surgery in patients with pulmonary hypertension., Methods: We reviewed data on redo mitral valve surgery in patients with pulmonary hypertension measured by Swan-Ganz catheter (mean pulmonary artery pressure ≥ 25 mm Hg or systolic pulmonary artery pressure ≥ 40 mm Hg)., Results: Between 1996 and 2010, 637 patients underwent 658 redo mitral valve operations; 138 of them had pulmonary hypertension. The mean patient age was 61.3 (13.9) years, with mean left ventricular ejection fraction of 47.6% (13.2%). The mean systolic pulmonary artery pressure was 61.5 (16.8) mm Hg, and mean pulmonary artery pressure was 40.8 (11.6) mm Hg. Patients had one (71%, 98/138), two (23.9%, 33/138), and three (5.1%, 7/138) previous mitral valve operations. Thirty-day mortality was 10.1% (14/138). Multivariate predictors of 30-day mortality were chronic renal failure [odds ratio (OR), 8.041; P = 0.022], peripheral vascular disease (OR, 5.976; P = 0.025), previous mitral valve replacement (OR, 9.034; P = 0.014), and increasing age (OR, 1.077; P = 0.013). The severity of pulmonary hypertension did not impact 30-day (P = 0.314) or late mortality (P = 0.860). Kaplan-Meier survival rates at 1, 3, and 5 years were 76.6% (n = 99), 65.7% (n = 62), and 55.9% (n = 41), respectively., Conclusions: Patients with pulmonary hypertension that undergo redo mitral valve surgery have a 55.9% 5-year survival rate. Increasing age, chronic renal insufficiency, peripheral vascular disease, and preexisting mitral valve prosthesis are associated with early mortality. The severity of pulmonary hypertension does not affect operative mortality rates, but it may decrease 1-, 3-, and 5-year survival.

Objective: More than 50% of atrial fibrillation surgery occurs in the setting of mitral valve surgery. Despite this, no risk models have been validated for concomitant arrhythmia surgery. The purpose of the present study was to quantify the additional risk of performing the Cox-maze IV procedure for patients undergoing mitral valve surgery., Methods: From January 2002 to June 2011, 213 patients with mitral valve disease and preoperative atrial fibrillation underwent mitral valve surgery only (n = 109) or in conjunction with a Cox-maze IV procedure (n = 104). The operative mortality for the mitral valve procedure alone was predicted for each group using the Society of Thoracic Surgeons perioperative risk calculator. The risk attributed to the added Cox-maze IV procedure was calculated by comparing the predicted mortality rate of an isolated mitral valve procedure and the actual mortality rate of mitral valve surgery with a concomitant Cox-maze IV procedure., Results: For patients not undergoing a Cox-maze IV procedure, the predicted and actual postoperative mortality rate was 5.5% and 4.6% (5 of 109), respectively. For patients receiving mitral valve surgery and a concomitant Cox-maze IV, the predicted and actual postoperative mortality of the mitral valve procedure was 2.5% and 2.9% (3 of 104), respectively, and not significantly different. Patients not offered a Cox-maze IV procedure had significantly more serious comorbidities., Conclusions: For patients with atrial fibrillation and mitral valve disease undergoing mitral valve surgery, the decision to offer a concomitant Cox-maze IV procedure will be influenced by the underlying comorbid conditions. Nonetheless, in selected lower risk patients, the addition of a Cox-maze IV procedure did not significantly affect the procedural mortality., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The presence of pulmonary hypertension historically has been considered a significant risk factor affecting early and late outcomes after valve replacement. Given the number of recent advances in the management of pulmonary hypertension after cardiac surgery, a better understanding of its impact on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine whether pulmonary hypertension remains a risk factor in the modern era for adverse outcomes after aortic valve replacement for aortic valve stenosis., Methods: From January 1996 to June 2009, a total of 1080 patients underwent aortic valve replacement for primary aortic valve stenosis, of whom 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had pulmonary hypertension. Pulmonary hypertension was defined as mild (sPAP 35-44 mm Hg), moderate (45-59 mm Hg), or severe (≥ 60 mm Hg). In the group of patients with pulmonary hypertension, 204 had postoperative echocardiograms., Results: Operative mortality was significantly higher in patients with pulmonary hypertension (47/506, 9%, vs 31/574, 5%, P = .02). The incidence of postoperative stroke was similar (P = .14), but patients with pulmonary hypertension had an increased median hospital length of stay (8 vs 7 days, P = .001) and an increased incidence of prolonged ventilation (26% vs 17%, P < .001). Preoperative pulmonary hypertension was an independent risk factor for decreased long-term survival (relative risk 1.7, P = .02). Those with persistent pulmonary hypertension postoperatively had decreased survival. Five-year survival (Kaplan-Meier) was 78% ± 6% with normal sPAP and 77% ± 7% with mild pulmonary hypertension postoperatively, compared with 64% ± 8% with moderate and 45% ± 12% with severe pulmonary hypertension (P < .001)., Conclusions: In patients undergoing aortic valve replacement, preoperative pulmonary hypertension increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe pulmonary hypertension after aortic valve replacement had decreased long-term survival. These data suggest that pulmonary hypertension had a significant impact on outcomes in patients undergoing aortic valve replacement and should be considered in preoperative risk assessment., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The purpose of this study was to determine the impact of prosthesis-patient mismatch on long-term survival after mitral valve replacement., Methods: From 1992 to 2008, 765 patients underwent bioprosthetic (325; 42%) or mechanical (440; 58%) mitral valve replacement, including 370 (48%) patients older than 65 years of age. Prosthesis-patient mismatch was defined as severe (prosthetic effective orifice area to body surface area ratio <0.9 cm(2)/m(2)), moderate (0.9 to 1.2 cm(2)/m(2)), or absent (>1.2 cm(2)/m(2))., Results: Multivariate analysis identified nine risk factors for late death including advanced age, earlier operative year, chronic renal insufficiency, peripheral vascular disease, congestive heart failure, nonrheumatic origin, concomitant coronary artery bypass grafting, lower body surface area, and more severe prosthesis-patient mismatch (lower effective orifice area to body surface area ratio; p < 0.05). For bioprosthetic recipients older than 65 years of age, survival at 5 and 10 years was 30% ± 7% and 0% ± 0% with severe mismatch compared with 43% ± 4% and 21% ± 5% for absent or moderate mismatch, respectively (p = 0.05). For mechanical recipients younger than 65 years of age, survival at 5 and 10 years was 77% ± 4% and 62% ± 6% with moderate or severe mismatch compared with 82% ± 3% and 66% ± 4%, respectively, without mismatch (p = 0.08)., Conclusions: Severe mismatch adversely affected long-term survival for older patients receiving bioprosthetic valves. With mechanical valves, there was a trend toward impaired survival when mismatch was moderate or severe in younger patients. Thus, selection of an appropriate mitral prosthesis warrants careful consideration of age and valve type., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this investigation was to examine the impact of prosthesis-patient mismatch after bioprosthetic aortic valve replacement on long-term survival in patients greater than 70 years of age compared with those less than or equal to 70 years of age., Methods: Between 1992 and 2007, 1399 patients underwent bioprosthetic aortic valve replacement, including 881 (63%) patients older than 70 years of age. Prosthesis-patient mismatch was defined as severe (prosthetic effective orifice area/body surface area < 0.65 cm(2)/m(2)), moderate (0.65-0.85 cm(2)/m(2)), or absent (>0.85 cm(2)/m(2)). For patients less than or equal to 70 years of age, mismatch was severe in 62 (12%), moderate in 251 (48%), and absent in 205 (40%). For patients greater than 70 years of age, mismatch was severe in 109 (12%), moderate in 451 (51%), and absent in 321 (37%). There was no difference in the distribution of prosthesis-patient mismatch between age groups (P = .50)., Results: For patients less than or equal to 70 years, prosthesis-patient mismatch was associated with impaired long-term survival (P = .02). Survival at 5 and 10 years was 61% +/- 7% and 28% +/- 12% for severe mismatch, 65% +/- 3% and 40% +/- 5% for moderate mismatch, and 73% +/- 5% and 46% +/- 9% for no mismatch. For patients greater than 70 years, prosthesis-patient mismatch did not affect long-term survival (P = .25). Survival at 5 and 10 years was 62% +/- 5% and 42% +/- 6% for severe mismatch, 62% +/- 2% and 30% +/- 5% for moderate mismatch, and 53% +/- 4% and 29% +/- 5% for absent mismatch., Conclusions: After bioprosthetic aortic valve replacement, prosthesis-patient mismatch had a negative impact on late survival for patients less than or equal to 70 years of age, but for patients greater than 70 years of age, prosthesis-patient mismatch did not influence late survival.

Background: The purpose of this study was to compare operative mortality and long-term outcome of patients undergoing tricuspid valve replacement versus tricuspid valve repair., Methods: From February 1986 to July 2006, 315 patients underwent tricuspid valve surgery including 93 replacements (72 biologic, 21 mechanical) and 222 repairs. To control for selection bias and varying comorbidities, a matched cohort of patients undergoing repair versus replacement was selected using propensity score analysis (68 patients in each group)., Results: In the propensity-matched cohorts, operative mortality was similar for tricuspid valve replacement (13% +/- 4%) and repair (18% +/- 5%; p = 0.64). Intensive care unit length of stay was similar between cohorts (replacement, 4 days; repair, 3 days; p = 0.45), but the replacements had a significantly longer hospital lengths of stay (9 days versus 6 days; p = 0.01). In the replacement cohort, survival was 85% at 1 year, 79% at 5 years, and 49% at 10 years. In the repair cohort, survival rates were similar with 80% at 1 year, 72% at 5 years, and 66% at 10 years (p = 0.66 versus replacement)., Conclusions: Surgical treatment of tricuspid valve disease, regardless of the operative approach, is associated with significant early and late mortality. However, there is no difference favoring tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for patients in whom we believe there is a reasonable chance for recurrence of regurgitation after repair.

Background: Excellent outcomes after aortic valve replacement (AVR) in elderly patients can be achieved, yet some practitioners are reticent to refer elderly patients for surgery. This study analyzed risk factors for mortality in patients aged 80 years and older undergoing AVR with or without concomitant coronary artery bypass grafting (CABG)., Methods: A retrospective review was performed of 245 patients (129 women) with a mean age of 83.6 +/- 2.9 years who had AVR with (n = 140) or without CABG (n = 105) at a single institution from 1993 to 2005. Data were analyzed with a multivariate logistic regression for predictors of operative mortality, Kaplan-Meier estimates of survival, and a Cox multivariate proportional analysis of factors influencing long-term survival., Results: Mean preoperative New York Heart Association (NYHA) classification was 3.1 +/- 0.9, and 78% (192/245) of patients were classified as NYHA class III or IV. Operative (30-day) mortality was 9% (22/245). Independent risk factors for operative mortality included postoperative renal failure (odds ratio [OR], 20.9; 95% confidence interval [CI], 6.5 to 67.6; p < 0.001), postoperative permanent stroke (OR, 11.3; 95% CI, 1.7 to 75.1; p = 0.019), or intraoperative/postoperative intraaortic balloon pump (IABP) placement (OR, 14.9; 95% CI 2.9 to 75.8; p = 0.002). Survival after surgery was 82% (n = 183) at 1 year and 56% (n = 88) at 5 years. Prognostic factors for decreased long-term survival were regurgitant valve pathology (hazard ratio [HR], 6.0; 95% CI, 2.5 to 14.2; p = 0.002), intraoperative/postoperative IABP (HR, 2.9; 95% CI, 1.4 to 6.0; p = 0.010), postoperative renal failure (HR, 3.5, 95% CI, 2.2 to 5.7; p < 0.001), and postoperative stroke (HR, 7.0, 95% CI, 3.2 to 15.9; p < 0.001). Performing concomitant CABG was protective in terms of operative mortality (OR, 0.3; 95% CI, 0.09 to 0.83; p = 0.017) and improved long-term survival (HR, 0.7, 95% CI, 0.47 to 0.96; p = 0.020). Preoperative NYHA classification did not affect operative or long-term survival., Conclusions: Patients aged 80 years and older who undergo AVR have acceptable short-term and long-term survival regardless of NYHA status. Concomitant CABG improved operative and long-term survival in this population. Despite their increased age, aggressive surgical treatment is warranted for most patients.

Background: Infective endocarditis is associated with a high rate of long-term mortality. Patients with a history of intravenous drug use (IVDU) are at increased risk for infective endocarditis. However, few studies have reported results of surgical treatment on this population. We present 19.5 years of experience with surgically treated patients with infective endocarditis., Methods: A retrospective study of all cardiac surgeries with a diagnosis of infective endocarditis at a single institution from 1986 to 2005 was performed. Logistic stepwise regression with an end point of operative mortality was done. Variables were age, gender, race, history of drug use, previous valve surgery, and previous valve replacement. Perioperative and outcome variables were compared between IVDU and non-IVDU populations., Results: The IVDU population required surgery at a younger age (39 +/- 9 years versus 54 +/- 15 years; p < 0.001). Overall operative mortality was 12% (41/346). The perioperative complication rate was similar for both groups. When adjusted for age, the two groups had similar long-term survival (p = 0.78). Kaplan-Meier estimator showed that survival at 10 and 15 years was 66% and 54% for IVDU and 56% and 42% for non-IVDU (number at risk, 19, 11, and 61, 28, respectively; p = 0.137). Reoperation for recurrent infective endocarditis was necessary in 9 (17%) of 52 of the IVDU group versus 14 (5%) of 270 of the non-IVDU group (p = 0.03)., Conclusions: Patients with a history of IVDU required reoperation for recurrent infective endocarditis at a significantly higher rate than the non-IVDU patients. Long-term survival was similar between the younger IVDU population and the older non-IVDU population. Anticipated life span is one of many factors when considering prosthetic valve choice in this population.