Impact of concomitant aortic regurgitation on long-term outcome after surgical aortic valve replacement in patients with severe aortic stenosis

<p>Abstract</p> <p>Background</p> <p>Prognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality.</p> <p>Methods</p> <p>Study group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR.</p> <p>Results</p> <p>Patients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality.</p> <p>Conclusion</p> <p>Our data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.</p

The influence of high‐dose systemic zoledronate administration on osseointegration of implants with different surface topography

To evaluate the influence of systemic zoledronate administration on the osseointegration of titanium implants with different surface topography in rat maxillae.Twenty Sprague-Dawley rats were divided into two groups-test (bisphosphonate) and control (healthy). Bisphosphonate administration began three weeks prior to implant placement, and the animals received zoledronate (66\ua0μg/kg) three times per week. Forty endosseous implants with a moderately rough (20 implants) or a turned surface (20 implants) were immediately placed bilaterally into extraction sockets of maxillary first molars. Animals were sacrificed after 14 and 28\ua0days of healing, and en bloc specimens were harvested for histological and histomorphometric analysis. Osseointegration was quantified by measuring the percentage of bone-to-implant contact.Bone-to-implant contact (BIC) (mean\ua0±\ua0SD) values of moderately rough and turned implants at day 14 in test group were 17.62\ua0±\ua06.68 and 10.69\ua0±\ua01.48, respectively, while in the control group, they were 46.36\ua0±\ua05.08 and 33.29\ua0±\ua08.89, respectively. At day 28, BIC values of moderately rough and turned implants in the test group were 25.94\ua0±\ua07.87 and 7.83\ua0±\ua04.30, respectively, while in the control group, they were 72.99\ua0±\ua06.60 and 47.62\ua0±\ua018.19, respectively. Statistically significant higher BIC values were measured on moderately rough implants compared to turned implants at 28\ua0days, and the control group compared to the test group for both implant surfaces. Histological observations for the control and the test groups demonstrated initial bone formation around moderately rough implants not only on the surface of the parent bone, as was the case with the turned surfaced implants, but also along the implant surface itself.Systemic zoledronate administration negatively influences osseointegration. Osseointegration was enhanced adjacent to moderately rough compared to turned implants in both the presence and absence of systemic zoledronate administration. Therefore, topographical surface modification may partially offset the negative impact of zoledronate administration

Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome

Objectives: To identify predictors of operative and postoperative mortality and of functional reversibility after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and severe left ventricular (LV) systolic dysfunction. Methods and results: Between 1990 and 2000, 155 consecutive patients (mean (SD) age 72 (9) years) in New York Heart Association (NYHA) heart failure functional class III or IV (n  =  138) and with LV ejection fraction (LVEF) ⩽ 30% underwent AVR for critical AS (mean (SD) valve area index 0.35 (0.09) cm(2)/m(2)). Thirty day mortality was 12%. NYHA class (3.7 (0.6) v 3.2 (0.7), p  =  0.004), cardiothoracic ratio (CTR) (0.63 (0.07) v 0.56 (0.06), p < 0.0001), pulmonary artery systolic pressure (63 (25) v 50 (19) mm Hg, p  =  0.03), and prevalence of complete left bundle branch block (22% v 8%, p  =  0.03) and of renal insufficiency (p  =  0.001) were significantly higher in 18 non-survivors than in 137 survivors. In multivariate analysis, the only independent predictor of operative mortality was a CTR ⩾ 0.6 (odds ratio (OR) 12.2, 95% confidence interval (CI) 5.4 to 27.4, p  =  0.002). The difference between preoperative and immediate postoperative LVEF (early-ΔEF) was > 10 ejection fraction units (EFU) in 55 survivors. In multivariate analysis, CTR (OR 5.95, 95% CI 3.0 to 11.6, p  =  0.006) and mean transaortic gradient (OR 1.05, 95% CI 1.0 to 1.1, p < 0.05) were independent predictors of an early-ΔEF > 10 EFU. During a mean (SD) follow up of 4.6 (3) years, 50 of 137 (36%) 30 day survivors died, 31 of non-cardiac causes. Diabetes (OR 3.8, 95% CI 2.4 to 6.0, p  =  0.003), age ⩾ 75 years (OR 2.6, 95% CI 2.1 to 4.5, p  =  0.004), and early-ΔEF ⩽ 10 EFU (OR 0.96, 95% CI 0.94 to 0.97, p  =  0.01) were independent predictors of long term mortality. Among 127 survivors, the percentage of patients in NYHA functional class III or IV decreased from 89% preoperatively to 3% at one year. The decrease in functional class was significantly greater in patients with an early-ΔEF > 10 EFU than patients with an early-ΔEF ⩽ 10 EFU (p  =  0.02). In addition, the mean (SD) LVEF at one year was 53 (11)% in patients with an early-ΔEF > 10 EFU and 42 (11)% in patients with early-ΔEF ⩽ 10 EFU (p < 0.001). Conclusions: Despite a relatively high operative mortality, AVR for AS and severely depressed LVEF was beneficial in the majority of patients. Early postoperative recovery of LV function was associated with significantly greater relief of symptoms and longer survival