Surgical treatment of hypertrophic obstructive cardiomyopathy in relatively elderly patients: Short- and long-term outcomes

OBJECTIVES: Our goal was to assess the short- and long-term outcomes of surgical treatment for hypertrophic obstructive cardiomyopathy in patients >= 65 years of age compared to patients < 65 years of age.METHODS: Sixty-four patients aged >= 65 years, surgically treated for symptomatic hypertrophic obstructive cardiomyopathy, were compared to a control group of 125 patients <65 years.RESULTS: Patients aged >65 years were less frequently male (36% vs 68%, P < 0.001) and had higher EuroSCORE II scores [1.4 (1.1-2.2) vs 0.8 (0.7-1.2), P < 0.001], lower risk of sudden death, higher pulmonary artery pressure [40 (30-50) vs 30 (30-43), P= 0.04) and more mitral annulus calcifications (44% vs 14%, P < 0.001) compared to younger patients.Hospital death was 1%, with no difference between the 2 groups (1.5% vs 0.8%, P = 0.9).Patients aged >= 65 years had more concomitant coronary bypass grafting (12% vs 5%, P= 0.05) and a higher incidence of blood transfusions (50% vs 17%, P < 0.001) and postoperative atrial fibrillation (19% vs 8%, P = 0.02).Follow-up was 98% complete [median 8.3 (5.3-12.8) years]. The 13-year survival in the group aged >= 65 was 54 (SD: 9) % vs 83 (SD: 5) % in the control group (P < 0.001), but it was comparable to that expected in the age-sex matched general national population.At 13 years, the cumulative incidence function of cardiac death in the elderly group was 19 (SD: 7)%, mostly unrelated to hypertrophic cardiomyopathy causes.At the last follow-up, 90% of patients were in New York Heart Association functional class I-II and 68% were in sinus rhythm.CONCLUSIONS: Selected elderly symptomatic patients with hypertrophic obstructive cardiomyopathy can benefit from surgery, with low hospital mortality and morbidity, relief of symptoms and late survival comparable to that expected in the age-sex matched general population

Edge-to-Edge Technique Used as a Bailout for Suboptimal Mitral Repair: long-term results

BACKGROUND: In case of initial sub-optimal mitral valve repair the edge-to-edge (EE) technique has been used as a bail-out procedure. However, the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long term clinical and echocardiographic results of the EE technique used to rescue patients with initial sub-optimal conventional mitral valve repair. METHODS: A retrospective review of our institutional database was carried on querying for patients who had undergone mitral valve repair with EE used as a bailout procedure. Cumulative Incidence Function using death as competitive event was used to estimate cardiac death and REDO for mitral valve replacement. To describe the time course of MR, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data. RESULTS: 81 patients were selected. The median follow-up was 9.1 years [IQR 6.7-12.1], maximum: 22.6 years. At 15 years the estimated Kaplan-Meier overall survival was 63.2 ± 8.69%, 95% CI [43.76-77.46] and the predicted rate of moderate to severe MR recurrence was 16.67%. At 15 years the CIF for REDO for mitral valve replacement with death as competing event was 2.5 %; 95% CI [0.48-7.84] No case of more than mild mitral stenosis was detected. CONCLUSIONS: The EE technique can be effectively used as a bailout procedure in patients with sub-optimal conventional mitral valve repair with very satisfactory long term results

Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy†

OBJECTIVES: Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. METHODS: Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. RESULTS: Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6-year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. CONCLUSIONS: Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control

Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease does the surgical approach have an Impact on the long-term results

OBJECTIVES: To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. METHODS: We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. RESULTS: No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P  = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P  = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P  = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. CONCLUSIONS: A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis

Risk Stratification and Management of Arterial Hypertension and Cardiovascular Adverse Events Related to Cancer Treatments: An Oncology Network from Piedmont and Aosta Valley (North-Western Italy) Consensus Document

Cancer patients receiving a potentially cardiotoxic oncologic therapy have an increased risk of cardiovascular adverse events (CVAEs), especially in presence of concomitant arterial hypertension (AH). Therefore, cancer patients should be evaluated before, during and after cardiotoxic treatments, to early identify new-onset or worsening AH or CVAEs. An expert panel of oncology networks from Piedmont and Aosta Valley (North-Western Italy) aimed to provide recommendations to support health professionals in selecting the best management strategies for patients, considering the impact on outcome and the risk–benefit ratio of diagnostic/therapeutic tools. We proposed an useful document for evaluating and managing AH related to cancer treatments. Patients should be divided into 4 cardiovascular (CV) risk groups before starting potentially cardiotoxic therapies: patients with low/moderate risk who should be entirely evaluated by oncologists and patients with high/very high risk who should be referred to a cardiologist or arterial hypertension specialist. According to the CV risk class, every patient should be followed up during cancer treatment to monitor any possible CV complications. Adequate control of AH related to antineoplastic treatments is crucial to prevent severe CVAEs. In the presence of high-profile risk or lack of response to anti-hypertensive therapy, the patients should be managed with a cardiovascular-oncology expert center