Prosthesis–patient mismatch is less frequent and more clinically indolent in patients operated for aortic insufficiency

ObjectiveTo date, no study has focused on the incidence and effects of prosthesis–patient mismatch in patients requiring aortic valve replacement for aortic insufficiency. We hypothesized that the incidence and implications of prosthesis–patient mismatch in patients with aortic insufficiency might be different than for aortic stenosis or mixed disease because the annulus is generally larger in aortic insufficiency and left ventricular remodeling might differ.MethodsNinety-eight patients with lone aortic insufficiency (≥3+ with a preoperative mean gradient <30 mm Hg) were followed over 7.7 ± 4.3 years (maximum, 17.5 years) with clinical and echocardiographic assessments. They were compared with 707 patients who had aortic valve replacement for aortic stenosis or mixed disease. Prosthesis–patient mismatch was defined as an in vivo indexed effective orifice area of 0.85 cm2/m2 or less.ResultsCompared with patients with aortic stenosis/mixed disease, patients with aortic insufficiency had approximately half the incidence of prosthesis–patient mismatch (P = .003). Patients with prosthesis–patient mismatch had significantly higher transprosthesis gradients postoperatively. An independent detrimental effect of prosthesis–patient mismatch on survival was observed in patients with aortic stenosis/mixed disease who had preoperative left ventricular dysfunction (hazard ratio, 2.3; P = .03) but not in patients with aortic insufficiency, irrespective of left ventricular function (hazard ratio, 0.7; P = .7). In patients with aortic stenosis/mixed disease with left ventricular dysfunction, prosthesis–patient mismatch predicted heart failure symptoms by 3 years after aortic valve replacement (odds ratio, 6.0; P = .002), but there was no such effect in patients with aortic insufficiency (P = .8). Indexed left ventricular mass regression occurred to a greater extent in patients with aortic insufficiency than in patients with aortic stenosis/mixed disease (by an additional 29 ± 5 g/m2, P < .001), and there was a trend for prosthesis–patient mismatch to impair regression in patients with aortic insufficiency (by 30 ± 17 g/m2, P = .1).ConclusionsThe incidence and significance of prosthesis–patient mismatch differs in patients with aortic insufficiency compared with those with aortic stenosis or mixed disease. In patients with aortic insufficiency, prosthesis–patient mismatch is seen less frequently and has no significant effect on survival and freedom from heart failure but might have a negative effect on left ventricular mass regression

Should Jehovah’s Witness patients be listed for heart transplantation?

This best evidence topic in Cardiac Surgery was written according to a structured protocol. The question addressed was: for [Jehovah’s Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without an increased rate of mortality. Altogether, 133 papers were found using the reported search strategy. Of those, 29 papers represented the best evidence to answer the clinical question. Five papers focusing on patients of the Jehovah’s Witness (JW) faith who had end-stage heart failure were published. Successful heart transplantation was performed in a total of seven patients without mortality, re-exploration or blood transfusion. One patient had left ventricular reduction surgery twice and another patient had bypass surgery several years after transplantation. Other successful organ transplantations were also reported, including lung, liver, kidney and pancreas in both adult and paediatric patients of the JW faith, with comparable mortality and morbidity to non-JW patients. A publication bias is likely; nevertheless, we conclude that although there are no large studies directly focused on heart transplantation in JW patients, a multidisciplinary team approach to such surgery can make it technically feasible and without an increased mortality risk in suitable candidates. Therefore, such patients may be considered for heart transplantation under selected and favourable circumstances

The clopidogrel after surgery for coronary artery disease (CASCADE) randomized controlled trial: clopidogrel and aspirin versus aspirin alone after coronary bypass surgery [NCT00228423]

Abstract Background Saphenous vein graft disease remains a major limitation of coronary artery bypass graft surgery. The process of saphenous vein intimal hyperplasia begins just days after surgical revascularization, setting the stage for graft atherosclerotic disease and its sequalae. Clopidogrel improves outcomes in patients with atherosclerotic disease, and is effective at reducing intimal hyperplasia in animal models of thrombosis. Therefore, the goal of this study will be to evaluate the efficacy of clopidogrel and aspirin therapy versus aspirin alone in the prevention of saphenous vein graft intimal hyperplasia following coronary artery bypass surgery. Methods Patients undergoing multi-vessel coronary artery bypass grafting and in whom at least two saphenous vein grafts will be used are eligible for the study. Patients will be randomized to receive daily clopidogrel 75 mg or placebo, in addition to daily aspirin 162 mg, for a one year duration starting on the day of surgery (as soon as postoperative bleeding has been excluded). At the end of one year, all patients will undergo coronary angiography and intravascular ultrasound assessment of one saphenous vein graft as selected by randomization. The trial will be powered to test the hypothesis that clopidogrel and aspirin will reduce vein graft intimal hyperplasia by 20% compared to aspirin alone at one year following bypass surgery. Discussion This trial is the first prospective human study that will address the question of whether clopidogrel therapy improves outcomes and reduces saphenous vein graft intimal hyperplasia following cardiac surgery. Should the combination of clopidogrel and aspirin reduce the process of vein graft intimal hyperplasia, the results of this study will help redefine modern antiplatelet management of coronary artery bypass patients.</p