Surgery for Young Adults With Aortic Valve Disease not Amenable to Repair

Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair

Pulmonary Protection Strategies in Cardiac Surgery: Are We Making Any Progress?

Pulmonary dysfunction is a common complication of cardiac surgery. The mechanisms involved in the development of pulmonary dysfunction are multifactorial and can be related to the activation of inflammatory and oxidative stress pathways. Clinical manifestation varies from mild atelectasis to severe respiratory failure. Managing pulmonary dysfunction postcardiac surgery is a multistep process that starts before surgery and continues during both the operative and postoperative phases. Different pulmonary protection strategies have evolved over the years; however, the wide acceptance and clinical application of such techniques remain hindered by the poor level of evidence or the sample size of the studies. A better understanding of available modalities and/or combinations can result in the development of customised strategies for the different cohorts of patients with the potential to hence maximise patients and institutes benefits

Postoperative acute kidney injury defined by RIFLE criteria predicts early health outcome and long-term survival in patients undergoing redo coronary artery bypass graft surgery

AbstractObjectiveTo investigate the impact of postoperative acute kidney injury (AKI) on early health outcome and on long-term survival in patients undergoing redo coronary artery bypass grafting (CABG).MethodsWe performed a Cox analysis with 398 consecutive patients undergoing redo CABG over a median follow-up of 7 years (interquartile range, 4-12.2 years). Renal function was assessed using baseline and peak postoperative levels of serum creatinine. AKI was defined according to the risk, injury, failure, loss, and end-stage (RIFLE) criteria. Health outcome measures included the rate of in-hospital AKI and all-cause 30-day and long-term mortality, using data from the United Kingdom's Office of National Statistics. Propensity score matching, as well as logistic regression analyses, were used. The impact of postoperative AKI at different time points was related to survival.ResultsIn patients with redo CABG, the occurrence of postoperative AKI was associated with in-hospital mortality (odds ratio [OR], 3.74; 95% confidence interval [CI], −1.3 to 10.5; P < .01], high Euroscore (OR, 1.27; 95% CI, 1.07-1.52; P < .01), use of IABP (OR, 6.9; 95% CI, 2.24-20.3; P < .01), and reduced long-term survival (hazard ratio [HR], 2.42; 95% CI, 1.63-3.6; P = .01). Overall survival at 5 and 10 years was lower in AKI patients with AKI compared with those without AKI (64% vs 85% at 5 years; 51% vs 68% at 10 years). On 1:1 propensity score matching analysis, postoperative AKI was independently associated with reduced long term survival (HR, 2.8; 95% CI, 1.15-6.7).ConclusionsIn patients undergoing redo CABG, the occurrence of postoperative AKI is associated with increased 30-day mortality and major complications and with reduced long-term survival