Publications by authors named "Thierry G Mesana"

100 Publications

Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist.

CMAJ 2021 Aug;193(34):E1333-E1340

Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont.

Background: Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery.

Methods: We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection.

Results: Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points.

Interpretation: We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.
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http://dx.doi.org/10.1503/cmaj.210170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432314PMC
August 2021

Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study.

BMJ Open 2021 08 25;11(8):e051192. Epub 2021 Aug 25.

Department of Anesthesiology and Pain Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.

Background: Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.

Objectives: We sought to determine the association between cardiac physician team sex discordance and patient outcomes.

Design: We performed a population-based, retrospective cohort study.

Participants And Setting: Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.

Primary And Secondary Outcome Measures: The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.

Results: 79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).

Conclusions: Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.
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http://dx.doi.org/10.1136/bmjopen-2021-051192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8388286PMC
August 2021

Aortic valve repair decreases risks of VRE in AI at 10 years: a propensity score-matched analysis.

Ann Thorac Surg 2021 Jul 3. Epub 2021 Jul 3.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada. Electronic address:

Background: Aortic valve repair(AVr) has emerged as a feasible and effective alternative to replacement(AVR) in patients with aortic insufficiency(AI), however, little data exists comparing outcomes. Thus, the objective of this study was to compare early and long-term valve related complications between AVr and AVR in the treatment of AI.

Methods: Single centre, retrospective study of all patients(n=417) undergoing AVr (n=264) or AVR (n=153) for primary AI. Propensity-matching using a 1:1 greedy matching algorithm identified 140 patients using six covariates (age, gender, LV function, size, presence of aortopathy, and urgency of operation) for comparison. The primary outcome was a composite of all valve-related events(VRE), including: endocarditis, myocardial infarction(MI), stroke, transient ischemic attack(TIA), thromboembolisms, bleeding, and aortic valve(AV) reoperation. VRE were defined as per published guidelines. Survival and freedom from VRE were reported using the Kaplan-Meier method.

Results: Propensity-matching identified 70 well matched pairs with no major differences in baseline demographics, comorbidities, or AI severity(p=0.57). Perioperative outcomes showed no significant differences in VRE (AVR 8 vs AVr 7,p=0.78) or mortality (AVR 3 vs AVr 1,p=0.62). Event-free survival from the primary outcome at 10-years was significantly better after AVr than after AVR (82%vs68%,p=0.024), with no significant differences in 10-year overall survival between groups(82%vs72%,p=0.29). No significant differences in AI severity(p=0.07) or reoperation rate(p=0.44) were detected between groups.

Conclusions: This study demonstrated a lower long-term risk of VRE with repair compared to replacement, with low mortality and comparable durability. Further prospective randomized control trials are necessary to formally compare outcomes and determine superiority.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.020DOI Listing
July 2021

Disability-free survival after major cardiac surgery: a population-based retrospective cohort study.

CMAJ Open 2021 Apr-Jun;9(2):E384-E393. Epub 2021 Apr 16.

The Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine (Sun), University of Ottawa Heart Institute; the School of Epidemiology and Public Health (Sun), University of Ottawa; the Institute for Clinical Evaluative Sciences (Sun, Bader Eddeen); the Division of Cardiac Surgery, Department of Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont.

Background: Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery.

Methods: We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models.

Results: The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability.

Interpretation: The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.
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http://dx.doi.org/10.9778/cmajo.20200096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084566PMC
August 2021

Derivation of Patient-Defined Adverse Cardiovascular and Noncardiovascular Events Through a Modified Delphi Process.

JAMA Netw Open 2021 01 4;4(1):e2032095. Epub 2021 Jan 4.

University of Ottawa Heart Institute Patient Alumni Association, Ottawa, Ontario, Canada.

Importance: There is little evidence to support patient-centered outcomes in patients with cardiovascular disease.

Objective: To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process.

Design, Setting, And Participants: This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019.

Main Outcomes And Measures: Defining PACE as a 5-item composite outcome.

Results: Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis.

Conclusions And Relevance: This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.32095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783543PMC
January 2021

Derivation and Validation of a Clinical Model to Predict Intensive Care Unit Length of Stay After Cardiac Surgery.

J Am Heart Assoc 2020 11 29;9(21):e017847. Epub 2020 Sep 29.

Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada.

Background Across the globe, elective surgeries have been postponed to limit infectious exposure and preserve hospital capacity for coronavirus disease 2019 (COVID-19). However, the ramp down in cardiac surgery volumes may result in unintended harm to patients who are at high risk of mortality if their conditions are left untreated. To help optimize triage decisions, we derived and ambispectively validated a clinical score to predict intensive care unit length of stay after cardiac surgery. Methods and Results Following ethics approval, we derived and performed multicenter valida tion of clinical models to predict the likelihood of short (≤2 days) and prolonged intensive care unit length of stay (≥7 days) in patients aged ≥18 years, who underwent coronary artery bypass grafting and/or aortic, mitral, and tricuspid value surgery in Ontario, Canada. Multivariable logistic regression with backward variable selection was used, along with clinical judgment, in the modeling process. For the model that predicted short intensive care unit stay, the c-statistic was 0.78 in the derivation cohort and 0.71 in the validation cohort. For the model that predicted prolonged stay, c-statistic was 0.85 in the derivation and 0.78 in the validation cohort. The models, together termed the , demonstrated a high degree of accuracy during prospective testing. Conclusions Clinical judgment alone has been shown to be inaccurate in predicting postoperative intensive care unit length of stay. The CardiOttawa LOS Score performed well in prospective validation and will complement the clinician's gestalt in making more efficient resource allocation during the COVID-19 period and beyond.
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http://dx.doi.org/10.1161/JAHA.120.017847DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763427PMC
November 2020

MitraClip Real-World Data: What Is Missing and Looking Into the Future.

Authors:
Thierry G Mesana

Cardiovasc Revasc Med 2020 09 22;21(9):1063-1064. Epub 2020 Jul 22.

University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.carrev.2020.06.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375297PMC
September 2020

The Impact of Preoperative Risk on the Association between Hypotension and Mortality after Cardiac Surgery: An Observational Study.

J Clin Med 2020 Jun 30;9(7). Epub 2020 Jun 30.

Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.

Background: Despite steady improvements in cardiac surgery-related outcomes, our understanding of the physiologic mechanisms leading to perioperative mortality remains incomplete. Intraoperative hypotension is an important risk factor for mortality after noncardiac surgery but remains relatively unexplored in the context of cardiac surgery. We examined whether the association between intraoperative hypotension and in-hospital mortality varied by patient and procedure characteristics, as defined by the validated Cardiac Anesthesia Risk Evaluation (CARE) mortality risk score.

Methods: We conducted a retrospective cohort study of consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass (CPB) from November 2009-March 2015. Those who underwent off-pump, thoracic aorta, transplant and ventricular assist device procedures were excluded. The primary outcome was in-hospital mortality. Hypotension was categorized by mean arterial pressure (MAP) of <55 and between 55-64 mmHg before, during and after CPB. The relationship between hypotension and death was modeled using multivariable logistic regression in the intermediate and high-risk groups.

Results: Among 6627 included patients, 131 (2%) died in-hospital. In-hospital mortality in patients with CARE scores of 1, 2, 3, 4 and 5 was 0 (0%), 7 (0.3%), 35 (1.3%), 41 (4.6%) and 48 (13.6%), respectively. In the intermediate-risk group (CARE = 3-4), MAP < 65 mmHg post-CPB was associated with increased odds of death in a dose-dependent fashion (adjusted OR 1.30, 95% CI 1.13-1.49, per 10 min exposure to MAP < 55 mmHg, = 0.002; adjusted OR 1.18 [1.07-1.30] per 10 min exposure to MAP 55-64 mmHg, = 0.001). We did not observe an association between hypotension and mortality in the high-risk group (CARE = 5).

Conclusions: Post-CPB hypotension is a potentially modifiable risk factor for mortality in intermediate-risk patients. Our findings provide impetus for clinical trials to determine if hemodynamic goal-directed therapies could improve survival in these patients.
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http://dx.doi.org/10.3390/jcm9072057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7408639PMC
June 2020

Sex Differences in Long-Term Survival After Major Cardiac Surgery: A Population-Based Cohort Study.

J Am Heart Assoc 2019 09 23;8(17):e013260. Epub 2019 Aug 23.

Institute for Clinical Evaluative Sciences Ontario Canada.

Background Little attention has been paid to the importance of sex in the long-term prognosis of patients undergoing cardiac surgery. Methods and Results We conducted a retrospective cohort study of Ontario residents, aged ≥40 years, who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral, or tricuspid valve surgery between October 1, 2008, and December 31, 2016. The primary outcome was all-cause mortality. The mortality rate in each surgical group was calculated using the Kaplan-Meier method. The risk of death was assessed using multivariable Cox proportional hazard models. Sex-specific mortality risk factors were identified using multiplicative interaction terms. A total of 72 824 patients were included in the study (25% women). The median follow-up period was 5 (interquartile range, 3-7) years. The long-term age-standardized mortality rate was lowest in patients who underwent isolated CABG and highest among those who underwent combined CABG/multiple valve surgery. Women had significantly higher age-standardized mortality rate than men after CABG and combined CABG/mitral valve surgery. Men had lower rates of long-term mortality than women after isolated mitral valve repair, whereas women had lower rates of long-term mortality than men after isolated mitral valve replacement. We observed a statistically significant association between female sex and long-term mortality after adjustment for key risk factors. Conclusions Female sex was associated with long-term mortality after cardiac surgery. Perioperative optimization and long-term follow-up should be tailored to younger women with a history of myocardial infarction and percutaneous coronary intervention and older men with a history of chronic obstructive pulmonary disease and depression.
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http://dx.doi.org/10.1161/JAHA.119.013260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755832PMC
September 2019

Reply.

Ann Thorac Surg 2017 09;104(3):1095

Division of Cardiac Surgery, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada.

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http://dx.doi.org/10.1016/j.athoracsur.2016.12.033DOI Listing
September 2017

Eight-year follow-up of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial.

J Thorac Cardiovasc Surg 2018 01 24;155(1):212-222.e2. Epub 2017 Jun 24.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

Objective: In this 8 years' follow-up study, we evaluated the long-term outcomes of the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting, versus aspirin plus placebo, with respect to survival, major adverse cardiac, or major cerebrovascular events, including revascularization, functional status, graft patency, and native coronary artery disease progression.

Methods: In the initial Clopidogrel After Surgery for Coronary Artery Disease trial, 113 patients were randomized to receive either daily clopidogrel (n = 56) or placebo (n = 57), in addition to aspirin, in a double-blind fashion for 1 year after coronary artery bypass grafting. All patients were re-evaluated to collect long-term clinical data. Surviving patients with a glomerular filtration rate > 30 mL/min were asked to undergo a coronary computed tomography angiogram to evaluate the late saphenous vein graft patency and native coronary artery disease progression.

Results: At a median follow-up of 7.6 years, survival rate was 85.5% ± 3.8% (P = .23 between the 2 groups). A trend toward enhanced freedom from all-cause death or major adverse cardiac or cerebrovascular events, including revascularization, was observed in the aspirin-clopidogrel group (P = .11). No difference in functional status or freedom from angina was observed between the 2 groups (P > .57). The long-term patency of saphenous vein graft was 89.11% in the aspirin-clopidogrel group versus 91.23% in the aspirin-placebo group (P = .79). A lower incidence of moderate to severe native disease progression was observed in the aspirin-clopidogrel group versus the aspirin-placebo group (7 out of 122 vs 13 out of 78 coronary segments that showed progression, respectively [odds ratio, 0.3 ± 0.2; 95% confidence interval, 0.1-0.8; P = .02]).

Conclusions: At 8 years' follow-up, the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting exhibited a lower incidence of moderate to severe progression of native coronary artery disease and a trend toward higher freedom from major adverse cardiac or cerebrovascular events, including revascularization, or death in the aspirin-clopidogrel group.

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00228423.
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http://dx.doi.org/10.1016/j.jtcvs.2017.06.039DOI Listing
January 2018

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial).

BMJ Open 2017 05 30;7(5):e015032. Epub 2017 May 30.

Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada.

Background: The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted.

Methods And Analysis: This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery.

Ethics And Dissemination: Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context.

Trial Registration Number: NCT02552771.
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http://dx.doi.org/10.1136/bmjopen-2016-015032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729977PMC
May 2017

Atherosclerotic arch and anemia: A dangerous combination.

Authors:
Thierry G Mesana

J Thorac Cardiovasc Surg 2017 07 3;154(1):e5-e6. Epub 2017 Apr 3.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2017.03.075DOI Listing
July 2017

How Does Mitral Valve Repair Fail in Patients With Prolapse?-Insights From Longitudinal Echocardiographic Follow-Up.

Ann Thorac Surg 2016 Nov 6;102(5):1459-1465. Epub 2016 Oct 6.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Background: Repair of mitral regurgitation (MR) caused by prolapse has been well validated. Although favorable early and late results after repair have been reported, few data are available that mechanistically describe how a mitral repair fails beyond the mere need for mitral valve reoperation. We therefore sought to determine the modes of valve repair failure in patients who underwent surgical correction of MR caused by prolapse.

Methods: Between 2001 and 2015, 855 patients underwent repair of MR caused by prolapse. Patients were a mean age of 63.7 ± 12.7 years, and 380 (44%) had bileaflet prolapse. The overall repair rate was 97.2%. These patients were monitored as part of a cohort initiative and underwent serial clinical and echocardiographic assessments at 1, 3 to 6, and 12 months after the operation. Beyond the first year of the MR repair, patients were assessed by echocardiography every 1 to 2 years or when clinically indicated. Clinical and echocardiographic follow-up averaged 4.3 ± 3.5 years.

Results: Freedom from recurrent MR of 2+ or higher was 92.4% ± 1.3% at 5 years and 86.6% ± 2.4% at 10 years. Overall, recurrent MR of 2+ or higher developed in 49 patients (5.7%) at a mean of 3.1 ± 2.5 years after the repair, of whom 14 (1.6%) had recurrent MR of 3+ or 4+. Among patients with bileaflet prolapse, recurrent MR of 2+ or higher was observed in 24, of whom 9 had 3+ or 4+ MR., The development of recurrent MR of 2+ or higher was categorized as prolapse in 6 and nonprolapse in 43. Severe mitral stenosis occurred in 3 patients at 8.2 years after the MR repair. Mitral reoperation was ultimately performed in 21 patients. Patients who had recurrent MR 2+ or higher within the first year after the operation were more likely to undergo a subsequent mitral valve reoperation (incident rate ratio, 5.2 ± 2.9; p = 0.003), although no association between recurrent MR and reoperation was observed after the first year.

Conclusions: Severe MR after repair is rare, although some may have recurrent moderate MR. Patients who required a subsequent mitral valve reoperation were most likely to have recurrent MR of 2+ or higher within the first year after the operation.
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http://dx.doi.org/10.1016/j.athoracsur.2016.08.088DOI Listing
November 2016

When Should the Mitral Valve Be Repaired or Replaced in Patients With Ischemic Mitral Regurgitation?

Ann Thorac Surg 2017 Mar 22;103(3):742-747. Epub 2016 Sep 22.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Background: Data comparing outcomes after repair versus replacement of chronic ischemic mitral regurgitation (MR) is evolving. Recent data suggest that repair is associated with recurrent MR, but not survival, when compared with replacement. However, it remains unclear when either surgical strategy should be applied based on preoperative mitral valve anatomy.

Methods: Between 2001 and 2013, 161 patients underwent repair or replacement of chronic ischemic MR. The mean age of these patients was 68.2 ± 9.0 years, 44 (27%) were female, and concomitant coronary artery bypass grafting was performed in 126 (78%). The mean preoperative posterior leaflet angle was 27.7 ± 14.2 degrees, and the left ventricular ejection fraction was 41.2 ± 12.4%. Detailed preoperative assessments of mitral valve anatomy were determined by transesophageal echocardiography. Clinical and echocardiographic follow-up was for 4.6 ± 3.2 years and extended to 11.7 years.

Results: Overall, perioperative death occurred in 6 (3.3%) patients; 2 patients died after valve repair and 4 after valve replacement. Five-year survival and freedom from recurrent MR (≥2+) rates were 74.0 ± 5.6% and 57.8 ± 8.0%, respectively, after valve repair and 69.4 ± 6.2% and 87.1 ± 7.0%, respectively, after valve replacement. Valve repair was associated with recurrent MR (≥2+) (hazard ratio [HR], 5.3 ± 3.3; p = 0.007), but not survival (HR, 0.9 ± 0.3; p = 0.8). Preoperative posterior leaflet tethering angle was associated with survival (HR, 1.09 ± 0.04; p = 0.005) and also recurrent MR (≥2+) (HR, 1.04 ± 0.02; p = 0.03) after valve repair. Based on a receiver operator curve describing the relationship between recurrent MR (≥2+) and posterior leaflet tethering angle, a threshold of 22 degrees was determined.

Conclusions: Surgical correction of chronic ischemic MR can be performed with favorable early and late results, although recurrent MR occurred more often after repair. Among patients who underwent repair of ischemic MR, a preoperative posterior leaflet tethering angle of 22 degrees or greater was associated with worse late outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2016.07.002DOI Listing
March 2017

Determinants of late outcomes in women undergoing mitral repair of myxomatous degeneration.

Interact Cardiovasc Thorac Surg 2016 11 29;23(5):779-783. Epub 2016 Jun 29.

Division of Cardiac Surgery, University of Ottawa, Ottawa, ON, Canada.

Objectives: Studies have consistently shown that women have worse perioperative outcomes following mitral surgery compared with men. Few data are available that explain these divergent outcomes. This study was conducted to determine whether women with degenerative mitral valve disease present to surgery with more advanced disease than men, and to determine whether these differences influence long-term clinical outcomes.

Methods: Seven hundred and forty-three patients underwent repair of mitral regurgitation due to myxomatous degeneration between 2001 and 2014. Of these, 208 (28%) were females and concomitant coronary bypass grafting was performed in 103 (14%). The mean clinical follow-up was for 3.1 years, and extended to 11.9 years.

Results: Perioperative mortality was 0.1%. Preoperatively, women had a larger indexed left atrial diameter (27.9 ± 5.7 vs 25.3 ± 4.7 mm/m, P = 0.0001), larger indexed left ventricle end-systolic dimension (20.6 ± 5.5 vs 18.7 ± 5.1 mm/m, P = 0.028) and higher right ventricular systolic pressure (44.4 ± 14.4 vs 41.7 ± 13.3 mmHg, P = 0.026) compared with men. Five-year survival and freedom from recurrent MR ≥2+ were 88.7 ± 1.8 and 90.7 ± 1.6%, respectively. Although gender was not associated with survival (hazard ratio: 1.04 ± 0.4, P = 0.91), women were more likely to develop recurrent MR ≥2+ at follow-up compared with men (hazard ratio: 1.9 ± 0.5, P = 0.007).

Conclusions: In this large series, women with degenerative mitral valve disease presented with echocardiographic markers suggestive of more advanced disease at the time of surgery. Although there was no difference in early or late survival between groups, women were more likely to develop recurrent MR ≥2+ over the course of follow-up. Earlier surgical referral of women may, therefore, be advised.
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http://dx.doi.org/10.1093/icvts/ivw222DOI Listing
November 2016

Functional mitral stenosis after mitral valve repair is a true anatomic problem that originates from the time of surgery.

J Thorac Cardiovasc Surg 2015 Nov 14;150(5):1091-2. Epub 2015 Aug 14.

University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2015.08.029DOI Listing
November 2015

Clinical Impact of Changes in Left Ventricular Function After Aortic Valve Replacement: Analysis From 3112 Patients.

Circulation 2015 Aug;132(8):741-7

From Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada.

Background: Our objectives were to identify correlates of mortality and congestive heart failure after aortic valve replacement (AVR) according to preoperative left ventricular (LV) function and to describe the incidence, time course, and correlates of LV recovery and mass regression postoperatively.

Methods And Results: A total of 3112 patients with AVR were assessed in a follow-up clinic with echocardiography (median follow-up, 6.0 years). At operation, their mean age was 67.8±13.4 years, one third were female, and 29% had LV dysfunction (ejection fraction <50%). In severe patients with severe aortic stenosis and LV dysfunction, transaortic valve mean pressure gradient <40 mm Hg, longer cardiopulmonary bypass duration, and prosthesis-patient mismatch (indexed effective orifice area ≤0.85 cm(2)/m(2)) were independent correlates of the composite outcome of death or congestive heart failure after AVR. In patients with severe aortic regurgitation and LV dysfunction, older age and higher preoperative LV mass were identified. LV recovery correlated with better survival and freedom from heart failure in patients with aortic stenosis. Maximum LV mass regression took 24 months in patients with aortic stenosis and nearly 5 years with aortic regurgitation; independent correlates included smaller LV end-systolic diameter in patients with aortic stenosis and low New York Heart Association class with aortic regurgitation.

Conclusions: Incomplete LV recovery, prosthesis-patient mismatch, low transaortic valve pressure gradient, and higher LV mass are associated with increased mortality or heart failure after AVR in patients with LV dysfunction. Higher LV end-systolic diameter and symptoms correlate with less LV mass regression, which takes at least 2 years. These findings help surgeons and cardiologists refine the indications, timing, prognostication, and follow-up of patients before and after AVR.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.115.015371DOI Listing
August 2015

Determinants of left ventricular dysfunction after repair of chronic asymptomatic mitral regurgitation.

Ann Thorac Surg 2015 Jan 6;99(1):38-42. Epub 2014 Nov 6.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Background: The evidence supporting early surgical intervention in patients with chronic asymptomatic mitral regurgitation (MR) is steadily accumulating. Although left ventricular (LV) enlargement and preoperative pulmonary hypertension are considered when deciding on surgical intervention, the threshold above which these factors influence clinical outcomes remains poorly defined.

Methods: One-hundred fifty asymptomatic patients of aged 59.3 ± 13.4 years underwent mitral valve repair of severe MR caused by myxomatous degeneration between 2001 and 2012. Mean preoperative left atrial diameter, LV end-systolic diameter (LVESD), and right ventricular systolic pressure were 41.2 ± 6.9 mm, 34.6 ± 5.4 mm, and 38.4 ± 11.8 mm Hg, respectively. Preoperative LV ejection fraction (LVEF) was greater than 60% in 136 (91%) patients, and none had preoperative atrial fibrillation. Clinical and echocardiographic follow-up averaged 3.3 years and extended to 9.1 years.

Results: There were no perioperative deaths. Five-year survival and freedom from recurrent MR greater than or equal to 2+ were 93.4% ± 3.2% and 94.0% ± 3.2%, respectively. A threshold LVESD indexed to body surface area greater than 19 mm/m(2) (hazard ratio [HR], 3.5 ± 2.0; p = 0.03) and a preoperative right ventricular systolic pressure greater than 45 mm Hg (HR, 3.8 ± 12.1; p = 0.01) were independently associated with postoperative LV dysfunction, defined as a LVEF less than 60%.

Conclusions: Mitral valve repair can be performed with favorable early and late outcomes in patients with asymptomatic severe MR. The presence of minimal LV enlargement and preoperative pulmonary hypertension were associated with postoperative LV dysfunction in this otherwise healthy population. Mitral valve repair may be considered in asymptomatic patients with an indexed LVESD (ILVESD) greater than 19 mm/m(2) or preoperative right ventricular systolic pressure greater than 45 mm Hg.
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http://dx.doi.org/10.1016/j.athoracsur.2014.07.025DOI Listing
January 2015

Perioperative deaths after mitral valve operations may be overestimated by contemporary risk models.

Ann Thorac Surg 2014 Aug 24;98(2):605-10; discussion 610. Epub 2014 Jun 24.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Background: Percutaneous therapies to manage mitral regurgitation are emerging as an alternative to conventional operations, especially for patients with a high estimated perioperative risk. However, contemporary risk models may not accurately reflect outcomes at reference mitral valve centers. The purpose of this study was to describe perioperative mortality rates after mitral valve operations in a contemporary cohort.

Methods: Between 2001 and 2011, 1,154 patients underwent mitral valve operations at a reference center. Of these, 851 underwent repair and 303 underwent replacement. Concomitant coronary artery bypass grafting was performed in 201 (17%). The Society of Thoracic Surgeons (STS) risk score version 2.73 and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II were used to estimate the number of perioperative deaths.

Results: The observed perioperative mortality was 1.0%. The STS score was 2.3%±2.6% and was higher than the observed mortality rate for each of the STS subgroups (all p<0.001). The EuroSCORE II expected mortality was 3.0%±3.4% and was greater than the observed mortality rate for isolated and combined procedures (both p<0.001). The STS and EuroSCORE II provided fair death discrimination, with an area under the receiver operating characteristic curve of 0.74 and 0.67, respectively.

Conclusions: Although current risk models aid in risk stratifying patients, the contemporary perioperative mortality rate at a reference mitral valve center is significantly lower than expected. The use of alternate therapies must therefore take into consideration differences in perioperative risk based on the treating center.
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http://dx.doi.org/10.1016/j.athoracsur.2014.05.011DOI Listing
August 2014

The impact of prosthesis-patient mismatch after aortic valve replacement varies according to age at operation.

Heart 2014 Jul 19;100(14):1099-106. Epub 2014 May 19.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada Department of Epidemiology and Community Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Objectives: Age may modify the impact of prosthesis-patient mismatch (PPM) on outcomes after aortic valve replacement (AVR), as physical functioning decreases with age, and comorbidities become more prevalent. We hypothesised that the consequences of PPM in patients 70 years old or older may be less important than in younger patients.

Methods: In total, 707 aortic stenosis patients were followed for a maximum of 17.5 years after AVR. PPM was defined as an in vivo indexed effective orifice area ≤0.85 cm2/m2, and severe PPM as ≤0.65 cm2/m2.

Results: In patients less than 70 years of age with normal LV function, the presence of PPM did not significantly alter survival. However, in patients under 70 with LV dysfunction, PPM was associated with decreased survival (HR 2.2; p=0.046). In patients aged 70 years of age or older, PPM had no effect on survival, regardless of LV function. Similarly, PPM was predictive of postoperative congestive heart failure (CHF) in patients under 70 with LV dysfunction (HR 3.6; p=0.046) but not in older patients. Similar results were observed for the composite endpoint of death or CHF. Postoperative LV mass regression was impaired by increased age (p=0.019), and by PPM in patients aged 70 years of age or older with LV dysfunction (by 28.8 g/m2; p=0.026).

Conclusions: The impact of PPM on outcomes after AVR depends on age at operation. PPM in patients under age 70 years with LV dysfunction is associated with decreased survival and lower freedom from CHF. In patients 70 years of age or older, PPM does not impact mortality or symptoms, but impairs LV mass regression beyond that explained by age alone.
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http://dx.doi.org/10.1136/heartjnl-2013-305118DOI Listing
July 2014

The role of integrin α2 in cell and matrix therapy that improves perfusion, viability and function of infarcted myocardium.

Biomaterials 2014 Jun 14;35(17):4749-58. Epub 2014 Mar 14.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa K1Y 4W7, Canada; Molecular Function and Imaging Program, University of Ottawa Heart Institute, Ottawa K1Y 4W7, Canada. Electronic address:

Injectable delivery matrices hold promise in enhancing engraftment and the overall efficacy of cardiac cell therapies; however, the mechanisms responsible remain largely unknown. Here we studied the interaction of a collagen matrix with circulating angiogenic cells (CACs) in a mouse myocardial infarction model. CACs + matrix treatment enhanced CAC engraftment, and improved myocardial perfusion, viability and function compared to cells or matrix alone. Integrin-linked kinase (ILK) was up-regulated in matrix-cultured CACs. Integrin α2β1 blocking prevented ILK up-regulation, significantly reduced the adhesion, proliferation, and paracrine properties of matrix-cultured CACs, and negated the benefits of CACs + matrix therapy in vivo. Furthermore, integrin α5 was essential for the angiogenic potential of CACs on matrix. These findings indicate that the synergistic therapeutic effect of CACs + matrix therapy in MI requires the matrix to enhance CAC function via α2β1 and α5 integrin signaling mechanisms, rather than simply delivering the cells.
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http://dx.doi.org/10.1016/j.biomaterials.2014.02.028DOI Listing
June 2014

Clinical evaluation of functional mitral stenosis after mitral valve repair for degenerative disease: potential affect on surgical strategy.

J Thorac Cardiovasc Surg 2013 Dec 26;146(6):1418-23; discussion 1423-5. Epub 2013 Sep 26.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada. Electronic address:

Background: Mitral annuloplasty with either a partial band or complete ring is an integral part of mitral valve repair for degenerative disease. The affect of annuloplasty type on outcomes has not been well described. The objective of our study was to compare echocardiographic and functional characteristics of patients who underwent mitral repair with either a complete ring or a partial band.

Methods: We evaluated 107 patients who underwent mitral repair of myxomatous degeneration at our institution by stress echocardiography, 6-minute walk testing, and short form-36 questionnaire. These assessments were performed 4.3 ± 2.2 years following mitral repair by a single surgeon. A band was used in 65 patients (61%) and a ring in 42 patients (39%). Parametric and nonparametric tests were used in the analyses.

Results: The labeled band and ring size used for repair were 30.7 ± 2.8 mm and 30.4 ± 2.1 mm, respectively (P = .6). The resting mean mitral gradient and valve area were 3.7 ± 1.9 mm Hg and 2.3 ± 0.6 cm(2) for patients who received a band and 5.8 ± 2.6 mm Hg and 1.8 ± 0.5 cm(2) for patients who received a ring (both P < .001). Distance traversed on 6-minute walk testing was 471 ± 77 m in the band group and 443 ± 107 m in the ring group (P = .1). At peak exercise, the mean mitral gradient (15.3 ± 8.2 mm Hg vs 10.6 ± 4.8 mm Hg; P < .001) and right ventricular systolic pressure (52.6 ± 14.2 mm Hg vs 45.8 ± 9.5 mm Hg; P = .004) were higher for patients who received a ring versus a band. Ring patients reported lower levels of energy (P = .02) and general health (P = .007) on short form-36 assessment.

Conclusions: Annuloplasty using a complete ring may be associated with a higher mitral valve gradient at rest and at peak exercise in certain patients. These patients may also have worse quality of life. In view of these findings, we recommend careful consideration of annuloplasty type and size at the time of mitral repair of organic disease.
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http://dx.doi.org/10.1016/j.jtcvs.2013.08.011DOI Listing
December 2013

Impact of mitral annular calcification on early and late outcomes following mitral valve repair of myxomatous degeneration.

Interact Cardiovasc Thorac Surg 2013 Jul 14;17(1):120-5. Epub 2013 Apr 14.

Division of Cardiac Surgery, University of Ottawa, Ottawa, ON, Canada.

Objectives: Mitral annular calcification is associated with significant morbidity and mortality at the time of mitral valve surgery. However, few data are available describing the impact of mitral annular calcification on early and late outcomes following mitral valve repair in the current era.

Methods: Between 2001 and 2011, 625 patients were referred for mitral valve repair of severe mitral regurgitation due to myxomatous degeneration. The mean patient age was 63.9 ± 12.7 years and 164 (26%) were female. Concomitant coronary artery bypass grafting was performed in 91 (15%) and 24 (4%) had previous cardiac surgery. Calcification of the mitral annulus was observed in 119 patients (19%), of whom complete debridement and extensive annulus reconstruction were performed in 14. The mean follow-up was for 2.4 ± 2.3 years.

Results: There were no deaths within 30 days of surgery. Risk factors associated with mitral annular calcification included older age (odds ratio 1.05 ± 0.02 per increasing year), female gender (odds ratio 1.88 ± 0.42) and larger preoperative left atrial size (odds ratio 1.04 ± 0.03 per increasing mm) (all P<0.01). Severe renal impairment defined as a creatinine clearance <30 mL/min was observed in 9 patients, all of whom had mitral annular calcification. Intraoperative conversion to mitral valve replacement was performed in 19 patients (97% repair rate), 5 of whom had mitral annular calcification. Extension of mitral annular calcification into one or more leaflet scallops was observed for all patients who required conversion to valve replacement. Five-year survival, freedom from recurrent mitral regurgitation ≥ 2+ and freedom from recurrent mitral regurgitation ≥ 3+ was 88.1 ± 2.4, 89.6 ± 2.3 and 97.8 ± 0.8%, respectively. Mitral annular calcification was not associated with survival or recurrent mitral regurgitation.

Conclusions: Risk factors for mitral annular calcification in patients with myxomatous degeneration and severe mitral regurgitation include older age, female gender, severe renal dysfunction and larger preoperative left atrial size. Nevertheless, favourable early and late results can be achieved with mitral valve repair in this population.
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http://dx.doi.org/10.1093/icvts/ivt163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686409PMC
July 2013

Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery.

Eur J Cardiothorac Surg 2013 Dec 25;44(6):1051-5; discussion 1055-6. Epub 2013 Mar 25.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada.

Objectives: The impact of anaemia on patients undergoing aortic valve surgery has not been well studied. We sought to evaluate the effect of anaemia on early outcomes following aortic valve replacement (AVR).

Methods: All patients undergoing non-emergent aortic valve surgery (n = 2698) with or without other concomitant procedures between 1997 and 2010 were included. Preoperative anaemia was defined as per World Health Organization guidelines as haemoglobin (Hb) < 130 g/l in men and Hb < 120 g/l in women. Multivariable analyses were used to determine the association between preoperative anaemia and postoperative outcomes.

Results: The prevalence of preoperative anaemia was 32.2%. Patients with anaemia were older (71 ± 12 vs 66 ± 13 years, P < 0.001), more likely to have urgent surgery, recent MI, higher creatinine level and impaired preoperative left ventricular function. Overall unadjusted mortality was 2.8% in non-anaemic patients vs 8% in anaemic patients. Anaemic patients were more likely to require renal replacement therapy (11 vs 3%, P < 0.0001) and prolonged ventilation (24 vs 10%, P < 0.0001). Following multivariable adjustment, lower preoperative Hb was an independent predictor of mortality (odds ratio 1.19, 95% CI: 1.04-1.34, P = 0.007) and composite morbidity (odds ratio 1.36, 95% CI: 1.05-1.77, P = 0.02) after AVR. Mortality and composite morbidity were significantly higher with lower levels of preoperative Hb.

Conclusions: Preoperative anaemia is a common finding in patients undergoing aortic valve surgery and is an important and potentially modifiable risk factor for postoperative morbidity and mortality.
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http://dx.doi.org/10.1093/ejcts/ezt143DOI Listing
December 2013

Giant cell myocarditis in a patient with a spondyloarthropathy after a drug hypersensitivity reaction.

Can J Cardiol 2013 Sep 6;29(9):1138.e7-8. Epub 2013 Mar 6.

Divisions of Cardiology, Cardiac Surgery and Nursing, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

A young woman thought to have seronegative rheumatoid arthritis developed Stevens-Johnson syndrome after treatment with sulfasalazine; this resolved with prednisone. Later she was found to be HLA-B27-positive in keeping with a spondyloarthropathy. Soon afterward, she developed clinical myopericarditis and cardiogenic shock that responded initially to methylprednisolone and intravenous immunoglobulin, but recurred. An endomyocardial biopsy demonstrated active myocarditis with a mixed cell composition including rare giant cells, but not enough to classify it as giant cell myocarditis. Heart failure symptoms returned and she eventually required a heart transplant; the explanted heart showed giant cell myocarditis.
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http://dx.doi.org/10.1016/j.cjca.2012.12.011DOI Listing
September 2013

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

Interact Cardiovasc Thorac Surg 2012 Oct 29;15(4):716-9. Epub 2012 Jun 29.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada.

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.
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http://dx.doi.org/10.1093/icvts/ivs157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445340PMC
October 2012

Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy during minimally invasive multivessel coronary artery bypass grafting: a stepwise approach to safety and reproducibility.

Semin Thorac Cardiovasc Surg 2012 ;24(1):79-83

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Minimally invasive coronary artery bypass grafting (MICS CABG) is a nonrobotic, nonthoracoscopic operation that achieves complete anatomical graft similarity with conventional CABG, while avoiding sternotomy and cardiac anoxia. We describe the stepwise approach to perform proximal anastomoses directly off the ascending aorta and also early results of this operation. All myocardial territories are accessed via a 4- to 6-cm left fifth intercostal thoracotomy. After takedown of the left internal thoracic artery, the ascending aorta is progressively brought into view by the following maneuvers: (1) administration of cardiac inotropes to minimize right ventricle filling, (2) increase in right lung positive end-expiratory pressures and tidal volumes, (3) placement of multilevel pericardial retractions, (4) leftward displacement of the ascending aorta with a gauze anterior to the superior vena cava, and (5) left posteroinferior displacement of the right ventricular outflow tract with an epicardial stabilizer. Handsewn proximal anastomoses can then be performed on the ascending aorta with a side-biting clamp. In the first 100 patients who underwent multivessel MICS CABG with proximal anastomoses directly off the aorta, the mean age was 62.6 ± 10.2 years, and median operative time was 3.5 hours. The mean number of grafts was 2.3 ± 0.5, and there were 3 conversions to open sternotomy. There were no preoperative deaths, 2 reoperations for bleeding, and 2 superficial wound infections. The median length of hospital stay was 4 days. MICS CABG is a safe alternative to conventional CABG, with excellent short-term results.
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http://dx.doi.org/10.1053/j.semtcvs.2011.12.010DOI Listing
October 2012

Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: The bilateral internal thoracic artery survey.

J Thorac Cardiovasc Surg 2012 Oct 18;144(4):874-9. Epub 2012 Feb 18.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Objective: The internal thoracic artery is the gold standard conduit in coronary artery bypass grafting. Although the right and left internal thoracic arteries are excellent conduits, the use of the bilateral internal thoracic artery is not widespread. A recent report of the Society of Thoracic Surgery revealed that only a small percentage of patients receive a bilateral internal thoracic artery in North America. The aim of this study was to determine the current use of the bilateral internal thoracic artery during coronary artery bypass grafting among cardiac surgeons in Canada and identify the main concerns that limit the use of these conduits.

Methods: We developed an online survey with 17 questions about the use of the bilateral internal thoracic artery in different clinical scenarios. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in Canada.

Results: A total of 101 surgeons (69%) of 147 currently in practice across 27 different hospitals completed the survey. Forty percent of surgeons use the bilateral internal thoracic artery only sometimes (6%-25% of cases), 37% of surgeons use the bilateral internal thoracic artery very infrequently (<5% cases), 16% of surgeons use the bilateral internal thoracic artery often (26%-50%), and only 7% of surgeons use the bilateral internal thoracic artery very often (>50%). The most common concerns in the use of the bilateral internal thoracic artery are the risk of sternal wound infection and the unknown superiority of the right internal thoracic artery over other conduits.

Conclusions: The majority of Canadian cardiac surgeons consider few clinical features, such as insulin-dependent diabetes mellitus or morbid obesity, as contraindications to the use of bilateral internal thoracic artery. However, the reported use of the bilateral internal thoracic artery is low. A wider diffusion of this technique is warranted to improve the results of coronary surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2012.01.022DOI Listing
October 2012

Clinical and echocardiographic outcomes after repair of mitral valve bileaflet prolapse due to myxomatous disease.

J Thorac Cardiovasc Surg 2012 Apr 4;143(4 Suppl):S8-11. Epub 2012 Feb 4.

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Objective: Repair of mitral regurgitation (MR) due to bileaflet prolapse poses many technical challenges. The late outcomes after repair are also not well characterized in this population. Published series have often included patients with mixed causes of prolapse and/or lack long-term echocardiographic follow-up. Myxomatous disease represents an important cause of bileaflet prolapse and MR and, thus, served as the focus of the present study.

Methods: A total of 142 patients, mean age 60.4 ± 13.2 years, underwent mitral valve (MV) repair of bileaflet prolapse due to myxomatous disease from 2001 to 2010. Concomitant coronary artery bypass grafting was performed in 16 patients (11%). All patients were followed up by a dedicated MV clinic with a follow-up interval that extended up to 8.6 years.

Results: No hospital deaths occurred. Ring annuloplasty was used for all patients. Additional MV repair techniques included chordal transfer in 73, a hybrid-flip-over technique in 23, polytetrafluoroethylene neochords in 26, edge-to-edge repair in 11, and commissuroplasty in 9. Prolapse involving more than 1 posterior leaflet scallop was observed in 103 patients (73%), and prolapse of more than 1 anterior leaflet scallop was observed in 76 (54%). During follow-up, 4 patients had MR grade 2+ or greater, and 2 patients required subsequent MV reoperation. The 5-year survival, freedom from recurrent MR (≥ 2+), and freedom from MV reoperation was 95.2% ± 2.8%, 92.6% ± 3.9%, and 94.0% ± 4.9%, respectively.

Conclusions: MV repair of bileaflet prolapse due to myxomatous disease is safe and durable. Successful repair often requires a combination of surgical repair techniques.
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http://dx.doi.org/10.1016/j.jtcvs.2012.01.046DOI Listing
April 2012
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