Incomplete and inaccurate death certification--the impact on research.
(65/2034)
BACKGROUND: The objectives of this study were (1) to investigate the extent of erroneous and/or omitted information on death certificates of patients-implanted with Bjork-Shiley Convexo-Concave (BSCC) heart valves; (2) to determine whether this information could be associated with a possible under-reporting of acute mechanical failure of this valve. METHODS: A review was carried out of death certificates and clinical notes for patients implanted in the United Kingdom with BSCC valves. This was a multicentre study (38 hospitals) based at the Cardiothoracic Department, NHLI, Imperial College School of Medicine at Hammersmith Hospital, London. The subjects were 478 patients implanted with a BSCC valve between 1979 and 1986 who died in the following years: 1984, 1987, 1990, 1993 and 1996. The main outcome measures were: (1) percentage of death certificates that record the presence of a valve prosthesis; (2) percentage of death certificates that record the presence of a valve prosthesis for patients who had a post mortem; (3) percentage of death certificates that record inaccurate or incomplete information related to the surgery; (4) percentage of death certificates that do not record a post mortem where one is known to have been performed. RESULTS: Twenty-one per cent (101/478) of the total number of death certificates record the presence of the valve prosthesis. Thirty-five per cent (43/123) of the death certificates for patients who had a post mortem record the presence of a valve prosthesis. Six per cent (30/478) of death certificates report inaccurate information related to the valve surgery. Twenty-five per cent (118/478) of the total number of death certificates recorded a single cause of death. Twenty-three per cent (110/478) of all death certificates reviewed recorded only the mode of dying. Eight per cent (10/123) of the total number of death certificates for patients who had a post mortem did not record a post mortem. CONCLUSIONS: The relatively high number of death certificates that do not record the presence of a valve prosthesis and the observed under-reporting of post mortems may lead to inaccurate reporting of the number of BSCC valves that fail. Previous recommendations to improve accuracy in death certification appear to have gone unheeded, and changes in the way certificates are completed for patients with implanted cardiac devices should be considered. (+info)
Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study.
(66/2034)
OBJECTIVES: This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery. BACKGROUND: Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely excluding the appendage from the circulation has never been systematically assessed. METHODS: Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage. RESULTS: Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgitation did not significantly correlate with the incidence of incomplete appendage ligation. However, the power to detect a significant difference in left atrial size was only 64%. Spontaneous echo contrast or thrombus was identified within appendages in 9 of 18 (50%) patients with incomplete ligation, while 4 of these 18 (22%) patients had thromboembolic events. CONCLUSIONS: Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events. (+info)
Predictors of outcome in severe, asymptomatic aortic stenosis.
(67/2034)
BACKGROUND: Whether to perform valve replacement in patients with asymptomatic but severe aortic stenosis is controversial. Therefore, we studied the natural history of this condition to identify predictors of outcome. METHODS: During 1994, we identified 128 consecutive patients with asymptomatic, severe aortic stenosis (59 women and 69 men; mean [+/-SD] age, 60+/-18 years; aortic-jet velocity, 5.0+/-0.6 m per second). The patients were prospectively followed until 1998. RESULTS: Follow-up information was available for 126 patients (98 percent) for a mean of 22+/-18 months. Event-free survival, with the end point defined as death (8 patients) or valve replacement necessitated by the development of symptoms (59 patients), was 67+/-5 percent at one year, 56+/-5 percent at two years, and 33+/-5 percent at four years. Five of the six deaths from cardiac disease were preceded by symptoms. According to multivariate analysis, only the extent of aortic-valve calcification was an independent predictor of outcome, whereas age, sex, and the presence or absence of coronary artery disease, hypertension, diabetes, and hypercholesterolemia were not. Event-free survival for patients with no or mild valvular calcification was 92+/-5 percent at one year, 84+/-8 percent at two years, and 75+/-9 percent at four years, as compared with 60+/-6 percent, 47+/-6 percent, and 20+/-5 percent, respectively, for those with moderate or severe calcification. The rate of progression of stenosis, as reflected by the aortic-jet velocity, was significantly higher in patients who had cardiac events (0.45+/-0.38 m per second per year) than those who did not have cardiac events (0.14+/-0.18 m per second per year, P<0.001), and the rate of progression of stenosis provided useful prognostic information. Of the patients with moderately or severely calcified aortic valves whose aortic-jet velocity increased by 0.3 m per second or more within one year, 79 percent underwent surgery or died within two years of the observed increase. CONCLUSIONS: In asymptomatic patients with aortic stenosis, it appears to be relatively safe to delay surgery until symptoms develop. However, outcomes vary widely. The presence of moderate or severe valvular calcification, together with a rapid increase in aortic-jet velocity, identifies patients with a very poor prognosis. These patients should be considered for early valve replacement rather than have surgery delayed until symptoms develop. (+info)
Postoperative exercise tolerance after aortic valve replacement by small-size prosthesis: functional consequence of small-size aortic prosthesis.
(68/2034)
OBJECTIVES: The objective of this study was to determine whether a small-size valve prosthesis contributes to exercise intolerance, as assessed by VO2 measurement during an exhaustive cycle ergometer exercise. BACKGROUND: The determinants of exercise capacity after mechanical aortic replacement are not well known. The selection of small valve sizes has, however, been described as an independent predictor of exercise intolerance as assessed by exercise duration. Maximal oxygen uptake (VO2max) is a good index of exercise tolerance. METHODS: Fourteen patients were eligible, with a mean age of 62 +/- 6 years. Before surgery, the mean left ventricular ejection fraction (LVEF) was 73 +/- 8%. Two valve types with small diameter (19 to 21 mm) were used: Medtronic Hall and St Jude Medical. A healthy sedentary control group (n = 14) paired for age, weight and size was constituted. After one year of follow-up, cardiorespiratory tests were performed. In addition, the gradients through the prostheses were determined by continuous pulse Doppler at rest and immediately after the cardiorespiratory test. RESULTS The exercise tolerance was not significantly different between the control group and patient group: VO2 peak (21.7 vs. 20.4 ml/kg/min; p = 0.42), workloads (115 vs. 93 W; p = 0.13) and ventilatory parameters were similar. The mean and peak gradients at rest and during exercise were not correlated with VO2max. CONCLUSIONS: Valve replacement by small aortic prosthesis does not seem to be a factor of exercise intolerance as assessed by VO2max in patients without LVEF dysfunction before surgery. (+info)
Osteomyelitis caused by Staphylococcus schleiferi and evidence of misidentification of this Staphylococcus species by an automated bacterial identification system.
(69/2034)
We report a case of sternal osteomyelitis due to Staphylococcus schleiferi in a patient who underwent thoracic surgery. This constitutes the first documented case of osteomyelitis caused by this Staphylococcus species. We also relate our experience in the utilization of commercially available MicroScan panels for the identification of this microorganism. (+info)
Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention.
(70/2034)
Prosthesis-patient mismatch is present when the effective orifice area of the inserted prosthetic valve is less than that of a normal human valve. This is a frequent problem in patients undergoing aortic valve replacement, and its main hemodynamic consequence is the generation of high transvalvular gradients through normally functioning prosthetic valves. The purposes of this report are to present an update on the concept of aortic prosthesis-patient mismatch and to review the present knowledge with regard to its impact on hemodynamic status, functional capacity, morbidity and mortality. Also, we propose a simple approach for the prevention and clinical management of this phenomenon because it can be largely avoided if certain simple factors are taken into consideration before the operation. (+info)
Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial.
(71/2034)
OBJECTIVES: The goal of this study was to compare long-term survival and valve-related complications between bioprosthetic and mechanical heart valves. BACKGROUND: Different heart valves may have different patient outcomes. METHODS: Five hundred seventy-five patients undergoing single aortic valve replacement (AVR) or mitral valve replacement (MVR) at 13 VA medical centers were randomized to receive a bioprosthetic or mechanical valve. RESULTS: By survival analysis at 15 years, all-cause mortality after AVR was lower with the mechanical valve versus bioprosthesis (66% vs. 79%, p = 0.02) but not after MVR. Primary valve failure occurred mainly in patients <65 years of age (bioprosthesis vs. mechanical, 26% vs. 0%, p < 0.001 for AVR and 44% vs. 4%, p = 0.0001 for MVR), and in patients > or =65 years after AVR, primary valve failure in bioprosthesis versus mechanical valve was 9 +/- 6% versus 0%, p = 0.16. Reoperation was significantly higher for bioprosthetic AVR (p = 0.004). Bleeding occurred more frequently in patients with mechanical valve. There were no statistically significant differences for other complications, including thromboembolism and all valve-related complications between the two randomized groups. CONCLUSIONS: At 15 years, patients undergoing AVR had a better survival with a mechanical valve than with a bioprosthetic valve, largely because primary valve failure was virtually absent with mechanical valve. Primary valve failure was greater with bioprosthesis, both for AVR and MVR, and occurred at a much higher rate in those aged <65 years; in those aged > or =65 years, primary valve failure after AVR was not significantly different between bioprosthesis and mechanical valve. Reoperation was more common for AVR with bioprosthesis. Thromboembolism rates were similar in the two valve prostheses, but bleeding was more common with a mechanical valve. (+info)
Up to seven years of experience with the Ross procedure in patients >60 years of age.
(72/2034)
OBJECTIVES: The objective of this study was to compare the outcome of patients >60 years of age with younger patients after the Ross procedure. BACKGROUND: Currently, the Ross procedure is performed predominantly in young patients. Main arguments against the Ross procedure in the elderly are the complexity of the operation and related risks. Experience with the Ross procedure in patients >60 years of age is scarce. METHODS: Between February 1990 and August 1998, the Ross procedure was performed in 27 patients (15 men and 12 women) >60 years of age (mean 64.2 +/- 3.1 years, range 60.5 to 70.6; group A) and in 84 patients (68 men, 12 women) <60 years of age (mean 43.8 +/- 12.4 years, range 15.2 to 59.4; group B). Echocardiography was applied at a mean follow-up of 28.4 +/- 21.0 and 25.2 +/- 21.4 months, respectively, to determine hemodynamic variables (ejection fraction, fractional shortening, stroke volume, cardiac output), cardiac dimensions and autograft and homograft valve function. RESULTS: There was one early and one late (esophageal bleeding) death in group B; the mortality rate was 0% in group A. One autograft was replaced because of a subvalvular aneurysm, and one patient was lost to follow-up (group B). There were no significant differences in cardiac dimensions, grade of insufficiencies across homografts and autografts and hemodynamic variables, except for a higher pressure gradient across the homograft in group B (maximal pressure gradient 11.3 +/- 5.6 vs. 7.7 +/- 4.6 mm Hg in group A). The median New York Heart Association functional class was I in both groups. CONCLUSIONS: Our seven years of experiences (mean follow-up 28 months) indicate that the Ross procedure may be performed in selected patients >60 years of age without increased risk for mortality or complications in experienced centers. (+info)