Important Negative Impact Factor

Moderate ischemic mitral regurgitation (MR) has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone.

According to scientists from Italy, "This study analyzes retrospectively a cohort of patients with ischemic cardiomyopathy (ejection fractionless than or equal to0.30) who underwent isolated coronary artery bypass grafting to evaluate the impact of no-to-moderate MR on long-term results. From January 1988 to December 2002, 6,108 patients had isolated coronary artery bypass grafting."

M. Dimauro and colleagues, European Hospital, wrote, "Two hundred thirty-nine (3.9%) had ischemic cardiomyopathy; 60 patients had no, 102 had mild, and 77 had moderate MR. Using propensity score, a group of 70 patients with no or mild MR (group A) was case-matched with a group of 70 patients with moderate MR (group B) to obtain two groups with similar preoperative characteristics. Nine patients (6.4%) died within the first 30 days; all deaths were cardiac-related. There was no difference in the early results between groups. Patients in group B showed lower freedom from death, from cardiac death, from cardiac death and ischemic events, and from death and New York Heart Association class III and IV than patients in group A."

They continued, "Cox analysis confirmed that moderate MR was an independent variable for worse late outcome in this subgroup of patients. Functional and echocardiographic results, after a mean of 62±28 months in 87.8% of survivors, showed a significant impairment of New York Heart Association class (from 2.2±0.5 to 2.8±0.6; p<.001) and MR degree (from 2.0 to 2.7±1.0; p=.023) in patients with preoperative moderate MR."

The researchers concluded, "This study confirms that moderate ischemic MR has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone."

Dimauro and colleagues published their study in the Annals of Thoracic Surgery (Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy. Ann Thorac Surg, 2006;81(6):2128-2134).

Why Chance It -- Get a Second Opinion from a Non-Invasive Cardiologist

Trauma to the aorta causes cognitive loss following coronary artery bypass surgery

Minimizing trauma to the aorta, during heart bypass surgery can significantly reduce cognitive loss that often follows the operation, a team from Wake Forest University School of Medicine reported in the Journal of Thoracic and Cardiovascular Surgery.

" A surgical strategy designed to minimize aortic manipulations can significantly reduce the incidence of cognitive deficits in coronary artery bypass graft patients compared with traditional techniques," said the team, headed by John W. Hammon Jr.

Surgical technique is the primary cause of later thinking – cognitive – problems in coronary artery bypass graft patients, concluded the research team from the School of Medicine, part of Wake Forest University Baptist Medical Center.

Since the late 1980s, the team has focused on surgical technique. In 1997, they reported reducing stroke and other acute complications following coronary artery bypass surgery from the national average of six percent of patients to less than one percent of patients at Wake Forest University Baptist Medical Center.

Difficulty in thinking is also a widespread problem following bypass surgery, reported at many institutions. Since 1992, the Wake Forest research team has been investigating these cognitive complications following bypass surgery which normally employs the heart-lung machine. They developed methods to track the causes of the complications and test techniques to reduce the complications.

They have also been developing methods for doing coronary artery bypass without using the heart-lung machine. Much of the research over the years was paid for with a major grant from the National Institutes of Health.

In the new study of 237 patients, the team compared the standard method of coronary artery bypass using the heart-lung machine with surgical techniques that minimized movement of the aorta while still using the machine. Movement was reduced by using a single clamp that exerted significantly less force on the aorta than the standard cross clamp. Surgery without the machine was also compared.

The researchers gave the patients a battery of 11 psychological tests before surgery, then at three to five days after surgery, again between three and six weeks and again at six months. The tests measured such things as fine motor function, verbal and nonverbal memory, attention and concentration.

In the week after surgery, at least 60 percent of the patients in all three groups showed neurological deficits. The number of patients with deficits declined steadily in both the group without the heart-lung machine, and the group with minimal movement of the aorta. By six months, only 32 percent of the patients who didn't use the machine and 30 percent of the patients who had minimal aortic movement had deficits, suggesting less permanent injury in both groups.

But 57 percent of the patients who had the traditional surgery still had deficits at six months, the researchers reported. Based on monitoring techniques developed over the past 10 years at Wake Forest, the team tracked particles called emboli and gaseous bubbles going to the brain during the surgery. Team members believe the emboli are the cause of the neurological deficits.

Patients on whom the heart-lung machine was not used had significantly fewer emboli than patients who had the traditional operation, but that option is generally reserved for younger patients. Among patients who had the machine, those with minimal movement of the aorta had fewer emboli than those who had the traditional operation, but the difference did not reach statistical significance.

Source: Wake Forest University Baptist Medical Center, 2006

Read the Red in Australian Study Report

PEOPLE on low incomes are more likely to die from heart attacks and related diseases than better-off patients, but the latter get more access to speedy treatment to unclog arteries, statistics show.

The proportion of deaths from heart and artery disease linked to poorer living standards has risen sharply since 1992, the Australian Institute of Health and Welfare has found.

An institute report released today shows that in 2002 adults from the most disadvantaged areas of the country had "significantly higher" death rates from cardiovascular disease, heart disease and stroke - 1.6 to 1.9 times higher than those from "least disadvantaged" localities.

The impact on health of low income, low education and high unemployment puts those from low socioeconomic areas at considerably increased risk of dying before more prosperous citizens.

The difference in life outcomes "translates to over 3400 deaths which may be regarded as being due to socioeconomic inequality", Lynelle Moon, of the institute's cardiovascular disease and diabetes unit, said.

Other institute findings showed that fewer than half - 44 per cent - of those getting state-of-the-art balloon treatment, or angioplasty, to unblock arteries were public patients, despite more than 55 per cent of Australians being public patients who would be more likely to require treatment than higher-income and generally healthier patients, whose health insurance enables private treatment.

Public patients are only slightly more likely to have coronary artery bypass graft surgery, the "open heart" procedure preserved for more serious conditions. The differences, indicating overservicing of private patients and underservicing of public hospital patients, raise equity issues, said Professor Garry Jennings, the director of the Baker Heart Research Institute in Melbourne.

"I think it's an issue that Australians expect to get the same level of treatment wherever they are treated. Equity is an important principle under Medicare," he said.

Angioplasty was more common for private patients with clogged arteries probably because cardiologists were more likely to recommend a low-risk procedure that could generate a fee of $5000 for them, he said.

But when a public hospital cardiologist was confronted with a patient with similar symptoms, the strain on resources made it more likely that the patient would be prescribed drugs to settle the problem "and probably get just as a good a result".

Professor Jennings said it was also likely that public patients were more likely to get open heart surgery instead of angioplasty because their problems were more serious.

Public patients from the country who may have waited longer for surgery than those in the city, and lower socioeconomic patients who were more likely to be smokers, overweight and prone to diabetes, were also more likely to require full-scale bypass surgery.