No abstract

A systematic strategy of mitral valve repair that uses a variety of techniques allows repair of all degenerative valves in a reference center, with good short-term outcomes and mid-term durability. Further study is required to document the long-term efficacy of an "all comers" mitral valve repair strategy in degenerative subgroups with very complex valve morphology.

Background-Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass (CPB).We hypothesized that the severity and duration of the decline in mean arterial pressure immediately after CPB is begun can be used as a predictor of patients will develop vasoplegia in the immediate post-CPB period and of poor clinical outcome. We quantified the decline in mean arterial pressure by calculating an area above the mean arterial blood pressure curve. Methods and Results-We retrospectively analyzed 2823 adult cardiac surgery cases performed between July 2002 and December 2006. Of these 2823, 577 (20.4%) were vasoplegic after separation from CPB. We found that 1645 patients (58.3%) had a clinically significant decline in mean arterial pressure after starting CPB (area above the mean arterial blood pressure curve Ͼ0) and were significantly more likely to become vasoplegic (23.0% versus 16.9%; odds ratio, 1.26; 95% confidence interval, 1.12 to 1.43; PϽ0.001). These patients were also far more likely either to die in hospital or to have a length of stay Ͼ10 days (odds ratio, 3.30; 95% confidence interval, 1.44 to 7.57; Pϭ0.005). Additional risk factors for developing vasoplegia that were identified included the additive euroSCORE, procedure type, prebypass mean arterial pressure, length of bypass, administration of pre-CPB vasopressors, core temperature on CPB, pre-and post-CPB hematocrit, the preoperative use of ␤-blockers or angiotensin-converting enzyme inhibitors, and the intraoperative use of aprotinin. Conclusions-The results of this investigation suggest that it is possible to predict vasoplegia intraoperatively before separation from CPB and that the presence of a clinically significant area above the mean arterial blood pressure curve serves as a predictor of poor clinical outcome. (Circulation. 2009;120:1664-1671.)

Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.

Gastrointestinal complications following cardiac surgery remain rare with an incidence <1% in a contemporary series. The key to a lower incidence of GICs lies in systematic application of preventive measures and new advances in intraoperative management. Identification of independent risk factors would facilitate the determination of patients who would benefit from additional perioperative monitoring. Future resources should therefore be redirected to mitigate GICs in high-risk patients.