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Different characteristics of postoperative heart failure after surgery for aortic stenosis and coronary disease
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery. Linköping University, Faculty of Health Sciences.
2004 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, Vol. 38, no 3, 152-158 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Postoperative heart failure (PHF) remains a major determinant of outcome after cardiac surgery. However, possible differences in characteristics of PHF after valve surgery and coronary surgery (CABG) have received little attention. Therefore, this issue was studied in patients undergoing aortic valve replacement (AVR) and CABG, respectively.

Design: Three hundred and ninety-eight patients undergoing isolated AVR for aortic stenosis were compared with 398 patients, matched for age and sex, undergoing on-pump isolated CABG. Forty-five AVR and 47 CABG patients required treatment for PHF and these were studied in detail.

Results: The AVR group had longer aortic cross-clamp time and higher rate of isolated right ventricular heart failure postoperatively. Myocardial ischemia during induction and perioperative myocardial infarction were more common in the CABG group. One-year mortality was 8.9% in the AVR group vs 25.5% in the CABG group (p = 0.05).

Conclusions: The incidence of PHF was similar in both groups but different characteristics were found. Isolated right ventricular failure and PHF precipitated by septicemia were more common in AVR patients. PHF was more clearly associated with myocardial ischemia and infarction in CABG patients, which could explain their less favorable survival.

Place, publisher, year, edition, pages
2004. Vol. 38, no 3, 152-158 p.
Keyword [en]
aortic valve surgery, complications of surgery, coronary artery bypass surgery, heart failure, prognosis
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-14018DOI: 10.1080/14017430410029734OAI: oai:DiVA.org:liu-14018DiVA: diva2:22471
Available from: 2006-09-28 Created: 2006-09-28 Last updated: 2009-08-21
In thesis
1. Surgery for aortic stenosis: with special reference to myocardial metabolism, postoperative heart failure and long-term outcome
Open this publication in new window or tab >>Surgery for aortic stenosis: with special reference to myocardial metabolism, postoperative heart failure and long-term outcome
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Postoperative heart failure (PHF) remains a major determinant of the outcome after cardiac surgery. However, characteristics of and risk factors for PHF after valve surgery have received little attention.

Post-ischaemic disturbances of myocardial metabolism that may contribute to PHF and are amenable to metabolic treatment have been identified early after coronary surgery (CABG). Knowledge derived from these studies may not be applicable to other patient groups. We therefore studied myocardial energy metabolism in 20 elective patients undergoing aortic valve replacement (AVR) for isolated aortic stenosis (AS). The metabolic studies indicated that myocardial oxidative metabolism had not fully recovered when the procedure was completed. Free fatty acids were the only major substrates taken up by the heart. Signs of preoperative and postoperative metabolic adaptation with substantial uptake of glutamate, previously demonstrated in patients with coronary artery disease, were found. Postoperative infusion of glutamate, (2 mL/kg body weight and hour of 0.125 M solution) based on assessment of myocardial glutamate requirements in CABG patients, resulted in a two-fold increase in myocardial glutamate uptake and a seven-fold increase in AV differences across the leg. This was associated with a significant myocardial uptake of lactate and metabolic changes in the leg suggesting mitigation of net amino acid loss and peripheral tissue lipolysis.

Characteristics of and risk factors for PHF were evaluated in 398 patients undergoing isolated AVR for AS from 1 January 1995 to 31 December 2000. These were compared with 398 patients, matched for age and sex, undergoing on-pump isolated CABG. Forty-five AVR and 47 CABG patients fulfilled criteria for PHF and these were studied in detail. PHF usually presented at weaning from cardiopulmonary bypass. After CABG it was closely associated with preoperative ischaemic events and intraoperatively acquired myocardial infarction. Potential causes and eliciting events of PHF after AVR for AS were obvious only in one-third of the patients. Risk factors for PHF after AVR for AS indicated either pre-existing myocardial dysfunction, increased right or left ventricular after-load, or intraoperatively acquired myocardial injury. PHF was associated with high early mortality after CABG, whereas the consequences of PHF after AVR for AS became evident only with time, resulting in a 42% five-year mortality. Although PHF had a different temporal impact on late mortality after CABG and AVR for AS, it emerged as the statistically most significant risk factor for mortality occurring within 5 years from surgery both after AVR for AS and after CABG. Potential implications of our findings include needs for greater focus on preoperative surveillance of patients with AS for optimal timing of surgery, mitigation of intraoperatively acquired myocardial injury and tailoring of treatment for PHF. Furthermore, the findings have implications for long-term follow up of AS patients after surgery.

Place, publisher, year, edition, pages
Institutionen för medicin och vård, 2006
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 952
Keyword
Aortic stenosis, Surgery, Postoperative heart failure, Long-term outcome, Metabolism
National Category
Clinical Science
Identifiers
urn:nbn:se:liu:diva-7471 (URN)91-85497-89-4 (ISBN)
Public defence
2006-06-09, Berzeliussalen, Campus US, Linköpings Universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2006-09-28 Created: 2006-09-28 Last updated: 2012-01-30

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Vánky, Farkas B.Håkansson, ErikSvedjeholm, Rolf

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