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J Thorac Cardiovasc Surg 2007;134:439-441
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Discussion

Dr Andrew S. Wechsler (Philadelphia, Pa). This and Vincent Dor’s series comprise the two largest observational series from single centers on this operative procedure, at least to my knowledge. Your results in this very challenging group of patients are excellent. I have four questions for you.

First, when I read the manuscript I noted that you used patch closure only in about 50% of the patients. Should I take away the implication that many of these ventricles were not severely dilated, or perhaps that you did the SVR as an incidental procedure when the primary operation was in fact coronary revascularization?

My second question, and I have asked Dr Dor this same question on several occasions, is this. When I did the calculations based on your own data, although there was an important increase in EF, I found little or no increase in stroke volume. Are you surprised that despite a reduction in end-diastolic volume, there is no increase in stroke volume? Do you think this implies that the primary benefit of the procedure is, in fact, in reducing myocardial oxygen consumption at the same external work level, or is it possible that after the surgery there is, in fact, restricted filling of the ventricles owing to a change in diastolic properties?

I noted that you indicated that pulmonary artery pressure greater than 60 mm Hg was a warning sign to you and that you tended not to operate on those patients, but I did not see within your data any actual calculation of pulmonary artery pressure as a continuous variable associated with enhanced mortality. Maybe you could comment on that.

Finally, in your analysis, MR and increased end-systolic volume both turn out to be predictors of poor outcome and mortality. Did you analyze these as discrete variables, or . . . [Full Text of this Article]