Chapter 21: Acquired Heart Disease

Key Points

• Although advances have been made in percutaneous coronary intervention techniques for coronary artery disease, survival is superior with coronary artery bypass grafting in patients with left main disease, multivessel disease, and in diabetic patients.

• Despite the theoretical advantages, the superiority of off-pump coronary artery bypass to conventional coronary artery bypass grafting has not been clearly established, and other factors likely dominate the overall outcome for either technique.

• Although mechanical valves offer enhanced durability over tissue valve prosthesis, they require permanent systemic anticoagulation therapy to mitigate the risk of valve thrombosis and thromboembolic sequelae and thus are associated with an increased risk of hemorrhagic complications.

• Mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic mitral regurgitation. The decision to proceed with mitral valve repair is based on the skill and experience of the surgeon in performing the repair and on the pathology of mitral valve disease encountered at the time of operation. Transcatheter mitral valve therapies are also becoming increasingly available as options to offer patients who are deemed high risk for surgical intervention for their mitral valve disease.

• Although open aortic valve replacement has traditionally been the only effective treatment in patients with severe calcific aortic stenosis, transcatheter aortic valve replacement is a developing technology that has proven beneficial for the treatment of aortic stenosis in seriously ill patients that had previously been deemed high risk or inoperable. It has also recently been approved for us in patients at moderate risk for surgical aortic valve replacement and is in clinical trials for low-risk patients.

• Mechanical circulatory support with newer generation continuous flow left ventricular assist devices has proven to be durable and effective both as a bridge to transplant and as a means of destination therapy for patients who are not transplant candidates.

• Performing a biatrial Cox-Maze lesion set results in freedom from atrial fibrillation in approximately 90% of patients and is superior to both catheter-ablation and more limited lesion sets for patients with persistent atrial fibrillation or enlarged left atria. Surgical ablation of atrial fibrillation is recommended for patients referred with concomitant valvular disease and those who have previously failed or are poor candidates for catheter-based approaches.

• The preferred treatment for pericarditis depends on the underlying cause, although the disease typically follows a self-limited course and is best managed medically. Surgical pericardiectomy may have a role in treating relapsing pericarditis and, more commonly, chronic constrictive pericarditis.

• Myxomas are the most common cardiac tumors, and, while benign, they should be promptly excised after diagnosis due to the risk of embolization, obstructive complications, and arrhythmias.