1
10 years actuarial survival rates were, respectively, 92%, 82% and 62%; freedom from sudden death was 99%, 97% and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), and mean improvement was 1.31.1 class per patient. Average postoperative increase in ejection fraction was 109%. Conclusions: Using wall thinning as a criterion for patient selection, LV reconstruction can be performed with low operative mortality; it provides good control of symptoms, excellent long-term survival, and freedom from sudden death. The investigators recommend that this approach should be considered in all patients with coronary disease, poor LV function, and relative wall thinning. Perspective: Despite great advances in medical therapy for congestive heart failure (CHF), some patients remain symp- tomatic; surgical interventions for advanced CHF attempt to improve symptoms and prognosis through a variety of procedures. This study describes encouraging results from a single surgeon’s experience with a ventricular remodeling procedure involving septal aneurysm patch exclusion. As always, broader experience is required to estimate the pro- cedure’s utility and its specific role among other medical and surgical therapies and in other clinical centers. DB Comparison of Endovascular Aneurysm Repair With Open Repair in Patients With Abdominal Aortic Aneurysm (EVAR Trial 1), 30-Day Operative Mortality Results: Randomized Controlled Trial The EVAR trial participants. Lancet 2004; 364:843– 8. Study Question: Endovascular aneurysm repair (EVAR) is a new technology to treat patients with abdominal aortic aneurysm (AAA) when the anatomy is suitable. Uncertainty exists about how endovascular repair compares with con- ventional open surgery. The EVAR Trial 1 compared endo- vascular repair with conventional open surgery in patients judged fit for open AAA repair. Methods: Between 1999 and 2003, 1082 elective (nonemer- gency) patients were randomized to receive either EVAR (n543) or open AAA repair (n539). Patients aged at least 60 years with aneurysms of diameter 5.5 cm or more, who were fit enough for open surgical repair (anesthetically and medically well enough for the procedure), were re- cruited for the study at 41 British hospitals proficient in the EVAR technique. The primary outcome measure was all- cause mortality. The primary analysis presented here is operative mortality by intention to treat, and a secondary analysis was done in per-protocol patients. Results: Patients (983 men, 99 women) had a mean age of 74 years (SD 6) and mean AAA diameter of 6.5 cm (SD 1). A total of 1047 (97%) patients underwent AAA repair and 1008 (93%) received their allocated treatment. The 30-day mortality in the EVAR group was 1.7% (9/531) vs. 4.7% (24/516) in the open-repair group (odds ratio 0.35 [95% CI 0.16 – 0.77]; p0.009). By per-protocol analysis, 30-day mortality for EVAR was 1.6% (8/512) vs. 4.6% (23/496) for open repair (0.33 [0.15– 0.74]; p0.007). Secondary inter- ventions were more common in patients allocated EVAR (9.8% vs. 5.8%; p0.02). Conclusions: The researchers conclude that, in patients with large AAAs, treatment by endovascular repair reduced the 30-day operative mortality by two-thirds compared with open repair. Perspective: These early results with endovascular repair, applied to large aneurysms in patients judged fit for open repair, provide justification for continued use of this tech- nique in controlled or trial settings. However, the early promise of endovascular repair cannot be guaranteed and may not be sustained in the long term. The 30-day mortality results should spur continued scientific evaluation of endo- vascular stent graft repair, but should not change clinical practice till longer-term data are available in larger co- horts. DM Cardiac Troponin After Major Vascular Surgery: The Role of Perioperative Ischemia, Preoperative Thallium Scanning, and Coronary Revascularization Landesberg G, Mosseri M, Shatz V, et al. J Am Coll Cardiol 2004;44:569 –75. Study Question: Does ischemia on preoperative thallium testing or preoperative percutaneous revascularization af- fect perioperative troponin release after major vascular sur- gery? Methods: Preoperative clinical data including thallium scan- ning and coronary revascularization, along with continuous perioperative 12-lead ST-segment trend monitoring, car- diac troponin-I and/or troponin-T, and creatine kinase-MB fraction in the first 3 postoperative days were recorded among 501 consecutive patients undergoing elective major vascular procedures. Results: Moderate to severe inducible ischemia on preoper- ative thallium scanning was associated with a 49.0% inci- dence of low-level (troponin-I 0.6 and/or troponin-T 0.03 ng/mL) and 22.4% conventional (troponin-I 1.5 and/or troponin-T 0.1 ng/mL) troponin elevation. In contrast, patients with preoperative coronary revasculariza- tion had 23.4% and 6.4% low-level and conventional tro- ponin elevations, respectively, similar to patients without ischemia on thallium. By multivariate logistic regression, ischemia on preoperative thallium scanning was the most important predictor of both low-level and conventional troponin elevations (adjusted odds ratios [ORs] 2.5 and 2.7; p 0.02 and 0.04, respectively), whereas preoperative coronary revascularization predicted fewer troponin eleva- tions (adjusted ORs 0.35 and 0.16; p 0.045 and 0.022, respectively). Prolonged postoperative ischemia 30 min was the only independent predictor of conventional tropo- nin elevation in addition to the preoperative predictors in the multivariate analysis (OR 22.8; p 0.001). ACC CURRENT JOURNAL REVIEW Nov 2004 68

Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: Randomized controlled trial

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Page 1: Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: Randomized controlled trial

10 years actuarial survival rates were, respectively, 92%,82% and 62%; freedom from sudden death was 99%, 97%and 94%. Among survivors, symptom class improved in140 of 208 patients (67%), and mean improvement was1.3�1.1 class per patient. Average postoperative increase inejection fraction was 10�9%.Conclusions: Using wall thinning as a criterion for patientselection, LV reconstruction can be performed with lowoperative mortality; it provides good control of symptoms,excellent long-term survival, and freedom from suddendeath. The investigators recommend that this approachshould be considered in all patients with coronary disease,poor LV function, and relative wall thinning.Perspective: Despite great advances in medical therapy forcongestive heart failure (CHF), some patients remain symp-tomatic; surgical interventions for advanced CHF attemptto improve symptoms and prognosis through a variety ofprocedures. This study describes encouraging results froma single surgeon’s experience with a ventricular remodelingprocedure involving septal aneurysm patch exclusion. Asalways, broader experience is required to estimate the pro-cedure’s utility and its specific role among other medicaland surgical therapies and in other clinical centers. DB

Comparison of Endovascular Aneurysm Repair WithOpen Repair in Patients With Abdominal AorticAneurysm (EVAR Trial 1), 30-Day Operative MortalityResults: Randomized Controlled TrialThe EVAR trial participants. Lancet 2004; 364:843– 8.

Study Question: Endovascular aneurysm repair (EVAR) is anew technology to treat patients with abdominal aorticaneurysm (AAA) when the anatomy is suitable. Uncertaintyexists about how endovascular repair compares with con-ventional open surgery. The EVAR Trial 1 compared endo-vascular repair with conventional open surgery in patientsjudged fit for open AAA repair.Methods: Between 1999 and 2003, 1082 elective (nonemer-gency) patients were randomized to receive either EVAR(n�543) or open AAA repair (n�539). Patients aged atleast 60 years with aneurysms of diameter 5.5 cm or more,who were fit enough for open surgical repair (anestheticallyand medically well enough for the procedure), were re-cruited for the study at 41 British hospitals proficient in theEVAR technique. The primary outcome measure was all-cause mortality. The primary analysis presented here isoperative mortality by intention to treat, and a secondaryanalysis was done in per-protocol patients.Results: Patients (983 men, 99 women) had a mean age of74 years (SD 6) and mean AAA diameter of 6.5 cm (SD 1).A total of 1047 (97%) patients underwent AAA repair and1008 (93%) received their allocated treatment. The 30-daymortality in the EVAR group was 1.7% (9/531) vs. 4.7%(24/516) in the open-repair group (odds ratio 0.35 [95% CI0.16–0.77]; p�0.009). By per-protocol analysis, 30-day

mortality for EVAR was 1.6% (8/512) vs. 4.6% (23/496) foropen repair (0.33 [0.15–0.74]; p�0.007). Secondary inter-ventions were more common in patients allocated EVAR(9.8% vs. 5.8%; p�0.02).Conclusions: The researchers conclude that, in patients withlarge AAAs, treatment by endovascular repair reduced the30-day operative mortality by two-thirds compared withopen repair.Perspective: These early results with endovascular repair,applied to large aneurysms in patients judged fit for openrepair, provide justification for continued use of this tech-nique in controlled or trial settings. However, the earlypromise of endovascular repair cannot be guaranteed andmay not be sustained in the long term. The 30-day mortalityresults should spur continued scientific evaluation of endo-vascular stent graft repair, but should not change clinicalpractice till longer-term data are available in larger co-horts. DM

Cardiac Troponin After Major Vascular Surgery: TheRole of Perioperative Ischemia, PreoperativeThallium Scanning, and Coronary RevascularizationLandesberg G, Mosseri M, Shatz V, et al. J Am Coll Cardiol2004;44:569 –75.

Study Question: Does ischemia on preoperative thalliumtesting or preoperative percutaneous revascularization af-fect perioperative troponin release after major vascular sur-gery?Methods: Preoperative clinical data including thallium scan-ning and coronary revascularization, along with continuousperioperative 12-lead ST-segment trend monitoring, car-diac troponin-I and/or troponin-T, and creatine kinase-MBfraction in the first 3 postoperative days were recordedamong 501 consecutive patients undergoing elective majorvascular procedures.Results: Moderate to severe inducible ischemia on preoper-ative thallium scanning was associated with a 49.0% inci-dence of low-level (troponin-I �0.6 and/or troponin-T�0.03 ng/mL) and 22.4% conventional (troponin-I �1.5and/or troponin-T �0.1 ng/mL) troponin elevation. Incontrast, patients with preoperative coronary revasculariza-tion had 23.4% and 6.4% low-level and conventional tro-ponin elevations, respectively, similar to patients withoutischemia on thallium. By multivariate logistic regression,ischemia on preoperative thallium scanning was the mostimportant predictor of both low-level and conventionaltroponin elevations (adjusted odds ratios [ORs] 2.5 and2.7; p � 0.02 and 0.04, respectively), whereas preoperativecoronary revascularization predicted fewer troponin eleva-tions (adjusted ORs 0.35 and 0.16; p � 0.045 and 0.022,respectively). Prolonged postoperative ischemia �30 minwas the only independent predictor of conventional tropo-nin elevation in addition to the preoperative predictors inthe multivariate analysis (OR 22.8; p � 0.001).

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