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ABSTRACT: BACKGROUND: We analyzed risks for severe morbidity in the early period after extracardiac Fontan operation. METHODS: Between November 1995 and May 2011, 140 patients (median age, 3.8 years) underwent extracardiac Fontan operation. We assumed as preoperative risk factors systemic right ventricle (n = 51), heterotaxia (n = 25), arterial oxygen saturation less than 75% (n = 22), and adult age (>16 years, n = 20) at time of surgery. Prolonged cardiopulmonary bypass time of longer than 120 minutes (n = 30) and use of cardioplegia (n = 26) were analyzed as intraoperative risks. RESULTS: Heterotaxia was revealed as a risk factor for postoperative prolonged inotropic support, acute renal failure, prolonged mechanical ventilation, prolonged pleural effusions, and tachyarrhythmias. With the exception of pleural effusions, the same held true for right ventricle morphology. Low preoperative arterial oxygen saturation was found to be associated with an increased risk of prolonged inotropic support, acute renal failure, and prolonged mechanical ventilation. Adult age was identified as a risk factor for acute renal failure. Of the intraoperative factors, prolonged cardiopulmonary bypass time longer than 120 minutes was a risk factor for acute renal failure and prolonged pleural effusions, whereas use of cardioplegia was associated with an increased risk of prolonged inotropic support, prolonged mechanical ventilation, acute renal failure, and tachyarrhythmias. Multivariate analysis demonstrated heterotaxia, right ventricular morphology, and low preoperative arterial oxygen saturation to be independent risk factors for postoperative prolonged inotropic support and prolonged mechanical ventilation. CONCLUSIONS: Patients with heterotaxia, systemic right ventricle, and low preoperative arterial oxygen saturation are still at high risk for early Fontan failure after extracardiac Fontan operation and require special management for optimal outcome.
The Annals of thoracic surgery 02/2013; · 3.74 Impact Factor
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The Journal of thoracic and cardiovascular surgery 11/2012; 144(5):1272. · 3.41 Impact Factor
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ABSTRACT: OBJECTIVES: The use of modified extracardiac Fontan operation (ECFO) for total cavo-pulmonary connection allows cardiopulmonary bypass (CPB) to be avoided and seems to improve early postoperative results. We evaluated our experience with the off-pump technique for ECFO. METHODS: Since 2009, the last 17 consecutive patients of 137 (median age 3.2 years, median weight 14.5 kg) in whom no intracardiac surgery was necessary underwent ECFO without CPB. The non-fenestrated graft was connected end-to-side to the pulmonary artery without bypass; subsequently temporary passive inferior vena cava (IVC)-to-atrial bypass was used for the anastomosis between IVC and graft. The perioperative and postoperative course was compared between consecutive paediatric patients operated on using the CPB vs off-pump technique. RESULTS: There was no mortality in the off-pump group, with a total early mortality of 3.0%. Overall operation time for the Fontan operation using the off-pump technique was significantly reduced (160 vs 200 min, P < 0.001). The median Fontan pressure 24 and 48 h postoperatively was significantly lower in the off-pump group (P = 0.002/0.042). Duration of mechanical ventilation (9 vs 14 h, P = 0.016), pleural effusions (4 vs 8 days, P < 0.001) as well as the median intensive care unit (2 vs 4 days, P = 0.013) and hospital stay (median 10 vs 15 days, P < 0.001) was significantly shorter in patients who underwent the off-pump Fontan operation. The necessity of blood transfusions was significantly reduced with the off-pump in comparison with the on-pump technique (14 of 17 vs 34 of 84 patients, P = 0.003). CONCLUSIONS: The ECFO without CPB is an established low-risk surgical procedure that improves the early postoperative course and significantly reduces the use of blood products and the duration of pleural effusions in selected patients.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 10/2012; · 2.40 Impact Factor
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Evgenij V Potapov,
Nikolay Dranishnikov,
Lars Morawietz,
Alexander Stepanenko,
Sajjad Rezai,
Cristiane Blechschmidt,
Hans B Lehmkuhl,
Yuguo Weng,
Miralem Pasic, Michael Hübler,
Roland Hetzer,
Thomas Krabatsch
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ABSTRACT: Continuous-flow (CF) ventricular assist devices (VAD) are an established option for treatment of end-stage heart failure. However, the effect of long-term CF with lack of peripheral arterial wall motions on blood pressure regulation and end-organ arterial wall sclerosis, especially in the case of long-term support (>3 years), remains unclear.
Tissue samples obtained at autopsy from liver, kidney, coronary arteries, and brain from 27 VAD recipients supported for >180 days between 2000 and 2010 were histologically examined to assess vascular alterations, including perivascular infiltrate, intravascular infiltrate, wall thickness, thrombosis, endothelial cell swelling, vessel wall necrosis, and peri-vascular fibrosis. Pulsatile-flow (PF) devices had been inserted in 9 patients and CF devices had been inserted in 16. The pathologist was blinded to the group distribution. Demographic, pharmacologic, and clinical data were retrospectively analyzed before surgery and during the follow-up period of up to 24 months.
Median duration of support was 467 days (range, 235-1,588 days) in the PF group and 263 days (range, 182-942 days) in the CF group. Demographic and clinical data before and after surgery were similar. Amiodarone was more often used during follow-up in CF group than in the PF group (61% vs 10%, p=0.009). Throughout the follow-up period, mean arterial pressure did not differ between recipients of the 2 pump types, nor did systolic and diastolic pressure, except at 2 weeks after VAD implantation, when systolic blood pressure was higher (p=0.05) and diastolic lower (p=0.03) in the PF group. Histologic studies did not identify any relevant differences in arterial wall characteristics between the 2 groups.
Long-term mechanical circulatory support with CF devices does not adversely influence arterial wall properties of the end-organ vasculature.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 09/2012; 31(11):1171-6. · 3.54 Impact Factor
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Nikolay Dranishnikov,
Alexander Stepanenko,
Evgenij V Potapov,
Michael Dandel,
Henryk Siniawski,
Alexander Mladenow, Michael Hübler,
Onnen Grauhan,
Yuguo Weng,
Thomas Krabatsch,
Roland Hetzer,
Marian Kukucka
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ABSTRACT: Aortic valve regurgitation or the presence of a mechanical aortic valve prosthesis is a relative contraindication for implantation of left ventricular assist devices (LVAD). However, concomitant aortic valve replacement by a biological prosthesis is one of the options in this situation. We analyzed our recent experience with left ventricular assist device implantation and concomitant aortic valve replacement.
Between January 1, 2008 and January 15, 2012, 318 adult patients (>18 years old) were supported with a long-term implantable LVAD in our institution. In 19, simultaneous aortic valve replacement (6 redo and 13 primary procedures) was performed. Patients were divided into 2 groups according to INTERMACS (IM) level: Group 1 (n = 7) consisted of patients with IM level 1-2 and Group 2 (n = 12) of IM level 3-4 patients. As a control cohort we analyzed all LVAD recipients during the study period (n = 299, study group excluded). The control cohort was similarly divided into two groups according to the IM level: Group 3 (n = 162) consisted of patients with IM level 1-2 and Group 4 (n = 137) of those with IM level 3-5. Perioperative data and outcomes in all groups were retrospectively analyzed and compared (Group 1 compared to Group 3; and Group 2 to Group 4).
In study Groups 1 and 2 all patients were male; in Groups 3 and 4, 80% and 88% respectively were male. Median age distribution in Groups was 55, 61, 54, and 57 years respectively. Patients from Group 2 were significantly older than those from Group 4 (p = 0.039). Body mass index was significantly lower in Group 1 than in Group 3 (p = 0.033). Cardio-pulmonary bypass time was significantly longer in Groups 1 and 2 compared with Groups 3 and 4 respectively (p=0.001). Patients from Group 1 had a trend more often to develop right ventricular failure requiring a right ventricular assist device (RVAD) than those in Group 3 (p = 0.09). Intensive care unit stay duration of mechanical ventilation and in-hospital mortality in Group 1 were significantly higher than in Group 3 (p = 0.025, p = 0.005, p = 0.038). Patients from Group 2 had similar outcomes compared to those from Group 4.
In stable patients, simultaneous aortic valve replacement and LVAD implantation are not associated with an impaired outcome. In patients with cardiogenic shock an additional aortic valve replacement may impair outcome; therefore alternative techniques should be considered.
The International journal of artificial organs 06/2012; 35(7):489-94. · 1.86 Impact Factor
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Hashim Abdul-Khaliq,
Stephan Schubert, Michael Hübler,
Dirk Triotzsch,
Wolfgang Böttcher,
V Alexi-Meskhishvili,
Michael Kopitz,
Hermann Kuppe,
Gisela Stoltenburg-Didinger,
Roland Hetzer,
Peter E Lange
Critical Care 04/2012; 4:1-2. · 4.93 Impact Factor
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ABSTRACT: We retrospectively compared early and long-term results of mitral (MV) and tricuspid valve (TV) repair in patients with isolated active infective atrioventricular valve (AV) endocarditis over a period of 23 years.
Between April 1986 and December 2009, a total of 1,409 patients with active infective endocarditis (AIE) were operated upon. Of these, 106 (7.2%) patients (n = 69 men, age 2-84 years) underwent repair of AVE (MV n = 68, TV n = 38). Repair techniques included vegetectomy and leaflet resection, annular plication and annuloplasty, and pericardial patch leaflet and annular reconstruction without any artificial device. Perioperative characteristics, probability of survival, freedom from recurrence and reoperation, and predictors for early mortality were analyzed. Follow-up (0-23 years) was completed in 95% with a total of 667 patient years.
The 30-day, 1-, 5- and 10-year survival rate for MV repair was 89.7 ± 0.4, 82.2 ± 4.6, 72.6 ± 5.5 and 56.5 ± 7.3% and for TV repair 94.7 ± 3.7, 88.7 ± 5.3, 69.4 ± 8.8 and 64.5 ± 9.5%, respectively (ns). Three patients (2.8%) had to undergo reoperation due to early failure of reconstruction (n = 2 MV, n = 1 TV). Freedom from valve-related reoperation at 1 and 10 years was 88.4 ± 4.1 and 75.4 ± 7.4% for the MV repair and 97.4 ± 2.6 and 93.94 ± 4.2% for the TV repair group (ns). Endocarditis reoccurred early in 2 MV repair patients (1.9%). Freedom from reoperation due to reinfection at 1 and 10 years after MV repair was 96.6 ± 2.3 and 91.6 ± 5.4% and after TV repair 100 and 83.3 ± 9.5%.
Repair for AV endocarditis yields excellent results. It is associated with low operative mortality and provides satisfactory early and long-term survival and favorable freedom from recurrent endocarditis and repeat operation. It should be considered as the primary surgical option in these patients, and AV replacement should be performed only in cases of severe AV destruction that renders repair techniques impossible.
Clinical Research in Cardiology 06/2011; 100(11):993-1002. · 2.95 Impact Factor
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ABSTRACT: Although mortality after direct aortic reimplantation for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) has significantly decreased, many questions remain unanswered.
Between 1986 and June 2010, we operated on 27 consecutive pediatric patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). All patients underwent reestablishment of a dual coronary system with direct aortic reimplantation of the left coronary artery into the aorta. Postoperative extracorporeal mechanical circulatory support was necessary in 7 cases. In all 7 patients, hemodynamic stability was achieved after 4 to 10 days of support. Mitral valve repair was performed in 9 patients with severe mitral valve incompetence and resulted in stable mitral valve function during follow-up as long as 19 years.
There were no early or late deaths. During follow-up (3 months-17.5 years), both early and late improvement of myocardial function was observed in all patients. Reduced left ventricular regional function late after successful surgical correction of ALCAPA was related to the presence of left ventricular myocardial scar tissue, as detected by magnetic resonance imaging.
Despite the absence of early and late mortality, the long-term prognosis for patients after reimplantation of ALCAPA into the aorta is not clear. Scars and perfusion deficits of the left ventricle may not be detected by standard echocardiographic evaluation of global left ventricular function and therefore may be underestimated. We therefore recommend lifelong surveillance of these patients, including magnetic resonance imaging.
The Journal of thoracic and cardiovascular surgery 06/2011; 142(4):868-74. · 3.41 Impact Factor
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ABSTRACT: The purpose of this study is to describe initial experience with a new continuous flow, ventricular assist system in the pediatric population.
Seven children (aged 6 to 16 years) received implantation of a novel third-generation, continuous flow, ventricular assist device (HeartWare, HeartWare Inc, Miami Lakes, FL) as a bridge to cardiac transplantation.
All children were in terminal heart failure despite inotropic support, and signs of renal or hepatic impairment developed. Six children had dilatative cardiomyopathy and 1 had congenital heart disease (hypoplastic left heart, total cavopulmonary connections with extracardiac conduit). Six patients have been successfully bridged to transplantation. Median support time was 75 days (range, 1 to 136 days). One child is still under continuous mechanical support. None of the patients suffered a thromboembolic event or an infection.
The HeartWare assist system can be successfully used as a bridge to transplantation in children and adolescents with end-stage heart failure.
The Annals of thoracic surgery 04/2011; 91(4):1256-60. · 3.74 Impact Factor
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ABSTRACT: Pediatric ventricular assist devices may be superior to extracorporeal membrane oxygenation in some respects, especially for medium- and long-term cardiac support. We present our nearly 20-year experience with pediatric ventricular assist devices.
Between 1990 and April 2009, Berlin Heart EXCOR (Berlin Heart AG, Berlin, Germany) was implanted in 94 children. Patients were compared according to period of treatment: group I, implantation between 1990 and 2001 (n = 45), and group II, implantation since 2002 (n = 49).
Preoperative serum creatinine (1.2 vs 0.7 mg/dL, P = .002) and bilirubin (1.5 vs 1 mg/dL, P = .002) were lower in period II, and fewer patients were artificially ventilated before surgery (26 vs 13, P = .002). In period I, more patients were supported with biventricular assist devices (64% vs 22.5%, P < .001). Median time on support was shorter in period I (10 vs 40 days, P < .001). Success (weaning from system or heart transplant) was achieved in 49% and 69%, respectively (P = .043). Whereas in period I 17% of children younger than 1 year were discharged home after transplant or weaning, rate during period II was 93% (P < .001), in particular because of improvement in discharge rate of patients with postcardiotomy heart failure (13% vs 50%). Rates of pump exchange for thrombus formation were 0.029/d in period I and 0.014/d in period II (P = 0.003).
Recent results show significant improvements in survival and discharge rate, especially for children younger than 1 year. Pediatric Berlin Heart EXCOR ventricular assist device may provide a safe mechanical support strategy in children with cardiogenic shock.
The Journal of thoracic and cardiovascular surgery 03/2011; 141(3):616-23, 623.e1. · 3.41 Impact Factor
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ABSTRACT: We retrospectively analysed the profile and outcome of surgically treated patients with active infective prosthetic valve endocarditis (PVE) over a period of 22 years.
Between May 1986 and December 2008, a total of 1313 patients with active infective endocarditis (AIE) were operated on, 349 (26.6%) of them for PVE. Of these, 77 (22.1%) had to be operated upon due to early PVE (≤60 days, n=55 men, median age: 58 years) and 272 (77.9%) due to late PVE (n=200 men, median age: 63 years). A large proportion of patients were referred to our department with advanced endocarditis and in a condition of cardiac and pulmonary decompensation. A total of 226 (64.8%) patients developed periannular abscess. Operations consisted of 80 aortic valve, 45 mitral valve, 39 double valve and 165 aortic root replacements, 134 of them with a homograft. Perioperative characteristics, probability of survival, freedom from recurrence and predictors for hospital mortality were analysed. Follow-up (maximum: 19.4 years) was completed in 96.3% (total: 1118 patient-years).
There was high early and late mortality. Overall in-hospital mortality was 28.4% (99/349). The 30-day, 1-, 5- and 10-year survival for the whole PVE study population was 71.4 ± 2.4%, 58.7 ± 2.7%, 44.5 ± 3% and 31.7 ± 3.5% with no significant differences between the early and late PVE patients: 67 ± 5.4%, 55.9 ± 5.8%, 49.4 ± 6.2% and 29.7 ± 7.6%, compared to 72.4 ± 3%, 60 ± 3%, 43.5 ± 3.3% and 31.1 ± 3.8% (p=0.93). Predictors of early mortality were mechanical support (risk ratio (RR): 4.3), emergency operation (RR: 2.1), preoperative high doses of catecholamines (RR: 1.8), mitral valve replacement (RR: 1.5) and age at operation (RR: 1.1). Freedom from re-operation due to recurrent endocarditis at 10 years was 85.8 ± 5.6% for early PVE compared to 92.1 ± 2.3% for late PVE patients (p=0.17). Staphylococcus aureus (S. aureus) (18.1%) was the most frequent causative micro-organism.
Surgery for active infective PVE continues to be challenging. It not only carries a high in-hospital mortality but is also associated with a high long-term mortality risk. Early PVE patients were in a more severe condition than late PVE patients. Preoperative status, complications and co-morbidity of PVE patients strongly predict early outcome. Because of the potential risk of late complications, PVE patients need close clinical follow-up.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 11/2010; 38(5):528-38. · 2.40 Impact Factor
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ABSTRACT: Deep hypothermic circulatory arrest (DHCA) is used in corrective cardiac surgery for complex congenital heart disease. Endogenous protective mechanisms may be responsible for the prevention of brain damage after hypothermic ischemia. Neuroglobin and cytoglobin are expressed in brain cells and appear to modulate hypoxic-ischemic brain injury. However, their neuroprotective potency is still not understood. Thus the aim of this study was to detect the influence exerted by DHCA on their expression.
The effects of DHCA were analyzed in a neonatal piglet model with cardiopulmonary bypass, DHCA of 60 and 120 min and subsequent reperfusion of 6h. Complete histological analysis and changes in the mRNA expression of neuroglobin and cytoglobin were measured in the brain.
In comparison to animals without DHCA, neuroglobin expression was stable after 60 min DHCA and neuronal cell necrosis in the cortex was mild (< 10 %). Neuroglobin expression was significantly reduced after 120 min DHCA, which was accompanied by substantial neuronal cell necrosis (> 50 %). Cytoglobin expression did not differ significantly between animals with neuronal necrosis vs. sham.
Constitutive expression levels of neuroglobin may explain the mild neuronal injury after 60 min DHCA. Significant neuronal cell death correlates with reduced neuroglobin expression and might reflect a limited capacity to compensate for ischemic injury. Both respiratory cell proteins may constitute attractive targets for therapeutic modulation of gene regulation, but further studies are necessary.
Brain research 10/2010; 1356:1-10. · 2.46 Impact Factor
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ABSTRACT: Patients with cyanotic congenital cardiac disease often develop major aortopulmonary collaterals. Vascular endothelial growth factor is a key promoter of angiogenesis. Its soluble receptor-1 acts as a potent antagonist. We studied 30 infants with cyanotic congenital cardiac disease and 27 infants with acyanotic congenital cardiac disease. Central venous plasma vascular endothelial growth factor and soluble vascular endothelial growth factor receptor-1 levels were measured before, and 24 and 96 hours after surgery. There was no difference between plasma vascular endothelial growth factor levels in infants with cyanotic and those with acyanotic congenital cardiac disease. In cyanotic infants, the soluble vascular endothelial growth factor receptor-1 levels tended to be higher than in the acyanotic infants. In conclusion, there is no significant difference in the plasma levels of vascular endothelial growth factor and its soluble receptor-1 between infants with cyanotic and those with acyanotic congenital cardiac disease.
Cardiology in the Young 10/2010; 20(5):505-8. · 0.76 Impact Factor
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ABSTRACT: Left ventricular (LV) mechanical circulatory support (MCS) may be necessary after repair of anomalous left coronary artery from the pulmonary artery. We evaluated LV function parameters for their ability to predict postoperative need for MCS.
Fourteen infants (median age, 3.6; range, 2.3 to 12 months) underwent direct aortic reimplantation of the left coronary artery. We compared preoperative LV end-diastolic diameter, end-diastolic pressure, ejection fraction, and fraction of shortening of 8 patients with successful weaning from cardiopulmonary bypass (group 1) and 6 patients with unsuccessful weaning from cardiopulmonary bypass and temporary MCS support (group 2).
No perioperative or late deaths occurred. All patients at follow-up were free of reoperation (median follow-up, 10.4 years [range, 1.4 to 17 years]). Median preoperative LV end-diastolic diameter (47 [range, 41 to 60 mm] vs 32 mm [range, 21 to 36 mm]) and LV end-diastolic pressure (20 [range, 18 to 25 mm Hg] vs 12 mm Hg [range, 7 to 20 mm Hg]) were significantly higher in group 2 than in group 1 (p = 0.002 and p = 0.048). LV ejection fraction (0.28 [range, 0.19 to 0.37] vs 0.43 [range, 0.23 to 0.76]) and LV fraction of shortening (9% [range, 7% to 15%] vs 22% [range 13% to 30%]) were significantly lower in group 2 than in group 1 (p = 0.035 and p = 0.002). MCS support duration ranged from 4 to 12 days. There were no significant differences in LV function parameters at discharge or during follow-up between the groups.
A preoperative LV end-diastolic diameter above 40 mm is the strongest predictor for postoperative temporary MCS after anomalous left coronary artery from the pulmonary artery repair in infancy. However, even with temporary MCS, direct aortic reimplantation for anomalous left coronary artery from the pulmonary artery can be performed with no mortality and excellent LV recovery.
The Annals of thoracic surgery 08/2010; 90(2):580-7. · 3.74 Impact Factor
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ABSTRACT: A retrospective analysis was conducted of the early and long-term results of mitral valve repair (MVRep) and mitral valve replacement (MVR) in patients with isolated infective mitral valve endocarditis.
Between May 1986 and December 2007, a total of 1,163 patients with active infective endocarditis (AIE) were operated on. Of these patients, 497 showed an endocarditic involvement of the mitral valve. Sixty-one of these patients underwent MVRep and 219 MVR, with 24% cases of prosthetic valve endocarditis (PVE). The patients' perioperative characteristics, cumulative survival, freedom from recurrence and reoperation and independent risk factors for early mortality were analyzed. Follow up (0-21 years) was complete in 96.5% of cases; the total follow up was 348 and 810 patient-years (pt-yr) in the MVRep and MVR groups, respectively.
Typically, the MVR patients were significantly older (p < or = 0.001), preoperatively more often intubated (p = 0.008) and in cardiogenic shock (p = 0.045), and more often underwent emergency surgery (p = 0.023). MVRep was associated with a significantly better survival, with 30-day, one-, five- and 10-year survival rates of 90.1 +/- 3.9%, 83.2 +/- 4.8%, 77.0 +/- 5.7% and 60.5 +/- 8.0%, respectively (p = 0.002). Survival after MVR was significantly worse with abscess formation (p = 0.0002) and PVE (p = 0.038). Freedom from reoperation due to reinfection after 10 years was 89.4 +/- 7.0% after MVRep, with early endocarditis recurrence in two patients (3%), and 91.0 +/- 2.5% after MV, with early recurrence in four patients (2%) (p = 0.46). Multivariate analysis identified preoperative ventilation (OR = 6.3), mitral valve abscess formation (OR = 5.3), PVE (OR = 3.1) and age > or = 60 years (OR = 2.8) as independent risk factors for early mortality.
Compared to the MVRep group, patients requiring MVR had more advanced endocarditis and were more critically ill. These results suggest that the early outcome might have been improved if patients had been operated on before either heart failure or the development of septic shock. MVRep for AIE showed a low operative mortality and provided satisfactory freedom from recurrent infection and repeat operation. If all infected material could be resected such that the remaining tissue would allow the re-shaping of a competent valve, then MVRep could be performed also in infective endocarditis, in line with the general recommendations for mitral valve surgery.
The Journal of heart valve disease 03/2010; 19(2):206-14; discussion 215. · 0.81 Impact Factor
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ABSTRACT: We compared early and long-term results of cryopreserved homograft aortic root replacement in native valve endocarditis or prosthetic valve endocarditis associated with periannular abscess.
Between May 1986 and December 2007, 1163 patients with endocarditis were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) had homograft aortic root replacement due to 99 cases of native valve endocarditis (45%) and 122 of prosthetic valve endocarditis (55%). Perinannular abscess developed in 189 patients (86%), and aortoventricular dehiscence in 120 (63.5%) of them. Perioperative characteristics, probability of survival, freedom from recurrence, and reoperation were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1127 patient-years.
Overall native valve endocarditis survival at 30 days and 1, 5, and 10 years was 83.8% +/- 3.7%, 76.6% +/- 4.3%, 66.5% +/- 4.9%, and 47.3% +/- 5.6%, respectively, significantly better than for patients with prosthetic valve endocarditis, who had a greater tendency toward abscess formation (P = .029). Thirty-one patients (14.0%) required reoperation either for structural valve deterioration (n = 19, 8.6%), with a greater tendency in patients aged <40 years, or for recurrent endocarditis of the homograft (n = 12, 5.4%). One-year reoperation mortality rate was 16.1% (n = 5).
Homograft aortic root replacement in active infective endocarditis with periannular abscess formation shows satisfactory early and long-term results with significantly better survival in native valve endocarditis than prosthetic valve endocarditis. It is associated with a low recurrence rate, although the risk of structural valve deterioration increases over time, especially in young patients, and reoperation remains a challenge. In our institution, the homograft remains the preferred valve substitute in active infective endocarditis with periannular abscess formation.
The Journal of thoracic and cardiovascular surgery 09/2009; 139(3):665-73. · 3.41 Impact Factor
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Jürgen Hörer,
Thorsten Hanke,
Ulrich Stierle,
Johanna J M Takkenberg,
Ad J J C Bogers,
Wolfgang Hemmer,
Joachim G Rein,
Roland Hetzer, Michael Hübler,
Derek R Robinson,
Hans H Sievers,
Rüdiger Lange
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ABSTRACT: For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR).
Neoaortic echo dimensions from 48 children (<16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years).
The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow-up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40).
Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR.
The Annals of thoracic surgery 08/2009; 88(2):594-600; discussion 600. · 3.74 Impact Factor
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Jürgen Hörer,
Thorsten Hanke,
Ulrich Stierle,
Johanna J M Takkenberg,
Ad J J C Bogers,
Wolfgang Hemmer,
Joachim G Rein,
Roland Hetzer, Michael Hübler,
Derek R Robinson,
Hans H Sievers,
Rüdiger Lange
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ABSTRACT: The Ross operation may be the ideal aortic valve replacement in pediatric patients. However, reoperations for replacement of the homograft in the pulmonary position are inevitable. This study determined influencing factors for the development of homograft stenosis and regurgitation in pediatric Ross patients.
Follow-up echocardiograms of 116 children (86 boys) undergoing Ross operations at a mean age, 9.3 +/- 4.9 years were analyzed using hierarchic multilevel modeling. Mean duration of the echocardiographic follow-up was 5.3 +/- 4.2 years (609 patient-years, 398 examinations).
Median homograft diameter z value was 0.3 (range -2.2 to +7.3). Mean homograft pressure gradient at implantation was 5.0 mm Hg with a significant increase of 4.2 mm Hg/y (p < 0.001) within the first 2 years and a steady state thereafter. Older donor age was significantly associated with lower mean pressure gradient at implantation (p = 0.037). Larger z value had no significant influence on the annual increase of pressure gradient (p = 0.87). Mean grade of regurgitation at implantation was 0.9, without significant annual increase (0.02 grade/y, (p = = 0.32). Older recipient (p = 0.005) and donor age (p < 0.0001) were significantly associated with lower mean regurgitation at implantation. Larger z value was associated with a higher annual increase of regurgitation (p = 0.014).
Relevant midterm homograft regurgitation is rare in children after the Ross operation. However, a significant annual increase occurs in the pressure gradient that cannot be influenced by larger graft size. Homograft oversizing may lead to a higher annual increase of regurgitation.
The Annals of thoracic surgery 08/2009; 88(2):609-15. · 3.74 Impact Factor
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ABSTRACT: We compared early results of homograft aortic root replacement (ARR) in native (NVE) and prosthetic (PVE) aortic valve endocarditis in order to identify predictors for early mortality (<30 days).
Between 05/1986 and 12/2007, 1,163 endocarditis patients were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) underwent homograft ARR due to 99 cases of NVE (45%) and 122 of PVE (55%) aortic root endocarditis. Demographics, clinical differences, survival rates and predictors of early mortality were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1,127 patient years.
Main causes of the 47 (21.2%) early deaths were septic multiorgan failure in 23 (48.9%) and myocardial failure in 10 (21.3%) patients with a significantly better survival for NVE than for PVE patients (patients = 0.029). The highest ORs were found in the univariate analysis for preoperative development of septic shock (OR 14.28), preoperative necessity of ventilation (OR 7.08), high doses of catecholamines (OR 5.60), severe aortic root destruction (OR 5.12), emergency operation (OR 4.25) and persistent fever despite antibiotic treatment (OR 4.11). Multivariate analysis showed that preoperative ventilation (OR 5.43), persistent fever under antibiotic treatment (OR 2.84) and prosthetic endocarditis (OR 2.32) were independent risk factors for early mortality.
Our results suggest that early outcome could be improved if patients were referred earlier for surgery. A multidisciplinary approach is necessary, involving at least specialists in intensive care medicine, cardiology, infectious disease and cardiac surgery in order to identify the optimal time for surgery and decrease early mortality.
Clinical Research in Cardiology 04/2009; 98(7):443-50. · 2.95 Impact Factor
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ABSTRACT: Several methods for surgical repair of partial anomalous pulmonary venous connection have been described. Sinus node dysfunction is known as a cause of morbidity after surgical repair. In this retrospective study, we attempted to determine the incidence of arrhythmias after use of two different techniques for repair of partial anomalous pulmonary venous connection.
Between 1988 and 2006, 119 patients (61 male, 58 female; aged 5 months to 66 years) with anomalous drainage of the pulmonary vein into the superior vena cava or the right atrium were analyzed. All patients had sinus rhythm before operation. In 64 patients (group 1), rerouting of the pulmonary veins was accomplished through a right atriotomy; and in 54 patients (group 2), the atriotomy incision was extended into the superior vena cava through the cavoatrial junction.
There were no perioperative deaths. New-onset nodal rhythm and atrial dysrhythmias developed significantly more often in patients with extended incision through the cavoatrial junction (group 1, 26.5%, versus group 2, 54.5%; p < 0.004). At discharge, the rate of dysrhythmias was 14% in group 1 and 32.7% in group 2 (p < 0.01). The hospital stay was longer in group 2. At 1-year follow-up of 58 patients, the rate of arrhythmias was 6.25% in group 1 versus 18.1% in group 2.
Extended incision through the cavoatrial junction increases atrial dysrhythmias, especially early postoperatively, but the incidence of such sinus node dysfunction decreased with time.
The Annals of thoracic surgery 02/2009; 87(2):580-3. · 3.74 Impact Factor
