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ABSTRACT: OBJECTIVE: Determine incidence and risk factors for possible paradoxical embolic events in patients who have Ebstein anomaly with severe tricuspid regurgitation. DESIGN: Retrospective study of clinical and imaging data. SETTING: Tertiary care center. PATIENTS: Patients undergoing clinical evaluation and echocardiography prior to cardiac surgery for Ebstein anomaly (1975-2010) performed at age ≥ 40 years. RESULTS: Mean age of 128 patients (81 female) was 53 ± 9 years. All had severe tricuspid regurgitation. Twenty-four (19%) had previous cardiac surgery (at <40 years), including 17 for interatrial shunt closure. Most (112 [88%]) had New York Heart Association functional class III/IV heart failure; 84 (66%) had interatrial shunting (58 had an atrial septal defect and 29 had a patent foramen ovale [3 had both]). During their lifetime, 29 patients (23%) had a history of ≥1 possible paradoxical embolic events (stroke or transient ischemic attack, brain abscess, or myocardial infarction). The best predictors of preoperative possible paradoxical embolic events were an atrial septal defect (P = .002) and older age at surgery (P = .007). There was no association of possible paradoxical embolic events with cardiovascular risk factors (hypertension, dyslipidemia, smoking, or family history of coronary artery disease) (all P ≥ .3) or atrial fibrillation (P = .69). Median age at occurrence of paradoxical embolism was 49 (range, 1.5-74 years). CONCLUSIONS: Possible paradoxical embolic events are common in adults with Ebstein anomaly and severe tricuspid regurgitation and are strongly associated with atrial septal defect. In patients with atrial septal defect or patent foramen ovale, shunt closure should be considered to reduce risk of possible paradoxical embolic events.
Congenital Heart Disease 04/2013; · 0.90 Impact Factor
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ABSTRACT: BACKGROUND: The long-term outcome and spectrum of reoperation after the arterial switch operation (ASO) has not been fully defined, and there are limited data in the literature. We reviewed our institutional experience with reoperation(s) after ASO. METHODS: Between January 1984 and January 2012, 32 patients (23 male) underwent reoperation(s) after ASO. Anatomy included simple transposition of the great arteries in 14, complex transposition of the great arteries in 14, and Taussig-Bing in 4. Mean age was 6.7 ± 1.4 years at first operation and 10.8 ± 13.4 years at the second operation. Isolated pathology was present in 11 (34.3%) and multiple pathologies in 21 (65.6%). Abnormalities at first reoperation were right-sided pathology in 18 (56.3%), left-sided pathology in 10 (31%), coronary artery in 3 (9%), mitral valve in 3 (9%), residual ventricular septal defect in 4 (12.5%), and recoarctation in 2 (6.3%). It was the second reoperation in 12 and the third reoperation in 3 patients. RESULTS: The first reoperation included pulmonary artery patch plasty in 18, aortic valve operation in 8 (4 valve replacement, 3 root replacement, and 1 repair), pulmonary valve replacement in 4, coronary artery bypass grafting in 3, and mitral valve repair in 3. Multiple reoperations occurred in 15 patients, comprising right-sided procedures (11), left-sided (2), and other (2). Pulmonary artery reconstruction occurred earlier than neoaortic intervention (5.4 ± 6.8 vs 13.8 ± 7.7 years, p < 0.001). There were 2 early deaths (6.2%); both patients had complex transposition of the great arteries and both were at early reoperation after ASO. Median follow-up was 14.5 years (maximum, 27 years). There were no late deaths. Freedom from reoperation at 1, 5, and 15 years was 88%, 78%, and 41%, respectively. CONCLUSIONS: The most common indication for reoperation after ASO is right-sided pathology, followed by neoaortic root pathology. Late survival after ASO is excellent and risk of late reoperation is low. Life-long medical surveillance is required.
The Annals of thoracic surgery 04/2013; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: Tetralogy of Fallot, or double-outlet right ventricle with atrioventricular (AV) septal defect (TOF/DORV-AVSD), is rare, with limited long-term data available. We report our institutional experience and outcome over a 50-year period. METHODS: From January 1961 to January 2011, 73 patients (50 males [68%]), with a mean age of 6.8 ± 4.4 years (range, 1 month to 35 years), underwent surgical repair of TOF/DORV-AVSD. Symptoms included cyanosis in 50 (69%) and heart failure in 12 (17%). Down syndrome was present in 25 (34%). Rastelli type A, B, and C was seen in 12%, 7%, and 81% of patients, respectively. Moderate or more common AV valve (AVV) regurgitation was present in 40%. Forty-nine patients (67%) had previous palliation, including 36 with a systemic-to-pulmonary arterial shunt. RESULTS: Surgical management included two-ventricle complete repair (CR) in 35 (48%) and single-ventricle (SV) palliation in 38 (52%). Overall, early mortality was 31% for CR and 34% for SV; after 1990, mortality was 6% for CR and 14% for SV. Repair before 1990 (p = 0.008) and the presence of significant common AVV regurgitation (p = 0.016) were univariate risk factors for early death in both groups. Median follow-up was 9.8 years (maximum, 32 years). Late mortality rate was 12% in CR (n = 6) and 18% (n = 9) in SV (p = 0.95). The presence of significant right AVV regurgitation was associated with late death (p = 0.02). Overall survival at 1, 5, and 15 years was 92%, 77%, and 77% in CR, and 83%, 79%, 70% in SV (p = 0.9). Freedom from reoperation at 1, 5, and 15 years was 95%, 85%, 67% in CR and 96%, 91%, 82% in SV (p = 0.1). Reoperations were most common for right ventricular outflow tract pathology, Fontan revision, and AVV intervention. Right AVV regurgitation (p = 0.018) and repair before 1990 (p = 0.041) were risk factors for late reoperation in both groups. CONCLUSIONS: Complete repair of TOF/DORV-AVSD is standard of care and associated with low early mortality rate in the current era, with reasonable long-term outcome. SV palliation continues to have significant risk. The presence of AVV regurgitation is a significant risk factor for death and reoperation.
The Annals of thoracic surgery 04/2013; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: The management of the zone of apposition (ZOA) in patients with atrioventricular septal defect (AVSD) and parachute left atrioventricular valve (LAVV) is controversial. METHODS: Between 1977 and 2010, 28 patients with parachute LAVV associated with AVSD were reviewed. The median age at operation was 10 months (range, 36 days to 14 years). Sixteen (57%) patients had complete AVSD and 12 (43%) had partial AVSD. Thirteen (46%) patients had moderate to severe LAVV regurgitation. RESULTS: The ZOA was managed with complete closure in 6 (22%), partial closure in 10 (36%), and no closure in 11 (39%) patients One patient underwent LAVV replacement for dysplastic leaflets. Dismissal echocardiogram demonstrated moderate LAVV regurgitation in 10 (36%) patients; 7 patients had no closure of ZOA, and 3 had partial closure. Mild or moderate LAVV stenosis was present in all 6 patients with complete closure of ZOA and 1 patient with partial closure. Median follow-up was 9 years (maximum, 22 years). Eight patients had progression of LAVV regurgitation through the unsutured ZOA; 6 patients subsequently underwent LAVV replacement. Of the 7 patients who had LAVV stenosis, 1 patient required opening of ZOA 1 month after surgery. The other 6 patients had a decrease in mean gradient. There was 1 late death after the fourth redo LAVV replacement. CONCLUSIONS: Progression of LAVV regurgitation from the unsutured ZOA was the main indication for reoperation in parachute LAVV with AVSD. The ZOA in parachute LAVV should be partially or completely closed at the time of AVSD repair. Although mild LAVV stenosis appeared to improve with time, life-long surveillance is essential.
The Annals of thoracic surgery 03/2013; · 3.74 Impact Factor
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Journal of the American College of Cardiology 03/2013; 61(10):1120. · 14.16 Impact Factor
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ABSTRACT: Extracorporeal life support (ECLS) is a reliable method to support pediatric patients with reversible cardiorespiratory failure associated with congenital heart disease, respiratory insufficiency, or after cardiac surgery. In 2010, our institution adopted an infant/pediatric extracorporeal membrane oxygenation (ECMO) circuit that contains a magnetically levitated centrifugal pump, polymethylpentene oxygenator, and shorter tubing length (ECMO II circuit). Our prior circuit contained a nonocclusive roller pump, polypropylene oxygenator, venous compliance chamber, and hemoconcentrator (ECMO I circuit). A retrospective chart review comparing ECMO I and ECMO II daily plasma-free hemoglobin (PFH) values was conducted. We hypothesized that the PFH is similar between the two ECMO circuit groups. We reviewed medical records of children 3 years of age or younger weighing less than 13 kg who required ECLS between January 2008 and February 2012. PFH levels from 18 ECMO II patients were compared with levels in a retrospective group of an equal number of well-matched ECMO I circuit patients. There was no significant difference between ECMO I and ECMO II circuit groups regarding mean time on ECMO, age in days, and weight. There was also no significant difference in the group mean levels of PFH between ECMO I and ECMO II circuits. There was a significant increase in PFH with hours on ECMO (p < .01) within and between both circuit groups (p < .01) and a significantly greater increase in PFH with ECMO hours (p = .0091) in the ECMO I circuit group. Although there was no significant difference in average PFH with the change in ECMO II circuit technology, advancements such as the magnetically levitated blood pump and polymethylpentene gas exchange device has been associated with significantly fewer mechanical component change-outs (p = .0156) and less clots and fibrin build-up in the circuits (p = .0548).
The Journal of extra-corporeal technology 03/2013; 45(1):21-5.
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ABSTRACT: BACKGROUND: Repeat operations are common in adult congenital heart disease (ACHD) and valve-related procedures are the most frequent indication for intervention. The purpose of this study is to review a single institution's experience with a large number of patients with ACHD undergoing reoperation requiring multivalve intervention. METHODS: Data from the most recent repeat median sternotomy of 254 consecutive ACHD patients with simultaneous intervention on 2 or more valves were analyzed. Mean age of 136 (54%) female and 118 (46%) male patients was 37.9 years (range, 18 to 83). Diagnoses were conotruncal anomaly 132 (52%), Ebstein-tricuspid valve 41(16%), pulmonary stenosis and right ventricular outflow tract obstruction 37 (14%), atrioventricular septal defect 22 (9%), and other 22 (9%). It was the second sternotomy in 130 (51%) patients, third in 80 (31%), fourth in 34 (13%), and fifth in 10 (4%). RESULTS: Intervention was on 2 valves in 219 patients (86.2%), 3 in 34 patients (13.4%), and 4 in 1 patient (0.4%). The most common valve combination was tricuspid and pulmonary (117, 43%). Early mortality overall was 4.7% (12 of 254) and 2.9% (7 of 239) after elective operation. Potentially modifiable risk factors identified for early mortality were preoperative hematocrit less than 35 (p = 0.01), cross-clamp time (p < 0.001), and cardiopulmonary bypass time (p < 0.001). Late survival was 96%, 89%, and 77% at 1, 5, and 10 years, respectively. Independent risk factors for late mortality were prolonged ventilation (p = 0.002), coronary artery disease (p = 0.005), and cardiac injury (p = 0.018). CONCLUSIONS: The need for simultaneous intervention on multiple valves is relatively common in ACHD, particularly with conotruncal anomalies. Prolonged bypass and cross-clamp times, lower hematocrit, and acquired coronary artery disease are significant predictors of adverse outcome. The number or position of valves requiring intervention did not affect early or late survival.
The Annals of thoracic surgery 02/2013; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: Computed tomography angiography (CTA) of the coronary arteries has been proposed as an alternative screening modality to catheter coronary angiography (CCA) prior to noncoronary cardiac surgery. The safety and utility of preoperative coronary CTA in patients undergoing robotic mitral valve repair is unknown. METHODS: One hundred and ninety consecutive patients undergoing robotic repair of degenerative mitral leaflet prolapse were eligible for preoperative CT evaluation; retrospective electrocardiogram-gated CTA of the chest to assess the coronary arteries, followed by contrast-enhanced CT of the abdomen and pelvis to assess the systemic arterial and vascular anatomy. If coronary CTA identified coronary artery stenosis 50% or greater, CCA was performed for further assessment. RESULTS: Computed tomography evaluation was performed in 178 patients (94%). Six patients (3%) had coronary artery stenosis 50% or greater identified on coronary CTA and underwent CCA. In each of these cases, CCA revealed no significant obstructive lesion. On a per patient basis, coronary CTA had an accuracy of 91% (95% confidence interval 0.81 to 0.96) for excluding obstructive coronary disease. The CT also demonstrated significant noncoronary vascular findings in 6 patients (3%). These findings included iliac artery dissection and aneurysm (n = 4), and pulmonary embolism (n = 2). Mitral repair rate was 100% and no patients underwent conversion to sternotomy. Median hospital stay was 3 days and there were no deaths. CONCLUSIONS: In patients at low-to-intermediate risk of coronary artery disease, CT is useful as a single screening modality of the coronary arteries and peripheral vasculature to determine candidacy for minimally invasive robotic mitral valve repair.
The Annals of thoracic surgery 02/2013; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: We developed and tested a clinical simulation program in the principles and conduct of postcardiotomy extracorporeal membrane oxygenation (ECMO) with the aim of improving confidence, proficiency, and crisis management. METHODS: Twenty-three thoracic surgery residents from unique residency programs participated in an ECMO course involving didactic lectures and hands-on simulation. A current postcardiotomy ECMO circuit was used in a simulation center to give residents training with basic operations and crisis management. Pretraining and posttraining assessments concerning confidence and knowledge were administered. Before and after the training, residents were asked to identify components of the ECMO circuit and manage crisis scenarios, including venous line collapse, arterial hypertension, and arterial desaturation. RESULTS: In the hands-on portion, residents had difficulty identifying the gas source and flow rate, centrifugal pump head inlet, and oxygenator outflow line. Timely and accurate ECMO component identification improved significantly after training. The arterial desaturation crisis scenario gave the residents difficulty, with only 22% providing the appropriate treatment recommendations in a timely and accurate fashion. At the end of the simulation training, most residents were able to manage the crises correctly in a timely manner. Posttraining confidence-related scores increased significantly. Most of the residents strongly recommended the course to their peers and reported simulation-based training was helpful in their postcardiotomy ECMO education. CONCLUSIONS: We developed a simulation-based postcardiotomy ECMO training program that resulted in improved ECMO confidence in thoracic surgery residents. Crisis management in a simulated environment enabled residents to acquire technical and behavioral skills that are important in managing critical ECMO-related problems.
The Annals of thoracic surgery 01/2013; · 3.74 Impact Factor
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Annals of Pediatric Cardiology 01/2013; 6(1):43-5.
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ABSTRACT: OBJECTIVES: We reviewed our experience with repair of congenital coronary artery fistulas. METHODS: From June 1983 to December 2009, 46 patients (median age, 59 years; range, 1-84 years) underwent surgical repair. The presenting symptoms included angina in 16 patients (35%), congestive heart failure in 11 (24%), and bacterial endocarditis in 5 (11%). Preoperatively, 9 patients (20%) had at least moderate tricuspid regurgitation. Coronary artery dominance was right in 38 patients (83%). Coronary artery aneurysms were found in 8 patients (17%). The most common pattern was right coronary artery-to-coronary sinus fistula (18 patients, 39%); 11 patients had (23%) more than 1 fistula. One patient had undergone previous coil embolization. RESULTS: Cardiopulmonary bypass was used in 39 patients (85%), with extracardiac and intracardiac repair performed in 30 (65%) and 16 (35%), respectively. The most common associated procedures were coronary artery bypass in 13 patients (28%). Early mortality occurred in 1 patient (2%). Postoperative myocardial infarction occurred in 5 patients (11%); 4 of these patients underwent simple ligation or division of their fistulas. The mean follow-up was 6 ± 5.8 years (maximum, 22 years). Late mortality occurred in 11 patients (24%). Two patients underwent reoperation for severe tricuspid regurgitation. Survival was significantly reduced compared with the age- and gender-matched population (P = .03). Residual fistulas were detected in 3 patients (6%), with no reintervention needed. CONCLUSIONS: Perioperative myocardial infarction is an important complication of ligation of coronary artery fistulas and can contribute to reduced late survival. The tricuspid valve should be evaluated carefully at repair because of the relatively high rate of residual regurgitation in survivors.
The Journal of thoracic and cardiovascular surgery 12/2012; · 3.41 Impact Factor
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Heart Surgery Forum 12/2012; 15(6):E306. · 0.63 Impact Factor
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Rakesh M Suri,
Hector I Michelena, Harold M Burkhart,
Kevin L Greason,
Richard C Daly,
Joseph A Dearani,
Soon J Park,
Lyle D Joyce,
John M Stulak,
Thoralf M Sundt,
Zhuo Li,
Hartzell V Schaff
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ABSTRACT: Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performance. We sought to determine whether there are clinically important early differences among these devices.
Three hundred adults with severe aortic valve stenosis undergoing aortic valve replacement were randomized to receive the Edwards Magna, Sorin Mitroflow, or St. Jude Epic bioprostheses (n = 100, n = 101, n = 99, respectively). Early hemodynamic performance was studied by echocardiography.
Mean patient age was 76 ± 8 years and there were 203 men (68%). There were no significant differences in baseline characteristics among implant groups. Early mortality was 1.7%, and there were no differences in early adverse events. Postoperative echocardiography showed small but statistically significant differences overall between the Magna, Mitroflow, and Epic valves in mean gradient (14.2 mm Hg, 16.3 mm Hg, 16.5 mm Hg, respectively; P = .011), aortic valve area (2.05 cm(2), 1.88 cm(2), 1.86 cm(2), respectively; P = .012), and indexed aortic valve area (1.05 cm(2)/m(2), 0.97 cm(2)/m(2), 0.95 cm(2)/m(2), respectively; P = .012). Prosthetic performance was similar among all with a small (≤21 mm) aortic annulus. Patients who received the Magna device with a 23-mm annulus had slightly greater indexed aortic valve area; those with >23 mm had a slightly lower transprosthetic gradient. Analogous trends were found when data were stratified by either commercial implant size or echocardiography-determined aortic annulus size. Severe patient-prosthesis mismatch was infrequent overall and was similarly low among devices (P value not significant).
This prospective, randomized comparison reveals that there are small but consistent early postoperative hemodynamic differences among current third-generation porcine and pericardial aortic valve prostheses. The 3 valves studied performed equally well in patients with a small (≤21 mm) aortic annulus. The Magna valve had a slightly lower mean gradient in those with larger annular size (>23 mm). Longitudinal follow-up of these randomized cohorts is essential to determine late clinical implications of these early postoperative findings.
The Journal of thoracic and cardiovascular surgery 12/2012; 144(6):1387-98. · 3.41 Impact Factor
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ABSTRACT: BACKGROUND: Reproducible repair of Ebstein's malformation is challenging and numerous surgical techniques have been described. We reviewed our experience with the cone reconstruction. METHODS: Between June 2007 and December 2011, 89 patients (47 female; 53%) underwent cone reconstruction (median age 19 years; range, 19 days to 68 years). Indication for operation was progressive cardiomegaly in 43 (48%), cyanosis in 29 (33%), and heart failure in 13 (15%). Prior tricuspid valve repair was performed in 12 patients (13%). Severe tricuspid regurgitation (TR) was present in 75 patients (84%). RESULTS: All patients underwent cone reconstruction (360-degree leaflet tissue repair anchored at true annulus). Modifications included ringed annuloplasty in 57 patients (64%), leaflet augmentation in 28 patients (31%), and autologous chordae in 17 patients (19%). Bidirectional cavopulmonary anastomosis was performed in 21 patients (24%). Early mortality occurred in 1 patient (1%). Early reoperation for recurrent TR occurred in 12 patients (13%); re-repair was performed in 6 patients (50%), and 6 (50%) required replacement. Mean follow-up was 19.7 ± 24.7 months. There was no late mortality or reoperation. At follow-up, 72 patients (87%) had no or mild TR, 9 (11%) had moderate TR, and 2 patients (2%) had severe TR. Ringed annuloplasty was associated with less than moderate TR at dismissal (p = 0.01). CONCLUSIONS: The learning curve for cone reconstruction is steep, but early mortality is low. Cone reconstruction with ringed annuloplasty results in less TR and should be used whenever possible. Longer follow-up is essential to determine late durability of cone reconstruction.
The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
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ABSTRACT: While minimally invasive approaches are used routinely to correct severe mitral regurgitation due to leaflet prolapse, isolated tricuspid valve prolapse is less frequent and usually addressed via sternotomy. A 34-year-old female presented with exertional dyspnea and severe tricuspid regurgitation due to an unsupported anterior leaflet causing prolapse, a tethered septal leaflet, and dilated annulus. Herein, the technique is described of a robot-assisted tricuspid valve repair using established open valvuloplasty principles. The robotic repair was performed by the placement of Gore-Tex neochordae from the anterior papillary muscle to the anterior tricuspid leaflet, plication of the anteroseptal and anteroposterior commissures, closure of an anterior leaflet cleft, and the insertion of an annuloplasty band. The patient had an uncomplicated hospital course and was dismissed home on the third postoperative day.
The Journal of heart valve disease 11/2012; 21(6):749-52. · 0.81 Impact Factor
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ABSTRACT: BACKGROUND: Obstructive hypertrophic cardiomyopathy (HCM) is an important cause of heart failure in children, but there are limited data addressing outcome of myectomy in children. Our objective was to evaluate the early and late results of septal myectomy in pediatric HCM. METHODS: We reviewed 127 consecutive patients (62% male) who underwent transaortic septal myectomy for obstructive HCM from January 1975 to December 2010 at 21 or less years of age. Mean age at operation was 12.9 ± 5.5 years. Preoperatively, mean maximum instantaneous gradient was 89 mm Hg and 95% had significant systolic anterior motion (SAM) with mitral regurgitation (MR). Implantable cardioverter defibrillator (ICD) and permanent pacemaker prior to surgery was present in 21 patients (17%) and 15 (11.7%), respectively. RESULTS: Transaortic extended left ventricular septal myectomy was performed in all patients with no early deaths. Iatrogenic morbidity included new aortic valve regurgitation requiring repair in 7 (5.5%), mitral regurgitation needing repair in 2 (1.5%), ventricular septal defect in 1 (1%), and heart block requiring permanent pacemaker in 1 (1%). An ICD was implanted postoperatively in 8 during the same hospital admission. Mean MIG decreased from 89 to 6 mm Hg (p < 0.0001). Postoperatively, residual chordal SAM was present in 23% with mild or no MR; moderate MR was detected in 1 patient. Four patients (3%) died late during the mean follow-up period of 8.3 years (maximum, 37 years); 1 death was sudden. Overall survival was 98.6%, 94.9%, 92.4%, and 92.4% at 5, 10, 15, and 20 years, respectively. Freedom from any cardiac reoperation was 91.2%, 87.8%, 78.7%, and 72.7% at 5, 10, 15, and 20 years, respectively. Repeat septal myectomy was performed in 6 patients (5%). At late follow-up, 95% were in New York Heart Association functional class I or II and 25 patients underwent late ICD placement. CONCLUSIONS: Septal myectomy is safe and effective in children with obstructive HCM, but limited exposure may increase risk of aortic or mitral valve injury. Late survival is better than the previously published untreated natural history of HCM. Patient selection and surgical expertise remain critical components of septal myectomy, especially before considering a prophylactic myectomy in a seemingly asymptomatic patient.
The Annals of thoracic surgery 10/2012; · 3.74 Impact Factor
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ABSTRACT: BACKGROUND: With improving surgical care yielding better outcomes, patients who have undergone a cardiac operation are surviving longer, and surgeons will inevitably face an increasing number of reoperative procedures. There are few data reporting risk and outcome for patients undergoing atrial fibrillation ablation in this clinical setting. METHODS: From January 1994 through May 2009, we performed surgery for AF in 245 patients (134 female) who have had at least1 prior cardiac operation. Median age was 45 years (range 1 to 75 years) and preoperative atrial fibrillation was paroxysmal in 161 patients (66%). Most common cardiac diagnoses included Ebstein anomaly (n = 43), tetralogy of Fallot (n = 36), and acquired valvular or ischemic heart disease (n = 35). Median prior sternotomies was 1 (range 1 to 6). RESULTS: Ablative lesions most commonly included isolated right-sided maze (n = 123; cryothermy in 84, cut and sew in 39), biatrial maze (n = 52; cryothermy in 26, cut and sew in 26), and right atrial isthmus ablation (n = 41; isolated in 30, concomitant in 11). There were 14 early deaths (5.7%). New permanent pacemaker was required in 39 patients (18%); indication was complete heart block in 9. Rhythm at late follow-up (median: 4.1 years, maximum: 17.2 years) was 89% in the setting of congenital heart disease and 78% in acquired heart disease. CONCLUSIONS: Atrial fibrillation is common with a variety of pathologies requiring redo cardiac surgery. Lesion set and energy source are dependent on primary procedure. Concomitant AF ablation during redo cardiac reoperations can be performed with reasonable safety and success.
The Annals of thoracic surgery 09/2012; · 3.74 Impact Factor
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ABSTRACT: OBJECTIVE: Self-testing to determine the international normalized ratio improves management with warfarin and reduces the risks of adverse events. Self-testing usually begins several weeks after hospital dismissal after valve replacement. We aimed to compare the in-hospital initiation of international normalized ratio self-testing with usual care in mechanical heart valve recipients. METHODS: A total of 200 adult mechanical heart valve recipients were randomly assigned to in-hospital international normalized ratio self-testing instruction or usual care. Instruction for self-testing patients began on the fourth postoperative day. The patients were followed up for 3 months to compare the number of international normalized ratio tests, percentage of time in the therapeutic range, and adverse events. RESULTS: The baseline characteristics were similar between the 2 groups. During the first 3 postoperative months, the usual-care group underwent an average of 10 international normalized ratio tests, and the self-testing group completed 14 international normalized ratio tests. The mean ± SD percentage of international normalized ratio tests within the therapeutic range was 45% ± 22% for the usual-care group and 52% ± 22% for the self-testing group (P = .05). Within 90 days after dismissal, transient ischemic attack occurred in 1 patient in the usual-care group and 2 patients in the self-testing group. Bleeding complications occurred in 3 patients in the usual-care group and 5 patients in the self-testing group. CONCLUSIONS: Management of anticoagulation with warfarin after mechanical valve replacement is improved with self-testing, even during the early postoperative phase when international normalized ratio testing is performed frequently. Although the incidence of adverse events was similar in the 2 groups, better control of the international normalized ratio would be expected to improve outcome in large populations of patients.
The Journal of thoracic and cardiovascular surgery 08/2012; · 3.41 Impact Factor
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Chaim Locker,
Hartzell V Schaff,
Joseph A Dearani,
Lyle D Joyce,
Soon J Park, Harold M Burkhart,
Rakesh M Suri,
Kevin L Greason,
John M Stulak,
Zhuo Li,
Richard C Daly
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ABSTRACT: Use of the left internal mammary artery (LIMA) in multivessel coronary artery disease improves survival after coronary artery bypass graft surgery; however, the survival benefit of multiple arterial (MultArt) grafts is debated.
We reviewed 8622 Mayo Clinic patients who had isolated primary coronary artery bypass graft surgery for multivessel coronary artery disease from 1993 to 2009. Patients were stratified by number of arterial grafts into the LIMA plus saphenous veins (LIMA/SV) group (n=7435) or the MultArt group (n=1187). Propensity score analysis matched 1153 patients. Operative mortality was 0.8% (n=10) in the MultArt and 2.1% (n=154) in the LIMA/SV (P=0.005) group, which was not statistically different (P=0.996) in multivariate analysis or the propensity-matched analysis (P=0.818). Late survival was greater for MultArt versus LIMA/SV (10- and 15-year survival rates were 84% and 71% versus 61% and 36%, respectively [P<0.001], in unmatched groups and 83% and 70% versus 80% and 60%, respectively [P=0.0025], in matched groups). MultArt subgroups with bilateral internal mammary artery/SV (n=589) and bilateral internal mammary artery only (n=271) had improved 15-year survival (86% and 76%; 82% and 75% at 10 and 15 years [P<0.001]), and patients with bilateral internal mammary artery/radial artery (n=147) and LIMA/radial artery (n=169) had greater 10-year survival (84% and 78%; P<0.001) versus LIMA/SV. In multivariate analysis, MultArt grafts remained a strong independent predictor of survival (hazard ratio, 0.79; 95% confidence interval, 0.66-0.94; P=0.007).
In patients undergoing isolated coronary artery bypass graft surgery with LIMA to left anterior descending artery, arterial grafting of the non-left anterior descending vessels conferred a survival advantage at 15 years compared with SV grafting. It is still unproven whether these results apply to higher-risk subgroups of patients.
Circulation 07/2012; 126(9):1023-30. · 14.74 Impact Factor
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ABSTRACT: We present a case of a 24-year-old woman who was diagnosed with quadricuspid aortic valve with ruptured sinus of Valsalva. Quadricuspid aortic valve is a rare congenital cardiac anomaly. The recognition of quadricuspid aortic valve has clinical significance as it causes aortic valve dysfunction, and is often associated with other congenital cardiac abnormalities. We showed the important role of multimodality imaging in diagnosing a quadricuspid aortic valve associated with ruptured sinus of Valsalva.
Cardiology in the Young 07/2012; · 0.76 Impact Factor
