-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: We set out to determine if intraoperative pre-bypass transoesophageal echocardiography could assist in predicting which patients are at greatest risk for systolic anterior motion (SAM) after mitral valve repair (MVR). METHODS: Three hundred and seventy-five consecutive patients who underwent reconstructive MVR surgery for degenerative disease were included. Data were collected using intraoperative echocardiographic images taken prior to the initiation of cardiopulmonary bypass. Based on the physiology of SAM, we postulated that 11 parameters could be potential risk factors for SAM: left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension, left ventricular end-diastolic dimension (LVEDD), basal septal diameter (basal-interventricular septal diameter in diastole (IVDd)), mid-ventricular septal diameter (mid-IVDd), coaptation-septal distance (c-sept), anterior leaflet height, posterior leaflet height, aorto-mitral angle, mitral annular diameter and left atrial diameter. These parameters were measured and recorded by a blinded single operator. Independent predictors of SAM were identified using multiple logistic regression analysis. RESULTS: Of the 375 patients, 345 (92%) did not develop SAM (No-SAM group), while 30 (8%) developed intraoperative or postoperative SAM (SAM group). The mean age was 56.8 ± 12.8 and 56.7 ± 13.8 in the No-SAM and SAM groups, respectively. The incidence of fibroelastic deficiency, forme fruste and Barlow's disease was similar in both groups. All patients received a complete annuloplasty ring as part of the repair. There was no statistical difference in the mean ring size used in each group. EF was similar in the No-SAM (56.2% ± 8.1) and SAM (57.0% ± 9.2) P = 0.63) groups. Independent predictors of developing SAM after valve repair were: EDD <45 mm [odds ratio (OR) 3.90; P = 0.028], aorto-mitral angle <120° (OR 2.74; P = 0.041), coaptation-septum distance <25 mm (OR 5.09; P = 0.003), posterior leaflet height >15 mm (OR 3.80; P = 0.012) and basal septal diameter ≥15 mm (OR 3.63; P = 0.039). CONCLUSIONS: The risk for SAM can be predicted using intraoperative transoesophageal echocardiography. The combination of a smaller left ventricle, tall posterior leaflet, narrow aorto-mitral angle and enlarged basal septum significantly increases the risk for SAM. Knowing these parameters prior to valve repair can assist the surgeon in adjusting their repair technique to minimize the risk.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2013; · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. METHODS: From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12-86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n = 42, 22%) or bileaflet prolapse (n = 146, 78%)]. Degenerative aetiology was Barlow's disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). RESULTS: Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III-IV) than those with bileaflet prolapse (28.6 vs 9.6%; P = 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5-8) days. In-hospital mortality was 1% (n = 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan-Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. CONCLUSION: A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 04/2013; · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Despite clinical and technical advances, acute aortic dissection carries high operative mortality. This study was designed to establish whether this is influenced by institution and surgeon volume. METHODS: Outcomes of 5,184 patients (mean age, 60.3 years; 65.9% male) diagnosed with acute aortic dissection from the Nationwide Inpatient Sample from 2003 to 2008 were analyzed with risk-adjustment for preoperative comorbidity using multivariate logistic regression analysis. RESULTS: Overall operative mortality was 21.6%, with similar preoperative patient risk profile across institutions and individual surgeons. A strong inverse relationship was observed between operative mortality and both institution and surgeon volume: surgeons who averaged less than 1 aortic dissection repair annually had a mean operative mortality of 27.5%, compared with 17.0% for those averaging 5 or more annually (odds ratio, 1.78; 95% confidence interval, 1.39 to 2.29; p < 0.001). This was similar to the relationship seen between institution volume and mortality: operative mortality was 27.4% in institutions performing 3 or fewer acute aortic dissections a year, compared with 16.4% in those performing more than 13 annually (p < 0.001). Nationally, operative mortality decreased steadily from 23% in 1998-2000 to 19% in 2005-2008, with no significant decrease in patient risk profile. CONCLUSIONS: Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. Routine involvement, whenever feasible, of teams experienced in acute aortic dissection repair may be a strategy to reduce operative mortality and major morbidity.
The Annals of thoracic surgery 04/2013; · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Prior coronary surgery has been associated with a higher incidence of adverse outcomes after reoperative cardiac surgery compared with previous valve surgery. It is unclear whether this association is primarily due to greater patient comorbidity or the technical challenges posed by mediastinal reentry and operation in the setting of previous bypass grafts. This study was therefore designed to examine whether previous coronary artery bypass grafting (CABG) is a significant risk factor for adverse outcomes after reoperative cardiac surgery. METHODS: From a prospective database of 1,093 consecutive adults who underwent reoperative cardiac surgery between 2000 and 2010, 363 patients undergoing isolated reoperative valve surgery were divided according to whether or not the previous surgery included CABG (group I, n = 133) or not (group II, n = 230). Propensity-adjusted multivariate analysis was performed in order to determine independent predictors of any morbidity or mortality, or decreased survival. RESULTS: Patients in group I were more likely to be elderly (p < 0.001), and have greater body mass indexes (p = 0.04), low ejection fractions (p = 0.001), and comorbidities of cerebrovascular disease (p = 0.04), peripheral vascular disease (p = 0.003), and diabetes (p < 0.001) compared with group II. Patent grafts were present in 94% (n = 111). Although group I patients were significantly more likely to experience major postoperative complications and had worse survival, after propensity adjustment no significant difference was observed in either any morbidity or mortality (p = 0.4) or in survival (p = 0.4). CONCLUSIONS: A history of CABG does not appear to present a unique risk in reoperative valve surgery. The major determinant of adverse outcomes is morbidity, not prior bypass grafts.
The Annals of thoracic surgery 04/2013; · 3.74 Impact Factor
-
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2013; · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: The objective of this study was to investigate the impact of bilateral internal mammary artery (BIMA) on early outcomes after coronary artery bypass grafting. DESIGN: Retrospective database analysis. SETTING: US hospitals. PATIENTS: 1 526 360 patients (mean age 65 years, 73% male) from the Nationwide Inpatient Sample from 2002-2008 who underwent isolated coronary artery bypass grafting with at least one internal mammary artery. INTERVENTIONS: Single versus BIMA bypass grafting. MAIN OUTCOME MEASURES: Inhospital mortality, deep sternal wound infection (DSWI). RESULTS: The rate of BIMA use was 3.9%. Use of BIMA was independently associated with slightly lower inhospital mortality (unadjusted rate 1.1% vs 1.7%, adjusted OR 0.86, 95% CI 0.79 to 0.93). The DSWI rate was 1.4%. The independent predictors of DSWI were female gender (OR 1.06), congestive heart failure (OR 6.22), chronic pulmonary disease (OR 1.57), obesity (OR 1.17), diabetes mellitus (OR 1.04; OR 1.51 with chronic complication) and chronic renal failure (OR 2.13; OR 2.63 with dialysis). The use of BIMA was not an independent predictor of DSWI (OR 1.03, 95% CI 0.96 to 1.10). BIMA was associated with higher incidence of DSWI in patients with chronic complications of diabetes mellitus (OR 1.90, 95% CI 1.51 to 2.41). CONCLUSIONS: BIMA grafting is associated with increased risk of DSWI only in patients with severe, chronic diabetes. The incremental morbidity and mortality of DSWI does not justify denial of BIMA in the majority of patients.
Heart (British Cardiac Society) 03/2013; · 4.22 Impact Factor
-
The Journal of thoracic and cardiovascular surgery 01/2013; · 3.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Unroofed coronary sinus (UCS) is a rare cardiac anomaly that results in communication between the coronary sinus and the left atrium. We described an unusual presentation of UCS in a 48-year-old female that was not corrected during an initial secundum ASD repair 22 years ago.
Journal of Cardiac Surgery 12/2012; · 0.87 Impact Factor
-
Circulation Heart Failure 11/2012; 5(6):e96-7. · 6.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Degenerative mitral valve disease is the most common etiology of mitral regurgitation in developed countries. Degenerative mitral valve disease should be distinguished from other valvular disease because most of the lesions caused by degenerative changes are amenable to valve repair as opposed to replacement, and successful durable repair with optimal timing can maintain the patient's normal life expectancy. Despite dramatic surgical progress in degenerative mitral valve repair over the past few decades and detailing of surgical indications in established practice guidelines, prevailing data suggest a significant number of patients are still not referred for surgery in a timely fashion or are even denied for surgery for inappropriate reasons. This article reviews the current surgical triggers which all practicing cardiovascular specialists should be familiar with and which should prompt immediate surgical referral.
Circulation Journal 10/2012; · 3.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although mitral valve repair is the recommended treatment for severe mitral regurgitation of degenerative etiology, valve replacement remains common, particularly for complex lesions or anterior leaflet involvement. We sought to characterize the feasibility and outcomes of an "all comers" repair strategy applied systematically in all cases of degenerative mitral valve disease, regardless of age, complexity, or leaflet involvement.
From January 2002 to December 2010, 744 consecutive patients (mean age, 58±13 years [range, 12-90]; mean LVEF, 55%±9%) with degenerative mitral valve regurgitation and prolapse (anterior leaflet: n=42, 6%; posterior leaflet: n=556, 75%; bileaflet: n=146, 19%) underwent mitral valve surgery. Annular, leaflet or chordal calcification was present in 27% of cases.
All patients underwent mitral valve repair and received a concomitant annuloplasty with a median ring size of 32 mm (interquartile range, 30-36). There was 1 early valve replacement (99.9% repair rate) due to atrioventricular groove bleeding and 5 late re-repairs (0.7%) due to disease progression or infective endocarditis. In-hospital mortality and major stroke rates were 0.8% and 0.5%, respectively. Survival rates at 1 and 5 years were 99.2%±0.3% and 97.4%±0.8%, respectively. Seven-year freedom from reoperation was 97.1%±0.6%. The estimate of patients with <3+ mitral regurgitation at 4 and 7 years was 98% and 96%, respectively, and 95% and 91%, respectively, for <2+ mitral regurgitation.
A systematic strategy of mitral valve repair that uses a variety of techniques allows repair of all degenerative valves in a reference center, with good short-term outcomes and mid-term durability. Further study is required to document the long-term efficacy of an "all comers" mitral valve repair strategy in degenerative subgroups with very complex valve morphology.
The Journal of thoracic and cardiovascular surgery 06/2012; 144(2):308-12. · 3.41 Impact Factor
-
The Journal of thoracic and cardiovascular surgery 04/2012; 143(4 Suppl):S1. · 3.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the effectiveness and outcomes of an intraoperative and postoperative algorithm for managing systolic anterior motion (SAM) after mitral valve repair (MVRr).
All consecutive patients who underwent MVRr for degenerative disease from January 2002 to June 2011 were included, with the data collected retrospectively. Patients who underwent MVRr for primary SAM were excluded from the study. Patients who developed SAM after the repair were systematically treated according to the algorithm. The intraoperative algorithm first involved medical management techniques, followed by surgical correction for significant SAM (mild or greater mitral regurgitation, left ventricular outflow tract gradient > 50 mm Hg). The postoperative algorithm focused on medical management and symptoms to guide the treatment decisions.
The overall in-hospital incidence of SAM was 6.6% (52/785). In 41 patients, SAM was identified in the operating room, and in 11 patients, it was found postoperatively on the predischarge echocardiogram. Of the 41 patients with intraoperative SAM, 35 (85.4%) had resolution with medical management and 6 (14.6%) required surgical repeat repair while in the operating room. No patient required mitral valve replacement for persistent SAM. Postoperatively, 11 new cases were identified, and 7 cases of resolved intraoperative SAM recurred. These postoperative cases of SAM were managed according to the postoperative SAM algorithm. At last follow-up, 17 (94.4%) of 18 patients had resolution of SAM and 1 (5.6%) patient had mild SAM (less than mild mitral regurgitation, peak left ventricular outflow tract gradient < 50 mm Hg) and were asymptomatic. No patients with postoperative SAM required reoperation after their initial surgery. The median echocardiographic follow-up was 1.3 years. During follow-up, 1 early death (noncardiac) and 2 late deaths (1 noncardiac, 1 of unknown etiology) occurred.
SAM is a relatively frequent complication after MVRr and can occur intraoperatively or postoperatively. A systematic approach addressing perioperative SAM after MVRr yields excellent mid-term results.
The Journal of thoracic and cardiovascular surgery 04/2012; 143(4 Suppl):S2-7. · 3.41 Impact Factor
-
JACC. Cardiovascular imaging 04/2012; 5(4):346-7. · 14.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To review selected recent publications on minimally invasive mitral valve surgery to help answer the question as to whether the minimally invasive approach should be routinely used in complex mitral valve repairs.
Other than cosmesis, there have not been demonstrable reproducible benefits of the minimally invasive approach. Although some workers report excellent results, there are other data that raise concern that complex repairs are less likely to be undertaken via the minimal access approach, resulting in lower repair rates, and also that the incidence of residual regurgitation may be higher. Some complications, such as stroke, may occur with greater frequency in patients having the minimally invasive approach.
The minimally invasive approach for complex mitral valve repair requires continued development and investigation, and current application should probably be largely restricted to high-volume reference minimally invasive surgery centers.
Current opinion in cardiology 03/2012; 27(2):118-24. · 2.66 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Feasibility of mitral repair is a key factor in the decision to operate for mitral regurgitation. Repair feasibility is highly dependent on surgical experience and repair complexity. We sought an objective means of predicting complexity of repair using three-dimensional (3D) transoesophageal echocardiography.
In a cohort of 786 patients who underwent mitral valve surgery between 2007 and 2010, 3D transoesophageal echocardiography was performed in 66 patients with mitral regurgitation prior to the institution of cardiopulmonary bypass. The surgeon reviewed the 2D echocardiographic images for all patients pre-operatively, but did not view the 3D echocardiographic quantitative data or volumetric analysis until after surgery. Repairs involving no or a single-segment leaflet resection, sliding-plasty, cleft closure, chordal or commissural repair techniques were classed as standard repairs. Complex repairs were defined as those involving bileaflet repair techniques, requiring multiple resections or patch augmentation. Disease aetiology included Barlow's disease (n = 18), fibroelastic deficiency (n = 22), ischaemic (n = 5), endocarditis (n = 5), rheumatic (n = 2) and dilated cardiomyopathy (n = 2).
No patient required mitral replacement or had more than mild mitral regurgitation on pre-discharge echocardiography. Anterior and posterior leaflet areas, annular circumference, anterior and posterior leaflet angles, prolapse and tenting heights and volumes were most strongly predictive of repair complexity. As 21 of the 22 patients with bileaflet pathology and multisegment prolapse were complex repairs, we sought to develop a model predicting repair complexity in the remaining patients. The most predictive model with a c-statistic of 0.91 included three predictors: multisegment pathology, prolapsing height and posterior leaflet angle. After bootstrap validation, the revised c-statistic was 0.88.
3D transoesophageal echocardiography provides an objective means of predicting mitral repair complexity in mitral regurgitation due to a range of aetiology.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2012; 41(3):518-24. · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Controversy exists regarding the indication and method of repair of functional tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. Whereas the American College of Cardiology/American Heart Association guidelines recommend tricuspid repair in the setting of severe TR, tricuspid repair is advised for less than severe TR in the setting of annular dilation or pulmonary hypertension. Although multiple repair strategies exist, the use of a ring annuloplasty (semirigid remodeling rings vs flexible bands) is the preferred method of therapy to avoid short- and long-term recurrence of TR. The new Tri-Ad Adams annuloplasty ring combines elements of semirigid and flexible bands that will not only allow for annular remodeling in the region of the right ventricular free wall but also potentially reduce injury to the conduction system with its flexible and "open" ends. In this article, we discuss the rational for an aggressive approach to functional tricuspid regurgitation, and show our initial clinical experience with the Tri-Ad Adams annuloplasty ring.
The Journal of thoracic and cardiovascular surgery 01/2012; 143(4 Suppl):S71-3. · 3.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Carcinoid tumors are neuroendocrine tumors with an unpredictable clinical behavior. In the setting of hepatic metastases, the release of bioactive amines from the tumor into the systemic circulation results in carcinoid syndrome: a constellation of clinical symptoms, among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most frequent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe endocardial fibrotic reaction that leads to progressive valve thickening and retraction. Imaging studies commonly reveal severe right-sided valve disease, with fixed leaflets or cusps in a semiopen position. The replacement of the right-sided valves, including the patch enlargement of the right ventricular outflow tract, is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend toward improved surgical outcomes has triggered a more liberal referral for valve replacement during the past decade.
Seminars in Thoracic and Cardiovascular Surgery 01/2012; 24(4):254-60.
-
[show abstract]
[hide abstract]
ABSTRACT: In the western world, the prevalence of mitral regurgitation-particularly that due to degenerative disease-has gradually increased despite a substantial decrease in rheumatic disease. If present, secondary ventricular dysfunction, potentially irreversible when clinically diagnosed, requires close echocardiographic follow-up in order to establish a subclinical diagnosis. Thus, echocardiography has become an essential tool in managing patients with mitral valve regurgitation. As well as assessing parameters of ventricular geometry, in the hands of an expert echocardiography offers systematic documentation of lesion in each segment, which together with the dysfunction type should give an accurate idea of the complexity involved in the valve repair. This is increasingly relevant given the growing number of asymptomatic patients referred for mitral valve surgery. Consequently, the echocardiographic study performed prior to referral is crucial to successful mitral valve repair and cardiologists, cardiac imaging experts, and surgeons should be guided by results when referring patients to specialists with the skills necessary to undertake adequate repair of the lesions found.
Revista Espa de Cardiologia 12/2011; 64(12):1169-81. · 2.53 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Mycotic pseudoaneurysm is a rare but potentially lethal complication after heart transplantation. Allograft has been advocated as the choice of material for aortic replacement. We report a series of 7 patients with pseudoaneurysm that was treated with primary repair or synthetic graft replacement.
Between October 2005 and February 2011, 8 patients (mean age, 55.3 years; range, 39 to 67 years), were diagnosed with mycotic pseudoaneurysms of the ascending aorta 2 to 29 months after transplantation. One patient declined operative repair, and the remainder had urgent or emergency surgical intervention. One patient had primary repair at the cardioplegia site, and one had primary end-to-end anastomosis after the infected recipient aortic segment was resected. Five patients had replacement of the infected aorta with a Dacron graft (DuPont, Wilmington, DE) for pseudoaneurysm development at the suture line or donor aorta. Clinical and radiologic follow-up assessments were performed in all patients.
There were no operative or in-hospital deaths. None of the patients had major postoperative complications, and there was no cardiac allograft dysfunction. Median follow-up was 25 months (range, 1 to 48 months). One patient died of a pulmonary embolism 10 months after the operation. The remaining 6 patients remain free of infection. The most recent radiologic follow-up showed no residual or recurrence of pseudoaneurysms among the surviving patients.
A synthetic vascular graft to replace the infected aorta is a viable aortic substitute among transplant recipients, and in the presence of a vascularized flap, can offer excellent midterm outcomes.
The Annals of thoracic surgery 12/2011; 92(6):2112-6. · 3.74 Impact Factor
