Heidi M Connolly

Mayo Clinic - Rochester, Rochester, Minnesota, United States

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Publications (191)1057.38 Total impact

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    ABSTRACT: The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.
    Mayo Clinic proceedings. 07/2014;
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    ABSTRACT: Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Current guidelines favour surgery or thrombolysis as initial treatment. We set forth to characterize timing, diagnostic criteria and treatment strategies in BPVT. A free-text search tool was used to identify patients diagnosed with BPVT at Mayo Clinic between 1997 and 2013. We compared patients treated initially with vitamin K antagonists (VKA group; N = 15) versus surgery/thrombolysis (non-VKA group; N = 17). Peak incidence of BPVT was 13-24 months after implantation in both groups. VKA and surgery/thrombolysis decreased prosthetic mean gradients to a similar extent (VKA group: 13 ± 5 to 6 ± 2 mmHg in mitral position, 9 ± 3 to 5 ± 1 mmHg in tricuspid position and 39 ± 3 to 24 ± 7 mmHg in aortic/pulmonary position; non-VKA group: 16 ± 12 to 5 ± 1 mmHg in mitral, 10 ± 5 to 4 ± 1 mmHg in tricuspid and 57 ± 9 to 18 ± 6 mmHg in aortic position; P = 0.59 for group effect). NYHA class improved in 11 of 15 patients in the VKA group and 10 of 17 patients in the non-VKA group (P = 0.39). There were no deaths, strokes or recognized embolic events; 1 patient in each group experienced gastrointestinal bleeding requiring transfusion. Index transthoracic echocardiogram formally identified BPVT in a minority of patients. BPVT may occur late after surgical implantation. VKA therapy resulted in haemodynamic and clinical improvement with minimal risk, and should be considered the first-line therapy in haemodynamically stable patients. Echocardiographic criteria for improving BPVT diagnosis are proposed.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2014; · 2.40 Impact Factor
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    ABSTRACT: Surgical correction of complex aortic coarctation can be associated with significant risks. Extraanatomic bypass may represent a safer alternative. Between January 1985 and December 2012, 80 consecutive patients with complex coarctation underwent ascending-to-descending aortic bypass through a median sternotomy. Patients were a median age of 42 years (range, 15 to 75 years), and 51 (64%) were males. Recurrent coarctation was present in 52 patients (65%), with 6 (8%) having undergone balloon dilatation. Uncontrolled hypertension was present in 63 patients (79%). The most common concomitant pathology was aortic valve stenosis in 21 patients (26%), subaortic stenosis in 10 (13%), and Shone complex in 4 (5%). There were no early deaths. The most common concomitant procedures were aortic valve replacement, coronary artery bypass grafting, and resection of subaortic stenosis. The mean aortic cross-clamp and cardiopulmonary bypass times were 33 ± 40 and 106 ± 54 minutes, respectively. Morbidity included atrial fibrillation in 17 patients (21%) and reexploration for bleeding in 6 (8%). There was no paraplegia or stroke. Upper extremity blood pressure significantly improved (p < 0.001). Mean systolic blood pressure decreased from 153 ± 26 mm Hg preoperatively to 123 ± 15 mm Hg postoperatively. Mean follow-up was 7 ± 6 years (maximum, 22 years). Late deaths occurred in 5 patients (6%) and were not graft-related. Three patients (4%) required reoperation for repair of periprosthetic regurgitation in 2 and mitral valve replacement in 1. The ascending-to-descending aortic bypass can be performed with low morbidity and mortality. It is an effective solution to complex aortic coarctation and represents a safe single-stage approach for patients with concomitant cardiac pathology.
    The Annals of thoracic surgery 04/2014; · 3.45 Impact Factor
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    ABSTRACT: Thoracic aortic aneurysms can be triggered by genetic disorders such as Marfan syndrome (MFS) and related aortic diseases as well as by inflammatory disorders such as giant cell arteritis or atherosclerosis. In all these conditions, cardiovascular risk factors, such as systemic arterial hypertension, may contribute to faster rate of aneurysm progression. Optimal medical management to prevent progressive aortic dilatation and aortic dissection is unknown. β-blockers have been the mainstay of medical treatment for many years despite limited evidence of beneficial effects. Recently, losartan, an angiotensin II type I receptor antagonist (ARB), has shown promising results in a mouse model of MFS and subsequently in humans with MFS and hence is increasingly used. Several ongoing trials comparing losartan to β-blockers and/or placebo will better define the role of ARBs in the near future. In addition, other medications, such as statins and tetracyclines have demonstrated potential benefit in experimental aortic aneurysm studies. Given the advances in our understanding of molecular mechanisms triggering aortic dilatation and dissection, individualized management tailored to the underlying genetic defect may be on the horizon of individualized medicine. We anticipate that ongoing research will address the question whether such genotype/pathogenesis-driven treatments can replace current phenotype/syndrome-driven strategies and whether other forms of aortopathies should be treated similarly. In this work, we review currently used and promising medical treatment options for patients with heritable aortic aneurysmal disorders.
    Current Cardiology Reviews 02/2014;
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    ABSTRACT: Aortopathy associated with bicuspid aortic valve commonly involves the ascending aorta above the sinotubular ridge, but it may also affect sinus portions of the aorta. In some persons, the enlarged portion of the aortic root is limited to the noncoronary sinus. In such patients, we have spared the remaining portions of the aortic root by replacing the ascending aorta with a polyethylene terephthalate fiber (Dacron) graft and a tongue-shaped extension of the graft, thereby replacing the noncoronary sinus. In the present study, we evaluated late outcomes of this procedure, with specific attention to the fate of aortic tissue in the remaining sinuses. We reviewed the medical records of 1,756 patients with repair of ascending aortic aneurysms at Mayo Clinic from 1993 through 2012. Among the patients, 631 (35.9%) had bicuspid aortic valve, and in 79 (4.5%) of the patients, the noncoronary sinus was replaced along with the ascending aorta. Associated aortic valve operations were performed in 70 patients; 15 had repair and 55 had aortic valve replacement. No early death occurred, but 3 patients died late after operation (5-year survival, 99%). There were 3 late reoperations, all because of native or prosthetic valve problems. Importantly, no instances occurred of aneurysm formation or aortic dissection related to the remaining aorta in the left and right aortic sinuses. In patients with bicuspid aortic valve and aortic root enlargement related mainly to enlargement of the noncoronary sinus, limited replacement of the noncoronary sinus and ascending aorta is a safe and simple procedure that is durable in midterm follow-up.
    The Annals of thoracic surgery 02/2014; · 3.45 Impact Factor
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    ABSTRACT: Objective To compare 1-year results after aortic valve-sparing (AVS) or valve-replacing (AVR) aortic root replacement from a prospective, international registry of 316 patients with Marfan syndrome (MFS). Methods Patients underwent AVS (n=239, 76%) or AVR (n=77, 24%) aortic root replacement at 19 participating centers between 2005 and 2010. One-year follow-up was completed for 312 patients (99%), with imaging available for 293 patients (94%). Time-to-events were compared between groups using Kaplan-Meier curves and Cox Proportional Hazards models. Results Two patients (0.6%)—1 in each group—died within 30 days. There were no significant differences in early major adverse valve-related events (MAVRE) (P=0.6). Two AVS patients required early reoperation for coronary artery complications. One-year survival rates were similar in the AVR (97%) and AVS groups (98%); procedure type was not significantly associated with any valve-related events. At 1 year and beyond, aortic regurgitation of at least moderate severity (≥2+) was present in 16 patients in the AVS group (7%) but in no patients in the AVR group (P=0.02). One AVS patient required late AVR. Conclusions Valve-sparing aortic root replacement was not associated with higher 30-day mortality or morbidity rates than AVR root replacement. At 1 year, there were no differences in survival, valve-related morbidity, or MAVRE between the AVS and AVR groups. Of concern, 7% of AVS patients developed ≥2+ aortic regurgitation, emphasizing the importance of 5- to 10-year follow-up to learn the long-term durability of AVS versus AVR root replacement in patients with MFS.
    The Journal of thoracic and cardiovascular surgery 01/2014; · 3.41 Impact Factor
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    ABSTRACT: Surgical pulmonary valve replacement (PVR) in previously repaired tetralogy of Fallot (TOF) is frequently required. There are few data in large series of patients with long-term follow-up. Our aim was to review our 40-year experience with PVR after TOF repair, and to evaluate prognostic factors for reintervention and death. Between 1973 and 2012, 278 patients with repaired TOF (53% males; 31.4±16.4 years of age) underwent first PVR 24±13 years after TOF repair. Three or more prior operations were performed in 17% of the patients and 42% were in NYHA class III/IV. PVR types included porcine (n=211), pericardial (n=37), homograft (n=27) and mechanical (n= 3). Early mortality was 1.4%. Mean follow-up was 7.3±6.8 years (maximum, 34 years). Overall survival at 5-10-15 years was 93%-83%-80% compared with 99%-97%-95% in a gender and age matched U.S. population, p<0.001. Independent risk factors for death were older age at complete repair (HR 1.2, p=0.012), ≥ 3 previous cardiac operations (HR 1.9, p = 0.019), NYHA class III/IV at PVR (HR 2.7, p=0.019) and large body surface area at PVR (HR 1.9, p<0.001). Reintervention after initial PVR occurred in 25 patients. Overall 5-10-15 year freedom from pulmonary valve reintervention was 97%-85%-75%, respectively. Multivariate analysis demonstrated older age at PVR to be protective from reintervention (HR 0.7, p<0.001). In conclusion, PVR is a safe operation with a low rate of reintervention in repaired TOF. The total number of cardiac operations, surgical timing, and the NYHA classification prior to PVR are important prognostic factors.
    The American Journal of Cardiology. 01/2014;
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    ABSTRACT: Objective To evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing either valve repair or replacement and to compare them to patients undergoing repair for myxomatous mitral valve disease. Methods We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between 03/17/1960 and 09/12/2011 for mitral regurgitation and performed a subanalysis of those with repairs compared to case-matched patients with myxomatous mitral valve disease who had repairs (03/14/1995-07/05/2013). Results Of 61 consecutive patients, 40 patients underwent mitral repair and 21 underwent mitral replacement (mean [SD] age, 40 [18] vs 31 [19] years; P=.09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P=.87). Ten-year survival was significantly better in Marfan syndrome patients with mitral repair vs replacement (80% vs 41%; P=.01). Mitral reintervention did not differ between mitral repair and replacement (cumulative risk of reoperation, 27% vs 15%; P=.64). In the matched cohort, ten-year survival after repair was similar for patients with Marfan syndrome and myxomatous mitral disease (84% vs 78%; P=.63), as was cumulative risk of reoperation (17% vs 12%; P=.61). Conclusions Patients with Marfan syndrome and mitral regurgitation have better survival with repair than with replacement. Survival and risk of reoperation for patients with Marfan syndrome were similar to those for patients with myxomatous mitral disease. These results support the use of mitral valve repair in patients with Marfan syndrome and moderate or more mitral regurgitation, including those having composite replacement of the aortic root.
    The Journal of Thoracic and Cardiovascular Surgery. 01/2014;
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    ABSTRACT: Isolated mechanical tricuspid valve replacement (mTVR) is uncommon, early mortality is reported to be high, and little is known regarding the long-term outcome. We sought to evaluate the long-term outcome of mTVR. From 1980 to 2007, isolated mTVR was performed in 64 patients (33 men) at our institution; the median age was 45.5 years (6-71 years). There were 2192 tricuspid valve (TV) repairs and 137 isolated bioprosthetic TV replacements during the same time interval. Valve dysfunction was caused by congenital TV abnormality in 45 patients (70%), carcinoid heart disease in 13 (20%), traumatic TV regurgitation in 3 (5%), and other reason in 3 (5%). Twenty-three patients (36%) had at least 1 previous cardiac procedure (TV repair in 8 and bioprosthetic TV replacement in 7). Mechanical prostheses used included Starr-Edwards (before 1993) in 36 patients (56%) and bileaflet prostheses in 28 (44%). Concomitant procedures included atrial septal defect closure in 28 (44%), arrhythmia surgery in 11 (17%), and pulmonary valvectomy for carcinoid disease in 10 patients (16%). Early mortality occurred in 5 patients (7.8%). Early morbidity included a permanent pacemaker in 9 (14%) and reexploration for bleeding in 2 patients (3%). Mean follow-up was 6 years (maximum 22.4 years). Five- and 10-year survival was 65% and 58%, respectively. There was no valve-related mortality. Late morbidity included valve thrombosis in 5 patients (8%); 3 were managed nonoperatively and 2 underwent TV rereplacement. Isolated mTVR still leads to increased early mortality. A mechanical valve can be considered in select situations when anticoagulation is necessary and in the presence of good right ventricular function.
    The Journal of thoracic and cardiovascular surgery 11/2013; · 3.41 Impact Factor
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    ABSTRACT: Tricuspid valve (TV) regurgitation in congenital heart disease includes a heterogeneous group of lesions, and few series have documented the outcomes. We reviewed the records of 553 patients with congenital heart disease who had undergone TV surgery for tricuspid regurgitation from January 1993 to December 2010. Patients with Ebstein malformation were excluded. Their mean age was 32 ± 21 years, and 300 were female (54%). The most common diagnoses were conotruncal anomaly in 216 patients (39%), previous ventricular septal defect closure in 83 (15%), atrioventricular septal defect in 77 (14%), and pulmonary atresia with an intact ventricular septum in 11 (2%). Preoperative right-sided heart failure was present in 124 patients (22%), and 55 patients (10%) had pulmonary hypertension. TV repair was performed in 442 (80%) and TV replacement in 111 (20%) patients. Repeat sternotomy was performed in 415 patients (75%). Previous TV repair was present in 44 patients (8%); of these, 17 (38.6%) underwent repeat TV repair. The overall early mortality was 3.1% (17 patients) and was 2.5% for TV repair and 5.4% for TV replacement (P = .001). The mean follow-up period was 4.5 ± 4.1 years (maximum, 18). The overall survival at 1, 5, and 10 years was 97%, 93%, and 85%, respectively. Survival was better for patients with repair than with replacement. TV repair was an independent predictor of better survival (P = .001). Important tricuspid regurgitation can occur with a variety of congenital diagnoses. Early mortality is low and late survival is superior with tricuspid repair than with valve replacement. Surgical treatment of tricuspid regurgitation in congenital heart disease should be performed before the onset of heart failure.
    The Journal of thoracic and cardiovascular surgery 09/2013; · 3.41 Impact Factor
  • J Wells Askew, Heidi M Connolly
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    ABSTRACT: Carcinoid is a rare neuroendocrine tumor that typically originates in the gastrointestinal tract and can result in a constellation of symptoms, mediated by vasoactive substances, referred to as carcinoid syndrome. Carcinoid valve and heart disease is characterized by the plaque-like, endocardial fibrous tissue deposits, primarily affecting the right heart endocardium and valves, which result as a consequence of the disease process. Potential mechanisms for the carcinoid valve disease include the complex role of excess serotonin and its interaction with serotonin receptors and transporters. Carcinoid valve and heart disease is a frequent occurrence in patients with carcinoid syndrome and is accountable for substantial morbidity and mortality. Cardiac surgery remains the most effective treatment option for carcinoid valve disease and a multidisciplinary approach at an experienced center is recommended for patients with metastatic carcinoid and carcinoid heart disease.
    Current Treatment Options in Cardiovascular Medicine 08/2013;
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    ABSTRACT: Cardiac malformations occur in approximately 1% of live births. Advances in surgery, interventional cardiology, and medical care have translated into increasing numbers of adult patients with congenital heart disease. These patients, even after intervention, have cardiac sequelae that require specialized care by cardiologists and cardiac surgeons with expertise in the management of congenital cardiac disease. We review 8 of the most common lesions encountered after intervention in an adult congenital cardiac practice and discuss longitudinal follow-up, with a focus on appropriate testing, common hemodynamic and electrophysiological issues, and indications for reintervention.
    Current problems in cardiology 08/2013; 38(8):293-357. · 3.96 Impact Factor
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    ABSTRACT: Our objective was to review the long-term outcome of patients undergoing surgical repair of aortic coarctation. Surgical repair of aortic coarctation has been performed at Mayo Clinic for over 60 years. Between 1946 and 2005, 819 patients with isolated coarctation of the aorta underwent primary operative repair. Medical records were reviewed and questionnaires mailed to patients. Mean age at repair was 17.2±13.6 years. The majority (83%) had preoperative hypertension. Operations included simple and extended end-to-end anastomosis (n=632), patch angioplasty (n=72), interposition graft (n=49), bypass graft (n=30) and subclavian flap or other (n=35). Overall early mortality (<30 days) was 2.4%. In the last 30 years (n=225), there were no operative deaths. Mean follow-up was 17.4±13.9 years with a maximum of 59.3 years. Actuarial survival was 93.3%, 86.4%, and 73.5% at 10, 20 and 30 years, respectively. When compared to an age and gender matched population, long-term survival was decreased (P<0.001). Older age at repair (>20 years) and preoperative hypertension were associated with decreased survival (P<0.001). Patients less than 9 years at the age of repair had significantly less hypertension at 5-15 years of follow-up (P<0.001). Freedom from reintervention on the descending aorta was 96.7%, 92.2%, and 89.4% at 10, 20 and 30 years, respectively. Younger age at time of repair (P<0.001) and an end-to-end anastomosis technique (P<0.001) were independently associated with lower reintervention rates on the descending aorta. Primary repair of isolated coarctation of the aorta can be performed with low mortality. However, long-term survival is reduced compared to an age and gender matched population and many patients will require further reoperation. These findings emphasize that patients with aortic coarctation need early recognition and intervention, as well as life-long informed follow-up.
    Journal of the American College of Cardiology 06/2013; · 14.09 Impact Factor
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    ABSTRACT: BACKGROUND: -Pulmonary arterial hypertension (PAH) is characterized by pulmonary vascular remodeling and right heart failure. The right (RV) and left ventricles (LV) do not function in isolation, sharing a common pericardial sac and interventricular septum. We sought to define the clinical and prognostic significance of ventricular interdependence in PAH and its association with left ventricular filling patterns through speckle-tracking strain echocardiography. METHODS AND RESULTS: -Echocardiography was performed in 71 adults with a new diagnosis of PAH. To separately analyze LV and RV function, we measured peak systolic longitudinal and circumferential strain of the LV and RV. Survival was assessed over two years. Patients had dilated right-sided chambers (RA volume index 44±19 mL/m(2); RV end-diastolic area 34±9 cm(2)), and reduced RV function (RV fractional area change 28±12%). Speckle tracking echocardiography revealed significant reductions in RV free wall peak systolic strain (-15±3%). Despite normal LV size and normal conventional measures of LV systolic function (end-diastolic dimension 42±6 mm; ejection fraction 65±8%; cardiac index 2.6±0.8 L/min/m(2)), patients had reduced LV free wall systolic strain (-15±3%). Decreased LV free wall systolic strain was associated with a delayed relaxation mitral inflow Doppler pattern, p=0.0002. During 2 years follow-up, 19 patients (27%) died. LV strain was associated with increased mortality (unadjusted HR 2.40 per 5% decrease in LV free wall strain, 1.22-4.68), which remained significant when adjusted for age, sex, WHO functional class, and PAH etiology (HR 3.11, 1.38-7.20). CONCLUSIONS: -The pressure loading in PAH results in geometric alterations and functional decline of the RV, with marked reduction in RV systolic strain. Despite preservation of LVEF, LV systolic strain was also reduced and associated with early mortality, highlighting the significance of ventricular interdependence in PAH.
    Circulation Heart Failure 05/2013; · 6.68 Impact Factor
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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; · 1.01 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; · 3.45 Impact Factor
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    ABSTRACT: Apical hypertrophic cardiomyopathy (HC) has been considered a "benign" form of HC, with limited data on long-term outcome. We compared apical HC patients with a non-HC, age- and gender-matched Minnesota white population to identify outcomes and prognostic factors. Between 1976 and 2006, 193 patients (62% men) with apical HC were seen at our clinic. Their most recent echocardiographic examinations were reviewed. Mean ± SD age at first presentation was 58 ± 17 years. A family history of HC or sudden cardiac death (SCD) was reported by 43 patients (22%); coronary artery disease was known in 22 (11%). An apical pouch was present in 29 patients, including an apical aneurysm in 6 and apical dilatation with hypokinesis in 23. Median follow-up (187 patients [97%]) was 78 months (range, 1-350). Death from all causes occurred in 55 patients (29%; 33 women) at a mean age of 72 years (range, 20-92). During follow-up, more women had heart failure (p = 0.001), atrial fibrillation (p = 0.009), or died (p <0.001) than men. Survival was worse than expected (p = 0.001); the observed versus expected 20-year survival was 47% versus 60%. SCD, resuscitated cardiac arrest, and/or defibrillator discharge was observed in 11 patients (6%) during follow-up. Multivariate predictors of decreased survival were higher age at baseline (p <0.001), female gender (p <0.001), and atrial fibrillation at baseline (p = 0.06). In conclusion, apical HC in this population was associated with increased mortality, especially in women. Because apical HC is less benign than previously suspected, careful longitudinal care is warranted.
    The American journal of cardiology 03/2013; · 3.58 Impact Factor
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    ABSTRACT: BACKGROUND: Two-dimensional and Doppler-derived echocardiographic data on normal St. Jude Medical mechanical mitral valve prosthesis function have been reported but remain limited. METHODS: Comprehensive retrospective two-dimensional and Doppler echocardiographic assessment of 368 normal St. Jude Medical mechanical mitral valve prostheses was performed early after implantation. The early postimplantation hemodynamic profiles of 98 patients were compared with profiles obtained by follow-up transthoracic echocardiography performed <13 months after implantation. RESULTS: Using mean ± 2 SDs to define the normal distribution of values for Doppler-derived hemodynamic variables, the calculated normal ranges of values were as follows: mean gradient, 2 to 7 mm Hg; peak early mitral diastolic velocity (E velocity), 1.1 to 2.4 m/sec; time-velocity integral of the mitral valve prosthesis (TVIMVP) 20 to 50 cm; ratio of the TVIMVP to the time-velocity integral of the left ventricular outflow tract (TVILVOT), 0.9 to 2.5; pressure half-time, 35 to 99 msec; and effective orifice area, 1.12 to 3.24 cm(2). Patients with severe prosthesis-patient mismatch (ie, indexed effective orifice area ≤ 0.9 cm(2)/m(2)) had significantly higher mean gradients, E velocity, TVIMVP, and TVIMVP/TVILVOT. There was a trend for longer pressure half-times for patients with severe prosthesis-patient mismatch than for patients without severe prosthesis-patient mismatch, but none of these patients had pressure half-times > 130 msec. Among the 98 patients with follow-up transthoracic echocardiography <1 year after implantation, no significant differences were observed between early postimplantation findings and follow-up hemodynamic profiles. CONCLUSIONS: This study establishes parameters (mean ± 2 SDs) defining the distribution of values for Doppler-derived hemodynamic data with normal St. Jude Medical mechanical mitral valve prostheses. Prostheses with hemodynamic values outside these parameters are likely dysfunctional; however, prosthesis dysfunction may be present even when hemodynamic values are within these ranges.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 02/2013; · 2.98 Impact Factor
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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; · 3.45 Impact Factor
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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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  • 1997–2014
    • Mayo Clinic - Rochester
      • • Department of Cardiovascular Diseases
      • • Department of Cardiovascular Surgery
      • • Department of Anesthesiology
      Rochester, Minnesota, United States
  • 2011
    • George Washington University
      • Division of Cardiology
      Washington, D. C., DC, United States
  • 2010
    • University of Alberta
      • Department of Anesthesiology and Pain Medicine
      Edmonton, Alberta, Canada
  • 1994–2010
    • Mayo Foundation for Medical Education and Research
      • • Division of Cardiovascular Diseases
      • • Department of Diagnostic Radiology
      Scottsdale, AZ, United States
  • 2008
    • University of Kentucky
      Lexington, Kentucky, United States
  • 2000
    • Hannover Medical School
      Hanover, Lower Saxony, Germany