[Show abstract][Hide abstract] 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.
Preview · Article · Jun 2013 · Journal of the American College of Cardiology
[Show abstract][Hide abstract] ABSTRACT: This chapter covers the Ebstein anomaly, starting with the anatomy and physiology, then discussing the indications for surgery and surgical strategies in the neonate, children, and adults, and finally discussing postoperative management, risk factors, and outcome.
[Show abstract][Hide abstract] ABSTRACT: Patients who require aortic valve replacement are increasingly receiving biologic valves to avoid long-term anticoagulation. The thromboembolic risk of bioprosthetic valves is reportedly low. The study objective was to review the incidence of early valve thrombosis requiring reoperation in patients who received a bioprosthetic valve in the aortic position.
We reviewed all adult patients who had a biologic valve implanted in the aortic position at Mayo Clinic between January 1993 and July 2009. Records were reviewed for all cases of reoperation that occurred less than 2 years postoperatively. Incidences of valve thrombosis were calculated including 95% Poisson confidence intervals.
During the study interval, 4568 patients received biologic valves for aortic valve replacement. We identified 8 patients who underwent reoperation to replace the aortic prosthesis because of thrombus that resulted in functional aortic stenosis. The median age of patients at the time of reoperation was 77 years (range, 52-86), and the median time to reoperation was 398 days (range, 106-626). All patients with valve thrombosis received a stented porcine valve: St Jude Biocor (St Jude Medical, Inc, St Paul, Minn) in 4 patients, Medtronic Mosaic (Medtronic Inc, Minneapolis, Minn) in 2 patients, and Medtronic Hancock (Medtronic Inc) in 2 patients. The calculated incidence of valve thrombosis was 1.26% (confidence interval, 0.56-1.96) for the Biocor valve, 0.37% (confidence interval, 0.19-0.56) for the Mosaic valve, and 0.84% (confidence interval, 0.42-1.25) for the Hancock valve (P = .34). There were no cases of valve thrombosis in patients who received a pericardial valve (5923 patient-years) or stentless valve (172 patient-years).
The incidence of early thrombosis of porcine aortic bioprostheses requiring reoperation was not insignificant. Potential causes and mechanisms for such thrombosis are unknown. Recognition of this unanticipated problem and reoperation resulted in a satisfactory outcome for patients.
No preview · Article · Aug 2011 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: In natural history studies, increased left ventricular mass and wall thickness are strongly associated with increased late mortality in patients with hypertrophic cardiomyopathy. Our objective was to determine the impact of left ventricular mass and wall thickness on survival after myectomy for hypertrophic obstructive cardiomyopathy.
We reviewed the case histories of 796 patients who underwent transaortic septal myectomy for hypertrophic obstructive cardiomyopathy from January 1993 to December 2006. We then selected for study patients who had transthoracic echocardiography within 30 days after myectomy, which included complete measurements of interventricular wall thickness, posterior wall thickness, and left ventricular end diastolic dimension. Late survival was determined for all patients using medical records and surveys.
Our study group included 416 patients with a mean age of 50±15 years, and 58% were male. Eight percent of patients had coronary artery disease, 17% had a history of arrhythmia, and 17% had a previous or concomitant insertion of an internal cardioverter defibrillator. All patients had successful myectomy, and 17% required an additional mitral valve procedure, most often mitral valve repair. On predismissal echocardiography, the average interventricular wall thickness was 16±5 mm, the posterior wall thickness was 13±3 mm, and the left ventricular end diastolic dimension was 45±6 mm. The indexed left ventricular mass was 135±46 g/m2. Late survival at 1, 5, and 10 years was 99%, 97%, and 85%, which was similar to that of an age- and gender-matched population (P=.453). On multivariate analysis, preoperative and postoperative wall thickness and left ventricular mass were not associated with death; only a history of coronary artery disease (hazard ratio 4.9) was predictive of late mortality.
Left ventricular mass and wall thickness were not predictors of late survival after myectomy for hypertrophic obstructive cardiomyopathy, and this is in contrast to natural history studies of patients who were not treated surgically. Late survival was similar to that of an age- and gender-matched population.
No preview · Article · Feb 2011 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Patients with complex cyanotic congenital heart disease and a bidirectional cavopulmonary connection who are not candidates for or had failed Fontan operation may experience progressive cyanosis. An axillary arteriovenous anastomosis may be constructed to augment pulmonary blood flow. This report reviews our results with this approach in this complex group of patients.
The records of patients with previous cavopulmonary connections who underwent a surgical anastomosis between the axillary artery and the vein for palliation of severe progressive cyanosis were reviewed.
Eleven patients were identified. The median age at the time of the axillary arteriovenous anastomosis was 19.2 years (7.97-41.75 years). Seven patients were not candidates for the Fontan operation, and 4 patients had failed Fontan surgery. Three of the anastomoses were constructed with a side-to-side technique, and 8 anastomoses were constructed with a short interposition graft. Median fistula size was 5 mm (3-6 mm). There was no operative mortality and 1 late death. Median survival was 2.85 years (0.01-7.22 years). All fistulae were patent at follow-up. Median preoperative arterial oxygen saturation was 84% (80%-86%) and 82% (76%-88%) at follow-up (P = .38). Median preoperative hemoglobin was 18.5 g/dL (11.7-22.6 g/dL) and 19.2 g/dL (14.6-22.6 g/dL) at follow-up (P = .97). Median preoperative systemic ventricular ejection fraction was 51% (27%-60%) and 46.5% (28%-60%) at follow-up (P = 1). Significant functional improvement was seen in only 1 patient.
In patients with complex cyanotic congenital heart disease who are not candidates for or had failed Fontan operation, palliation with an axillary arteriovenous fistula did not improve cyanosis or polycythemia. Functional outcome and ventricular ejection fraction did not improve or deteriorate.
No preview · Article · Jan 2011 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Our objective was to examine the impact of team changeover and unfamiliar teams in cardiovascular surgery on traditional clinical outcome measures.
The importance of teamwork in the operating room is increasingly being appreciated, but the impact on more traditional outcome measures is unclear. Methods: Elective or urgent cardiovascular procedures were divided into categories: team D (patients who had an operation with a day team); team E (patients who had an operation with an evening team); team C (patients who had an operation which included changeover between a day and evening team). Comparison groups were adjusted using propensity scores.
We identified 6698 patients who met inclusion criteria (team D, n =3781; team E, n = 518; team C, n = 2399). After propensity score adjustment,there was an increased skin–skin time of 28 minutes in team C when compared with team D (P < 0.001) and of 21 minutes when compared with team E (P <0.001). There were also more episodes of septicemia among team C patients(OR 1.85, P = 0.013) when compared with team D. Patients operated by a day team had a statistically significantly lower number of ventilated hours and shorter hospital length of stay when compared with team E and team C (P < 0.001 and P < 0.001, respectively). There was no difference between teams in operative death, reoperation for bleeding, blood transfusion, renal failure/dialysis, neurologic events, or deep/superficial wound infections.
The change in operating room personnel from the day team to the evening team added significant length to the total operating department time in cardiovascular surgery; however, its impact on most traditional outcome measures was difficult to demonstrate. More sensitive outcome measures may be required to assess the impact of teamwork interventions.
No preview · Article · Dec 2010 · Annals of surgery
[Show abstract][Hide abstract] ABSTRACT: The Society of Thoracic Surgeons (STS) score aims at predicting operative mortality in cardiac surgery. The value of this score in predicting short- and long-term survival with medical or surgical management in patients with asymptomatic severe aortic stenosis (AS) is unknown.
In a cohort of 694 patients (aged 71 ± 11 years) with isolated, asymptomatic severe AS (velocity ≥4 m/s), STS score was calculated at baseline and its link to survival analyzed. Patients were stratified by STS score less than 4%, 4% to 6.5%, and 6.5% or greater.
The STS score showed no association with operative mortality within 1 year of diagnosis or any time (1%, 2.9%, and 6.1%, respectively, by strata; p = 0.08) and a weak association with 1-year survival (p = 0.04). Conversely, long-term survival (10-year) was strongly predicted by STS score strata (78%, 47%, and 16%, respectively; p < 0.0001). In multivariate analysis, STS score independently predicted mortality (hazard ratio/1%, 1.15 [1.12 to 1.18], p < 0.0001) or cardiac death (1.21 [1.17 to 1.25], p < 0.0001). Aortic valve replacement within 1 year of diagnosis markedly improved survival (adjusted hazard ratio, 0.58, p < 0.001). However, benefit of early surgery varied according to strata, with no overt benefit with low score (p = 0.83), whereas early surgery considerably improved survival in the intermediate strata (p < 0.001).
For patients with asymptomatic severe AS, STS score is a powerful tool for predicting long-term outcome and for selecting patients (particularly those at intermediate risk) who benefit markedly from early surgery. Hence, risk-scoring using STS score should be routinely performed in patients with AS to support the clinical decision-making process.
Full-text · Article · Dec 2010 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: We examined the role of prosthesis-patient mismatch on left ventricular mass regression after aortic valve replacement for chronic aortic valve regurgitation.
We selected patients who had complete preoperative and follow-up echocardiograms with measurement of left ventricular mass. Patients were excluded who had moderate or greater aortic valve stenosis, concomitant coronary artery bypass grafting, or mitral valve procedures.
Patients' mean age was 55 ± 17 years; 21% were female. The mean preoperative indexed left ventricular mass was 150 ± 45 g/m(2). Patients with mildly (n = 44; mean indexed mass, 126 ± 15 g/m(2)), moderately (n = 31; mean indexed mass, 168 ± 11 g/m(2)), or severely (n = 15; mean indexed mass, 241 ± 34 g/m(2)) increased preoperative indexed left ventricular mass, were similar, except for lower ejection fractions, larger end-diastolic dimensions, and larger ventricular wall thicknesses in the severely enlarged group (P < .001). Thirteen patients had prosthesis-patient mismatch and were similar to patients without prosthesis-patient mismatch, except for a greater body surface area, fewer mechanical valves, and smaller valve sizes in those with prosthesis-patient mismatch (P < .05). At a mean follow-up of 3.2 ± 2.4 years, the average reduction in indexed left ventricular mass was 50 ± 38 g/m(2); late mass regression was unrelated to labeled valve size, prosthesis-patient mismatch, or measured indexed effective aortic valve area. A greater preoperative indexed left ventricular mass (P < .001) was an independent predictor of greater left ventricular mass regression. Despite having greater left ventricular mass regression, patients with severe preoperative indexed left ventricular mass did not return to normal values (mean, 142 ± 25 g/m(2)).
Left ventricular mass regression after aortic valve replacement for chronic aortic regurgitation is unrelated to indexed prosthetic valve area. Although incomplete, regression is greatest in patients with the largest preoperative indexed left ventricular mass.
Full-text · Article · Nov 2010 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: After repair of aortic coarctation, patients may develop restenosis, aneurysms, and pseudoaneurysms at the site of prior repair. We assessed the outcomes of late reintervention on the descending aorta after aortic coarctation repair.
From March 1954 to July 2008, 130 patients had operations or endovascular procedures on the descending aorta after previous coarctation repair. We excluded patients who had complex left-sided cardiac lesions or interrupted aortic arch. Mean age at reintervention was 32±24 years and 28% were female. The interval between coarctation repair and reintervention was 17±13 years. Seventy-four percent of patients had hypertension. Reasons for reintervention were restenosis (n=122 [94%]), aneurysm (n=4 [3%]), and pseudoaneurysm (n=4 [3%]). Ninety-five patients (73%) underwent operative procedures including an extra-anatomic conduit (n=41), patch repair (n=32), interposition graft (n=14), end-end anastomosis (n=6), and subclavian flap (n=2). Thirty-five patients underwent endovascular treatment (balloon dilatation, n=22 or stenting, n=13). There was no early mortality. In the surgical group, 5 patients required early reoperation for bleeding and 5 patients had early vocal cord paralysis. One patient in the endovascular group had aortic rupture at the time of intervention requiring urgent operation. Survival was 97% at 10 years. At 5 years, freedom from a second repeat procedure on the descending aorta was 96% in the surgical group and 72% in the endovascular group (P<0.001). Five years after reintervention, fewer patients required treatment for hypertension (57% versus 74%, P<0.001) and a median of 1 antihypertensive medication was prescribed compared with a median of 2 medications preintervention.
Operative and endovascular management of recoarctation can be performed safely with good late outcomes.
[Show abstract][Hide abstract] ABSTRACT: Since 1989, data have been reported to the Society of Thoracic Surgeons National Adult Cardiac Surgery Database for quality improvement. This information is also data mined for national quality indicators, policy initiatives, and research. Such use has important limitations, because data elements cannot be verified for accuracy. We determined variability of disease etiology and operative data database elements when abstracted by untrained physician abstractors.
We selected 30 patients who underwent cardiovascular surgery from January to December 2005 (10 each of coronary artery bypass grafting, mitral valve repairs, and aortic valve and associated aortic procedures). Four abstractors (2 cardiothoracic residents and 2 fellows) abstracted 28 variables. Results were compared with abstraction performed by a professional abstractor.
Median percentage agreement among all cases was 89% (range, 42%-100%). Agreements were 94% (28%-100%) for mitral valve, 84% (48%-100%) for aortic valve, and 93% (35%-100%) for coronary artery bypass grafting. Among the aortic valve group, etiology of aortic valve disease had poor agreement (68%) because of cases in which multiple definitions could apply. Degree of valvular regurgitation also had poor agreement (median, 67%; range, 28%-95%). Number of internal thoracic artery grafts and absence of significant valvular disease were reported consistently. Agreements between types of aortic valve procedure and between methods of mitral valve repair (65% and 83%, respectively) were less than expected.
We found variable agreement among untrained data abstractors. This has important implications regarding interpretation of database studies with de-identified data. Without good quality control and consistent standardized definitions, aggregate data in clinical databases may be suspect.
Preview · Article · Aug 2010 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: The management of chronic stable angina has undergone considerable evolution over the past two decades. This review highlights the need for a comprehensive approach to management, which includes careful identification of cardiac risk factors, use of therapeutic lifestyle interventions (especially in high-risk patients with diabetes mellitus or metabolic syndrome), aggressive, multifaceted medical therapy, and the judicious use of myocardial revascularization. Traditional anti-ischemic therapy continues to comprise aspirin, beta-blockers and calcium channel blockers, along with adjunctive therapies that include statins and ACE inhibitors. Ranolazine is a novel anti-anginal and anti-ischemic agent that has promise in reducing refractory ischemia and as add-on therapy for patients who ischemia cannot be optimally controlled with standard anti-ischemic agents. The role of coronary artery bypass graft surgery and percutaneous coronary intervention (PCI) in the management of the chronic stable angina patients is discussed, as are the clinical implications of the COURAGE Trial. The combined use of both a “focal” approach (PCI to treat the culprit stenosis) and a “systemic” approach (lifestyle intervention and aggressive pharmacotherapy with comprehensive secondary prevention) may afford the best opportunity to enhance event-free survival and optimize clinical outcomes in patients with chronic coronary artery disease and stable angina.
[Show abstract][Hide abstract] ABSTRACT: Apical hypertrophic cardiomyopathy is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle. A subset of patients have progressive, drug-refractory diastolic heart failure with severely limiting symptoms caused by low cardiac output. Heart transplantation has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by means of left ventricular cavity enlargement.
Forty-four symptomatic patients underwent apical myectomy to augment left ventricular end-diastolic volume. Myectomy was performed through an apical incision, and hypertrophic muscle was excised at the apex and midventricle. Information from a prospective database was supplemented by surveys, patient contact, and medical records.
The mean age of the patients was 50 +/- 17 years, and 66% were women. All patients were severely limited with dyspnea, 61% had angina, and 59% had syncope/presyncope. Ninety-one percent of patients were in New York Heart Association class III or IV. A mean of 16 +/- 7 g of muscle was removed. Preoperative and postoperative hemodynamic catheterization (n = 14) showed a decrease in left ventricular end-diastolic pressure from 28 +/- 9 to 24 +/- 7 mm Hg (P = .002) and an increase in end-diastolic volume index from 55 +/- 17 to 68 +/- 18 mL/m(2) (P = .003). Invasive measurements of stroke volume increased from 56 +/- 17 to 63 +/- 19 mL (P = .007). Of the 42 patients who survived to hospital discharge, 41 had improvement in symptoms. Mean peak maximum oxygen consumption with exercise (n = 5) increased from 13.5 +/- 4.4 to 15.8 +/- 4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At follow-up of 2.6 +/- 3.1 years, 23 (74%) patients were in New York Heart Association class I or II. One patient underwent heart transplantation 5 years after apical myectomy.
Apical myectomy improves functional status by decreasing left ventricular end-diastolic pressure, improving operative compliance, and increasing stroke volume. This procedure might be of value in other patients with hypertrophic cardiomyopathy who have severe hypertrophy and small left ventricular end-diastolic volume.
No preview · Article · Mar 2010 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Our objectives are to describe the contents of cardiovascular surgical operative notes and to develop and test a standards-based structured electronic operative note that might be used for secondary purposes.
Operative notes were selected for patients who underwent primary, isolated coronary artery bypass grafting (n = 33); aortic valve replacement (n = 33); reoperative coronary artery bypass grafting (n = 11); or aortic valve replacement (n = 11). The content was qualitatively assessed and categorized into 3 sections, ie, technical/procedural, anatomic/physiologic description, and judgment/opinion. An electronic operative note was developed using a standards-based approach to categorize the type of operation.
Average length +/- SD of the operative note was 495 +/- 186 words (range 243 to 1,267 words). The procedural category made up a mean proportion of 73% +/- 12% (range 32% to 95%). The descriptive category was the second largest category in the operative note; mean percentage 22% +/- 8% (range 5% to 43%). The dictation of the judgment portion made up 6% +/- 6% (range 0% to 25%) of the operative note. In the pilot electronic note system, 5 surgeons entered 23 procedures performed on 18 patients (14% of eligible patients). Seventeen (74%) procedures entered by surgeons were in complete agreement with the data for the Society of Thoracic Surgeons database collected by professional abstractors.
Freeform dictation of cardiovascular notes varied by individual surgeon style and case complexity. Up to 25% of the operative note was dedicated to judgment/opinion, which would be difficult to recreate in a structured data-entry format. An electronic system for entering procedural details can improve efficiency for secondary purposes of data collection but must be carefully implemented to avoid loss of important information.
No preview · Article · Feb 2010 · Journal of the American College of Surgeons
[Show abstract][Hide abstract] ABSTRACT: Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure of delamination of the tricuspid valve leaflets from the underlying endocardium, leading to severe tricuspid valve regurgitation and some degree of right ventricular dysfunction. In neonates or infants who remain in congestive heart failure or profoundly cyanotic while receiving appropriate medical therapy, operation is required. Current strategies include biventricular or single-ventricle repair. In children and adults, medical management may be used, but most patients eventually require surgery. Tricuspid valve repair is preferred; we believe the cone repair is the most anatomic repair and is the operation of choice. Tricuspid valve replacement may be necessary in cases in which the valve is not repairable. A bidirectional cavopulmonary shunt is useful in patients with severe right ventricular dilatation and/or dysfunction. Transplantation rarely is necessary.
No preview · Article · Oct 2009 · Current Treatment Options in Cardiovascular Medicine
[Show abstract][Hide abstract] ABSTRACT: The purpose of the present review is to outline some of the challenges of surgical and medical management in the adult with congenital heart disease (CHD).
The number of adult patients with CHD continues to grow. These patients require specialized care and there are few cardiologists and surgeons, as well as other subspecialists (e.g., anesthesia, hepatology, nephrology, etc.) with training who are comfortable in the management of this patient population. When operations on adults with CHD are performed by surgeons trained in congenital cardiac surgery, mortality rates and hospital costs are significantly lower than when performed by adult cardiac surgeons. Reoperations are frequent; peripheral vascular access may be compromised and sternal reentry is more likely to result in cardiac injury. End organ dysfunction, particularly liver and kidney, is not uncommon, further complicating perioperative care. Finally, adults with CHD may have complex psychosocial issues. A comprehensive multidisciplinary team approach can best address all of these issues.
Adults with CHDs present difficult challenges in the preoperative, intraoperative, and postoperative setting. Regional centers of excellence with congenitally-trained cardiac surgeons, cardiologists, and other medical subspecialists are required to optimize outcome.
Preview · Article · Aug 2009 · Current opinion in pediatrics
[Show abstract][Hide abstract] ABSTRACT: Fibrosing mediastinitis is a rare disease characterized by an excessive fibrotic reaction in the mediastinum, which may entrap mediastinal structures including the pulmonary arteries. Our objectives were to assess the surgical strategies and outcomes of repair of pulmonary artery occlusion attributable to mediastinal fibrosis.
With approval from the Mayo Clinic Institutional Review Board, we identified all patients with fibrosing mediastinitis who underwent an operation for relief of pulmonary artery obstruction between 1980 and 2008. Perioperative data were collected using medical records and late follow-up surveys.
Operative procedures to bypass or reconstruct an obstructed pulmonary artery were performed in 5 patients. Patients' median age was 40 years (range, 27 to 51 years), and all patients were symptomatic and had right ventricular hypertension. In 3 patients, a double-outlet right ventricle was constructed using a valved conduit (porcine valved conduit, n = 1; aortic homograft, n = 2) from the right ventricle to the right pulmonary artery. Two patients required complete reconstruction of the pulmonary artery confluence using a pulmonary homograft in 1 patient and a hybrid technique of autologous pericardial reconstruction and intraoperative stenting in another patient. All patients had a reduction in right ventricular pressures after operation. One patient died perioperatively owing to respiratory failure; the remaining 4 patients were alive at a median follow-up of 7.4 years (range, 0.5 to 14.7 years). One patient required late balloon dilatation of the conduit and distal pulmonary arteries 10 years after initial operation, but the remaining conduits were widely patent at late follow-up. Late functional improvement was limited owing to other complications from mediastinal fibrosis or other comorbidities.
Treatment of pulmonary artery occlusion attributable to mediastinal fibrosis can be challenging. Successful operative strategies include both creation of a double-outlet right ventricle and complete reconstruction of the pulmonary artery confluence. Hybrid techniques of both conduit placement and stenting should also be considered for patients with occluded pulmonary arteries.
No preview · Article · Aug 2009 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: This study was undertaken to determine hemodynamic and clinical outcomes of annuloplasty with a standard-sized (63 mm) posterior band in adult patients undergoing mitral valve repair for degenerative valve disease.
We studied 511 patients who underwent isolated mitral valve repair for degenerative disease with a 63-mm posterior band used for annuloplasty. Operations were performed between 1994 and 2001, and average follow-up was 4.8 +/- 3.1 years. Echocardiographic data were reviewed, with specific focus on the relationship between patient size and residual mitral regurgitation and gradient.
Mean age at the time of operation was 59.3 +/- 13.5 years, and 72% were male. Body mass index was 25.8 +/- 4.1 kg/m(2), and body surface area was 1.97 +/- 0.24 m(2). Preoperative mean ejection fraction was 64% +/- 7%, and 96% of patients had severe mitral regurgitation on preoperative echocardiography. The 30-day mortality was 0.8%. At hospital discharge, the mean gradient was 4.7 +/- 3.1 mm Hg. Body surface area, body mass index, and weight were not associated with postoperative gradients or residual regurgitation at discharge. At last follow-up, 89% of patients had no or mild regurgitation, and the mean ejection fraction was 58% +/- 9%. At 5 years, survival was 95% and cumulative risk of reoperation was 3%.
A standard-sized (unmeasured) posterior annuloplasty band provided excellent intermediate results with good durability. There were neither excess gradients in larger patients nor excess regurgitation in smaller patients. Measured annuloplasty is unnecessary for most adults undergoing mitral valve repair.
No preview · Article · May 2009 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation.
Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status.
Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001).
In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.
No preview · Article · May 2009 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Most aortic valve replacements are by conventional full median sternotomy. Less invasive approaches have been developed with partial upper sternotomy (ministernotomy).
Systematic review and meta-analysis were performed with studies comparing ministernotomy and full sternotomy for aortic valve replacement.
Twenty-six studies were selected, with 4586 patients with aortic valve replacement (2054 ministernotomy, 2532 full sternotomy). There was no difference in mortality (odds ratio 0.71, 95% confidence interval 0.49-1.02). Ministernotomy had longer crossclamp and bypass times (weighted mean difference 7.90 minutes, 95% confidence interval 3.50-10.29 minutes, and 11.46 minutes, 95% confidence interval 5.26-17.65 minutes, respectively). Both intensive care unit and hospital stays were shorter with ministernotomy (weighted mean difference -0.46 days, 95% confidence interval -0.72 to -0.20 days, and -0.91 days, 95% confidence interval -1.45 to -0.37 days, respectively). Ministernotomy had shorter ventilation time and less blood loss within 24 hours (weighted mean difference -2.1 hours, 95% confidence interval -2.95 to -1.30 hours, and -79 mL, 95% confidence interval -23 to 136 mL, respectively). Randomized studies tended to demonstrate no difference between ministernotomy and full sternotomy. Rate of conversion from partial to conventional sternotomy was 3.0% (95% confidence interval 1.8%-.4%).
Ministernotomy can be performed safely for aortic valve replacement, without increased risk of death or other major complication; however, few objective advantages have been shown. Surgeons must conduct well-designed, prospective studies of relevant, consistent clinical outcomes to determine the role of ministernotomy in cardiac surgery.
No preview · Article · Apr 2009 · The Journal of thoracic and cardiovascular surgery