Low-Dose vs Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Trial.

BACKGROUND: Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve. METHODS: After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin. RESULTS: Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, -0.07%; 95% CI, -3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding. CONCLUSIONS: Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525).

WITHDRAWN: Low-Dose Versus Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Controlled Trial.

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4-Factor Prothrombin Complex Concentrate (PCC4, Kcentra®) Protocol Reduces Blood Requirements for Heart Transplantation: A Novel Protocol.

BACKGROUND All patients with a ventricular assist device (VAD) awaiting heart transplantation are anticoagulated with warfarin to prevent thromboembolism. The use of 4 factor prothrombin complex concentrate (PCC4, Kcentra®) for anticoagulation reversal prior to surgery may include benefits such as quicker reversal, longer duration of action, and a reduction in total volume of blood products used compared to other reversal practices. The study objective is to evaluate benefits of using an anticoagulation reversal protocol featuring PCC4, over standard of care in heart transplant patients requiring anticoagulation. MATERIAL AND METHODS This is a single center, combined retrospective and prospective, time-matched cohort study compared 12 patients transplanted pre-protocol and 11 patients transplanted post-protocol. The primary outcome was the total volume of blood and blood products used. Secondary outcomes included length of hospital and ICU stay, safety and adverse events, primary chest closure, and a cost comparison. RESULTS The PCC4 reversal protocol showed a significant reduction in total blood volume received with an overall decrease of 1.76L (4.20L pre-protocol, 2.45L post-protocol, P=0.037), total units of blood products infused (20 units pre, 12 units post, P=0.033), and units of packed red blood cells (7 units pre, 3 units post, P=0.033). All heart transplant recipients were listed Status 1A with the primary indication being infection (n=12; 52%). Baseline characteristics, survival, and cost were not different between the two groups. There were no thrombotic events or patient that experienced serious reactions to PCC4. Secondary outcomes were only significant to time to INR reversal. CONCLUSIONS Patients treated with the PCC4 protocol demonstrated a significant decrease in volume of blood and units of blood products required prior to chest closure for heart transplant patients. PCC4 was found to be a safe and beneficial agent in anticoagulation reversal for patients on anticoagulation prior to heart transplantation.

Successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.

Catheter ablation of arrhythmias can result in the rare but devastating complication of an atrioesophageal fistula. This complication can be associated with significant neurologic morbidity and high mortality and requires a high index of suspicion to facilitate life-saving surgical intervention. Herein, we report the successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.

Inspiring medical students to pursue surgical careers: outcomes from our cardiothoracic surgery research program.

BACKGROUND: The past several years have witnessed a dramatic decline in the number of general surgery residents pursuing cardiothoracic surgery residency training. We believe that attracting individuals to pursue surgical careers should begin during the formative years of medical education. We implemented a program to introduce first-year medical students to cardiothoracic surgery and laboratory research. METHODS: In 2003, we began a program providing an introduction to cardiothoracic laboratory research and surgery for medical students. Students are competitively selected for our three-part 8-week summer program. First, students are paired with a cardiothoracic surgery attending for shadowing in clinic and the operating room. Second, students actively participate in large-animal operations in the laboratory. Finally, students complete a clinical research project under the direction of a laboratory resident and faculty mentor. These projects are the students' own. They are responsible for presenting their findings to the division of cardiac surgery at the end of the program. RESULTS: Since 2003, 18 students have completed the program. Each one has completed a project, collectively resulting in 39 peer-reviewed manuscripts. One student has published 28 peer-reviewed manuscripts. Of 10 students eligible for residency, 8 have applied in general surgery or surgical subspecialty (3 general, 2 plastic, 2 cardiothoracic, and 1 neurosurgery). CONCLUSIONS: Implementing a program to introduce medical students to clinical and laboratory surgery has been successful, as measured by academic productivity. Eighty percent of eligible students entered a surgical field. Programs like these serve to stimulate interest in our specialty.

Subclavian flap aortoplasty: still a safe, reproducible, and effective treatment for infant coarctation.

OBJECTIVE: Subclavian flap repair of infant coarctation has been criticized and in many centers abandoned in favor of resection with end-to-end anastomosis. The goal of this study was to examine intermediate and long-term results of infant subclavian flap aortoplasty, which has been the preferred technique at our institution over the last two decades. METHODS: Our patient database identified all infants (age<1 year) who underwent repair of isthmic coarctation via thoracotomy between January 1984 and December 2004. Procedure details and late results were collected by retrospective review of hospital and clinic data. Follow-up was 95.8% complete at a mean of 6.7 years. RESULTS: Between January 1984 and December 2004, 119 infants underwent isolated subclavian flap repair of coarctation. Mean age and weight at operation were 35+/-52 days (range 1-269 days) and 3.5+/-1.3kg (range 0.7-9.3kg), respectively. Concomitant pulmonary artery banding was performed in 22% (26/119). In-hospital mortality was 4% (5/119) and cumulative late mortality was 6% (7/114) of patients with long-term follow-up. Actuarial survival at 1, 5, and 10 years was 91, 85, and 85%, respectively. Overall re-intervention rate for re-stenosis was 11% (12/114); 10 patients (9%) underwent balloon angioplasty while 3 patients (3%) required operative revision. All re-stenoses occurred in the descending aorta, and all occurred in patients who had undergone neonatal repair. At late follow-up, there were no significant neurologic events (left recurrent laryngeal nerve injury, stellate ganglion dysfunction, or paraplegia), no clinically significant ischemic arm complications, and no flap aneurysms. CONCLUSIONS: Subclavian flap aortoplasty remains our procedure of choice for isthmic coarctation, as it is a simple, technically straightforward technique with a low incidence of re-stenosis and serious early and late morbidity. Furthermore, subclavian flap re-stenoses are easily treated with percutaneous intervention and seldom require surgical re-intervention via thoracotomy.

Clinical outcomes of noninfectious sternal dehiscence after median sternotomy.

BACKGROUND: Infectious complications of median sternotomy carry significant morbidity and mortality. However, the outcomes of noninfectious sternal dehiscence have not been addressed. We have identified the preoperative characteristics, postoperative complications, and long-term functional outcomes of patients after reoperation for noninfectious sternal dehiscence and compared these patients with a control group to determine risk factors for dehiscence. METHODS: Retrospective review of the cardiac surgery database identified 48 patients with noninfectious sternal dehiscence in a group of 12,380 median sternotomies between 1994 and 2004. The review included diagnosis, demographics, concomitant medical conditions, and surgical outcomes. Functional outcomes were assessed using the Short Form-12 questionnaire. One hundred fifty-six median sternotomy patients served as controls. Follow-up was 97.9% (47 of 48 patients) complete, for a total of 150.1 patient-years. RESULTS: Mean age of patients at reoperation was 58.8 +/- 12.8 years, with a male to female ratio of 45:3. Multivariate analysis determined that New York Heart Association class IV, obesity, and chronic obstructive pulmonary disease were preoperative risk factors for sternal dehiscence. The incidence of sternal dehiscence was 0.39% at a mean interval between initial operation and reoperation of 5.4 months. At a mean interval of 3.9 months, 14.6% (7 of 48) of patients required additional sternal procedures. Infectious complications after reoperation occurred in 12.5% (6 of 48). Functional outcomes demonstrated that 72.2% (26 of 36) had no or mild limitation of physical activities, with 90.5% (38 of 42) reporting no or mild sternal pain at follow-up. CONCLUSIONS: Although patients undergoing surgical correction of noninfectious sternal dehiscence fare better than those with infectious complications, optimal sternal approximation during the initial procedure and sternal precautions during convalescence should be emphasized to prevent recurrent complications.

Valve-sparing aortic root replacement: early experience with the De Paulis Valsalva graft in 51 patients.

BACKGROUND: Valve-sparing aortic root replacement for treatment of aortic sinus disease avoids the problems of prosthetic valves, but some patients suffer late valve incompetence as a result of leaflet distortion or annular dilatation. The reimplantation technique using the De Paulis Valsalva graft might improve late results of valve-sparing aortic root replacement by maintaining annular stability and re-creating sinuses that minimize leaflet stress. METHODS: Retrospective review was conducted of all patients at our institution who underwent valve-sparing aortic root replacement using the Valsalva graft. Clinical data were obtained from hospital and clinic charts and patient contacts; echocardiograms were analyzed for aortic root dimensions and valve function. RESULTS: Between May 2002 and June 2005, 51 patients underwent valve-sparing aortic root replacement using the reimplantation technique with the Valsalva graft. Mean age was 33 +/- 15 years; 22% (11 of 51) were children, and 80% (41 of 51) were male. Primary indication for surgery was root aneurysm in all patients. Preoperative mean root diameter was 5.0 +/- 0.5 cm. Marfan syndrome was present in 67% (34 of 51), and 10% (5 of 51) had the newly described Loeys-Dietz syndrome. There were no operative or late deaths, and no patient required reoperation for bleeding. At mean follow-up of 1.8 years, there were no episodes of endocarditis or thromboembolism. Echocardiograms showed stability of the annulus and root dimensions on follow-up. No patient had more than 0 to 1+ aortic insufficiency or progression of aortic insufficiency. All were in New York Heart Association class I. CONCLUSIONS: Valve-sparing aortic root replacement using the Valsalva graft and reimplantation technique has excellent early results. Preservation of valve competence is encouraging, but long-term results will determine whether the anatomic design of this aortic root prosthesis is superior for preservation of valve integrity.

Valproic acid prevents brain injury in a canine model of hypothermic circulatory arrest: a promising new approach to neuroprotection during cardiac surgery.

BACKGROUND: The anticonvulsant valproic acid (sodium valproate, Depacon) acts as a neuroprotectant in rodents, but has never been tested in larger animals. We used valproate in our canine model of hypothermic circulatory arrest to evaluate its neuroprotective benefit in complex cardiac surgical cases. METHODS: Thirteen dogs pretreated with valproate before 2 hours of hypothermic circulatory arrest survived for 24 hours (n = 7) or 72 hours (n = 6). Thirteen control animals (placebo only) also survived for 24 hours (n = 7) or 72 hours (n = 6) after hypothermic circulatory arrest. Blinded clinical neurologic evaluation was performed daily until sacrifice using the Pittsburgh Canine Neurologic Scoring System. Brains were harvested for blinded histopathologic analysis by a neuropathologist to determine the extent of apoptosis and necrosis in 11 brain regions (Total Brain Cell Death Score: 0 = normal, 99 = extensive neuronal death in all regions). Quantification of N-acetyl-aspartate, an established marker for brain injury, was performed with mass spectrometry. RESULTS: Valproate dogs scored significantly better than control animals on clinical neurologic evaluation. Histopathologic examination revealed that valproate animals demonstrated less neuronal damage (by Total Brain Cell Death Score) than control animals at both 24 hours (16.4 versus 11.4; p = 0.03) and 72 hours (21.7 versus 17.7; p = 0.07). At 72 hours, the entorhinal cortex, an area involved with learning and memory, was significantly protected in valproate dogs (p < 0.05). Furthermore, the cortex, hippocampus, and cerebellum demonstrated preservation of near-normal N-acetyl-aspartate levels after valproate pretreatment. CONCLUSIONS: These data demonstrate clinical, histologic, and biochemical improvements in dogs pretreated with valproate before hypothermic circulatory arrest. This commonly used drug may offer a promising new approach to neuroprotection during cardiac surgery.

Noninvasive assessment of brain injury in a canine model of hypothermic circulatory arrest using magnetic resonance spectroscopy.

BACKGROUND: Studies have confirmed the neuroprotective effect of diazoxide in canines undergoing hypothermic circulatory arrest (HCA). A decreased N-acetyl-asparate:choline (NAA:Cho) ratio is believed to reflect the severity of neurologic injury. We demonstrated that noninvasive measurement of NAA:Cho with magnetic resonance spectroscopy facilitates assessment of neuronal injury after HCA and allows for evaluation of neuroprotective strategies. METHODS: Canines underwent 2 hours of HCA at 18 degrees C and were observed for 24 hours. Animals were divided into three groups (n = 15 in each group): normal (unoperated), HCA (HCA only), and HCA+diazoxide (pharmacologic treatment before HCA). The NAA:Cho ratios were obtained 24 hours after HCA by spectroscopy. Brains were immediately harvested for fresh tissue NAA quantification by mass spectrometry. Separate cohorts of HCA (n = 16) and HCA+diazoxide (n = 23) animals were kept alive for 72 hours for daily neurologic assessment. RESULTS: Cortical NAA:Cho ratios were significantly decreased in HCA versus normal animals (1.01 +/- 0.29 versus 1.31 +/- 0.23; p = 0.004), consistent with severe neurologic injury. Diazoxide pretreatment limited neurologic injury versus HCA alone, reflected in a preserved NAA:Cho ratio (1.21 +/- 0.27 versus 1.01 +/- 0.29; p = 0.05). Data were substantiated with fresh tissue NAA extraction. A significant decrease in cortical NAA was observed in HCA versus normal (7.07 +/- 1.9 versus 8.54 +/- 2.1 micromol/g; p = 0.05), with maintenance of normal NAA levels after diazoxide pretreatment (9.49 +/- 1.1 versus 7.07 +/- 1.9 micromol/g; p = 0.0002). Clinical neurologic scores were significantly improved in the HCA+diazoxide group versus HCA at all time points. CONCLUSIONS: Neurologic injury remains a significant complication of cardiac surgery and is most severe after HCA. Magnetic resonance spectroscopy assessment of NAA:Cho ratios offers an early, noninvasive means of potentially evaluating neurologic injury and the effect of neuroprotective agents.

Impact of donor lung organisms on post-lung transplant pneumonia.

BACKGROUND: Fear of transmission of donor organisms that may result in recipient pneumonia has a negative impact on donor lung utilization. We reviewed our experience with routine donor bronchial aspiration and culture at the time of transplantation to study the impact of donor bronchial organisms on the development of recipient post-lung transplant pneumonia (PTP) and other outcomes. METHODS: We reviewed 80 consecutive single and bilateral lung transplants (SLTs and BLTs) from August 1998 to August 2001. Pediatric recipients and those not surviving >3 days were excluded. All donors met standard criteria for donor acceptance. All recipients received broad-spectrum antibiotics pending the results of final operating room cultures. PTP required clinical evidence (fever, leukocytosis and hypoxia), radiologic evidence (infiltrate), and culture confirmation during initial hospitalization or within 30 days. RESULTS: Sixty-four donors for 71 recipients (39 SLTs, 32 BLTs) comprised the study population. Organisms were grown from 57 (89%) donors and 46 were polymicrobial. A total of 149 organisms were cultured consisting of 21 different species, with Staphylococcus (n = 35) and Streptococcus (n = 33) being the most common. PTP was seen in 31 (41%) recipients, with Pseudomonas species (n = 13) the most prevalent. Of the 71 donor-recipient pairs, 2 had both donor and recipient with no growth and PTP. The donor organisms had a sensitivity of 0.75 with a low specificity of 0.04 and were negatively correlated with development of PTP. PTP was an independent predictor of overall mortality. CONCLUSIONS: The presence of donor organisms does not predict PTP. Therefore, donor acceptance criteria need to be re-examined.

Surgical ventricular remodeling for patients with clinically advanced congestive heart failure and severe left ventricular dysfunction.

BACKGROUND: Surgical ventricular remodeling (SVR) is an accepted therapy for post-infarction ventricular remodeling. Current literature on SVR outcomes has focused on heterogeneous populations with regard to left ventricular function and New York Heart Association (NYHA) class. We assessed outcomes after SVR in patients with advanced congestive heart failure (CHF) (NYHA Class III/IV) and a pre-operative ejection fraction (EF) < or =20%. METHODS: Data were analyzed for 51 consecutive SVR patients from January 2002 to June 2004. Cardiac catheterization, echocardiography and magnetic resonance imaging (MRI) identified 62.7% (32 of 51) of patients with an EF < or =20%, with the majority having an EF < or =15% (65.6%; 21 of 32). Cox regression analysis was performed to determine predictors of mortality in patients with an EF < or =20%. Follow-up was 100% (32 of 32) complete. RESULTS: Mean age was 61.9 +/- 10.3 (range 40 to 80) years with a male:female ratio of 27:5. Operative mortality was 6.3% (2 of 32). Twenty-two percent (7 of 32) had concomitant mitral valve procedures. Follow-up demonstrated a statistically significant improvement in left ventricular volumes and EF in survivors. Cox regression analysis identified the following to be significant predictors of mortality: pre-operative left ventricular end-systolic volume index >130 ml/m2; pre-operative diabetes; and intra-aortic balloon pump usage. Pre-operatively, all patients (32 of 32) were categorized as NYHA Class III/IV, with 69% (22 of 32) improving to NYHA Class I/II at follow-up (p < 0.01). Survival did not differ statistically between patients with an EF < or =20% and an EF >20% (n = 19). CONCLUSIONS: Our results indicate that SVR improves left ventricular function and functional status for patients with advanced CHF and a pre-operative EF < or =20%. Therefore, SVR is a viable surgical alternative for patients with severe left ventricular dysfunction.

Surgical ventricular remodeling for multiterritory myocardial infarction: defining a new patient population.

OBJECTIVE: Because of limited medical and surgical options for patients with end-stage congestive heart failure, we expanded the criteria for surgical ventricular remodeling to include patients with multiterritory myocardial infarction, a group historically considered high-risk candidates. We present our series of patients with multiterritory myocardial infarction who underwent surgical ventricular remodeling and propose a new patient population who may benefit from this procedure. METHODS: Data were analyzed for 51 consecutive patients undergoing surgical ventricular remodeling from January 2002 to June 2004, with 100% follow-up. Three left ventricular vascular territories were defined: anteroapicoseptal (left anterior descending), lateral (circumflex), and inferior (right coronary artery). Infarction was assessed with magnetic resonance imaging and intraoperative findings. RESULTS: Multiterritory myocardial infarction was found in 64.7% of patients (33/51) undergoing surgical ventricular remodeling. Mean age was 61.6 +/- 11.1 years (range 40-81 years). Sixty-one percent (20/33) demonstrated evidence of myocardial infarction in all three territories. Five patients underwent concomitant mitral valve repair or replacement. Operative mortality was 6.1% (2/33) and did not differ from that of patients with single-territory infarction (11.1%, P = .61). Surgical ventricular remodeling significantly improved left ventricular volumes and ejection fraction in patients with multiterritory myocardial infarction. Three patients required assist device implantation, and 2 patients required defibrillator placement. Sixty-nine percent of patients in preoperative New York Heart Association functional class III or IV (22/32) had improvement to class I or II at follow-up (P < .01). Cox regression analysis discriminated a preoperative left ventricular end-systolic volume index greater than 100 mL/m(2) as a significant risk factor for mortality (odds ratio 12.1, 95% confidence interval 1.27-114.51, P = .03). Thirty-month survival of patients with multiterritory myocardial infarction (73.5% +/- 8.3%) did not differ statistically from that of patients with single-territory infarction (n = 18). CONCLUSION: Surgical ventricular remodeling improves cardiac function and New York Heart Association functional status in patients with multiterritory myocardial infarction. Our initial results are promising and should prompt further studies to confirm our results and potentially expand the surgical ventricular remodeling inclusion criteria to include patients with multiterritory myocardial infarction.

Attenuation of DNA damage in canine hearts preserved by continuous hypothermic perfusion.

BACKGROUND: Continuous hypothermic perfusion is a novel cardiac preservation technique. Reactive oxygen species play a role in ischemia reperfusion injury and limit organ preservation. Oxidative stress mediates a DNA mismatch lesion (7, 8-dihydro-8-oxoguanine [8-oxo-G]), which is repaired by the enzymes MutY homologue (MYH), 8-oxo-G glycosylase (OGG1), and MutS homologue 2 (MSH2). We hypothesized that continuous hypothermic perfusion would allow for maintenance of cardiac function while attenuating myocardial DNA damage with respect to the current clinical practice of static preservation at 4 degrees C. METHODS: In our canine orthotopic transplant model, donor hearts were harvested after echocardiograms, and hemodynamic studies were obtained and served as controls. The hearts were transplanted after 24 hours of continuous hypothermic perfusion or 4 hours of static preservation, and were studied for 6 hours. Quantification of 8-oxo-G lesions, MYH, OGG1, and MSH2 concentrations were performed on biopsies using immunohistochemistry. RESULTS: Postimplant echocardiograms, completed in 7 continuously perfused and 8 statically preserved hearts, demonstrated good function and normal wall motion. Positive staining for 8-oxoG was markedly increased in the static preservation group. Staining density for MYH, OGG1, and MSH2 were significantly decreased in statically preserved hearts and equivalent between continuously perfused and control hearts. CONCLUSIONS: The DNA damage assayed by 8-oxoG was significantly increased in statically preserved versus continuously perfused hearts. The DNA repair enzymes MYH, OGG1, and MSH2 were also markedly decreased in the static preservation versus continuous hypothermic perfusion groups. Continuous hypothermic perfusion reduces oxidative damage and extends preservation without compromising function.

Impact of secondary pulmonary hypertension on lung transplant outcome.

INTRODUCTION: Secondary pulmonary hypertension (SPH), defined as a mean pulmonary artery pressure (PAM) greater than 25 mm Hg, complicates end-stage lung diseases of varying etiology. Although previous studies have suggested that SPH does not adversely affect outcome, no study has assessed the impact of the degree of SPH. METHODS: A retrospective review of the lung transplant database was used to identify patients who underwent either single-lung (SLT) or bilateral lung transplantation (BLT) complicated by SPH. SPH patients were stratified into low SPH (PAM = 30-40 mm Hg) and high SPH (PAM > or = 40 mm Hg). Each group was further sub-categorized into SLT or BLT. Patients with a heart-lung transplant or primary pulmonary hypertension were excluded. Recipients without pulmonary hypertension transplanted over the same time were used as controls. Data are reported as controls vs low SPH vs high SPH. RESULTS: One hundred-four patients received lung transplants between August 1998 and March 2003. There were 45 patients (18 men and 27 women) with SPH. Of these, 28 patients had low SPH, and 17 patients had high SPH. Forty-two patients (18 men and 24 women) without PH were the controls. There were no significant differences between groups except pre-operative oxygen dependence (81% vs 100% vs 94%, respectively) and use of CPB (28.6% vs 57.1% vs 64.7%, respectively). PAO2-PaO2 gradients and PaO2/FIO2 ratios were significantly worse in the high SPH group (116.2 vs 132.9 vs 186.3; p < 0.006) and (277.8 vs 234.3 vs 214.4; p < 0.026) respectively. There was no statistical difference in length of mechanical ventilation or duration of intensive care unit stay between groups. PAMs were significantly different pre-operatively (22.2 +/- 0.8 vs 34.0 +/- 0.6 vs 47.8 +/- 2.0; p < 0.001) and post-operatively (20.9 +/- 1.1 vs 23.7 +/- 1.3 vs 24.8 +/- 2.1; p < 0.001). There were no operative deaths. There were 3 early deaths in the control group, 1 in the low SPH group, and 3 in the high SPH group, none were related to pulmonary hypertension. Actuarial survival at 12, 24, and 48 months was not significantly different among the groups nor between SLT or BLT with SPH. CONCLUSION: Although SPH increases the risk of reperfusion injury; survival is equivalent with mild or moderate pulmonary hypertension. Either SLT or BLT may be used in patients with SPH without compromising outcome. This has the added benefit of expanding the donor pool.

Aortic valve replacement and concomitant mitral valve regurgitation in the elderly: impact on survival and functional outcome.

BACKGROUND: The impact of mitral regurgitation (MR) on elderly patients (> or = 70 years) undergoing isolated aortic valve replacement (AVR) is not clearly defined. This study investigates the long-term effects of preoperative, moderate MR on survival and functional outcome in elderly AVR patients. METHODS AND RESULTS: A retrospective review identified 408 consecutive elderly patients who underwent isolated AVR from January 1983 to February 2004. The pathologic etiology of MR was determined on preoperative echocardiogram, and patients were stratified into no/mild MR (Group I; n = 338) versus moderate MR (Group II; n = 70). Follow-up was 95.1% complete. Functional outcome was evaluated using the Short Form-12 questionnaire. On univariate analysis, Groups I and II differed in incidence of previous myocardial infarction (13.9% versus 28.6%; P = 0.004), hyperlipidemia (18.7% versus 33.3%; P = 0.009), and congestive heart failure (50.0% versus 70.0%; P = 0.002). On multivariate analysis, moderate MR was an independent risk factor impacting long-term survival (P = 0.04). Actuarial survival at 1, 5, and 10 years for Group I was 93.8%, 73.3%, and 40.1% versus 92.3%, 58.2%, and 14.6% for Group II (P = 0.04). Available postoperative echocardiograms for Group II (n = 37) demonstrated improvement in MR in 81.8% of functional MR patients. However, MR persisted or worsened in 65.4% of patients with intrinsic mitral valve disease (myxomatous, calcific, or ischemic MR). Functional outcomes showed 77% of Group I versus 78.6% of Group II rated their health as good to excellent post-AVR. CONCLUSIONS: Moderate MR is an independent risk factor impacting long-term survival in elderly patients undergoing AVR. Therefore, patients with intrinsic mitral valve disease should be considered for concomitant MV surgery.

Results of aortic valve-sparing operations: experience with remodeling and reimplantation procedures in 65 patients.

BACKGROUND: Valve-sparing operations for aortic root aneurysms are increasing in frequency, but techniques and results are still in evolution. We reviewed our experience with 65 patients (adults and children) who had this operation at our institution to determine early and late outcomes. METHODS: A retrospective clinical review was undertaken using hospital records, clinical and echocardiographic, computed tomography, magnetic resonance imaging data, and telephone interviews with patients and their physicians. RESULTS: Between July 1994 and December 2002, 65 patients (46 adults and 19 children) underwent a valve-sparing operation for aortic root aneurysm. Forty-four of the patients had the Marfan syndrome; the remaining 21 had either a nonspecific connective tissue disorder (14 patients) or a miscellaneous disease process such as Ehlers-Danlos syndrome (7 patients). Fifty-eight (89%) had a David II (remodeling) procedure and 7 had a David I (reimplantation) procedure. The DePaulis "Valsalva graft" was used in six of the David I patients. There were no operative or hospital deaths; only one late death occurred in an adult due to salmonella meningitis. Overall, survival was 100% at one year and 98% at 3 and 5 years. Ten patients (7 adults and 3 children) developed significant late aortic insufficiency (AI). Nine of these patients had a David II procedure and in 8 of these cases, AI was secondary to significant late annular dilatation. One of the 10 patients developed late AI 8.2 years after a David I procedure; his AI was secondary to aortic leaflet extension and prolapse. Six of the 10 patients who developed significant late AI required aortic valve replacement (4 adults and 2 children). Freedom from late aortic valve replacement (AVR) in this series of 65 patients was 91% at 3 and 84% at 5 years. At the close of this study, 58 patients were New York Heart Association (NYHA) class I and 6 were NYHA class II; no patients were class III or IV. There were no episodes of endocarditis or clinically significant thromboembolism. CONCLUSIONS: Valve-sparing operations provide satisfactory results for many patients with an aortic root aneurysm, but the David II remodeling procedure has a greater risk of late annular dilatation and AI. The David I reimplantation procedure utilizing the DePaulis Valsalva graft may obviate this problem.

Impact of 24 h continuous hypothermic perfusion on heart preservation by assessment of oxidative stress.

INTRODUCTION: Despite investigating numerous solutions, additives, and techniques over the last two decades, extending donor heart preservation beyond 4-6 h has not been achieved. Hypothermic heart preservation (HP) induces oxidative stress (OS) with reactive oxygen species (ROS) production, causing DNA cleavage and impairing repair. Quantification of cardiomyocyte concentrations of DNA damage by-products (8-oxoG) and mismatch repair enzymes (MYH, OGG-1, MSH2) reflects the severity of OS. If increased repair enzyme production is insufficient to repair injury, cell death occurs and functional outcomes are impacted. We investigated continuous hypothermic perfusion (CHP), a new form of HP, and the mechanism of injury associated with hypothermic storage, by assessing functional outcome and OS after allotransplantation of canine hearts. METHODS: Fourteen canine hearts were harvested using standard techniques after baseline echocardiograms and haemodynamic parameters were obtained. The hearts were implanted after 24 h CHP (n = 10) or 4 h static preservation (SP; n = 4). After weaning from cardiopulmonary bypass (CPB), recipients were kept alive for 6 h. Repeat echocardiograms and haemodynamic parameters were obtained. Quantification of MYH, OGG-1, and MSH2 concentrations were performed on biopsies using immunohistochemistry and Western blot analysis. RESULTS: Twelve out of 14 hearts (8/10 CHP; 4/4 SP) were successfully weaned on moderate inotropic support. Post-implant echocardiogram, completed in 6/10 CHP and 2/4 SP hearts, demonstrated hyperdynamic function and normal wall motion. The expression and activity of DNA repair enzymes was identical between normal baseline and CHP hearts. CONCLUSION: CHP reduces OS associated with prolonged hypothermic preservation and may allow longer preservation periods without compromising function. CHP offers several potential advantages: (1) resuscitation of non-beating heart donor organs, (2) time for HLA tissue typing, (3) facilitate interventions improving graft function, and (4) increased organ sharing.

Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?

The role of diagnostic laparoscopy in patients with periampullary and pancreatic malignancies is controversial. A retrospective review was performed including all patients (n = 188) with a periampullary or pancreatic malignancy who underwent both CT and laparotomy at our institution between January 1997 and December 1999. The overall resectability rate for all periampullary cancers was 67.3% (115 of 171 patients). This compared favorably with the resectability rate for cancers of the pancreatic body and tail (3 of 17 patients, 17.6%; P < 0.01 vs. periampullary cancers). Fifty percent of patients with periampullary cancers were unresectable because of metastatic disease, whereas metastatic disease precluded resection in 64.3% of patients with cancers of the pancreatic body and tail. After patients undergoing operative palliation were eliminated, a nontherapeutic laparotomy would have been precluded by the use of diagnostic laparoscopy in only 2.3% of patients with periampullary cancers (4 of 171 patients). In contrast, 6 (35.3%) of 17 patients with cancers of the pancreatic body and tail underwent a nontherapeutic laparotomy (P < 0.01 vs. periampullary cancers). One hundred fifty-eight (84%) of the 188 CT reports reviewed could be definitively categorized as either "likely to be resectable" or "likely to be unresectable." The remaining 16% were equivocal. Of the 107 patients categorized as likely to be resectable, 89 were actually resected (83.2%). In contrast, only 10 of the 51 patients categorized as likely to be unresectable could be resected (19.6%).