Clinical outcomes of Carbomedics Top Hat valve with a robust follow-up system.

AIM: Late failure of bioprosthetic valves may limit their use in patients < 60 years. The superior hemodynamic performance offered by the Carbomedics Top Hat supraannular valve enables greater effective orifice areas to be achieved. The aim of this study was to assess the clinical outcomes of this valve, using a robust follow-up system. METHODS: Patients who underwent aortic valve replacement with or without coronary artery bypass grafting between July 1997 and January 2010 with Carbomedics supraannular Top Hat valves were identified. Details of readmissions and late deaths were obtained from the National Hospital Episodes Statistics data and the Office of National Statistics, tracked by the Quality and Outcomes Research Unit. Late complications associated with this prosthesis were evaluated. RESULTS: Of 253 patients identified, 181 underwent isolated aortic valve replacement and 72 had aortic valve replacement with coronary artery bypass grafting. The 30-day mortality was 1.6%, and 5- and 10-year survival rates were 91.4% and 80.5%, respectively. Detailed readmission data were available after 2001 (n = 170). Two (1.2%) patients required reoperation for endocarditis and pannus formation. Of the 17 late deaths in this subset, 4 were attributable to cardiac causes. One patient was treated for heart failure, and 2 developed bleeding complications. CONCLUSIONS: Implantation of the Carbomedics Top Hat supraannular valve in our unit resulted in satisfactory in-hospital and midterm survival with low incidences of endocarditis and late heart failure.

UK specialist cardiothoracic management of thoracic injuries in military casualties sustained in the wars in Iraq and Afghanistan.

OBJECTIVES: Outcomes of casualties with thoracic wounding at the deployed UK military field hospital (Role 3(R3)) have been previously described. The level of cardiothoracic specialist input required on repatriation to the UK is less clear. This study aimed to assess the outcomes of casualties with thoracic injuries repatriated to the UK (Role 4 (R4)) and evaluate the impact of specialist cardiothoracic care. METHODS: Casualties were identified through the UK Joint Theatre Trauma Registry. Casualties coded for pulmonary contusions and/or thoracotomy between March 2006 and March 2011 were identified and case-notes reviewed. Subgroup analysis was performed for patients with a documented thoracic abbreviated injury score ≥3. RESULTS: One hundred and eighty-two UK patients were admitted to UK R4 coded to have a thoracic injury; overall mortality 4.9%. Ninety-three were classified as a thoracic AIS of ≥3; mortality 6.5%. Sixty-four were coded for pulmonary contusions and/or thoracotomy; mortality 1.6, and 66% had thoracic AIS ≥3. Improvised explosive devices injured 54 and 62% had a penetrating injury. Pulmonary contusions were present in 70%; 43% developed a chest infection. Thoracotomy/sternotomy was performed in 13 casualties in R3; 3 re-explored in R4. Oscillatory ventilation and extracorporeal membrane oxygenation was required in 1 case. Cardiothoracic surgery was involved in managing 39% (n = 24) of cases; 11 (45%) required surgical intervention and 19 (79%) had cardiothoracic outpatient follow-up. CONCLUSION: Morbidity and mortality associated with significant thoracic injury is low at UK R4. Follow-up is required to assess long-term outcomes. Specialist cardiothoracic support and intervention was required in the management of complex thoracic trauma. Early specialist support at R4 may improve morbidity and outcomes associated with life-threatening thoracic injury.

Stab to the chest causing severe great vessel injury.

Penetrating trauma has increased in developed and urban environments. Pulmonary artery injury is rare, but can be associated with significant morbidity. We report a case of delayed cardiac arrest following a stab injury to the chest. The patient had active great vessel bleeding and required extensive surgical intervention. Clinicians should have a high index of suspicion for life-threatening thoracic injuries following a stab injury to the chest, despite initial clinical stability or negative baseline radiological findings.

Patient-prosthesis mismatch in patients with aortic stenosis undergoing isolated aortic valve replacement does not affect survival.

BACKGROUND: Data suggest that patient-prosthesis mismatch (PPM) adversely effects late survival after aortic valve replacement (AVR). This study examined the incidence and implications of PPM in patients undergoing isolated AVR. METHODS: Prospectively collected data on patients undergoing isolated AVR for aortic stenosis between January 1, 1997 and December 31, 2007 were analyzed. The projected effective valve orifice area from in vivo data was indexed to body surface area (EOAi). PPM was defined as moderate for EOAi of < or = 0.85 cm(2)/m(2) and severe if < or = 0.6 cm(2)/m(2). The reference group comprised patients with EOAi > 0.85 cm(2)/m(2). The effect of PPM on postoperative survival was assessed by multivariate analysis. RESULTS: Of 801 patients, PPM was severe in 48 (6.0%), moderate in 462 (57.8%), and nonexistent in 291 (36.4%). Mismatch was associated with increasing age and female gender, thus resulting in an increase in the EuroSCORE (reference group, 4.9 +/- 2.6; moderate PPM, 5.8 +/- 2.4; and severe PPM, 6.1+/-2.1; p < 0.001). PPM did not significantly increase hospital mortality. Four deaths occurred in the reference group (1.4%), 12 in the moderate PPM (2.6%), and none in the severe PPM group (p = 0.311). The 5-year survival estimates were 83% in reference, 86% in moderate PPM, and 89% in severe PPM (p = 0.25). By multivariate analysis, PPM was not an independent risk factor for reduced in-hospital or late survival. CONCLUSIONS: Moderate PPM is common in patients undergoing AVR for aortic stenosis, but severe mismatch is rare. Patients with PPM have similar early and late postoperative survival rate.