Disentangling nature from nurture in examining the interplay between parent-child relationships, ADHD, and early academic attainment.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment. METHOD: This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock-Johnson test was used to examine child reading and math aptitude. RESULTS: Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038-1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years). CONCLUSION: Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.

The relationship between parental depressive symptoms and offspring psychopathology: evidence from a children-of-twins study and an adoption study.

BACKGROUND: Parental depressive symptoms are associated with emotional and behavioural problems in offspring. However, genetically informative studies are needed to distinguish potential causal effects from genetic confounds, and longitudinal studies are required to distinguish parent-to-child effects from child-to-parent effects. METHOD: We conducted cross-sectional analyses on a sample of Swedish twins and their adolescent offspring (n = 876 twin families), and longitudinal analyses on a US sample of children adopted at birth, their adoptive parents, and their birth mothers (n = 361 adoptive families). Depressive symptoms were measured in parents, and externalizing and internalizing problems measured in offspring. Structural equation models were fitted to the data. RESULTS: Results of model fitting suggest that associations between parental depressive symptoms and offspring internalizing and externalizing problems remain after accounting for genes shared between parent and child. Genetic transmission was not evident in the twin study but was evident in the adoption study. In the longitudinal adoption study child-to-parent effects were evident. CONCLUSIONS: We interpret the results as demonstrating that associations between parental depressive symptoms and offspring emotional and behavioural problems are not solely attributable to shared genes, and that bidirectional effects may be present in intergenerational associations.

Risk factors associated with perioperative myocardial damage in patients with severe aortic stenosis.

AIM: Few studies have been performed about the risk factors associated with perioperative myocardial damage in patients undergoing valve surgery for severe aortic stenosis. METHODS: To assess the prevalence of perioperative myocardial damage, we studied 103 consecutive patients with aortic stenosis. Perioperative myocardial damage (PMD) was diagnosed by both enzymatic data of peak creatine kinase iso-enzyme (CK-MB) and new appearance of electrocardiographic abnormality. PMD was noticed in 16 patients, and PMD was not noticed in 87 patients. A stepwise multiple logistic regression model was used to investigate predictors of PMD in several categorized parameters such as preoperative data, cardioplegic delivery method, and aortic clamping time. RESULTS: A multivariate analysis identified that cardioplegic delivery method, preoperative left ventricular (LV) wall thickness, and aortic clamping time were independent predictors of PMD. The incidence of PMD in the combined antegrade and continuous retrograde delivery method was significantly lower than that in antegrade delivery method (odds ratio 0.11, CI 0.02-0.61, p=0.011). The peak CK-MB value of the combined antegrade and retrograde method was significantly lower than that of the antegrade method (48+/-24 vs 71+/-50 IU/L; p=0.009). The peak lactate-dehydrogenase value of the combined method was significantly lower than that of the antegrade method (590+/-249 vs 1058+/-656 IU/L; p<0.001). The combined method decreased the incidence of PMD in patients with increased total wall thickness. CONCLUSION: Cardioplegic delivery method, LV total wall thickness, and aortic clamping time were independent predictors for PMD. Combined antegrade and continuous retrograde delivery method may be an important factor to obtain adequate myocardial protection.

[Novel strategy for thoracoabdomianl aortic aneurysm repair; intraoperative selective perfusion of the Adamkiewicz artery].

We report our method for delineating the Adamkiewicz artery using multidetector row computed tomography (MDCT) with selective perfusion using a distal perfusion cannula that is clinically available for off-pump coronary artery bypass (OPCAB). The tip of a distal perfusion catheter (Medtronic Quickflow, Minneapolis) designed for OPCAB was applicable for selective perfusion of the segmental arteries. The femoro-femoral venoarterial bypass was branched off into selective perfusion of the segmental arteries, using an independent roller pump and heat exchanger. Our method of visualization of the Adamkiewicz artery was MDCT scanning with injection of contrast medium directly into the proximal descending aorta: namely, "CT during aortography". Lower descending aorta to abdominal aorta (the range involving the aneurysm) was scanned in a cephalad-to-caudal direction using a detector collimation of 4 x 1.25 mm with a table speed of 9.4 mm/sec, pitch of 6, and image thickness of 1.25 mm. All images were reviewed on a workstation to investigate the continuity between the Adamkiewicz artery and its proximal segmental artery with paging, mulitplanar reformation and curved planar reformation. Distal perfusion cannulae of 2.0 mm in diameter were inserted into the respective intercostal arteries. 4-0 polyethylene sutures were placed to tourniquet the catheters. Segmental arteries were perfused with total flow of approximately 80 ml/min at a circuit pressure of 120 mmHg. Reattachment of the ninth intercostal arteries related to the Adamkiewicz artery was carried out. A total of 6 consecutive 6 patients with thoracoabdominal aortic aneurysm (TAAA) have undergone graft replacement by the methods described, since April 2002. All patients survived surgery without any neurological complications. This method is expected to minimize the ischemic time of the spinal cord and attenuate the reperfusion injury.

[Left atrial thrombus without mitral disease; report of a case].

A 76-year-old man was admitted to our hospital because of surgical treatment for mass in the left atrium(LA). Echocardiography and computed tomography(CT) revealed mobile mass in LA which had stalk at the left atrial appendage. It was difficult to distinguish myxoma from thrombus. LA mass has risk of sudden circulatory collapse and systemic emboli, so it is indicated for emergent operation. Mass resection with appendage was performed through the transseptal superior incision using cardiopulmonary bypass. Pathological diagnosis was thrombus. Most of LA thrombus were complicated with mitral stenosis, LA thrombus without mitral disease is rare. A few authors reported the useful of CT and echocardiography, but we could not lead to precise diagnosis from preoperative image.

[Combined carotid endarterectomy and off-pump coronary artery bypass grafting].

Patients with angina undergoing carotid endarterectomy have a high mortality. A 74-yaer-old man who has severe carotid stenosis was performed combined carotid endarterectomy and off-pump coronary artery bypass grafting successfully. At first, carotid endarterectomy was performed with Jamieson's specially designed dissector, which allow simultaneous dissection and removal blood from the surgical field. Secondly, then off-pump CABG was performed. Skeletonized internal mammary artery was harvested with ultrasound dissector. The advantage of that the dissected artery is not only long and greater blood flow, but also less damage to sternal blood flow which prevent infection and complications. Then internal mammary artery was anastomosed to left anterior discending artery with Octopus II stabilizer. After the operation, he recovered uneventfully without neurological complication. Combined single staged carotid endarterectomy and off-pump CABG appears to be a safe method.

Coronary endothelial damage during off-pump CABG related to coronary-clamping and gas insufflation.

OBJECTIVE: Although off-pump coronary artery bypass grafting (CABG) has been recognized less invasive than conventional CABG on cardiopulmonary bypass, off-pump CABG may be partly invasive especially to the coronary endothelium. The present study was designed to evaluate the adverse effects of coronary snaring with looped sutures and gas insufflation on the coronary endothelium. The protective efficacies on the coronary endothelium of coronary snaring with elastic sutures or humidified gas insufflation with/without heparin and dipyridamole-added were also tested. METHODS: Thirty-six mongrel dogs were used. After systemic heparinization (150 U/kg), a 5 mm longitudinal coronary incision was made with looped non-elastic monofilament sutures or elastic sutures applied proximally and distally. The incised coronary artery was exposed to non-humidified carbon dioxide, humidified carbon dioxide with lactated Ringer solution, or humidified carbon dioxide with heparin and dipyridamole-added lactated Ringer solution for 10 or 20 min in each group. After gas insufflation, the incised coronary artery was repaired, then, the coronary was reperfused. Perfusion-fixation was done for observation of the coronary endothelium by scanning electron microscopy. The adverse effect on the endothelium was graded as follows: grade 1, appeared normal; grade 2, few blood cells deposited; grade 3, many blood cells deposited; grade 4, few endothelial cells delaminated with blood cells deposited; grade 5, many endothelial cells delaminated with blood cells deposited. RESULTS: Non-elastic looping caused much more endothelial tears than elastic looping (P<0.00001). Non-humidified gas blowing for 20 min caused more endothelial cell damage than humidified gas blowing (P=0.00005). Non-humidified gas blowing for 10 min caused less damage than for 20 min (P=0.00326), but still caused more damage than humidified gas blowing (P=0.00253). Heparin and dipyridamole-added humidification reduced coronary endothelial area mottled by the deposited cells when compared with simple humidification (P=0.00120). CONCLUSIONS: Coronary snaring resulted in coronary endothelial injury, which was ameliorated by using elastic sutures instead of non-elastic sutures. Non-humidified gas insufflation made blood cells deposited and endothelial cells delaminated with time. Humidified gas insufflation attenuated these adverse effects. Heparin and dipyridamole-added humidification had potential advantage in terms of reducing deposited blood cells on the endothelium over simple humidification.

Experimental use of a compact centrifugal pump and membrane oxygenator as a cardiopulmonary support system.

Compactness and high performance are the most important requirements for a cardiopulmonary support system. The Nikkiso (HPM-15) centrifugal pump is the smallest (priming volume; 25 ml, impeller diameter; 50 mm) in clinically available centrifugal pumps. The Kuraray Menox (AL-2000) membrane oxygenator, made of double-layer polyolefin hollow fiber, has a minimum priming volume (80 ml) and a low pressure loss (65 mm Hg at 2.0 L/min of blood flow) compared with other oxygenators. The aim of this study was to evaluate the performance of the most compact cardiopulmonary support system (total priming volume: 125 ml) in animal experiments. The cardiopulmonary bypass was constructed in a canine model with the Nikkiso pump and Menox oxygenator in comparison with a conventional cardiopulmonary support system. The partial cardiopulmonary bypass was performed for 4 h to evaluate the gas exchange ability, blood trauma, serum leakage, hemodynamics, and blood coagulative parameters. The postoperative plasma free hemoglobin level of the compact cardiopulmonary system was 29.5 +/- 10.21 mg/dl (mean +/- SD), which was lower than that of the conventional cardiopulmonary system, 48.75 +/- 27.39 mg/dl (mean +/- SD). This compact cardiopulmonary system provided the advantage in terms of reduction of the priming volume and less blood damage. These results suggested the possibility of miniaturization for the cardiopulmonary bypass support system in open-heart surgery in the near future.

Immediate contact hypersensitivity induced by repeated hapten challenge in mice.

An immediate reaction was investigated during repeated challenge testing for contact hypersensitivity to dinitrofluorobenzene (DNFB) in BALB/c mice. The mice were sensitized to DNFB on back skin and repeatedly challenged with the same hapten on the left ear at 1 week intervals. The ear after the 5th challenge showed biphasic responses which consisted of an immediate and a delayed-type reaction. The reactions were hapten specific. Mast cell-deficient WBB6F1 W/WV mice did not show any immediate reaction, while congenic normal mice showed both immediate and delayed-type reactions. Histologically, numerous dermal mast cells were found in the left ear of repeatedly challenged BALB/c and WBB6F1 normal mice, while there were few mast cells in the ear of WBB6F1 W/WV mice. Anti-DNP IgE antibodies were detected in BALB/c, WBB6F1 normal and W/WV mice after repeated challenge with DNFB. Intradermal injection of anti-IgE antibodies in the repeatedly DNFB-challenged ear elicited an immediate reaction. These results suggest that immediate contact hypersensitivity develops through the production of anti-DNP IgE antibodies and an increase in dermal mast cells after repeated challenge with DNFB.

Leukocyte-depleted reperfusion after long cardioplegic arrest attenuates ischemia-reperfusion injury of the coronary endothelium and myocardium in rabbit hearts.

OBJECTIVE: Cardiopulmonary bypass activates leukocytes, which should injure the coronary endothelium and myocardium during reperfusion especially after long cardioplegic arrest with long cardiopulmonary bypass time. The present study was designed to determine the protective efficacy of leukocyte-depleted reperfusion in blood-perfused parabiotic isolated rabbit hearts as a surgically relevant model with long cardioplegic arrest. METHODS: Each isolated rabbit heart, with a latex balloon inserted in the left ventricle, was parabiotically blood-perfused using a modified Langendorff column. The left ventricular developed pressure (DP), rate of pressure development (dP/dT), and coronary flow with a left ventricular end-diastolic pressure of 10 mmHg were measured before ischemia and after 15, 30, 45, and 60 min reperfusion after 4 h cardioplegic arrest kept at 20 degrees C (control, n=10). Leukocyte-depleted reperfusion was done in the test group (n=10). The endothelium of the coronary artery was observed by scanning electron microscopy (SEM) with percent injured area of endothelial cells measured to evaluate the extent of endothelial ischemia-reperfusion injury. RESULTS: The control hearts showed 53.3, 54.3, 48.4, and 39.0% recovery of DP compared to the pre-ischemia baseline data at 15, 30, 45, and 60 min after reperfusion began respectively. Leukocyte-depleted reperfusion enhanced the recovery of DP at 45 min (81.3%, P=0.0021) and 60 min (85.8%, P=0.0005) after reperfusion compared with that in the control group. The control hearts revealed 58.8%, 59.8%, 52.6%, and 43.4% recovery of dP/dT compared to the pre-ischemia baseline data at 15, 30, 45, and 60 min after reperfusion began, respectively. Leukocyte-depleted reperfusion also enhanced the recovery of dP/dT at 45 min (93.2%, P=0.0071) and 60 min (98.8%, P=0.0011) after reperfusion compared with that in the control group. There was also improvement of the recovery of coronary flow by leukocyte-depleted reperfusion (97.2%) compared with that in the control group (58.3%) after 60 min reperfusion (P=0.0121). Scanning electron microscopy showed that 69. 7% of coronary endothelial cells were morphologically injured in the control group. In contrast, leukocyte-depleted reperfusion prevented the extent of coronary endothelial damage with less injured area (0. 5%, P=0.0002). CONCLUSIONS: Leukocyte-depleted reperfusion improved functional recovery with reduced coronary endothelial injury after long cardioplegic arrest.

Ulinastatin attenuates reperfusion injury in the isolated blood-perfused rabbit heart.

BACKGROUND: Ventricular dysfunction after long cardioplegic arrest has been observed in cardiac operations. Urinary trypsin inhibitor, also called ulinastatin, may attenuate myocardial ischemia-reperfusion injury. The present study was designed to determine the protective efficacy of ulinastatin in blood-perfused parabiotic isolated rabbit hearts as a surgically relevant model with long (4-hour) cardioplegic arrest. METHODS: Each isolated rabbit heart, with a latex balloon inserted in the left ventricle, was parabiotically blood-perfused using a modified Langendorff column. The left ventricular developed pressure, rate of pressure development, and coronary flow with a left ventricular end-diastolic pressure of 10 mm Hg were measured before ischemia and 15, 30, 45, and 60 minutes after reperfusion began (control, n = 10). Ulinastatin (15,000 U/kg) was administered to the support animal just before reperfusion began (group U-1, n = 10) or at the beginning of the extracorporeal circulation and readministered before reperfusion (group U-2, n = 10). The endothelium of the coronary artery was observed by scanning electron microscopy to evaluate the extent of endothelial ischemia-reperfusion injury. RESULTS: Ulinastatin enhanced the recovery of developed pressure in both the U-1 (p<0.05) and U-2 (p < 0.01) groups compared with the control group. Although ulinastatin given just before reperfusion (group U-1) did not enhance the recovery of the rate of pressure development or the coronary flow compared with the control, earlier administration did improve the recovery of the rate of pressure development compared with the control (U-2, p<0.05), and there was improvement of the recovery of coronary flow after 60 minutes of reperfusion (U-2, p<0.05). Scanning electron microscopy showed that ulinastatin had ameliorated coronary endothelial damage. CONCLUSIONS: Ulinastatin improved functional recovery after long cardioplegic arrest and reduced coronary endothelial injury. Administration of ulinastatin at the beginning of cardiopulmonary bypass and just before reperfusion may be useful clinically in cases requiring prolonged aortic cross-clamping.

Successful valve-sparing in aortic root reconstruction under endoscopic guidance.

OBJECTIVE: Aortic insufficiency (AI) associated with ascending aneurysm can be corrected by valve-sparing aortic root reconstruction ('David' reimplantation, 'Yacoub' remodeling). Intraoperative endoscopic evaluation in the aortic root may help to clarify the procedure and to access competence of the preserved valve. METHODS: Following cross-clamping of the ascending aorta, an endoscopy was inserted into the proximal aortic root. Perfusion of crystalloid cardioplegia enabled the visualization of the pressure-loaded valve in the closed position. Conventional macroscopic evaluation would have overlooked valve prolapse because of a release from perfusion pressure. Valve coaptation was imaged directly before and after the valve-sparing procedure. A total of 17 patients underwent aortic root reconstruction under endoscopic guidance. Indications of the valve-sparing were determined with endoscopic findings. The degree of AI before and after the surgery was evaluated by aortography and scored (0, none; 1 trivial; 2, mild; 3, moderate; 4, severe). RESULTS: Remodeling was employed to eight patients and reimplantation to four. The other five patients were replaced with prosthetic valved-conduit. There was no early and late mortality. Before and after the valve-sparing surgery, grades of AI were significantly reduced. Three patients who underwent reimplantation procedure required late valve replacement for late progression of AI, however, none of the patients with remodeling required reoperation. CONCLUSION: Introduction of an endoscopy successfully reduced postoperative AI and clarified indications and limitations of valve-sparing aortic root operations.

Evaluation of postoperative cardiac function and long-term results in patients after aortic valve replacement for aortic valve disease with increased left ventricular mass.

OBJECTIVE: This clinical study was designed to evaluate the postoperative cardiac function in patients after aortic valve replacement for aortic valve disease with increased left ventricular mass. METHODS: Aortic valve replacement was performed in 117 patients using the St. Jude Medical valve. Their valve lesion was aortic regurgitation in 71, and aortic stenosis in 46. The mean value of the left ventricular mass index was 272 g/m2. The 117 patients were subdivided into 4 groups according to their preoperative left ventricular mass index-Group I (n = 35) with aortic regurgitation and a large left ventricular mass index (> or = 273 g/m2), Group II (n = 36) with aortic regurgitation and a small left ventricular mass index Group III (n = 19) with aortic stenosis and a large left ventricular mass index, and Group IV (n = 27) with aortic stenosis and a small left ventricular mass index. The cardiac function was evaluated by radionuclide ventriculography. RESULTS: In a comparative study of postoperative parameters among the 4 groups, the postoperative systolic and diastolic parameters of Group I patients were more significantly impaired compared with these parameters of the other 3 groups. The postoperative values the left ventricular mass index were significantly higher in Group I than in the other 3 groups. The 10-year survival rate was significantly lower in Group I than in the other 3 groups (30 +/- 22% in Group I). CONCLUSION: Aortic valve replacement is recommended for patients with eccentric hypertrophy in the adequate clinical phase of patients whose left ventricular mass index is less than 272 g/m2.

[A report of 4 cases of aortic operation using open proximal anastomosis under the hypothermic circulatory arrest and left lateral exposure].

Four cases of aortic operations using open proximal anastomosis (OPA) under the hypothermic circulatory arrest (HCA) and left lateral approach (LLA) are reported. Three of 4 cases had extensive aortic disease from distal arch to descending thoracic aorta (Stanford type B chronic aortic dissection, double false aneurysms, and double true aneurysms). Another one case had ruptured aneurysm of thoracic aorta. LLA should have been selected in all cases, however, aortic proximal cross-clamp was impossible in them, because of giant pseudolumen, diseased lesion of aortic arch, hemothorax followed rupture of aneurysm. Therefore OPA under the HCA was performed. There were no complication associated with HCA, bleeding, neurological deficiency and respiratory dysfunction. We conclude that, although the HCA may have some problems, if there is the proper indication, OPA under the HCA is useful method at aortic operation for difficult aortic disease.

Early valve failure after aortic valve-sparing root reconstruction.

Aortic valve-sparing root reconstructive surgery has been widely adopted to improve the patient's quality of life. We experienced a patient who required reoperation for progressive aortic regurgitation 17 months after the initial operation of valve-sparing root reconstruction with the reimplantation method in acute aortic dissection. In this study, we were concerned with valve durability because of the absence of sinuses of Valsalva in the new aortic root and the need for careful follow-up after this procedure.

Argatroban as a potential anticoagulant in cardiopulmonary bypass-studies in a dog model.

Argatroban is a selective thrombin inhibitor synthesized in Japan. Argatroban, which has a high affinity for thrombin, and markedly inhibits thrombin-induced reactions, has been used in patients with artherosclerosis obliterans. The efficiency of argatroban, instead of heparin, as an anticoagulant in dog models of cardiopulmonary bypass was explored. In the first study, argatroban was administered as a bolus plus infusion for 1 h during cardiopulmonary bypass at doses of 1.0 mg + 10 microg/kg per min, 2.0 mg + 10 microg/kg per min and 3.0 mg + 10 microg/kg per min (n = 2 per group). Activated clotting time and arterial gas analyses were performed beforehand and 10 min thereafter. In the second study, there were four groups. In the first group (n = 5), no coated extracorporeal circuit was used and heparin (2 mg/kg) was used as an anticoagulant. In the second group (n = 5), a coated extracorporeal circuit was used and heparin was used (2 mg/kg) as an anticoagulant. In the third group (n = 3), no coated extracorporeal circuit was used and argatroban (2.0 mg + 10 microg/kg per min) was used as an anticoagulant. In the fourth group (n = 5), a coated extracorporeal circuit was used and argatroban was used (2.0 mg + 10 microg/kg per min) as an anticoagulant. All animals were perfused for 120 min at 40 ml/kg per minute. Platelet count, activated clotting time, thrombin-antithrombin III complex, antithrombin III, fibrinogen, fibrinogen degradation products and C3a were measured to evaluate platelet, coagulofibrinolytic and the complement system. Activated clotting time values and the effect of argatroban during cardiopulmonary bypass indicated a dose-dependent response. The next highest dosing group (2.0 mg + 10 microg/kg per minute) had activated clotting time values of 250-300 seconds during cardiopulmonary bypass, and fell after reaching near-normal levels within 60 minutes. No clots were noted in the extracorporeal circuit. The argatroban group showed lower levels in their coagulofibrinolytic system compared with the heparin group. The platelet count remained at a high level in the argatroban group. It is concluded that the combination of heparinized cardiopulmonary bypass circuits, and the use of argatroban as an anticoagulant, is safe and reduces the activation of coagulation and fibrinolytic systems and preserves platelet count.

Systemic hypertension as a risk factor for complications with an aortic mechanical valve.

We sought to determine the effect of preoperative systemic hypertension on prosthesis related complications or postoperative aortic dissection after valve replacement in patients with aortic regurgitation. The patients were divided into two groups according to the presence or absence of systemic hypertension: Group I, with hypertension (n = 35), and Group II, without hypertension (n = 37). The survival rate and event free rate were examined for 72 patients who were alive 30 days after valve replacement with a St. Jude Medical valve for aortic regurgitation. The cumulative 10 year survival rate of Group I (65% +/- 12%) was lower than that of Group II (79% +/- 15%). The 10 year event free rate of all prosthesis related complications was 62% +/- 13% in Group I, and 96% +/- 3% in Group II (p < 0.05). The 10 year event free rate for ascending aortic dissection was 73% +/- 12% in Group I and 100% in Group II (p < 0.05). The linearized event rate of all prosthesis related complication was 3.8% per patient-year in Group I and 0.5% per patient-year in Group II. In conclusion, systemic hypertension was a risk factor for prosthesis related complications and for complicated aortic lesions after aortic valve replacement. Careful postoperative management for hypertension is necessary in patients with systemic hypertension after aortic valve replacement. Tissue valves may be recommended in patients with aortic valve disease and severe hypertension.

Aortic complications after aortic valve replacement in patients with dilated ascending aorta and aortic regurgitation.

BACKGROUND AND AIMS OF THE STUDY: Postoperative aortic complications of aortic dissection or enlargement of the ascending aortic develop in patients with aortic valve replacement (AVR) and dilated ascending aorta. This clinical study aimed to demonstrate the incidence of aortic complications after AVR in patients with dilated ascending aorta, and to clarify the surgical indication and approach for dilated ascending aorta and aortic regurgitation. METHODS: A total of 82 patients who underwent AVR between 1985 and 1997 were allocated to two groups according to the preoperative diameter of the ascending aorta. A dilated ascending aorta with diameter > or = 40 mm was seen in 38 patients (group I), and a small ascending aorta with diameter < 39 mm in 44 patients (group II). Group I patients were further allocated to two subgroups: 12 patients underwent aortoplasty (group IA) and 26 did not (group IB). Event-free rates of aortic complications and survival rate were compared between groups I and II. RESULTS: Postoperative aortic dissection during the follow up period occurred in four hypertensive patients in group I (one in group IA, three in group IB); no aortic dissection was seen in group II. Freedom from all aortic complications at 10 years after surgery was 75 +/- 10% in group I and 100% in group II (p < 0.05). The cumulative survival rate at 10 years was 59 +/- 11% in group I (group IA: 71 +/- 18%, group IB: 51 +/- 14%) and 95 +/- 4% in group II (p < 0.05). CONCLUSIONS: Patients with a dilated ascending aorta (> or = 40 mm diameter) were more likely to encounter complications of the aortic dissection or enlargement after AVR than those with a small ascending aorta. Surgery to prevent aortic dissection or enlargement must be selected in patients with mildly dilated ascending aorta and hypertension.