Long-Term Comparison of Three Types of Aortic St. Jude Medical Mechanical Prosthesis in Japanese Patients.

BACKGROUND: The long-term results achieved with aortic St. Jude Medical (SJM) mechanical prostheses in various age groups of Japanese patients have not been previously compared or reported. METHODS AND RESULTS: Since 1981, a total of 240 SJM valves were implanted in 79 patients using the Standard model, in 58 patients with the Hemodynamic Plus model, and in 103 patients with the Regent model for aortic valve replacement (AVR). Follow-up was completed for 2,397 patient-years in 97.5% of the patients, among whom the effect of age was compared, and the subjects were divided into younger (<65 years) and older (≥65 years) groups. Hospital mortality rate was 2.5%. No structural valve deterioration was observed during the follow-up period. In addition, no significant differences were observed in long-term survival between the 3 models. In contrast, significantly better rates of freedom from all-cause death (P<0.0001), valve-related death (P=0.0018) and valve-related morbidity (P=0.0021), including bleeding events (P=0.0007), were observed in the younger group (n=157, 50.6±1.0 years old) than in the older group (n=83, 72.5±0.7 years old). CONCLUSIONS: All types of SJM valve used for single AVR achieved satisfactory early and long-term results in each age group even 25 years after surgery. When selecting this prosthesis for elderly patients, however, relatively worse performance may be expected compared with that observed in younger patients.

Quantitative assessment of right ventricular function and pulmonary regurgitation in surgically repaired tetralogy of Fallot using 256-slice CT: comparison with 3-Tesla MRI.

OBJECTIVES: To compare 256-slice cardiac computed tomography (CCT) with cardiac magnetic resonance (CMR) imaging to assess right ventricular (RV) function and pulmonary regurgitant fraction (PRF) in patients with repaired tetralogy of Fallot (TOF). METHODS: Thirty-three consecutive patients with repaired TOF underwent retrospective ECG-gated CCT and 3-Tesla CMR. RV and left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and ejection fraction (EF) were measured using CCT and CMR. PRF-CCT (%) was defined as (RVSV - LVSV)/RVSV. PRF-CMR (%) was measured by the phase-contrast method. Repeated measurements were performed to determine intra- and interobserver variability. RESULTS: CCT measurements, including PRF, correlated highly with the CMR reference (r = 0.71-0.96). CCT overestimated RVEDV (mean difference, 17.1 ± 2.9 ml), RVESV (12.9 ± 2.1 ml) and RVSV (4.2 ± 2.0 ml), and underestimated RVEF (-2.6 ± 1.0%) and PRF (-9.1 ± 2.0%) compared with CMR. The limits of agreement between CCT and CMR were in a good range for all measurements. The variability in CCT measurements was lower than those in CMR. The estimated effective radiation dose was 7.6 ± 2.6 mSv. CONCLUSIONS: 256-slice CCT can assess RV function and PRF with relatively low dose radiation exposure in patients with repaired TOF, but overestimates RV volume and underestimates PRF. KEY POINTS: 256-slice CT assessment of RV function is highly reproducible in repaired TOF. Pulmonary regurgitation can be evaluated by biventricular systolic volume difference. CT overestimates RV volume and underestimates pulmonary regurgitation, compared with MRI.

Long-term results of aortic valve replacement with mechanical prosthesis or carpentier-edwards perimount bioprosthesis in Japanese patients according to age.

BACKGROUND: The long-term results of aortic valve replacement (AVR; n=737) with bileaflet mechanical prosthesis (MP) or Carpentier-Edwards Perimount bioprostheses (BP) were evaluated in different age groups. METHODS AND RESULTS: Since 1981, a total of 737 prostheses (424 bileaflet MP vs. 313 BP) were implanted for AVR in 278 patients aged ≥70 years (79 MP vs. 199 BP), in 191 patients aged 60-69 years (128 MP vs. 63 BP) and in 268 patients aged <60 years (217 MP vs. 51 BP). Follow-up was completed for 6,523 patient-years in 98.5% of cases. Among the patients ≥70 years, both the actuarial survival rate (P=0.0434) and freedom from valve-related morbidity (P=0.0205) were better in the BP group than in the MP group without any difference in occurrence of structural valve deterioration in both groups. Among the patients aged 60-69, anticoagulant-related complications occurred less often in the BP group (P=0.0134) without any difference in long-term survival. Among the patients aged <60, long-term survival was significantly better in the MP group, whereas freedom from anticoagulant-related events did not differ. CONCLUSIONS: The use of BP is suitable in patients aged ≥70 years, while the use of bileaflet MP is preferable in patients aged <60 years. Among patients aged 60-69 years, the use of BP is acceptable because of the lower incidence of anticoagulant-related events and the equivalent long-term survival.

Staphylococcal endocarditis as the first manifestation of heritable protein S deficiency in childhood.

A 12-year-old Japanese girl developed infective endocarditis and central nervous system disease. The previously healthy girl showed altered consciousness and abnormal behaviors along with the classical signs of septic emboli. Staphylococcus aureus was isolated from peripheral blood, but not, the pleocytotic cerebrospinal fluid. Diagnostic imaging studies revealed a vegetative structure in the morphologically normal heart, and multiple thromboembolisms in the brain and spleen. Low plasma activity of protein S (12%) and thrombophilic family history allowed the genetic study, demonstrating that she carried a heterozygous mutation of PROS1 (exon 13; 1689C > T, p.R474C). Surgical intervention of the thrombotic fibrous organization and subsequent anticoagulant therapy successfully managed the disease. There are no reports of infective endocarditis in childhood occurring as the first presentation of heritable thrombophilia. Protein S deficiency might be a risk factor for the development or exacerbation of infective endocarditis in children having no pre-existing heart disease.

Left atrioventricular valve regurgitation after correction of atrioventricular septal defects.

PURPOSE: Progressive regurgitation of the left atrioventricular valve (AV) remains a major postoperative problem in the repair of atrioventricular septal defect (AVSD). The aim of this study was to review a case series of AVSD repair and reoperation for significant left AV valve regurgitation from this institution. METHODS: Forty-nine patients underwent initial repair of AVSD between February 1990 and March 2011, and 4 of them underwent reoperation for left AV valve regurgitation. Another 5 patients, who had received initial repair of AVSD before 1990, underwent reoperation of the left AV valve during the same period. This study retrospectively reviewed all cases of AVSD operation, and considered the causes of the left AV valve incompetence, and furthermore addressed how to manage most effectively this problem. RESULTS: There were 4 early deaths (8.6%) and no late deaths after initial repair of AVSD. No death was observed after reoperation of the left AV valve. Six patients underwent re-repair of left AV valve, but three patients needed prosthetic valve replacement. An additional cleft closure and commissuroplasty were performed on the 6 re-repaired cases. No significant AV valve regurgitation was observed among the 6 re-repaired cases. The actuarial survival was 92% at 10 and 15 years after AVSD repair. Freedom from reoperation of the left AV valve was 81% at 10 and 15 years for the patients who survived the initial repair during the study period. Freedom from significant left AV valve regurgitation was 46% at 10 years for all patients who survived the initial repair during the study period. A partial ring annuloplasty using Gore-Tex graft was applied to the last 2 cases, and this employment yielded encouraging results. CONCLUSION: The results were acceptable in terms of the mortality and reoperation free ratio, but the freedom from significant left AV valve regurgitation was disappointing. The outcome of reoperation for significant left AV valve regurgitation was also satisfactory. The application of Gore-Tex graft partial annuloplasty of the left AV valve appears to be a potentially useful and effective treatment modality.

Para-Hisian pacing for a pediatric patient with a congenitally corrected transposition of the great arteries (SLL).

We report a pediatric patient with a congenitally corrected transposition of the great arteries (ccTGA)(SLL) in which permanent para-Hisian pacing (PPHP) could improve dyssynchrony-associated systemic ventricular (SV) dysfunction resulting from permanent morphologic left ventricular pacing for complete atrioventricular block. Since, in patients with ccTGA(SLL), an elongated His-bundle runs medially toward the upper septum to the site of the fibrous continuity between the right-sided mitral valve and pulmonary artery, the His-bundle may easily be captured by a pacing lead, unlike in normal hearts. Thus, PPHP may be an effective therapeutic strategy for the treatment of dyssynchrony-associated SV dysfunction associated with ccTGA (SLL).

The somatic growth of autologous vessels in venous pathway after extracardiac total cavopulmonary connection.

OBJECTIVE: In a total cavopulmonary connection (TCPC) with an extracardiac conduit, the future development of stenosis in the venous pathway and distortion of the pulmonary artery according to the somatic growth of the patients is a major concern for surgeons and pediatricians. METHODS: Thirty patients who underwent extracardiac TCPC (EC-TCPC) between 1990 and 1998 and who had received at least two postoperative angiograms were enrolled in this study. To evaluate the postoperative change in the anastomosis, the cross-sectional area of the venous root at three different points was measured on the first and second angiograms after the EC-TCPC. Further, to evaluate the somatic growth of the autologous tissue, 12 patients who grew more than 10 cm in height after the completion of the EC-TCPC were selected among the 30 patients. We measured the length of three different parts, the diameter of the pulmonary artery, length of the artificial graft, and length between the branching point of the hepatic vein and artificial graft's anastomotic site to the inferior vena cava. RESULTS: The cross-sectional area at each point did not change during the follow-up, and the pressure gradient across the grafts has not been observed. The diameter of the pulmonary artery and length of the inferior vena cava above the hepatic vein insertion grew similarly during the follow-up. CONCLUSIONS: The mid-term clinical results after the completion of the EC-TCPC, including the somatic growth of the venous pathway, were satisfactory.

Midterm results of mitral valve repair with artificial chordae in children.

OBJECTIVE: We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children. METHODS: From April 1995 through September 2003, mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures was performed in 39 patients. In all patients the preoperative grade of mitral regurgitation was moderate or more because of prolapse of the anterior mitral leaflet. The mean age and body weight at the time of the operation were 4.7 +/- 5.3 years (range, 1 month to 17.8 years) and 14.4 +/- 12.2 kg (range, 3.9-54.4 kg), respectively. The number of expanded polytetrafluoroethylene sutures ranged from 1 to 3 (mean, 1.4). The mean follow-up period and body weight at the latest follow-up were 5.0 +/- 2.3 years (range, 1.1-8.5 years) and 25.7 +/- 16.4 kg (range, 6.9-73 kg), respectively. RESULTS: There were no operative or late deaths. Only one patient required mitral valve replacement, which occurred 17 days after repair. Two patients underwent redo mitral valve repair 2 and 5 years after initial repair, respectively. The actuarial freedom from reoperation at 5 and 8 years was 94.8% and 89.5%, respectively. At the latest follow-up, trivial or less mitral regurgitation was observed in 33 (84.6%) patients. CONCLUSIONS: Mitral valve repair with expanded polytetrafluoroethylene sutures in children demonstrated favorable midterm outcome. The procedure is safe and effective, with potential for patients' growth.

Comparison of hemodynamics between Norwood procedure and systemic-to-pulmonary artery shunt for single right ventricle patients.

OBJECTIVE: Despite that surgical outcomes of patients with hypoplastic left heart syndrome have improved, one of the problems remaining is the high interstage mortality after a stage I Norwood procedure. The purpose of this study was to determine the hemodynamic characteristics of hypoplastic left heart syndrome after a Norwood procedure. We examined the perioperative hemodynamic differences of the staged operation between the first stage of the Norwood procedure and systemic pulmonary shunt for single right ventricle patients. METHODS: Data from 39 patients who underwent a Norwood procedure (right ventricle to pulmonary artery conduit: 19, Blalock-Taussig shunt, 20) were analyzed. There were nine early and seven interstage deaths. Bidirectional cavopulmonary shunt was performed in 15 patients and the Fontan procedure in 9 (group H). We defined the control group as 26 patients who underwent the first stage of a systemic pulmonary shunt for a single ventricle. Bidirectional cavopulmonary shunt was performed in 14 patients and the Fontan procedure in 8 (group C). We compared the perioperative hemodynamics of the staged operation between the two groups. RESULTS: Cardiothoracic ratio and single ventricular diastolic dimension before bidirectional cavopulmonary shunt were acutely increased in group H (P=0.02, <0.001). There was no significant difference between the two different types of Norwood procedures. The pulmonary artery index for the right heart bypass operation was lower in group H than in group C (P<0.001). Oxygen saturation before bidirectional cavopulmonary shunt in group H decreased (P<0.001) and thus was lower than that in group C (P=0.003). Mortality and the postoperative clinical parameters of the right heart bypass operation were not different between the two groups. CONCLUSIONS: Patients with hypoplastic left heart syndrome showed hemodynamic instability of acutely increased cardiothoracic ratio, and single ventricular diastolic dimension despite decreased oxygen saturation interstage after stage I of a Norwood procedure. This suggests that this hemodynamic characteristics in hypoplastic left heart syndrome correlates with the higher mortality before second stage palliation than in found with single right ventricle patients.

More than 20-year experience of Bentall operation with mechanical prostheses for chronic aortic root aneurysm.

OBJECTIVES: Long-term results of Bentall operations with mechanical prostheses were analyzed and evaluated over 30 years. METHODS: Seventy-one patients aged 50.2 ± 1.8 years old underwent an elective Bentall operation from 1975 to 2013 for chronic aortic root aneurysm, while 129 patients aged 51.6 ± 1.3 underwent isolated AVR with a mechanical valve for pure aortic regurgitation. The follow-up was completed for a total of 2,336-patient-years in 99.5% of these patients. RESULTS: No significant differences were observed in the hospital mortality (2.8 and 0.78%), actuarial survival rate (43.3 ± 9.9 and 50.0 ± 9.2%), freedom from valve-related death (84.9 ± 6.8 and 68.1 ± 11%), and freedom from valve-related morbidity (43.7 ± 19 and 40.1 ± 15%) at 30 years between the two groups. No significant differences were observed in the valve-related events; however, a higher incidence of rupture of aortic aneurysm was observed in the Bentall group (P = 0.0005). CONCLUSIONS: Both our short- and long-term results of Bentall operation with mechanical prostheses were satisfactory at 30 years after the surgery and were comparable with those of simple AVR. However, to prevent rupture of the aortic aneurysm, special care should be taken after the primary Bentall operations.

Left ventricular performance of pulmonary atresia with intact ventricular septum after right heart bypass surgery.

OBJECTIVE: The left ventricular performance in patients with pulmonary atresia with intact ventricular septum who were Fontan candidates before and after the bidirectional Glenn procedure and a staged total cavopulmonary connection was compared with that in patients with tricuspid atresia. METHODS: Contractility (end-systolic elastance), afterload (effective arterial elastance), and ventricular efficiency (ventriculoarterial coupling, arterial elastance/end-systolic elastance ratio), and the ratio of stroke work and pressure-volume area were approximated on the basis of cardiac catheterization data before the bidirectional Glenn procedure, before and after staged total cavopulmonary connection, and approximately 1 year after the completion of total cavopulmonary connection in 20 patients with pulmonary atresia with intact ventricular septum and 21 patients with tricuspid atresia. RESULTS: The end-systolic elastance of the pulmonary atresia with intact ventricular septum group was significantly inferior to that of the tricuspid atresia group after bidirectional Glenn procedure and total cavopulmonary connection (1 year after total cavopulmonary connection 1.85 +/- 0.51 mm Hg . m 2 . mL -1 vs 2.84 +/- 0.96 mm Hg . m 2 . mL -1 , P < .01). The arterial elastance was not different between groups throughout the assessment period and tended to increase in a stepwise fashion after bidirectional Glenn procedure and total cavopulmonary connection. The arterial elastance/end-systolic elastance ratio and ratio of stroke work and pressure-volume area of the pulmonary atresia with intact ventricular septum group tended to worsen, whereas those of the tricuspid atresia group tended to improve. The difference reached statistical significance 1 year after total cavopulmonary connection (1.15 +/- 0.35 vs 0.82 +/- 0.23 and 64.2% +/- 6.7% vs 71.3% +/- 5.7%, respectively, P < .05 and P < .05, respectively). CONCLUSION: The contractility and ventricular efficiency of patients with pulmonary atresia with intact ventricular septum are inferior to those of patients with tricuspid atresia after bidirectional Glenn procedure and total cavopulmonary connection. A high-pressure residual right ventricle may impair the left ventricular performance of patients with pulmonary atresia with intact ventricular septum after bidirectional Glenn procedure and total cavopulmonary connection.

Midterm surgical results of total cavopulmonary connection: clinical advantages of the extracardiac conduit method.

OBJECTIVE: We evaluated the midterm surgical outcomes of intra-atrial lateral tunnel and extracardiac conduit total cavopulmonary connection to clarify the clinical superiority. METHODS: Patients (n = 167) underwent total cavopulmonary connection (88 with lateral tunnel and 79 with extracardiac conduit) from November 1991 to March 1999. Survival, incidence of reoperation and late complications, exercise tolerance, hemodynamic variables, and plasma concentration of natriuretic peptide type A were compared. In the lateral tunnel group, time-related change in lateral tunnel size was investigated for its relationship to postoperative arrhythmias. RESULTS: The 8-year survival was 93.2% in the lateral tunnel group and 94.9% in the extracardiac conduit group. Seven reoperations were performed in the lateral tunnel group but none in the extracardiac conduit group. Supraventricular arrhythmias developed in 14 patients (15.9%) in the lateral tunnel group and in 4 patients (5.1%) in the extracardiac conduit group (P =.003). Freedom from cardiac-related events was 72.5% in the lateral tunnel group and 89.8% in the extracardiac conduit group at 8 years (P =.0098). Hemodynamic variables and exercise tolerance were similar in both groups but plasma natriuretic peptide type A concentration, a parameter of atrial wall tension, was higher in the lateral tunnel group. In the lateral tunnel group, intra-atrial tunnel size increased by 19.4% during the 44.2-month interval and the percent increase in tunnel size was an independent predictor of supraventricular arrhythmias. CONCLUSIONS: The midterm survival, hemodynamic variables, and exercise tolerance were similar and satisfactory in both lateral tunnel and extracardiac conduit groups; however, the incidence of cardiac-related events was significantly less frequent in the extracardiac conduit group. In the lateral tunnel group, careful observation is required to monitor the relationship of the dilating tendency of the intra-atrial tunnel and the development of late complications.

Left atrial appendage aneurysm in a child.

We report a case of left atrial appendage aneurysm in a 1-year-old child. The patient was asymptomatic, and a mediastinal liquid mass that was confirmed to be an aneurysm of the left atrial appendage was incidentally revealed by transthoracic echocardiography. Aneurysmectomy was performed during cardioplegic arrest under the support of cardiopulmonary bypass. The postoperative course was uneventful.

Surgical results of double-orifice left atrioventricular valve associated with atrioventricular septal defects.

BACKGROUND: Double-orifice left atrioventricular valve (LAVV) is a rare but surgically important anomaly, which is regarded as a risk factor for surgical correction of atrioventricular septal defects (AVSDs). METHODS: Of 209 consecutive patients with AVSDs, double-orifice LAVV was identified in 19 patients (9.1%, including 7 infants). Preoperative LAVV function, surgical procedures and results, incidence of postoperative LAVV dysfunction and reoperations were reviewed and compared between patients with this valve malformation (group I, n = 19) and those without it (group II, n = 190). RESULTS: There were no operative or late deaths in group I. Preoperative LAVV function was similar in both groups. The cleft was totally closed in 77.2% of group II and 47.1% of group I (p < 0.01). In partial AVSDs, freedom from postoperative LAVV insufficiency was 77.0% in group II versus 30.5% in group I at 5 years (p = 0.009) and freedom from reoperation was 89.9% in group II versus 58.3% in group I at 5 years (p = 0.012); however, there was no difference in complete AVSDs. None of the infants in group I underwent total cleft closure and 4 of them showed more than moderate LAVV insufficiency postoperatively. CONCLUSIONS: Double-orifice LAVV is a significant predictor for postoperative LAVV incompetence and reoperation in partial AVSDs, but not in complete AVSDs. Surgical procedures for the cleft should be individualized with careful intraoperative evaluation of the structure and function of this abnormal valve, especially in partial AVSDs and infants.

The low resistance strategy for the perioperative management of the Norwood procedure.

BACKGROUND: Postoperative course of the Norwood procedure is fragile because of an unstable pulmonary to systemic blood flow ratio caused by fluctuation of systemic and pulmonary vascular resistance. METHODS: Twenty-seven patients with hypoplastic left heart syndrome who underwent the Norwood procedure from June 1998 to February 2002 were managed with the following low-resistance strategy. Intraoperative high-flow and low-resistance cardiopulmonary bypass was achieved with total avoidance of circulatory arrest and a large dose of chlorpromazine. In weaning from the bypass, pulmonary vascular resistance was maximally decreased by inspired oxygen fraction (100%), inhaled nitric oxide (20 ppm), and nitroglycerin (2 to 4 microg/kg/min). Then pulmonary blood flow was determined by adjusting the systemic to pulmonary shunt. Postoperatively, with continuous infusion of chlorpromazine and nitroglycerin as a systemic and pulmonary vasodilator, the inspired oxygen fraction and inhaled nitric oxide were tapered as the arterial oxygen saturation improved. RESULTS: In most patients, inhaled nitrous oxide and inspired oxygen fraction were weaned within 3 days. The postoperative course was stable with minimum changes in circulatory and respiratory status for the survivors. Patients were extubated on a median of 6 postoperative days. Early mortality was 11.1% (3 of 27), and none of the patients died of hemodynamic deterioration. CONCLUSIONS: The low resistance strategy is a simple and useful method for perioperative management of the Norwood procedure, minimizing fluctuation in both pulmonary and systemic vascular resistance and maintaining stable circulatory and respiratory status.

Total cavopulmonary connection with an extracardiac conduit: experience with 100 patients.

BACKGROUND: In the Fontan procedures total cavopulmonary connection with an extracardiac conduit is a concern. The potential benefits of an extracardiac conduit may be the avoidance of postoperative supraventricular arrhythmias over the long-term, hemodynamic benefits due to laminar flow, possibility of completion without anoxic arrest, and applicability to anomalous systemic or pulmonary venous return, or both anomalous systemic and pulmonary venous return. We demonstrate early to midterm results of total cavopulmonary connection with an extracardiac conduit. METHODS: Between March 1994 and February 2000, a total of 100 patients underwent total cavopulmonary connection with an extracardiac conduit. In 27 patients, who underwent a single stage total cavopulmonary connection operation, 7 were done without palliation. Seventy-three patients had undergone a bidirectional Glenn shunt before completion of the total cavopulmonary connection. We used an expanded polytetrafluoroethylene tube graft as the extracardiac conduit. RESULTS: Cardiopulmonary bypass time was 133.2+/-55.2 minutes. Myocardial ischemic time was 38.5+/-23.2 minutes in 40 patients who needed cardioplegic cardiac arrest for intracardiac procedures. Intraoperative fenestration was done in only 1 patient. There were no operative deaths. During follow-up of 37.3 months, there were 5 late deaths. When compared with the patients treated by the lateral tunnel technique in our institute, there was no significant difference in actuarial survival rate, but the event free rate of the extracardiac conduit group was significantly superior to the lateral tunnel group. CONCLUSIONS: Total cavopulmonary connection with the extracardiac conduit produced good results in short to midterm follow-up.

Uhl's anomaly complicated with critical ventricular arrhythmia in a 2-month-old infant.

We report a case of Uhl's anomaly in a 2-month-old infant who presented with critical ventricular arrhythmia. The patient underwent a successfully surgical repair by semitotal resection of the right ventricle free wall, tricuspid annuloplasty, and one and one-half ventricular repair.

Modified Ross procedure using a conduit with a synthetic valve.

OBJECTIVE: In the Ross procedure, a homograft conduit is commonly used in place of an autotransplanted pulmonary valve. Homograft availability may be a problem and has resulted in a search for alternatives. We performed a modified Ross procedure for right ventricular outflow tract reconstruction with a synthetic valved conduit as an alternative to homograft. Our early results of valvular and right ventricular function were evaluated in patients who used a conduit with a synthetic valve. METHODS: Subjects consisted of 11 patients, who ranged in age from 5 to 22 years (12.0+/-4.9), and whose body weight ranged from 15.1 to 52.5 (34.3+/-14.4) kg. Indications for surgery were aortic stenosis (n=3), aortic stenosis and regurgitation (n=4), and aortic regurgitation (n=4). Right ventricular outflow tract reconstruction was performed using a hand-fashioned valved conduit prepared by sewing a 0.1 mm thick polytetrafluoroethylene sheet onto the luminal cavity of the 20-28 mm conduit. A conduit made with polytetrafluoroethylene was used in 8 patients, and a Dacron graft was used in 3 patients. RESULTS: There was no in-hospital or late mortality and angiocardiography at discharge revealed that all artificial valves remained active. The mean right atrial pressure and right ventricular end-diastolic pressure were not statistically different from preoperative values. The latest echocardiography (mean interval, 12.6 months) revealed that a mean pressure gradient across the synthetic valve was 11.4+/-11.1 mmHg and none of the patients had moderate or severe regurgitation. CONCLUSIONS: We demonstrated that a modified Ross procedure for right ventricular outflow tract reconstruction using a conduit with an appropriate synthetic valve is particularly effective in older children.

The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms.

OBJECTIVES: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was developed to improve the overestimation of surgical risk associated with the original (additive and logistic) EuroSCOREs. The purpose of this study was to evaluate the significance of the EuroSCORE II by comparing its performance with that of the original EuroSCOREs in Japanese patients undergoing surgery on the thoracic aorta. METHODS: We have calculated the predicted mortalities according to the additive EuroSCORE, logistic EuroSCORE and EuroSCORE II algorithms in 461 patients who underwent surgery on the thoracic aorta during a period of 20 years (1993-2013). RESULTS: The actual in-hospital mortality rates in the low- (additive EuroSCORE of 3-6), moderate- (7-11) and high-risk (≥11) groups (followed by overall mortality) were 1.3, 6.2 and 14.4% (7.2% overall), respectively. Among the three different risk groups, the expected mortality rates were 5.5 ± 0.6, 9.1 ± 0.7 and 13.5 ± 0.2% (9.5 ± 0.1% overall) by the additive EuroSCORE algorithm, 5.3 ± 0.1, 16 ± 0.4 and 42.4 ± 1.3% (19.9 ± 0.7% overall) by the logistic EuroSCORE algorithm and 1.6 ± 0.1, 5.2 ± 0.2 and 18.5 ± 1.3% (7.4 ± 0.4% overall) by the EuroSCORE II algorithm, indicating poor prediction (P < 0.0001) of the mortality in the high-risk group, especially by the logistic EuroSCORE. The areas under the receiver operating characteristic curves of the additive EuroSCORE, logistic EuroSCORE and EuroSCORE II algorithms were 0.6937, 0.7169 and 0.7697, respectively. Thus, the mortality expected by the EuroSCORE II more closely matched the actual mortality in all three risk groups. In contrast, the mortality expected by the logistic EuroSCORE overestimated the risks in the moderate- (P = 0.0002) and high-risk (P < 0.0001) patient groups. CONCLUSIONS: Although all of the original EuroSCOREs and EuroSCORE II appreciably predicted the surgical mortality for thoracic aortic surgery in Japanese patients, the EuroSCORE II best predicted the mortalities in all risk groups.

Single-institution, 22-year follow-up of 786 CarboMedics mechanical valves used for both primary surgery and reoperation.

OBJECTIVES: The long-term (>20 years) results for CarboMedics mechanical valves (Sorin Group, Milano, Italy) used for both primary surgery and reoperation have never been reported or compared. METHODS: Since 1990, a total of 787 CarboMedics valves have been implanted in 694 patients for aortic valve replacement, including 19 redo cases in 220 patients; for mitral valve replacement, including 108 redo cases in 381 patents; and for double (aortic and mitral) valve replacement, including 29 redo cases in 93 patients. The follow-up data were complete for 7201 patient-years in 99.3% of the patients. RESULTS: The hospital mortality rate of the aortic, mitral, and double valve replacement groups was 0.9%, 3.7%, and 4.3%, respectively. The corresponding freedom from valve-related morbidity rates in each group were 66.0%, 40.6%, and 48.0% at 20 years (P = .0206). A higher incidence of paravalvular leakage was observed in the mitral and double valve replacement groups than in the aortic valve replacement group (P = .0019). Of the cases of mitral paravalvular leakage after single mitral valve replacement, 97% occurred after redo single mitral valve replacement; 73% of the cases of mitral paravalvular leakage after double valve replacement occurred after redo double valve replacement. CONCLUSIONS: CarboMedics mechanical valves used for both primary surgery and reoperation for aortic, mitral, and double valve replacement can achieve satisfactory early and long-term results, even 20 years after surgery. Care should be taken, however, to prevent paravalvular leakage in the mitral position during reoperation.