Long-term clinical outcomes after aortic valve replacement using cryopreserved aortic allograft.

BACKGROUND: Although the frequency of biological valve use in treating aortic valve disease is increasing, the critical limiting factor, "structural deterioration," remains unresolved. Analysis of long-term outcomes after implantation of cryopreserved aortic allografts will yield further information related to the durability of the aortic allograft, possibly suggesting mechanisms underlying or strategies to prevent or treat the structural deterioration of biological valve substitutes. METHODS: A total of 840 cryopreserved aortic allografts implanted in the last 35 years were reviewed with clinical follow-up completed in 99% of the consecutive series. By June 2010, 285 implanted allografts had been surgically explanted, 288 patients died before allograft removal, and 267 patients are under continued follow-up. RESULTS: Cryopreserved aortic allografts were durable for more than 15 years in the middle-aged and older patient population. The estimated median time until structural deterioration was 20 years post-implantation, and 2 allografts have been functioning well for more than 30 years. Structural deterioration was independently related to the young age of the recipient, elderly age of the donor, severe obesity in the recipient, history of blood transfusion in the recipient, and full-root implantation technique. Infection of the implanted allograft necessitating reintervention rarely occurred. Reintervention for the allograft demonstrated 2% in-hospital mortality. CONCLUSIONS: Cryopreserved aortic allografts were durable for more than 15 years. Structural deterioration of aortic allografts was related to multiple factors. The age of the recipient and the donor, obesity and blood transfusion history of the recipient, and implantation technique were identified as the most important factors contributing to allograft failure.

Fistula between subclavian arterial graft and oesophagus.

This is the first reported case of an oesophageal fistula arising from a subclavian arterial graft. A 28 year-old woman presented with massive haematemesis in severe haemorrhagic shock, three months after surgery to detach and relocate an aberrant right subclavian artery. Acutely, she was haemodynamically unstable and required transfusion of 45 units of blood. The fistula was identified with angiography (via the right brachial artery) after endoscopic and open visualisation were unsuccessful because of the torrential haemorrhage. The patient was stabilised and the fistula was managed with an endovascular covered stent. She had further surgery subsequently to remove the infected graft and to salvage the right arm.

Cardiac myxoma with oncocytic change--cardiac oncocytoma?

We report the case of an incidental cardiac myxoma that was remarkable for the presence of extensive oncocytic change, a feature that has not be reported previously. The oncocytes most likely represent part of a spectrum of degenerative changes present in the tumor, but the possibility that they are neoplastic is also discussed.

Clinical informatics: a workforce priority for 21st century healthcare.

This paper identifies the contribution of health and clinical informatics in the support of healthcare in the 21st century. Although little is known about the health and clinical informatics workforce, there is widespread recognition that the health informatics workforce will require significant expansion to support national eHealth work agendas. Workforce issues including discipline definition and self-identification, formal professionalisation, weaknesses in training and education, multidisciplinarity and interprofessional tensions, career structure, managerial support, and financial allocation play a critical role in facilitating or hindering the development of a workforce that is capable of realising the benefits to be gained from eHealth in general and clinical informatics in particular. As well as the national coordination of higher level policies, local support of training and allocation of sufficient position hours in appropriately defined roles by executive and clinical managers is essential to develop the health and clinical informatics workforce and achieve the anticipated results from evolving eHealth initiatives.

Partial replacement of tricuspid valve using cryopreserved homograft.

BACKGROUND: The optimal choice of prosthesis for tricuspid valve (TV) replacement is yet to be determined. Partial replacement of the TV using a homograft atrioventricular valve might offer resistance to infection, good durability, and excellent functionality, in addition to avoiding prosthesis-related morbidity. METHODS: We present 14 patients who underwent replacement of the TV using a homograft between 1997 and 2008. The mean age at operation was 32 years, including 5 patients younger than the age of 10. All patients preoperatively showed severe TV regurgitation as a result of active infective endocarditis in 5 patients, Ebstein anomaly in 4 patients, other cardiac anomalies in 4 patients, and rheumatic valvular disease in 1 patient. The TV homograft was used in 13 patients, and mitral homograft was used in 1 patient. Eleven patients had replacement of one leaflet only, whereas 3 patients required replacement of two leaflets. Concomitant cardiac procedures were performed in 7 patients. RESULTS: No mortalities occurred during the average postoperative follow-up of 61 months (range, 12 to 126 months). Reoperation for TV regurgitation after TV repair with homograft was performed in 3 patients. The remaining 11 patients had minimal symptoms without reintervention for TV regurgitation. CONCLUSIONS: Partial replacement of the TV using a homograft provided good hospital and mid-term outcomes. This strategy might be useful in active infective endocarditis and congenital TV disease.

Determinants of in-hospital and long-term surgical outcomes after repair of postinfarction ventricular septal rupture.

OBJECTIVES: Surgical repair of post-myocardial infarction ventricular septal rupture is challenging with reported early mortality being substantial. In addition, congestive cardiac failure and ventricular tachyarrhythmia frequently occur long term after the operation, although frequency and predictive factors of these events have been poorly identified. METHODS: A consecutive series of 68 patients who underwent repair of postinfarction ventricular septal rupture by 14 surgeons between 1988 and 2007 was studied. Fifty-eight (85%) patients underwent repair in an urgent setting (<48 hours after diagnosis). Coronary artery bypass grafting was concomitantly performed in 48 (71%) patients. Mean follow-up period was 9.2 +/- 4.9 years. RESULTS: Thirty-day mortality was 35%, with previous myocardial infarction, previous cardiac surgery, preoperative left ventricular ejection fraction less than 40%, and urgent surgery being independent risk factors. Actuarial survival of 30-day survivors was 88% at 5 years, 73% at 10 years, and 51% at 15 years. Actuarial freedom from congestive cardiac failure and ventricular tachyarrhythmia was 70% and 85% at 5 years, 54% and 71% at 10 years, and 28% and 61% at 15 years, respectively. Independent predictors for congestive cardiac failure included hypertension, posterior septal rupture, residual interventricular communication, and preoperative left ventricular ejection fraction less than 40%, whereas concomitant ventricular aneurysmectomy and preoperative occlusion of the left anterior descending artery were independent predictors of ventricular tachyarrhythmia. CONCLUSIONS: Long-term outcomes after surgical repair of postinfarction ventricular septal rupture was favorable, despite infrequent exposure by individual surgeons to the pathologic features, indicating that an aggressive surgical approach is warranted. Predictors of congestive cardiac failure and ventricular arrhythmia long term varied.

Perioperative predictors of developmental outcome following cardiac surgery in infancy.

At 1 year we assessed the neurodevelopmental outcomes in infants undergoing cardiac surgery, seeking to explore the predictive value of perioperative markers of cerebral injury. We prospectively enrolled 47 neurodevelopmentally normal infants prior to planned cardiac surgery. Postoperative monitoring consisted of 10-channel video synchronised, continuous electroencephalography from 6 to 30 h, Doppler assessment of cerebral blood flow in the anterior cerebral artery at 1, 2, 3 and 5 h, and measurement of serum S-100B at 0 and 24 h. Neurodevelopmental assessments were performed using the second edition of the Bayley Scale of Infant Development. Follow-up at 1 year was available on 35 infants. The mean age of these patients at surgery had been 57 +/- 15 days. We observed clinical seizures in 1 patient, with 3 other patients having electroencephalographic abnormalities. At follow-up of 1 year, neurodevelopmental scores were lower than preoperative scores, with mean mental scores changing from 103 +/- 5 to 94 +/- 13 (p = 0.001), and mean motor scores changing from 99 +/- 8 to 89 +/- 20 (p = 0.004). No association was found between electroencephalographic abnormalities, reduced cerebral blood flow, or elevation of serum S-100B levels and impaired neurodevelopmental outcome at 1 year. Infants with electroencephalographic abnormalities had elevation of the levels of S-100B in the serum (p = 0.02). At 1 year of follow-up, infants undergoing cardiac surgery demonstrated a reduction in the scores achieved using the second edition of the Bayley Scale of Infant Development. They require ongoing assessment of their progress. Electroencephalographic abnormalities, cerebral blood flow, or levels of S-100B in the serum were not useful perioperative markers for predicting a poor neurodevelopmental outcome in the clinical setting.

Formation of pannus on prosthetic valves in a child with pseudoxanthoma elasticum.

A child with pseudoxanthoma elasticum had mitral valvar prolapse with severe regurgitation necessitating replacement with a prosthetic valve. Extensive formation of pannus caused obstruction of two mechanical valves, one after twenty months and the second after three years. Histology of the pannus was similar to the endocardial lesions that are considered unique to pseudoxanthoma elasticum.

Multiple valvar replacements for hypereosinophilic syndrome.

A boy with familial eosinophilia had the hypereosinophilic syndrome, with involvement of mitral and tricuspid valves. Between the ages of 11 and 20 years, he underwent eight surgical procedures on his atrioventricular valves. The pathology included recurrent thrombotic vegetative masses related to hypereosinophilia. Initial repair of the mitral valve was shortlived, but recurrent repairs of the tricuspid valve were helpful. Mechanical prostheses inserted in the mitral position thrombosed despite anticoagulant therapy, and bioprosthetic valves deteriorated with thrombus, fibrosis, or tearing. The hypereosinophilic syndrome is unusual in children, and produces additional problems with valvar surgery.