Surgical Relief of Left Ventricular Outflow Tract Obstruction in Adults With Congenital Aortic Stenosis and Associated Aortic Annulus Hypoplasia and/or Subaortic Obstruction.

BACKGROUND: In children and adolescents, a Ross/Konno operation is commonly done to both enlarge the aortic root and provide a competent aortic valve with relief of left ventricular outflow tract obstruction (LVOTO). Optimum management is not so straightforward in adults. METHODS: Between 1995 and 2014, 16 patients of mean age 39.4 years (18-57 years) with hypoplastic aortic annulus (AA) measuring 20mm and less, and mean aortic valve/LVOT gradient of 61mmHg (30-70mmHg) presented for surgery. RESULTS: Eight patients with mean LVOT/AA diameter 19.6mm (18-20mm) underwent an "inclusion-cylinder" type Ross procedure (RP). Eight patients with more severe LVOT/AA obstruction, with mean diameter of 17.4mm (16-19mm) underwent mechanical aortic valve replacement (AVR) with standard Konno-type aortoventriculoplasty. There was zero early and late mortality; with mean follow-up of 11.6 years (3-21 years) in the Ross group and 6 years (2-10 years) in the Konno-AVR group. One patient in the Konno-AVR group had reoperation after 2 years for RVOT obstruction. The postoperative echocardiograms of these patients at last follow-up show residual mean gradient across LVOT/AA of 4.4mmHg (2-6mmHg) after RP, and 11.9mmHg (8-17mmHg) after Konno-AVR. CONCLUSIONS: In adults, the "inclusion-cylinder" Ross-procedure is a good alternative for mild to moderate aortic root hypoplasia. However, for cases with severe LVOT obstruction, a Ross-Konno is not possible with the same method of autologous support used in a non-Konno RP, and this could be expected to have an impact on late durability and the need for further intervention, in a group that has already undergone multiple procedures in childhood. Both methods of RP and Konno-AVR lead to excellent early and late results.

Adult Scimitar Syndrome: A Surgical Approach.

BACKGROUND: Scimitar syndrome is a rare congenital condition characterised by partial or total anomalous pulmonary venous drainage of the right lung. We present an adult case of Scimitar syndrome that was managed with an intra-atrial baffle repair. CASE DESCRIPTION: The patient was a 52 year-old lady who had symptoms of increasing dyspnoea and fatigue with a long-term history of poor exercise tolerance. Several investigations such as a chest X-ray, echocardiogram and coronary angiogram confirmed the diagnosis of Scimitar syndrome with significant left to right shunt. The operation proceeded under cardiopulmonary bypass with a short period of hypothermic circulatory arrest. Postoperative recovery was uneventful and a follow-up echocardiogram confirmed the correction of the condition. DISCUSSION: There are many alternative and novel surgical techniques developed which include the reimplantation of the scimitar vein into the right atrium with the creation of a baffle through an ASD, direct anastomosis of the divided scimitar vein to the left atrium and many others. However, none of them have outcomes which are proven to be better than the technique we chose. CONCLUSION: We utilised a well-recognised technique for a patient that had indications for surgical repair and this resulted in a good prognosis.

Long term follow-up after aortic valve replacement (Ross procedure): echocardiographic determinants of ventricular recovery.

AIMS AND METHODS: This prospective cohort study aimed to assess LV recovery post aortic valve replacement, stratified according to pre-operative valve lesion (aortic stenosis (AS), mixed disease (AS/AR) or aortic regurgitation (AR)), as well as define predictors of persistent LV dilatation post operation. We prospectively followed all patients post Ross procedure performed between 1992 and 2009 by a single surgeon. Echocardiography was performed pre-operatively, at approximately one year post operation then second yearly thereafter. RESULTS: 265 patients were followed for a mean of 6.4 years (range 1-14 years, total 1702 patient-years). Seventy percent were male and mean age was 38.8 ± 12.6 years. The indication for surgery was AS in 44.5% (118), AS/AR in 23.4% (62), and AR in 32.1% (85). Overall mortality was 1.8% and 80% of deaths were non-cardiac. Morbidity was low and the need for pacing was less than 1%. Ninety-nine percent of patients were NYHA class 1 at one year follow up. The indexed LV end diastolic diameter (LVEDDi) decreased significantly post-operation in the AR (3.34 ± 0.39-2.66 ± 0.32 cm/m(2), p<0.001) and mixed (2.85 ± 0.38-2.65 ± 0.30 cm/m(2), p = 0.01) groups, whilst the indexed systolic LV dimension decreased significantly post-operation in the AR group (2.26 ± 0.34-1.87 ± 0.27, p<0.001). At five years post operation, independent predictors for a larger LVEDDi were female gender, a pre-operative LVEDDi >3.0 cm/m(2) and the presence of mild aortic regurgitation at one year post-operation. Pre-operative valve lesion was not a predictor. The only independent predictor of a lesser reduction of LVEDDi at five year follow-up was mild post-operative AR, whilst predictors of a lesser reduction in indexed left ventricular end systolic diameter (LVESDi) at five year follow-up included mild post-operative AR and a larger pre-operative LVEDDi. LV wall thickness decreased significantly the AS and AS/AR groups within one year post operation, whilst the neo-aortic root size remained stable throughout follow-up. CONCLUSIONS: Recovery of LV size post Ross procedure is influenced predominantly by the pre-operative LV size, in particular the indexed LV end diastolic diameter. The pre-operative valve lesion was not predictive of larger ventricular dimensions post AVR, but independent predictors of a larger ventricular dimensions post operation included female gender, enlarged pre-operative LVEDDi and the presence of mild AR in the first post operative year. Those with mild post-operative AR did not have progressive LV enlargement, thus the clinical significance of this finding remains unclear.

Cardio-cutaneous fistulae-beware the late sternal wound lesion.

Cardio-cutaneous fistula is a very rare complication of cardiac surgery, and the optimal management strategy is unclear. We present a case of a right ventricle-to-pulmonary artery conduit (RV-PA) forming a cutaneous fistulate that was successfully surgically repaired. A 43-year-old male presented for an elective RV-PA conduit replacement with a cutaneous skin lesion and associated sub-sternal collection. The patient underwent redo-sternotomy for the previous surgical replacement RV-PA conduit, of pulmonary atresia, ventricular septal defect, and ligation of main aorto-pulmonary collateral arteries in childhood, with the subsequent upgrade of the RV-PA conduit using pulmonary homograft. Upon entry into the thoracic cavity, it was clear that there was a direct fistula formed from the RV-PA conduit that was responsible for the skin lesion and hence a direct communication to the PA. We discuss the surgical method and surrounding discussions regarding Cardio-cutaneous fistula in a successful surgical repair when the pathology is difficult to truly identify preoperatively.

Perceval valve intermediate outcomes: a systematic review and meta-analysis at 5-year follow-up.

OBJECTIVES: New technologies for the treatment of Aortic Stenosis are evolving to minimize risk and treat an increasingly comorbid population. The Sutureless Perceval Valve is one such alternative. Whilst short-term data is promising, limited mid-term outcomes exist, until now. This is the first systematic review and meta-analysis to evaluate mid-term outcomes in the Perceval Valve in isolation. METHODS: A systematic literature review of 5 databases was performed. Articles included evaluated echocardiographic and mortality outcomes beyond 5 years in patients who had undergone Perceval Valve AVR. Two reviewers extracted and reviewed the articles. Weighted estimates were performed for all post-operative and mid-term data. Aggregated Kaplan Meier curves were reconstructed from digitised images to evaluate long-term survival. RESULTS: Seven observational studies were identified, with a total number of 3196 patients analysed. 30-day mortality was 2.5%. Aggregated survival at 1, 2, 3, 4 and 5 years was 93.4%, 89.4%, 84.9%, 82% and 79.5% respectively. Permanent pacemaker implantation (7.9%), severe paravalvular leak (1.6%), structural valve deterioration (1.5%), stroke (4.4%), endocarditis (1.6%) and valve explant (2.3%) were acceptable at up to mid-term follow up. Haemodynamics were also acceptable at up mid-term with mean-valve gradient (range 9-13.6 mmHg), peak-valve gradient (17.8-22.3 mmHg) and effective orifice area (1.5-1.8 cm2) across all valve sizes. Cardiopulmonary bypass (78 min) and Aortic cross clamp times (52 min) were also favourable. CONCLUSION: To our knowledge, this represents the first meta-analysis to date evaluating mid-term outcomes in the Perceval Valve in isolation and demonstrates good 5-year mortality, haemodynamic and morbidity outcomes. KEY QUESTION: What are the mid-term outcomes at up to 5 years follow up in Perceval Valve Aortic Valve Replacement? KEY FINDINGS: Perceval Valve AVR achieves 80% freedom from mortality at 5 years with low valve gradients and minimal morbidity. KEY OUTCOMES: Perceval Valve Aortic Valve Replacement has acceptable mid-term mortality, durability and haemodynamic outcomes.

Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years.

OBJECTIVE: There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. METHODS: A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). RESULTS: There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). CONCLUSIONS: Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection.

The Outcomes of the Inclusion Ross in Select Patients Aged ≥ 50 Years, Compared to a Younger Cohort.

BACKGROUND: The Ross procedure is rarely considered in older patients. The aim of this study is to compare the perioperative and long-term outcomes of patients aged 50 years and older with younger patients after the Ross procedure. METHODS: Between 1992 and 2018, 455 patients underwent the Ross procedure utilizing the inclusion technique. Patients with redo surgery, nonaortic procedures, and unsupported root replacement were excluded. The remaining were matched for native valve morphology, valve lesion, and annular manipulation and yielded 96 matched pairs. Preoperative and operative characteristics, perioperative outcomes, survival rates, valve-related adverse events, and valve hemodynamics were assessed. RESULTS: There was no in-hospital mortality. The median follow-up was 11 years for both cohorts. Overall survival at 15 years was similar: 99% (95% confidence interval [CI] 89.8%-99.8%) for patients aged ≥50 years and 98% (95% CI 89.3-99.7%) for younger patients. Patients 50 years and older had a notable freedom from Ross-related reintervention at 15 years: 94% (95% CI 84.8%-97.7%) vs 90% (95% CI 80.2%-95.6%) in younger patients. The mixed model analysis revealed that being 50 years and older was not significantly associated with higher autograft gradient or regurgitation. Interestingly, being 50 years and older correlated with decreased allograft regurgitation and stenosis. CONCLUSIONS: Older patients undergoing the Ross procedure had comparable outcomes to younger patients. Patients aged 50 years and over who are high-functioning with minimal comorbidities should be considered for the Ross procedure.

Systematic review and meta-analysis of long-term outcomes in adults undergoing the Ross procedure.

BACKGROUND: The management of aortic valve disease is becoming increasingly complicated with the evolution of treatment options available to cardiac surgeons and cardiologist. Pulmonary autograft replacement of the aortic valve, commonly known as the Ross procedure, involves excision of the pulmonary valve from the right ventricular outflow tract and implantation in the aortic position. This systematic review aims to evaluate the long-term outcomes, following the Ross procedure. METHODS: An electronic search strategy queried five online medical referencing databases from inception to 21 August 2020. All studies detailing the long-term outcomes of adults undergoing the Ross procedure were included. A random effects model was used to determine pooled continuous data. Enhanced secondary survival analysis was performed on reconstructed individual patient data. RESULTS: Twenty-three studies were included in the qualitative synthesis, including a total of 6,278 patients with a mean follow-up duration of 6.0±2.8 years. Long-term survival was 95.6%, 91.8%, 86.3% and 80.5% at five, ten, fifteen and twenty years, respectively. Freedom from autograft reoperation was 95.7%, 91.2%, 84.9% and 76.1% at five, ten, fifteen and twenty years, respectively. CONCLUSIONS: When performed in experienced centres and for appropriately selected patients, the Ross procedure represents a durable replacement of the aortic valve with excellent long-term survival.

Long-term outcomes of right ventricle-to-pulmonary artery conduit insertion in adults with congenital heart disease: survival analysis by National Death Index.

OBJECTIVES: The aim of this study was to investigate the long-term outcomes following right ventricle-to-pulmonary artery (RV-to-PA) conduit insertion of Medtronic Freestyle® porcine valve (MFV) or pulmonary allograft valve (PAV) in adult patients with congenital heart disease. METHODS: Retrospective medical record review of consecutive RV-to-PA conduit insertion, using either PAV or MFV from 1991 to 2017. Perioperative data and clinic reports were collected. Cause and date of death were obtained from the Australian National Death Index to obtain survival function. RESULTS: In total, 232 patients (median age 31.5 years, interquartile range 25-41 years) underwent RV-to-PA conduit insertion (PAV = 84 and MFV = 148) and were eligible for inclusion [63.8% tetralogy of Fallot (TOF); 11.6% congenital pulmonary stenosis (PS); 24.6% other diagnoses]. The overall median follow-up time was 9.1 years (interquartile range 5.3-12.6 years). The mean gradient was 11.8 ± 7.1 mmHg in PAV and 16.6 ± 9.6 mmHg in MFV patients. Congenital PS patients had 100% survival at 20 years, TOF patients at 5, 10, 15 and 20 years had 99%, 97%, 96% and 96% survival, respectively. Patients with other primary diagnoses at 5, 10, 15 and 20 years had 93%, 91%, 87% and 87% respectively. Freedom from reintervention did not differ significantly at 5 and 10 years between pulmonary allograft (98.6%, 98.6%) and Freestyle® porcine bioprosthesis (97.5%, 93%). CONCLUSIONS: Both valves perform equally well with regard to patients' freedom from reoperation, although transvalvular gradient was higher for Freestyle® patients. Congenital PS and TOF patients had better survival than patients with other primary diagnoses.

Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure.

Importance: There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. Objective: To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. Design, Setting, and Participants: A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Main Outcomes and Measures: Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. Results: During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Conclusions and Relevance: Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.

Pulmonary Valve Function Late After Ross Procedure in 443 Adult Patients.

BACKGROUND: Limited data exist on long-term pulmonary valve function after the Ross procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross procedure. METHODS: All 443 patients who underwent a Ross procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study's outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. RESULTS: Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n = 4), severe pulmonary stenosis (n = 4), or severe pulmonary regurgitation (n = 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. CONCLUSIONS: The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.

Re-implantation of an anomalous right coronary artery arising from the left coronary sinus and coursing between the great arteries.

The patient with a coronary artery anomaly remains a treatment dilemma. We present a 62-year-old woman who underwent re-implantation of her anomalous right coronary artery (ARCA) from the left coronary sinus and describe our techniques according to potential anatomic variations of ARCA. The ARCA from the left coronary sinus is increasingly being recognized as a cause of angina, acute myocardial infarction, syncope, and sudden death. We describe a case that was treated by direct coronary artery re-implantation into the right coronary sinus and suggest that this technique be the first considered when planning surgical correction.

Comparison of reduction ascending aortoplasty and ascending aortic replacement for bicuspid valve related aortopathy in young adult patients undergoing aortic valve replacement--long-term follow-up.

BACKGROUND: We aimed to determine the long-term outcomes of reduction ascending aortoplasty and ascending aortic replacement. A secondary aim was to document our experience with the long-term "growth" of woven Dacron grafts. METHODS: Over a nine-year period (1992-2001), 154 patients underwent aortic valve replacement using the Ross procedure for bicuspid aortic valve disease (BAV). Twenty-five also underwent reduction ascending aortoplasty (RAA), and 16 underwent ascending aorta replacement (AAR), using a Dacron graft. Preoperative diameters were measured prospectively. Patients had a follow-up CT chest between January and December 2007 to measure the mid-ascending aortic diameter. RESULTS: Mean age at operation was 31.8+/-13.5 years (RAA), and 40.0+/-8.6 years (AAR) (p=NS). Mean follow-up was 101 months (+/-43.0, 95% CI) in the RAA group, and 107 months (+/-29.0, 95% CI) in the AAR group. Mean pre-operative diameter in the RAA group was 41.5mm (+/-11.8, 95% CI) and in the AAR group 46.2mm (+/-7.8, 95% CI) (p=0.004). Mean follow-up diameter in the RAA group was 35.4mm (+/-4.6, 95% CI) and in the AAR group 31.9 mm (+/-6.8, 95% CI) (p=0.003). Growth of the woven Dacron prosthesis was 23.4% (+/-26.8, 95% CI) in the 107-month follow-up period. There was no early or late mortality and no further aortic surgery during follow-up. CONCLUSIONS: We have demonstrated satisfactory long-term outcomes with both RAA and AAR in patients with BAV related aortopathy who have undergone the Ross procedure. We have noted a greater diameter reduction with AAR when compared with RAA over nine years. In this series, "growth" of the woven Dacron grafts occurred, however individual measures did not correlate with other studies.

Clinical characteristics and early mortality of patients undergoing coronary artery bypass grafting compared to percutaneous coronary intervention: insights from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and the Melbourne Interventional Group (MIG) Registries.

OBJECTIVES: Controversy continues over the optimal revascularisation strategy for patients with multi-vessel coronary artery disease. Clinical characteristics, risk profile, and mortality of patients undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are thought to differ but there are limited contemporary comparative data. METHODS: We compared clinical characteristics, in-hospital and 30-day mortality of 3841 consecutive patients undergoing isolated CABG and 4417 undergoing PCI. Independent predictors of 30-day mortality were determined by multiple logistic regression analysis. RESULTS: CABG patients were older (p<0.01). The CABG group had a higher incidence of diabetes, heart failure, left ventricular ejection fraction <45%, multi-vessel coronary artery, peripheral vascular and cerebro-vascular disease (all p<0.01). Patients undergoing PCI had a higher incidence of recent myocardial infarction (MI) as the indication for revascularisation (p<0.01). In-hospital and 30-day mortality was 1.8% and 1.7% in the CABG group, and 1.4% and 1.8% in the PCI group, respectively. Independent predictors of 30-day mortality after CABG were age (odds ratio 1.1 per year, 95% confidence interval 1.0-1.1), cardiogenic shock (4.10, 1.7-10.5) and previous CABG (6.6, 2.4-17.7). Predictors after PCI were diabetes (2.7, 1.4-5.1), female gender (3.0, 1.6-5.5), renal failure (3.2, 1.2-8.0), MI<24h (4.0, 2.2-7.6), left main intervention (5.4, 1.0-27.7), heart failure (6.0, 2.6-14.0) and cardiogenic shock (11.7, 5.4-25.2). CONCLUSIONS: In contemporary clinical practice, CABG is preferred in patients with multi-vessel coronary and associated non-coronary vascular disease, while PCI is the dominant strategy for acute MI. Despite this, in-hospital and 30-day mortality rates were similar. Predictors of early mortality after CABG differ to those of PCI.

Pulmonary Allograft Versus Medtronic Freestyle Valve in Surgical Pulmonary Valve Replacement for Adults Following Correction of Tetralogy of Fallot or Its Variants.

BACKGROUND: Following corrective surgery in infancy/childhood for tetralogy of Fallot (TOF) or its variants, patients may eventually require pulmonary valve replacement (PVR). Debate remains over which valve is best. We compared outcomes of the Medtronic Freestyle valve with that of the pulmonary allograft valve following PVR. METHODS: A retrospective study was undertaken from a single surgical practice of adult patients undergoing elective PVR between April 1993 and March 2017. The choice of valve was at the surgeon's discretion. There was a trend toward the almost exclusive use of the more readily available Medtronic Freestyle valve since 2008. RESULTS: One hundred fifty consecutive patients undergoing 152 elective PVRs were reviewed. Their mean age was 33.8 years. Ninety-four patients had a Medtronic Freestyle valve, while 58 had a pulmonary allograft valve. There were no operative or 30-day mortality. The freedom from reintervention at 5 and 10 years was 98% and 98% for the pulmonary allograft and 99% and 89% for the Medtronic Freestyle. There was no significant difference in the rate of reintervention, though this was colored by higher pulmonary gradients across the Medtronic Freestyle despite its shorter follow-up. CONCLUSIONS: Pulmonary valve replacement following previous surgical repair of TOF or its variants was found to be safe with no significant differences in mortality or reintervention between either valve. Although the Medtronic Freestyle valve had a greater tendency toward pulmonary stenosis, additional follow-up is needed to further document its long-term outcomes.

Acute presentation in adult in Bland-White-Garland syndrome: double-conduit, two-coronary repair.

Adult presentation with myocardial infarction in anomalous origin of the left main coronary artery from the pulmonary artery is rare. We describe the different coronary flow physiology in the adult form. A double-conduit repair with a separate feeder vessel to each limb of the left coronary circulation may be necessary to balance the myocardial demand and supply in large systemic collateral coronary beds. The report describes the use of the left internal mammary and radial artery for repair.

Human leukocyte antigen mismatch and other factors affecting cryopreserved allograft valve function.

The causes of cryopreserved allograft heart valve degeneration are poorly understood. We investigated HLA mismatch and other factors implicated in allograft valve degeneration. For this study we recruited 110 adult recipients of allograft heart valves who underwent surgery between June 1998 and March 2003 in the state of Victoria, Australia. Recipients and donors were HLA typed using serological and molecular methods. Valve function at most recent echocardiographic follow-up was examined for an association with the following variables using univariate and multivariate methods: HLA-A,-B, and -DR donor-recipient mismatch; HLA class I mismatch; total HLA mismatch; valve ischemic time; recipient age; donor age; ABO blood group donor-recipient match; and allograft size. Mean recipient age was 45 years (18-75 years), 75% were men. Seventy-four pulmonary (62 Ross procedure) and 36 aortic allografts were examined. Median valve ischemic time was 31 hours, range 20-48 hours. Echocardiographic follow-up was complete at a mean of 41 (+/-18) months, range 6-85 months. At univariate analysis longer ischemic time and younger recipient age were associated with valve dysfunction. HLA-A, -B, or DR mismatch, HLA class I mismatch, total HLA mismatch, donor age, ABO mismatch, and allograft size were not associated with valve dysfunction. Only younger recipient age remained significant at multivariate analysis. In conclusion, longer ischemic times and younger patient age predicted valve dysfunction at a mean of 3 years follow-up. Recipient age remained the strongest predictor of valve dysfunction. These results indicate that allograft ischemic times should be minimized.