The first successful repair of postinfarction ventricular septal defect: influence of good fortune, team work, and an inquisitive mind.

Research in our institution identified the first case in which cardiopulmonary bypass was utilized. By happenstance, it turned out to be the presumed first repair of postinfarction ventricular septal defect. The circumstances of this interesting case are presented and discussed in the context of our surgical heritage.

Eight-year results of aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis.

BACKGROUND: Stentless porcine aortic valves offer several advantages over traditional valves. Among these are superior hemodynamics, laminar flow patterns, lack of need for anticoagulation, and perhaps improved durability. METHODS: One hundred four patients were operated on from September 17, 1992, to October 31, 1997, as part of a multicenter worldwide investigation of the Medtronic Freestyle stentless porcine bioprosthesis. All patients received a total aortic root replacement. The patients were evaluated postoperatively at discharge, at 3 to 6 months, and yearly by clinical examination and color flow Doppler echocardiography. RESULTS: Operative mortality was 3.9%. No patient experienced structural valve deterioration, nonstructural deterioration, perivalvular leak, or unacceptable hemodynamic performance. At 8 years, survival was 59.8%. Freedom from thromboembolic complications was 83.3%. Freedom from postoperative endocarditis was 96.9%. Freedom from reoperation was 100%. Mean systolic gradients did not change over the time period studied. They were 6.4 +/- 3.8 mm Hg at 1 year and 6.7 +/- 2.6 mm Hg at 8 years. Correspondingly, effective orifice area was 1.9 +/- 0.7 cm2 at 1 year and 1.8 +/- 0.8 cm2 at 8 years. The incidence of any aortic insufficiency also did not change over the length of follow-up. At 1 year, 98% of patients had no or trivial aortic insufficiency and 2% had mild aortic insufficiency. At 8 years, 100% of patients evaluated were free of any aortic insufficiency. CONCLUSIONS: The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root or aortic valve for aortic valve and aortic root pathology. Total root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Results up to 8 years show excellent survival and no signs of degeneration. Further follow-up is still needed to determine valve durability.

Results of valve replacement with Omniscience mechanical prostheses.

BACKGROUND: The Omniscience mechanical valve has been the subject of multiple clinical investigations with variable results, including reports of high complication and reoperation rates. METHODS: Records of all patients who received Omniscience valves were reviewed, and follow-up interviews were conducted to determine the incidence of valve-related morbidity, mortality, and functional results. Incidence of complications was expressed as events per 100 patient-years follow-up. Survival and freedom from valve-related complications and mortality were calculated using a product limit method. RESULTS: Between 1984 and 1988, 192 patients received 213 Omniscience valves [93 mitral (M), 79 aortic (A), and 20 multiple (D) valve replacements]. Perioperative mortality was 9%. The incidence of major valve-related morbidity was as follows: thrombosis, 1.30 M, 0.17 A, 0.72 D; endocarditis, 0.48 M, 0.18 A, 0 D; hemorrhagic, 4.67 M, 2.84 A, 5.00 D; embolic, 2.90 M, 2.27 A, 1.57 D; nonstructural dysfunction, 1.66 M, 1.08 A, 2.27 D; reoperation, 4.02 M, 1.99 A, 6.48 D. All explanted valves (n = 43) were examined, and 40% (n = 17) were found to have limited disc excursion in the absence of thrombus. Freedom from valve-related morbidity, mortality, or reoperation at 10 years was 22% for mitral, 39% for aortic, and 17% for multivalve replacements. At follow-up, only 73% of patients were New York Heart Association class I or II. Five- and 10-year estimated survivals were 72% and 55% for M, 80% and 51% for A, and 65% and 50% for D replacements. CONCLUSIONS: Use of the Omniscience valve provided poor functional improvement and a significant incidence of valve-related complications, including the need for reoperation.

Coronary insufficiency after stentless aortic root replacement: risk factors and solutions.

BACKGROUND: Coronary insufficiency is a dreaded complication of total aortic root replacement (ARR) with few defined risk factors. This study describes the incidence, risk factors, management options, and outcomes of this condition after ARR with stentless porcine valves. METHODS: The study consisted of a retrospective analysis of 503 patients (mean age, 68.9 +/- 10.2 years) undergoing stentless porcine total ARR (Medtronic Freestyle and St. Jude Toronto) between the years 1993 and 2005 at a single institution. Coronary insufficiency was defined as the need for unplanned bypass grafting during, or after removal from cardiopulmonary bypass to correct wall motion abnormalities, arrhythmias, or right ventricular failure in the absence of known obstructive coronary disease. RESULTS: A total of 13 cases of right coronary artery and no cases of left coronary insufficiency were identified (overall incidence 13 of 503, 2.6%). All were treated with aortocoronary bypass grafting to the right coronary artery using saphenous vein. Compared with patients who did not have coronary insufficiency, patients with this complication were more likely to be female (11 of 13, 85%, versus 201 of 490, 41%; p = 0.006), had higher mean body mass index (34.6 +/- 12.0 kg/m2 versus 28.3 +/- 3.8 kg/m2, p = 0.04), and were implanted with smaller prostheses (23.9 +/- 2.1 mm versus 25.6 +/- 2.4 mm, p = 0.026), a finding not explained by the preponderance of female sex. Mean age, ejection fraction, and other demographic variables were similar. Despite longer cardiopulmonary bypass times (238 +/- 61 minutes versus 180 +/- 35 minutes, p = 0.005), operative mortality was not significantly different (1 of 13, 7.7%, versus 29 of 490, 5.9%; p = not significant). CONCLUSIONS: Coronary artery insufficiency is uncommon after stentless aortic root replacement and more often affects the right coronary artery. Risk factors appear to be female sex, higher body mass index, and small aortic root. Preventive measures include recognition of coronary orientation, routine valve rotation, and adequate coronary button mobilization. When this complication occurs, good outcomes can still be obtained with early recognition and prompt bypass grafting.

Medicine at the medical center then and now: one hundred years of progress.

The health and life expectancy of persons residing in the United States has improved dramatically during the 20th century. The average life span in the US has increased by more than 30 years since 1900. This significant gain is attributable to improvements in both public health and medical care. Tempering this notable achievement is the observation that the mortality rate per 1,000 population, although showing a significant decline in the era from 1920 to 1940, has now plateaued, and may be showing a slight increase. Our scientists and physicians have appropriately exploited the scientific discoveries of the 20th century and are poised as a medical tour de force for the 21st century. The decline in deaths from coronary artery disease and stroke has resulted from risk-factor modification and the innovations of surgeons and physicians who have dedicated themselves to early detection and better treatment of these cases. During the 1960s, patients admitted to our medical center with advanced Hodgkin's disease, hairy cell leukemia, and the acute leukemias had a life expectancy of < 1 year. Today, even advanced Hodgkin's disease and hairy cell leukemia are curable, and many patients with other acute leukemias respond to therapy and have very durable remissions. The rate of maternal mortality has shown a dramatic decline, and many childhood diseases have been eradicated or reduced to infrequent occurrences. Our public health scientists and physicians are joining forces to further diminish the morbidity and mortality rates for many of our common diseases. The achievements of our past afford us the vision for what we can become.