Anterior mitral valve perforation in the absence of acute infection: Diagnosis by two-dimensional and three-dimensional transesophageal echocardiography.

Anterior mitral valve leaflet (AMVL) perforation is most commonly seen in the setting of infective endocarditis. We present a case of AMVL perforation in a previously healthy 62-year-old male who presented with a six-month history of worsening dyspnea and peripheral edema. Blood cultures, inflammatory markers, and autoimmune profile were negative. Transthoracic echocardiography demonstrated severe mitral regurgitation (MR) with a possible AMVL perforation, which was confirmed by three-dimensional transesophageal echocardiography as a well-circumscribed hole in the A2 segment. The patient made a successful recovery from mitral valve repair surgery.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

INTRODUCTION: The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. METHODS: Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). RESULTS: There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. CONCLUSIONS: Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

A case of Tropheryma whipplei infective endocarditis of the aortic and mitral valves in association with psoriatic arthritis and lumbar discitis.

Whipple's disease is a chronic condition that is characterized by diarrhea, weight loss and arthropathy, and caused by infection with the fastidious bacterium Tropheryma whipplei. Although once rare, Whipple's disease is being increasingly described owing mainly to advances in molecular genetics and an improved isolation of the organism. Whilst cardiac Whipple's disease occurs less commonly, especially in the absence of gastrointestinal symptoms, it has become apparent that some cases of culture-negative endocarditis may well be attributable to T. whipplei. The case is reported of a patient with Whipple's disease endocarditis in association with psoriatic arthritis and lumbar discitis.

Surgical management of valve disease in the early 21st century.

Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.

Hemodynamic performance of Trifecta: single-center experience of 400 patients.

OBJECTIVE: To evaluate postoperative hemodynamic gradients and early outcomes of aortic valve replacement with the Trifecta bioprosthesis. METHODS: Between 2011 and 2013, 400 patients underwent aortic valve replacement with a Trifecta bioprosthesis. Gradients were calculated by transthoracic echocardiography before discharge. Data were collected retrospectively; patients with postoperative severe left ventricular dysfunction or > mild mitral regurgitation were excluded. RESULTS: The mean age was 75.9 ± 8.5 years, 197 (49.25%) patients were male, and 140 (35%) were >80-years old. Concomitant procedures were performed in 207 (51.75%) patients, and 30 (7.5%) had redo procedures. Supraannular aortoplasty with bovine pericardium was necessary in 25 (6.25%) cases. Hospital mortality was 2.75% (11 patients). Postoperative peak and mean gradients were 21.7 ± 9.3 and 11.1 ± 4.3 mm Hg for 19-mm valves (n = 29); 19.5 ± 7 and 9.7 ± 3.6 mm Hg for 21-mm valves (n = 158); 17.3 ± 6.6 and 8.7 ± 3.2 mm Hg for 23-mm valves (n = 134); 15.1 ± 6.1 and 7.8 ± 3.3 mm Hg for 25-mm valves (n = 56); 13.2 ± 3.7 and 6.9 ± 2.6 mm Hg for 27-mm valves (n = 11). Nine patients had trivial and one had mild transvalvular regurgitation. Mean follow-up was 1 ± 0.62 years; no patient required reoperation. Kaplan-Meier survival at 1 and 2 years was 94.3% ± 1.3% and 93.7% ± 1.4%. CONCLUSION: Early postoperative gradients are low after Trifecta implantation. Significant transvalvular regurgitation was not observed, but the incidence of supraannular aortoplasty may be increased.

Risk of reoperation for structural failure of aortic and mitral tissue valves.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the risk of reoperation for patients with a failing stented tissue valve. METHODS: Between 1980 and 1999, 259 patients (118 males, 141 females; mean age 60.1+/-15.4 years) underwent redo valve replacement to replace a failing stented tissue valve. Of these patients, 94 (36.3%) underwent redo aortic valve replacement (AVR), 105 (40.5%) redo mitral valve replacement (MVR), and 60 (23.2%) redo aortic and mitral valve replacement (DVR). Twenty patients (7.7%) had previous coronary artery bypass grafting (CABG); further CABG were performed in 32 cases (12.4%). Preoperatively, 216 patients (83.3%) were in NYHA functional class III or IV. RESULTS: The early mortality was (6.5%; n = 17), including three patients who had AVR, five DVR, and nine MVR. A higher preoperative NHYA status (p <0.0004) and emergency surgery (p <0.0001) were significantly associated with an increased risk of operative death (univariate analysis). Age at surgery (p = 0.45), previous CABG (p = 0.45), position of the valve replaced (p = 0.2), type of implant (p = 0.06) and presence of coronary artery disease (p = 0.51) were not associated with a significant risk of operative mortality. Including those patients who died, 88 (34.0%) experienced a peri- or postoperative complication, seven of which (2.7%) were permanent. CONCLUSION: A failing tissue valve can be replaced, with acceptable operative mortality and morbidity. The choice of valve is a balance of its advantages and disadvantages, and these must be discussed with the patient. It appears, however, that the trend towards reducing the age at which tissue valve implantation is performed may be justified.

The effect of leucodepletion on leucocyte activation, pulmonary inflammation and respiratory index in surgery for coronary revascularisation: a prospective randomised study.

OBJECTIVE: Leucocyte activation is central to end-organ damage that occurs during cardiac surgery under cardiopulmonary bypass (CPB). Exhaled nitric oxide (NO) increases in inflammatory lung conditions and has been proposed as a marker of pulmonary inflammation during CPB. This study examined the effect of leucodepletion on leucocyte activation, pulmonary inflammation and oxygenation in patients undergoing coronary revascularisation. METHODS: Fifty low-risk patients undergoing first time coronary artery bypass graft (CABG) were randomised to two groups. Twenty-five patients had an arterial line leucocyte-depleting filter and 25 controls had a standard filter. Arterial blood samples were taken before CPB, 5 and 30 min on CPB, 5 min after aortic clamp removal and 6 h post-operatively. Activated leucocytes were identified with Nitroblue Tetrazolium staining. NO was sampled via an endotracheal teflon tube 15 min after median sternotomy before CPB and 30 min after discontinuation of CPB using a real-time chemiluminescense analyser. Respiratory index (alveolar-arterial oxygenation index, AaOI) was calculated before CPB, 1, 2, 4, 8 and 18 h post-operatively. Clinical outcome end-points were also recorded. RESULTS: Total and activated leucocyte counts were significantly lower following leucodepletion during CPB (P < 0.0001). Exhaled NO rose significantly after CPB in the control group (3.8+/-1 ppb/s before CPB vs 5.6+/-2 ppb/s after CPB (P = 0.003) but not in the leucodepleted group (3.7+/-1 ppb/s before CPB vs 3.9+/-1 ppb/s after CPB (P = 0.051). AaOIs were consistently lower after leucodepletion (anova, P = 0.001). The duration of mechanical ventilation, the intensive care and hospital stay and the frequency of cardiac and respiratory complications were similar in the two groups. CONCLUSIONS: Leucodepletion reduces the numbers of circulating activated leucocytes and the pulmonary inflammation during CPB. This appears to limit lung injury and improve oxygenation in low-risk patients undergoing CABG surgery. Larger numbers of patients are required to evaluate the effect of continuous arterial line leucodepletion on the clinical outcome.

Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register.

OBJECTIVES: To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience). DESIGN: Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification. SETTING: UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012. PARTICIPANTS: All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon. MAIN OUTCOME MEASURES: All-cause in-hospital mortality. RESULTS: A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience'). CONCLUSIONS: Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required.

Long-term outcome following repair of acute type A aortic dissection after previous cardiac surgery.

We evaluated the outcome after repair for acute spontaneous type A aortic dissection in patients with previous cardiac surgery. From January 2000 to December 2009, 114 patients underwent emergency repair for acute spontaneous type A dissection at Southampton University Hospital. Eleven (median age 64 years; range 36-83 years; two females) patients (9.8%) had undergone previous cardiac surgery and were included in this study. Aortic root replacement was performed in three patients (27%), aortic arch replacement in four patients (36%) and two patients (18%) required aortic valve re-suspension. The elephant trunk operation was performed in two patients (18%). There were two hospital deaths (18%). Two patients (18%) suffered a stroke, two needed re-opening for bleeding (18%) and two patients (18%) required haemofiltration postoperatively. Median length of hospital stay was 16 days (range 6-34 days). Actuarial survival at five and eight years for redo compared to first-time surgery was 68±3.63% vs. 81±5.34% and 51±3.8% vs. 61±5.4%, respectively (P=0.365). In conclusion, acute type A aortic dissection repair in patients with previous cardiac surgery has an acceptable mortality and comparable long-term outcome to first-time surgery.

Impact of surgeon-specific data reporting on surgical training.

INTRODUCTION: Since April 2002, collection and publication of surgeon-specific data in adult cardiac surgery has become mandatory in the UK. It has been suggested that this may discourage consultants from allowing trainees to perform cases. The aim of this study was to attempt to analyse the effect of the introduction of surgeon-specific data (SSD) on surgical training in a large cardiac surgical centre. PATIENTS AND METHODS: A retrospective analysis was performed on 2111 consecutive patients undergoing elective coronary artery bypass surgery, aortic and mitral valve surgery at Southampton General Hospital between April 2000 and April 2004. Results were analysed and compared over a 2-year period prior to and a 2-year period following the introduction of SSD. RESULTS: There were no changes in the overall mortality rate following the introduction of SSD. SSD was associated with a reduction in the overall proportion of cases performed by trainees (49% versus 42.8%; P = 0.004) and, in particular, a reduction in the proportion of aortic and mitral valve procedures performed by trainees. In addition, the proportion of cases performed by the trainees without consultant supervision declined significantly following SSD (18.7% versus 10.4%; P < 0.001). CONCLUSIONS: Publication of surgeon-specific data has coincided with a decrease in both the proportion and variety of cases performed by trainees.

Subcoronary allograft aortic valve replacement: parametric risk-hazard outcome analysis to a minimum of 20 years.

BACKGROUND: Differences in sterilization, preservation, and implantation have been implicated in aortic allograft longevity. We report follow-up to 30 years of patients from a single unit who underwent aortic valve replacement with aortic allografts sterilized in antibiotics and refrigerated at 4 degrees C. METHODS: Two hundred consecutive patients underwent subcoronary allograft aortic valve replacement and have been followed up to a minimum of 20 and maximum of 30 years. Follow-up was 96% complete. Parametric hazard phase modeling was used to identify incremental predictors of time-related risk. RESULTS: Early mortality was 1.5%. Kaplan-Meier actuarial survival, including early death, was 81.2% +/- 2.8% (mean +/- standard error of the mean), 58.0% +/- 3.7%, and 52% +/- 5.1% at 10, 20, and 25 years, respectively. Freedom from reoperation for any reason was 86.4% +/- 2.6%, 39.6% +/- 5.2%, and 35.0% +/- 5.4% at 10, 20, and 25 years, respectively. Larger implanted valve, reexploration for bleeding, previous cardiac surgery, and operative rank were independent risks for reoperation. Early mortality in reoperations was 5.1%. Allograft endocarditis has occurred in 6 patients, giving an overall freedom of 94% at 25 years. Seven patients of the original cohort are known to be alive with their original allograft valve in situ, and of these the longest follow-up period is 29.8 years. CONCLUSIONS: The use of antibiotic-sterilized allografts for subcoronary aortic valve replacement confers low operative mortality and excellent long-term survival with durability matching any other nonmechanical device. Significantly reduced time-related risk of reoperation and excellent internal to external diameter ratio renders allograft aortic valve replacement especially ideal for smaller roots.