Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta.

BACKGROUND: Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation. METHODS AND RESULTS: Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43+/-13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had >/=1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery. CONCLUSIONS: CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.

Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement?

OBJECTIVES: Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution. METHODS: Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006). RESULTS: Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis. CONCLUSIONS: Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.

Indications, effectiveness, and long-term dependency in permanent pacing after cardiac surgery.

The purposes of this study were to define predictors of long-term pacemaker dependency in patients having permanent pacemakers implanted shortly after cardiac surgery, and to evaluate short- and long-term results and survival in this population. Data from 120 adult patients with implantation since 1980 were retrospectively analyzed. Acute and chronic complication rates (4.2% and 16.6%, respectively) were not higher than those expected in the general paced population. In addition, continuous rhythm was evaluated by use of pacemaker inhibition in a subgroup of 20 patients to verify the validity of clinical criteria for pacemaker dependency. Of the patients evaluated for dependency, 41% eventually became nondependent. Prolonged monitoring with an inhibited pacemaker confirmed the accuracy of our method of clinical evaluation of pacemaker dependency. Significant predictors of long-term pacemaker dependency were complete atrioventricular block as the indication and bypass time of > 120 minutes (by multivariate and univariate analyses, respectively). Postoperative complete atrioventricular block is the most important predictor of pacemaker dependency, enabling an earlier decision on permanent pacemaker implantation (no later than the sixth and the ninth postoperative days for wide-complex and narrow-complex escape, respectively). Further prospective studies are needed to define optimal implantation times for indications other than complete atrioventricular block.

Aortic valve homografts in adults: a clinical perspective.

Aortic valve replacement is a lifesaving measure in patients with severe aortic valve disease. In the United States, the most commonly used prostheses are the mechanical and bioprosthetic valves. With mechanical valves, long-term anticoagulation is necessary because of high thrombogenic potential. Bioprosthetic valves have a relatively high incidence of structural failure, especially in younger patients. Aortic valve homografts, derived from human heart donors or autopsy material, provide an alternative to mechanical or animal valves. The advantages of the homograft in comparison with the mechanical prostheses are the low incidence of thromboembolism without anticoagulation and lower valvular gradients in smaller sizes. Homografts are relatively resistant to endocarditis and are the valve of choice during active endocarditis. Their major mode of failure has been aortic regurgitation; however, recent advances in preservation and operative techniques have decreased this problem. Whether implantation of an aortic valve homograft should be the procedure of choice in subsets of patients remains controversial. Herein we review the history, techniques, results, complications, and current indications for aortic valve homografts.

Cardiac transplantation for end-stage congenital heart defects: the Mayo Clinic experience. Mayo Cardiothoracic Transplant Team.

OBJECTIVE: To review the outcome of cardiac transplantation undertaken in patients with congenital heart defects. MATERIAL AND METHODS: Between November 1991 and March 1998 at our institution, cardiac transplantation was performed in 16 patients with congenital heart disease (age range, 3 to 57 years; mean, 26.1). Preoperative diagnoses included univentricular heart (N = 4); complete transposition of the great arteries (N = 3); Ebstein's anomaly (N = 2); tetralogy of Fallot (N = 2); levotransposition (N = 2); dextrocardia, corrected transposition, ventricular and atrial septal defects, and pulmonary stenosis (N = 1); double-outlet right ventricle (N = 1); and hypertrophic obstructive cardiomyopathy (N = 1). All patients had undergone from one to five previous palliative operations. RESULTS: Four patients required permanent pacemaker implantation during the first month postoperatively because of bradycardia; more than 2 years later, another patient required a permanent pacemaker because of sick sinus syndrome. In addition, one patient had an automatic implantable cardioverter-defibrillator. Three patients required reconstruction of cardiovascular structures with use of prosthetic material (Teflon patches or donor tissue) at the time of cardiac transplantation. Actuarial 1-, 2-, and 5-year survival was 86.2 +/- 9.1%. During the first year after transplantation, two deaths occurred--one at 41 days of putative vascular rejection and the second at 60 days of severe cellular rejection. All other patients are alive and functionally rehabilitated; the mean follow-up period has been 26.1 months (range, 2 to 89.6). CONCLUSION: Cardiac transplantation for patients with congenital heart disease can be accomplished with a low perioperative mortality and an excellent medium-term survival despite the challenges presented by the technical difficulties during invasive diagnostic procedures and at operation and the need for adherence to long-term multiple-drug therapy in this patient population.

Late pulmonary valve replacement after repair of tetralogy of Fallot.

BACKGROUND: Pulmonary regurgitation appears to be well tolerated early after repair of tetralogy of Fallot; however, it may result in progressive right ventricular dilatation and dysfunction necessitating eventual valve replacement. Our objective was to review our experience with late pulmonary valve replacement after complete repair of tetralogy of Fallot. METHODS AND RESULTS: A total of 42 patients (16 female and 26 male) were operated on between July 1, 1974, and January 1, 1998. Mean age was 22 years (range 2-65 years). The mean interval between tetralogy repair and pulmonary valve replacement was 10.8 years (range 1.6 months-33 years). Mean follow-up was 7.8 +/- 6.0 years (maximum 23 years). Indications for pulmonary valve replacement included decreased exercise tolerance in 58%, right heart failure in 21%, arrhythmia in 14%, syncope in 10%, and progressive isolated right ventricular dilatation in 7%. Heterograft prostheses were used in 33 patients and homografts in 9. Five patients underwent isolated pulmonary valve replacement; concomitant procedures performed in 37 patients included tricuspid valve repair/replacement (n = 18), residual ventricular septal defect repair (n = 12), atrial septal defect closure (n = 4), pulmonary artery patch angioplasty (n = 17), and right ventricular outflow tract enlargement (n = 13). One patient died early (2%) of multiorgan failure. There were 6 late deaths, 3 of which were cardiac related. Survival was 95.1% +/- 3.4% and 76.4% +/- 8.9% at 5 and 10 years, respectively. Functional class of patients was improved significantly; preoperatively, 76% of patients were in New York Heart Association class III-IV, and after pulmonary valve replacement, 97% of surviving patients were in class I-II (P =.0001). Moderate to severe reduction in right ventricular function was noted on preoperative echocardiography in 59% and on late echocardiography in 18% (P =.03). Of the 5 patients who had supraventricular arrhythmias before pulmonary valve replacement, 1 had postoperative recurrence and the arrhythmia is controlled with antiarrhythmic therapy; the other 4 are in normal sinus rhythm at late follow-up. Eight patients subsequently underwent pulmonary valve re-replacement without early mortality at a mean interval of 9.0 +/- 4.2 years (range 3.8-16.8 years). Freedom from pulmonary valve re-replacement was 93.1% +/- 4.7% and 69.8% +/- 10.7% at 5 and 10 years, respectively. The only significant risk factor for re-replacement was young age at the time of the initial pulmonary valve replacement (P =.023). CONCLUSION: Late pulmonary valve replacement after tetralogy repair significantly improves right ventricular function, functional class, and atrial arrhythmias, and it can be performed with low mortality. Subsequent re-replacement may be necessary to maintain functional improvement.

Electrode-derived myocardial pH measurements reflect intracellular myocardial metabolism assessed by phosphorus 31-nuclear magnetic resonance spectroscopy during normothermic ischemia.

To determine the ability of extracellular myocardial tissue pH measured with an intramural electrode to reflect myocardial intracellular metabolic status during normothermic ischemia, we studied 14 open-chest dogs with in vivo phosphorus 31-nuclear magnetic resonance spectroscopy during left anterior descending coronary artery occlusion (experimental group, group I, n = 7) or after a sham operation (control group, nonischemic, group II, n = 7). Phosphorus nuclear magnetic resonance spectra were acquired every 5 minutes at 4.7 tesla (256 averages, TR = 1000 msec, pulse width = 30 microseconds) with a 2 cm two-turn radiofrequency surface coil. Intracellular myocardial adenosine triphosphate peak area was normalized to an external phosphate standard. The change in adenosine triphosphate peak area was expressed as percent of baseline value. During 3 hours of normothermic ischemia the observed extracellular myocardial pH correlated with nuclear magnetic resonance-calculated myocardial pH in the ischemic dogs with an average r value of 0.94 (p less than 0.0001). During this same interval, the fall in extracellular myocardial pH correlated with the loss of adenosine triphosphate peak in each ischemic dog, with an average r value of 0.91 (p less than 0.0001). Thus extracellular myocardial pH, measured with an intramural electrode, correlated with nuclear magnetic resonance-derived myocardial pH and loss of myocyte adenosine triphosphate peak content and reflected the metabolic status of the myocyte during ischemia. These data validate the use of extracellular myocardial pH to assess the adequacy of myocardial preservation during aortic crossclamping for cardiac operations.

Results of allograft aortic valve replacement for complex endocarditis.

METHODS: Between November 1985 and July 1995, 36 patients underwent allograft aortic valve replacement for endocarditis. The mean age of the 29 men and seven women was 53 years (range 25 to 79 years). Previous procedures included mechanical (n = 9), bioprosthetic (n = 5), and allograft (n = 2) aortic valve replacement, aortic valvotomy (n = 1), and orthotopic heart transplantation (n = 1). Infecting organisms were Staphylococcus and Streptococcus species in 69% of patients and fungi in 6%. Intraoperative findings demonstrated valvular vegetations (n = 25), annular abscesses (n = 25), and cusp destruction (n = 13). Complex reconstruction of the aortic anulus was required in 25 patients, and associated procedures included mitral valve repair (n = 2), mitral valve replacement (n = 3), coronary artery bypass grafting (n = 8), repair of ventricular septal defect (n = 4), left ventricular aneurysmectomy (n = 1), and repair of atrial septal defect (n = 1). Allograft valve insertion was performed by the scalloped technique in seven, intraaortic cylinder technique in 19, and allograft aortic root replacement in 10. RESULTS: Follow-up was 100% complete at a mean of 2.6 +/- 2.8 years after valve replacement. Operative mortality was 13.8%. Complications included low cardiac output (n = 10), bleeding (n = 2), myocardial infarction (n = 1), stroke (n = 1), renal insufficiency (n = 2), respiratory insufficiency (n = 3), and heart block (n = 8). Late echocardiogram (mean 2.6 +/- 1.8 years) demonstrated grade III/IV aortic regurgitation in five patients. There were seven late deaths (five cardiac, not valve-related; two noncardiac). No patient has had recurrence of endocarditis. Actuarial survival at 5 years was 53.1% +/- 11.5%. Univariate analysis demonstrated prosthetic valve endocarditis to adversely affect late survival (p = 0.04). Cumulative risk of reoperation at 5 years was 8.0% +/- 5.6%. CONCLUSION: Allograft aortic valve replacement facilitated reconstruction of complex aortic valve endocarditis with a low reoperation rate and no recurrent endocarditis in this series.

Operation for partial atrioventricular septal defect: a forty-year review.

BACKGROUND: We describe the long-term outcome of repair of partial atrioventricular septal defect by determining the rates of survival, reoperation, and occurrence of left atrioventricular valve regurgitation, left atrioventricular valve stenosis, left ventricular outflow tract obstruction, and arrhythmia. METHODS: We studied 334 patients who underwent repair of partial atrioventricular septal defect before 1995. RESULTS: The 30-day and 5-, 10-, 20-, and 40-year survival were 98%, 94%, 93%, 87%, and 76%, respectively. Closure of the left atrioventricular valve cleft (P =. 03) and age less than 20 years at operation (P <.001) were associated with better survival. Reoperation was performed for 38 patients (11%). Repair of residual/recurrent left atrioventricular valve regurgitation or stenosis was the most common reason for reoperation. Left ventricular outflow tract obstruction occurred in 36 patients, and 7 patients underwent reoperation to relieve this obstruction. Supraventricular arrhythmias were observed in 58 patients (16%) after the operation. Supraventricular arrhythmias increased with increasing age at primary operation (P =.001). Complete atrioventricular block occurred in 9 patients (3%). Permanent pacemakers were implanted in 11 patients. CONCLUSIONS: Long-term survival after repair of partial atrioventricular septal defect is good. It is important to close the cleft in the left atrioventricular valve. Reoperation for persistent or recurrent left atrioventricular valve malfunction and relief of left ventricular outflow tract obstruction is necessary in approximately 11% of patients.

Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998.

STUDY OBJECTIVES: This study assessed the clinical features, timing of presentation, and echocardiographic characteristics associated with clinically significant pericardial effusions after cardiothoracic surgery. The outcomes of echocardiographically (echo-) guided pericardiocentesis for the management of these effusions were evaluated. DESIGN: From the prospective Mayo Clinic Registry of Echo-guided Pericardiocentesis (February 1979 to June 1998), 245 procedures performed for clinically significant postoperative effusions were identified. Clinical features, effusion causes, echocardiographic findings, and management outcomes were studied and analyzed. Cross-referencing the registry with the Mayo Clinic surgical database provided an estimate of the incidence of significant postoperative effusions and the number of cases in which primary surgical management was chosen instead of pericardiocentesis. RESULTS: Use of anticoagulant therapy was considered a significant contributing factor in 86% and 65% of early effusions (< or =7 days after surgery) and late effusions (>7 days after surgery), respectively. Postpericardiotomy syndrome was an important factor in the development of late effusions (34%). Common presenting symptoms included malaise (90%), dyspnea (65%), and chest pain (33%). Tachycardia, fever, elevated jugular venous pressure, hypotension, and pulsus paradoxus were found in 53%, 40%, 39%, 27%, and 17% of cases, respectively. Transthoracic echocardiography permitted rapid diagnosis and hemodynamic assessment of all effusions except for three cases that required transesophageal echocardiography for confirmation. Echo-guided pericardiocentesis was successful in 97% of all cases and in 96% of all loculated effusions. Major complications (2%), including chamber lacerations (n = 2) and pneumothoraces (n = 3), were successfully treated by surgical repair and chest tube reexpansion, respectively. Median follow-up duration for the study population was 3.8 years (range, 190 days to 16.4 years). The use of extended catheter drainage was associated with reduction in recurrence for early and late postoperative effusions by 46% and 50%, respectively. CONCLUSIONS: The symptoms and physical findings of clinically significant postoperative pericardial effusions are frequently nonspecific and may be inadequate for a decision regarding intervention. Echocardiography can quickly confirm the presence of an effusion, and pericardiocentesis under echocardiographic guidance is safe and effective. The use of a pericardial catheter for extended drainage is associated with lower recurrence rates, and the majority of patients so treated do not require further intervention.

Coronary artery bypass grafting in patients with previous mediastinal radiation therapy.

OBJECTIVES: Our objectives were to characterize the outcome of coronary artery bypass grafting in patients with previous mediastinal radiation therapy and to identify special features of this condition that relate to surgical management. PATIENTS AND METHODS: We conducted a retrospective review of 47 patients (28 women, 19 men) with a mean age of 63.5 +/- 12.8 years (range 31.0-82. 9 years) from 1976 through December 1996 undergoing coronary artery bypass graft after mediastinal radiation therapy. RESULTS: The mean interval between mediastinal radiation therapy and coronary artery bypass grafting was 15.1 +/- 9.8 years (range 1.1-37.8 years). In the 44 patients with isolated coronary surgery, operative mortality was 3 patients (6.8%). Sternal wound infection occurred in 3 patients (6.8%). Actuarial survival at 1 and 5 years was 87.2% +/- 4. 9% and 71.6% +/- 7.1%, respectively. Total follow-up was 293.7 patient-years (mean 6.2 +/- 5.1 years). There were 17 late deaths (malignancy, n = 7; heart failure, n = 6; stroke, n = 1; other noncardiac causes, n = 2; and sudden death, n = 1). Twelve of 43 discharged patients had the development of valvular disease demonstrated by follow-up echocardiography. CONCLUSIONS: The early results of coronary artery bypass grafting for the treatment of ischemic heart disease after mediastinal radiation therapy are good. Late survival, however, is limited by malignancy, either recurrent or new, and the development of heart failure. Inasmuch as 25 other patients after radiation therapy required concomitant valve surgery and 12 of 43 (28%) discharged patients had later development of valvular disease, with 2 requiring reoperation, careful assessment of any valvular lesion is important during the initial coronary artery bypass grafting. Careful follow-up, including regular echocardiographic screening, is recommended in this patient population.

Cardiac retransplantation for graft vasculopathy in children: should we continue to do it?

BACKGROUND: Cardiac transplantation (CTx) has been established as an effective therapy for a variety of inoperable cardiac conditions in infants and children. However, graft vasculopathy (GV) has emerged as the main limiting factor to long-term survival of CTx recipients. The only treatment of severe GV is cardiac retransplantation (re-Tx). Controversy exists regarding the use of scarce donor organs for cardiac re-Tx. OBJECTIVE: To compare the outcome of cardiac re-Tx for GV with that of primary CTx in children. DESIGN: A 12-year retrospective cohort review. SETTING: A university-affiliated children's hospital. PATIENTS: All infants and children who underwent CTx (group 1, n = 322) had complete follow-up of 1389.7 patient-years. Graft vasculopathy was confirmed in 32 recipients (1.1-8.2 years after undergoing CTx). Thirteen patients died suddenly, 3 died waiting for cardiac re-Tx (1-17 days after relisting), 4 are pending cardiac re-Tx, and 12 (group 2) underwent cardiac re-Tx. INTERVENTION: Cardiac re-Tx at a mean (+/- SD) interval from the first CTx of 6.3 +/- 1.8 years (range, 2.2-9.4 years). Two patients required additional aortic arch aneurysm repair with cardiac re-Tx. RESULTS: When group 1 was compared with group 2, there was no significant difference in operative mortality (9.0% vs 8.3%; P = .9), rejection rate (0.98 vs 0.86; P = .1), and hospital stay (23.0 +/- 18.8 days vs 20.5 +/- 11.6 days; P = .65). Actuarial survival for groups 1 and 2 at 1 and 4 years was 84.3% vs 83.3% (P = .59) and 74.4% vs 83.3% (P = .85), respectively. CONCLUSIONS: The surgical outcome and intermediate survival of cardiac re-Tx for GV and primary CTx are similar. Children with severe cardiac GV are at risk of sudden death and can benefit from early cardiac re-Tx.

Congenital Heart Surgery Nomenclature and Database Project: Ebstein's anomaly and tricuspid valve disease.

Ebstein's anomaly is a rare congenital heart defect that is characterized by a spectrum of anatomical abnormalities of the tricuspid valve that also involve the right atrium and right ventricle. The extant nomenclature for Ebstein's anomaly and our approach to the description of the severity of Ebstein's anomaly are reviewed with the objective of establishing a unified reporting system. Although there are common features in Ebstein's anomaly, there is a wide spectrum of pathology with an infinite variety of combinations of severity of the involved structures. An effort was made to develop a classification system that would take into consideration the anatomic abnormalities that help direct the surgical management, particularly in regard to tricuspid valve repair or valve replacement. Isolated congenital tricuspid stenosis and regurgitation are also rare, and a simple classification system is presented. Acquired causes of tricuspid regurgitation and stenosis are more common and are included in the classification system. A comprehensive database set for these malformations is presented so that a comprehensive risk stratification analysis can be performed. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and risk factors are presented.

Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy.

A technique of greater saphenous vein harvesting for coronary artery revascularization using an endoscopic approach is herein detailed. The saphenous vein is directly identified at the knee through a single incision. An endoscopic dissector is advanced proximally and distally along the course of the vein, ligating side-branches with clips. The vein is divided at the ends of dissection, dependent on patient anatomy, by either a counterincision, endoscopic clips, or ligation with an Endo-loop.

Minimally invasive saphenous vein harvesting: endothelial integrity and early clinical results.

BACKGROUND: Endoscopic harvesting of vein grafts may reduce wound complications but the effect on the venous endothelium is unknown. Endothelium-derived vasoactive substances may be important in vein graft disease prevention. We investigated the impact of endoscopic harvesting on the release of these factors and proceeded to evaluate the clinical applicability. METHODS AND RESULTS: Porcine veins were harvested in either an endoscopic or open fashion. Superfusion bioassay from endoscopic veins had a similar basal secretion as control veins (6.5% +/- 1.5% versus 3.2% +/- 2.2%, respectively; n = 5, p = 0.39). Calcium ionophore A23187 stimulation was similar in both groups (24.6% +/- 5.1% versus 27.3% +/- 9.6%; n = 5, p = 0.68). Light and electron microscopy documented a normal endothelial monolayer in both groups with no endothelial cell or connective tissue loss. Encouraged by these results, 38 patients have subsequently undergone this procedure at our institution. Total operative time for harvesting 35 to 45 cm of saphenous vein was 62.3 +/- 5.3 minutes (range, 35 to 120 minutes). The procurement time in the most recent five patients was 41.6 +/- 3.3 minutes. Patients had little incisional pain, but did have mild ecchymosis. CONCLUSIONS: Endothelial release of vasoactive substances after endoscopic harvesting is similar to that after the traditional, extended incision technique, and microscopy confirmed similar histology. These laboratory findings support the satisfactory early clinical experience with endoscopic harvesting of saphenous veins.

Comparison of techniques for implantation of aortic valve allografts.

BACKGROUND: Various implantation techniques for allograft aortic valve replacement have evolved over the years. Our objective was to examine the effects of different implantation methods on subsequent valve performance and durability. METHODS: Between May 1985 and January 1994, 137 patients underwent allograft aortic valve replacement. The first 59 aortic valve allografts were inserted by the freehand scalloped technique with removal of the aortic sinuses, and the last 78 valves were inserted by the cylinder technique, in which the aortic sinuses and sinotubular junction were retained. The mean age of the 91 men and 46 women was 53.7 years (range, 18 to 83 years). Preoperative diagnoses were aortic stenosis (n = 57), aortic regurgitation (AR, n = 40) and aortic stenosis/AR (n = 40); 27 patients had prior aortic valve operations and 1 patient had a previous heart transplantation. Active endocarditis was present in 29 patients. Associated procedures included coronary artery bypass (n = 33), ascending aneurysm repair (n = 4), left ventricular aneurysmectomy (n = 3), repair of atrial septal defect (n = 2), mitral valve repair or replacement (n = 6), and aortic root enlargement (n = 24). Follow-up was complete in 133 patients (97%) a mean of 4.9 years (range, 1 day to 9.8 years) after allograft aortic valve replacement. RESULTS: Operative mortality was 6.5% for all patients but only 1.9% for patients without infection having isolated aortic valve replacement. Early echocardiography (mean of 8.4 days postoperatively) demonstrated no AR or mild AR and a mean gradient of 10.6 +/- 6.2 mm Hg in all patients. The cumulative risk of development of grade III or IV AR at 7 years postoperatively was 26.2% +/- 6.3% in the scallop group and 12.4% +/- 5.6% in the cylinder group (p = 0.4). Late postoperatively, transvalvular gradient by echocardiography was 13.1 +/- 9.4 mm Hg, and was similar in the two study groups. Late AR led to reoperation in 13 patients (22%) who had initial implantation with the scallop method and only 4 patients (5.4%) who had the valve inserted with the cylinder method. However, because duration of follow-up was longer for patients in the scallop group, cumulative risk of reoperation was similar at 5 years postoperatively (scallop, 13.7% [95% confidence interval, 76.7% to 95.8%]; cylinder, 11.5% [95% confidence interval, 75.5% to 99.1%]). CONCLUSIONS: The insertion of an aortic valve allograft as a cylinder, retaining the sinotubular junction, appears to result in less aortic regurgitation at 7 years postoperatively, and with additional follow-up may result in less reoperation for AR.

Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening.

BACKGROUND: To determine the optimal method of repair for severe, segmental anterior leaflet prolapse, we analyzed outcome of 121 patients who underwent chordal shortening (n = 46) and chordal replacement (n = 75) from 1988 to 1996. METHODS: Chordae were replaced with expanded polytetrafluoroethylene sutures. Patients had an annuloplasty with either chordal replacement or shortening. Follow-up was 100% complete (mean, 3.7 years). RESULTS: Mean age was 62.1 years, 86 were men, and 60 patients had isolated valve repair. There was one hospital death and 14 late deaths for a 5-year actuarial survival of 86.4%+/-4.5%. Sixteen patients underwent reoperation, 5 in the replacement group and 11 in the shortening group. Mechanism of valve failure in the replacement group was native chordae rupture (n = 4) and neochordae dehiscence (n = 1). With chordal shortening, repair failure was attributed to rupture of shortened chordae (n = 8), leaflet prolapse with and without annuloplasty ring dehiscence (n = 2), and native chordae elongation (n = 1). Risk of reoperation because of repair failure at 3.5 years was 1.4% in the chordal replacement group and 14.8% in the chordal shortening group (p = 0.02). CONCLUSIONS: Chordal replacement is superior to chordal shortening, providing a predictable method for correction of mitral regurgitation with a low incidence of reoperation.

Ultra fast track in elective congenital cardiac surgery.

BACKGROUND: Changes in healthcare delivery have affected the practice of congenital cardiac surgery. We recently developed a strategy of limited sternotomy, early extubation, and very early discharge, and reviewed the perioperative course of 198 pediatric patients undergoing elective cardiovascular surgical procedures, to assess the efficacy and safety of this approach. METHODS: One hundred ninety-eight patients aged 0 to 18 years (median 3.2 years) underwent 201 elective cardiovascular surgical procedures over a 1-year period. All patients were admitted on the day of surgery. Patients were divided into six diagnostic groups: group 1, complex left-to-right shunts (n = 14, 7.0%); group 2, simple left-to-right shunts (n = 83, 41.3%); group 3, right-to-left shunts with pulmonary obstruction (n = 33, 16.4%); group 4, isolated, nonvalvular obstructive lesions (n = 30, 14.9%); group 5, isolated valvular anomalies (n = 20, 10.0%); and group 6, miscellaneous (n = 21, 10.4%). RESULTS: After 201 procedures, 175 patients (87.1%) were extubated in the operating room and 188 (93.6%) within 4 hours from operation. Four patients (2.0%) were extubated more than 24 hours from completion of the procedure, and 2 (1.0%) died while on respiratory support (never weaned). Five patients (2.6%) failed early extubation (<4 hours). Early discharge was achieved for the vast majority of patients. Overall median length of stay (LOS, including day of surgery as day 1) was 2.0 days, with a median LOS of 3.0 days for those patients requiring circulatory arrest duration exceeding 20 minutes. Of 195 patients, 43 (24.6%), 121 (74.0%), and 159 (81.5%) were discharged, respectively, at <24, <48, <72 hours from admission. Longest and shortest mean postoperative LOS were in group 6 (9.9+/-14.5 days) and group 2 (1.6 = 0.7 days), respectively. Six patients (2.9%) died, and 11 (5.5%) suffered in-hospital complications. Thirty patients (15.4%) were either treated as outpatients (n = 11, 5.7%) or readmitted (n = 19, 9.7%) within 30 days from the time of surgery. Only 8 of 195 patients (4.1%) were readmitted with true surgical complications requiring invasive therapeutic procedures. CONCLUSIONS: Selected patients with a broad spectrum of congenital heart disease may enjoy same-day admission, limited sternotomy, immediate extubation, and very early discharge with excellent outcomes and acceptable morbidity.

Pediatric cardiac retransplantation: intermediate-term results.

BACKGROUND: Cardiac retransplantation (re-CTx) in children is a controversial therapy, yet it remains the best treatment option to recipients with failing grafts. Our objective was to determine the incidence of re-CTx in a large pediatric population of recipients and evaluate the outcome of such therapy. METHODS: Between November 1985 and November 1999, 347 children underwent cardiac transplantation at the Loma Linda University Medical Center. Of these, 32 children were listed for re-CTx. Ten patients died while waiting, and 22 recipients underwent re-CTx. Median age at re-CTx was 7.1 years (range, 52 days to 20.1 years). RESULTS: Indications for re-CTx were allograft vasculopathy (n = 16), primary graft failure (n = 5), and acute rejection (n = 1). Two patients with primary graft failure underwent retransplantation within 24 hours of the first transplantation procedure while on extracorporeal membrane oxygenation support. Median time interval to re-CTx for the others was 7.2 years (range, 32 days to 9.4 years). Operative mortality for all cardiac re-CTx procedures was 13.6%. Causes of hospital mortality were pulmonary hypertension with graft failure (n = 2) and multiorgan failure (n = 1). Median hospital stay after re-CTx was 14.1 days (range, 6 to 45 days). There was one late death from severe rejection. Actuarial survival at 3 years for re-CTx was 81.9% +/- 8.9% compared with 77.3% +/- 2.6% for primary cardiac transplantation recipients (p = 0.70). CONCLUSIONS: Elective re-CTx can be performed with acceptable mortality. Although the number of patients undergoing retransplantation in this report is small and their long-term outcome is unknown, the intermediate-term survival after re-CTx is similar to that of children undergoing primary cardiac transplantation.

Safety and therapeutic effectiveness of reinfused shed blood after open heart surgery.

This prospective study was designed to determine whether use of nonwashed shed mediastinal blood exacerbated platelet and related hematologic dysfunctions after cardiopulmonary bypass, compared with the alternative use of autologous and homologous standard liquid preserved blood for volume support. Thirty-two patients undergoing cardiopulmonary bypass for open heart operations were randomized to receive either nonwashed shed mediastinal blood (group 1; n = 16) or liquid preserved packed red blood cells (group 2; n = 16) for transfusion therapy in the management of postoperative bleeding. Patient blood samples and bleeding times were obtained preoperatively, after cardiopulmonary bypass but before transfusions, 2 and 24 hours after transfusion, and on postoperative days 2, 3, and 7. Group 1 patients received an average of 710 +/- 90 mL (range, 300 to 1,700 mL) of nonwashed shed mediastinal blood containing significantly greater (p < 0.0001) amounts of fibrin degradation products and D-dimer protein. Of the hematologic, microaggregate, and plasma protein measurements performed, only the protein C level was significantly greater in group 1 (p < 0.05) after transfusion. Patient bleeding times were not significantly different between the groups at any of the time points, and the total postoperative blood loss was not different between the groups. There was a trend toward less need for homologous transfusion in group 1 (p < 0.1). This study documents the safety and ease of using nonwashed shed mediastinal blood as a primary blood volume support after an open heart operation.