Mulibrey Nanism Syndrome: A Case for Heart Transplantation.

Mulibrey nanism syndrome is a rare genetic disorder affecting multiple organ systems. The cardiovascular system is one of the most significantly affected, with simultaneous myocardial and pericardial disease. These patients are usually managed by pericardiectomy to resolve the milieu of hemodynamic problems ensuing due to concurrent constrictive and restrictive pathologies. We highlight the use of cardiac transplantation as a definitive management for a hemodynamically decompensated patient with Mulibrey nanism syndrome.

Early Outcomes After Mitral Valve Repair versus Replacement in the Elderly: A Propensity Matched Analysis.

BACKGROUND: To compare early outcomes of mitral valve repair versus replacement in elderly patients with degenerative mitral valve disease. METHODS: A retrospective review of prospectively collected clinical data of patients over 75 years of age, who underwent mitral valve surgery for degenerative disease, between 2010 and 2013, was carried out. Those undergoing mitral valve repair and replacement were propensity matched to adjust for baseline clinical differences. RESULTS: A total 260 patients were identified: mitral valve repair was undertaken in 145 and replacement in 115 patients. After propensity matching, 78 patients were included in each group. In the entire, unmatched population, in-hospital mortality was significantly higher in those undergoing replacement compared with those undergoing repair (9.6% vs 1.4%, p=0.003). In-hospital death occurred in six (7.7%) of the propensity matched replacement group and none in the repair group (p=0.012). Amongst the propensity matched groups, probability of survival at 1, 2 and 3 years were 0.94, 0.90 and 0.86 respectively for the repair group and 0.85, 0.77 and 0.69 for the replacement group: the HR for death between replacement and repair is 2.5 (1.2-5.4), p=0.012. CONCLUSIONS: Within the limitations imposed by retrospective analyses, our study demonstrates that, in elderly patients with degenerative disease of the mitral valve, repair is associated with improved short-term and mid-term outcomes compared with mitral valve replacement.

Lung donation after circulatory determined death: a single-centre experience.

OBJECTIVES: Donor organ utilization and shortage remain the major limitations to the opportunity of a lung transplantation (LTx). Donation after circulatory determined death (DCD) has been adopted as a source of additional organs worldwide. However, concerns about organ quality and ischaemia-reperfusion injury have limited its application. The aim of this study was to retrospectively analyse a single-centre experience in the DCD LTx and compare early and mid-term outcomes with those from a standard donation after brain death (DBD). METHODS: During the 6-year study period, 186 LTxs were performed: 147 bilateral LTxs (79%) and 39 single LTxs (21%). Of these, 23 recipients received organs retrieved from DCD donors (12.4%). RESULTS: No differences were found between the 2 groups of recipients except for age and cystic fibrosis as an underlying disease. No differences in terms of duration of mechanical ventilation, incidence of postoperative extracorporeal membrane oxygenation support, intensive care unit stay, hospital length of stay, airway anastomotic complications, incidence and grade of rejection and freedom from bronchiolitis obliterans syndrome were demonstrated. There was a non-statistically significant trend towards older age in the DCD group. Actuarial survival in the subgroup of bilateral LTx at 1 year and 5 years was 75% and 51% for the DCD group and 82% and 61% for the DBD group, respectively (P = 0.12). CONCLUSIONS: Short- and medium-term outcomes after the DCD LTx are comparable with those achieved after transplantation from the DBD donors, despite a tendency to use DCD lungs for older recipients. Therefore, the DCD LTx is a clinical option that can be used with favourable results to expand the lung donor pool.

Impact of donor cardiac arrest on heart transplantation.

BACKGROUND: Cardiac transplantation is an effective therapy for patients with end-stage heart failure, but it is still hindered by the lack of donor organs. A history of donor cardiac arrest raises trepidation regarding the possibility of poor post-transplant outcomes. The impact of donor cardiac arrest following successful cardiopulmonary resuscitation on heart transplant outcomes is unknown. Therefore, we sought to evaluate the impact of donor cardiac arrest on orthotropic heart transplantation using the United Network for Organ Sharing database. METHODS: We performed a secondary longitudinal analysis of all cardiac transplants performed between April 1994 and December 2011 through the United Network for Organ Sharing registry. Multiorgan transplants, repeat transplants, and pediatric recipients were excluded. Survival analyses were performed using Kaplan-Meier methods as well as multivariate adjusted logistic regression and Cox proportional hazard models. RESULTS: A total of 19,980 patients were analyzed. In 856 cases, the donors had histories of cardiac arrest, and in the remaining 19,124 cases, there was no history of donor cardiac arrest. The unadjusted 1-, 5-, and 10-year actuarial survival rates between the arrest and the nonarrest groups were not significantly different. Multivariate logistic regression demonstrated no difference in survival in the donor arrest group at 30 days, 1 year, or 3 years. Furthermore, the adjusted Cox proportional hazard model for cumulative survival also showed no survival difference between the 2 groups. CONCLUSION: If standard recipient and donor transplantation criteria are met, a history of donor cardiac arrest should not prohibit the potential consideration of an organ for transplantation.

A cardioprotective preservation strategy employing ex vivo heart perfusion facilitates successful transplant of donor hearts after cardiocirculatory death.

BACKGROUND: Ex vivo heart perfusion (EVHP) has been proposed as a means to facilitate the resuscitation of donor hearts after cardiocirculatory death (DCD) and increase the donor pool. However, the current approach to clinical EVHP may exacerbate myocardial injury and impair function after transplant. Therefore, we sought to determine if a cardioprotective EVHP strategy that eliminates myocardial exposure to hypothermic hyperkalemia cardioplegia and minimizes cold ischemia could facilitate successful DCD heart transplantation. METHODS: Anesthetized pigs sustained a hypoxic cardiac arrest and a 15-minute warm ischemic standoff period. Strategy 1 hearts (S1, n = 9) underwent initial reperfusion with a cold hyperkalemic cardioplegia, normothermic EVHP, and transplantation after a cold hyperkalemic cardioplegic arrest (current EVHP strategy). Strategy 2 hearts (S2, n = 8) underwent initial reperfusion with a tepid adenosine-lidocaine cardioplegia, normothermic EVHP, and transplantation with continuous myocardial perfusion (cardioprotective EVHP strategy). RESULTS: At completion of EVHP, S2 hearts exhibited less weight gain (9.7 ± 6.7 [S2] vs 21.2 ± 6.7 [S1] g/hour, p = 0.008) and less troponin-I release into the coronary sinus effluent (4.2 ± 1.3 [S2] vs 6.3 ± 1.5 [S1] ng/ml; p = 0.014). Mass spectrometry analysis of oxidized pleural in post-transplant myocardium revealed less oxidative stress in S2 hearts. At 30 minutes after wean from cardiopulmonary bypass, post-transplant systolic (pre-load recruitable stroke work: 33.5 ± 1.3 [S2] vs 19.7 ± 10.9 [S1], p = 0.043) and diastolic (isovolumic relaxation constant: 42.9 ± 6.7 [S2] vs 65.2 ± 21.1 [S1], p = 0.020) function were superior in S2 hearts. CONCLUSION: In this experimental model of DCD, an EVHP strategy using initial reperfusion with a tepid adenosine-lidocaine cardioplegia and continuous myocardial perfusion minimizes myocardial injury and improves short-term post-transplant function compared with the current EVHP strategy using cold hyperkalemic cardioplegia before organ procurement and transplantation.

Enhanced left ventricular mass regression after aortic valve replacement in patients with aortic stenosis is associated with improved long-term survival.

BACKGROUND: Aortic valve replacement in patients with aortic stenosis is usually followed by regression of left ventricular hypertrophy. More complete resolution of left ventricular hypertrophy is suggested to be associated with superior clinical outcomes; however, its translational impact on long-term survival after aortic valve replacement has not been investigated. METHODS: Demographic, operative, and clinical data were obtained retrospectively through case note review. Transthoracic echocardiography was used to measure left ventricular mass preoperatively and at annual follow-up visits. Patients were classified according to their reduction in left ventricular mass at 1 year after the operation: group 1, less than 25 g; group 2, 25 to 150 g; and group 3, more than 150 g. Kaplan-Meier and multivariable Cox regression were used. RESULTS: A total of 147 patients were discharged from the hospital after aortic valve replacement for aortic stenosis between 1991 and 2001. Preoperative left ventricular mass was 279 ± 98 g in group 1 (n = 47), 347 ± 104 g in group 2 (n = 62), and 491 ± 183 g in group 3 (n = 38) (P < .001). Mean time to last echocardiogram was 6.2 ± 3.2 years. Left ventricular mass at late follow-up was 310 ± 119 g in group 1, 267 ± 107 g in group 2, and 259 ± 96 g in group 3 (P = .05). Transvalvular gradients at follow-up were not significantly different among the groups (group 1, 24.8 ± 23 mm Hg; group 2, 21.4 ± 16 mm Hg; group 3, 14.7 ± 9 mm Hg) (P = .31). There was no difference in the prevalence of other factors influencing left ventricular mass regression such as ischemic heart disease or hypertension, valve type, or valve size used. Ten-year actuarial survival was not statistically different in patients with enhanced left ventricular mass regression when compared with the log-rank test (group 1, 51% ± 9%; group 2, 54% ± 8%; and group 3, 72% ± 10%) (P = .26). After adjustment, left ventricular mass reduction of more than 150 g was demonstrated as an independent predictor of improved long-term survival on multivariate analysis (P = .02). CONCLUSIONS: Our study is the first to suggest that enhanced postoperative left ventricular mass regression, specifically in patients undergoing aortic valve replacement for aortic stenosis, may be associated with improved long-term survival. In view of these findings, strategies purported to be associated with superior left ventricular mass regression should be considered when undertaking aortic valve replacement.

Intractable ventricular tachycardia secondary to cardiac hemangioma.

Cardiac tumors are rare and have a known association with ventricular dysrhythmias, especially ventricular tachycardia. We report a case of intractable ventricular tachycardia in a middle-aged man developing on a background of known, presumed benign, cardiac neoplasm. The ventricular tachycardia was controlled with long-term medical therapy. Surgical resection of the cardiac mass combined with cryoablation cured the dysrhythmia. Appearances at histopathology were those of a benign intracardiac hemangioma. Surgical treatment has an important but forgotten role in the management of ventricular arrhythmias, which is more definitive and carries a higher success rate compared with medical management.

Is stress cardiomyopathy the underlying cause of ventricular dysfunction associated with brain death?

Most deaths in the first 30 days after cardiac transplantation are due to failure of the donor heart, often with the clinical picture of right ventricular failure. Indeed, there is a significant reduction in contractility of the human donor heart and loss of contractile reserve before and soon after transplantation. This myocardial insult appears in association with brain death in the donor and follows a "catecholamine storm" associated with a rapidly rising intracranial pressure. Microscopy of the myocardium in organ donors shows a picture typical of catecholamine-induced injury and similar to changes found in endomyocardial specimens of stress cardiomyopathy (catecholamine-induced cardiomyopathy, or Takotsubo cardiomyopathy). There are 3 common features between stress cardiomyopathy and the heart of a brain-dead donor: exposure of the heart to unusually high catecholamine levels, ventricular dysfunction, and prompt recovery. Stress cardiomyopathy is a temporary myocardial dysfunction that has been described after sub-arachnoid hemorrhage, traumatic head injury, pheochromocytoma, acute emotional distress, exogenous administration of catecholamines, and non-related surgery. Given the common features of this catecholamine-mediated myocardial insult, we ask if brain-dead donor heart dysfunction is an extreme variant of stress cardiomyopathy? And, if so is it, like stress cardiomyopathy, reversible? Can we therefore expect recovery of the dysfunctional donor heart over time, thereby permitting increased use of hearts offered for transplantation?

Impact of the indexed effective orifice area on mid-term cardiac-related mortality after aortic valve replacement.

BACKGROUND: There has been ongoing controversy as to whether prosthesis-patient mismatch (PPM, defined as indexed effective orifice area (EOAI) <0.85 m(2)/cm(2)) influences mortality after aortic valve replacement (AVR). In most studies, PPM is anticipated by reference tables based on mean EOAs as opposed to individual assessment. These reference values may not reflect the actual in vivo EOAI and hence, the presence or absence of PPM may be based on false assumptions. OBJECTIVE: To assess the impact of small prosthesis EOA on survival after aortic valve replacement AVR. METHODS: 645 patients had undergone an AVR between 2000 and 2007 entered the study. All patients underwent transthoracic echocardiography for determination of the actual EOAI within 6 months postoperatively. In order to predict time from surgery to death a proportional hazards model for competing risks (cardiac death vs death from other causes) was used. EOAI was entered as a continuous variable. RESULTS: PPM occurred in 40% of the patients. After a median follow-up of 2.35 years, 92.1% of the patients were alive. The final Cox regression model showed a significantly increased risk for cardiac death among patients with a smaller EOAI (HR=0.32, p=0.022). The effect of EOAI on the 2-5 year mortality risk was demonstrated by risk plots. CONCLUSIONS: In contrast to previous studies these EOAI values were obtained through postoperative echocardiography, substantially improving the accuracy of measurement, and the EOAI was modelled as a continuous variable. There was a significantly improved survival for larger EOAIs following AVR. Strategies to avoid PPM should become paramount during AVR.

What are the predictors that affect the excellent long-term benefits of redo coronary artery bypass grafting?

OBJECTIVE: Recurrent angina refractory to medical therapy in patients having undergone prior coronary artery bypass grafting (CABG) is an indication for repeat surgical revascularisation. The primary aim of this retrospective study was to determine the benefit of redo surgery over the longer term with regards to survival and freedom from cardiac symptoms/events. Our secondary aim was to identify risk factors that compromise surgical efficacy of redo revascularisation. METHODS: Patients were identified through case note review. Survivors were interviewed by telephone according to a defined protocol. Actuarial freedom from cardiac symptoms/events and survival were determined. A composite outcome for cardiac symptoms/events was used and defined as angina class> or =2 or NYHA> or =2 or myocardial infarction or need for percutaneous intervention. Univariate and multivariate analysis was performed. Survival was assessed using a Kaplan-Meier method, and determinants of survival with the Cox proportional hazards model. RESULTS: Between January 1st, 1996 and February 1st, 2004, 101 consecutive patients underwent redo CABG at our institution under the care of a single surgeon. There were 91 men and 10 women, 64% (65/101) had an age> or =70 years. 30-Day mortality was 1.2% (2/101). Mean time to follow-up was 5.3+/-3.8 years. Poor left ventricular function and pre-operative NYHA> or =2 status were independent predictors of decreased survival with hazard ratios (HR) of 2.12 (1.042-4.31) and 3.98 (1.39-11.39) respectively. The use of a radial artery graft at re-operation was an independent predictor of peri-operative death OR=18 (1-346). Actuarial survival at 1, 5 and 8 years was 90.1%, 84.4% and 76.9% and freedom from cardiac symptoms/events was 100%, 95% and 68% respectively. CONCLUSION: This study shows acceptable short- and long-term survival and freedom from symptoms/events in patients undergoing redo coronary artery bypass grafting at a single institution. The apparent association between radial arterial grafts and impaired early clinical outcome warrants further investigation.

Medium to long-term clinical outcome following stentless aortic valve replacement: comparison between allograft and xenograft valves.

The xenograft stentless valve was designed to emulate the haemodynamic performance of the allograft. Early outcomes using either surgical option (stentless xenograft valve or allograft) have been similar. However, follow-up outcomes remain to be compared. Between 1st January 1991 and 1st January 2001, 415 patients underwent aortic valve replacement. Two hundred and seventeen patients received an allograft and in 198 patients a Toronto stentless porcine valve (TSPV) was implanted. Mean time to follow-up was 6.3+/-4.4 years. Ten years freedom from structural valve deterioration (SVD) (TSPV 86+/-5%, allograft 82+/-5%, P=0.49) and freedom from reoperation (RE) (TSPV 80+/-4% vs. allograft 85+/-4%, P=0.61) were not significantly different. The TSPV was associated with significantly worse actuarial survival than the homograft (TSPV 40+/-4% vs. homograft 55+/-4%, P=0.02). However, after adjustment for other variables using a multivariate model, TSPV use was not an independent predictor of impaired late survival (LS) (P=0.44). Kaplan-Meier analysis in a subgroup of patients aged 45-65 years comparing LS, RE and SVD between xenografts and allografts identified similar results. The porcine stentless valve may be associated with similar clinical performance to the allograft over the medium to long-term.

Stentless aortic valve replacement in patients with bicuspid aortic valve disease: clinical outcome and aortic diameter changes during follow-up.

OBJECTIVE: A bicuspid aortic valve (BAV) may be associated with an aortopathy affecting clinical outcome. Our aim was to assess long-term outcome and analyse if progressive aortic dilatation occurs with time in patients with BAV disease who underwent stentless valve replacement. METHODS: Demographic, operative and clinical data were retrospectively reviewed. Patients were classified according to whether their native aortic valve was identified as tricuspid (TC) or bicuspid (BC) at the time of AVR. Serial transthoracic echocardiography was used to measure changes in ascending aortic diameter over time. Propensity adjustment and multivariate regression were used. Events over time were assessed using the Kaplan-Meier method, and the determinants of events were assessed with the Cox proportional-hazards model. RESULTS: Between January 1991 and January 2001, 215 patients underwent AVR. They had a serial follow-up echocardiography performed for a mean of 6.1+/-4.3 years postoperatively. Ninety patients (41%) had a BAV, and the BC group was younger (BC 62+/-15 years vs TC 71+/-12 years; p=0.002). We found no difference in the increase in ascending aortic diameter over follow-up (BC 0.1+/-0.5 cm vs TC 0.0+/-0.5 cm; p=0.34). BC morphology was not an independent predictor of increased overall mortality (propensity-adjusted hazard ratio: 0.79; 95% confidence interval (CI): 0.42-1.44; p=0.44) or increased risk of reoperation (propensity adjusted hazard ration: 1.84; 95% CI: 0.88-3.36; p=0.11). CONCLUSION: Stentless AVR is protective against progressive aortic aneurysmal disease and confers excellent clinical outcomes in patients with BAV and normal preoperative ascending aortic diameter.

Propensity analysis of survival after subcoronary or root replacement techniques for homograft aortic valve replacement.

OBJECTIVE: Homograft aortic valve replacement is associated with excellent clinical and hemodynamic outcomes. Valves are implanted predominantly by using 2 techniques: the freehand subcoronary technique or as an aortic root replacement. Our aim was to identify any difference in survival, durability, and clinical performance. METHODS: Demographic, operative, and clinical data were obtained retrospectively through case-note review. All operations were performed by a single surgeon. Propensity score-adjusted analysis was used by developing a nonparsimonious logistic regression model for implantation with subcoronary versus root replacement. Actuarial survival and freedom from valve-related events were compared with Kaplan-Meier curves and multivariable proportional hazard Cox regression. RESULTS: Between January 1, 1991, and January 1, 2001, 215 patients underwent aortic valve replacement with a homograft. The subcoronary technique was used in 131 (61%) patients. Eighty-four (39%) patients underwent free-standing aortic root replacement. After propensity risk adjustment, the subcoronary implantation technique was associated with a decreased risk of 30-day death (adjusted odds ratio, 0.18; 95% confidence interval, 0.06-0.34; P = .03). Technique of insertion was not an independent predictor of overall mortality during follow-up after adjustment (propensity adjusted hazard ratio, 0.35; 95% confidence interval, 0.09-1.41; P = .18). There were no significant differences in 1- and 5-year actuarial survival, freedom from structural valve disease, endocarditis, or reoperation. CONCLUSIONS: Both the subcoronary and root replacement techniques for homograft aortic valve replacement are associated with excellent midterm survival and clinical performance. Root replacement was associated with an increased risk of perioperative death after adjustment for covariates by using propensity analysis.

Longitudinal study of the profile and predictors of left ventricular mass regression after stentless aortic valve replacement.

BACKGROUND: The aim of this study was to evaluate the long-term profile and determine the factors that would influence the effect and rate of ventricular mass regression with time after aortic valve replacement with a stentless or a homograft valve. METHODS: We studied 300 patients during a 10-year period with at least a year of follow-up with a total of 1,273 serial echocardiographic measurements. Left ventricular mass was calculated from M-mode recordings and indexed to body surface area. Longitudinal data analysis was performed using a linear mixed effects model. RESULTS: The mean age (+/- standard deviation) was 65 (+/-14) years, consisting of 216 (72%) males. A stentless valve was implanted in 156 (52%), and a homograft in 144 (48%). The median time (interquartile range) to follow-up was 4.7 (2.8 to 6.6) years. The greatest rate of left ventricular mass regression occurred in the first year after surgery. On multivariable modeling, independent predictors of left ventricular mass were valve size (p = 0.011), left ventricular function (moderate impairment, p = 0.418; severe impairment, p = 0.011), and baseline left ventricular mass (middle tercile, p < 0.001; highest tercile, p < 0.001). Only baseline ventricular mass influenced the rate of subsequent left ventricular mass regression; the greatest rate of regression occurred in patients with the highest baseline values of ventricular mass (p < 0.001). CONCLUSIONS: The greatest rate of left ventricular mass regression occurs in the first year with baseline left ventricular mass as the strongest predictor and the only identified variable that influenced the rate of left ventricular mass regression.

Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques.

Sub-valvular apparatus preservation after mitral valve replacement is not a new concept, yet to date there has been no quantification of its clinical effectiveness as a procedure and no consensus as to which surgical preservation technique should be adopted to achieve the best immediate and midterm clinical outcomes. This systematic review of current available literature aims to use an evidence synthesis and meta-analytic approach to compare outcomes following replacement of the mitral valve with (MVR-P) or without preservation (MVR-NP) of its apparatus. It considers all the relevant anatomical, experimental, echocardiographic, and clinical studies published in the literature and appraises all reported mitral valve sub-valvular apparatus preservation techniques. The results of this review strongly suggest that MVR-P is superior to MVR-NP with regards to the incidence of early postoperative low-cardiac output requiring inotropic support, and early or mid-term survival. They also suggest that the operative decision should be individualised based on patient's anatomy, pathology and ventricular function and therefore surgeons should be familiar with more than one surgical preservation technique. Finally, this paper highlights the need for further high quality research focusing particularly on the long-term assessment of quality of life and health utility following MVR-P.

Remote ischemic preconditioning reduces myocardial and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial.

BACKGROUND: Myocardial and renal injury commonly contribute to perioperative morbidity and mortality after abdominal aortic aneurysm repair. Remote ischemic preconditioning (RIPC) is a phenomenon whereby brief periods of ischemia followed by reperfusion in one organ provide systemic protection from prolonged ischemia. To investigate whether remote preconditioning reduces the incidence of myocardial and renal injury in patients undergoing elective open abdominal aortic aneurysm repair, we performed a randomized trial. METHOD AND RESULTS; Eighty-two patients were randomized to abdominal aortic aneurysm repair with RIPC or conventional abdominal aortic aneurysm repair (control). Two cycles of intermittent crossclamping of the common iliac artery with 10 minutes ischemia followed by 10 minutes reperfusion served as the RIPC stimulus. Myocardial injury was assessed by cardiac troponin I (>0.40 ng/mL), myocardial infarction by the American College of Cardiology/American Heart Association definition and renal injury by serum creatinine (>177 micromol/L) according to American Heart Association guidelines for risk stratification in major vascular surgery. The groups were well matched for baseline characteristics. RIPC reduced the incidence of myocardial injury by 27% (39% versus 12% [95% CI: 8.8% to 45%]; P=0.005), myocardial infarction by 22% (27% versus 5% [95% CI: 7.3% to 38%]; P=0.006), and renal impairment by 23% (30% versus 7%; [95% CI: 6.4 to 39]; P=0.009). Multivariable analysis revealed the protective effect of RIPC on myocardial injury (OR: 0.22, 95% CI: 0.07 to 0.67; P=0.008), myocardial infarction (OR: 0.18, 95% CI: 0.04 to 0.75; P=0.006) and renal impairment were independent of other covariables. CONCLUSIONS: In patients undergoing elective open abdominal aortic aneurysm repair, RIPC reduces the incidence of postoperative myocardial injury, myocardial infarction, and renal impairment.

Early clinical and hemodynamic outcomes after stented and stentless aortic valve replacement: results from a randomized controlled trial.

BACKGROUND: Stentless aortic bioprostheses were shown to be hemodynamically superior to earlier generations of stented bioprostheses. Modern stented valve designs have improved hemodynamics. A prospective randomized controlled trial was undertaken to compare stentless versus modern stented valves. Our aim was to determine any differences in early postoperative clinical and hemodynamic outcomes. METHODS: Patients with severe aortic valve stenosis (n = 161) undergoing aortic valve replacement were randomized intraoperatively to receive either the C-E Perimount (Edwards Lifesciences, Irvine, CA) pericardial stented bioprosthesis (n = 81) or the Prima Plus (Edwards Lifesciences) (porcine stentless bioprosthesis (n = 80). Transthoracic echocardiograms were performed at one week and eight weeks postoperatively to assess left ventricular mass (LVM) and transvalvular gradients (TVG). RESULTS: There were no differences between the two groups in baseline characteristics. Cardiopulmonary bypass and ischemic times were longer in the stentless group. Despite similar native aortic annular diameters, the mean size of the prosthesis used in the stentless group was 2.1 mm (SD = 2.8) larger (p < 0.001). Early (30-day) mortality (stentless 3.7% vs stented 2.5%; p = 0.68) and morbidity was similar between groups. Eight weeks postoperatively, LVM (stentless 199 +/- 70 vs stented 204 +/- 66 grams; p = 0.32) and TVG decreased in both groups (mean systolic gradient; stentless 10 +/- 3 vs stented 10 +/- 4 mm Hg; p = 0.54) but there was no significant difference between groups. CONCLUSIONS: Despite longer ischemic times in the stentless group, early postoperative outcomes were similar. Both stented and stentless aortic valve replacement offers excellent hemodynamics and can be achieved with low perioperative mortality.

Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation.

OBJECTIVE: Cardiac arrest in the organ donor raises concerns about the possibility of ischemic cardiac damage. We evaluated the outcome of heart transplantation in patients receiving an organ from donors who had suffered a period of cardiac arrest. METHODS: Demographics, operative details and outcome data were obtained retrospectively. Actuarial survival was reported using Kaplan-Meier analysis and compared with the log rank test. Cox proportional hazards regression was used to model risk adjusted survival. RESULTS: Between 1 January 1991 and 1 November 2004 38 patients were transplanted with hearts from multiorgan donors who were resuscitated after a cardiac arrest. The mean (standard deviation) duration of cardiac arrest was 15 (8)min. The interval between donor cardiac arrest and organ excision was 69 (5)h. The 30-day mortality was 2.6% (1/38). In the same interim 566 patients underwent cardiac transplantation with hearts from organ donors without a cardiac arrest. Median time to follow up was 61 months (IQR 15-166). One and 5-year survival comparing the arrest and non-arrest groups was 94.2% versus 83.6% and 79.8% versus 74.5%, respectively, p=0.35. Donor cardiac arrest was not an adverse predictor of mortality on multivariate analysis, the adjusted odds ratio was 0.86 (95% CI 0.60-1.25, p=0.42). CONCLUSIONS: With careful case selection, there was no evidence that survival after cardiac transplantation was worse following a period of cardiac arrest in the organ donor. A history of cardiac arrest in the organ donor should not exclude an organ from being considered for transplantation.

Acute leukaemoid reaction following cardiac surgery.

Chronic myelomonocytic leukaemia is an atypical myeloproliferative disorder with a natural history of progression to acute myeloid leukaemia, a complex and poorly understood response by the bone marrow to stress. Cardiac surgery activates many inflammatory cascades and may precipitate a systemic inflammatory response syndrome. We present a case of undiagnosed chronic myelomonocytic leukaemia who developed rapidly fatal multi-organ dysfunction following cardiac surgery due to an acute leukaemoid reaction.

Are stentless valves superior to modern stented valves? A prospective randomized trial.

BACKGROUND: It is presumed that stentless aortic bioprostheses are hemodynamically superior to stented bioprostheses. A prospective randomized controlled trial was undertaken to compare stentless versus modern stented valves. METHODS AND RESULTS: Patients with severe aortic valve stenosis (n=161) undergoing aortic valve replacement (AVR) were randomized intraoperatively to receive either the C-E Perimount stented bioprosthesis (n=81) or the Prima Plus stentless bioprosthesis (n =80). We assessed left ventricular mass (LVM) regression with transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI). Transvalvular gradients were measured postoperatively by Doppler echocardiography to compare hemodynamic performance. There was no difference between groups with regard to age, symptom status, need for concomitant coronary artery bypass surgery, or baseline LVM. LVM regressed in both groups but with no significant difference between groups at 1 year. In a subset of 50 patients, MRI was also used to assess LVM regression, and again there was no significant difference between groups at 1 year. Hemodynamic performance of the 2 valves was similar with no difference in mean and peak systolic transvalvular gradients 1 year after surgery. In patients with reduced ventricular function (left ventricular ejection fraction [LVEF] <60%), there was a significantly greater improvement in LVEF from baseline to 1 year in stentless valve recipients. CONCLUSIONS: Both stented and stentless bioprostheses are associated with excellent clinical and hemodynamic outcomes 1 year after AVR. Comparable hemodynamics and LVM regression can be achieved using a second-generation stented pericardial bioprosthesis. In patients with ventricular impairment, stentless bioprostheses may allow for greater improvement in left ventricular function postoperatively.