Role of paediatric assist device in bridge to transplant.

BACKGROUND: While heart transplantation has gained recognition as the gold standard therapy for advanced heart failure, the scarcity of donor organs has become an important concern. The evolution of surgical alternatives such as ventricular assist devices (VADs), allow for recovery of the myocardium and ensure patient survival until heart transplantation becomes possible. This report elaborates the role of VADs as a bridge to heart transplantation in infants and children (≤18 years old) with end-stage heart failure. METHODS: A retrospective review of the medical records of 201 heart transplant recipients between May 1986 and September 2014 identified 78 children [38.8%; mean age 7.2 (7.8±6.0) years old; IQR: 2.6-11.8 years] with advanced heart failure who were supported with a VAD [left VAD (LVAD) =21; biventricular VAD (BVAD) =57] as a bridge to heart transplantation. Fourteen (17.9%) patients were less than 1 year old; 15 (19.2%) children had a cardiac arrest and underwent cardiopulmonary resuscitation, with 7 of these patients also requiring extracorporeal membrane oxygenation (ECMO) support prior to implantation of a VAD. The aetiology of heart failure was primarily cardiomyopathy (dilative, restrictive from endocardial fibrosis, idiopathic or toxic-induced), reported in 56 (71.8%) patients. The VADs employed were primarily Berlin Heart EXCOR® (n=63), HeartWare (n=13), Berlin Heart INCOR® (n=1), and Toyobo (n=1). RESULTS: Mean duration of VAD support was 59 (133.37±191.57) days (range, 1-945 days; IQR: 23-133 days) before a donor heart became available. The primary complication encountered while patients were being bridged to transplant was mediastinal bleeding (7.8%). The main indication for pump exchanges was thrombus formation in the valves. There was no incidence of technical failure of the blood pump or driving system components. Skin infections around the cannulae occurred in 2.5%. Adverse neurological symptoms (thromboembolism 11.1%, cerebral haemorrhage 3.6%) that occurred did not have any permanent neurological sequelae that could be detected on clinical examination in this study. Mean duration of follow-up was 9.4 (10.3±7.6) years (IQR: 3.74-15.14 years). Cumulative survival rates of patients bridged to transplantation with VAD were 93.6%±2.8%, 84.6%±4.1%, 79.1%±4.7%, 63.8%±6.2%, 61.6%±7.1%, and 52.1%±9.3% at 30 days, 1, 5, 10, 15 and 20 years, respectively. There was no statistically significant difference (P=0.79) in survival rates of patients bridged to heart transplantation with VAD compared to those who underwent primary heart transplantation. Post-transplant survival rates stratified according to the type of VAD implanted and number of ventricles supported were not statistically different (P=0.93 and 0.73, respectively). In addition, post-transplant survival rates were not significantly different when age, gender and diagnosis were adjusted for. Furthermore, no statistically significant difference was found when post-transplant survival rates of children who had episodes of rejection were compared to those who did not have episodes of rejection. CONCLUSIONS: The results in this series demonstrate that VADs satisfactorily support paediatric patients with advanced heart failure from a variety of aetiologies until heart transplantation. The data further suggests that patients bridged with VADs have comparable long-term post-transplant survival as those undergoing primary heart transplantation.

Repair for Congenital Mitral Valve Stenosis.

We report the techniques and long-term outcome of mitral valve (MV) repair to correct congenital mitral stenosis in children. Between 1986 and 2014, 137 children (mean age 4.1 ± 5.0, range 1 month-16.8 years) underwent repair of congenital mitral stenosis (CMS). In 48 patients, CMS is involved in Shone's anomaly. The typical congenital MS (type I) was seen in 56 patients. Hypoplastic MV (type II, n = 15) was associated with severe left ventricular outflow tract abnormalities and hypoplastic left ventricular cavity and muscle mass. Supravalvar ring (type III, n = 48) ranged from a thin membrane to a thick discrete fibrous ridge. Parachute MV (type IV, n = 10) have 2 leaflets and barely distinguishable commissures, but all chordae merged either into 1 major papillary muscle or asymmetric papillary muscles-1 dominant and the other minuscule. Hammock valve (type IV, n = 8) appeared dysplastic with shortened chordae directly inserted into the posterior left ventricular muscle mass. MV repair was performed using commissurotomy, chordal division, papillary muscle splitting and fenestration, and mitral ring resection, each applied according to the presenting morphology. During the 28-year follow-up period, 23 patients underwent repeat MV repair and 3 underwent MV replacement after failed attempts at repeat repair. At 1 and 15 years postoperatively, freedom from reoperation was 89.3 ± 5.1% and 52.8 ± 11.8%, and cumulative survival rates were 92.3 ± 4.3% and 70.3 ± 8.9, respectively. Mortality unrelated to repair accounted for 9 (20%) deaths. Long-term functional outcome of MV repair in children with CMS is satisfactory. Repeat repair or replacement may be deemed necessary during the course of follow-up.

Existing issues and valid concerns in continuous-flow ventricular assist devices.

INTRODUCTION: Through concerted endeavours in the fields of surgery, medicine, and biomedical engineering, patronized by government and industry, ventricular assist devices have become an established surgical treatment to support the failing heart, which could easily and simply surpass the frequency of heart transplantation. Be it as it may, complications and adverse events have unfolded, and these facilitated the way to newer biomedically-engineered pump designs in search of the perfect support for a failing heart. Areas covered: This review focuses on the evolution of the continous-flow ventricular assist device as an accepted mode of treatment in advanced heart failure, as a bridge to myocardial recovery, as a bridge to heart transplantation and as a permanent therapy, with its attendant complications and long-term outcome. Expert commentary: Continuous flow devices offer improved durability, less surgical trauma due to their smaller size, high-energy efficiency, and lower thrombogenicity, regardless of administration of single or dual anti-thrombotic therapy. These benefits translate into better survival, lower frequency of adverse events, improved quality of life and higher functional capacity of patients. Through ceaseless innovations and technology, newer pumps have been developed; however, none has been proven to be superior over the others.

Long-term outcome of simultaneous septal myectomy and anterior mitral leaflet retention plasty in hypertrophic obstructive cardiomyopathy: the Berlin experience.

BACKGROUND: Various surgical strategies designed to relieve left ventricular outflow tract obstruction (LVOTO) and correct mitral regurgitation (MR) in hypertrophic obstructive cardiomyopathy (HOCM) have evolved, yet reports on the long-term outcomes of each technique are scarce. We provide an update on over 20 years' experience at our institution in the standardized surgical treatment of HOCM. METHODS: Between April 1986 and April 2014, 320 cases of endomyocardial resection and 305 septal myectomies were performed at our institution. Out of this sample, 57 patients (mean age 38±2.5 years, median 16.2, range 3 months-79.8 years) underwent surgery for HOCM involving septal myectomy and anterior leaflet retention plasty (ALRP), intended to obviate the systolic anterior motion (SAM) phenomenon. The preoperative mean LVOT pressure gradient was 98.98±26.2 (median 90, range 60-160) mmHg with moderate-severe MR. Standard transaortic septal myectomy was performed by resecting long blocks of septal myocardium, continued apically beyond the point of the mitral-septal contact. Through a left atriotomy, the segment of anterior mitral leaflet (AML) closest to the trigones was sutured to the corresponding posterior annulus on both sides. Cardiopulmonary bypass was resumed for repeat septal myectomy if the LVOT pressure gradient was greater than 20 mmHg. RESULTS: Following surgical correction, the mean LVOT pressure gradient was significantly decreased to 12.3±2.7 (median 14, 18-25) mmHg (P<0.001). Septal thickness was reduced from a preoperative mean of 28.2±3.4 (median 30, 25-34) to 10.5±1.1 (12, 15-23) mm (P<0.001). During a mean follow-up of 17.5±1.3 years (median 12, range 1-23.2 years), MR was trivial in 87% and SAM was non-existent in all, outcomes that were maintained at the latest follow-up. Two patients underwent mitral valve (MV) replacement 1 and 5 years after ALRP for recurrent MR. Two patients eventually underwent heart transplantation for end-stage heart failure, 2 and 11 years later, respectively. Twenty-year freedom from repeat MV intervention and cumulative survival rate was 92.9% and 91.2%, respectively. CONCLUSIONS: Long-term follow up of HOCM patients who underwent simultaneous septal myectomy and ALRP showed sustained absence of SAM, attenuation of MI, absence of residual LVOT obstruction and sustained improvement in hemodynamic and functional status.

Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch.

OBJECTIVES: Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch. METHODS: Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9-23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmHg at rest and 180 ± 40 mmHg during exercise, with a mean pressure gradient of 80 ± 11.6 (range 40-120) mmHg. RESULTS: Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10-26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmHg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon. CONCLUSIONS: Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.

The Double-Orifice Valve Technique to Treat Tricuspid Valve Incompetence.

BACKGROUND: A straightforward tricuspid valve (TV) repair technique was used to treat either moderate or severe functional (normal valve with dilated annulus) or for primary/organic (Ebstein's anomaly, leaflet retraction/tethering and chordal malposition/tethering, with annular dilatation) TV incompetence, and its long-term outcome assessed. METHODS: A double-orifice valve technique was employed in 91 patients (mean age 52.6 ± 23.2 years; median age 56 years; range: 0.6-82 years) with severe tricuspid regurgitation. Among the patients, three had post-transplant iatrogenic chordal rupture, five had infective endocarditis, 11 had mitral valve insufficiency, 23 had Ebstein's anomaly, and 47 had isolated severe TV incompetence. The basic principle was to reduce the distance between the coapting leaflets, wherein the most mobile leaflet could coapt to the opposite leaflet, by creating two orifices, ensuring valve competence. The TV repair was performed through a median sternotomy or right anterior thoracotomy in the fifth intercostal space under cardiopulmonary bypass. The degree and extent of creating a double-valve orifice was determined by considering the minimal body surface area (BSA)-related acceptable TV diameter. Repair was accomplished by passing pledgeted mattress sutures from the middle of the true anterior annulus to a spot on the opposite septal annulus, located approximately two-thirds of the length of the septal annulus to avoid injury to the bundle of His. The annular apposition divides the TV into a larger anterior and a smaller posterior orifices, enabling valve closure, on both sides. In adults, the diameter of the anterior valve orifice should be 23-25 mm, and the posterior orifice 15-18 mm; thus, the total valve orifice area is 5-6 cm2. In children, the total valve orifice should be a standard deviation of 1.7 mm for a BSA of <1. 0m2, and 1.5 mm for a BSA of >1.0m2. RESULTS: During a mean follow up of 8.7 ± 1.34 years (median 10 years; range: 1.5-25.9 years) there have been no reoperations for TV insufficiency or stenosis. Reoperations on three patients (mean age 42.5 ± 8.7 years) were indicated for aortic valve replacement at 14 months postoperatively (n = 1) and for assist device implantation (n = 2) who eventually underwent heart transplant at 18 and 20 months after TV repair, respectively. The cumulative 12-year survival rate was 86.9%. CONCLUSIONS: This double-orifice technique is technically a straightforward repair to abolish TV incompetence with highly satisfactory results, particularly in patients with severe annular dilatation or with leaflet and chordal tethering. In the present series, the technique provided no pitfalls (if the location of the conduction system was borne in mind), requiring only a gentle placement of sutures. It also led to no residual regurgitation or reoperation during the follow up period.

Rotary Blood Pumps as Long-Term Mechanical Circulatory Support: A Review of a 15-Year Berlin Experience.

This article reports our 15-year single-center experience with rotary blood pumps (RBPs) as long-term mechanical circulatory support (MCS) with emphasis on outcomes. For more than 15-year period, we have used various RBPs as bridge to transplantation or to myocardial recovery. Our group performed the first human implantation worldwide of RBCs, the MicroMed DeBakey ventricular assist device in November 1998 in a patient with end-stage heart failure who was supported for 47 days until his death. Based on this initial experience, we recognized the feasibility of providing long-term support and since then it has been our primary armamentarium in treating patients with heart failure. Between 1987 and September 2013, we have implanted 2208 ventricular assist devices ranging from pulsatile to continuous-flow systems, as short-term, long-term, or permanent support in patients with end-stage heart failure. In total, 1009 RBPs were implanted on 908 patients, and their outcomes are reported here. We have shared some milestones in MCS including the first implantation of Jarvik 2000 on the oldest patient (81-year old) in 2008 and the first worldwide implantation of a biventricular HeartWare. Over time, implantation techniques, anticoagulation, and postoperative care have been modified and individualized. A relevant aspect of our experience has been the incidence of pump thrombosis. This is particularly frustrating because the problem has occurred in the setting of full anticoagulation and antiplatelet therapy, guided by strict anticoagulation monitoring. It has become clear to us that the devices are still not perfect. Technical pump failures such as cable breaks also occur, prompting urgent pump exchange, and infection. A 15-year cumulative mortality rate is 46.9%. This report emphasizes that MCS with RBPs has evolved into a routine treatment in heart failure and is a highly feasible option for permanent therapy particularly for elderly patients.

Primary Cardiac Tumors in Infants and Children: Surgical Strategy and Long-Term Outcome.

BACKGROUND: Primary cardiac tumors in infants and children are extremely rare; hence, there is very little literature available, and most knowledge is based on collections of case reports. This report is a comprehensive review of our 26-year experience with primary cardiac tumors in children with emphasis on surgical indications, strategies, and long-term outcome. METHODS: Between 1986 and 2012, 47 children (mean age 5.9 ± 2.4 months; range, 1 day to 17 years) underwent either subtotal or total resection of cardiac tumors (rhabdomyoma, 13; fibroma, 12; teratoma, 9; myxoma, 8; hemangioma, 2; rhabdomyosarcoma, 1; non-Hodgkin's lymphoma, 1; lymphangioma, 1). The majority were diagnosed by echocardiography (n = 33). Clinical patterns were varied: 40 had an atypical heart murmur and 6 were asymptomatic. Outflow tract obstruction of more than 30 mm Hg was present in 11 children. Three patients had abnormal coronary arteries secondary to pressure from tumor bulk. Indications of resection were hemodynamic/respiratory compromise, severe arrhythmia, and a significant embolization risk. Strategy of resection varied according to location and hemodynamic status without damage to adjacent structures. RESULTS: Morbidity included bleeding in a patient and a transient low output state in another. A 5-month-old infant with left ventricular fibroma underwent left ventricular assist device implantation secondary to failure from weaning off cardiopulmonary bypass, and she eventually underwent heart transplantation 17 days later. Early mortality (n = 2, 4.2%) included a 5-month-old infant who underwent complete resection of rhabdomyoma located in the left ventricle, with concomitant pulmonary valve replacement; unfortunately, he underwent left ventricular assist device implantation for postoperative heart failure and died on the 13th postoperative day. An 8-month-old child with 3 cm × 4 cm fibroma obstructing the right ventricular outflow tract compressing the right coronary artery died of severe right-side heart failure on the 13th postoperative day. One late death (2.1%) occurred; a 16-year-old with non-Hodgkin's lymphoma died 7 months after the surgery. Mean duration of follow-up is 11.6 ± 3.5 years. All survivors (93.4%) are well, free of tumor-related symptoms and tumor recurrence/progression, even when resection was incomplete. CONCLUSIONS: This study illustrates that although primary cardiac tumors in infants and children have a wide and unusual spectrum of clinical presentation, an individualized approach to tumor resection allows restoration of an adequate hemodynamic function and satisfactory long-term, tumor-free outcome.

Paediatric mechanical circulatory support with Berlin Heart EXCOR: development and outcome of a 23-year experience.

This paper reviews the development and establishment of the Berlin Heart EXCOR® (BHE®) as a paediatric mechanical circulatory support and reports our entire experience with regard to indications, timing of implantation and explantation and outcome. The Berlin group reported the first successful paediatric bridge to transplantation using a pulsatile pneumatic paracorporeal biventricular assist device, the BHE®, in 1990 in an 8-year-old boy with end-stage heart failure and coarctation of the aorta. This experience prompted them to develop miniaturized pump systems for children through the company Berlin Heart Mediproduct GmbH. The development and production of BHE® to support paediatric patients with heart failure then began. Between 1990 and 2013, the BHE® has been implanted in 122 patients (median age 8.64 years, range 3 days to 17 years) with heart failure, who were inotrope-dependent or switched from extracorporeal membrane oxygenation support or had postcardiotomy low-output syndrome. Thirty-five patients were <1 year old (median 125 days). The aetiology of heart failure included cardiomyopathy in 56 (median age 9.14 years), fulminant myocarditis in 17 (median age 8.2 years), end-stage congenital heart disease in 18 (median age 6.4 years), postcardiotomy heart failure (after correction of congenital heart disease) in 28 (median age 9.6 years) and transplant graft failure in 3 (median age 12.5 years). The overall median duration of implantation was 63.6 (range 1-841) days. Fifty-six children eventually underwent orthotopic heart transplantation. Eighteen patients had myocardial recovery and were weaned successfully. They had entirely normal cardiac function after a range of 4-10 years after surgery. At the time of this report, five patients were still on support, with a duration of 354-369 days. Forty-three patients died on the system from loss of peripheral circulatory resistance, multiorgan damage, sepsis or haemorrhagic or thrombotic complications. Re-exploration because of bleeding was necessary in 22 patients. Pump exchange because of thrombus formation in the valves was necessary 35 times. With the introduction of a modified anticoagulation regimen in 2000, the pump exchange rate has decreased. The BHE® can reliably support the circulation at any age for long periods with good results. It is now an established treatment for children with heart failure of any aetiology.

Repair of Parachute and Hammock Valve in Infants and Children: Early and Late Outcomes.

Parachute and hammock valves in children remain one of the most challenging congenital malformations to correct. We report our institutional experience with valve-preserving repair techniques and the early and late surgical outcomes in parachute and hammock valves in infants and children. From January 1990-June 2014, 20 infants and children with parachute (n = 12, median age = 2.5 years, range: 2 months-13 years) and hammock (n = 8, median age = 7 months, range: 1 month-14.9 years) valves underwent mitral valve (MV) repair. Children with parachute valves have predominant stenosis, whereas those with hammock valves often have predominant insufficiency. Intraoperative findings included fused and shortened chordae with single papillary muscles in children with parachute valves. MV repair was performed using annuloplasty, commissurotomy, leaflet incision toward the body of the papillary muscles, and split toward its base. Children with hammock valves have dysplastic and shortened chordae, absence of papillary muscles with fused and thickened commissures. MV repair consisted of carving off a suitably thick part of the left ventricular wall carrying the rudimentary chordae. The degree and extent of incision and commissurotomy is determined by the minimal age-related acceptable MV diameter to avoid mitral stenosis. During a median duration of follow-up of 9.6 years (range: 6.4-21.4 years), cumulative survival rate and freedom from reoperation in parachute valves were 43.7 ± 1.6% and 53.0 ± 1.8%, respectively. In hammock valves, during a median duration of follow-up of 6.7 years (range: 2.7-19.4 years), cumulative survival rate and freedom from reoperation was 72.9 ± 1.6% and 30.0 ± 1.7%, respectively. Age less than 1 year proved to be a high-risk factor for reoperation and mortality (P < 0.005). In conclusion, children with parachute and hammock valves, repeat MV repair may be necessary during the course of follow-up. Infants have a greater risk for reoperation and mortality.

Cardiomyopathy in Marfan syndrome.

OBJECTIVES: This report aims to evaluate the existence of primary and secondary cardiomyopathy in patients with Marfan syndrome (MFS) who underwent surgical management for primary cardiovascular sequelae of this genetic disorder. Likewise, we aim to determine whether the myocardium in MFS is susceptible to ischaemia independent of myocardial protection used during surgery. METHODS: Between April 1986 and May 2012, 421 patients with MFS were surgically treated for cardiovascular manifestations. Among them, 47 (mean age: 39.45 ± 12.64, median: 36, range: 19-66, years) eventually were surgically treated for cardiomyopathy. They were grouped into A: patients who subsequently developed ischaemic cardiomyopathy and eventually underwent coronary revascularization for coronary artery disease (n = 11); B: patients who subsequently developed end-stage cardiomyopathy for which a mechanical circulatory support device was implanted to support the failing heart (n = 13) and C: patients who subsequently developed end-stage cardiomyopathy (n = 23), among whom 21 underwent primary heart transplantation, while 2 patients are still waiting for donor hearts. RESULTS: Retrospective analysis of the medical records of 47 patients revealed the following: In Group A, 3 (27.2%) patients had already existing ischaemic cardiomyopathy before the first various cardiovascular surgeries, while ischaemic cardiomyopathy in the other 8 (72.7%) developed postoperatively. The interval between previous surgery and development of cardiomyopathy was a mean of 8.0 ± 07 years. In Group B, 5 (38.4%) had existing primary cardiomyopathy prior to surgery, while 8 (61.5%) developed end-stage cardiomyopathy postoperatively. The interval between previous surgery and development of cardiomyopathy was a mean of 9.0 ± 4 months. In Group C, 5 (21.7%) had been diagnosed with cardiomyopathy prior to the cardiovascular surgery, while 18 (78.2%) developed end-stage cardiomyopathy postoperatively. The mean interval between previous surgery and development of cardiomyopathy was 3 ± 0.9 years. At a mean follow-up of 9.4 ± 1.37 years, the overall survival rate is 51.8%. Categorized based on the surgical treatment done for cardiomyopathy, survival rates of 54.5% (the mean follow-up of 9.35 ± 1.8 years), 40.1% (mean follow-up of 7.01 ± 2.8 years) and 70% (mean follow-up of 10.5 ± 2.0 years) were seen in Groups A, B and C, respectively. There is no significant difference in survival rates (P = 0.56) among groups. Likewise, the type of myocardial protection and duration of ischaemic times were not significant (P > 0.78) to the development of cardiomyopathy. CONCLUSIONS: Our finding supports the existence of cardiomyopathy in a subset of patients with MFS. Marfan cardiomyopathy appears to be independent of the type of myocardial protection and duration of ischaemia.

The long-term impact of various techniques for tricuspid repair in Ebstein's anomaly.

OBJECTIVE: We describe a repertoire of repair techniques according to type of Ebstein's anomaly to correct tricuspid valve (TV) incompetence, and report long-term ventricular function and functional outcomes. METHODS: Sixty-eight patients (mean age, 26.9 ± 7.3 years) with Ebstein's anomaly (type A, n = 21; type B, n = 23; type C, n = 15; type D, n = 9) underwent correction of TV incompetence under normothermic cardiopulmonary bypass. The atrialized ventricle, TV, and subvalvar apparatus were inspected to analyze the precise morphology and determine which leaflet was the most mobile. Various repair strategies (anterior and/or posterior annulorrhapy, Sebening stitich, double-orifice valve technique, with bidirectional Glenn anastomosis if necessary) were used according to the presenting morphology and applied according to the type of Ebstein's anomaly. In all, the atrialized right ventricle (RV) was incorporated into the contractile RV by partial closure of the natural annulus using the most mobile leaflet for valve competence. RESULTS: The mean duration of follow-up was 13.25 ± 1.3 years (median, 9.34 years; range, 1-24 years). The mean New York Heart Association class improved from 3.4 to 1.3 (P < .001). The mean severity of TV incompetence was reduced from 3.2 to 1.3 (P < .001). Exercise tolerance tests demonstrated improved maximal oxygen uptake from a mean of 15 ± 7.8 ng/kg/min preoperatively to a mean of 24.9 ± 2.0 ng/kg/min postoperatively (P < .02). Displacement tissue Doppler imaging was used to evaluate overall cardiac performance of the RV and left ventricle and interventricular septum. The mean basal, middle, and apical ventricular strain improved significantly from preoperative values of 18.08%, 15.6%, and 13.9%, respectively to postoperative values of 25.7% (P < .011), 23.7% (P < .001), and 19.36% (P < .05), respectively. Freedom from reoperation was 100% at 1 year, 98.3% at 5 years, and 92.9% at 20 years. Early mortality was 2.9%, and late mortality was 5.8%. The overall survival rate was 97.6% at 30 days, 92.7% at 5 years, and 91.26% at 20 years. CONCLUSIONS: The various repair techniques, all of which preserve the atrialized chamber and are used individually according to morphology, provide satisfactory long-term ventricular function and functional outcome even in severe types of Ebstein's anomaly.

Posterior annulus shortening increases leaflet coaptation in ischemic mitral incompetence: a new and valid technique.

BACKGROUND: We introduce a technique of posterior annulus shortening to augment leaflet coaptation which addresses the restrictive mitral leaflet mobility in ischemic mitral incompetence (IMI), and report its long-term outcome. METHODS: Between 1992 and 2012, 75 patients (mean age, 64.6±10.4 years; median, 66.0 years; range, 35.0-86.1 years) underwent repair of IMI by posterior annulus shortening to augment leaflet coaptation surface area. This technique reduces the annular diameter to between 23 and 25 mm and decreases the valve orifice to between 3.5 to 4.5 cm(2), which is sufficient to ensure an adequate leaflet coaptation area. An untreated pericardial strip is used to reinforce the shortened annulus in order to avoid redilatation. This augments the posterior leaflet by increasing the ratio of leaflet area/valve orifice where the coaptation gap is the greatest. The tissue strip increases and heightens the area which the posterior leaflet offers to the anterior leaflet for coaptation during closure, making valve closure possible in advanced leaflet restriction. RESULTS: During a mean follow-up of 7.62±0.66 (median 8.53, range, 3.6-20.9) years, New York Heart Association (NYHA) functional class significantly improved, left ventricular ejection fraction (LVEF) increased and there was a tremendous abatement of MI (P<0.01). Annular area was reduced from 9.2 to 5.8 cm(2). Coaptation area was increased from a complete lack thereof to 6.6 mm(2) post-repair. CT showed posterior annulus size reduction from 70.4 to 54 mm and an increase in posterior leaflet length from 15.9 to 19.6 mm. A remarkable CT finding was the increase in coaptation length from 5.2 to 8.2 mm. Eighteen-year freedom from moderate MI, freedom from reoperation and survival rates were 80.7%±9%, 84.9%±4.2% and 65.1%±6.3%, respectively. CONCLUSIONS: Posterior annulus shortening with pericardial strip augmentation addressing the lack of leaflet coaptation is a simple, reproducible and highly effective technique to restore valve competence in IMI.

The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): first annual report.

The European Registry for Patients with Mechanical Circulatory Support (EUROMACS) was founded on 10 December 2009 with the initiative of Roland Hetzer (Deutsches Herzzentrum Berlin, Berlin, Germany) and Jan Gummert (Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany) with 15 other founding international members. It aims to promote scientific research to improve care of end-stage heart failure patients with ventricular assist device or a total artificial heart as long-term mechanical circulatory support. Likewise, the organization aims to provide and maintain a registry of device implantation data and long-term follow-up of patients with mechanical circulatory support. Hence, EUROMACS affiliated itself with Dendrite Clinical Systems Ltd to offer its members a software tool that allows input and analysis of patient clinical data on a daily basis. EUROMACS facilitates further scientific studies by offering research groups access to any available data wherein patients and centres are anonymized. Furthermore, EUROMACS aims to stimulate cooperation with clinical and research institutions and with peer associations involved to further its aims. EUROMACS is the only European-based Registry for Patients with Mechanical Circulatory Support with rapid increase in institutional and individual membership. Because of the expeditious data input, the European Association for Cardiothoracic Surgeons saw the need to optimize the data availability and the significance of the registry to improve care of patients with mechanical circulatory support and its potential contribution to scientific intents; hence, the beginning of their alliance in 2012. This first annual report is designed to provide an overview of EUROMACS' structure, its activities, a first data collection and an insight to its scientific contributions.

Heart transplantation after longest-term support with ventricular assist devices.

The use of mechanical circulatory support devices to keep patients alive until transplantation has become essential in the face of an increasing organ shortage. We report successful heart transplantations after 841 days of left ventricular assist device (LVAD) support in a child with hypoplastic left heart syndrome, and after 547 days of biventricular assist device (BVAD) support in another child with cardiomyopathy. To our knowledge, this report is the first on the longest-term (841 days) LVAD and the longest-term (547 days) BVAD support in children who were mobile and awake during the support, as a most effective bridge to heart transplantation.

No ring at all in mitral valve repair: indications, techniques and long-term outcome.

OBJECTIVES: In mitral valve (MV) repair, we adhere to a biological concept of preservation of the native valves and avoidance of any prosthetic materials except for sutures whenever possible. Untreated autologous pericardium is the biological tissue of choice we use to support the repair. We report our 25-year institutional experience with no-ring MV repair in terms of indications, repair techniques and long-term results. METHODS: Patients with ruptured chordae or posterior leaflet prolapse from degenerative MV disease, active infective endocarditis (IE), ischaemic mitral incompetence (IMI), annular dilatation with or without ruptured chordae along the posterior leaflet, and various lesions of the MV and its subvalvar apparatus underwent suture-repair techniques tailored to their valve morphology. These are personal series of modified Gerbode-Hetzer posterior leaflet plication and modified Paneth-Hetzer posterior annulus shortening techniques. Indications for the use of each technique and technical details are described in this report. RESULTS: Modified Gerbode-Hetzer posterior leaflet plication: mean duration of the follow-up is 15.84±0.58 years. Overall freedoms from reoperation and cumulative survival rate are 55.4±4.7 and 44.7±5.4%, respectively. Freedom from reoperation is 83.5±4.3%, in ruptured chordae from degenerative disease (n=161), 74.4±10.1% in active infectious endocarditis (IE) (n=22) and 100% from both ruptured chordae of ischaemic origin (n=10) and deceleration trauma (n=1), respectively. Likewise, freedoms from reoperation at a mean duration of the follow-up of 11.2±7.2 years in 62 children stratified based on age groups are: <3 months: 61.4±2.7%; 3 months to 2 years: 78.7±3.7%; 2-18 years: 97.1±2.4%. Modified Paneth-Hetzer posterior annulus shortening: Mean duration of the follow-up is 11.98±1.14 years. Overall freedoms from reoperation and cumulative survival rate in 179 patients are 82.95±4.1 and 63.4±8.5%, respectively. Freedom from reoperation is 85.9±13.9% in patients with annular dilatation from any form of cardiomyopathy (n=81), 78.4±5.6% in those with IMI (n=75) and 100% in those who underwent asymmetric valve repair (n=23). In IMI, mean New York Heart Association functional class, ejection fraction and degree of mitral incompetence (MI) were significantly abated (P=0.001). In 78 children, freedoms from reoperation at a mean duration of the follow-up of 11.2±7.2 years stratified based on age groups are as follows: <3 months: 82.79±3.5%; 3 months to 2 years: 71.6±5.3%; 2-18 years: 85.1±4.4%. CONCLUSIONS: No-ring MV repair using the aforementioned techniques in patients with MI resulting from chordal rupture, degenerative valve disease, IE, annular dilatation and posterior leaflet prolapse and from IMI as well as various MV lesions in children offers excellent long-term functional results with satisfactory freedom from reoperation.

Extraanatomic bypass technique for the treatment of midaortic syndrome in children.

BACKGROUND: This report aims to introduce the extraanatomic bypass technique to treat the midaortic syndrome and to document its long-term effectiveness and durability. METHODS: Fourteen patients (mean age, 6.7 ± 3.76 years; range 8 months to 11 years) received diagnoses of midaortic syndrome, characterized by severe narrowing of the abdominal aorta with involvement of the renal and visceral branches. Angiography showed variable lengths of high-grade midaortic stenosis, with 7 children having visceral artery involvement and 9 having renal artery involvement. All children were hypertensive (mean blood pressure, 165 ± 15.7 mm Hg). Three had had previous nephrectomies. Six patients had had previous percutaneous transluminal renal artery angioplasties. The midaortic obstruction was relieved by descending abdominal aorta bypass (left thoracoabdominal approach) and by an ascending abdominal aorta bypass (median sternotomy and transabdominal approach) in 12 patients. No visceral artery revascularization was done. RESULTS: There was a considerable blood pressure reduction in all patients and relief of intermittent claudication in 6 affected patients. One patient had a bilateral renal artery bypass 2 weeks postoperatively because of recurrence of renal hypertension. At a mean follow-up time of 5.8 ± 1.36 years (range, 9 months to 15 years), there was no further reoperation nor mortality. Twelve patients had complete relief of hypertension, and 2 had mild hypertension. All patients have normal renal function and no signs or symptoms of visceral malperfusion. Growth and development have proceeded normally. Follow-up magnetic resonance tomography showed patent grafts without any strictures. CONCLUSIONS: Extraanatomic bypass provides very effective and long-term relief of hypertension and any malperfusion in midaortic syndrome.