Comparison of homografts and bovine jugular vein conduits in the pulmonary position in patients <20 years of age.

OBJECTIVE: To compare the performance of homografts and bovine jugular vein (BJV) conduits in the pulmonary position. METHODS: All patients with congenital heart disease up to age 20 years who underwent pulmonary valve replacement with homografts or BJV at 3 centers in Australia were evaluated. There were 674 conduits, with 305 (45%) pulmonary homografts (PHs), 303 (45%) BJV conduits, and 66 (10%) aortic homografts (AHs). Endpoints were freedom from reintervention, structural valve degeneration (SVD), and infective endocarditis (IE). Propensity score matching was used to balance the comparison of PH and BJV conduits. RESULTS: The median follow-up was 6.4 years (interquartile range, IQR, 3.1-10.7 years). Freedom from reintervention at 5 and 10 years was 92% and 80%, respectively, for PH, 74% and 37% for BJV, and 75% and 47% for AH. BJV conduits had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs. These findings were confirmed with propensity score matching valid for conduit size >15 mm. AHs >15 mm had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs >15 mm. The performance of AHs and BJV conduits was similar across all sizes (reintervention, P = .94; SVD, P = .72). The incidence of IE was 1% for PH, 10% for BJV, and 1.5% for AH. CONCLUSIONS: In patients age <20 years with a conduit >15 mm, PHs outperformed BJV conduits and AHs in the pulmonary position. The performance of AH and BJV was comparable. Small conduits (≤15 mm) had similar performance across all conduit types.

Propensity-matched comparison of the long-term outcome of the Nunn and two-patch techniques for the repair of complete atrioventricular septal defects.

OBJECTIVES: To compare the long-term performance of the Nunn and 2-patch techniques for the repair of complete atrioventricular septal defects. METHODS: Between January 1995 and December 2015, a total of 188 patients (Nunn n = 41; 2-patch n = 147) were identified from hospital databases. Univariable Cox regression was performed to calculate the risk of reintervention in each group. Propensity score matching was used to balance the Nunn group and the 2-patch group. RESULTS: Baseline characteristics including age at surgery, weight, trisomy 21, other cardiac anomalies, previous operations and preoperative atrioventricular valve regurgitation did not differ between the 2 groups. Overall, there was no difference in mortality between the 2 groups (P = 0.43). Duration of cardiopulmonary bypass (CPB) and myocardial ischaemia time were 29 min (P < 0.001) and 28 min (P < 0.001) longer, respectively, in the 2-patch group. Median follow-up was 10.8 years (2-21 years). Unadjusted Cox regression did not reveal a significant difference in the risk of reoperation for either group 9 years after initial surgery [hazard ratio (HR) (Nunn) 0.512, 95% confidence interval 0.176-1.49; Nunn 89%; 2-patch 82%]. This finding was reiterated from Cox regression performed on the propensity-matched sample (31 pairs). The probability of freedom from moderate or worse left atrioventricular valve regurgitation or left ventricular outflow obstruction was similar in the 2 groups. CONCLUSIONS: The Nunn and 2-patch techniques are comparable in terms of the long-term mortality and probability of freedom from reoperation, moderate or severe left atrioventricular valve regurgitation and left ventricular outflow obstruction. However, the duration of CPB and myocardial ischaemia is longer in the 2-patch group.

Homografts versus stentless bioprosthetic valves in the pulmonary position: a multicentre propensity-matched comparison in patients younger than 20 years.

OBJECTIVES: The aim of this study was to compare the performance of pulmonary homografts with stentless bioprosthetic valves [Medtronic Freestyle™ (Medtronic, Minneapolis, MN, USA)] in the pulmonary position in patients with congenital heart disease (CHD) younger than 20 years. METHODS: Between January 2000 and December 2017, 215 patients were retrospectively identified from hospital databases in 3 congenital heart centres in Australia. Valve performance was evaluated using standard criteria. Propensity score matching was used to balance the 2 treatment groups. RESULTS: Freedom from reintervention for patients who received a pulmonary homograft (n = 163) was 96%, 88% and 81% at 5, 10 and 15 years and for patients who received a Freestyle™ valve (n = 52) was 98%, 89% and 31% at 5, 10 and 15 years, respectively. Freedom from structural valve degeneration for patients with a homograft was 92%, 87% and 77% at 5, 10 and 15 years and for patients with a Freestyle valve was 96%, 80% and 14% at 5, 10 and 15 years, respectively. In the first 10 years, there was no difference in outcomes [reintervention hazard ratios (HR) = 0.69, 95% confidence intervals (CI) (0.20-2.42), P = 0.56; structural valve degeneration HR = 0.92 (0.34-2.51), P = 0.87]. After 10 years, the recipients of the Freestyle valves were at higher risk of both outcomes [reintervention HR = 7.89; 95% CI (2.79-22.34), P < 0.001; structural valve degeneration HR = 7.41 (2.77-19.84), P < 0.001]. The findings were similar when analysed by implantation in the orthotopic position and in the propensity-matched groups. CONCLUSIONS: The Freestyle stentless bioprosthetic valve is a comparable alternative to cryopreserved pulmonary homografts up to 10 years after implantation when implanted in an orthotopic pulmonary position in patients younger than 20 years with CHD.

Long-term performance of homografts versus stented bioprosthetic valves in the pulmonary position in patients aged 10-20 years.

OBJECTIVES: We aimed to compare the long-term performance of pulmonary homografts and stented bioprosthetic valves in the pulmonary position in patients aged 10-20 years. METHODS: Between January 1995 and December 2015, 188 patients aged 10-20 years undergoing pulmonary valve replacement were identified retrospectively from hospital databases in both congenital cardiac centres in Brisbane. Valve performance was evaluated using previously described standard criteria. Propensity score matching was used to balance the 2 treatment groups. RESULTS: Freedom from structural valve degeneration in homografts (n = 131) was 97%, 92% and 85% at 3, 5 and 10 years, respectively, and 91% and 53% at 3 and 5 years, respectively, in the bioprosthesis group (n = 57). Freedom from reintervention in homografts was 96%, 93% and 88% at 3, 5 and 10 years, respectively, and 93% and 68% at 3 and 5 years, respectively, in the bioprosthesis group. The unadjusted Cox regression analysis demonstrated that a bioprosthesis was at 5.64 times the risk of structural valve degeneration and 3.89 times the risk of reintervention. The Cox regression analysis performed on the propensity matched sample (45 pairs of patients) revealed that a bioprosthesis was at almost 10 times the risk of experiencing structural valve degeneration [hazard ratio (HR) = 9.18] and at more than 8 times the risk of undergoing a reintervention (HR = 8.34). CONCLUSIONS: In our patient population, pulmonary homografts outperformed stented bioprosthetic valves within 5 years when implanted in the pulmonary position in patients aged 10-20 years. We recommend the use of a pulmonary homograft for pulmonary valve replacement in this age group in patients undergoing surgery for congenital heart disease.

Unique presentation of a primary pleomorphic sarcoma of the left atrium.

This report describes an extremely rare cause of a common presentation. A 59-year-old man who presented with symptoms of progressive cardiac failure, was demonstrated to have a large left intraatrial mass on computed tomography pulmonary angiography and an echocardiogram. He proceeded to urgent surgery under cardiopulmonary bypass. Histology of the resected mass diagnosed primary pleomorphic sarcoma of the left atrium. This exceedingly rare malignancy has a poor prognosis and often presents with nonspecific symptoms. Echocardiography remains vital in diagnosis, and treatment is primarily surgical excision, with some reports of adjuvant chemotherapy.

Long-term clinical outcomes after aortic valve replacement using cryopreserved aortic allograft.

BACKGROUND: Although the frequency of biological valve use in treating aortic valve disease is increasing, the critical limiting factor, "structural deterioration," remains unresolved. Analysis of long-term outcomes after implantation of cryopreserved aortic allografts will yield further information related to the durability of the aortic allograft, possibly suggesting mechanisms underlying or strategies to prevent or treat the structural deterioration of biological valve substitutes. METHODS: A total of 840 cryopreserved aortic allografts implanted in the last 35 years were reviewed with clinical follow-up completed in 99% of the consecutive series. By June 2010, 285 implanted allografts had been surgically explanted, 288 patients died before allograft removal, and 267 patients are under continued follow-up. RESULTS: Cryopreserved aortic allografts were durable for more than 15 years in the middle-aged and older patient population. The estimated median time until structural deterioration was 20 years post-implantation, and 2 allografts have been functioning well for more than 30 years. Structural deterioration was independently related to the young age of the recipient, elderly age of the donor, severe obesity in the recipient, history of blood transfusion in the recipient, and full-root implantation technique. Infection of the implanted allograft necessitating reintervention rarely occurred. Reintervention for the allograft demonstrated 2% in-hospital mortality. CONCLUSIONS: Cryopreserved aortic allografts were durable for more than 15 years. Structural deterioration of aortic allografts was related to multiple factors. The age of the recipient and the donor, obesity and blood transfusion history of the recipient, and implantation technique were identified as the most important factors contributing to allograft failure.

Partial replacement of tricuspid valve using cryopreserved homograft.

BACKGROUND: The optimal choice of prosthesis for tricuspid valve (TV) replacement is yet to be determined. Partial replacement of the TV using a homograft atrioventricular valve might offer resistance to infection, good durability, and excellent functionality, in addition to avoiding prosthesis-related morbidity. METHODS: We present 14 patients who underwent replacement of the TV using a homograft between 1997 and 2008. The mean age at operation was 32 years, including 5 patients younger than the age of 10. All patients preoperatively showed severe TV regurgitation as a result of active infective endocarditis in 5 patients, Ebstein anomaly in 4 patients, other cardiac anomalies in 4 patients, and rheumatic valvular disease in 1 patient. The TV homograft was used in 13 patients, and mitral homograft was used in 1 patient. Eleven patients had replacement of one leaflet only, whereas 3 patients required replacement of two leaflets. Concomitant cardiac procedures were performed in 7 patients. RESULTS: No mortalities occurred during the average postoperative follow-up of 61 months (range, 12 to 126 months). Reoperation for TV regurgitation after TV repair with homograft was performed in 3 patients. The remaining 11 patients had minimal symptoms without reintervention for TV regurgitation. CONCLUSIONS: Partial replacement of the TV using a homograft provided good hospital and mid-term outcomes. This strategy might be useful in active infective endocarditis and congenital TV disease.

Determinants of in-hospital and long-term surgical outcomes after repair of postinfarction ventricular septal rupture.

OBJECTIVES: Surgical repair of post-myocardial infarction ventricular septal rupture is challenging with reported early mortality being substantial. In addition, congestive cardiac failure and ventricular tachyarrhythmia frequently occur long term after the operation, although frequency and predictive factors of these events have been poorly identified. METHODS: A consecutive series of 68 patients who underwent repair of postinfarction ventricular septal rupture by 14 surgeons between 1988 and 2007 was studied. Fifty-eight (85%) patients underwent repair in an urgent setting (<48 hours after diagnosis). Coronary artery bypass grafting was concomitantly performed in 48 (71%) patients. Mean follow-up period was 9.2 +/- 4.9 years. RESULTS: Thirty-day mortality was 35%, with previous myocardial infarction, previous cardiac surgery, preoperative left ventricular ejection fraction less than 40%, and urgent surgery being independent risk factors. Actuarial survival of 30-day survivors was 88% at 5 years, 73% at 10 years, and 51% at 15 years. Actuarial freedom from congestive cardiac failure and ventricular tachyarrhythmia was 70% and 85% at 5 years, 54% and 71% at 10 years, and 28% and 61% at 15 years, respectively. Independent predictors for congestive cardiac failure included hypertension, posterior septal rupture, residual interventricular communication, and preoperative left ventricular ejection fraction less than 40%, whereas concomitant ventricular aneurysmectomy and preoperative occlusion of the left anterior descending artery were independent predictors of ventricular tachyarrhythmia. CONCLUSIONS: Long-term outcomes after surgical repair of postinfarction ventricular septal rupture was favorable, despite infrequent exposure by individual surgeons to the pathologic features, indicating that an aggressive surgical approach is warranted. Predictors of congestive cardiac failure and ventricular arrhythmia long term varied.

Mitral valve replacement in calcified annulus following ring annuloplasty.

We present a patient with persistent severe hemolysis following mitral valve repair which resolved after valve replacement with bioprosthesis. The posterior portion of the annuloplasty ring was retained due to severe calcifications of the posterior mitral valve annulus. All chordae were preserved to avoid disruption of the mitral annulus.

Total chordal augmentation in a child with Marfan syndrome and severe mitral insufficiency.

Mitral valve repair has become an established treatment in adults, but there is limited experience with the procedure in children, in whom the avoidance of a valve prosthesis is particularly advantageous. Repair of the mitral valve in children who have Marfan syndrome is especially difficult due to the presence of generalized connective tissue disorder, which may lead to future elongation and rupture of chordae tendineae that were unaffected at the time of mitral valve repair. We performed a total augmentation of all segments of the mitral valve, using artificial chordae tendineae. Herein, we describe the procedure and the positive outcome in a 10-year-old girl.

CryoLife-O'Brien stentless valve: 10-year results of 402 implants.

BACKGROUND: This truly stentless porcine valve is composite, without Dacron, and implanted supra-annularly. Ten-year analysis with magnetic resonance imaging is presented. METHODS: From 1992 to 2002, 402 patients (mean 73.5 years) had aortic valve replacement. Associated procedures were required in 252 patients (63%). Serial echoes provided 1340 studies. Clinical follow-up was 100%. Magnetic resonance imaging focused on aortic annulus extensibility. RESULTS: The 30-day mortality was 0.99% (4 deaths). Morbidity comprised thromboembolism (40 patients including 18 patients with permanent strokes); endocarditis (9 patients); and reoperation (9 patients [periprosthetic leak, 2; endocarditis, 5; technical needle damage, 1; and structural degeneration, 1]). Of 402 valves more than 10 years, five valves were explanted, one only for structural failure. Except for endocarditis (2 patients), no late deaths (69 patients, 1.5 months to 5.7 years) were valve related. Echocardiography demonstrated low gradients with good orifice areas, excellent ventricular regression (p = 0.0001 preoperative and postoperative comparisons) and late incompetence (mild in 45 patients and moderate in 9 patients). No living patient has severe incompetence. Magnetic resonance imaging demonstrated the annulus 'expanding and relaxing' throughout the cardiac cycle, the mean increase in cross-sectional area being 37%, resembling normal aortic root dynamics. CONCLUSIONS: Elderly patients received this hemodynamically acceptable valve with its simple, supra-annular implantation and satisfactory mid-term morbid-free lifestyle to 10 years maximum follow-up. With only one structural failure, restoration of valve annular extensibility may have a favorable influence on long-term durability.

Anomalous origin of the left anterior descending artery from the pulmonary artery associated with bicuspid aortic valve and aortic coarctation.

A 15-year-old boy presented with exertional palpitations and chest pain. Investigation revealed anomalous origin of his left anterior descending coronary artery from his pulmonary trunk causing myocardial ischaemia. He previously had aortic coarctation repair with known aortic root dilation and a bicuspid aortic valve. His left anterior descending artery was implanted into the aortic root using a Gortex interposition conduit. This represents an interesting combination of cardiac abnormalities for which repair required consideration of the requirement of further surgery in the future.

BioGlue Surgical Adhesive--an appraisal of its indications in cardiac surgery.

BACKGROUND: The recent emergence of BioGlue Surgical Adhesive has widened the field of surgical adhesives for the cardiac surgeon. We believe the present series, in a wider spectrum of cardiac conditions, is the first larger scale evaluation of the use of this new adhesive. METHODS: BioGlue was used in 115 consecutive patients (90 male and 25 female, age range 5 days to 87 years) from September 9, 1998 to March 12, 2001. Preoperative, intraoperative, and postoperative data were examined to establish its use, indications, and outcomes in patients undergoing cardiac surgical procedures. RESULTS: The most common underlying pathologic conditions were aortic dissections (30 patients) and aortic aneurysms (39 patients). The procedures carried out were aortic root replacement (36 patients), aortic wall replacement (39), ascending aorta repair (2), coronary artery bypass grafting (28), valve procedures (11), ventricular aneurysm repair (6), repair of postinfarct ventricular septal defect (2), and correction of congenital conditions (13 patients). The indications for BioGlue use were hemostasis in 79 patients, tissue adherence in 21, and tissue strengthening in 30. The hospital mortality was 10.1% (11 patients). Only 1 patient required a late reoperation for dehiscence of a suture line with formation of a false aneurysm. The mean postoperative blood loss at 12 hours was 702 mL. Ten patients developed a cerebrovascular accident postoperatively, which was considered to be unrelated to the use of BioGlue. CONCLUSIONS: All surgeons in this study believed that BioGlue facilitated the operation. Future follow-up of patients is required to validate our early promising results and to assess the long-term outcome of patients treated with BioGlue.