Complex Cardiac Surgery on Patients with a Body Weight of Less Than 5 kg without Donor Blood Transfusion.

Performing safe cardiac surgery in neonates or infants whose parents are Jehovah's Witnesses is only possible in a coordinated team approach. An unconditional prerequisite is a cardiopulmonary bypass (CPB) circuit with a very low priming volume to minimize hemodilution. In the past decade, we have developed a functional blood-sparing approach at our institution. The extracorporeal circuit was miniaturized. This had to be recently adapted, faced with a challenge associated with the switch to high-volume crystalloid cardioplegia. A filtration circuit was added. Here, we report an open heart surgery on three consecutive children of Jehovah's Witness parents with a body weight of 2.7, 4.5, and 4.8 kg, respectively. Procedures consisted of one arterial switch operation and two repairs of complete atrioventricular septal defects. Our static priming volume of less than 90 mL resulted in a nadir hematocrit during CPB of 27.7% (Hb 8.9 g/dL) in a patient which happened to have the lowest body weight of 2.7 kg. The two other patients had their lowest hematocrit at 31.4% (Hb 10.2 g/dL). The three children could be treated without any kind of transfusion of blood which had left the circulation or its extensions, in accordance with the parents' wishes, and enjoy favorable outcomes without transfusion of blood products during their entire hospital stay.

Further experience with the "no-react" bioprosthesis in patients with active infective endocarditis: 11-year single center results in 402 patients.

OBJECTIVES: We investigated early, midterm, and long-term results following valve replacement with the "No-React" bioprosthesis in patients with active infective endocarditis (AIE).Patients and Methods Between February 2000 and February 2011, a total of 402 patients (median 61 years, 17 to 91 years) received "No-React" bioprostheses due to single valve AIE in 315 (aortic valve replacement n = 158, aortic conduit n = 30, mitral valve replacement n = 116, tricuspid valve replacement n = 11) and double valve AIE in 87 cases. Prosthetic AIE was found in 105 patients (26.1%). Mean follow-up was 2.8 ± 3.2 years (1 month to 11.4 years) with 1,124 patient years, completed in 97.1%. This retrospective study analyzes both prospectively updated data (n = 255) and patients recently operated upon (n = 147). RESULTS: There was a highly significant difference in the survival between patients operated on urgently and patients operated on in an emergency (30-day, 1-, 5-, and 10-year survival were 80.9 ± 2.3%, 63.8 ± 2.9%, 48.3 ± 3.3%, and 39.7 ± 4.1% vs. 61.3 ± 4.5%, 45.0 ± 4.7%, 33.1 ± 4.6%, and 14.0 ± 5.1%, respectively, p < 0.001), due to native versus prosthetic AIE (p = 0.032), single versus double valve replacement (p = 0.005), and with or without abscess formation (p < 0.001). Thirty-day, 1-, 5-, and 10-year freedom from reoperation due to recurrent endocarditis were 100%, 95.1 ± 1.4%, 86.4 ± 2.6%, and 82.1 ± 3.6% and due to structural valve deterioration (SVD) were 100%, 100%, 98.9 ± 0.8%, and 91.4 ± 4.0%, respectively. There was no difference in prosthesis durability between the older (> 60 years) and the younger patients. CONCLUSIONS: Our experience in the use of "No-React" bioprostheses in patients with native and prosthetic AIE shows satisfactory early, midterm, and long-term results, in particular low rates of reoperation due to recurrent endocarditis and SVD. Because these prostheses are readily available and their implantation straightforward, we strongly recommend their use in patients with AIE. Patients' survival differed significantly depending on their surgical urgency. Early mortality was independently predicted by septic shock, abscess formation, and number of implanted valves besides age per 10 years.

Surgery for active infective mitral valve endocarditis: a 20-year, single-center experience.

BACKGROUND AND AIM OF THE STUDY: A retrospective analysis was conducted of the early and long-term results of mitral valve repair (MVRep) and mitral valve replacement (MVR) in patients with isolated infective mitral valve endocarditis. METHODS: Between May 1986 and December 2007, a total of 1,163 patients with active infective endocarditis (AIE) were operated on. Of these patients, 497 showed an endocarditic involvement of the mitral valve. Sixty-one of these patients underwent MVRep and 219 MVR, with 24% cases of prosthetic valve endocarditis (PVE). The patients' perioperative characteristics, cumulative survival, freedom from recurrence and reoperation and independent risk factors for early mortality were analyzed. Follow up (0-21 years) was complete in 96.5% of cases; the total follow up was 348 and 810 patient-years (pt-yr) in the MVRep and MVR groups, respectively. RESULTS: Typically, the MVR patients were significantly older (p < or = 0.001), preoperatively more often intubated (p = 0.008) and in cardiogenic shock (p = 0.045), and more often underwent emergency surgery (p = 0.023). MVRep was associated with a significantly better survival, with 30-day, one-, five- and 10-year survival rates of 90.1 +/- 3.9%, 83.2 +/- 4.8%, 77.0 +/- 5.7% and 60.5 +/- 8.0%, respectively (p = 0.002). Survival after MVR was significantly worse with abscess formation (p = 0.0002) and PVE (p = 0.038). Freedom from reoperation due to reinfection after 10 years was 89.4 +/- 7.0% after MVRep, with early endocarditis recurrence in two patients (3%), and 91.0 +/- 2.5% after MV, with early recurrence in four patients (2%) (p = 0.46). Multivariate analysis identified preoperative ventilation (OR = 6.3), mitral valve abscess formation (OR = 5.3), PVE (OR = 3.1) and age > or = 60 years (OR = 2.8) as independent risk factors for early mortality. CONCLUSION: Compared to the MVRep group, patients requiring MVR had more advanced endocarditis and were more critically ill. These results suggest that the early outcome might have been improved if patients had been operated on before either heart failure or the development of septic shock. MVRep for AIE showed a low operative mortality and provided satisfactory freedom from recurrent infection and repeat operation. If all infected material could be resected such that the remaining tissue would allow the re-shaping of a competent valve, then MVRep could be performed also in infective endocarditis, in line with the general recommendations for mitral valve surgery.

Molecular methods for diagnosis of infective endocarditis.

Infective endocarditis (IE) is a life-threatening disease associated with high mortality. Conventional microbiologic diagnosis is based mainly on culture-dependent methods that often fail because of previous antibiotic therapy or the involvement of fastidious or slowly growing microorganisms. In recent years, molecular techniques entered the field of routine diagnostics. Amplification-based methods proved useful for detection of microorganisms in heart valve tissue. More recently, they were applied to blood samples from patients with IE. Direct detection of microorganisms in valve specimens by fluorescence in situ hybridization allowed identification of the causative agent and simultaneous visualization of complex microbial communities. These techniques will gain more importance in the near future, provided that procedures are standardized and results are interpreted with caution. With this review, we intend to give an overview of the impact and limitations of molecular techniques for the diagnosis of IE, including a focus on recent developments.

Aerococcus urinae - A potent biofilm builder in endocarditis.

The diagnosis of infective endocarditis (IE) remains a challenge. One of the rare bacterial species recently associated with biofilms and negative cultures in infective endocarditis is Aerococcus urinae. Whether the low number of reported cases might be due to lack of awareness and misidentification, mainly as streptococci, is currently being discussed. To verify the relevance and biofilm potential of Aerococcus in endocarditis, we used fluorescence in situ hybridization to visualize the microorganisms within the heart valve tissue. We designed and optimized a specific FISH probe (AURI) for in situ visualization and identification of A. urinae in sections of heart valves from two IE patients whose 16S rRNA gene sequencing had deteced A. urinae. Both patients had a history of urinary tract infections. FISH visualized impressive in vivo grown biofilms in IE, thus confirming the potential of A. urinae as a biofilm pathogen. In both cases, FISH/PCR was the only method to unequivocally identify A. urinae as the only causative pathogen for IE. The specific FISH assay for A. urinae is now available for further application in research and diagnostics. A. urinae should be considered in endocarditis patients with a history of urinary tract infections. These findings support the biofilm potential of A. urinae as a virulence factor and are meant to raise the awareness of this pathogen.

Surgical therapy in patients with active infective endocarditis: seven-year single centre experience in a subgroup of 255 patients treated with the Shelhigh stentless bioprosthesis.

OBJECTIVE: We investigated outcomes after surgical therapy in patients with active infective endocarditis (AIE) with regard to survival in relation to surgical urgency, valve position, number of valves implanted and abscess formation. We aimed to identify independent risk factors for early mortality. METHODS AND RESULTS: Two hundred and fifty-five patients received Shelhigh bioprostheses between February 2000 and March 2007. A total of 74.1% had native and 25.9% prosthetic AIE. Surgery was regarded as urgent in 57.3% and as an emergency procedure in 38.4%. There was a highly significant difference in survival rate between patients who were operated on urgently versus in an emergency (p<0.0001), between single and double valve replacement (p=0.0206) and between patients with and without abscess formation (p=0.0245). There were two cases of early reinfection (0.78%) and six of late reinfection (2.35%) leading to re-operation. CONCLUSIONS: The survival of patients differs significantly in dependence on their surgical urgency. Better outcome could have been achieved if patients had been referred earlier for surgery and operated upon before heart failure or septic shock developed. Long-term survival was better in patients without abscess formation. The low reinfection rate of Shelhigh bioprostheses in AIE is promising and the early and mid-term results achieved need to be verified in the long-term course.

Heart valve operations in solid organ recipients: an 18-year single-center experience.

BACKGROUND: We retrospectively analyzed the outcome of heart valve operations in solid organ recipients, who were referred for operation to our institution. METHODS: Over an 18-year period, 23 heart (group 1) and 16 renal (group 2) transplant recipients in New York Heart Association (NYHA) classes III and IV underwent valve operation. The mean interval from the time of transplantation to cardiac surgery was 77.9 months with a mean follow-up time of 34.6 months in group 1 and 87.2 months with a mean follow-up time of 39.2 months in group 2. RESULTS: Group 1 underwent tricuspid valve replacement (n=12), tricuspid valve reconstruction (n=7), aortic valve replacement (AVR, n=3), and mitral valve replacement (MVR, n=1). In group 2, mechanical valve replacement was performed in 14 patients (9 AVR, 3 MVR, 2 AVR and MVR) and tricuspid or mitral valve reconstruction in two patients. There was no operative death. During hospitalization, multiorgan failure due to sepsis was the main cause of mortality (2 in both groups). In the mean follow-up period of 41.2 months, there were four late non-cardiac-related deaths in group 1. Currently 29 surviving transplant recipients (16 heart, 69.6% and 13 renal, 81.3%) are in NYHA classes I and II. CONCLUSION: In heart and renal recipients, valve operations can be performed effectively and safely with acceptable mortality, low cardiac morbidity, and excellent clinical results, although infection is the most serious complication.

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.

Implantation of a left ventricular assist device in situs inversus.

A 42-year-old man with situs inversus was referred to our institution because of end-stage ischemic cardiomyopathy. Cardiac arrest occurred after admission, and the patient underwent cardiopulmonary resuscitation. An extracorporeal left ventricular assist device (Berlin Heart) was implanted as a bridge to transplantation. This is one of the first reports of left ventricular assist device implantation in a patient with situs inversus and ischemic cardiomyopathy.

Intravascular ultrasound assessment of longitudinal plaque distribution patterns in patients with angiographically silent coronary artery disease after heart transplantation.

AIMS: The purpose of this three-dimensional intracoronary ultrasound (ICUS) study was to assess longitudinal plaque distribution patterns in patients with angiographically silent coronary artery disease (CAD) after heart transplantation (HTX). METHODS AND RESULTS: Out of 334 patients without diameter stenosis >/=25% determined by coronary angiography, 321 underwent successful three-dimensional ICUS (30 MHz) of the left main coronary artery (LMCA) and all segments of the left anterior descending coronary artery (LAD). Early plaque formation was found in 296 patients (92.2%). Single (focal CAD, n = 65) or multiple (polyfocal CAD, n = 77), discrete coronary lesions were found in 142 patients and continuous plaque formation of at least one entire coronary segment (diffuse CAD) in 154 patients. Using multivariate regression analysis, male sex (P = 0.01), increasing post-transplantation time (P = 0.003) and increasing donor age (P = 0.001) were independent clinical predictors for diffuse CAD. Both focal and diffuse CAD most frequently affected the proximal LAD (88% compared with 89.6%, NS). The mean intimal index of each LAD segment was significantly higher in patients with diffuse CAD (P < 0.001) and showed a proximal-to-distal decline in patients with focal/polyfocal (LMCA, 10.1 +/- 14.3, LAD-6, 30.1 +/- 17.4%, LAD-7, 16.3 +/- 14.1%, LAD-8, 4.6 +/- 11.1%; P < 0.001) and diffuse (LMCA, 27.0 +/- 16.0, LAD-6, 47.8 +/- 16.1%, LAD-7, 41.9 +/- 14.5%, LAD-8, 24.9 +/- 23.3%; P < 0.01) CAD. CONCLUSION: Evaluation of longitudinal plaque distribution after HTX by three-dimensional ICUS revealed a time-dependent increase in the incidence of diffuse CAD and a proximal-to-distal decline in frequency and magnitude of early plaque formation.

Repair for active infective atrioventricular valve endocarditis: 23-year single center experience.

OBJECTIVES: We retrospectively compared early and long-term results of mitral (MV) and tricuspid valve (TV) repair in patients with isolated active infective atrioventricular valve (AV) endocarditis over a period of 23 years. METHODS: Between April 1986 and December 2009, a total of 1,409 patients with active infective endocarditis (AIE) were operated upon. Of these, 106 (7.2%) patients (n = 69 men, age 2-84 years) underwent repair of AVE (MV n = 68, TV n = 38). Repair techniques included vegetectomy and leaflet resection, annular plication and annuloplasty, and pericardial patch leaflet and annular reconstruction without any artificial device. Perioperative characteristics, probability of survival, freedom from recurrence and reoperation, and predictors for early mortality were analyzed. Follow-up (0-23 years) was completed in 95% with a total of 667 patient years. RESULTS: The 30-day, 1-, 5- and 10-year survival rate for MV repair was 89.7 ± 0.4, 82.2 ± 4.6, 72.6 ± 5.5 and 56.5 ± 7.3% and for TV repair 94.7 ± 3.7, 88.7 ± 5.3, 69.4 ± 8.8 and 64.5 ± 9.5%, respectively (ns). Three patients (2.8%) had to undergo reoperation due to early failure of reconstruction (n = 2 MV, n = 1 TV). Freedom from valve-related reoperation at 1 and 10 years was 88.4 ± 4.1 and 75.4 ± 7.4% for the MV repair and 97.4 ± 2.6 and 93.94 ± 4.2% for the TV repair group (ns). Endocarditis reoccurred early in 2 MV repair patients (1.9%). Freedom from reoperation due to reinfection at 1 and 10 years after MV repair was 96.6 ± 2.3 and 91.6 ± 5.4% and after TV repair 100 and 83.3 ± 9.5%. CONCLUSIONS: Repair for AV endocarditis yields excellent results. It is associated with low operative mortality and provides satisfactory early and long-term survival and favorable freedom from recurrent endocarditis and repeat operation. It should be considered as the primary surgical option in these patients, and AV replacement should be performed only in cases of severe AV destruction that renders repair techniques impossible.

Surgical treatment for active infective prosthetic valve endocarditis: 22-year single-centre experience.

OBJECTIVE: We retrospectively analysed the profile and outcome of surgically treated patients with active infective prosthetic valve endocarditis (PVE) over a period of 22 years. METHODS: Between May 1986 and December 2008, a total of 1313 patients with active infective endocarditis (AIE) were operated on, 349 (26.6%) of them for PVE. Of these, 77 (22.1%) had to be operated upon due to early PVE (≤60 days, n=55 men, median age: 58 years) and 272 (77.9%) due to late PVE (n=200 men, median age: 63 years). A large proportion of patients were referred to our department with advanced endocarditis and in a condition of cardiac and pulmonary decompensation. A total of 226 (64.8%) patients developed periannular abscess. Operations consisted of 80 aortic valve, 45 mitral valve, 39 double valve and 165 aortic root replacements, 134 of them with a homograft. Perioperative characteristics, probability of survival, freedom from recurrence and predictors for hospital mortality were analysed. Follow-up (maximum: 19.4 years) was completed in 96.3% (total: 1118 patient-years). RESULTS: There was high early and late mortality. Overall in-hospital mortality was 28.4% (99/349). The 30-day, 1-, 5- and 10-year survival for the whole PVE study population was 71.4 ± 2.4%, 58.7 ± 2.7%, 44.5 ± 3% and 31.7 ± 3.5% with no significant differences between the early and late PVE patients: 67 ± 5.4%, 55.9 ± 5.8%, 49.4 ± 6.2% and 29.7 ± 7.6%, compared to 72.4 ± 3%, 60 ± 3%, 43.5 ± 3.3% and 31.1 ± 3.8% (p=0.93). Predictors of early mortality were mechanical support (risk ratio (RR): 4.3), emergency operation (RR: 2.1), preoperative high doses of catecholamines (RR: 1.8), mitral valve replacement (RR: 1.5) and age at operation (RR: 1.1). Freedom from re-operation due to recurrent endocarditis at 10 years was 85.8 ± 5.6% for early PVE compared to 92.1 ± 2.3% for late PVE patients (p=0.17). Staphylococcus aureus (S. aureus) (18.1%) was the most frequent causative micro-organism. CONCLUSIONS: Surgery for active infective PVE continues to be challenging. It not only carries a high in-hospital mortality but is also associated with a high long-term mortality risk. Early PVE patients were in a more severe condition than late PVE patients. Preoperative status, complications and co-morbidity of PVE patients strongly predict early outcome. Because of the potential risk of late complications, PVE patients need close clinical follow-up.

Homograft aortic root replacement in native or prosthetic active infective endocarditis: twenty-year single-center experience.

OBJECTIVE: We compared early and long-term results of cryopreserved homograft aortic root replacement in native valve endocarditis or prosthetic valve endocarditis associated with periannular abscess. METHODS: Between May 1986 and December 2007, 1163 patients with endocarditis were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) had homograft aortic root replacement due to 99 cases of native valve endocarditis (45%) and 122 of prosthetic valve endocarditis (55%). Perinannular abscess developed in 189 patients (86%), and aortoventricular dehiscence in 120 (63.5%) of them. Perioperative characteristics, probability of survival, freedom from recurrence, and reoperation were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1127 patient-years. RESULTS: Overall native valve endocarditis survival at 30 days and 1, 5, and 10 years was 83.8% +/- 3.7%, 76.6% +/- 4.3%, 66.5% +/- 4.9%, and 47.3% +/- 5.6%, respectively, significantly better than for patients with prosthetic valve endocarditis, who had a greater tendency toward abscess formation (P = .029). Thirty-one patients (14.0%) required reoperation either for structural valve deterioration (n = 19, 8.6%), with a greater tendency in patients aged <40 years, or for recurrent endocarditis of the homograft (n = 12, 5.4%). One-year reoperation mortality rate was 16.1% (n = 5). CONCLUSIONS: Homograft aortic root replacement in active infective endocarditis with periannular abscess formation shows satisfactory early and long-term results with significantly better survival in native valve endocarditis than prosthetic valve endocarditis. It is associated with a low recurrence rate, although the risk of structural valve deterioration increases over time, especially in young patients, and reoperation remains a challenge. In our institution, the homograft remains the preferred valve substitute in active infective endocarditis with periannular abscess formation.

Predictors of early mortality in patients with active infective native or prosthetic aortic root endocarditis undergoing homograft aortic root replacement.

PURPOSE: We compared early results of homograft aortic root replacement (ARR) in native (NVE) and prosthetic (PVE) aortic valve endocarditis in order to identify predictors for early mortality (<30 days). METHODS: Between 05/1986 and 12/2007, 1,163 endocarditis patients were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) underwent homograft ARR due to 99 cases of NVE (45%) and 122 of PVE (55%) aortic root endocarditis. Demographics, clinical differences, survival rates and predictors of early mortality were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1,127 patient years. RESULTS: Main causes of the 47 (21.2%) early deaths were septic multiorgan failure in 23 (48.9%) and myocardial failure in 10 (21.3%) patients with a significantly better survival for NVE than for PVE patients (patients = 0.029). The highest ORs were found in the univariate analysis for preoperative development of septic shock (OR 14.28), preoperative necessity of ventilation (OR 7.08), high doses of catecholamines (OR 5.60), severe aortic root destruction (OR 5.12), emergency operation (OR 4.25) and persistent fever despite antibiotic treatment (OR 4.11). Multivariate analysis showed that preoperative ventilation (OR 5.43), persistent fever under antibiotic treatment (OR 2.84) and prosthetic endocarditis (OR 2.32) were independent risk factors for early mortality. CONCLUSIONS: Our results suggest that early outcome could be improved if patients were referred earlier for surgery. A multidisciplinary approach is necessary, involving at least specialists in intensive care medicine, cardiology, infectious disease and cardiac surgery in order to identify the optimal time for surgery and decrease early mortality.

Levitronix CentriMag to Berlin Heart Excor: a "bridge to bridge" solution in refractory cardiogenic shock.

Levitronix CentriMag is a third generation bearingless temporary rotary pump designed for short-term mechanical support. The device, combined with Berlin Heart cannulas, was implanted in 30 patients suffering from acute cardiogenic shock with biventricular failure. Fifteen patients were successfully bridged to long-term Excor support due to lack of myocardial recovery. The approach produces good results, avoiding the risks of repeated sternotomy and cardiopulmonary bypass and reducing the costs involved.

Unusual tumor in the left ventricular outflow tract.

We report an unusual case of a pseudocyst in the left ventricular outflow tract in a 58-year-old woman. The cyst was successfully resected by a transatrial approach.

Body mass index and outcome after ventricular assist device placement.

BACKGROUND: The implantation of ventricular assist devices (VAD) is an established treatment for end-stage congestive heart failure. Extremes of body mass index (BMI) are associated with decreased survival after cardiac surgery. Many patients with congestive heart failure develop cardiac cachexia. In this study the association between BMI and outcomes after VAD implantation was investigated. METHODS: Consecutive patients (n = 590) who underwent VAD placement between 1996 and 2006 were divided into five groups based on BMI (kg/m2) quintiles (<20; 20-24; 25-29; 30-35; and >35). In a multivariate analysis adjusted for age, sex, diagnosis, emergency level, and type of device (left ventricular or biventricular assist device), procedural success (recovery, transplantation, or 30-day survival) and complications were analyzed. The best group was set as reference category for calculation of odds ratios. RESULTS: The groups with both extremes of BMI had the worst outcomes. The best procedural success was in the group with BMI 25 to 29 kg/m2. Underweight patients had similar survival rates to patients with normal weight. Overweight and obese patients did not have decreased survival. Extreme obesity at the time of VAD implantation showed elevated risk for postoperative death. There was no significant difference for BMI groups in the type of complications and cause of death. Cumulative survival curves for BMI category and overall VAD patient survival showed no significant differences. CONCLUSIONS: Cardiac cachexia need not be an exclusion criterion for VAD placement. Underweight patients appear to have benefit from mechanical support. Severely obese patients should be carefully selected before VAD placement.

Aortic valve replacement with the Mitroflow pericardial bioprosthesis: durability results up to 21 years.

OBJECTIVE: The study aim was to analyze the performance profile of a large series of Mitroflow pericardial valves (Sorin Group Canada Inc. Mitroflow Division) in the very long term. METHODS: Data from 1513 patients with isolated aortic valve replacement who received pericardial bioprostheses between 1986 and 2007 were analyzed. Cumulative duration of follow-up was 6164 patient-years with a maximum duration of 21 years. Actuarial rates of valve-related events were calculated by the Kaplan-Meier method and the Cox multivariate analysis to identify independent determinants of outcome. RESULTS: Hospital mortality for elective surgery was 2.5%. Late death was 40.6%. Reoperation was required in 86 (5.7%) patients and was valve related in 83: structural valve deterioration in 64 (4.2%) patients, prosthetic valve endocarditis in 17 patients (1.1%), valve thrombosis in 1, and periprosthetic leak in 1. Rates of 20-year actuarial freedom from valve-related morbidity were as follows: structural valve deterioration 84.8% (actual 96.6%) in patients 70 years of age or older; thromboembolism 94.1%; and prosthetic valve endocarditis 96.8%. Twenty-year actual risk of reoperation for structural valve deterioration was 11.4% in all patients and 3.4%, in patients 70 years or age or older. Advanced age, renal insufficiency, pulmonary disease, and low body mass index were independent risk factors for late outcome (P < .001). CONCLUSIONS: After 2 decades of follow-up, the Mitroflow pericardial aortic valve continues to be a valve of choice with a predictable low rate of valve-related events, particularly for patients over the age of 65 to 70 years and others with comorbidities.

Mitral valve repair for infective endocarditis in children.

BACKGROUND: Surgery for mitral valve endocarditis in children is relatively uncommon. This study assesses its operative outcome and reoperation and long-term survival rates. METHODS: We reviewed the cases of 8 consecutive children who underwent mitral valve repair for infective endocarditis between 1989 and 2005 at our institution. Mean age was 13.8 years (range, 9.4 to 16.9 years). The mitral valve was affected in all 8 patients, and both aortic and mitral valve in 2. Congenital cardiac malformation was the predisposing factor in 3 patients. Three patients had floppy mitral valve owing to leaflet perforation. All 8 patients had severe mitral regurgitation. Indications for operations were cardiac failure in 2, septic embolization in 2, and severe mitral regurgitation in 4. Four surgical interventions were elective, two were urgent, and two were emergencies. The offending microorganism was identified in 7 of the 8 patients. Mitral valve repair or reconstruction was performed in all 8, and 2 patients had additional aortic valve replacement. Follow-up was complete (mean, 9.5 years; range, 0.67 to 16 years; total, 76.7 patient-years). RESULTS: There were no operative deaths. Actuarial freedom from reoperation and actuarial survival rate at 1, 5, 10, and 15 years were 100%. Early echocardiographic follow-up showed 4 patients to have mild mitral valve regurgitation, 2 had mild to moderate, and 2 had no regurgitation. Long-term follow-up showed no progression of the lesions. CONCLUSIONS: Mitral valve repair achieves excellent results and can be performed without morbidity or mortality. Functional improvement and follow-up echocardiography evaluating the degree of mitral valve regurgitation and stenosis are satisfactory.