Cardiac surgery in patients with haemophilia.

Today the populations of haemophilia patients in many countries have a higher life expectancy than previously known, and age-related disorders such as arterial disease are expected to become more prevalent, calling for surgical intervention. Cardiac surgery constitutes a major haemostatic challenge because of sternotomy, the need of total heparinization, extracorporal circulation, mild hypothermia and cardiac arrest. To evaluate our current experience and results with cardiac surgery in patients with haemophilia the present case series report on six patients with haemophilia A (Severe = 1, Moderate = 1, Mild = 4) undergoing cardiac surgery (coronary artery bypass grafting; CABG = 2, aortic valve replacement = 1, CABG + aortic valve replacement = 2, ventricular resection + mitral valve reconstruction = 1). The present paper provides detailed information on the haemostatic treatment regimens adopted (factor concentrate dosages, timing and duration) and postoperative thromboprophylaxis (dosing and duration of low molecular weight heparin). Moreover, we present data on concomitant disorders (hypertension, hypercholesterolaemia, atrial fibrillation and diabetes), left ventricle ejection fraction (30-60%), type of anaesthesia, total amount of heparin (34 500-53 500 IU) and duration of extracorporeal circulation (80-115 min). Clinical outcomes included: re-operation because of bleeding (none), transfusion requirements, peri- and postoperative blood loss and complications and postoperative development of inhibitors (none). Clinical outcomes were compared with a control group of patients (n = 5993) without haemophilia and we found no difference in postoperative morbidity. Adopting meticulously supervised haemostatic treatment regimens, we have successfully performed major cardiac surgery in patients with haemophilia A. The clinical outcome as well as the severity and incidence of postoperative complications were similar to patients without haemophilia.

Geometric determinants of chronic functional ischemic mitral regurgitation: insights from three-dimensional cardiac magnetic resonance imaging.

BACKGROUND AND AIM OF THE STUDY: The assessment of three-dimensional (3-D) mitral valve geometry in patients with chronic functional ischemic mitral valve regurgitation (FIMR) has been hampered by a lack of adequate imaging techniques. The study aim was to use a clinically applicable cardiac magnetic resonance imaging (MRI) technique to assess the 3-D mitral annular, leaflet and papillary muscle geometry in pigs with chronic FIMR. METHODS: Ten pigs with moderate chronic FIMR induced by catheter-based coiling of the circumflex artery, were examined using cardiac MRI. The reconstruction of 3-D data from two-dimensional cardiac MRI scans allowed the mitral annulus and leaflet geometries to be assessed. Using 3-D morphology scans, the spatial position of the posterior papillary muscle (PPM) relative to the anterior papillary muscle (APM), mitral annulus and anterior (A-trig) and posterior (P-trig) trigones was assessed. Using dedicated software for image analysis, data were transferred to a Cartesian coordinate system (x,y,z) for geometric analysis. Ten healthy pigs served as controls. RESULTS: Compared to controls, at end-systole in the chronic FIMR group the PPM was significantly displaced (p <0.05) from the APM (38 +/- 2 versus 23 +/- 1 mm), A-trig (48 +/- 2 versus 36 +/- 1 mm) and P-trig (41 +/-1 versus 33 +/- 1 mm). There was no significant apical PPM displacement (20 +/- 2 versus 20 +/- 1 mm). The annular area (1,240 +/- 90 versus 850 +/- 90 mm2), septolateral distance (36 +/- 2 versus 26 +/- 1 mm), commissure-to-commissure distance (38 +/- 2 versus 33 +/- 1 mm), mean tenting height (8 +/- 1 versus 5 +/- 0 mm), maximum tenting height (10 +/- 1 versus 7 +/- 0 mm), tenting volume (2,600 +/- 400 versus 1,500 +/- 200 mm3), and occlusional leaflet area (1,820 +/- 110 versus 1,120 +/- 70 mm2) were each significantly increased. CONCLUSION: This clinically applicable cardiac MRI modality permitted a detailed geometric insight to be made into the mitral annular, leaflet and PPM geometries that cause FIMR. Such a reliable tool for geometric mitral valve analysis has previously been demonstrated only by using invasive techniques. Hence, this approach holds promise for further clarifying the pathogenesis of chronic FIMR and improving preoperative surgical planning.

Bridge to heart transplantation with the HeartMate device in Gothenburg, Sweden.

BACKGROUND: Patients rapidly deteriorating while waiting for heart transplantation present a major problem. Our strategy for this entity is the HeartMate left ventricular assist device (LVAD) VELVAS, an electrically driven implantable LVAD. Herein we report our initial experience. METHODS: The medical records of all the patients who received HeartMate LVAS at our institution were reviewed. RESULTS: From January 1997 through May 2004, 19 patients received a HeartMate. The mean age was 39 (15 to 61) years and 84% were men. The diagnoses were: dilated cardiomyopathy (n = 8), ischemic heart disease (n = 6), myocarditis (n = 3), congenital heart disease (n = 1), and hypertrophic cardiomyopathy (n = 1). Mean time on LVAD was 113 (10 to 353) days. Ten patients were discharged from the hospital to their homes awaiting transplant or recovery. Three patients showed recovery of heart function and were subsequently weaned from mechanical support. Thirteen patients underwent heart transplantation. Three patients died during LVAD treatment. Major adverse events occurred in nine patients, including severe right heart failure (n = 3), severe bleeding (n = 3), stroke (n = 1), hepatic failure (n = 1), and septicemia (n = 2). Nine of the 13 transplanted patients are alive and well today. CONCLUSION: HeartMate LVAS is a valuable option for patients rapidly deteriorating while awaiting a heart transplant. Our results are comparable with those reported from larger centers.

Pulmonary capillary wedge pressure and natriuretic peptide levels in patients with sinus rhythm and severe left atrial enlargement following mitral valve surgery: early and late changes.

INTRODUCTION: Chronic mitral regurgitation is often accompanied by left atrial and ventricular remodeling and elevated natriuretic peptide levels. Our aim was to examine the relation between severe preoperative left atrial enlargement and changes in hemodynamics and natriuretic peptide levels after mitral valve surgery. METHODS: A prospective study was conducted including 40 consecutive patients in sinus rhythm, with severe degenerative mitral regurgitation. N-terminal protype-B natriuretic peptide levels and hemodynamics were measured at predefined time points. An echocardiographic evaluation was performed the day before valve surgery and six months postoperatively. RESULTS: Patients with left atrial volume index ≥60 mL/m(2), n=26, had higher baseline mean pulmonary capillary wedge pressure (17±9 mmHg vs 9±4 mmHg, p=0.010) and N-terminal protype-B natriuretic peptide (1326±2573 ng/L vs 233±221 ng/L, p=0.002) than patients with left atrial volume index <60 mL/m(2). The mean pulmonary capillary wedge pressure decreased to normal in patients with severe left atrial enlargement early after surgery, while it remained normal in patients without severe left atrial enlargement. The natriuretic peptide levels increased during the early postoperative period and decreased in both groups at 6-month follow-up. CONCLUSIONS: A severe left atrial enlargement in patients with chronic degenerative mitral regurgitation and sinus rhythm indicates higher pulmonary capillary wedge pressure and natriuretic peptide levels than in those without. These findings may support early referral to surgery and may facilitate perioperative management. The potential reversibility of left atrial enlargement after surgery may be associated with postoperative reductions in pulmonary capillary wedge pressure and natriuretic peptide levels.

Is repair preferable to replacement for ischemic mitral regurgitation?

OBJECTIVE: This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation. METHODS: From 1985 through 1997, a total of 482 patients with ischemic mitral regurgitation underwent either valve repair (n = 397) or valve replacement (n = 85). Patients more likely (P < or =.01) to undergo repair had functional mitral regurgitation or coronary revascularization with an internal thoracic artery graft; those more likely to receive valve replacement were in higher New York Heart Association functional classes or underwent emergency operations. These factors were used for multivariable propensity matching. Risk factors for early and late death were identified by multivariable, multiphase hazard function analysis. RESULTS: Within the propensity-matched better-risk group, survivals after valve replacement were 81%, 56%, and 36% at 30 days, 1 year, and 5 years, but survivals after repair were 94%, 82%, and 58% at these intervals (P =.08). In contrast, within the poor-risk group, survivals after repair and replacement were similar (P =.4). Risk factors (P < or =.01) included older age, higher functional class, greater wall motion abnormality, and renal dysfunction. Approximately 70% of patients were predicted to benefit from repair; the benefit lessened or was negated if an internal thoracic artery graft was not used, if a lateral wall motion abnormality was present, or if the mitral regurgitation jet pattern was complex. Freedom from repair failure at 5 years was 91%. CONCLUSION: Late survival is poor after surgery for ischemic mitral regurgitation. Most patients with ischemic mitral regurgitation benefit from mitral valve repair. In the most complex, high-risk settings, survivals after repair and replacement are similar.

Gas exchange function one month after transplantation of lungs topically cooled for 2 hours in the non-heart-beating cadaver after failed resuscitation.

BACKGROUND: If lungs from subjects dying of heart attacks could be used for transplantation, the lung donor shortage could be radically reduced. The aim of this study was to investigate, in an experimental survival model, the results of lung transplantation using lungs from non-heart-beating donors. METHODS: The left lung, topically cooled to 25 degrees C for 2 hours in situ after 5 minutes of circulatory arrest and 26 minutes of unsuccessful cardiopulmonary resuscitation, was transplanted into a syngeneic rat. Five weeks after the transplantation, right pneumonectomy was performed and blood gases measured every 10 minutes for 1 hour. Comparison were made with two control groups, one where fresh donor lungs were transplanted and another where only right pneumonectomy was done. RESULTS: All animals survived and were in good condition at the end of the observation period. There was no statistically significant difference in arterial oxygen or carbon dioxide tension between the groups. The bronchial anastomoses showed normal healing in all cases. CONCLUSION: Lungs from non-heart-beating donors topically cooled in situ to 25 degrees C for 2 hours before being harvested showed excellent gas exchange and bronchial healing 5 weeks after transplantation.

Bronchial healing, lung parenchymal histology, and blood gases one month after transplantation of lungs topically cooled for 2 hours in the non-heart-beating cadaver.

BACKGROUND: The aim of this study was to investigate, in an experimental survival model, the functional and morphologic results of lung transplantation using lungs from non-heart-beating donors. METHODS: Left lungs, topically cooled to 25 degrees C for 2 hours in situ after 5 minutes of circulatory arrest followed by 26 minutes of unsuccessful cardiopulmonary resuscitation, were transplanted into syngeneic rats. Five weeks after the transplantation, right pneumonectomy was performed and blood gases measured after 60 minutes. In a control group, fresh donor lungs were used for transplantation and comparison was made with the cadaver group and a group of normal rats after right pneumonectomy. Morphologic changes were evaluated by semiquantitative scoring of 13 different parameters to obtain a total histologic index for each rat. RESULTS: Computerized tomography scans of the chest made during the third post-operative week showed normal lung parenchyma in both groups, and at 5 weeks there were no significant differences in blood gases. The bronchial anastomoses showed normal healing in all cases. The histologic changes in the lung parenchyma were generally mild and focal, primarily consisting of interstitial and perivascular mononuclear inflammation, bronchial inflammation and athelectasis. Surprisingly, the transplanted controls demonstrated the most pronounced changes, although only the difference in total histologic index between groups was significant. CONCLUSIONS: Lungs from non-heart-beating donors, topically cooled in the cadaver for two hours after failed resuscitation, showed normal bronchial healing and favorable parenchymal histology compared to transplanted control lungs 5 weeks after transplantation.

Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse?

BACKGROUND: Traditionally, bileaflet prolapse has been treated by posterior leaflet resection combined with one of a number of procedures designed to support the anterior leaflet. However, most patients with bileaflet prolapse do not have important anterior chordal pathology. This study was undertaken to evaluate the effectiveness of a strategy of posterior leaflet resection and annuloplasty alone for patients with bileaflet prolapse and no anterior chordal rupture or severe anterior chordal elongation. METHODS: From 1993 to 1997, 93 patients with transesophageal echocardiography (TEE) demonstrated bileaflet prolapse and without anterior chordal rupture or important anterior chordal elongation had primary isolated mitral valve repair consisting only of posterior leaflet resection (quadrangular in 28 and sliding in 65) and annuloplasty (Cosgrove-Edwards in 83, pericardial in 9, and Carpentier-Edwards in 1). All patients had severe mitral regurgitation documented by intraoperative TEE. Mean age was 55+/-13 years; 60% were men. RESULTS: Postrepair, mitral regurgitation was 0 to trace in 93% and 1+ in 7%. There were no operative deaths. Late follow-up was available in all patients, with 277 patient-years of follow-up available for analysis. Five-year actuarial survival was 95%. At a mean interval of 2.3+/-1.3 (SD) years, echocardiography demonstrated no or trace mitral regurgitation in 65%, 1+ in 28%, and 2+ in 7%. No correlates of late mitral regurgitation were identified by multivariable analysis. No patient has required reoperation. CONCLUSIONS: In the absence of significant anterior chordal pathology, a strategy of posterior leaflet resection and annuloplasty corrects anterior leaflet prolapse and mitral regurgitation, and provides a durable repair without the necessity of additional procedures on the anterior leaflet.

Radical endarterectomy of severely calcified ascending aorta prevents stroke during open-heart surgery.

In ten patients (7 women), mean age 73 years, with severely calcified ascending aorta, aortic valve and coronary artery disease were surgically treated after radical endarterectomy of the ascending aorta during cardiopulmonary bypass and with or without deep hypothermic total circulatory arrest. One patient died 10 days and one 11 months postoperatively of complications which neither directly nor indirectly could be attributed to the aortic endarterectomy. The eight surviving patients are doing well after follow-up averaging 16 months. CT scans 1 year postoperatively showed no aneurysmal dilation of the ascending aorta or aortic dissection distal to the endarterectomy site. Radical endarterectomy of calcified ascending aorta thus can be performed with relatively low mortality and stroke risk and may be considered in patients undergoing valve replacement and/or coronary artery bypass grafting.

Upgrade to dual chamber pacing after long-term ventricular stimulation: feasibility and intermediate term follow-up.

AIMS: To evaluate the feasibility and follow-up results of atrial lead implantation and a change to dual chamber pacing following long-term treatment with single chamber ventricular stimulation. METHODS AND RESULTS: During a 30-month period, 70 consecutive patients with ventricular pacemakers were referred for pulse generator exchange or lead reoperation. Using defined criteria, an upgrade procedure was considered indicated in 34 of the cases (49%); these patients had a mean age of 74.8+/-8.8 years, and had been treated with VVI or VVIR pacing for a mean time of 7.8+/-3.8 years (range 1.8-17). An atrial lead was successfully implanted via ipsilateral subclavian venipuncture through the existing pectoral pacemaker pocket in 33 of the 34 cases (97% of the attempts). Postoperatively, one atrial lead dislodgement was seen, and another patient required atrial lead adjustment due to P wave undersensing. The mean follow-up period was 14+/-10 months. During this time, four patients developed permanent atrial fibrillation (annual incidence 11%. In 82% of the patients in whom an upgrade procedure was attempted, dual chamber pacing was maintained at the end of follow-up. CONCLUSION: Restoration of AV synchrony is possible in a substantial proportion of patients treated with long-term ventricular stimulation. Atrial lead placement through ipsilateral subclavian venipuncture is generally feasible, and the vast majority of cases remain in dual chamber pacing with normal function during intermediate term follow-up.