Thoracic Epidural Anesthesia Reduces Right Ventricular Systolic Function With Maintained Ventricular-Pulmonary Coupling.

BACKGROUND: Blockade of cardiac sympathetic fibers by thoracic epidural anesthesia may affect right ventricular function and interfere with the coupling between right ventricular function and right ventricular afterload. Our main objectives were to study the effects of thoracic epidural anesthesia on right ventricular function and ventricular-pulmonary coupling. METHODS: In 10 patients scheduled for lung resection, right ventricular function and its response to increased afterload, induced by temporary, unilateral clamping of the pulmonary artery, was tested before and after induction of thoracic epidural anesthesia using combined pressure-conductance catheters. RESULTS: Thoracic epidural anesthesia resulted in a significant decrease in right ventricular contractility (ΔESV25: +25.5 mL, P=0.0003; ΔEes: -0.025 mm Hg/mL, P=0.04). Stroke work, dP/dtMAX, and ejection fraction showed a similar decrease in systolic function (all P<0.05). A concomitant decrease in effective arterial elastance (ΔEa: -0.094 mm Hg/mL, P=0.004) yielded unchanged ventricular-pulmonary coupling. Cardiac output, systemic vascular resistance, and mean arterial blood pressure were unchanged. Clamping of the pulmonary artery significantly increased afterload (ΔEa: +0.226 mm Hg/mL, P<0.001). In response, right ventricular contractility increased (ΔESV25: -26.6 mL, P=0.0002; ΔEes: +0.034 mm Hg/mL, P=0.008), but ventricular-pulmonary coupling decreased (Δ(Ees/Ea) = -0.153, P<0.0001). None of the measured indices showed significant interactive effects, indicating that the effects of increased afterload were the same before and after thoracic epidural anesthesia. CONCLUSIONS: Thoracic epidural anesthesia impairs right ventricular contractility but does not inhibit the native positive inotropic response of the right ventricle to increased afterload. Right ventricular-pulmonary arterial coupling was decreased with increased afterload but not affected by the induction of thoracic epidural anesthesia. CLINICAL TRIAL REGISTRATION: URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2844. Unique identifier: NTR2844.

Left ventricular reverse remodeling after aortic valve surgery for acute versus chronic aortic regurgitation.

AIMS: Extent of left ventricular (LV) reverse remodeling after aortic valve repair or replacement (AVR) may differ between patients operated for acute aortic regurgitation (AR) and chronic AR. The aim of this study was to compare changes in LV volumes and function between patients with acute and chronic AR who underwent AVR. METHODS AND RESULTS: A total of 98 patients (54±15 years, 61% men) with acute (n=21) or chronic AR (n=77) were included in the present retrospective evaluation. LV volumes, LV ejection fraction, and global longitudinal strain indexed for LV end-diastolic volume (GLSi) were assessed preoperatively and after a median follow-up of 28 months (interquartile range: 17-66 months). Patients with acute AR tended to have smaller preoperative LV end-diastolic volume compared with chronic AR (156±15 vs 183±6 mL; P=.070). Both in patients with acute and chronic AR, significant LV reverse remodeling with sustained reduction in LV volumes occurred during follow-up with a significant smaller LV end-diastolic volume in acute AR compared with chronic AR (106±8 vs 128±5 mL; P=.032). Preoperative and postoperative LV ejection fractions were not significantly different between groups. In contrast, GLSi was better in patients with acute AR compared with chronic AR before AVR (-1.34±0.20 vs -0.96±0.07%/10 mL; P=.042) and during follow-up (-1.65±0.16 vs -1.29±0.07%/10 mL; P=.017). CONCLUSIONS: After AVR, LV reverse remodeling occurs both in patients with acute and chronic AR. However, LV end-diastolic volume was more reduced and GLSi was more preserved during follow-up in acute AR than in chronic AR.

Aortic valve repair versus replacement for aortic regurgitation: effects on left ventricular remodeling.

BACKGROUND: Left ventricular (LV) reverse remodeling after aortic valve replacement (AVR) for aortic regurgitation (AR) is associated with superior prognosis. The outcomes of valve-sparing aortic root replacement techniques on LV performance have not been compared with LV reverse remodeling in AVR. The present evaluation compared the extent of long-term LV reverse remodeling in patients with aortic root pathology and/or AR who underwent aortic valve repair (AVr) with patients who underwent AVR. METHODS: A total of 226 patients (54.7 ± 14.3 years, 63% male) with AR or aortic root pathology who underwent AVr (n = 135) or AVR with the Freestyle® stentless aortic root bioprosthesis [Medtronic, Inc.; Minneapolis, Minnesota] (n = 91) were included in the present retrospective evaluation. LV volumes and ejection fraction were assessed preoperatively, postoperatively (before hospital discharge) and during follow-up. RESULTS: Baseline characteristics were comparable between patient groups, except for higher prevalence of bicuspid aortic valve anatomy among AVR patients (38% vs. 16%, p < 0.001). In addition, patients undergoing AVR had significantly larger LV end-diastolic and end-systolic volumes than their counterparts. After a median follow-up of 46 months (interquartile range: 17 to 78 months), both groups of patients showed a significant and sustained reduction in LV end-diastolic and end-systolic volumes, with significantly larger reduction in patients undergoing AVR. Ejection fraction decreased significantly postoperatively and improved later during follow-up similarly in both groups. The incidence of significant AR at long-term follow-up was comparable among groups (AVr: 8% vs. AVR: 7%). CONCLUSIONS: LV reverse remodeling occurs after AVR and AVr, reaching comparable LV volumes and function after a median of four years of follow-up.

Comparing hemodynamic effects with three different measurement devices, of two methods of external leg compression versus passive leg raising in patients after cardiac surgery.

External leg compression (ELC) may increase cardiac output (CO) in fluid-responsive patients like passive leg raising (PLR). We compared the hemodynamic effects of two methods of ELC and PLR measured by thermodilution (COtd), pressure curve analysis Modelflow™ (COmf) and ultra-sound HemoSonic™ (COhs), to evaluate the method with the greatest hemodynamic effect and the most accurate less invasive method to measure that effect. We compared hemodynamic effects of two different ELC methods (circular, A (n = 16), vs. wide, B (n = 13), bandages inflated to 30 cm H2O for 15 min) with PLR prior to each ELC method, in 29 post-operative cardiac surgical patients. Hemodynamic responses were measured with COtd, COmf and COhs. PLR A increased COtd from 6.1 ± 1.7 to 6.3 ± 1.8 L·min(-1) (P = 0.016), and increased COhs from 4.9 ± 1.5 to 5.3 ± 1.6 L·min(-1) (P = 0.001), but did not increase COmf. ELC A increased COtd from 6.4 ± 1.8 to 6.7 ± 1.9 L·min(-1) (P = 0.001) and COmf from 6.9 ± 1.7 to 7.1 ± 1.8 L·min(-1) (P = 0.021), but did not increase COhs. ELC A increased COtd and COmf as in PLR A. PLR B increased COtd from 5.4 ± 1.3 to 5.8 ± 1.4 L·min(-1) (P < 0.001), and COhs from 5.0 ± 1.0 to 5.4 ± 1.0 L·min(-1) (P = 0.013), but not COmf. ELC B increased COtd from 5.2 ± 1.2 to 5.4 ± 1.1 L·min(-1) (P = 0.003), but less than during PLR B (P = 0.012), while COmf and COhs did not change. Bland-Altman and polar plots showed lower limits of agreement with changes in COtd for COmf than for COhs. The circular leg compression increases CO more than bandage compression, and is able to increase CO as in PLR. The less invasive Modelflow™ can detect these changes reasonably well.

Postoperative complications associated with transfusion of platelets and plasma in cardiac surgery.

BACKGROUND: Studies in cardiac surgery have reported increased postoperative morbidity and mortality after allogeneic red blood cell (RBC) transfusions. Whether platelet (PLT) and/or plasma transfusions are a marker for more concomitant RBC transfusions or are independently associated with complications after cardiac surgery is unknown. STUDY DESIGN AND METHODS: Data from two randomized controlled studies were combined to analyze the effects of PLT and/or plasma transfusions on postoperative infections, length of stay in the intensive care unit (ICU), all-cause mortality, and mortality in the presence or absence of infections in the postoperative period. RESULTS: After adjusting for confounding factors, plasma units and not RBC transfusions were associated with all-cause mortality. White blood cell (WBC)-containing RBC transfusions and PLT transfusions were associated with mortality occurring in the presence of or after infections. The number of (WBC-containing) RBC transfusions was also significantly associated with postoperative infections and with ICU stay for 4 or more days. CONCLUSION: Although it is difficult to separate the effects of blood components, we found that in cardiac surgery, perioperative plasma transfusions are independently associated with all-cause mortality. WBC-containing RBC transfusions and PLT transfusions are independently associated with mortality in the presence of infections in the postoperative period. Future transfusion studies in cardiac surgery should concomitantly consider the possible adverse effects of all the various transfused blood components.

The clinical spectrum of missense mutations of the first aspartic acid of cbEGF-like domains in fibrillin-1 including a recessive family.

Marfan syndrome (MFS) is a dominant disorder with a recognizable phenotype. In most patients with the classical phenotype mutations are found in the fibrillin-1 gene (FBN1) on chromosome 15q21. It is thought that most mutations act in a dominant negative way or through haploinsufficiency. In 9 index cases referred for MFS we detected heterozygous missense mutations in FBN1 predicted to substitute the first aspartic acid of different calcium-binding Epidermal Growth Factor-like (cbEGF) fibrillin-1 domains. A similar mutation was found in homozygous state in 3 cases in a large consanguineous family. Heterozygous carriers of this mutation had no major skeletal, cardiovascular or ophthalmological features of MFS. In the literature 14 other heterozygous missense mutations are described leading to the substitution of the first aspartic acid of a cbEGF domain and resulting in a Marfan phenotype. Our data show that the phenotypic effect of aspartic acid substitutions in the first position of a cbEGF domain can range from asymptomatic to a severe neonatal phenotype. The recessive nature with reduced expression of FBN1 in one of the families suggests a threshold model combined with a mild functional defect of this specific mutation.

Effects of allogeneic leukocytes in blood transfusions during cardiac surgery on inflammatory mediators and postoperative complications.

OBJECTIVE: To investigate whether the higher prevalence of postoperative complications in cardiac surgery after transfusion of leukocyte-containing red blood cells can be related to inflammatory mediators. DESIGN: Analysis of inflammatory markers interleukin-6, interleukin-10, interleukin-12, and procalcitonin in patients participating in a randomized trial comparing leukocyte-depleted with leukocyte-containing, buffy-coat-depleted red blood cells. SETTING: Two university-affiliated hospitals in the Netherlands. SUBJECTS: A total of 346 patients undergoing cardiac valve surgery with a complete series of pre- and postoperative blood samples. MEASUREMENTS AND MAIN RESULTS: There were no differences in the cytokines and procalcitonin concentrations between both study arms when the patients arrived in the intensive care unit. In subgroups, patients who received zero to three red blood cell transfusions showed similar cytokine concentrations in both study arms, whereas patients with > or = 4 red blood cell transfusions had significantly higher interleukin-6 concentrations in the leukocyte-containing, buffy-coat-depleted red blood cell group. Patients who developed postoperative infections and multiple organ dysfunction syndrome showed, respectively, increased concentrations of interleukin-6 and interleukin-12 in the leukocyte-containing, buffy-coat-depleted, red blood cell group. The interaction tests in these subgroups showed significantly different reaction patterns in the leukocyte-containing, buffy-coat-depleted red blood cell group compared with leukocyte-depleted red blood cell group for interleukin-6 and interleukin-12. Multivariate analysis showed a high interleukin-6 concentration with multiple organ dysfunction syndrome and both high interleukin-6 and interleukin-10 concentrations with hospital mortality. CONCLUSIONS: Allogeneic leukocyte-containing blood transfusions compared with leukocyte-depleted blood transfusions induce dose-dependent significantly higher concentrations of proinflammatory mediators in the immediate postoperative period after cardiac surgery. High concentrations of interleukin-6 are strong predictors for development of multiple organ dysfunction syndrome, whereas both interleukin-6 and interleukin-10 are associated with hospital mortality. These findings suggest that leukocyte-containing red blood cells interfere with the balance between postoperative proinflammatory response, which may further affect the development of complications after cardiac surgery.

Prognostic factors in pulmonary metastasized high-grade osteosarcoma.

INTRODUCTION: Resection of pulmonary metastases has previously been reported to improve outcome in high-grade osteosarcoma (OS) patients. Factors influencing survival in OS patients with pulmonary metastases are important for clinical decision making. METHODS: All 88 OS patients with pulmonary metastases either at diagnosis or during follow-up treated at the Leiden University Medical Center between January 1, 1990 and January 1, 2008 under the age of 40 were included in this study, including 79 cases of conventional, 8 cases of telangiectatic and 1 case of small cell OS. RESULTS: In total, 56 of 88 patients with pulmonary metastases were treated by metastasectomy. Resectability of pulmonary metastases was the main prognostic factor. In patients with primary non-metastatic OS, a longer relapse free interval to pulmonary metastases was significantly associated with better survival (P = 0.02). Independent risk factors determining worse survival after metastasectomy in multivariate analysis were male sex (P = 0.05), higher number of pulmonary nodules (P = 0.03), and non-necrotic metastases (P = 0.04). Whether surgery for recurrent pulmonary metastases was performed did not influence survival. Histological subtype of the primary tumor, histological response in the primary tumor after neo-adjuvant chemotherapy, occurrence of local relapse, local resection or amputation of the primary tumor and age at diagnosis did not influence outcome. CONCLUSION: This cohort of patients with detailed follow-up data enabled us to identify important risk factors determining survival in OS patients with pulmonary metastases. We demonstrate that after repeated metastasectomies, a subset of patients can be cured.

Strain analysis in patients with severe aortic stenosis and preserved left ventricular ejection fraction undergoing surgical valve replacement.

AIMS: To evaluate myocardial multidirectional strain and strain rate (S-and-SR) in severe aortic stenosis (AS) patients with preserved left ventricular (LV) ejection fraction (EF), using two-dimensional speckle-tracking strain imaging (2D-STI). The long-term effect of aortic valve replacement (AVR) on S-and-SR was also evaluated. METHODS AND RESULTS: Changes in LV radial, circumferential, and longitudinal S-and-SR were evaluated in 73 severe AS patients (65 +/- 13 years; aortic valve area 0.8 +/- 0.2 cm2) with preserved LVEF (61 +/- 11%), before and 17 months after AVR. Strain and strain rate data were compared with data from 40 controls (20 healthy individuals and 20 patients with LV hypertrophy) matched by age, gender, body surface area, and LVEF. Compared with controls, severe AS patients had significantly decreased values of LV S-and-SR in the radial (33.1 +/- 14.8%, P = 0.2; 1.7 +/- 0.5 s(-1), P = 0.003), circumferential (-15.2 +/- 5.0%, P = 0.001; -0.9 +/- 0.3 s(-1), P < 0.0001), and longitudinal (-14.6 +/- 4.1%, P < 0.0001; -0.8 +/- 0.2 s(-1), P < 0.0001) directions. At 17 months after AVR, LV S-and-SR significantly improved in all the three directions, whereas LVEF remained unchanged (60 +/- 12%, P = 0.7). CONCLUSION: In severe AS patients, impaired LV S-and-SR existed although LVEF was preserved. After AVR, a significant S-and-SR improvement in all the three directions was observed. These subtle changes in LV contractility can be detected by 2D-STI.

Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial.

CONTEXT: Mediastinal nodal staging is recommended for patients with resectable non-small cell lung cancer (NSCLC). Surgical staging has limitations, which results in the performance of unnecessary thoracotomies. Current guidelines acknowledge minimally invasive endosonography followed by surgical staging (if no nodal metastases are found by endosonography) as an alternative to immediate surgical staging. OBJECTIVE: To compare the 2 recommended lung cancer staging strategies. DESIGN, SETTING, AND PATIENTS: Randomized controlled multicenter trial (Ghent, Leiden, Leuven, Papworth) conducted between February 2007 and April 2009 in 241 patients with resectable (suspected) NSCLC in whom mediastinal staging was indicated based on computed or positron emission tomography. INTERVENTION: Either surgical staging or endosonography (combined transesophageal and endobronchial ultrasound [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread. MAIN OUTCOME MEASURES: The primary outcome was sensitivity for mediastinal nodal (N2/N3) metastases. The reference standard was surgical pathological staging. Secondary outcomes were rates of unnecessary thoracotomy and complications. RESULTS: Two hundred forty-one patients were randomized, 118 to surgical staging and 123 to endosonography, of whom 65 also underwent surgical staging. Nodal metastases were found in 41 patients (35%; 95% confidence interval [CI], 27%-44%) by surgical staging vs 56 patients (46%; 95% CI, 37%-54%) by endosonography (P = .11) and in 62 patients (50%; 95% CI, 42%-59%) by endosonography followed by surgical staging (P = .02). This corresponded to sensitivities of 79% (41/52; 95% CI, 66%-88%) vs 85% (56/66; 95% CI, 74%-92%) (P = .47) and 94% (62/66; 95% CI, 85%-98%) (P = .02). Thoracotomy was unnecessary in 21 patients (18%; 95% CI, 12%-26%) in the mediastinoscopy group vs 9 (7%; 95% CI, 4%-13%) in the endosonography group (P = .02). The complication rate was similar in both groups. CONCLUSIONS: Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00432640.

Risk factors and clinical significance of elevated mitral valve gradient following valve repair for degenerative disease.

OBJECTIVES: The risk factors and clinical effect of elevated mitral valve (MV) gradients after valve repair for degenerative valve disease remain insufficiently understood. METHODS: Between January 2004 and December 2015, a total of 484 patients underwent valve repair for degenerative disease. A true-sized full annuloplasty ring was implanted in all cases. We analysed the effect of preoperative and intraoperative factors on the postrepair gradient. Additionally, we explored the effect of postrepair gradients on long-term outcomes. RESULTS: On linear regression analysis, postrepair MV gradients were associated with patient age (coefficient = -0.110, standard error = 0.005, P = 0.034), body surface area (coefficient = 0.905, standard error = 0.340, P = 0.008), implanted annuloplasty ring size (coefficient = -0.181, standard error = 0.018, P < 0.001) and the use of Physio I ring (coefficient = 0.414, standard error = 0.122, P = 0.001). On multivariable analysis, postrepair MV gradient was not associated with overall survival [hazard ratio (HR) 1.034, 95% confidence interval (CI) 0.889-1.203; P = 0.66] or freedom from atrial fibrillation (HR 0.849, 95% CI 0.682-1.057; P = 0.14), but did emerge as a risk factor for MV reintervention (HR 1.378, 95% CI 1.033-1.838; P = 0.029). Two out of 11 reinterventions were performed due to MV stenosis and in both patients, high postrepair gradients were seen readily on predischarge echocardiography. CONCLUSIONS: Following valve repair for degenerative MV disease, elevated gradients occur even when true-sized annuloplasty is performed. The late clinical results of valve repair with elevated postrepair gradient are impaired and further studies are needed to explore preventive measures aimed at resolving the issue.

Left ventricular ejection fraction as criterion for implantation of an implantable cardioverter-defibrillator in heart failure patients undergoing surgical left ventricular reconstruction.

BACKGROUND: Besides implantation of an implantable cardioverter-defibrillator (ICD), a proportion of patients with left ventricular (LV) dysfunction due to ischemic cardiomyopathy are potential candidates for surgical LV reconstruction (Dor procedure), which changes LV ejection fraction (LVEF) considerably. In these patients, LVEF as selection criterium for ICD implantation may be difficult. This study aimed to determine the value of LVEF as criterium for ICD implantation in heart failure patients undergoing surgical LV reconstruction. METHODS: Consecutive patients with end-stage heart failure who underwent ICD implantation and LV reconstruction were evaluated. During admission, two-dimensional (2D) echocardiography (LV volumes and LVEF) was performed before surgery and was repeated at 3 months after surgery. Over a median follow-up of 18 months, the incidence of ICD therapy was evaluated. RESULTS: The study population consisted of 37 patients (59 +/- 11 years). At baseline, mean LVEF was 23 +/- 5%. Mean left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) were 175 +/- 73 mL and 225 +/- 88 mL, respectively. At 3-month follow-up, mean LVEF was 41 +/- 9% (P < 0.0001 vs. baseline), and mean LVESV and LVEDV were 108 +/- 65 mL and 176 +/- 73 mL, respectively (P < 0.0001 vs. baseline). During 18-month follow-up, 12 (32%) patients had ventricular arrhythmias, resulting in appropriate ICD therapy. No significant relations existed between baseline LVEF (P = 0.77), LVEF at 3-month follow-up (P = 0.34), change in LVEF from baseline to 3-month follow-up (P = 0.28), and the occurrence of ICD therapy during 18-month follow-up. CONCLUSION: LVEF before and after surgical LV reconstruction is of limited use as criterium for ICD implantation in patients with end-stage heart failure.

Methods for updating a risk prediction model for cardiac surgery: a statistical primer.

Risk prediction models in cardiac surgery tend to lose their predictive performance over time. This statistical primer aims to provide an overview of updating methods with their strengths and weaknesses. This is important, as model updating may be an efficient and good alternative to the de novo development of risk models. The discussed methods are intercept recalibration, logistic recalibration, model revision, closed test procedure and Bayesian modelling. It is recommended to report an updated model according to the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) statement and to include calibration and discrimination plots of the original and updated models to assess the model performance. An example is provided for updating the EuroSCORE II model in a national cohort from the Netherlands. Logistic recalibration results in a significant improvement of model performance, without the risk of overfitting. The example illustrates that more data allow for more extensive updating methods.

Excessive leaflet tissue in mitral valve repair for isolated posterior leaflet prolapse-leaflet resection or shortening neochords? A propensity score adjusted comparison.

BACKGROUND: Chordal replacement techniques are progressively used to treat posterior mitral valve leaflet (PMVL) prolapse while leaflet resection remains commonly in use to address excessive leaflet tissue. For excessive tissue in height, shortening neochords can be used alternatively. Use of chordal replacement techniques has been suggested to result in lower diastolic transvalvular gradients, higher freedom from reoperation and improved left ventricular function. METHODS: From 1/2005 to 12/2016, 150 patients underwent valve repair for isolated PMVL prolapse with excessive tissue. Excessive tissue in height was treated by leaflet resection (N.=99) or shortening neochords (N.=51). Excessive tissue in width was always resected. Logistic regression was used to generate propensity scores for risk-adjusted comparison. RESULTS: Two patients died postoperatively. In the Neochords group, resection of excessive tissue in width was still needed in 28 (55%) cases. Postoperative echocardiography demonstrated residual (≥2+) mitral regurgitation in 2/150 patients (Resect group). No differences in anuloplasty ring size, postoperative diastolic transvalvular gradients or left ventricular function were observed. Median clinical follow-up duration was 4.4 (IQR 2.0-7.0; 98% complete) years. There was no inter-group difference in overall survival or freedom from reintervention. Mean echocardiographic follow-up was 3.0 (IQR 1.2-5.4; 93% complete) years. In the matched population, the 6-year freedom from recurrent mitral regurgitation rates were 91.3% (95% CI: 81.9-100%) and 97.2% (95% CI: 91.9-100%) for the Resect and Neochords group, respectively (P=0.43). CONCLUSIONS: Both leaflet resection and shortening neochords provide a valuable tool to address excessive PMVL height. Repair durability is excellent regardless of the technique utilized.

Reinterventions after freestyle stentless aortic valve replacement: an assessment of procedural risks.

OBJECTIVES: Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after full-root replacement. We analysed our experience with reinterventions after stentless AVR. METHODS: A total of 75 patients with previous AVR using a Freestyle stentless bioprosthesis (31 subcoronary, 15 root-inclusion and 29 full-root replacement) underwent reintervention in our centre from 1993 until December 2018. Periprocedural data were retrospectively collected from the department database and follow-up data were prospectively collected. RESULTS: Median age was 62 years (interquartile range 47-72 years). Indications for reintervention were structural valve deterioration (SVD) in 47, non-SVD in 13 and endocarditis in 15 patients. Urgent surgery was required in 24 (32%) patients. Reinterventions were surgical AVR in 16 (21%), root replacement in 51 (68%) and transcatheter AVR in 8 (11%) patients. Early mortality was 9.3% (n = 7), but decreased to zero in the past decade in 28 patients undergoing elective reoperation. Per indication, early mortality was 9% for SVD, 8% for non-SVD and 13% for endocarditis. Aortic root replacement had the lowest early mortality rate (6%), followed by surgical AVR (13%) and transcatheter AVR (25%, 2 patients with coronary artery obstruction). Pacemaker implantation rate was 7%. Overall survival rate at 10 years was 69% (95% confidence interval 53-81%). CONCLUSIONS: Repeat aortic valve interventions after stentless AVR carry an increased, but acceptable, early mortality risk. Transcatheter valve-in-valve procedures after stentless AVR require careful consideration of prosthesis leaflet position to prevent obstruction of the coronary arteries.

Male-female differences in characteristics and early outcomes of patients undergoing tricuspid valve surgery: a national cohort study in the Netherlands.

OBJECTIVES: This study aims to explore male-female differences in baseline and procedural characteristics, and outcomes of patients undergoing isolated or concomitant tricuspid valve (TV) surgery. METHODS: All TV procedures registered between 2007 and 2016 in the database of the Netherlands Association for Cardio-Thoracic Surgery were analysed. Logistic regression analyses with interaction terms were used to determine whether sex was associated with hospital mortality. RESULTS: Five thousand five hundred and eighty-two patients underwent TV surgery [isolated: N = 685 (49% male), TVrepair: N = 5286 (50% male) and TVreplacement: N = 250 (46% male)]. In the TVrepair group, females were significantly older, had less prior percutaneous/surgical coronary interventions, less extracardiac arteriopathies, a lower prevalence of renal impairment, less endocarditis, a lower prevalence of preoperative critical condition, less recent myocardial infarction, less concomitant coronary artery bypass grafting (CABG) and, in case of concomitant mitral valve surgery, less concomitant mitral valve repair compared to males. In the TVreplacement group, females more often had a history of prior valve surgery and less prior CABG. Hospital mortality for males and females was 7.0% (N = 183) and 6.1% (N = 163), P = 0.241 in the TVrepair group and 2.6% (N = 3) and 8.8% (N = 12), P = 0.074 in the TVreplacement group. Sex was not associated with hospital mortality (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.88-1.48; P = 0.322). Sex demonstrated a significant interaction with the parameter 'critical preoperative condition' (OR 0.44, 95% CI 0.22-0.90; P = 0.026). CONCLUSIONS: Substantial differences in patient and procedural characteristics existed between male and female patients undergoing TV surgery, although sex was not a derterminant for hospital mortality. Nevertheless, sex interacted with a critical preoperative condition, indicating the usefulness of separate risk factor models for males and females requiring TV surgery.

Outcomes of Valve Repair for Degenerative Disease in Patients With Mitral Annular Calcification.

BACKGROUND: The risk factors for the development of mitral annular calcification (MAC) in degenerative mitral valve disease and the effect it may have on patient-and valve-related outcomes require further evaluation. METHODS: Between January 2002 and December 2015, 627 patients underwent mitral valve operations for degenerative disease. MAC was seen in 75 patients (12%); 73 (97%) underwent valve repair (6 without annuloplasty ring implantation) and 2 (3%) underwent valve replacement after an unsuccessful repair attempt. RESULTS: MAC was linked to patient age, female sex, and degenerative disease subtype. Early mortality was comparable between patients with and without MAC (3 of 75 [4%] vs 10 of 552 [2%], p = 0.20]. In patients with MAC, one-third of the deaths were directly related to annular decalcification and reconstruction. Early repair failure was more common in patients with MAC (8 of 75 [11%] vs 17 of 552 [3%], p = 0.006). During follow-up, no differences in overall survival or freedom from late reintervention were observed. However, at 8 years after the operation, freedom from recurrent mitral regurgitation was worse in patients with MAC. In these patients, repair failure was linked to nonuse of ring annuloplasty. For patients with MAC in whom annular decalcification and annuloplasty were performed, repair durability was comparable to patients without MAC. CONCLUSIONS: Mitral valve surgery in degenerative disease accompanied by MAC is safe. Optimal surgical strategy includes annular decalcification (when this would prevent implantation of an annuloplasty ring) and ring annuloplasty and will lead to results similar to patients without MAC. However, repair performance is hampered when the annulus is not addressed. For these patients, alternative repair techniques should be explored in the future.

Multicenter Phase II Clinical Trial of Isolated Lung Perfusion in Patients With Lung Metastases.

BACKGROUND: Up to 66% of patients show local pulmonary disease progression after pulmonary metastasectomy. Regional treatment with isolated lung perfusion (ILuP) may improve local control with minimal systemic adverse effects. The aims of this study were to evaluate local and distant control after ILuP, determine the effect on overall survival compared with historical controls, and confirm the safety and feasibility of ILuP. METHODS: A total of 107 patients with resectable pulmonary metastases of colorectal carcinoma, osteosarcoma, and soft-tissue sarcoma were included in a prospective phase II study of pulmonary metastasectomy combined with ILuP with 45 mg melphalan at 37°C. Local and distant control, overall survival, lung function, and 90-day mortality and morbidity were monitored. RESULTS: We report 0% mortality, low morbidity, and no long-term pulmonary toxicity. For colorectal carcinoma, median time to local pulmonary progression, median time to progression, and median survival time were 31, 14, and 78 months, respectively. Median time to local progression was not reached for sarcoma, whereas median time to progression and median survival time were 13 and 39 months, respectively. The 5-year disease-free rate and pulmonary progression-free rate were 26% and 44% for colorectal carcinoma and 29% and 63% for sarcoma, respectively. CONCLUSIONS: ILuP with melphalan combined with metastasectomy is feasible and safe. Compared with historical controls, favorable results were obtained in this phase II study for local control. Further evaluation of locoregional lung perfusion techniques with other chemotherapeutic drugs is warranted.

Early and late results of surgical treatment for isolated active native mitral valve infective endocarditis.

OBJECTIVES: Native mitral valve infective endocarditis (IE) is a complicated disease with high mortality and morbidity rates. Mitral valve repair (MVRep) is feasible when limited valve destruction is present. However, recurrent valve dysfunction and reintervention are common. METHODS: Between January 2000 and March 2016, 83 patients underwent surgery for isolated active native mitral valve IE. We applied an early surgery, MVRep-oriented approach with progressive utilization of patch techniques to secure a durable repair; MVRep was attempted in 67% of patients. Fifty-one (61%) patients underwent MVRep (including full-ring annuloplasty in 94%) and 32 (39%) patients underwent mitral valve replacement. RESULTS: Early mortality was 13%. No cases of early recurrent IE occurred. Predischarge echocardiography demonstrated good MVRep function in all, except 1 patient with residual (Grade 2+) regurgitation. The mean duration of follow-up was 3.7 years (interquartile range 1.5-8.4). For hospital survivors, 8-year overall survival rates were 92.4% (95% confidence interval 84.0-100%) and 74.2% (95% confidence interval 53.8-94.6%) for the MVRep and mitral valve replacement groups, respectively. Propensity score-adjusted Cox regression analysis revealed no significant difference in survival between the 2 groups (hazard ratio 0.359, 95% confidence interval 0.107-1.200; P = 0.096). Four reinterventions occurred, 2 in each group. Echocardiographic follow-up demonstrated excellent MVRep durability; no cases of mitral regurgitation and 1 case of mitral valve stenosis were seen. CONCLUSIONS: Native mitral valve IE is linked to high mortality and morbidity rates. A durable MVRep is feasible in most patients and provides excellent mid-term durability. Mitral valve replacement is a reasonable alternative when a durable repair is not likely.

Papillary muscle head repositioning for commissural prolapse in degenerative mitral valve disease.

OBJECTIVES: Surgical correction of commissural mitral valve prolapse can be challenging. Several surgical techniques, including commissural closure, leaflet resection with sliding plasty and chordal replacement, remain commonly in use. Conversely, papillary muscle head repositioning remains uncommonly utilized for the treatment of commissural prolapse. METHODS: Between January 2003 and December 2015, 518 patients underwent primary mitral valve repair for severe degenerative mitral valve regurgitation at our institution. Among them, 116 patients had non-isolated commissural prolapse (14 anterolateral, 82 posteromedial and 20 bicommissural prolapse). Eighty-eight patients underwent papillary muscle head repositioning and presented the study cohort. RESULTS: The mean patient age was 62.8 ± 12.5 years, and 32 (36%) patients were women. Postoperative echocardiography showed no residual mitral regurgitation in all but 1 (1%) patient in whom Grade 2+ regurgitation was seen. The freedom from late reintervention rates at 5 and 10 years were 96.1% [95% confidence interval (CI) 91.8-100%] and 92.7% (95% CI 86.4-99.0%), respectively. Upon reoperation, no recurrent commissural prolapse was observed. Echocardiographic follow-up demonstrated excellent valve repair durability. The freedom from Grade ≥2+ mitral regurgitation rates at 5 and 10 years were 92.6% (95% CI 86.3-98.9%) and 86.1% (95% CI 76.7-95.5%), respectively. CONCLUSIONS: Papillary muscle head repositioning for the treatment of commissural mitral valve prolapse is a reproducible and reliable technique that provides excellent long-term results.