Decellularized Pulmonary Xenograft Matrix PplusN versus Cryopreserved Homograft for RVOT Reconstruction during Ross Procedure in Adults.

BACKGROUND: Decellularized pulmonary homografts are being increasingly adopted for right ventricular outflow tract reconstruction in adult patients undergoing the Ross procedure. Few reports presented Matrix PplusN xenograft (Matrix) in a negative light. The objective of this study was to compare our midterm outcomes of Matrix xenograft versus standard cryopreserved pulmonary homograft (CPHG). METHODS: Eighteen patients received Matrix xenograft between January 2012 and June 2016, whereas 66 patients received CPHG. Using nonparametric statistical tests and survival analysis, we compared midterm echocardiographic and clinical outcomes between the groups. RESULTS: Except for significant age difference (the Matrix group was significantly older with 57 ± 8 years than the CPHG group, 48 ± 9 years, p = 0.02), the groups were similar in all other baseline characteristics. There were no significant differences in cardiopulmonary bypass times (208.3 ± 32.1 vs. 202.8 ± 34.8) or in cross-clamp times (174 ± 33.9 vs. 184.4 ± 31.1) for Matrix and CPHG, respectively. The Matrix group had significantly inferior freedom from reintervention than the CPHG group with 77.8 versus 98.5% (p = 0.02). Freedom from pulmonary valve regurgitation ≥ 2 was not significantly different between the groups with 82.4 versus 90.5% for Matrix versus CPHG, respectively. After median follow-up of 4.9 years, Matrix xenograft developed significantly higher peak pressure gradients compared with CPHG (20.4 ± 15.5 vs. 12.2 ± 9.0 mm Hg; p = 0.04). CONCLUSION: After 5 years of clinical and echocardiographic follow-up, the decellularized Matrix xenograft had inferior freedom from reintervention compared with the standard CPHG. Closer follow-up is necessary to avoid progression of valve failure into right ventricular deterioration.

Long-Term Outcomes of Patients Undergoing the Ross Procedure.

BACKGROUND: Treatment of aortic-valve disease in young patients still poses challenges. The Ross procedure offers several potential advantages that may translate to improved long-term outcomes. OBJECTIVES: This study reports long-term outcomes after the Ross procedure. METHODS: Adult patients who were included in the Ross Registry between 1988 and 2018 were analyzed. Endpoints were overall survival, reintervention, and major adverse events at maximum follow-up. Multivariable regression analyses were performed to identify risk factors for survival and the need of Ross-related reintervention. RESULTS: There were 2,444 adult patients with a mean age of 44.1 ± 11.7 years identified. Early mortality was 1.0%. Estimated survival after 25 years was 75.8% and did not statistically differ from the general population (p = 0.189). The risk for autograft reintervention was 0.69% per patient-year and 0.62% per patient-year for right-ventricular outflow tract (RVOT) reintervention. Larger aortic annulus diameter (hazard ratio [HR]: 1.12/mm; 95% confidence interval [CI]: 1.05 to 1.19/mm; p < 0.001) and pre-operative presence of pure aortic insufficiency (HR: 1.74; 95% CI: 1.13 to 2.68; p = 0.01) were independent predictors for autograft reintervention, whereas the use of a biological valve (HR: 8.09; 95% CI: 5.01 to 13.08; p < 0.001) and patient age (HR: 0.97 per year; 95% CI: 0.96 to 0.99; p = 0.001) were independent predictors for RVOT reintervention. Major bleeding, valve thrombosis, permanent stroke, and endocarditis occurred with an incidence of 0.15% per patient-year, 0.07% per patient-year, 0.13%, and 0.36% per patient-year, respectively. CONCLUSIONS: The Ross procedure provides excellent survival over a follow-up period of up to 25 years. The rates of reintervention, anticoagulation-related morbidity, and endocarditis were very low. This procedure should therefore be considered as a very suitable treatment option in young patients suffering from aortic-valve disease. (Long-Term Follow-up After the Autograft Aortic Valve Procedure [Ross Operation]; NCT00708409).

Rapid deployment valve system shortens operative times for aortic valve replacement through right anterior minithoracotomy.

BACKGROUND: There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT. METHODS: Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted. RESULTS: Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23-27 mm vs. 23 mm; IQR 21-25; p = 0.009). CONCLUSIONS: Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings.

Prevalence of severe mitral regurgitation eligible for edge-to-edge mitral valve repair (MitraClip).

OBJECTIVES: We assessed the prevalence of moderately severe or severe mitral regurgitation (MR) justifying edge-to-edge mitral valve (MV) repair (MitraClip(®)) in patients attending the University Hospital Wuerzburg, a tertiary care centre located in Wuerzburg, Germany. BACKGROUND: Transcatheter edge-to-edge MV repair of advanced MR is a non-surgical treatment option in inoperable and high-risk patients. It is unknown how many patients are potentially eligible for MitraClip(®) since several anatomical prerequisites of the MV apparatus have to be met for optimal treatment results. METHODS: Using a novel clinical data warehouse we searched for all patients attached to our Department of Internal Medicine from 01/2008 to 01/2012 with moderately severe or severe MR and aged ≥18 years. The current status of their treatment regime and eligibility for MitraClip(®) was assessed and re-evaluated according to current guidelines and echocardiographic criteria. RESULTS: The search of electronic medical records amongst 43,690 patients employed an innovative validated text extraction method and identified 331 patients with moderately severe or severe MR who had undergone echocardiographic assessment at our institution. Of these, 125 (38 %) received MV surgery and 206 (62 %) medical therapy only. Most patients not undergoing surgery had secondary MR (70 %). After evaluation of medical and echocardiographic data of medically treated patients (n = 206), 81 (39 %) were potential candidates for MitraClip(®) therapy, and 90 (44 %) died during the median follow-up time of 23 months. CONCLUSION: A large fraction of patients with moderately severe or severe MR but not operated was detected. Medically treated patients had a bad prognosis and about 40 % of them were potential candidates for MitraClip(®) therapy.

Degree of Carotid Artery Stenosis in Neurologically Asymptomatic Cardiac Surgical Patients Suffering from Perioperative Stroke: Results of an Observational Study.

Background Postoperative stroke in cardiac surgical patients remains a serious adverse outcome. Methods A total of 2,784 consecutively operated cardiac surgical patients without preoperative neurologic impairment were analyzed retrospectively with regard to impact of preoperative carotid stenosis on the incidence of postprocedural new onset of stroke. Therefore, all analyzed patients were assigned to four groups depending on preoperative degree of carotid artery stenosis detected by carotid duplex sonography (group I: < 50%, group II: 50-75%, group III: 76-89%, and group IV: > 90%). Results All pre-, intra-, and postoperative risk factors for neurological disorders were comparable throughout the cohort. Of the 2,784 patients, 65 (2.3%) met the inclusion criteria (preoperatively neurologically asymptomatic status, preoperatively carotid duplex ultrasonography study not older than 6 months, heart surgery with extracorporeal circulation, stroke until 48 hours after operation). Of the 65 patients who met the inclusion criteria, 43 (66.2%) were in group I, 11 (16.9%) in group II, 5 (7.7%) in group III, and 6 (9.2%) in group IV (p = 0.175). The overall incidence of an ipsilateral stroke relating to the carotid stenosis was 38 (1.4%) patients. Of these, 27 (71.1%) patients were in group I, 6 (15.8%) patients in group II, 2 (5.3%) patients in group III, and 3 (7.9%) patients in group IV (p = 0.568). Conclusion This observational study demonstrates that the degree of carotid stenosis in neurologically asymptomatic cardiac surgical patients is not able to predict the probability of perioperative stroke. Until further results from prospective randomized trials with neurologically asymptomatic cardiac surgical patients are presented, a cautious attitude for concomitant carotid endarterectomy is still justified.

A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry†.

OBJECTIVES: Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients. METHODS: Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years. RESULTS: The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7 and 86.7%, respectively, whereas freedom from homograft reoperation was 97.6, 95.5 and 92.3%, respectively. The overall freedom from reoperation was 94.9, 91.1 and 82.7%, respectively. Longitudinal modelling of functional valve performance revealed a low (<5%) probability of a patient being in higher autograft regurgitation grades throughout the first decade. Similarly, excellent homograft function was observed throughout the first 15 years. CONCLUSION: The autograft principle results in postoperative long-term survival comparable with that of the age- and gender-matched general population and reoperation rates within the 1%/patient-year boundaries and should be considered in young, active patients who want to avoid the shortcomings of conventional prostheses.

Age-related reoperation rate after the Ross procedure: a report from the German Ross Registry.

BACKGROUND AND AIM OF THE STUDY: An increasing number of young adult patients are choosing bioprostheses for aortic valve replacement (AVR). In this context, the Ross operation deserves renewed consideration as an alternative biological substitute. After both the Ross procedure and bioprosthetic AVR, reoperation rates remain a concern and may be related to age at surgery. Herein are reported details of freedom from reoperation after the Ross procedure for different age groups. METHODS: The reoperation rates of 1,925 patients (1,444 males, 481 females; mean age 41.2 ± 15.3 years) from the German Ross registry with a mean follow up of 7.4 ± 4.7 years (range: 0.00-18.51 years; total 12,866.6 patient-years) were allocated to three age groups: group I < 40 years; group II 40-60 years; and group III > 60 years. RESULTS: At 10 years (respectively 15 years) of follow up, freedom from reoperation was 86% (76%) in group I, 93% (85%) in group II, and 89% (83%) in group III. CONCLUSION: There is some evidence that, at least during the first 10 and 15 years after AVR, the Ross procedure provides a significantly lower reoperation rate in young adult and middle-aged patients aged < 60 years. This information may be of interest to the patients' or physicians' decision-making for aortic valve surgery.

Cardiac surgery antibiotic prophylaxis and calculated empiric antibiotic therapy.

BACKGROUND: Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients. METHODS: A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy. RESULTS: The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents. CONCLUSION: This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.

Preoperative serum h-FABP concentration is associated with postoperative incidence of acute kidney injury in patients undergoing cardiac surgery.

BACKGROUND: Fatty acid binding protein (FABP) is an intracellular transport protein associated with myocardial damage size in patients undergoing cardiac surgery. Furthermore, elevated FABP serum concentrations are related to a number of common comorbidities, such as heart failure, chronic kidney disease, diabetes mellitus, and metabolic syndrome, which represent important risk factors for postoperative acute kidney injury (AKI). Data are lacking on the association between preoperative FABP serum level and postoperative incidence of AKI. METHODS: This prospective cohort study investigated the association between preoperative h-FABP serum concentrations and postoperative incidence of AKI, hospitalization time and length of ICU treatment. Blood samples were collected according to a predefined schedule. The AKI Network definition of AKI was used as primary endpoint. All associations were analysed using descriptive and univariate analyses. RESULTS: Between 05/2009 and 09/2009, 70 patients undergoing cardiac surgery were investigated. AKI was observed in 45 patients (64%). Preoperative median (IQR) h-FABP differed between the AKI group (2.9 [1.7-4.1] ng/ml) and patients without AKI (1.7 [1.1-3.3] ng/ml; p = 0.04), respectively. Patients with AKI were significantly older. No statistically significant differences were found for gender, type of surgery, operation duration, CPB-, or X-Clamp time, preoperative cardiac enzymes, HbA1c, or CRP between the two groups. Preoperative h-FABP was also correlated with the length of ICU stay (rs = 0.32, p = 0.007). CONCLUSIONS: We found a correlation between preoperative serum h-FABP and the postoperative incidence of AKI. Our results suggest a potential role for h-FABP as a biomarker for AKI in cardiac surgery.

Impact of cardiac magnet resonance imaging on management of ventricular septal rupture after acute myocardial infarction.

A 74-year-old man was admitted to the cardiac catheterization laboratory with acute myocardial infarction. After successful angioplasty and stent implantation into the right coronary artery, he developed cardiogenic shock the following day. Echocardiography showed ventricular septal rupture. Cardiac magnet resonance imaging (MRI) was performed on the critically ill patient and provided detailed information on size and localization of the ruptured septum by the use of fast MRI sequences. Moreover, the MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. As the patient's condition worsened, he was intubated and had intra-aortic balloon pump implanted, and extracorporeal membrane oxygenation was initiated. During the following days, the patient's situation improved, and surgical correction of the ventricular septal defect could successfully be performed. To the best of our knowledge, this case report is the first description of postinfarction ventricular septal rupture by the use of cardiac MRI in an intensive care patient with cardiogenic shock and subsequent successful surgical repair.

Interference with ERK(Thr188) phosphorylation impairs pathological but not physiological cardiac hypertrophy.

Extracellular signal-regulated kinases 1 and 2 (ERK1/2) are central mediators of cardiac hypertrophy and are discussed as potential therapeutic targets. However, direct inhibition of ERK1/2 leads to exacerbated cardiomyocyte death and impaired heart function. We have previously identified ERK(Thr188) autophosphorylation as a regulatory phosphorylation of ERK1/2 that is a key factor in cardiac hypertrophy. Here, we investigated whether interference with ERK(Thr188) phosphorylation permits the impairment of ERK1/2-mediated cardiac hypertrophy without increasing cardiomyocyte death. The impact of ERK(Thr188) phosphorylation on cardiomyocyte hypertrophy and cell survival was analyzed in isolated cells and in mice using the mutant ERK2(T188A), which is dominant-negative for ERK(Thr188) signaling. ERK2(T188A) efficiently attenuated cardiomyocyte hypertrophic responses to phenylephrine and to chronic pressure overload, but it affected neither antiapoptotic ERK1/2 signaling nor overall physiological cardiac function. In contrast to its inhibition of pathological hypertrophy, ERK2(T188A) did not interfere with physiological cardiac growth occurring with age or upon voluntary exercise. A preferential role of ERK(Thr188) phosphorylation in pathological types of hypertrophy was also seen in patients with aortic valve stenosis: ERK(Thr188) phosphorylation was increased 8.5 ± 1.3-fold in high-gradient, rapidly progressing cases (≥40 mmHg gradient), whereas in low-gradient, slowly progressing cases, the increase was not significant. Because interference with ERK(Thr188) phosphorylation (i) inhibits pathological hypertrophy and (ii) does not impair antiapoptotic ERK1/2 signaling and because ERK(Thr188) phosphorylation shows strong prevalence for aortic stenosis patients with rapidly progressing course, we conclude that interference with ERK(Thr188) phosphorylation offers the possibility to selectively address pathological types of cardiac hypertrophy.

Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry.

OBJECTIVES: Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry. PATIENTS AND METHODS: From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years). RESULTS: In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P < .001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P < .001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation. CONCLUSIONS: The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation.

Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be used as an "ultima ratio" strategy in multiple injured patients with severe thoracic trauma. However, systemic anticoagulation during ECMO is recommended and thus traumatic brain injury (TBI) and intracranial bleeding are well-accepted contraindications for ECMO therapy. METHODS: This report describes three cases of prolonged heparin-free venovenous ECMO in multiple injured acute respiratory distress syndrome patients with severe TBI failing conventional mechanical ventilation. RESULTS: : Using this strategy, neither ECMO-associated bleeding nor clotting of the extracorporeal circuit occurred. All patients survived. CONCLUSIONS: Based on our experience, we recommend the use of heparin-free ECMO in multiple injured patients with pulmonary failure that is not successfully controlled by lung-protective ventilation even if severe TBI is present. LEVEL OF EVIDENCE: IV, therapeutic study.

Gentamicin-collagen sponge reduces sternal wound complications after heart surgery: a controlled, prospectively randomized, double-blind study.

OBJECTIVE: Prophylactic retrosternal placement of a gentamicin-collagen sponge has been the subject of several recent clinical studies and is a matter of controversy. The present study is the first controlled, prospective, randomized, double-blind, single-center study to investigate the efficacy of a retrosternal gentamicin-collagen sponge in reducing sternal wound complications after heart surgery. METHODS: From June 2009 to June 2010, 720 consecutive patients who underwent median sternotomy were assigned to a control placebo group (collagen sponge) or an intervention group (gentamicin-collagen sponge). All patients received guideline-compliant perioperative antibiotic prophylaxis. The primary end point was the occurrence of deep sternal wound infections within 30 days of index surgery (follow-up period). Secondary end points were the occurrence of superficial sternal wound infections requiring treatment, as well as further clinical parameters, including revision, bleeding volume, and need for transfusions during the follow-up period. RESULTS: A total of 720 of 994 patients (72.4%) were enrolled (control group: n = 367 vs intervention group: n = 353). Risk factors for sternal wound infection and demographic variables were comparable in the 2 groups. The incidence of deep sternal wound infections was 13 of 367 (3.52%) in the control group versus 2 of 353 (0.56%) in the intervention group (P = .014; adjusted odds ratio, 0.15; 95% confidence interval, 0.02-0.69). The numbers needed to treat relation for all sternal wound infections and deep sternal wound infections were 26 and 33, respectively. No statistically significant differences were demonstrated concerning secondary end points, such as postoperative bleeding and transfusion of red cell units, thrombocytes, and fresh-frozen plasma. CONCLUSIONS: Routine prophylactic retrosternal use of a gentamicin-collagen sponge in patients undergoing cardiac surgery significantly reduces deep sternal wound infections.

Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey.

OBJECTIVE: To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany. METHODS: A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words 'End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit'. RESULTS: We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families' choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%). CONCLUSIONS: This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.

Iatrogenic perforation of the left heart during placement of a chest drain.

Chest drain placement is a standard procedure for treating pneumothorax and pleural effusions and has a low complication rate. It is a safe and efficient procedure if image guidance is used. If the anatomic orientation is hampered and neither air nor fluids can be initially aspirated, more complex imaging than a chest x-ray is indicated to avoid major complications. We report the case of an 88-year-old male patient suffering from chronic heart failure who was admitted to another hospital following acute cardiac decompensation. Because of dyspnea with voluminous bilateral effusions, an attempt was made to drain the left pleural cavity. A malposition of the chest drain was suspected because blood was initially draining from the catheter. The hemodynamically stable patient was referred to our university hospital, where computed tomography of the chest revealed the location of the intercostal drain. The drain had perforated the left ventricle, run through the mitral valve and exited the left atrium via a pulmonary vein, ending in the middle lobe. The patient was brought to the surgical theater, where cardiac surgeons performed a left anterolateral thoracotomy and extracted the drain successfully. Three days later, the patient was discharged from our hospital in a good general condition.

Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German-Dutch Ross Registry.

BACKGROUND: The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. METHODS AND RESULTS: One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. CONCLUSIONS: Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

Fourteen years' experience with 501 subcoronary Ross procedures: surgical details and results.

OBJECTIVE: During the past decade the Ross procedure using the full root has become the predominant surgical technique. However, progressive autograft dilatation and eventual failure remain a concern. Here we report on the surgical techniques and results of the subcoronary technique over a 14-year period. METHODS: A total of 501 patients (mean age, 44.9 ± 12.9 years; 117 female; 384 male) were operated on from June 1994 to December 2007. The follow-up database, with a completeness of 98.2%, was closed on December 2008, comprising of 2931 patient-years with a mean follow-up of 5.9 ± 3.6 years (range, 0.1-14.1 years). RESULTS: Surgical details are presented. Early and late mortality were 0.4% (n = 2) and 4% (n = 20), respectively, valve-related mortality was 1.2% (n = 6), whereas the overall survival did not differ from that of the normal population. Neurologic events occurred in 22 patients, major bleeding in 9, autograft endocarditis in 8, and homograft endocarditis in 10. Freedom from autograft and homograft reoperation was 91.9% at 10 years. For the majority of patients, hemodynamics was excellent and no root dilatation was observed. CONCLUSIONS: Midterm results after the original subcoronary Ross procedure are excellent, including normal survival and low risk of valve-related morbidity. Longer-term results are necessary for continuous judgment of the subcoronary technique.

Heartmate II implantation with right coronary bypass grafting in ischemic cardiomyopathy with "fixed" pulmonary hypertension: treatment strategy to protect right ventricular function.

A 49-year-old male patient suffering from end-stage ischemic cardiomyopathy with a left ventricular ejection fraction below 15% was presented to redo coronary artery bypass grafting (CABG). Coronary angiogram demonstrated an occluded left anterior descending artery and occluded right coronary artery, perfused retrogradely from the circumflex artery. Since positron emission tomography did not demonstrate viable left ventricular myocardium except for the basis of the left ventricle, CABG was considered futile. Cardiac transplantation was contra-indicated due to pharmacologically unresponsive pulmonary artery hypertension. The patient successfully underwent left ventricular assist device implantation in combination with right coronary artery revascularization. The article reflects the regimen of right ventricular preservation in this patient.