Kissing Balloon "Valvuloplasty" of Obstructed Mechanical Aortic Valve: When You Are Running Out of Options.

We report an unusual case where "stuck" bileaflet aortic prosthetic valve occluders were partly released by performing emergency balloon dilatation with 2 noncompliant balloons by a percutaneous femoral approach. (Level of Difficulty: Advanced.).

Outcome of isolated aortic valve replacement in patients with classic and paradoxical low-flow, low-gradient aortic stenosis.

OBJECTIVE: To analyze operative outcomes and mid-term results after isolated aortic valve replacement (AVR) in low-flow, low-gradient aortic stenosis (LFLG AS) by comparing the 2 subcategories (classic low-flow, low-gradient aortic stenosis [CLFLG] and paradoxical low-flow, low-gradient aortic stenosis [PLFLG]). METHODS: This was a retrospective analysis of prospectively collected data for all isolated AVR in LFLG AS performed in our center during the last 13 years (n = 198; CLFLG AS, n = 66, 33% and PLFLG AS, n = 132, 67%). Median follow-up was 3.7 ± 3.3 years. RESULTS: Preoperative mean gradient was 30.2 ± 8.8 mm Hg in the CLFLG AS group and 31.4. ± 7.0 mmHg in the PLFLG AS group (P = .001). Female sex, hypertension, and neurologic and renal disease were more frequent in the PLFLG AS group (P < .01) whereas advanced New York Heart Association class, atrial fibrillation, and pulmonary hypertension were more frequent in the CLFLG AS group (P < .01). In-hospital mortality was 3% in the CLFLG AS group and 2.3% in the PLFLG AS group, P = .08. One- and five-year mortality rates were significantly greater in the CLFLG AS group (27% and 42% vs 6% and 20% in the PLFLG AS group, respectively, P = .001). On follow-up, 90% of the total survivors were in New York Heart Association class I-II, and 51% of the patients in the CLFLG AS group had an improvement in their ventricular function. CONCLUSIONS: AVR can be performed in LFLG AS with low in-hospital mortality. CLFLG AS carries similar in-hospital mortality to PLFLG AS but greater mid-term mortality. Surgery provided excellent functional status among survivors.

Winning Hearts and Minds: Inspiring Medical Students into Cardiothoracic Surgery Through Highly Interactive Workshops.

BACKGROUND: The cardiothoracic surgical (CTS) specialty has witnessed a decline in the applicant pool. Early exposure, positive experiences, inspiring role models, and career insight are key in the decision-making process for specialty choice. Our objective was to assess the effect of high tutor:student ratio interactive CTS workshops in influencing the career choice of UK undergraduate medical students. METHODS: Medical students attended a workshop comprising (1) guided dissection of fresh animal hearts, (2) surgical skills practice on models and fresh hearts, (3) operative videos (adult, congenital, transplant, and aortic) with interactive commentary, and (4) careers seminar. The tutor:student ratio was very high (between 3-1 and 5-1). A questionnaire was completed at the end of each workshop to assess its effect, including a 10-point Likert scale on the perceived attraction to CTS before and after the workshop. RESULTS: A total of 96 delegates attended 5 workshops in 3 UK medical schools. Response rate was 83% from 80 undergraduate students. In all, 58% were male (46/80). There was an equal proportion of sexes in the early years of medical school, but was significantly skewed toward male in the later years. There was a statistically significant increase of 2.1 (standard deviation [SD] = 1.5) in the Likert scores before (µ = 5.0, SD = 2.1) and after (µ = 7.1, SD = 1.9) (p = 0.001). This represents a 42% increase in the perceived attraction to the CTS specialty because of the workshops. CONCLUSIONS: Our workshops have a significant effect in stimulating undergraduate medical students toward a career in cardiothoracic surgery. We encourage national take-up of these easily organized daylong workshops to foster interest in the next generation of cardiothoracic surgeons.

Low-flow low-gradient aortic stenosis: surgical outcomes and mid-term results after isolated aortic valve replacement.

OBJECTIVES: To analyse operative outcomes and mid-term results following isolated aortic valve replacement (AVR) in patients with low-flow low-gradient severe aortic stenosis (LFLG AS) compared with normal flow high-gradient aortic stenosis (NFHG AS). METHODS: A retrospective analysis of data for all isolated AVRs performed for AS at our centre in the last 17 years (n = 846). Two groups were identified: LFLG AS (n = 198, 23%) [subdivided into: True LFLG AS (n = 66, 33%) and paradoxical LFLG AS (n = 132, 67%)] and NFHG AS (n = 648, 77%). Follow-up was done by clinical visits and telephone interviews. The mean follow-up was 5.8 ± 4.2 years. RESULTS: The mean age was 71.5 ± 9.7 years in the LFLG AS group and 68.7 ± 10.8 years in the NFHG group (P = 0.01). The LFLG AS group had a mean gradient 31.2 ± 7.4 mmHg compared with 59.1 ± 16.6 mmHg in the NFHG group (P = 0.001). Diabetes, chronic obstructive pulmonary disease, previous coronary disease, peripheral vascular disease, atrial fibrillation and pulmonary hypertension were significantly more frequent in the LFLG AS patients (P < 0.01). The in-hospital mortality rate was 2% in the LFLG and 1% in the NFHG group, P = 0.13. One- and 5-year mortality rates were significantly higher in the LFLG group (13 and 28 vs 4 and 16% in the NFHG, respectively, P = 0.001). Patients with true LFLG AS also had a significantly higher long-term mortality than those with paradoxical LFLG AS (27 vs 6% at 1 year and 42 vs 20% at 5 years, P < 0.05). CONCLUSIONS: AVR in patients with LFLG AS is associated with similar surgical mortality but increased mid-term mortality compared with NFHG AS. Patients with true LFLG AS have the worst outcomes. Surgery should still be offered for LFLG AS on prognostic grounds and for symptomatic benefit among survivors.

Effect of body mass index on early clinical outcomes after cardiac surgery.

BACKGROUND: there are several reports on the outcomes of cardiac surgery in relation to body mass index. Some concluded that obesity did not increase morbidity or mortality after cardiac surgery, whereas others demonstrated that obesity was a predictor of both morbidity and mortality. METHODS: this was a retrospective study of 3370 adult patients undergoing cardiac surgery. The patients were divided into 4 groups according to body mass index. The 4 groups were compared in terms of preoperative, operative, and postoperative characteristics. RESULTS: obese patients had a significantly younger mean age. Diabetes, hypertension, and hyperlipidemia were significantly more common in obese patients. The crossclamp time was significantly longer in the underweight group. Reoperation for bleeding, and pulmonary, gastrointestinal, and renal complications were significantly more common in the underweight group. Wound complications were significantly more frequent in the obese group. Mortality was inversely proportional to body mass index. The adjusted odds ratios of the early clinical outcomes demonstrated a higher risk of wound complications in overweight and obese patients CONCLUSION: body mass index has no effect on early clinical outcomes after cardiac surgery, except for a higher risk of wound complications in overweight and obese patients.

Multiple penetrating aortic ulcers involving the aortic arch and brachiocephalic artery.

Penetrating aortic ulcers are frequently observed in the descending thoracic and abdominal aorta. They are uncommon in the aortic arch, and they are extremely rare in the major branches of the aorta. We present the case of a 71-year-old woman who presented with multiple penetrating aortic ulcers affecting both the aortic arch and the brachiocephalic artery, and its successful treatment.

Carpentier-Edwards PERIMOUNT Magna bioprosthesis: a stented valve with stentless performance?

OBJECTIVE: We designed this study to evaluate the early hemodynamic performance of the recently introduced Carpentier-Edwards PERIMOUNT Magna bioprosthesis (Edwards Lifesciences, Irvine, Calif) and compare it with those of the conventional Carpentier-Edwards PERIMOUNT stented bioprosthesis (Edwards Lifesciences) and Edwards Prima Plus porcine stentless bioprosthesis (Edwards Lifesciences). METHODS: Sixty-three patients (>70 years old) were enrolled in this prospective, randomized study. At operation, once the annulus had been measured, the best size suitable was assessed for each of the three valves before random assignment. Transthoracic echocardiography was performed before discharge to evaluate early postoperative hemodynamic performances of the different valves implanted. RESULTS: The best size suitable of Edwards Prima Plus (24.3 +/- 1.7 mm) was significantly superior to those of both the Carpentier-Edwards PERIMOUNT Magna (23.4 +/- 2.1 mm) and Carpentier-Edwards PERIMOUNT (22.4 +/- 1.8 mm). The best size suitable of the Carpentier-Edwards PERIMOUNT Magna, however, was significantly superior to that of the Carpentier-Edwards PERIMOUNT. Furthermore the best size suitable of the Carpentier-Edwards PERIMOUNT Magna was equal to the measured annulus in 55% of patients, as opposed to 25% for the Carpentier-Edwards PERIMOUNT (P < .001). Mean implanted labeled size of the Edwards Prima Plus was significantly higher than those of both the Carpentier-Edwards PERIMOUNT Magna and the Carpentier-Edwards PERIMOUNT (24.6 +/- 1.9 mm, 23.1 +/- 1.9 mm, and 22.5 +/- 1.8 mm, respectively). Early postoperative hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna, however, was superior to those of both the Edwards Prima Plus and the Carpentier-Edwards PERIMOUNT in both effective orifice area index (1.07 +/- 0.4 cm2/m2, 0.87 +/- 0.3 cm2/m2, and 0.80 +/- 0.2 cm2/m2, respectively) and mean peak gradient (20 +/- 6 mm Hg, 27 +/- 8 mm Hg, and 28 +/- 12 mm Hg, respectively). CONCLUSION: The improved design of the recently introduced third-generation stented bioprosthesis Carpentier-Edwards PERIMOUNT Magna allows implantation of a significantly bigger valve than with the old generation. Furthermore, the improved hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna compares favorably with both the Carpentier-Edwards PERIMOUNT and the Edwards Prima Plus.

Long and short-term outcomes in patients requiring continuous renal replacement therapy post cardiopulmonary bypass.

OBJECTIVE: The development of acute renal failure following cardiac surgery is a rare but devastating complication with high morbidity and mortality. This study aimed to assess the incidence of acute renal failure necessitating continuous renal replacement therapy (CRRT) in patients who required cardiopulmonary bypass, to determine the factors associated with mortality and to evaluate long-term outcome. METHODS: Patients who underwent cardiac surgery between October 1997 and 2003 and treated with CRRT were included (n=98). Six patients were then excluded (already in established renal failure pre-operatively) and one patient lost to follow-up. A retrospective analysis was carried out. RESULTS: Overall CRRT was used in 2.9% (92/3172). The mean (SD) age of patients was 68 (10) years. Their mean pre-operative creatinine level and duration of cardiopulmonary bypass were 154 (87)micromol/l and 160 (84)min, respectively. Mean duration from surgery to establishment of CRRT was 50 (42)h. Mean creatinine level prior to hospital discharge was 168 (93)micromol/l. Thirty-day mortality was 42%. Significant risk factors for death were complex procedures (odds ratio=9.9), gastro-intestinal complications (OR=7.2), cross-clamp time over 88min (OR=5.9), re-exploration (OR=4.0) and patients age over 75 years (OR=3.3). Actuarial 1 and 5-year survivals (95% CI) were 53 (43, 63) % and 52 (42, 62) %, respectively. Only 2 (2.2%) patients required long term renal support. CONCLUSIONS: Acute renal failure necessitating the use of CRRT is a rare but serious complication post cardiopulmonary bypass. In the long-term, surviving patients are not likely to require further renal support.