Postoperative Myocardial Infarction Due to Coronary Embolization of Valve Tissue After Surgical Mitral Valve Replacement.

We present the case of a 61-year-old man with known Morbus Barlow disease, who presented with postoperative myocardial infarction and cardiac arrest within 1 hour after minimally invasive mitral valve surgery owing to coronary artery occlusion by native mitral valve tissue.

Midterm outcomes of minimally invasive mitral valve surgery in a heterogeneous valve pathology cohort: respect or resect?

Background: Minimally invasive mitral valve surgery (MIV) through a right lateral thoracotomy has become the standard of care at specialized centers and might soon will be the only acceptable surgical treatment option in the future era of interventional procedures. The aim of our study was to analyze the outcomes of our MIV-specialized, single-center, mixed valve pathology cohort with regard to morbidity, mortality and midterm outcomes comparing two different repair techniques (respect versus resect). Methods: Baseline and operative variables, postoperative outcomes and follow-up information about survival, valve competence and freedom from reoperation were retrospectively collected and analyzed. The repair cohort was divided into three groups (resection, neo-chordae and both) and compared for outcomes. Results: Between July 22nd 2013 and May 31st 2022 a total of 278 consecutive patients underwent MIV. Out of those, we identified 165 eligible patients for the three repair groups: 82 patients (29.5%) had "resection", 66 "neo-chordae" (23.7%) and 17 "both" (6.1%). All preoperative variables were comparable between the groups. The predominant valve pathology of the entire cohort was degenerative disease with 20.5% Barlow's, 20.5% bi-leaflet and 32.4% double segment pathology. Bypass time was 164±47, cross-clamp time 106±36 minutes. All valves planned for repair (85.6%) were successfully repaired except for 13 resulting in a repair rate of 94.5%. Only 1 patient (0.4%) had to be converted to clamshell and 2 (0.7%) needed rethoracotomy for bleeding. Mean intensive care unit (ICU) stay was 1.8 days and hospital stay 10.6±1.3 days. In-hospital mortality was 1.1% and the incidence of stroke (1.8%). All in-hospital outcomes were comparable between the groups. Follow up was complete in 86.2% (n=237) for a mean of 3.7±0.8, up to 9 years. Five-year survival was 92.6% (P=0.5) and freedom from re-intervention 96.5% (P=0.1). All but 10 patients had mitral regurgitation less than grade 2 (95.8%, P=0.2) and all but two had less than New York Heart Association (NYHA) II (99.2%, P=0.1). Conclusions: Despite a heterogeneous cohort with mixed valve pathologies, there is a high reconstruction rate, low short- and midterm morbidity, mortality and need for re-intervention with comparable outcomes of the resect and respect technique in a specialized MIV center.

Propensity Matched Outcomes of Minimally Invasive Mitral Surgery: Does a Heart-Team Approach Eliminate Female Gender as an Independent Risk Factor?

BACKGROUND: There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort. METHODS: In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups. RESULTS: Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008-8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3). CONCLUSIONS: Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

Heart team approach in treatment of mitral regurgitation: patient selection and outcome.

OBJECTIVE: A multidisciplinary heart valve team is recommended for the evaluation of treatment in patients with valvular heart disease, but evidence supporting this concept is lacking. In patients with severe mitral regurgitation, we thought to analyse the patient selection process by the heart team for different treatment options and the outcome after treatment. METHODS: In this single-centre cohort study, all patients treated for mitral regurgitation between July 2013 and September 2018 were included. Primary end points during follow-up were all-cause mortality and a combined end point, consisting of all-cause mortality, cardiovascular rehospitalisation and mitral valve reintervention. RESULTS: 179 patients (44.8%) were treated using Mitraclip, 185 (46.2%) by surgical repair and 36 (9.0%) by surgical replacement. The mortality risk according to EuroScore II differed significantly between treatment groups (6.6%±5.6%, 1.7%±1.5% and 3.6%±2.7% for Mitraclip, surgical repair and replacement, respectively, p<0.001). In-hospital mortality for the 3 groups were 3.4%, 1.6% and 8.3%, respectively (p=0.091). Overall, surgical repair patients had higher 4-year survival (HR 0.40 (95% CI 0.26 to 0.63), p<0.001) and fewer combined end points (HR 0.51 (95% CI 0.32 to 0.80), p<0.001) compared with surgical replacement and Mitraclip patients. However, patients undergoing Mitraclip for isolated, primary mitral regurgitation achieved very good long-term survival. CONCLUSION: The multidisciplinary heart team assigned only low-risk patients with favourable anatomy to surgical repair, while high-risk patients underwent Mitraclip or surgical replacement. This strategy was associated with lower than expected in-hospital mortality for Mitraclip patients and high 4-year survival rates for patients undergoing surgical or percutaneous repair of isolated primary mitral regurgitation.

Single-center experience with the combination of Cardioplexol™ cardioplegia and MiECC for isolated coronary artery bypass graft procedures.

BACKGROUND: Cardioplexol™ with its low volume (100 mL) was originally conceived as cardioplegic solution for MiECC procedures. Introduced in its current form in 2008 in our clinic, it has immediately demonstrated attractive advantages including the easy and rapid administration by the surgeon him/herself, the almost immediate cardiac arrest and a prolonged delay before a second dose is necessary. We report here the results of our initial experience with this simple solution. METHODS: Single centre, retrospective observational analysis of prospectively collected data of isolated coronary artery bypass graft (CABG) procedures performed with a MiECC. RESULTS: Of 7,447 adult cardiac surgical operations performed during a 76 months period, 2,416 were isolated CABG-MiECC procedures. Patients were 81.3% males, 66.2±9.7 years old and had a median logistic EuroSCORE of 3.2. In average 3.2±0.8 vessels were bypassed. Median cross-clamp time was 45 minutes and more than 75% of the patients received only one 100 mL dose of Cardioplexol™. At reperfusion more than 90% of the hearts spontaneously recovered a rhythmic activity. Maximal value of troponin T during the first hours following myocardial reperfusion was 0.9±4.5 ng/mL (median =0.4 ng/mL). Mortality at 30 days was 0.9%. CONCLUSIONS: Cardioplexol™ seems very promising. It appears especially efficient and safe when used for CABG procedures performed with a MiECC.

The Freedom Solo pericardial stentless valve: Single-center experience, outcomes, and long-term durability.

OBJECTIVES: To report our institutional experience and long-term results with the Freedom Solo bovine pericardial stentless bioprosthesis (Sorin Group, Saluggia, Italy). METHODS: Between January 2005 and November 2009, 149 patients (mean age, 73.6 ± 8.7 years; 68 [45.6%] female) underwent isolated (n = 75) or combined (n = 74) aortic valve replacement (AVR) using the Solo in our institution. Follow-up was 100% complete with an average follow-up time of 5.9 ± 2.6 years (maximum, 9.6 years) and a total of 885.3 patient years. RESULTS: Operative (30-day) mortality was 2.7% (1.3% for isolated AVR [n = 1] and 4.0% for combined procedures [n = 3]). All causes of death were not valve-related. Preoperative peak (mean) gradients of 74.2 ± 23.0 mm Hg (48.6 ± 16.3 mm Hg) decreased to 15.6 ± 5.4 mm Hg (8.8 ± 3.0 mm Hg) after AVR, and remained low for up to 9 years. The postoperative effective orifice area was 1.6 ± 0.57 cm(2), 1.90 ± 0.45 cm(2), 2.12 ± 0.48 cm(2), and 2.20 ± 0.66 cm(2) for the valve sizes 21, 23, 25, and 27, respectively, with absence of severe prosthesis-patient mismatch and 0.7% (n = 1) experienced moderate prosthesis-patient mismatch. During follow-up, 26 patients experienced structural valve deterioration (SVD) and 14 patients underwent explantation. Kaplan-Meier estimates for freedom from death, explantation, and SVD at 9 years averaged 0.57 (range, 0.47-0.66), 0.82 (range, 0.69-0.90), and 0.70 (range, 0.57-0.79), respectively. CONCLUSIONS: The Freedom Solo stentless aortic valve is safe to implant and shows excellent early and midterm hemodynamic performance. However, SVD was observed in a substantial number of patients after only 5-6 years and the need for explantation increased markedly, suggesting low durability.

Massive pulmonary embolism: surgical embolectomy versus thrombolytic therapy--should surgical indications be revisited?

OBJECTIVES: The treatment of massive pulmonary embolism (PE) is a matter of debate. We present our institutional experience of patients suffering from massive PE with the aim of comparing the early results, the outcome and quality of life (QoL) between patients primarily assigned to either pulmonary surgical embolectomy (SE) or thrombolytic therapy (TL). A subgroup of patients (TS) with failed responses to TL requiring SE was separately analysed. METHODS: All consecutive patients (January 2001-December 2007) with computed tomography (CT)-scan-confirmed massive bilateral central or paracentral PE were reviewed. All clinical data were retrieved from our patients' registry and completed by the evaluation of the CT-scan-derived right ventricle/left ventricle ratio (RV/LV ratio). Follow-up focused on clinical outcome and QoL was obtained. RESULTS: Eighty patients were analysed including 28 SE (35%) and 52 TL (65%), of whom 11 (21%) required TS. Demographics and preoperative characteristics were similar between SE and TL. Analysis of the RV/LV ratio revealed a ratio of 1.66 for SE and 1.44 for TL. The early mortality rate was not significantly different between the two groups (SE: 3.6% versus TL: 13.5%), whereas early mortality was 27% in those patients treated initially with thrombolysis and subsequently requiring SE (TS-group). Severe bleeding complications were lower in the SE-group (3.6% versus 26.5% P = 0.013). Intracerebral bleeding rates and neurological events were not statistically different. After a mean follow-up of 63 ± 21 months, the mortality rate was 17.9% in the SE-group and 23.1% in the TL-group. CONCLUSIONS: SE is an excellent treatment option in massive PE with comparable early mortality rates and significantly less bleeding complications than TL. Patients having surgery after inefficient thrombolysis have the worst early outcome. The RV/LV CT-scan ratio might serve as a predictor to differentiate patients, who could profit from direct surgical intervention than thrombolytic treatment attempts. Further studies are required to confirm these results.

Ten-year comparison of pericardial tissue valves versus mechanical prostheses for aortic valve replacement in patients younger than 60 years of age.

OBJECTIVE: Aortic valve replacement using a tissue valve is controversial for patients younger than 60 years old. The long-term survival in this age group, the expected event rates during long-term follow-up, and valve-related complications are not clearly determined. METHODS: From January 2000 to December 2009, overall survival, valve-related events, and echocardiographic outcomes were analyzed in all patients younger than 60 years of age, who underwent biologic aortic valve replacement. Patients who received a Perimount Carpentier-Edwards pericardial tissue valve (n = 103) were selected and compared with a propensity matched group of 103 patients who received aortic valve replacement using a mechanical bileaflet valve. The mean follow-up was 33 ± 24 months (range, 2-120), and the mean age at implantation was 50.6 ± 8.8 years (bioprosthesis, 55 ± 8.9 years; mechanical valve, 50 ± 8.6 years; P = .03). RESULTS: Survival was significantly reduced in patients after biologic aortic valve replacement (90.3% vs 98%; P = .038). Freedom from all valve-related complications (bioprosthesis, 54.5%; mechanical valve, 51.6%; P = NS) and freedom from reoperation (bioprostheses, 100%; mechanical valve, 98%; P = NS) were comparable in both groups. The average transvalvular mean (11.2 ± 4.2 mm Hg vs 10.5 ± 6.0 mm Hg, P = .05) and peak (19.9 ± 6.7 mm Hg vs 16.7 ± 8.0 mm Hg, P = .03) gradients were greater after biologic aortic valve replacement. Regression of the left ventricular mass index was more pronounced after mechanical valve replacement (118.5 ± 24.9 g/m(2) vs 126.5 ± 38.5 g/m(2); P = NS). The echocardiographic patient-prosthesis mismatch was greater at follow-up after biological aortic valve replacement (0.876 ± 0.2 cm(2)/m(2) vs 1.11 ± 0.4 cm(2)/m(2); P = .01). Oral anticoagulation was a protective factor for survival among the bioprosthetic valve patients (P = .024). CONCLUSIONS: In the present limited cohort of patients younger than 60 years old, biologic aortic valve replacement was associated with reduced mid-term survival compared with survival after mechanical aortic valve replacement. Despite similar valve-related event rates in both groups, the better hemodynamic performance of the mechanical valves and/or protective effect of oral anticoagulation seemed to improve the outcome. The transcatheter valve-in-valve intervention as potential treatment of tissue valve degeneration should not be considered the sole bailout strategy for younger patients because no evidence is available that this would improve the outcome.

Effect on false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection.

OBJECTIVE: The aim of the study is to evaluate midterm results with regard to false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection. METHODS: We performed ascending/hemiarch replacement during hypothermic circulatory arrest with additional open implantation of the Djumbodis Dissection System (non-self-expanding bare metal stent) to readapt the dissected layers in the arch and the proximal descending aorta in a consecutive series of 15 patients (mean age 61 years, 20% female) suffering from acute type A aortic dissections. The primary end point was the status of the false lumen at the level of the stent. RESULTS: We observed three in-hospital deaths (20%). Complete thrombosis of the false lumen was observed in one patient (8%). In 25% of patients, partial thrombosis of the false lumen was observed. The remaining patients had continuing antegrade perfusion. Surgical conversion during a mean follow-up of 37 months was required in two patients (16%) due to continuing enlargement of the distal arch and the proximal descending aorta. No late deaths were observed. CONCLUSION: Additional implantation of the Djumbodis Dissection System to readapt the dissected layers in the arch and the proximal descending aorta does not seem to have additive value as an adjunct to standard ascending/hemiarch replacement with regard to closure of the false lumen in the arch and the proximal descending aorta. The most limiting factor seems to be the non-self-expanding capability of the device.

Ideal site for ventricular anchoring of artificial chordae in mitral regurgitation.

OBJECTIVE: Surgical treatment of mitral leaflet prolapse using artificial neochordae shows excellent outcomes. Upcoming devices attempt the same treatment in a minimally invasive way but target the left ventricular apex as an anchoring point, rather than the tip of the corresponding papillary muscle. In this study, cine cardiac magnetic resonance imaging was used to compare these 2 different anchoring positions and their dynamic relationship with the mitral leaflets. METHODS: Eleven healthy volunteers (mean age, 31 years; 6 female; mean ejection fraction, 62%) were examined by cardiac magnetic resonance imaging (3 Tesla, cine steady free precession technique with retrospective gating), whereby dedicated software enabled assessment of the physiologic distances among 3 anchoring sites (anterior papillary muscle, posterior papillary muscle, and apex) and the plane of the mitral annulus at the level of leaflet coaptation. These distances were measured in systole and diastole, and the performance of virtual neochordae was analyzed for the 3 potential anchoring sites. RESULTS: Length difference between systole and diastole for the 3 measured distances were 0.19 ± 0.11 cm (5.9% ± 3.4%) for the anterior papillary muscle, 0.19 ± 0.09 cm (6.7% ± 3.6%) for the posterior papillary muscle, and 1.52 ± 0.18 cm (17.8% ± 2.8%) for the left ventricular apex (P = .001). Virtual neochordae between the leaflet and the left ventricular apex were first adjusted in systole to achieve leaflet coaptation. Leaflet tear in diastole can only be avoided if the width of the attached leaflet is larger than the systole-diastole length difference. On the other hand, if virtual neochordae are adjusted in diastole to avoid leaflet tear, residual leaflet prolapse during systole can result. Because the systole-diastole length difference for papillary muscle anchored chordae is smaller than for apical chordae by a factor 10, there is a strongly reduced risk of prolapse or tearing and the leaflet width is unimportant. Furthermore, if the neochordae attached to the anterior mitral leaflet uses the apex as a distal anchoring site, the angle α between the aortic valve plane and this mitral leaflet is significantly reduced in diastole and therefore increases the risk of systolic anterior motion. CONCLUSIONS: Anchoring of neochordae at the papillary muscles, thereby mimicking the real anatomy, should be preferred over the left ventricular apex. Further analysis of dilated hearts and papillary muscle displacement is necessary to include the whole spectrum of pathologies.

Persistent sensitivity disorders at the radial artery and saphenous vein graft harvest sites: a neglected side effect of coronary artery bypass grafting procedures.

OBJECTIVE: The use of radial artery conduits in coronary artery bypass grafting (CABG) surgery is associated with improved long-term patency and patient survival rates as compared with saphenous vein conduits. Despite increasing popularity, relative incidence of local harvest-site complications and subjective perception of adverse long-term sequelae remain poorly described. METHODS: To allow for direct comparison, we investigated a consecutive series of patients in whom both the radial artery and the saphenous vein had been harvested for isolated CABG during a 36-month period. Patients were identified from a prospective database that collects baseline clinical information. The patients' own perceptions were assessed by a standardized direct telephone survey regarding any persistent functional impairment from their arm and leg operation sites. RESULTS: Out of 1756 CABG patients during the study period, 168 (10%) were eligible (78% men, median age: 60.1 ± 9.6 years, range: 29.6-82.4 years). Of these, 123 (73%) could be contacted and interviewed at a median follow-up time of 2.5 ± 0.9 years. Surgical wound complications at harvest sites (arms and legs) had occurred in 3% and 12%, respectively, and persistent symptoms (arms and legs) were self-reported as follows: chronic pain (5% and 8%), numbness (32% and 34%) and paresthesia/dysesthesia (14% and 7%). Overall, 39% of the patients reported persistent discomfort at the arm and 39% at the leg. Both sites were simultaneously affected in 21% (P = n.s., paired testing). Logistic regression modeling showed that patients with adverse long-term sequelae were younger (P < 0.005), had a higher body mass index (P < 0.05) and a lower EuroSCORE (P < 0.001) at the time of operation (EuroSCORE, European System for Cardiac Operative Risk Evaluation). Perioperative wound complications, however, did not predict persistence of symptoms. CONCLUSIONS: Persistent harvest-site discomfort occurs with astonishing frequency after CABG surgery and affects arms and legs equally. Although usually considered a minor complication, long-term limitation to quality of life may be substantial, particularly in younger and relatively healthy patients. Thus, harvest-site discomfort clearly belongs to the list of possible post-CABG complications of which patients need to be aware.

Clinical experience with the second-generation 3f Enable sutureless aortic valve prosthesis.

OBJECTIVE: The 3f Enable aortic bioprosthesis (ATS Medical, Inc, Minneapolis, Minn) represents a new generation of equine pericardial self-expanding valve designed for sutureless implantation. This study evaluated technical aspects of implantation and safety and effectiveness of the valve in the short term. METHODS: In an outcome analysis of a consecutive series of 28 patients who underwent aortic valve replacement for aortic stenosis with the 3f Enable during an 18-month period, mean age was 75.7 +/- 6.6 years, 18 patients were female (64.2%), and mean EuroSCORE was 7.1% +/- 1.7%. RESULTS: Most implanted valves were 23 mm in diameter (19-27 mm). Mean aortic crossclamp time was 39 +/- 15 minutes (29-103 minutes), mean cardiopulmonary bypass time was 58 +/- 20 minutes (41-127 minutes), mean hospital stay was 11 days (7-22 days), and 30-day mortality was 3.5%. Mean and peak intraoperative transvalvular pressure gradients were 6.1 +/- 2.6 and 18 +/- 5 mm Hg, respectively. Trivial and mild paravalvular leaks were observed in 1 patient each. One patient underwent reoperative aortic valve replacement 4 months after initial surgery for severe valve-unrelated paravalvular leakage. Five patients (18.5%) required permanent pacemakers. No patients were unavailable for follow-up. One-year survival was 86.2%. CONCLUSIONS: The 3-f Enable aortic bioprosthesis can be implanted safely with favorable early hemodynamics. The self-expanding stent allows sutureless implantation with a large valve area. The procedure was fast, although not as fast as expected. This experience has led to continued design and procedural enhancements to facilitate and accelerate future implantation.

Absence of prosthesis-patient mismatch with the new generation of Edwards stented aortic bioprosthesis.

Prosthesis-patient mismatch (PPM) remains a controversial issue with the most recent stented biological valves. We analyzed the incidence of PPM after implantation of the Carpentier-Edwards Perimount Magna Ease aortic valve (PMEAV) bioprosthesis and assessed the early clinical outcome. Two hundred and seventy consecutive patients who received a PMEAV bioprosthesis between January 2007 and July 2008 were analyzed. Pre-, peri- and postoperative data were assessed and echocardiographic as well as clinical follow-up was performed. Mean age was 72+/-9 years, 168 (62.2%) were males. Fifty-seven patients (21.1%) were below 65 years of age. Absence of PPM, corresponding to an indexed effective orifice area >0.85 cm(2)/m(2), was 99.5%. Observed in-hospital mortality was 2.2% (six patients), with a predicted mortality according to the additive EuroSCORE of 7.6+/-3.1%. At echocardiographic assessment after a mean follow-up period of 150+/-91 days, mean transvalvular gradient was 11.8+/-4.8 mmHg (all valve sizes). No paravalvular leakage was seen. Nine patients died during follow-up. The Carpentier-Edwards PMEAV bioprosthesis shows excellent hemodynamic performance. This valve can be implanted in all sizes with an incidence of severe PPM below 0.5%.

Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade.

OBJECTIVE: Prolonged deep hypothermic circulatory arrest (DHCA) adversely affects outcome and quality of life in thoracic aortic surgery. Several techniques of antegrade cerebral perfusion are routinely used: bilateral selective antegrade cerebral protection (SACP) by introducing catheters in the innominate and left carotid artery, unilateral perfusion through the right axillary antegrade cerebral perfusion (RAACP) or a combination of right axillary perfusion with an additional catheter in the left carotid artery (RAACCP), resulting also in bilateral perfusion. The aim of the present study was to analyse the impact of the different approaches on the quality of life (QoL). METHODS: The data of 292 patients who underwent surgery of the thoracic aorta using DHCA at our hospital between January 2004 and December 2007 have been analysed and a follow-up was performed focussing on QoL, assessed with the Short Form-36 Health Survey Questionnaire (SF-36). Results were analysed according to the type of cerebral perfusion and the duration of DHCA. RESULTS: Patients' characteristics were similar in all groups. Of the total, 3.4% patients underwent DHCA (average 8.3+/-6.4 min) without ACP, 45.9% underwent SACP (average DHCA of 15.6+/-7.1 min), 40.4% had RAACP (average DHCA of 28.1+/-11.6 min) and 9.4% bilateral perfusion (RAACCP) (average DHCA of 43.1+/-16.7 min). The average follow-up was 23.2+/-15.1 months. QoL was preserved in all groups. For DHCA above 40 min, bilateral ACP provides superior midterm QoL than unilateral RAACP (average SF-36 95.1+/-44.4 vs 87.6+/-31.3; p=0.072). CONCLUSIONS: When midterm QoL is assessed, bilateral SACP provides the best cerebral protection for prolonged DHCA (>40 min).

Preliminary results following reinforcement of the pulmonary autograft to prevent dilatation after the Ross procedure.

OBJECTIVE: The Ross operation remains a controversially discussed procedure, because concern exists regarding late dilatation of the neoaortic root and progressive regurgitation of the autograft valve. We present our early experience with an external reinforcement of the autograft, which is inserted into a prosthetic Dacron graft with an artificial aortic root configuration. This detail should help to prevent neoaortic root dilatation. PATIENTS AND METHODS: Between 2006 and 2007, 12 patients (mean age 16 +/- 38 years; range 15-38 years) underwent a Ross procedure by this technique. Indications were aortic regurgitation (n = 2), aortic stenosis (n = 5), and combined aortic stenosis and insufficiency (n = 5). A bicuspid aortic valve was present in 9 patients. Balloon valvuloplasty had been performed in 7 patients. Follow-up was performed by clinical and echocardiographic examinations. RESULTS: No early or late deaths occurred in this small series, and freedom from reoperation is 100%. Echocardiographic follow-up confirmed absence of aortic insufficiency in 11 patients after a mean of 11 months (range 2-30 months). In 1 patient, a small asymmetric regurgitation jet was already observed at discharge echocardiography. As expected, no neoaortic root dilatation was observed during follow-up. All patients are in New York Heart Association class I. CONCLUSIONS: The present technique is a simple and reproducible technical step that does not require significant additional time. Inclusion of the autograft within a root prosthesis may be especially indicated in situations known for late autograft dilatation, namely, bicuspid aortic valve, predominant aortic insufficiency, and ascending aortic enlargement.

Influence of patient-prosthesis mismatch on long-term results after aortic valve replacement with a stented bioprosthesis.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to compare long-term results of bioprostheses implanted in the aortic position, with and without patient-prosthesis mismatch (defined as effective orifice area (EOA)/body surface area (BSA) < or =0.85 cm2/m2). METHODS: Between 1986 and 1990, 90 consecutive patients (mean age 72.6 years; mean BSA 1.77+/-0.2 m2) each received an aortic Medtronic Intact valve (19 mm, n = 35; 21 mm, n = 29; >23 mm, n = 26). Of these patients, 64 had a patient-prosthesis mismatch, and 26 had no mismatch. Median follow up was 7.3 years. RESULTS: At 10 years postoperatively, there was no significant inter-group difference in actuarial freedom from thromboembolism (90.7% in mismatch group, 79.6% in no-mismatch group; p = 0.16), hemorrhage (86% versus 83.3%; p = 0.59), endocarditis (98.2% versus 86.7%; p = 0.1), structural valve deterioration (97% versus 100%; p = 0.57) and reoperation (96.4% versus 94.8%; p = 0.2). At the same time, overall actuarial survival was 42.1+/-6.5% in the mismatch group and 22.6+/-8.6% in the no-mismatch group (p = 0.08). By multivariate analysis, the main risk factor for late death was a preoperative left ventricular ejection fraction (LVEF) <50% (p = 0.001). Freedom from cardiac death was 70+/-6% and 35.7+/-11% in the mismatch and no-mismatch groups respectively (p = 0.005), but this was not significantly different when LVEFs were paired (LVEF >50% p = 0.33, LVEF <50% p = 0.28). The NYHA functional status of survivors showed 94.4% of the mismatch group and 100% of the no-mismatch group to be in NYHA classes I and II (p = 1). CONCLUSION: Within this patient population it was not possible to demonstrate any negative effects of patient-prosthesis mismatch at 10 years after Intact aortic valve replacement; the LVEF was the only predictor for late death.

Clinical outcome after repair of acute type A dissection in patients over 70 years-old.

BACKGROUND: Despite current aging of patients proposed for cardiac surgery, published results of type A dissection repair in the elderly are sparse and controversial though an increased operative risk when compared to younger patients is well-documented. Whether any patient of an advanced aged suffering from acute dissection of the proximal aorta should be referred for surgery deserves specific clinical studies. OBJECTIVE: To define factors of poor outcome after repair of type A dissection in the elderly by focusing on both early and late results. METHOD: A retrospective study including a consecutive series of 83 patients operated on in two neighboring French university centers between 1988 and 1999 with similar outstanding methods. Complete follow-up was achieved in March 2000. Results were compared according to: (i) the presence or the absence of complications at admission; and (ii) the use of hypothermic circulatory arrest (HCA) for completion of the distal suture. RESULTS: Mean age was 75.2+/-3.6 years (70-85). Overall operative mortality (OM) was 37.3%. OM was significantly higher (51.2 versus 23.8%, P=0.01) for patients who presented at admission any one of the following complications: tamponade, shock, endotracheal intubation upon arrival or evidence of brain, myocardial, mesenteric, renal or limb malperfusion. OM was not significantly affected by age or by the use of HCA during repair. Overall Kaplan-Meier survival was 50% at 1 year, 30% at 5 years and 13% at 10 years and was significantly lower (P=0.004) for patients who presented at least one complication at admission. Kaplan-Meier survival (excluding OM) was respectively 81, 48 and 21% and was significantly lower in case of prolonged stay in ICU (P=0.014) and for patients operated on without HCA (P=0.02). CONCLUSIONS: Results of repair of acute type A dissections in the elderly are acceptable for uncomplicated cases at admission. Using HCA in elderly patients whenever required for appropriate repair does not worsen early or late survival.