Sutureless Aortic Valve Replacement in a Patient with Transfemoral Aortic Valve Replacement and Left Ventricular Hypertrophy.

Background Transarterial valve intervention (TAVI) is valuable in high-risk patients, however, in case of left ventricular outflow tract (LVOT) obstruction, conventional surgery, including partial myectomy, is indicated. Case Description An 84-year-old female patient presented with increasing fatigue after TAVI in 2012, demonstrated a narrowed LVOT. Conventional surgery was performed, including removal of the transcathether valve, partial septal myectomy, and implantation of a sutureless valve. The postoperative course was uncomplicated. Conclusion Aortic valve stenosis combined with severe left-ventricular hypertrophy is not ideal for TAVI. Conventional surgery, performing partial septal myectomy and implantation of sutureless aortic prosthesis, seems more appropriate.

Clinical outcome and hemodynamic behavior of the Labcor Dokimos Plus aortic valve.

BACKGROUND: The Labcor Dokimos Plus (LDP) is a stented externally mounted pericardial aortic bioprosthesis, which was recently introduced in Europe. Aims of the study are evaluation of operative and postoperative results as well as hemodynamic performance. METHODS: One hundred consecutive patients with a mean age of 65.9 ± 10.7 years (range 35-87) and a mean EuroSCORE II of 3.1 ± 3.9 (range 0.67-24.5) underwent aortic valve replacement with the LDP. Mean valve-size was 25.2 ± 1.7 mm. Concomitant procedures were performed in 34% of the cases. Postoperative clinical data were analyzed and hemodynamic performance of the prostheses was evaluated by transthoracic echocardiography. Clinical follow-up was 100%, echocardiographic follow-up was 93% complete. RESULTS: Intraoperatively no peculiarities occurred. Mean cross clamp times for isolated and complex procedures were 74.5 ± 20.0 min and 103.7 ± 37.1 min, respectively. Patients were extubated after a mean of 9.4 ± 15.8 h. There were no perioperative strokes. Bleeding events occurred in 4 patients. 30-day-mortality was 2%. One case of early endocarditis occurred. Echocardiography showed maximum and mean pressure gradients of 18.1 ± 6.4 and 9.6 ± 3.7 mmHg, respectively. Correspondingly to valve sizes 21, 23, 25 and 27 mm, mean pressure gradients were 17.3, 9.5, 8.5 and 10.2 mmHg, effective orifice areas were 1.92, 1.79, 2.0, 2.16 cm2 and indexed effective orifice areas were 1.08, 0.95, 0.99 and 1.01 cm2/m2, respectively. No relevant regurgitations occurred. CONCLUSIONS: The LDP showed operatively no peculiarities and a satisfactory clinical outcome with low perioperative morbidity and mortality. The hemodynamic performance of the implanted valve sizes was satisfactory.

Surgery for prosthetic valve endocarditis: associations between morbidity, mortality and costs.

OBJECTIVES: Surgery for prosthetic valve endocarditis (PVE) is associated with significant morbidity and mortality as well as with increased resource utilization and costs. For risk and cost reduction, an understanding of contributing factors and interrelations is essential. METHODS: Out of 1080 heart valve procedures performed between January 2010 and December 2012, 41 patients underwent surgery for PVE. Complete economic data were available for 30 of them (study cohort). The patients' mean age was 64 ± 12 years (range 37-79 years), and 73% were men. The clinical course was reviewed and morbidity, mortality and costs as well as associations between them were analysed. The cost matrix for each individual patient was obtained from the Institute for the Hospital Remuneration System (InEK GmbH, Germany). The median follow-up was 2.6 years [interquartile range (IQR) 3.7 years; 100% complete]. RESULTS: Preoperative status was critical (EuroSCORE II >20%) in 43% of patients. Staphylococci were the most common infecting micro-organisms (27%). The operative mortality rate (≤30 days) was 17%. At 1 year, the overall survival rate was 71 ± 9%. At least one disease- or surgery-related complication affected 21 patients (early morbidity 70%), >1 complication affected 12 patients (40%). There was neither a recurrence of endocarditis, nor was a reoperation required. The mean total hospital costs were 42.6 ± 37.4 Thousand Euro (T€), median 25.7 T€, IQR 28.4 T€ and >100 T€ in 10% of cases. Intensive care unit/intermediate care (ICU/IMC) and operation accounted for 40.4 ± 18.6 and 25.7 ± 12.1% of costs, respectively. There was a significant correlation (Pearson's sample correlation coefficient) between total costs and duration of hospital stay (r = 0.83, P < 0.001) and between ICU/IMC costs and duration of ICU/IMC stay (r = 0.97, P < 0.001). The median daily hospital costs were 1.8 T€/day, but >2.4 T€/day in 25% of patients (upper quartile). The following pattern of associations was identified (P < 0.05). Early mortality was related to preoperative morbidity and postoperative renal failure. Early morbidity was associated with preoperative morbidity and urgency. Total costs were mainly explained by preoperative morbidity, postoperative morbidity and urgency. High EuroSCORE II, complex surgery, need for mechanical circulatory support as well as postoperative mortality and morbidity increased daily costs. CONCLUSIONS: The timely diagnosis and treatment of these patients must be a priority, as preoperative morbidity is the major contributor towards mortality, morbidity and costs after surgery for PVE.

From baby to man with a piggyback heart: long-term success of heterotopic heart transplantation.

We present a case of a young man, who underwent heterotopic heart transplantation 20 years ago, when he was 6 months old. The baby suffered from severe intractable cardiomyopathy. In this desperate situation only a miniature, compromised donor heart became available. Today, the young man is fully active under minimal immunosuppression. His surgical course is reviewed and described.

The St. Jude Toronto stentless bioprosthesis: up to 20 years follow-up in younger patients.

BACKGROUND: A retrospective long-term evaluation of the St. Jude Toronto stentless bioprosthesis in patients aged 60 years or younger. METHODS: From 1994 to 1997, 50 patients underwent aortic valve replacement with the prosthesis. Patients mean age at surgery was 54.5±6.3 years. Follow-up data were acquired by patient file research and telephone interviews. Morbidity and mortality were evaluated with time-to-event analyses using the Kaplan-Meier-method. The log-rank test was used to determine influencing factors for long-term survival and reoperation. RESULTS: Mean follow-up was 13.5±6.3 years with a total follow-up of 661.8 patient-years and a maximum of 20.0 years. Follow-up was 97.8% complete. Associated procedures were performed in 12 patients (24%), including coronary artery bypass grafting, mitral valve replacement and replacement of the ascending aorta. Freedom from reoperation at 10 and 15 years was 76.0±6.7% and 44.1±8.9%, respectively. Reoperations (n=26) started 4.4 years after implantation and were necessary due to: valve degeneration with regurgitation in 79.2% and stenosis in 12.5%, endocarditis in 4.2% and sinus valsalva aneurysm in 4.2% of the cases. The log-rank test revealed that only body-mass-index>25 lowered freedom-from-reoperation, while renal dysfunction, diabetes mellitus and arterial hypertension were not. Overall long-term survival at 10 and 20 years was 82.3±5.7% and 49.9±8.9%, respectively. CONCLUSION: In younger patients the Toronto-bioprosthesis provided reliable long-term survival despite limited durability.

Risk and Outcome of Aortic Valve Surgery in the Transcatheter Valve Era: The Gender Aspect.

OBJECTIVES: In 2009, a transcatheter valve intervention program was introduced at our centre. The aim of this single-centre retrospective study was to evaluate gender-specific risk profiles and outcome of patients undergoing surgical aortic valve replacement before and after 2009. METHODS: We assessed the preoperative logistic EuroSCORE and age, gender and 30-day-survival of 357 patients diagnosed with symptomatic severe aortic stenosis that underwent primary isolated surgical aortic valve replacement in 2007-2008 (group I, n = 191, 47% female) and 2010-2011 (group II, n = 166, 40% female). Survival follow up data was 100% complete. RESULTS: Women in group II were significantly younger (71.6 ± 9.0 years; p = 0.004) and showed significantly lower risk profiles (logistic EuroSCORE: 9.6 ± 9.9%; p = 0.04) than women in group I (age: 75.6 ± 8.5 years, logistic EuroSCORE: 13.9 ± 15.9). Men's age and risk profiles remained similar in both groups. Observed survival at 30 days was 98.8% in group II and 95.8% in group I which represented a statistical trend (p = 0.09). Female survival in group I was 92.2% and significantly worse as compared to 99% male survival in group I (p = 0.03). This significant difference in gender ratio of mortality was not detected in group II (female survival 97%, male survival 100%; p = 0.2). Being female was a significant risk factor in group I (odds ratio; 8.4; p = 0.03) but not in group II any longer (odds ratio: 1.0; p = 0.2). CONCLUSIONS: The possibility of transcatheter aortic valve replacement for therapy of aortic stenosis has led to a lower risk and improved outcome of surgical aortic valve replacement especially for women.

Predictive Power and Implication of EuroSCORE, EuroSCORE II and STS Score for Isolated Repeated Aortic Valve Replacement.

OBJECTIVE: We evaluated the predictive power of the EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons (STS) score for isolated redo aortic valve replacement. MATERIALS AND METHODS: 78 consecutive patients underwent the aforementioned procedure mainly with a stentless valve prosthesis at our institution. Observed mortality was compared to the predicted mortality, Receiver Operating Characteristics (ROC) curves were calculated and the area under the curve (AUC) analyzed. RESULT: Observed mortality was 11.5%. EuroSCORE and EuroScore II predicted a mortality of 28.2 ± 21.6% (p <0.001) and 10.2 ± 11.8% (p = 0.75), respectively. AUC of the EuroSCORE was 0.74 (95% CI: 0.62-0.83), p = 0.009 and of the EuroSCORE II 0.86 (95% CI: 0.76-0.93), p <0.0001. Optimal Youden index of the EuroSCORE II was 0.59 referring to a predicted mortality of 9.9% (sensitivity: 77.8% and specificity: 81.2%). Predicted mortality of STS score was 17.8 ± 10.6% (p = 0.08) and AUC was 0.64 (95% CI: 0.53-0.75), p = 0.06. CONCLUSION: EuroSCORE II calculation was not only superior to EuroSCORE and STS score but led to a very realistic mortality prediction for this special procedure at our institution. A EuroSCORE II greater 10 should encourage to consider an alternative treatment.

Hemodynamic behavior of stentless aortic valves in long term follow-up.

OBJECTIVES: Stentless aortic valve replacements show improved hemodynamics due to larger orifice area and lower transvalvular gradients in short and mid-term follow-up. Hemodynamic long-term behavior and the adaptation of the left ventricle as well as valve-durability in patients aged ≤60 years remains unclear. METHODS: 7 to 16 years after aortic valve replacement, 54 patients (mean age at operation 53.1 ± years) received echocardiography and clinical examination. Mean follow-up time was 10.8 ± 2.2 years. Evaluated were NYHA class, transvalvular gradients, estimated aortic valve orifice area, degree of aortic valve insufficiency, left ventricular mass and function. RESULTS: At follow-up only one patient presented with NYHA class III. All other patients were in NYHA class I or II. Maximum and mean pressure gradients of the prostheses were 16.3 ± 7.4 mmHg and 9.1 ± 4.2 mmHg, respectively. Compared to echocardiography at discharge the mean pressure gradients dropped 18.0% (2.0 ± 0.9 mmHg) and stayed stable until 14 years after the operation. Only 5 patients showed relevant regurgitation (at 13-16 years after valve replacement), 49 showed no or trivial regurgitation. Left ventricular mass had decreased 26.5% (107.9 ± 18.5 g). Left ventricular ejection fraction (LVEF) had increased in most patients and decreased in only one. For patients with preoperatively impaired left ventricular function an increase of LVEF of 13.1 ± 3.1% was seen. CONCLUSION: Porcine stentless aortic valves provide excellent hemodynamic long-term results without significant rise of transvalvular pressure gradients or relevant insufficiencies until 14 years after implantation, leading to sustained decrease of left ventricular mass and improvement of left ventricular function.

Suitability of the rat subdermal model for tissue engineering of heart valves.

BACKGROUND: Tissue engineering (TE) is a promising approach to overcome problems associated with biological heart valve prosthesis. Currently several animal models are used to advance this method. The rat subdermal model is uncomplicated and widely used, but its suitability for TE has not yet been shown. MATERIAL AND METHODS: Using the rat subdermal model we implanted two decellularized porcine aortic wall specimens (of which one was endothelialized) and one native porcine aortic wall specimen in 30 Lewis rats, respectively. Endothelial cells (EC) were harvested from the rat jugular veins. After explantation Hematoxylin/Eosin-staining, CD-68-positive cell staining, fibroblast-staining and Von-Willebrand factor staining were performed. RESULTS: All animals survived without complications. Endothelialization was confirmed to be effective by Giemsa staining. Histological evaluation of specimens in Hematoxylin/Eosin staining showed significant decrease (p<0.05) of inflammatory reaction (confirmed by CD-68-positive cell staining) after decellularization. All specimens showed strongest inflammatory reactions at areas of destroyed extracellular matrix. Fibroblasts could be detected in all specimens, with strongest infiltration in decellularized specimens (p<0.05). Surrounding endothelialized specimens had no monolayer of endothelial cells, but a higher density of blood vessels occurred (p<0.05). CONCLUSIONS: The subdermal model provides excellent contact of host tissue with implanted specimens leading to rapid cellular infiltration; therefore, we could ascertain reduced inflammatory response to decellularized tissue. Due to the subdermal position, an absence of blood stream and mechanical stress occurs, which influences cellular repopulation; therefore, endothelialization did not lead to an EC monolayer, but rather to increased vascularization. Thus, the model appears ideal for investigating basic biological compatibility, but further questions must be researched using other models.

Outcome after surgery for prosthetic valve endocarditis and the impact of preoperative treatment.

OBJECTIVES: This study examined the outcomes of surgery for active prosthetic valve endocarditis in a recent decade, with special interest in preoperative treatment and predictors for early and late events. METHODS: From 2000 to 2010, a cohort of 149 consecutive patients (mean age, 64±13.9 years; 72% were male) underwent redo-surgery for prosthetic valve endocarditis and were reviewed regarding early (≤60 days) and late (>60 days) events (death, reinfection, reoperation). Kaplan-Meier survival curves and Cox regression analysis were used to investigate the impact of preoperative intervals and predictors for events, respectively. RESULTS: Preoperative status was critical (European System for Cardiac Operative Risk Evaluation>20%) in 121 patients (81.2%). Staphylococci were the most common infecting microorganisms (27.5%). The median interval between onset of symptoms and diagnosis and between diagnosis and operation was 2 days (interquartile range, 1-5) and 8 days (interquartile range, 2-23), respectively. Operative mortality (≤30 days) was 12.8%. Mean follow-up was 4±2.9 years. In 53 patients, 47 early (24 deaths, 14 recurrences, 9 reoperations) and 22 late events (11 deaths, 9 recurrences, 2 reoperations) occurred. Overall and event-free survivals at 10 years were 75%±3.8% and 64%±4.0%, respectively. Freedom from recurrent infection and reoperation at 10 years were 81%±3.6% and 91%±2.6%, respectively. In multivariate Cox regression, mechanical circulatory support, prolongation between onset of symptoms and diagnosis more than 30 days, and preoperative presence of renal failure predicted early events, and double valve replacement predicted late events. CONCLUSIONS: Cardiac and renal function, need for double valve replacement, and preoperative treatment predicted outcomes. A prolonged interval in which patients were left untreated while symptomatic, but not prolongation of preoperative antibiotic treatment, increased risk.

Eprosartan improves cardiac function in swine working heart model of ischemia-reperfusion injury.

BACKGROUND: Eprosartan is an angiotensin II receptor antagonist used as an antihypertensive. We sought to evaluate the regional effect of Eprosartan on postinfarct ventricular remodeling and myocardial function in an isolated swine working heart model of ischemia-reperfusion injury. MATERIAL AND METHODS: 22 swine hearts were perfused with the Langendorff perfusion apparatus under standard experimental conditions. Myocardial ischemia was induced by a 10-min left anterior descending artery ligation. Hearts were reperfused with either saline (control group, n=11), or Eprosartan (treatment group, n=11). Left ventricular pressure (LVP) and regional heart parameters such as intramyocardial pressure (IMP), wall thickening rate (WTh), and pressure-length-loops (PLL) were measured at baseline and after 30 min of reperfusion. RESULTS: Measured parameters were statistically similar between the 2 groups at baseline. The administration of Eprosartan led to a significantly better recovery of IMP and WTh: 44.4±2.5 mmHg vs. 51.2±3.3 mmHg, p<0.001 and 3.8±0.4 µm vs. 4.4±0.3 µm, p=0.001, respectively. PLL were also significantly higher in the treatment group following reperfusion (21694±3259 units vs. 31267±3429 units, p<0.01). There was no difference in the LVP response to Eprosartan versus controls (63.6±3.0 mmHg vs. 62.5±3.1 mmHg, p=0.400). CONCLUSIONS: Pre-treatment with Eprosartan is associated with a significant improvement in regional cardiac function under ischemic conditions. Pharmacological treatment with eprosartan may exert a direct cardioprotective effect on ischemic myocardium.

Successful implantation of a decellularized equine pericardial patch into the systemic circulation.

BACKGROUND: In the past, successful use of decellularized xenogenic tissue was shown in the pulmonary circulation. This study, however, evaluates a newly developed decellularized equine pericardial patch under high pressure circumstances. MATERIAL AND METHODS: Seven decellularized equine pericardial scaffolds were implanted into the descending aorta of the juvenile sheep. The implanted patches were oversized to evaluate the durability of the decellularized tissue under high surface tension (Law of Laplace). After 4 months of implantation, all decellularized patches were inspected by gross examination, light microscopy (H&E, Serius red, Gomori, Weigert, and von Kossa straining), and immunohistochemical staining. RESULTS: The juvenile sheep showed fast recovery after surgery. There was no mortality during follow-up. At explantation, only limited adhesion was seen at the surgical site. Gross examination showed a smooth and pliable surface without degeneration, as well as absence of aneurysmatic dilatation. Light microscopy showed a well preserved extracellular scaffold with a monolayer of endothelial cells covering the luminal side of the patch. On the outside part of the patch, a well developed neo-vascularization was seen. Host fibroblasts were seen in all layers of the scaffolds. There was no evidence for structural deterioration or calcification of the decellularized equine pericardial scaffolds. CONCLUSIONS: In the juvenile sheep, decellularized equine tissue showed no structural deterioration, but regeneration and remodeling processes at systemic circulation.

Cerebroprotective effect of preoperative dual antiplatelet therapy in patients undergoing coronary bypass surgery.

OBJECTIVES: Reduction of cognitive function is a possible side effect after coronary artery surgery using cardiopulmonary bypass (CPB). We investigated the effect of single versus dual antiplatelet therapy on cognitive performance in patients undergoing coronary artery bypass grafting (CABG) with CPB. METHODS: 50 consecutive CABG patients with preoperative intake of aspirin were compared to 49 consecutive patients with aspirin and clopidogrel. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day. To assess the overall cognitive function and the degree of cognitive decline across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: Patients had a mean age of 66.1 ± 9.3 years, received a mean of 2.8 ± 1.0 bypasses within an average of 87 ± 31 minutes on cardiopulmonary bypass. These parameters as well as the preoperative combined neurocognitive score were not significantly different between the groups. After the operation there was a significant deterioration of the combined neuropsychological score in both groups (single: preop -0.2 ± 1.5 vs. postop -1.8 ± 1.7, p = 0.000 and dual: preop 0.2 ± 1.5 vs. postop -0.5 ± 2.1, p = 0.004). However, the patients operated under dual antiplatelet therapy showed a significant less decline of overall cognitive function compared to the single antiplatelet therapy patients (dual: 0.7 ± 1.5 vs single: 1.6 ± 1.6, p = 0.004). CONCLUSION: Dual antiplatelet therapy has a cerebroprotective effect in patients undergoing coronary artery bypass surgery. Compared to single antiplatelet therapy it reduces an early postoperative substantial decline of neuropsychological abilities.

Long-term follow-up after aortic valve replacement with Edwards Prima Plus stentless bioprostheses in patients younger than 60 years of age.

OBJECTIVES: The Edwards Prima Plus was one of the first stentless aortic valve bioprostheses, with larger orifice areas and improved hemodynamics compared to stented bioprostheses. The aim of the present single-center retrospective study was to assess the long-term results of the Edwards Prima Plus in patients 60 years old or younger. METHODS: From 1993 to 2001, 120 patients (99 men and 21 women) aged 60 years or younger underwent implantation of the Edwards Prima Plus. The indications were stenosis and/or insufficiency. Associated procedures were performed in 38 patients (31.7%). Of the patients, 39% had impaired left ventricular function. Follow-up data were acquired by telephone interview. Time-to event analyses were performed using the Kaplan-Meier method. Variables affecting survival and freedom from reoperation were evaluated using Cox regression analysis. The mean patient age at surgery was 53.1 ± 8.0 years. The follow-up data were 88.8% complete at a mean of 8.5 ± 4.5 years. The total follow-up was 1022.7 patient-years. RESULTS: At 10 and 15 years, the overall actuarial survival rate was 71.8% ± 4.4% and 48.8% ± 9.6%, respectively. Survival was significantly lower for patients with older age, aortic insufficiency as the surgical indication, and small prosthesis size (≤25 mm vs ≥27 mm). Reoperation was performed in 20 patients (16.7%), with a hospital mortality of 5%. At 10 and 14 years, the overall freedom from reoperation rate was 85.6% ± 3.7% and 65.2% ± 8.6%, respectively. Freedom from reoperation was significantly lower in patients with a small prosthesis size (≤25 mm) and insufficiency as the indication for surgery. CONCLUSIONS: In patients aged 60 years or younger, an Edwards Prima Plus can provide reliable long-term results with acceptable freedom-from-reoperation rates.

Six years of clinical follow-up with endothelial cell-seeded small-diameter vascular grafts during coronary bypass surgery.

This clinical study was performed to investigate the patency rate of endothelial cell-seeded small-diameter expanded polytetrafluoroethylene grafts during coronary artery bypass surgery. Between September 1995 and December 1998, 14 patients (median age: 71 years, range: 61-79 years) received 21 endothelial cell-seeded small-diameter grafts. In all, 43% of the performed implantations were reoperations. Endothelial cells were harvested from a forearm vein, cultured and characterized in the laboratory until a sufficient number was available. After in vitro seeding, the grafts were allowed to mature for another 10 days, prior to implantation. Graft patency was investigated with angiography, angioscopy, and intravascular ultrasonography during follow-up. Cumulative data represented 58 patients' years and was 100% complete. The seeded autologous vascular endothelial cell density was 1.05 × 10(5) ± 0.12 × 10(5) cells/cm(2) with a cell viability of 95.5 ± 1.5%. Operative mortality was 7.1% (one patient). Patency rate at discharge was 95.2%, and at a mean follow-up of 27 months was 90.5%. The proven patency rate at up to 72 months was at least 50.0%, as five patients refused angiographic evaluation. None of these five patients suffered from angina pectoris and so the best scenario would have shown a patency rate of 85.7%. Angioscopy and intravascular ultrasonography showed absence of atheroma or stenosis in the investigated patent grafts. Autologous vascular endothelial cell seeding improves patency rate of small-caliber expanded polytetrafluoroethylene grafts in patients without suitable autologous graft material.

Stentless aortic valve replacement in the young patient: long-term results.

BACKGROUND: Stentless aortic valve replacement (SAVR) became a common surgical procedure to treat aortic valve disease, as it offers larger orifice area and improved hemodynamics. The aim of our single-centre retrospective study was to assess long term results of first generation stentless aortic valves in young patients, where mechanical prostheses are considered first line therapy. METHODS: From 1993 to 2001, 188 (149 male and 39 female) patients (≤60 years) underwent SAVR. Indications were in 63.3% stenosis or mixed lesions and in 36.7% isolated regurgitation. Mean age of patients at surgery was 53.1 ± 7.1 years. Associated procedures were performed in 60 patients (31.9%). Follow-up data were acquired through telephone interviews. Follow-up was 90.4% complete at a mean of 8.8 ± 4.7 years. Total follow-up was 1657.6 patient-years with a maximum of 17 years. RESULTS: Overall hospital mortality was 3.2% (2.5% for isolated SAVR). Overall actuarial survival-rate at 10/15 years and freedom from reoperation at 10/14 years were 73.0% ± 3.5%/ 55.8% ± 5.4% and 81.0% ± 3.4%/ 58.0% ± 7.5%, respectively. For isolated SAVR, actuarial survival at 10/15 years and freedom from reoperation at 10/14 years were 70.1% ± 4.4%/ 64.1% ± 4.8% and 83.1% ± 4.0%/ 52.9% ± 9.0%, respectively. Reoperation was performed in 42 patients (22.3%) due to structural valve deterioration and endocarditis. Age (≤50 years) and associated procedures did not significantly lower survival and freedom from reoperation, however, small prosthesis sizes (≤25 mm) did. CONCLUSION: In patients aged 60 and younger, SAVR provides reliable long-term results especially for larger aortic valves.

Transfemoral versus conventional aortic valve implantation--early postoperative cognitive outcome.

OBJECTIVES: Reduction of cognitive function is a possible side effect after cardiac surgery. We investigated the effect of transfemoral versus conventional aortic valve replacement on cognitive performance early after surgery. METHODS: 50 patients with transfemoral, catheter-based aortic valve implantations were compared to 50 patients with conventional surgical aortic valve replacement. Six neuropsychological subtests from the Syndrom Kurz Test and Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day in a double blind fashion. To assess the overall cognitive function and the degree of cognitive change across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: The preoperative (Spre), as well as postoperative (Spost) overall cognitive function scores, were not significantly different between the groups and showed deterioration within both groups (Spre conv. 0.2 ± 1.0 vs Spost conv. -0.6 ± 1.1, p <0.0005 and Spre transfem. -0.2 ± 1.0 vs Spost transfem. -0.6 ± 1.1, p = 0.002). This decline (Spre -Spost) was not associated with the type of operation (p = 0.1). CONCLUSION: Transfemoral aortic valve implantation has no cerebroprotective advantage since it leads also to an early postoperative decline of neuropsychological abilities, which is comparable to conventional aortic valve replacement.

Effect of different pump heads for CPB on early cognitive outcome after coronary artery bypass surgery.

OBJECTIVES: Reduction of cognitive function is a possible side effect after coronary artery surgery using cardiopulmonary bypass (CPB). We investigated the effect of roller versus centrifugal pumps for CPB on cognitive performance in patients undergoing coronary artery bypass grafting (CABG). METHODS: 50 consecutive CABG patients operated with centrifugal pump were compared to 50 roller pump patients matched for age and duration of CPB. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day in a double blind fashion. To assess the overall cognitive function and the degree of cognitive decline across all tests after surgery we combined the six test-scores by principal component analysis. RESULTS: Patients with a mean age of 63.9±8.4 years received a mean of 3.0±0.9 bypasses within an average of 80.6±20.7 mins on CPB. These parameters as well as the preoperative combined neurocognitive score were not significantly different between the groups. After the operation there was a significant deterioration of the combined neuropsychological score in both groups (centrifugal: preop 0.41±2.49 vs.postop -2.86±2.70, p <0.0005 and roller: preop -0.41±2.35 vs. postop -2.73±3.16, p <0.0005). However, the patients operated with a centrifugal pump had a significantly greater decline of overall cognitive function compared to the roller pump patients(3.3±1.7 vs. 2.3±2.7, p = 0.04). CONCLUSION: Roller pumps have a less cerebro-damaging effect than centrifugal pumps since they lead to a smaller postoperative decline of neuropsychological abilities in coronary bypass patients.

Surgical-transcatheter approach for endocarditis of a calcified aortic homograft.

Repeat aortic valve replacement (AVR) after freestanding homograft root replacement with reimplantation of the coronary arteries is challenging and risky, especially in patients with major homograft wall calcifications. Although new transcatheter techniques for AVR may offer an alternative in structurally degenerated homografts, they are not suitable to treat endocarditis. Here, the case is reported of successful treatment of bacterial endocarditis within a totally calcified homograft after aortic root replacement by combining conventional surgery and transcatheter techniques.

Extracellular matrix in deoxycholic acid decellularized aortic heart valves.

BACKGROUND: Only limited information is available regarding the influence of decellularization on the extracellular matrix in heart valves. Within the extracellular matrix proteoglycans (PG) play a central role in the structural organization and physical functioning of valves and in their capability of settling with endothelial and interstitial cells partially myofibroblasts. We have therefore estimated the effects of decellularization using deoxycholic acid on the structure of the extracellular matrix and PG´s in porcine aortic valves. MATERIAL/METHODS: Cupromeronic blue was used, alone or in combination with OsO4/thio-carbo-hydrazide/OsO4 for electron microscopic visualization. For PG and glycosaminoglycan (GAG) investigation a papain digestion was employed in combination with photometric determination using dimethylmethylene blue. RESULTS: The results indicate that deoxycholic acid affects the compartmentation of the PG-associated interstitial network not significantly. Compared to controls the PG-rich network was preserved even after deoxycholic acid treatment for 48 h. In parallel to electron microscopy immune assays (ELISA) showed smooth muscle cell -actin to be reduced to 0.96% ± 0.71 and total soluble protein to 6.68% ± 2.0 (n=3) of untreated controls. Protein loss corresponded well with the observations in electron micrographs of rupture and efflux of cell content. Further signs of lysis were irregular cell contours and loss of the basement membrane. CONCLUSIONS: Efficient cell-lysis without disintegration or loss of integrity of the interstitial PG network can be achieved by treatment of aortic valves with deoxycholic acid for 48h. This protocol might also be suitable for clinical use to optimize conditions for growth and autologous remodelling of valves.