Technique for Adaptation of Konno Aortoventriculoplasty in Patient-Prosthesis Mismatch.

The patient-prosthesis mismatch has been reported as an important cause of adverse outcome following aortic valve replacement. The relief of patient-prosthesis mismatch generally requires a reoperation of comprehensive nature, which necessitates an extensive aortic root enlargement. The Konno aortoventriculoplasty represents an efficient treatment option, as this technique provides both extreme root enlargement and relief of the frequently associated subvalvular obstruction. However, the application and conduct of the procedure may somewhat differ from the pediatric Konno procedures.This article describes our surgical technique adaptation in Konno-aortoventriculoplasty for adult patient-prosthesis mismatch cases, highlighting the differing points from the pediatric-Konno.

Rerouting anomalous coronary artery origin in aortopulmonary window in newborn.

Coronary artery anomalies may accompany the aortopulmonary window and, if not noticed, may cause catastrophic consequences. The repair of the aortopulmonary window is quite straightforward; however, establishing a normal coronary pattern may challenge the repair. When the anomalous origin of the coronary artery is on the defect rim, right at the location where sutures are to be placed, it may interfere with proper suture placement. A technique to overcome such a technical obstacle and reroute the anomalous right coronary in such cases is described.

Mitral Patient-Prosthesis Mismatch Predicts Suboptimal Hemodynamic Recovery after Mitral Valve Replacement.

BACKGROUND: A possible relationship between an obstructive prosthesis and suboptimal hemodynamic recovery, as reflected by unsatisfactory regression in systolic pulmonary artery pressure (sPAP) and functional tricuspid regurgitation (FTR) following mitral valve replacement (MVR), was investigated. A delineating effective orifice area index (EOAI) value was sought in order to define a patient-prosthesis mismatch. METHODS: A total of 128 patients undergoing isolated mechanical MVR were followed up for a mean of 46 ± 9 months. Patients were allocated to two groups. Group I comprised 83 patients (65%) exhibiting a satisfactory (≥30%) regression in sPAP and FTR, while group II comprised 45 patients with a <30% (suboptimal) decrease in these parameters. A cutoff value for the prosthetic mitral valve in-vivo EAOI was explored as a predictor of postoperative hemodynamic recovery. RESULTS: The mean in-vivo EOAI differed significantly between the groups (1.23 cm2/m2 in group I versus 1.11 cm2/m2 in group II; p <0.0001). The consequent receiver operating characteristic curve analysis revealed an EOAI of 1.19 cm2/m2 as the cut-off value, below which a suboptimal postoperative regression in pulmonary hypertension and FTR is predicted. CONCLUSIONS: An in-vivo EOAI <1.19 cm2/m2 strongly suggests a suboptimal hemodynamic recovery following MVR with the bileaflet mechanical prosthesis used in the present study. Although no direct relationship between prosthesis size and in vivo EOAI was demonstrated, the logical approach is to implant a prosthesis of the largest possible size.

Recommendations for Valve Replacement in Ischemic Mitral Regurgitation with Compromised Ventricle.

The unique features of ischemic mitral regurgitation may necessitate attention to certain points during mitral valve replacement (MVR). A few simple but practical recommendations are offered for concomitant or isolated MVR in this high-risk population which is often burdened by an extremely limited myocardial reserve.

Remote Targets for Right Coronary Artery Bypass: Distal Trunk or Posterior Descending Artery Grafting.

BACKGROUND: Choosing a good anastomotic site is crucial during surgical revascularization of the right coronary artery (RCA) system. In many instances of distal and/or sequential main trunk disease, either the right posterior descending coronary artery (RPDA) or distal part of the right main coronary artery (DRCA) is preferred as the target vessel. In this article, the saphenous vein graft (SVG) patency is compared between these two main targets in the long term. MATERIALS AND METHODS: Postoperative control coronary angiograms were obtained and assessed from 452 patients undergoing conventional on-pump coronary artery bypass grafting with either a DRCA (n = 305) or a RPDA graft (n = 147) after an average postoperative period of 5.8 ± 4.3 years (range: 2 months-20 years; a total of 2,627 patient-years). RESULTS: The overall graft patency was 60%. The 15-year patency rate was better for the DRCA grafts than that for the RPDA grafts (32 ± 5% vs. 19 ± 6%, respectively; p = 0.001), irrespective of target vessel caliber. Other factors adversely influencing the long-term graft patency were poor target vessel quality (p = 0.002) and hypercholesterolemia (p = 0.01). On the other hand, target vessel diameter, diabetes mellitus, hypertension, chronic renal insufficiency, obesity, peripheral arterial disease, or SVG quality were not associated with poor long-term graft patency in these patients having distal-type RCA disease. CONCLUSIONS: In the presence of distal and/or sequential right coronary disease, DRCA may be the target vessel of choice for bypass grafting, rather than the RPDA, mainly for better long-term SVG patency rates in this location.

Aortoventriculoplasty for correction of patient-prosthesis mismatch examples.

OBJECTIVE: Patient-prosthesis mismatch is often considered as an important cause of adverse outcome following aortic valve replacement. A small annulus represents a challenge for the surgeon; yet can be best managed at the initial operation using relatively simple techniques, as later-on correction is often far more challenging. Corrective reoperations necessitate drastic root enlargement, along with the relief of subvalvular muscular obstruction. PATIENTS AND METHODS: The Konno-type aorto-ventriculoplasty is preferred in the present case series in order to achieve a radical aortic annulus enlargement in difficult reoperation settings and to address the accompanying subvalvular obstruction due to muscular hypertrophy simultaneously as well, with the septal patch included in the technique. RESULTS: This approach provides satisfactory relief of the obstruction at both valvular and subvalvular level and the benefits are immediately evident, as symptoms abruptly end in all cases. CONCLUSION: Long-term outcome is also excellent in both clinical and haemodynamic terms, as reflected by the significant left ventricle mass regression, absence of symptoms and improved quality of life.

Visceral protection during moderately hypothermic selective antegrade cerebral perfusion through right brachial artery.

OBJECTIVE: This study investigates distal organ protection during moderately hypothermic right brachial artery selective antegrade cerebral perfusion (MHSACP) in patients undergoing aortic arch repair. METHODS: Fifty patients undergoing ascending aorta/aortic arch repair using the MHSACP technique (study group) were compared with another 50 patients randomly selected amongst those undergoing moderately hypothermic open heart procedures (control group). The data from successive clinical examinations and blood samplings were then compared to detect any sign of distal organ damage attributable to the MHSACP technique. RESULTS: The mortality rate did not differ between the two groups (2%). The average cardiopulmonary bypass and aortic cross-clamping durations were 154+/-53 min versus 102+/-25 min and 101+/-41 min versus 70+/-31 min for the study and control groups, respectively. The mean MHSACP period was 32+/-14 min (11-81 min) in the study group. The average discharge time was 6.4+/-1.4 days (5-12 days). Repeated clinical examinations revealed no organ dysfunction and there was no difference between the two groups (with the exception of lactate dehydrogenase) with regard to compared biochemical markers, which might be suggestive of a visceral damaging effect of the MHSACP technique. CONCLUSIONS: The present data show that with the use of MHSACP, distal organs are relatively well protected during aortic arch repairs.

Ventricular assist device applications.

Since the commencement of the artificial-heart program at the National Institutes of Health in 1964, many circulatory-support devices have been developed for short-term use in patients with end-stage heart failure. In the last decade, the interest on mechanical devices for ventricular assistance increased rapidly. As a result, significant advances in both the technology and clinical experience in the field of mechanical cardiac assist occurred over the last decade. In the current era, there is a wide variety of devices both available and in development. This article briefly reviews the evolving concepts and current systems on ventricular assist devices, as well as their role in today's clinical practice.

What to expect after tricuspid valve replacement? Long-term results.

OBJECTIVE: Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series. METHODS: Forty-two patients (16 male, 26 female; mean age: 33+/-15) underwent tricuspid valve replacement between March 1987 and December 2004. The etiology was rheumatic in 64%, Ebstein's anomaly in 31%, and endocarditis in 5%. Nineteen patients were in New York Heart Association (NYHA) Class III functional capacity (45%), and 13 in class IV (31%). Twenty patients (48%) underwent isolated tricuspid valve replacement. The remaining underwent combined (mitral and/or aortic) valve replacements. Tricuspid replacement device was mechanical in 31% and bioimplant in 69%. RESULTS: Hospital mortality was 26%. Rheumatic etiology, reoperation and elevated pulmonary artery pressure were associated with higher early mortality. The patients with decreased functional capacity (NYHA Class III/IV), congestive symptoms and rheumatic origin were more prone to low cardiac output development. The Kaplan-Meier survivals were 37% at 10 years and 30% at 15 years. The 10-year event-free survival was 31%. Elevated pulmonary artery pressure and rheumatic etiology unfavorably affected the long-term results. The average functional capacity in survivors improved significantly after operation. CONCLUSIONS: Any tricuspid disease not amenable to repair thus necessitating replacement is an unfortunate situation since both the short and long-term results of valve replacement are suboptimal in regard to those of left-sided valve replacements, probably due to different structural and geometrical characteristics of right ventricle and the low-pressure venous system hemodynamics. Etiology, clinical presentation and pulmonary vascular hemodynamics are major determinants of the outcome.

Cardiac surgery during pregnancy.

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery during pregnancy represents a major challenge as it comprises a single operation for two survivors. METHODS: Between 1988 and 2005, 16 pregnant women underwent cardiac surgery at the authors' institution. Among 14 patients with rheumatic mitral stenosis operated on due to clinical deterioration, closed mitral valvulotomy was performed in 12 cases (three urgently in the third trimester, nine at term concomitantly with cesarean delivery). Two patients underwent mitral valve replacement, again, concomitantly with cesarean delivery at term, while two others underwent emergency reoperation for mechanical valve thrombosis during the second trimester, using a strategy of high-flow, high-pressure perfusion with mild hypothermia. RESULTS: A total of 12 closed mitral valvulotomies and four mitral valve replacements was performed. There was no maternal mortality, and only one stillborn occurred in the urgent closed valvulotomy group. The remaining 15 babies were born healthy. CONCLUSION: In addition to protective perinatal procedures, instances occur during pregnancy when urgent or emergency surgery becomes unavoidable due to life-threatening cardiac decompensation. In patients with mitral stenosis, which is the case in most scenarios, closed mitral valvulotomy is life-saving and offers low fetomaternal risk, as a viable, efficient and practical alternative to percutaneous mitral balloon commissurotomy. When cardiopulmonary bypass (CPB) becomes mandatory, the shortest possible periods of mildly hypothermic or normothermic CPB with a strategy of high flow-high pressure perfusion should be followed.

Acute renal failure following open heart surgery: risk factors and prognosis.

BACKGROUND: Acute renal failure (ARF) development after cardiac surgery carries high mortality and morbidity. METHODS: Out of 14437 consecutive patients undergoing open-heart surgery between January 1991 and May 2001, 168 (1.16%) developed postoperative ARF mandating hemodialysis. Possible perioperative risk factors, and the prognosis of this dreadful, often fatal complication were investigated. RESULTS: The mortality rate in this group was 79.7% (134 patients). The risk factors associated with postoperative ARF were advanced age (p=0.000), diabetes mellitus (p=0.000), hypertension (p=0.000), high preoperative serum creatinine levels (p=0.004), impaired left ventricular function (p= 0.002), urgent operation (p=0.000) or reoperation (p=0.007), prolonged cardiopulmonary bypass (CPB) (p =0.000) and aortic cross-clamp (ACC) (p =0.000) periods, level of hypothermia (p =0.000), concomitant procedures (p =0.000), low cardiac output state (p =0.000), re-exploration for bleeding or pericardial tamponade (p =0.000), and deep sternal or systemic infection (p = 0.000). Of those who could be discharged from hospital, renal functions were restored in 21 patients (12.5%); however, eight patients (4.7%) became hemodialysis dependent. The mean follow-up period was 5.7+/-3.2 years (range: 4 months to 13 years; a total of 195 patient-years), and 10-year survival was 58.6+/-10.2% in the discharged patients. CONCLUSIONS: ARF development after cardiac surgery often results in high morbidity and mortality. Recognizing risk factors permits the timely institution of proper treatment, which is the key to reducing untoward outcomes.

Does delayed correction interfere with pulmonary functions and exercise tolerance in patients with tetralogy of fallot?

STUDY OBJECTIVES: To assess exercise tolerance and determine the distinct role of cardiac, respiratory, or peripheral factors on it after delayed surgical repair in patients with tetralogy of Fallot. DESIGN: The aerobic exercise capacity of 15 adult patients (mean [+/- SD] age, 21 +/- 6; age range, 9 to 30 years) undergoing successful total correction at a mean age of 12 +/- 5 years (patients) was compared to healthy, matched control subjects by using right ventricle echocardiography, resting spirometry, and cardiopulmonary exercise tests at a mean postoperative time of 7.5 +/- 4.6 years. SETTING: Tertiary care referral centers. PATIENTS: Fifteen adult patients (mean age, 21 +/- 6 years; age range, 9 to 30 years) undergoing successful total correction at a mean age of 12 +/- 5 (patients) and 15 healthy, matched volunteers (control subjects). RESULTS: There was evidence for a slight right ventricular diastolic dysfunction in the patients. Mean FVC (88 +/- 9% vs 109 +/- 12% predicted, respectively) and FEV1 (89 +/- 9% vs 109 +/- 12% predicted, respectively), although being within the normal range, were also decreased in comparison to those of control subjects (p < 0.0001). Maximal oxygen consumption (V(O2max) decreased in both groups (55 +/- 16% vs 61 +/- 23% predicted, respectively; p = 0.5); however, there were more individuals with severely decreased values among the patients (p = 0.05). V(O2) at the anaerobic threshold was also decreased in patients (33 +/- 15% vs 51 +/- 8% predicted, respectively; p = 0.004). The maximum tolerable exercise time was 17.3 +/- 4.5 min in patients vs 21.2 +/- 6.4 min in control subjects (p = 0.06). CONCLUSIONS: The exercise capacity after delayed repair was good in general compared to matched control subjects; however, exercise capacity may be slightly limited by ventilatory dysfunction, low anaerobic threshold, and lack of physical fitness despite New York Heart Association class improvement after undergoing the operation.

Off-pump, in situ internal thoracic artery grafting: a durable treatment for single-vessel coronary artery disease.

BACKGROUND: The value of off-pump in situ left internal thoracic artery to left anterior descending coronary artery bypass grafting in single-vessel coronary artery disease was assessed by long-term angiographic and clinical data. METHODS: One-hundred three randomly selected patients (87 male, 16 female; mean age, 57.4 +/- 10.5 years) underwent postoperative angiographic control after an average postoperative period of 4.8 +/- 2.9 years (up to 8.2 years; a total of 490 patient-years). RESULTS: Fifty-five patients (52%) were asymptomatic, whereas 31 (30%) had anginalike chest pain. Ninety-seven patients (94.2%) were in New York Heart Association class I or II. Five-year angina-free survival was 81% +/- 5%. Of 103 left internal thoracic arteries assessed, 99 were patent (overall patency, 96.1%). All four cases having occluded grafts had mild native vessel stenoses (<80%) before operation. The patency rate was 99% +/- 1% at 3 years, and 93% +/- 4% at 5 years. The left ventricular segmental wall motion score of the left anterior descending coronary arterial distribution improved from 4.1 +/- 1.1 to 3.7 +/- 0.9 (p = 0.001). Consequently, 15 patients (15%) underwent secondary revascularization (11 interventional and 4 surgical) 4.8 +/- 2.1 years after the primary operation. The most frequent indication for interventional revascularization was atherosclerotic progression in systems other than left anterior descending artery. The cases with graft occlusion were treated surgically. Five-year freedom from interventional or surgical repeat revascularization was 91% +/- 4%. CONCLUSIONS: In addition to the well-documented safety and reliability, off-pump in situ left internal thoracic artery grafting is also a durable treatment for isolated left anterior descending artery disease, in both clinical and angiographic terms.