Outcomes of the extracardiac fontan procedure using cardiopulmonary bypass: early results.

BACKGROUND: Although the avoidance of cardiopulmonary bypass during the Fontan procedure has potential advantages, using cardiopulmonary bypass during this procedure has no adverse effects in terms of morbidity and mortality rates. In this study, we assessed the postoperative outcomes of our first 9 patients who have undergone extracardiac Fontan operation by the same surgeon using cardiopulmonary bypass. METHODS: Between September 2011 and April 2013, 9 consecutive patients (3 males and 6 females) underwent extracardiac Fontan operation. All operations were performed under cardiopulmonary bypass at normothermia by the same surgeon. The age of patients ranged between 4 and 17 (9.8 ± 4.2) years. Previous operations performed on these patients were modified Blalock-Taussig shunt procedure in 2 patients, bidirectional cavopulmonary shunt operation in 6 patients, and pulmonary arterial banding in 1 patient. Except 2 patients who required intracardiac intervention, cross-clamping was not applied. In all patients, the extracardiac Fontan procedure was carried out by interposing an appropriately sized tube graft between the inferior vena cava and right pulmonary artery. RESULTS: The mean intraoperative Fontan pressure and transpulmonary gradient were 12.3 ± 2.5 and 6.9 ± 2.2 mm Hg, respectively. Intraoperative fenestration was not required. There was no mortality and 7 patients were discharged without complications. Complications included persistent pleural effusion in 1 patient and a transient neurological event in 1 patient. All patients were weaned off mechanical ventilation within 24 hours. The mean arterial oxygen saturation increased from 76.1% ± 5.3% to 93.5% ± 2.2%. All patients were in sinus rhythm postoperatively. Five patients required blood and blood-product transfusions. The mean intensive care unit and hospital stay periods were 2.9 ± 1.7 and 8.2 ± 1.9 days, respectively. CONCLUSIONS: The extracardiac Fontan operation performed using cardiopulmonary bypass provides satisfactory results in short-term follow-up and is associated with favorable postoperative hemodynamics and morbidity rates.

Surgical treatment of aortic valve endocarditis: a 26-year experience.

OBJECTIVE: We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. METHODS: From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. RESULTS: Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. CONCLUSION: Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

Surgical treatment of double valve endocarditis.

BACKGROUND: We have retrospectively analyzed the results of the operations made for aortic infective endocarditis with mitral involvement in a single center in 19 years. METHODS: From May 1992 to January 2011, we have operated on 72 patients with infective endocarditis of the aortic valve with mitral valve involvement. Fifty-two patients (72.2%) were male and the mean age was 40.5 ± 15.5 (9-73) years. The blood cultures were positive in 33 patients (45.8%) and the most commonly identified microorganism was Streptococcus. Nine patients (12.5%) had prosthetic valve endocarditis. The mean duration of follow-up was 6.8 ± 4.7 (0.1-16.9) years, adding up to a total of 156.1 patient/years. RESULTS: A total of 155 procedures were performed on these 72 patients. The most commonly performed procedure was aortic valve replacement, in 63 patients (87.5%). Aortic annular involvement was present in 9 cases (12.5%). In-hospital mortality was seen in 13 patients (18.1%). Postoperatively, 13 (18.1%) patients had low cardiac output, 9 (12.5%) had heart block, and only 1 of them required permanent pacemaker implantation. The actuarial survival rates for 1, 5, and 10 years were 96.4% ± 2.5%, 84.4% ± 5.1%, and 77.4 ± 6.7%, respectively. CONCLUSIONS: Double-valve endocarditis is a serious condition and the surgeon must be aware of the high rates of mortality and morbidity in these patients. Although no association was found, heart blocks and septic embolization must be handled with caution. The patients generally do well after surgery, and recurrences and reoperations decrease by the second year after operation.

Surgical treatment of aortic valve endocarditis: a 26-year experience / Tratamento cirúrgico da endocardite da válvula aórtica: 26 anos de experiência

Objective: We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. Methods: From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. Results: Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. Conclusion: Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low. .

Objetivo: Analisamos, retrospectivamente, os resultados das operações realizadas para endocardite valvar aórtica em um único centro em 26 anos. Métodos: De junho de 1985 a janeiro de 2011, 174 pacientes foram operados por endocardite da válvula aórtica. Cento e trinta e oito (79,3%) pacientes eram do sexo masculino e a média de idade foi de 39,3 ± 14,4 (9-77) anos. Vinte e sete (15,5%) pacientes apresentavam endocardite na prótese valvar. O tempo médio de acompanhamento foi de 7,3 ± 4,2 anos (0,1- 18,2) totalizando 1.030,8 paciente/ano . Resultados: Duzentos e oitenta e dois procedimentos foram realizados. O procedimento mais realizado foi a substituição da valva aórtica por prótese mecânica (81,6 %). A mortalidade intra-hospitalar ocorreu em 27 (15,5%) casos. No pósoperatório, 25 (14,4% ) pacientes apresentaram baixo débito cardíaco e 17 (9,8%) bloqueio cardíaco . As taxas de sobrevida atuarial para 10 e 15 anos foram 74,6±3,7% e 61,1±10,3%, respectivamente. A mortalidade intra-hospitalar foi encontrada esteve associada com o sexo feminino, operação de emergência, insuficiência renal pós-operatória e baixo débito cardíaco. A mortalidade a longo prazo foi significativamente associada com o envolvimento da válvula mitral. O sexo masculino encontrado mostrou-se um fator de risco para a recorrência no seguimento. Conclusão: A cirurgia para tratamento da endocardite da válvula aórtica apresenta mortalidade. Operação de emergência, o sexo feminino, insuficiência renal pós-operatória e baixo débito cardíaco são fatores de risco significativos. O risco de recorrência e necessidade de reoperação são baixos. .

Surgical treatment of culture-negative aortic infective endocarditis.

BACKGROUND: We retrospectively analyzed the results of operations done for culture-negative aortic infective endocarditis at a single center over a period of 26 years. METHODS: From June 1985 to January 2011, we operated on 82 patients with infective endocarditis of the aortic valve for which the results of culture were negative. Sixty-five of the patients (79.3%) were male and the patients' mean age was 38.0±14.4 years (range, 9 to 73 years). Nineteen of the patients (23.2%) had a history of previous cardiac surgery, and 16 of the patients (19.5%) had endocarditis of a prosthetic valve. Two patients (2.4%) had conduction blocks. The mean duration of follow-up was 7.1±4.3 years (range, 0.1 to 16.9 years), yielding a total of 477.0 patient-years for the study population. RESULTS: One hundred and thirty-eight procedures were done on the 82 patients in the study. The most common procedure was aortic valve replacement, which was done on 67 patients (81.7%). Thirty-nine patients (47.6%) had concomitant procedures done on the mitral valve. In-hospital death occurred in 14 patients (17.1%). Postoperatively, 17 patients (20.7%) had a low cardiac output and 9 patients (11.0%) had heart block, of whom 3 required implantation of a permanent pacemaker. The actuarial rate of survival of the patient population at 1, 5, 10, and 15 years was 92.5%±3.2%, 85.6%±4.5%, 82.5±5.3%, and 72.2±10.7% respectively. CONCLUSIONS: Culture-negative infective endocarditis is a major problem in the diagnosis and treatment of a significant proportion of cases of endocarditis. Most of the affected patients are in a healed state, which could be a cause of negative culture results. In-hospital mortality in patients with culture-negative infective aortic endocarditis is associated with a history of previous cardiac surgery, whereas long-term mortality in this patient population is associated with nonaortic procedures.

Repair of pulmonary artery aneurysms.

BACKGROUND AND AIM OF THE STUDY: We have presented the results of pulmonary arterial aneurysm repairs performed over eight years. METHODS: From 2002 to December 2010, we performed nine operations for pulmonary artery aneurysms in our department. The mean age of the patients was 37.8 ± 17.1 years and four were females. Five patients had pulmonic valve stenosis, three patients had concomitant pathologies on the aortic or mitral valves, and two had isolated pulmonary arterial aneurysm. Aneurysm repairs were performed by plication in eight patients and with Dacron patch repair in one patient. RESULTS: There were no postoperative deaths. Three patients required inotropic support postoperatively. One patient had pulmonary morbidity. The results of the pathology revealed intimal hyalinization, edema, and elastic fiber degeneration in the media, fibrosis in the adventitia, and increased vascularity. All patients were in New York Heart Association Class I or II except for one patient who had a prolonged intensive care stay. The mean duration of follow-up was 48.6 ± 33.2 months (range, 2 to 107) adding up to a total of 36.4 patient/years. The mean diameter of the pulmonary artery in the recent imaging was 3.6 ± 0.4 cm. CONCLUSION: Pulmonary artery aneurysms are rare entities which are usually associated with other congenital defects. While surgery is the preferred treatment for symptomatic aneurysms, controversy exists as to the indications for repair in asymptomatic patients.

Aortic valve replacement in isolated severe aortic stenosis with left ventricular dysfunction: long-term survival and ventricular recovery.

OBJECTIVE: The aim of this study was to assess the effects of aortic valve replacement (AVR) on the recovery of left ventricular function and the predictors for long-term survival in patients suffering from isolated severe aortic stenosis (AS) with a significant left ventricular dysfunction (LVD). METHODS: This retrospective study was conducted on 46 patients with isolated severe AS and LVD [left ventricular ejection fraction (LVEF) = or < 40%] who underwent AVR in our clinic between January 1993 and March 2006. Patients with coronary artery disease, with more than moderate aortic regurgitation (>2), with previous valve replacement or repair, and with other valve pathologies were excluded. The mean aortic valve area was 0.7+/- 0.09 cm2. The following fourteen variables were analyzed: etiology, age (= or >70 years), sex, preoperative New York Heart Association (NYHA) functional class, chronic obstructive pulmonary disease, hypertension, diabetes, peripheral arterial disease, chronic renal insufficiency, need for concomitant procedures for the ascending aorta, cardiopulmonary bypass time = or >120 min, aortic cross-clamp time = or >90 min, intraaortic balloon pump support and inotropic support. Statistical analysis for comparison of pre- and postoperative changes in clinical and functional variables was performed using Wilcoxon rank test. The predictors of early mortality after AVR were analyzed using logistic regression analysis and late survival was studied using Cox proportional regression and Kaplan Meier survival analyses. RESULTS: Operative mortality was 8.6% with four patients. As the result of univariate logistic regression analysis, preoperative NYHA functional class = or >3 was found to be predictive of early mortality. Patients with NYHA class = or >3 had 12.6 times (OR: 12.6; 95%CI: 1.2-131.3; p=0.035) higher probability of early mortality than those with a lower NYHA class. However, multivariate logistic regression analysis demonstrated no predictor for early mortality. A positive change was observed in the LVEF in 79.3% of survivors and the mean LVEF increased from 34.5+/- 3.9% to 44.7+/- 10.4% (p<0.001). There were eight (19%) late deaths. Actuarial survival was 83. +/- 5.9% at 5 years and 59.6% +/- 10.9% at 10 years. Cox proportional hazards regression analysis demonstrated diabetes mellitus (HR: 6.6; 95% CI: 1.19-36.9, p=0.031) and intraaortic balloon pump use (HR: 10.7; 95% CI: 2.9-39.7, p<0.001) as significant predictors for late mortality. CONCLUSION: Left ventricular ejection fraction and symptoms improve after AVR in patients with isolated severe AS and LVD with an acceptable operative mortality and satisfactory long-term survival.