Child-Pugh score predicts survival after radical pericardiectomy for constrictive pericarditis.

BACKGROUND: Constrictive pericarditis causes hepatic congestion, which results in congestive hepatopathy and finally leads to cardiac cirrhosis. However, in previous studies, risk stratification from the viewpoint of liver dysfunction was not performed in patients who underwent pericardiectomy for constrictive pericarditis. METHODS: Sixty-four patients with constrictive pericarditis who were operated on with de novo radical pericardiectomy through a left anterolateral thoracotomy in our institute were entered into the study. Patients with a Child-Pugh score less than 7 (class A) were assigned to group CP-A (n = 45) and those with a score of 7 or higher (class B or C) were assigned to group CP-BC (n = 19). Actuarial survival of patients after operation was studied in each group, and prognostic factors were analyzed with Cox regression analysis. RESULTS: Survival after radical pericardiectomy in group CP-BC (Child-Pugh score ≥ 7) was significantly worse than in group CP-A (37.9% versus 80.8% for 5-year survival; p = 0.0001, log-rank test). After multivariate Cox analysis, a Child-Pugh score of 7 or more (hazard ratio [HR] 4.316; p = 0.0028), mediastinal irradiation (HR, 23.872; p < 0.0001), age (HR, 1.064; p = 0.0042), and end-stage renal disease (HR, 4.670; p = 0.029) were identified as independent prognostic factors for mortality after radical pericardiectomy. CONCLUSIONS: It is meaningful to apply the Child-Pugh scoring system for the prediction of mortality after radical pericardiectomy in patients with constrictive pericarditis.

Reverse graft placement in the Florida sleeve procedure for aortic root aneurysm.

Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta.

Long-term surgical outcome of mitral valve repair in infants and children with Shone's anomaly.

OBJECTIVES: Having assembled information on a large series of patients with Shone's anomaly with the longest follow-up, we studied the operative results and long-term outcome of mitral valve (MV) repair techniques performed to correct the left ventricular inflow tract lesions of this congenital anomaly. METHODS: Between 1986 and 2011, 45 infants and children [mean age 5.16 ± 5.0 (median 3.9; range 2 months to 16.8 years] underwent surgical correction of Shone's anomaly. Left ventricular outflow tract obstructive lesions consisted of coarctation of the aorta, found in 89%, subaortic stenosis due to fibromuscular hypertrophy in 71% and subvalvular membrane in 51%. Left ventricular inflow tract obstructions concentrated on the mitral valve included mitral ring in all cases and the gamut of small and narrowed mitral orifice, commissural fusion, dysplastic or thickened leaflets, shortened and fused chordae, fibrous obliteration of interchordal spaces, underdeveloped papillary muscles, parachute valve, and supravalvular mitral ring-all contributing to mitral stenosis. RESULTS: MV repair was performed using commissurotomy, division of chordae tendinae, papillary muscle splitting and fenestration, and resection of mitral ring, applied according to the presenting morphology in patients with either previously-corrected or concomitant correction of the left-sided obstructive lesions. Postoperative echocardiography showed absence of MV stenosis and immediate improvement of symptoms, except in a 3-month-old infant who died 18 days postoperatively due to myocardial failure. During the 23-year follow-up, 23 patients underwent repeat MV repair and one underwent MV replacement after failed attempts at repair. Mean duration of follow-up was 17.5 ± 1.5 years (range 6.4-22.7 years). Freedom from reoperation was 97.6 ± 2.4%, 89.3 ± 5.1%, 77.1 ± 7.2%, 72.0 ± 8.3% and 52.8 ± 11.8%, at 30 days, 1, 5, 10 and 15 years postoperatively, respectively Cumulative survival rate was 97.6 ± 2.4%, 92.3 ± 4.3%, 83.8 ± 6.1%, 75.7 ± 7.8% and 70.3 ± 8.9%, at 30 days, 1, 5, 10 and 15 years postoperatively, respectively. Mortality unrelated to valve repair accounted for nine deaths (20%). Age at operation, severity of mitral abnormalities and concomitant left ventricular outflow tract lesions proved to be independent risk factors for reoperation and mortality (P < 0.05). CONCLUSIONS: Long-term functional outcome of mitral valve repair in children with Shone's anomaly is satisfactory. Repeat MV repair and/or replacement may be deemed necessary during the course of follow-up.

Lower body surface area is highly related to mortality due to stroke or systemic bleeding in patients receiving an axial flow blood pump as a left ventricular assist device.

OBJECTIVES: Even though left ventricular assist devices (LVADs) may fit into the bodies of small adult patients, their prognosis is worse than that of larger patients. We investigated the relationship between lethal complications and the body surface area (BSA) in patients who received an LVAD. METHODS: Our study included 167 patients who received a BerlinHeart INCOR LVAD in our centre. The median BSA was 2.00 m(2) (range: 1.56-2.47 m²). From the line graph showing the relationship between the BSA for the cut-off point and the P-value of the log-rank test for the Kaplan-Meier probability of freedom from events, the definitive cut-off point was determined on the basis that, with a decrease in the BSA below this value, the P-value gradually increases. RESULTS: For freedom from death due to stroke or systemic bleeding, a definitive cut-off point existed and this was a BSA of 1.867 m(2). For freedom from death due to sepsis, no definitive cut-off point was found. The multivariate Cox analysis revealed that a BSA of <1.867 m(2) was an independent risk factor for death due to stroke or systemic bleeding (hazard ratio: 2.665, 95% confidence interval: 1.349-5.265, P = 0.0048). One-year freedom from death due to stroke or systemic bleeding during the VAD support was 49.1% in patients with a BSA of <1.867 m(2) (n = 42) and 82.7% in those with a BSA of ≥ 1.867 m(2) (n = 125; P = 0.0033). CONCLUSIONS: The lower BSA is an independent risk factor for mortality due to stroke or systemic bleeding during the VAD support.

How to do the double orifice valve technique to treat tricuspid valve incompetence.

A straightforward tricuspid valve repair technique is illustrated here, which may be employed either for functional (normal valve with dilated annulus) or for primary or organic (Ebstein's anomaly, leaflet retraction/tethering and chordal malposition/tethering, with annular dilatation) tricuspid valve incompetence and for moderate and severe degrees of incompetence, without any residual regurgitation or reoperation. The basic principle is to reduce the distance between the coapting leaflets in a manner in which the most mobile leaflet, which is usually the anterior, could coapt to the opposite leaflet, by creating two orifices, ensuring valve competence. Additionally, it reduces annular dilatation and lessens tricuspid valve leaflet tethering, thereby stabilizing the annulus and increasing leaflet coaptation.

Overweight is advantageous for heart-transplant candidates to survive the period of critically ill status.

Although extreme obesity and being underweight are both known as risk factors for mortality in patients with ventricular assist devices (VAD) and in those listed for urgent heart transplantation (HTx), the risk in patients between these extremes is controversial. We investigate the risk of mortality after their progression to critically ill status (i.e., urgency listing or VAD implantation) in patients stratified by body mass index (BMI). Risk of mortality on the waiting list was studied in group N (n = 134), normal weight, BMI: 18.5-24.9 kg/m(2); group OWt (n = 112), overweight, BMI: 25.0-29.9 kg/m(2); and group OB-I (n = 39), obesity class I, BMI: 30.0-34.9 kg/m(2). Patients' 1 year survival rate on the waiting list in group N (62.2%) and group OB-I (50.6%) was significantly lower than in group OWt (74.3%, p = 0.036 and p = 0.022, respectively). After adjustment for age, gender, serum creatinine, and primary use of VAD, group OB-I (hazard ratio [HR] 1.971, 95% confidence interval [CI] 1.062-3.659, p = 0.032) and group N (HR 1.792, 95% CI 1.058-3.036, p = 0.030) were at higher risk of mortality compared with group OWt. Overweight HTx candidates have the best prognosis on the waiting list. Obesity class I patients are encouraged to reduce their body weight to at least overweight.

A giant neuroendocrine tumor of the thymus gland causing superior vena cava syndrome.

We describe the case of a 37-year-old man with a rare giant thymic neuroendocrine tumor. The patient presented with a swelling of the neck associated with superior vena cava syndrome and underwent stent implantation in the right innominate vein (brachiocephalic vein). Computed tomography imaging revealed a large tumor of the mediastinum, measuring 15 × 10 × 12 cm. CT-guided core-needle biopsy for histology revealed a thymic carcinoid. Surgical resection of the tumor and repair with interposition of a 14-mm Gore-Tex prosthesis between the left innominate vein and the right atrial appendage were performed. Histopathological analysis classified the tumor as an atypical thymic carcinoid. Postoperative course was uneventful. Since complete resection could not be achieved, the patient received two cycles of peptide-receptor radionuclide therapy followed by conventional radiotherapy, and remains symptom-free at 12 months after surgery.

Absence of posterior tricuspid valve leaflet and valve reconstruction.

We report a rare case of the absence of a posterior tricuspid valve leaflet. A male patient, aged 46, suffering from severe tricuspid valve regurgitation (TR) of unknown aetiology and atrial septal aneurysm was referred to our hospital for surgery. On surgical inspection, the posterior tricuspid valve leaflet and its subvalvular apparatus were completely absent and only the valve annulus was seen in the corresponding position. The anterior and septal leaflets were normal. We successfully reconstructed the tricuspid valve as follows: the head of an anterior papillary muscle was approximated to the ventricular septum (Sebening stitch). After the approximation of the centre of the tricuspid annulus of the anterior leaflet to the tricuspid annulus on the opposite side, a sizer of 29 mm in diameter was easily passed through the anterior orifice. The posterior orifice was closed with running sutures (posterior annulorrhaphy after Hetzer). Before these procedures, we attempted to reconstruct the tricuspid valve with a posterior annulorrhaphy alone; however, valve competence was insufficient. A Sebening stitch was necessary to improve the valve competence. Echocardiography showed TR grade 1 at the patient's discharge from hospital and TR grade 1 to 2 at the follow-up, 10 months after the operation.

Surgical reconstruction techniques for mitral valve insufficiency from lesions with restricted leaflet motion in infants and children.

OBJECTIVES: We report our 23-year experience with leaflet and annular remodeling techniques in infants and children with congenital mitral valve insufficiency from lesions with restricted leaflet motion (type III). METHODS: A review of the medical records, including follow-up echocardiographic studies of 49 children, aged 20 days to 14 years, was performed. These children were divided into age groups of 0 to <1 year (n = 4; mean age, 3.2 ± 1.2 months), 1 to 5 years (n = 17; mean age, 2.8 ± 1.6 years), and older than 5 to 15 years (n = 28; mean age, 12.3 ± 2.5 years). All had severe mitral insufficiency from type III Carpentier's functional classification of mitral valve lesion. Restricted leaflet motion was secondary to commissural fusion in 17 children, thickened leaflets in 9, short chordae in 6, matted chordae in 2, papillary muscle hypoplasia in 3, a parachute valve in 11, and a hammock valve in 1. Various repair strategies were applied. RESULTS: The perioperative course was unremarkable. The mean follow-up duration was 11.5 ± 1.8 years. A 2-year-old patient with a parachute valve underwent mitral valve replacement 2 years after the initial repair. She died 8 years later of noncardiac causes. The freedom from reoperation rate was 100% at 30 days and 1 year and 97.9% at 5, 10, 15, and 20 years. The actuarial survival rate was 100% at 30 days, 1 year, and 5 years and 95.96% at 10, 15, and 20 years. CONCLUSIONS: Mitral valve reconstruction of congenital mitral insufficiency from restricted leaflet motion in infants and children using various modified repair techniques tailored to the presenting valve morphology can be successfully performed in children with excellent long-term results.

Cardiac surgery for carcinoid heart disease in 12 cases.

PURPOSE: Cardiac involvement is now a major source of morbidity and mortality in patients with carcinoid tumors. We reviewed patients with carcinoid heart disease who underwent valvular surgery in our center. METHODS: Twelve patients with carcinoid heart diseases underwent cardiac surgery between 2000 and 2008. Patients were divided into two groups: group A (n = 6) comprised patients who survived more than 6 months after cardiac surgery, and group D (n = 6) comprised those who died within 6 months. Preoperative factors were compared between the groups. RESULTS: All the 12 patients with carcinoid heart disease underwent tricuspid valve surgery (3 had tricuspid repair and 9 had tricuspid replacement with a bioprosthetic valve). Postoperative 30-day mortality was 16.7% and 2-year actuarial survival was 50.0%. Median survival after the first diagnosis of carcinoid disease was 4.4 years that from first diagnosis of carcinoid heart disease was 2.7 years. Preoperative median left ventricular ejection fraction in group D (52.5%) was significantly lower than that in group A (67.2%, P < 0.05). There were no statistically significant differences between the groups in other parameters. CONCLUSION: Postoperative prognosis may be worse when preoperative left ventricular ejection fraction is borderline, even if it is within the normal limits. Cardiac evaluation is needed in all patients with carcinoid disease from the earliest time of medical and oncological therapy to improve patient outcome.

Combined anterior mitral valve leaflet retention plasty and septal myectomy in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: Septal myectomy is the treatment of choice for patients with hypertrophic obstructive cardiomyopathy (HOCM) with significant left-ventricular outflow tract (LVOT) obstruction. In some HOCM patients, however, systolic anterior motion (SAM) of the anterior mitral leaflet significantly contributes to LVOT obstruction, resulting in mitral regurgitation and insufficient release of the obstruction after myectomy. We, therefore, developed a strategy of combined myectomy and anterior leaflet retention plasty (ALRP), and investigated its results in adult HOCM patients with manifest SAM. METHODS: Subaortic septal myectomy and ALRP were performed in 25 adult HOCM patients with significant SAM, as assessed by echocardiography (mean age = 48.5 ± 15 years). All patients received cardiac catheterization and echocardiography evaluation prior to the operation, before discharge, and at follow-up. Follow-up ranged between 0.8 and 14 years (median = 2.5 years). RESULTS: All patients survived the operation, and the Kaplan-Meier estimated survival was 100% at 1 year and 82 ± 6% at 5 years. Freedom from re-operation at 5 years was 83 ± 8%. The mean LVOT pressure gradient decreased from 84 ± 32 to 19 ± 11 mm Hg postoperatively (p < 0.001), and only two patients had mild residual or recurrent SAM at follow-up. Mitral regurgitation and New York Heart Association classification were also markedly improved at follow-up. CONCLUSIONS: Combined subaortic septal myectomy and ALRP is a safe and effective therapy in HOCM patients with significant SAM. ALRP can help prevent residual or recurrent LVOT obstruction and improves mitral regurgitation.

Adult candidates for heart transplantation with larger body surface area have better prognosis on waiting list after progression to critically ill status.

OBJECTIVE: Smaller body size is one of the characteristics of female patients. We analyzed whether lower body surface area (BSA) of adult patients affects their prognosis after listing for heart transplantation (HTx). METHODS: Adult candidates (≥ 18 and <65 years) for de novo HTx in our center, who were newly listed as T (transplantable) by Eurotransplant without ventricular assist device (VAD) support between 2000 and 2009 (n = 545), were studied. The patients were divided into two groups: group S (n = 272): BSA<1.9563 m(2) (median value of total patients) and group L (n = 273): BSA ≥ 1.9563 m(2). Most female patients (82/84, 97.6%) belong to group S. Among all these patients, 286 progressed to critically ill status, that is, they were listed in urgent status or received a VAD. Actuarial survival rates were studied in each group. RESULTS: Overall survival rates after listing for HTx in group S were comparable to those in group L (43.0% vs 43.7% for 7-year survival, p=0.95). However, 1-year survival rate on waiting list after progression to critically ill status in group S (58.0%, n = 135) and that of female patients in group S (55.8%, n = 33) were significantly lower than those in group L (67.3%, n = 151, all were men; p = 0.042 and p = 0.044, respectively). After multivariate Cox analysis, BSA<1.9563 m(2) (hazard ratio 2.120, p = 0.0019), serum creatinine (hazard ratio 1.202, p = 0.033), obesity defined as body mass index ≥ 30 kg m(-2) (hazard ratio 2.043, p = 0.0096) and primary use of VAD (hazard ratio 3.243, p < 0.0001) were identified as independent risk factors for mortality on waiting list after progression to critically ill status. One-year survival rate on waiting list after VAD implantation in group S (44.4%, n = 65) and that of female patients in group S (38.1%, n = 14) were significantly lower than those in group L (63.0%, n = 78, all were men; p = 0.020 and p = 0.012, respectively). CONCLUSIONS: Adult HTx candidates with lower BSA, including most women, had worse prognosis on waiting list after progression to critically ill status, especially after VAD implantation. As almost all HTx are nowadays performed in critical status, this problem has emerged as important.

Surgical experience with right ventricular tumors in 17 patients.

PURPOSE: Resection of cardiac tumors in the right ventricle sometimes requires valve plasty or replacement. We retrospectively studied surgical treatment for right ventricular tumors. METHODS: The study cohort consists of 210 consecutive patients who underwent surgical treatment for a cardiac tumor in our hospital between January 1990 and December 2008. Clinical findings were reviewed retrospectively, and a follow-up study was performed. RESULTS: Of 210 cardiac tumors, 17 were located in the right ventricle. Of these17 right ventricular (RV) tumors, 13 were endocardial or intracavitary tumors, and 4 were epicardial tumors. Of the 17 patients, 5 underwent concomitant tricuspid valve surgery. Three of the five patients had endocardial tumors and underwent Kay annuloplasty; the other two had epicardial tumors, one of whom underwent reconstruction of the tricuspid annulus by suturing of an autologous pericardial strip, and one had tricuspid valve replacement with a 31-mm Hancock valve. Of the five patients with concomitant tricuspid valve surgery, none had an increase to grade 3 tricuspid regurgitation during follow-up. CONCLUSION: Tricuspid valve annuloplasty for resection of RV tumors may be necessary, even for palliative operations, to improve the hemodynamics.

Modified repair in patients with Ebstein's anomaly.

BACKGROUND AND AIM OF THE STUDY: Since 1988, a modified repair technique has been used at the authors' institution to treat patients with Ebstein's anomaly. This technique restructures the valve mechanism at the level of the true tricuspid annulus by using the most mobile leaflet for valve closure, without plication of the atrialized chamber. A total of 19 patients had additional attachment of the anterior right ventricular wall to the interventricular septum (Sebening's stitch) and reconstruction of the tricuspid valve as a double-orifice valve. The long-term results of the study are presented. METHODS: Between 1988 and 2008, tricuspid valve repair was performed in 50 patients with Ebstein's anomaly (33 females, 17 males; median age 22 years; range: 0.6 to 60 years), at the authors' institution. The median follow up was 68 months (range: 5 to 238) months. Details of the survival rate, reoperations, NYHA class, maximal VO2, right ventricular function (velocity-time integral pulmonary artery (VTI-PA)), and tricuspid valve insufficiency were documented. RESULTS: No patient deaths occurred during surgery; the early mortality was 7.1%, and late mortality 2.4%. Those patients who died were all aged > 50 years, and in NYHA class III or IV. No additional patient deaths have occurred since 2004. Four reoperations were necessary. Both, the NYHA class and tricuspid valve insufficiency were improved significantly (from 3.1 to 1.8; p < 0.001 and from 3.2 to 1.9; p < 0.001, respectively). The VTI-PA was increased significantly, with a stable heart rate (p = 0.01). No aneurysm of the right ventricle was observed. CONCLUSION: The long-term follow up demonstrated good clinical results in tricuspid repair, without plication of the right ventricle, even in cases where tricuspid valve replacement was discussed. Modifications seemed to support these results. Surgery in older patients with a progressive NYHA class seemed to carry a higher operative mortality.

New prioritization of heart transplant candidates on mechanical circulatory support in an era of severe donor shortage.

BACKGROUND: Nearly all patients receiving heart transplantation (HTx) in Germany are now those listed in urgent status. In this study we review urgency-based allocation policy for HTx candidates with ventricular assist devices (VADs). METHODS: We retrospectively studied 345 adult candidates for de novo HTx. Group U (n = 160) comprised patients primarily listed in urgent status without VAD. Group VAD-45 (n = 167) comprised patients with intended bridging to HTx who survived >45 days after VAD implantation (after initial drop in survival rates). Among these patients, those who died of stroke or were awarded urgent status due to difficulties of coagulation management (thrombus formation, thromboembolism and bleeding) in the first year after VAD implantation were assigned to Group COAG (n = 36), and those who died or were awarded urgent status due to device-related infection in the same period were assigned to Group INF (n = 31). Actuarial survival rates were studied in each group. RESULTS: Survival rates during support in Group VAD-45 were comparable to those during urgent status in Group U. Bridge-to-transplant rate was 63.9% in Group COAG and 58.1% in Group INF. The post-transplant 3-year survival rate of 85.3% in Group COAG was significantly higher than that in Group INF (46.8%, p < 0.01) and Group U (62.4%, p < 0.05). CONCLUSIONS: Patients who have a VAD for >45 days should be awarded some priority for urgent HTx, which is currently prohibited in Germany. Patients listed in urgent status due to difficulties of coagulation management should be prioritized over those listed for device-related infection to make effective use of limited resources.

New aortic root remodeling surgery in aortic root aneurysm.

PURPOSE: We have introduced a new surgical technique for aortic root remodeling in aortic root aneurysm, comprised of aortic annuloplasty, reduction of sinus of Valsalva, and wrapping of the aortic root. DESCRIPTION: At the level of the basal ring, the aortic annulus is fixed with the collar of a Gelweave Valsalva vascular graft (Vascutek, Ltd, Inchinnan, UK). After plication of the dilated sinuses of Valsalva from outside the aorta, the aortic root is wrapped with this prosthesis. The distal end of the graft and the transected aortic wall are sutured together with running sutures. EVALUATION: Since September 2006, 10 patients suffering from aortic root aneurysm were successfully operated on using this technique. After a median follow-up of 20.7 months, there were no early deaths and no reoperations due to failure of remodeling surgery. Median diameter of the sinus of Valsalva was reduced from 49.5 mm to 34.0 mm. All patients showed aortic regurgitation of grade 0 or grade 1 at follow-up. CONCLUSIONS: Long-term follow-up is necessary to prove the durability of this operation.

Giant aneurysm of the right coronary artery and fistula to the coronary sinus.

We describe the case of a 67-year-old man with a rare combination of a giant coronary artery aneurysm with a fistula draining into the coronary sinus. The patient presented with a sensation of retrosternal pressure. He was examined by coronary angiography, which revealed a large aneurysm of the right coronary artery (RCA) with a fistula. This fistula originated from the distal RCA shortly beyond the crux and drained into the coronary sinus. The aneurysm was in the proximal portion of the RCA, measuring 4 cm in diameter and 7 cm in length. Surgical repair by closure of the fistula under direct vision, suture closure and plication of the aneurysm, and coronary artery bypass was performed. Postoperative echocardiography and computed tomography confirmed closure of the fistula. The patient remains symptom-free at 4 months after surgery.