The Ross procedure in adult patients: a single-centre analysis of long-term results up to 28 years.

OBJECTIVES: This study aimed to provide an in-depth insight into our single-centre experience with the Ross procedure. METHODS: All adults who underwent the Ross procedure between 1991 and 2014 were included. Based on the total number of Ross procedures performed by each surgeon at our centre during this 24-year period, surgeon volume was classified as low (<25 procedures), intermediate (25-44 procedures) and high (≥45 procedures). Survival, complications and reinterventions were evaluated. A single cardiologist assessed the pulmonary autograft's function and the neoaortic root diameter by echocardiography. RESULTS: The outcomes of 224 patients {176 men, 48 women; mean age 37.2 [standard deviation (SD) 10.0] years} were analysed. Patients operated on by a low-volume surgeon had 7.22 times higher odds (P < 0.001) for a serious adverse event during the intraoperative or early postoperative course than patients operated on by a high-volume surgeon. Early mortality was 1.8%. Overall survival was 87.3% at 20 years. Compared with the demographically matched general population, the patients' survival was significantly lower (P = 0.002). The cumulative incidence of autograft and right ventricular outflow tract conduit reintervention was 21.5% and 5.9% at 20 years, respectively. Patients with preoperative aortic regurgitation had 6.25 times the subdistribution hazard of autograft reintervention (Bonferroni-adjusted P = 0.042) and a higher neoaortic root z-score [1.37 (SD 2.04) vs 0.17 (SD 1.81), P = 0.004] than patients with aortic stenosis. In patients with preoperative aortic regurgitation, autograft wrapping (remnant aortic wall and/or Vicryl® mesh) was associated with a 74% reduction in the subdistribution hazard of autograft reintervention (Bonferroni-adjusted P = 0.002) and with a reduced incidence of neoaortic root dilatation (P = 0.037). CONCLUSIONS: The Ross procedure performed by a specialized surgeon provides very satisfying long-term results. The higher risk of autograft reintervention in preoperative aortic regurgitation may be counteracted by supporting the autograft.

Long-term performance of pulmonary homografts after the Ross procedure: experience up to 25 years.

OBJECTIVES: The aim of this study was to evaluate the long-term durability and function of pulmonary homografts used for right ventricular outflow tract reconstruction in the Ross procedure at a single centre with 25 years of experience. METHODS: The study included 274 patients (212 male patients and 62 female patients; age 3-59 years), who underwent the Ross procedure between 1991 and 2014. Homograft-related complications and reinterventions were assessed. Homograft haemodynamic function was determined using transthoracic echocardiography undertaken by a single cardiologist. RESULTS: The all-cause 30-day mortality was 1.1% (3 patients), and there were 17 late deaths. One death was associated with a homograft-related complication. During the observation period (median 13.3 years; 3327.5 cumulative patient-years), 21 patients (7.7%) underwent at least 1 right ventricular outflow tract reintervention. Freedom from homograft reintervention was 95.6%, 90.4% and 87.5% at 10, 15 and 20 years, respectively. Paediatric patients had a significant lower rate of freedom from reintervention (log-rank P < 0.001). Remarkably, all patients who underwent reintervention were male (log-rank P = 0.009). Female patients received homografts with a significantly higher (P < 0.001) indexed diameter than male patients, which might be causally related to absent reinterventions in women. The linearized rate of homograft endocarditis was 0.2% per patient-year. At the latest echocardiography (median follow-up time 14.7 years; 164 patients), the peak transhomograft pressure gradient was <40 mmHg in 150 patients (91.5%), and homograft incompetence was none or trivial in 111 patients (67.7%), mild in 49 patients (29.9%) and moderate in 3 patients (1.8%). In 1 patient (0.6%), it was not possible to determine the degree of incompetence. Younger patient age (P < 0.001), a smaller homograft diameter (P = 0.014) and an increase in the body surface area during the follow-up time (P = 0.006) were significantly correlated with a higher peak transhomograft pressure gradient. Men had a significantly higher peak transhomograft pressure gradient than women (P = 0.018). CONCLUSIONS: Pulmonary homografts provide very satisfying long-term results after the Ross procedure. Differences in long-term performance are related to undersizing and young age.

Intravenous Heme Arginate Induces HO-1 (Heme Oxygenase-1) in the Human Heart.

Objective- HO-1 (heme oxygenase-1) induction may prevent or reduce ischemia-reperfusion injury. We previously evaluated its in vivo induction after a single systemic administration of heme arginate in peripheral blood mononuclear cells. The current trial was designed to assess the pharmacological tissue induction of HO-1 in the human heart with heme arginate in vivo. Approach and Results- Patients planned for conventional aortic valve replacement received placebo (n=8), 1 mg/kg (n=7) or 3 mg/kg (n=9) heme arginate infused intravenously 24 hours before surgery. A biopsy of the right ventricle was performed directly before aortic cross-clamping and after cross-clamp release. In addition, the right atrial appendage was partially removed for analysis. HO-1 protein and mRNA concentrations were measured in tissue samples and in peripheral blood mononuclear cells before to and up to 72 hours after surgery. No study medication-related adverse events occurred. A strong, dose-dependent effect on myocardial HO-1 mRNA levels was observed (right ventricle: 7.9±5.0 versus 88.6±49.1 versus 203.6±148.7; P=0.002 and right atrium: 10.8±8.8 versus 229.8±173.1 versus 392.7±195.7; P=0.001). This was paralleled by a profound increase of HO-1 protein concentration in atrial tissue (8401±3889 versus 28 585±10 692 versus 29 022±8583; P<0.001). Surgery and heme arginate infusion significantly increased HO-1 mRNA concentration in peripheral blood mononuclear cells ( P<0.001). HO-1 induction led to a significant increase of postoperative carboxyhemoglobin (1.7% versus 1.4%; P=0.041). No effect on plasma HO-1 protein levels could be detected. Conclusions- Myocardial HO-1 mRNA and protein can be dose-dependently induced by heme arginate. Protective effects of this therapeutic strategy should be evaluated in upcoming clinical trials. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT02314780.

Case report: Pacemaker lead perforation of a papillary muscle inducing severe tricuspid regurgitation.

INTRODUCTION: We report a rare but severe pacemaker complication of a pacemaker lead perforating the papillary muscle. This induced severe tricuspid regurgitation and right heart failure. Patients suffering from right heart failure have an increased operative risk of open-heart surgery and therefore represent a clinical challenge due to the lack of clear guidelines. CASE PRESENTATION: A 70-year-old male patient presented with severe tricuspid regurgitation and a history of decompensated right heart failure. One pacemaker lead was described as 'whipping'. Four years earlier he had received a VVIR pacemaker with a passive lead. This lead failed after three years and a new ventricular lead had been placed. We performed on-pump beating heart surgery after a multidisciplinary decision process. One lead was perforating the posterior papillary muscle, severely impairing valve movement. The tricuspid valve was replaced with a stented bioprosthesis. Epicardial pacemaker wires were placed on the right and left ventricle to enable cardiac resynchronization therapy in the case of postoperative heart failure. However, the patient recovered quickly without left ventricular pacing and could be discharged home 12 days after surgery. CONCLUSION: This particular case emphasizes the importance of meticulous surgical technique during pacemaker lead implantation and a tight postoperative follow-up including echocardiography in complicated cases. The management of patients with an indication for lead removal having developed secondary severe tricuspid valve dysfunction inducing ventricular impairment represents a clinical challenge and should be approached by a multidisciplinary team.

Left ventricular thrombus in a patient with cutaneous T-cell lymphoma, hypereosinophilia and Mycoplasma pneumoniae infection - a challenging diagnosis: a case report.

Differential diagnoses of cardiac masses include primary benign and malignant neoplasms, secondary neoplasms, and non-neoplastic masses, such as thrombi. Owing to different therapeutic approaches and the way these affect the prognosis, the early and correct diagnostic determination of the etiology of a cardiac mass is of utmost importance and essential for the appropriate management of patients.We report a case of a 52-year-old woman with a left ventricular mass in the setting of a recent Mycoplasma pneumoniae infection and a medical history of cutaneous T-cell lymphoma and hypereosinophilia. Imaging findings were consistent with both an infiltrative process of the lymphoma and a cardiac thrombus. An estimated very high risk for embolization led to the indication for open-heart surgery for the removal of the cardiac mass. Histopathological examination confirmed the presence of a thrombus; there were no signs of malignancy. The patient was discharged 11 days after surgery in good general condition and is now in outpatient care for follow-up and further management.This case highlights possible challenges in the diagnostic assessment of cardiac masses and their management in a patient with several underlying diseases and a complex medical history.

Quadruple valve replacement and bypass surgery 23 years after the Ross operation†.

This report describes a case of simultaneous quadruple valve replacement, coronary artery bypass surgery and reconstruction of one aortic sinus performed in a patient who had undergone the Ross operation 23 years previously.