The long-term outcome of an isolated vascular ring - A single-center experience.

BACKGROUND AND OBJECTIVES: The aim of this study is to document the long-term outcome of patients with a vascular ring. METHODS: A single-center retrospective review of clinical symptoms was conducted in all patients born between 1980 and 2013, diagnosed with a complete vascular ring and at least 2 years of follow-up. Data were extracted from patient files and clinical symptoms were assessed by questionnaires sent to the parents. Age and diagnostic tools, type of surgery, postoperative complications, and the prevalence of clinical symptoms (stridor at rest, stridor with exercise, cough, exercise intolerance, dysphagia, and frequent respiratory infections) were reviewed. RESULTS: Fifty-one patients were included. The diagnosis was made before the age of 2 in 35/51. Surgery was performed in 41/51 patients with a limited number of reversible complications. The median follow-up was 8 (IQR 5-12) years. After 2 years, 21/51 patients were asymptomatic: 2/7 asymptomatic patients at diagnosis became symptomatic and symptoms resolved in 16/44 initially symptomatic patients. Consequently, 30/51 patients still had symptoms after 2 years. Of these, 16 had partial improvement, 5 stable symptoms, and 9 aggravation of symptoms. After 10 years, 26/36 patients were free of complaints. The most frequent long-term symptom was stridor. CONCLUSION: Surgical treatment of a congenital vascular ring is safe and mostly performed in patients with a double aortic arch. Conservative treatment for patients with little symptoms seems to be justifiable. A considerable number of patients have residual long-term symptoms after surgical relief of the vascular ring.

Durability of homografts used to treat complex aortic valve endocarditis.

BACKGROUND: Acute bacterial endocarditis may be extremely destructive for cardiac valves and their periannular structures. It has been suggested that complex reconstruction procedures require the use of homografts because of their versatility and potency to resist repeated infection. METHODS: We studied the long-term results of 69 patients with complex endocarditis who received homografts in the aortic position. RESULTS: The results after a mean follow-up of 8.1 ± 5.1 years (median, 8.0 years) showed that the recurrence of endocarditis even in these complex cases is low (7%), but the incidence of structural valve degeneration (SVD) is high. Freedom from SVD at 10 years is only 60.0%. When aortic homografts degenerate, they predominantly calcify. CONCLUSIONS: The use of homografts to reconstruct endocarditis-related aortic valve destruction is associated with a low recurrence of endocarditis but a high incidence of SVD in the long run.

Evolution of the Z-score in size-reduced bicuspid homografts.

BACKGROUND AND AIM OF THE STUDY: Human homografts are frequently used to establish an anatomic continuity between the right ventricular outflow tract (RVOT) and the pulmonary artery. Their limited availability, especially in small sizes, has encouraged the use of alternative strategies, such as size-reduced bicuspid homografts. The study aim was to analyze the follow up of patients who had received a standard tricuspid or size-reduced bicuspid homograft in the RVOT position, and to investigate modifications of the patients' Z-scores over the years. METHODS: A consecutive series of 107 patients aged < or = 16 years, who underwent RVOT repair between 1989 and 2010 to treat tetralogy of Fallot (ToF), was retrospectively reviewed. Of these patients, 17 received a size-reduced bicuspid pulmonary homograft, while 90 received a standard tricuspid homograft. The mean follow up periods were 10.5 years (range: 0.02-21.4 years) for the whole study population, and 11.8 years and 3.4 years, respectively, for the tricuspid and size-reduced bicuspid homograft groups. RESULTS: Freedom from mortality at 10 years was 95 +/- 3%. During the observation period, 27 patients (31%) in the tricuspid homograft group and two (125) in the size-reduced bicuspid group presented with graft failure. According to the multivariable analysis, the only independent predictor of graft failure was patient age (hazards ratio 0.86). The 17 patients who had received a size-reduced bicuspid homograft were then age-matched to an equal-sized population of tricuspid homograft patients. A comparative analysis of the time-weighted average of the Z-scores for these tricuspid and size-reduced bicuspid homograft subgroups during the follow up period failed to identify any statistical difference (p = 0.5). CONCLUSION: In terms of Z-score evolution, size-reduced bicuspid homografts offer results which are comparable to those achieved with tricuspid homografts.

The Contegra conduit in the right ventricular outflow tract is an independent risk factor for graft replacement.

OBJECTIVE: A large spectrum of congenital heart diseases requires valved conduits to establish an anatomical continuity between the right ventricle outflow tract (RVOT) and the pulmonary artery. The aim of the present study was to compare the incidence of graft replacement in patients receiving the Contegra conduit (bovine jugular vein graft) with that in patients receiving a homograft implanted in the RVOT. METHODS: We reviewed a total of 347 conduits (Contegra 54; homografts 293) implanted in the RVOT from 1989 to 2003 in 323 patients (median age 12.7 years, range 4 days-69 years). Indications were Tetralogy of Fallot (n = 148), Ross operation (n = 89), truncus arteriosus communis (n = 47), pulmonary valve atresia (n = 30), double-outlet right ventricle (n = 15), transposition of the great arteries (n = 12), and endocarditis (n = 6). Follow-up was 99.4% complete (mean time: 5.9 years; range: 0-14.2 years). RESULTS: Freedom from graft replacement at 1, 5, and 10 years of follow-up in the Contegra and homograft groups were 98.1 ± 1.9%, 78.3 ± 5.8%, and 63.5 ± 7.2% and 99.6 ± 0.4%, 94.0 ± 1.6%, and 81.4 ± 3.4%, respectively (log-rank test, p < 0.001). Independent predictors of graft replacement of the whole sample population were: graft size ≤ 20 mm (hazard ratio (HR) 3.6), age ≤ 10.4 years (HR 3.0), the non-anatomical position of the graft (HR 2.9), and the use of the Contegra conduit (HR 2.5). The multivariable analysis carried out on the propensity-score-matched population confirmed three independent predictors of graft replacement: graft size ≤ 20 mm (HR 8.0), the non-anatomical position of the graft (HR 2.3), and the use of the Contegra conduit (HR 3.7). CONCLUSIONS: Besides size of the graft, age of the patients, and the non-anatomical position of the graft, the use of the Contegra conduit was found to be an independent risk factor for graft replacement in the RVOT. Patients receiving this conduit were more than twice as likely to undergo re-operation for graft replacement as those receiving a homograft.

Surgery for transposition of the great arteries, ventricular septal defect and left ventricular outflow tract obstruction: European Congenital Heart Surgeons Association multicentre study.

OBJECTIVES: Optimal surgical management for patients with transposition of the great arteries (TGA), ventricular septal defect (VSD) and left ventricular outflow obstruction (LVOTO) remains controversial. Although the Rastelli operation has been the most widely performed surgical procedure during the past decades, several studies have shown its suboptimal long-term prognosis. Other operations have been developed to improve results. This study was performed to compare the outcomes of the different surgical approaches for patients with TGA, VSD and LVOTO, as well as to determine risk factors for mortality and re-intervention. METHODS: Records from 146 patients undergoing surgery from 1980 to 2008 from eight European hospitals were reviewed. Median age at operation was 21.5 months (range 0.2-165.1 months), and median weight was 10.0 kg (range 2.0-41.0 kg). Surgical procedures involved were the Rastelli procedure (82), arterial (24) and atrial (5) switch operation with relief of LVOTO, Réparation à l'Etage ventriculaire (REV) procedure (7) and the Metras modification (24), as well as the Nikaidoh procedure (4). RESULTS: The overall survival was 88%, 88% and 58% at 1, 10 and 20 years, respectively. The overall event-free survival was 80%, 45% and 26% at 1, 10 and 20 years, respectively. The REV procedure and the Metras modification were found to have the best long-term results in both survival and event-free survival rates. Multivariate analysis revealed year of operation, non-commitment of the VSD and prolonged cardiopulmonary bypass (CPB) time as risk factors for mortality while age at surgery, year of operation and type of corrective surgery were risk factors for re-intervention. CONCLUSIONS: Different surgical approaches have been developed for patients with TGA, VSD and LVOTO. The REV procedure and the Metras modification were observed to have favourable long-term results in survival and event-free survival rates. Aortic translocation techniques such as the Nikaidoh procedure seem promising, but further studies will be needed to confirm this in the long term.

Surgery for complications of trans-catheter closure of atrial septal defects: a multi-institutional study from the European Congenital Heart Surgeons Association.

OBJECTIVE: This study aims to analyse the collective experience of participating European Congenital Heart Surgeons Association centres in the surgical management of complications resulting from trans-catheter closure of atrial septal defects (ASDs). METHODS: The records of all (n=56) patients, aged 3-70 years (median 18 years), who underwent surgery for complications of trans-catheter ASD closure in 19 participating institutions over a 10-year period (1997-2007) were retrospectively reviewed. Risk factors for surgical complications were sought. Surgical outcomes were compared with those reported for primary surgical ASD closure in the European Association of Cardio-thoracic Surgery Congenital Database. RESULTS: A wide range of ASD sizes (5-34mm) and devices of various types and sizes (range 12-60mm) were involved, including 13 devices less than 20mm. Complications leading to surgery included embolisation (n=29), thrombosis/thrombo-embolism/cerebral ischaemia or stroke (n=12), significant residual shunt (n=12), aortic or atrial perforation or erosion (n=9), haemopericardium with tamponade (n=5), aortic or mitral valve injury (n=2) and endocarditis (n=1). Surgery (39 early emergent and 17 late operations) involved device removal, repair of damaged structures and ASD closure. Late operations were needed 12 days to 8 years (median 3 years) after device implantation. There were three hospital deaths (mortality 5.4%). During the same time period, mortality for all 4453 surgical ASD closures reported in the European Association of Cardio-Thoracic Surgery Congenital Database was 0.36% (p=0.001). CONCLUSIONS: Trans-catheter device closure of ASDs, even in cases when small devices are used, can lead to significant complications requiring surgical intervention. Once a complication leading to surgery occurs, mortality is significantly greater than that of primary surgical ASD closure. Major complications can occur late after device placement. Therefore, lifelong follow-up of patients in whom ASDs have been closed by devices is mandatory.

Long-term results with a stentless porcine aortic valve: the Edwards PRIMA model 2500.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the very long-term patient survival, clinical and hemodynamic status after aortic valve replacement (AVR) with the Edwards PRIMA model 2500 stentless porcine aortic valve. METHODS: A cohort of 50 patients was prospectively followed between September 1991 and November 2006, with clinical evaluation and echocardiography. The mean patient age at implantation was 72.2 +/- 5.2 years, and the mean valve size 24 mm (range: 19-29 mm). Most patients were in NYHA class II or III before valve implantation. RESULTS: The early mortality was 4% (n=2). Early morbidity included two revisions for bleeding, and thromboembolic events in four patients. A total of 41 patients died during the follow up period; death was cardiac-related or sudden in 19 patients (40%) and undefined in seven (15%). Prosthetic valve endocarditis was diagnosed in five patients, and late thromboembolic events were reported in nine. Bioprosthesis explantation was performed in four patients because of severe structural valve deterioration (SVD). After 10 years, the aortic regurgitation (AR) was grade 1+ or 2+ in 12 of the 17 survivors (71%), and grade > or = 3+ in three (18%); at this time the effective orifice area was 1.81 +/- 0.59 cm2. After 12 years, the aortic regurgitation was grade 1+ or 2+ in two of seven survivors (28%), and grade > or = 3+ in four (57%). Survival of the patients did not differ significantly from that of an age-matched Belgian population. CONCLUSION: Patient survival was comparable with that of an age-matched population after AVR with the Edwards PRIMA model 2500 valve. SVD was mainly characterized by the development of AR.

Behaviour of polyester grafts in adult patients with repaired coarctation of the aorta.

AIMS: Whatever the technique used for surgical or endovascular repair of a coarctation of the aorta (CA), long-term complications might occur. Aneurysm formation after patch angioplasty is not uncommon and may lead to a life-threatening condition. Therefore, we were interested in the long-term results of different types of tube grafts, from which a lower degree of dilatation is expected. METHODS AND RESULTS: All patients, currently older than 16 years, who underwent (redo) surgery for CA, and in whom a tube graft was inserted, were selected from the database of congenital heart disease of our hospital. Follow-up data were collected by reviewing the patients' files. The degree of graft dilatation was calculated for each patient. Fifty-three patients (41 males, median age 33.1 years, Q1-Q3 29.9-40.2 years) could be included in the study, in which 20 (38%) 'Gelseal', 12 (23%) 'Gelsoft', 8 (15%) 'Gelweave', and 13 (24%) older types of grafts were used. Twenty patients underwent a primary repair and in all others a tube graft was implanted after a previous patch angioplasty. The median graft diameter (manufacturer size) at implantation was 20 mm (Q1-Q3 16-22 mm). The median follow-up time of the grafts was 13.1 years (Q1-Q3 9.0-17.2 years). The graft size increased to a median value of 26 mm (Q1-Q3 22-30 mm) (median 50% increase in diameter, range 0-271%, P < 0.0001). The diameter of six grafts remained unchanged during follow-up. Three deaths occurred, of whom two were cardiac-related. False aneurysms occurred in four patients, graft aneurysm in two, endarteritis in two, and graft stenosis in one. CONCLUSION: Nearly, all tube grafts dilated up to 50% of the manufacturer diameter during follow-up. Re-interventions were inevitable in more than 10 per cent of the cases, primarily because of (false) aneurysm formation. Our series illustrates that late complications are not uncommon, so that rigorous follow-up of these CA patients remains mandatory.

Homograft survival after tetralogy of Fallot repair: determinants of accelerated homograft degeneration.

AIMS: Homografts are frequently implanted in patients with tetralogy of Fallot (TOF). However, the lifespan of homografts is shorter than that of graft recipients, thus making surgical re-intervention unavoidable. Therefore, to determine variables that could influence their survival, we retrospectively studied the survival pattern of homografts used to treat TOF. METHODS AND RESULTS: Sixty-eight TOF patients, >14 years of age (mean age: 34 +/- 11; 71% male), were selected from our database of congenital cardiology cases. These patients underwent their first homograft implantation at a median age of 24 years (range: 14-49). The primary endpoint, homograft failure, was defined as homograft replacement or percutaneous balloon dilatation when the echocardiographic gradient reached more than 50 mmHg. Kaplan-Meier analysis revealed that the mean event-free survival time of first homografts was 14.6 years (CI, 12.9-16.2 years). The median increase in the homograft gradient was 1.1 mmHg/year (range: 0.0-22.1) for a median follow-up time of 8.4 years (range: 1.3-17.9). Stepwise regression analysis identified the homograft gradient at 1 month after surgery to be prognostic for homograft degeneration (R(2) = 0.23, beta = 0.26, P = 0.001). Immunological variables, gender, and post-operative inflammatory indicators were unrelated to the degree of homograft gradient increase. Finally, patient age at the time of first homograft implantation and previous palliative surgery was significantly associated with the gradient at 1 month (Spearman's rho = -0.41 and -0.29, respectively; P = 0.004 and 0.048, respectively). CONCLUSION: Homograft survival in patients with TOF repair is quite good. However, some patients develop accelerated homograft degeneration. We found that the gradient of the homograft 1 month after surgery is most indicative of accelerated homograft degeneration. We hypothesize that mechanical, not immunological, factors play an important role in homograft degeneration.

Endovascular stenting of juvenile vessels: consequence of surgical stent removal on vessel architecture.

AIMS: To investigate the effect of stenting and later surgical removal on the architecture and therefore growth potential of juvenile vessels. METHODS AND RESULTS: Stents were implanted in the carotid artery and jugular vein of six 6-week-old lambs. Ten weeks later, stents were excised and the vessels closed without the use of patch material. After another 10 weeks, the vessel size (treated and untreated control side) was measured angiographically and the animals terminated for histology. All arteries were patent: treated arterial size was 9 +/- 1 mm compared with 11 +/- 1 mm on the control side (P = ns). Two veins were completely occluded and two severely stenosed; vessel size was smaller compared with the control side (8 +/- 8 vs. 14 +/- 5 mm; P = 0.02). Preserved vessel wall integrity was observed in both arteries and veins (except for local rupture of the internal elastic lamina with neointimal formation in two arteries leading to mild stenosis). CONCLUSION: Vessel wall architecture remains well preserved after surgical removal of stents implanted in juvenile arteries and veins. However, stenting and subsequent surgical removal results in a high risk of venous thrombosis (probably due to the lower blood velocity, lower pressure, and the absence of pulsatility in venous vessels).

Risk of surgery for congenital heart disease in the adult: a multicentered European study.

BACKGROUND: Surgery for congenital heart disease (CHD) has changed considerably during the last three decades. The results of primary repair have steadily improved, to allow treating almost all patients within the pediatric age; nonetheless an increasing population of adult patients requires surgical treatment. The objective of this study is to present the early surgical results of patients who require surgery for CHD in the adult population within a multicentered European study population. METHODS: Data relative to the hospital course of 2,012 adult patients (age > or = 18 years) who required surgical treatment for CHD from January 1, 1997 through December 31, 2004 were reviewed. Nineteen cardiothoracic centers from 13 European countries contributed to the data collection. RESULTS: Mean age at surgery was 34.4 +/- 14.53 years. Most of the operations were corrective procedures (1,509 patients, 75%), followed by reoperations (464 patients, 23.1%) and palliative procedures (39 patients, 1.9%). Six hundred forty-nine patients (32.2%) required surgical closure of an isolated ostium secundum atrial septal defect. Overall hospital mortality was 2%. Preoperative cyanosis, arrhythmias, and NYHA class III-IV, proved significant risk factors for hospital mortality. Follow-up data were available in 1,342 of 1,972 patients (68%) who were discharged home. Late deaths occurred in 6 patients (0.5%). Overall survival probability was 97% at 60 months, which is higher for corrective procedures (98.2%) if compared with reoperations (94.1%) and palliations (86.1%). CONCLUSIONS: Surgical treatment of CHD in adult patients, in specialized cardiac units, proved quite safe, beneficial, and low-risk.

The arterial switch operation in Europe for transposition of the great arteries: a multi-institutional study from the European Congenital Heart Surgeons Association.

OBJECTIVES: This study analyzes the results of the arterial switch operation for transposition of the great arteries in member institutions of the European Congenital Heart Surgeons Association. METHODS: The records of 613 patients who underwent primary arterial switch operations in each of 19 participating institutions in the period from January 1998 through December 2000 were reviewed retrospectively. RESULTS: A ventricular septal defect was present in 186 (30%) patients. Coronary anatomy was type A in 69% of the patients, and aortic arch pathology was present in 20% of patients with ventricular septal defect. Rashkind septostomy was performed in 75% of the patients, and 69% received prostaglandin. There were 37 hospital deaths (operative mortality, 6%), 13 (3%) for patients with an intact ventricular septum and 24 (13%) for those with a ventricular septal defect (P < .001). In 36% delayed sternal closure was performed, 8% required peritoneal dialysis, and 2% required mechanical circulatory support. Median ventilation time was 58 hours, and intensive care and hospital stay were 6 and 14 days, respectively. Although of various preoperative risk factors the presence of a ventricular septal defect, arch pathology, and coronary anomalies were univariate predictors of operative mortality, only the presence of a ventricular septal defect approached statistical significance (P = .06) on multivariable analysis. Of various operative parameters, aortic crossclamp time and delayed sternal closure were also univariate predictors; however, only the latter was an independent statistically significant predictor of death. CONCLUSIONS: Results of the procedure in European centers are compatible with those in the literature. The presence of a ventricular septal defect is the clinically most important preoperative risk factor for operative death, approaching statistical significance on multivariable analysis.

Epicardial pacing: a single-centre study on 321 leads in 138 patients.

OBJECTIVE: This study presents the long-term outcome of 321 epicardial leads in 138 patients. METHODS AND RESULTS: All leads were Medtronic CapsureEpi model 4965 steroid eluting leads. The 1-, 3-, and 5-year patient survival was 91%, 83% and 77%, respectively.Twenty-seven patients died. In 25/27 deaths a pacing-related death could be excluded. Strangulation of the heart by an abandoned epicardial lead was the cause of death in one child. One other patient died suddenly at the age of 3 years. Failures occurred in 57 of 321 epicardial leads (18%). For all 321 leads, the 1-, 3- and 5-year freedom from failure was 91%, 85% and 71%, respectively. The cumulative proportion of patients without any lead defect was 85% after I year, 76% after 3 years and 62% after 5 years. The percentage of patients without serious adverse events at 1, 3, and 5 years was 97%, 91%, 85%, respectively. Lead fracture was the cause of failure in 15 leads of 9 patients. An important increase in pacing threshold occurred in 35 leads of 30 patients. Other failures were: diaphragmatic stimulation, infection, excessive traction and strangulation. Eighteen failures were repaired by 11 surgical interventions in 9 patients.Thirty-nine defects were corrected non-invasively in 31 patients. CONCLUSIONS: The use of steroid-eluting epicardial leads has proven to be an adequate option. In paediatric cardiology, the epicardial approach remains an indispensable tool for achieving a life-long pacing.

Implementation of an intervention plan designed to optimize donor referral in a donor hospital network.

CONTEXT: The shortage of donor organs remains the most important factor of waiting list mortality in organ transplantation worldwide. Donor detection is influenced by the legal system, family refusal, and underreporting caused by erroneous knowledge of donation criteria and lack of familiarity with the procedure. OBJECTIVE: To identify possible key factors of donor referral patterns within an existing cooperation with donor hospitals and donor units across the Dutch-speaking part of Belgium, an area of approximately 3 million inhabitants. An intervention plan to optimize the cooperation and procedure quality and efficiency was designed. DESIGN: The intervention plan was based on 3 essential principles in donor referral by donor reporters, information on donor criteria, facilitation of the donor procedure, and communication between donor reporters and the transplant center. The interventions were structured to optimize all 3 of these principles. Two successive periods of 4 years were retrospectively compared. PARTICIPANTS: Data were collected retrospectively on donor referral behavior from a total of 37 donor hospitals and donor units over an 8-year period. MAIN OUTCOME MEASURES: The referrals were reviewed for potential donors, effective donors, percentage of effective donors, refusal rate of relatives, number of tissue donors, impact on local and national transplant programs, and national donor numbers. RESULTS: Data showed a significant positive impact on donor referrals and donor referral behavior (+27% potential donors, +30% effective donors, +172.7% tissue donors, -7% family refusals rates, +9.63% national donors). The results stress the importance of reduced workload and optimization of communication and information availability in an existing donor hospital network.

Effect of azithromycin on bronchiectasis and pulmonary function in a heart-lung transplant patient with severe chronic allograft dysfunction: a case report.

Azithromycin has been shown to be beneficial in several diseases with chronic neutrophilic inflammation of the airways, such as cystic fibrosis and bronchiolitis obliterans syndrome (BOS) after lung transplantation. Up to now, however, its healing effect on bronchiectasis has never been demonstrated. We report a heart-lung transplant patient who developed chronic rejection (BOS stage 3) with the appearance of gross bronchiectasis on a spiral computed tomography (CT) chest scan. Within 2 weeks after starting azithromycin, the patient's forced expiratory volume in 1 second increased significantly and a repeat spiral CT chest scan 5 months later, showed a major improvement of the bronchiectasis. This case report illustrates that bronchiectasis may greatly improve after treatment with azithromycin and no longer needs to be considered an endstage finding in patients with severe BOS.

Factors influencing the survival of cryopreserved homografts. The second homograft performs as well as the first.

OBJECTIVE: To determine the life span of cryopreserved homografts implanted in the right ventricular outflow tract and the factors influencing it. METHODS: From 1989 through 2003, we reconstructed the pulmonary valve with 301 homografts in 272 patients (median age 13 years; range 4 days-69 years). Indications were tetralogy of Fallot (136), truncus (23), Rastelli repair (11), double outlet ventricle (13), endocarditis (5), and the Ross operation (84). Median follow-up was 5.7 years (range 0-14). We analyzed possible predictors of graft replacement by simple and multiple Cox regression. RESULTS: Actuarial survival was 96+/-1.2% at 1, 95+/-1.4% at 5, and 94+/-1.5% at 10 years follow-up. Three homografts were explanted because of endocarditis (excluded from the analysis). Freedom from explantation was 99.6+/-0.4% at 1, 94.5+/-1.7% at 5, and 81.8+/-4.1% at 10 years. Variables, significantly related to explantation in the univariate analysis, were younger age, small graft size, implantation in a non-anatomical position, the aortic donor homograft, a shorter aortic cross-clamp time and the implantation of a second homograft. In the multiple model, non-anatomical position (P=0.001), smaller graft size (P<0.0001) or younger age (on square root scale, P<0.0001) and clamp time (P=0.01) remain as independent risk factors. Immunological variables, like blood group incompatibility, implantation of a second homograft and short warm ischemic time were not significant. CONCLUSIONS: The life span of a cryopreserved homograft is determined by graft size (correlates with age) and the non-anatomic position (correlates with indication). In a specific patient, the second homograft performs as well as the first.

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Pulmonary thromboendarterectomy (PTE) is a surgical procedure which is considered the only effective and potentially curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a rare outcome from pulmonary emboli and, when left untreated, will result in right ventricular failure and death. METHODS: From June 1999 to November 2003, 40 of these procedures were performed in our institution. Emphasis is placed on multidisciplinarity and cooperation between different medical and surgical disciplines. Perfusion management consists of myocardial and cerebral protection, deep hypothermia with multiple periods of circulatory arrest, reperfusion at hypothermia, hemofiltration and cellsaving techniques. RESULTS: Hemodynamic improvement occurs immediately post operation. Mean pulmonary artery pressure decreased from 50 +/- 11 to 38 +/- 10 mmHg, pulmonary vascular resistance from 1246+482 to 515 +/- 294 dynes s/cm5 and cardiac index increased from 1.54 +/- 0.54 to 2.63 +/- 0.75 L/min per m2. Pump runs had an average duration of 187 +/- 29 min, circulatory arrest time was 29 +/- 11 min and crossclamp time 36 +/- 14 min. Extracorporeal membrane oxygenation can be an ultimate treatment for specific postoperative problems like persistent pulmonary hypertension and/or reperfusion pulmonary edema.

Acute hemodynamic benefit of left ventricular apex pacing in children.

BACKGROUND: Despite the fact that pacing at the right ventricular apex acutely and chronically decreases left ventricular contractile function, this pacing site is still conventionally used in adults and children. Because animal studies showed beneficial effects of left ventricular pacing, we compared the hemodynamic performance of left ventricular apex, left ventricular free wall, and right ventricular apex pacing in children. METHODS: Studies were performed in 10 children (median age, 2.5 years; range, 2 months to 17 years) undergoing surgery for congenital heart disease with normal systemic left ventricular anatomy and intraventricular conduction. High-fidelity left ventricular and arterial pressure measurements were performed during epicardial right ventricular apex and left ventricular apex and free wall pacing. RESULTS: Left ventricular apex pacing increased the maximum rate of rise of left ventricular pressure and pulse pressure significantly relative to right ventricular apex pacing (by 7.7% +/- 7.2% and 7.7% +/- 7.0%, respectively) without changes in end-diastolic left ventricular pressure. Left ventricular free wall pacing did not significantly improve hemodynamics as compared with right ventricular apex pacing. The QRS duration was not different among pacing at the three sites. CONCLUSIONS: In this short-term study left ventricular apex pacing is hemodynamically superior to right ventricular apex and left ventricular free wall pacing in children. Therefore, the left ventricular apex appears a favorable pacing site after pediatric cardiac surgery.

Anaesthesia management for pulmonary endarterectomy.

PURPOSE OF REVIEW: Options for the surgical treatment of chronic thromboembolic pulmonary hypertension are either lung transplantation or pulmonary endarterectomy. Pulmonary endarterectomy is considered permanently curative and the treatment of choice. The procedure dramatically improves functional status and provides an excellent immediate and long-term survival, much better than transplantation. Pulmonary endarterectomy, until recently performed in only a few highly specialized centres, is now spreading worldwide with good results. This review will focus on the understanding of the pathophysiology of the disease and on recent advances in assessment and treatment strategies. RECENT FINDINGS: Recent data reinforce the thromboembolic nature of chronic thromboembolic pulmonary hypertension, and have shown that the disorder is more common than was thought and remains underdiagnosed. There has recently been a remarkable surge in the understanding of the mechanisms involved in the pathogenesis of pulmonary hypertension. Advances in diagnosis, surgical techniques, preoperative treatment, and perioperative management have improved the prognosis of this debilitating disease. New information about pretreatment and medical treatment with prostanoids and endothelin receptor antagonists is now available. SUMMARY: Pulmonary endarterectomy can be successfully performed in selected centres using a multidisciplinary approach involving the specialities of surgery, pulmonary medicine, cardiology, radiology, anaesthesiology and critical care medicine. The largest risk factor remains the degree of operability related to a high pulmonary vascular resistance caused by permanent changes in the pulmonary vascular bed. Early operation is now recommended to prevent these irreversible changes. Further investigations are warranted to establish the role of new drugs in surgical patients with chronic thromboembolic pulmonary hypertension.