Aortic annulus diameter and valve design each determine the valve size implanted.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare the sizing characteristics and hemodynamics of the Medtronic Mosaic Ultra porcine and Carpentier-Edwards PERIMOUNT Magna bovine pericardial bioprosthetic stented aortic valves in relation to the patient's true aortic annulus size. METHODS: In this prospective multicenter randomized study, data acquired perioperatively and at six months postoperatively were collected. Following aortic valve excision and debridement, the annulus was measured by blinded sizers prior to the randomization of 141 patients (Ultra, n=72; Magna, n=69). RESULTS: The median patient age was 75 years, and 89% of the patients had aortic stenosis. A good left ventricular function was present in 75% of patients, and the EuroSCORE-predicted mortality was 9%. Concomitant procedures (coronary artery bypass grafting, mitral/tricuspid repair, septal myectomy, modified Maze) were performed in 61% of patients. The in-hospital mortality was 3%, and at six months postoperatively 96% of the patients were NYHA class I or II, with no intergroup differences. The mean 'true aortic annulus' size was 23.0 +/- 1.4 mm for the Ultra valve, and 22.6 +/- 1.8 mm for the Magna valve (p = NS). The implanted labeled valve size was > or = 23 mm for 83% of Ultra valves, and for 52% of Magna valves (p < 0.01), and smaller than the measured true aortic diameter (44% Magna versus 33% Ultra). The mean echo gradients were lower with Magna valves (11 +/- 6 mmHg) than with Ultra (17 +/- 6 mmHg; p < 0.01), while the effective orifice area (EOA) was higher with Magna than with Ultra (1.6 +/- 0.4 versus 1.4 +/- 0.4 ; p < 0.01). Both groups showed a similar left ventricular mass regression (Ultra -48 +/- 83 g; Magna -42 +/- 70 g). Trivial to moderate regurgitation was noted in 24% of Ultra valves compared to 48% of Magna valves (p < 0.01). CONCLUSION: Selection of the Ultra bioprosthetic valve allowed the implantation of larger valve sizes. However, when compared to the 'true aortic annulus', the Magna was associated with lower transprosthetic gradients and larger EOAs. The longer term significance of these observations remains inconclusive in terms of bioprosthesis selection, however.

Relative survival after CABG surgery is poorer in women and in patients younger than 70 years at surgery.

OBJECTIVE: The difference in survival between genders after coronary artery bypass surgery (CABG) have been studied with varying results. We wanted to investigate gender and age specific relative survival in the CABG population. Risk factors increasing hazard of death in female patients were isolated. DESIGN: Retrospectively, 6699 primary isolated CABG procedures were investigated. Long-term survival compared to expected survival in the background population was described through Kaplan-Meier plots. Two subgroups of female patients were described through baseline characteristics, t-tests, odds ratio and multivariate analysis to investigate risk factors for death within one year after surgery. RESULTS: Women had significantly decreased relative long-term survival compared to men in this study. Relative survival was lower in patients below 70 years of age at surgery with about the same gender difference. Low ejection fraction, left main stem stenosis and reduced renal function were found to increase risk of death within one year after CABG in women, while body size quantified by body surface area (BSA) did not. CONCLUSION: Relative long-term survival after CABG was poorer in female compared to male patients. This tendency was kept or strengthened when only those less than 70 years of age at surgery were investigated. Lower female survival was most likely due to more comorbidity in female patients. Relative survival was lower in patients <70 years.

Patient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarction.

BACKGROUND: Patient-reported outcomes are increasingly seen as complementary to biomedical measures. However, their prognostic importance has yet to be established, particularly in female long-term myocardial infarction (MI) survivors. We aimed to determine whether 10-year survival in older women after MI relates to patient-reported outcomes, and to compare their survival with that of the general female population. METHODS: We included all women aged 60-80 years suffering MI during 1992-1997, and treated at one university hospital in Norway. In 1998, 145 (60% of those alive) completed a questionnaire package including socio-demographics, the Sense of Coherence Scale (SOC-29), the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF) and an item on positive effects of illness. Clinical information was based on self-reports and hospital medical records data. We obtained complete data on vital status. RESULTS: The all-cause mortality rate during the 1998-2008 follow-up of all patients was 41%. In adjusted analysis, the conventional predictors s-creatinine (HR 1.26 per 10% increase) and left ventricular ejection fraction below 30% (HR 27.38), as well as patient-reported outcomes like living alone (HR 6.24), dissatisfaction with self-rated health (HR 6.26), impaired psychological quality of life (HR 0.60 per 10 points difference), and experience of positive effects of illness (HR 6.30), predicted all-cause death. Major adverse cardiac and cerebral events were also significantly associated with both conventional predictors and patient-reported outcomes. Sense of coherence did not predict adverse events. Finally, 10-year survival was not significantly different from that of the general female population. CONCLUSION: Patient-reported outcomes have long-term prognostic importance, and should be taken into account when planning aftercare of low-risk older female MI patients.

Esmolol before 80 min of cardiac arrest with oxygenated cold blood cardioplegia alleviates systolic dysfunction. An experimental study in pigs.

OBJECTIVE: Myocardial dysfunction after reperfusion can be a clinical problem in the early postoperative phase after on-pump cardiac surgery. The aim was, in an experimental setting, to investigate if administration of the beta-adrenergic receptor blocker esmolol prior to cross-clamping for 80 min with cold oxygenated blood cardioplegia would improve myocardial protection and early postoperative function. METHODS: Twenty-four anaesthetised pigs were randomly allocated into one of two equally sized groups and put on mild hypothermic cardiopulmonary bypass. Esmolol 1 mg kg(-1) or saline was administered into the arterial line 4 min prior to aortic cross-clamp. Cardiac arrest during 80 min of cross-clamp was obtained with repeated antegrade cold oxygenated blood cardioplegia; the pigs were weaned from bypass following a standardised protocol. Left ventricular global and regional myocardial function and tissue blood flow were evaluated with conductance catheter, echocardiography and coloured microspheres at baseline and at 1, 2 and 3 h after declamping. Four animals did not fulfil the protocol and were excluded. RESULTS: No significant differences between groups could be demonstrated for left ventricular global and local function and tissue blood flow at baseline. At 1h after declamping the slope of preload recruitable stroke work (PRSW(slope)) averaged 73.7+/-12.7 mm Hg (SD) in controls and 72.7+/-11.1 mm Hg in esmolol-treated animals. In controls PRSW(slope) decreased to 62.1+/-11.0 and 58.4+/-12.7 mm Hg after 2 and 3h, respectively (p<0.005 vs 1h for both). In the esmolol-treated animals PRSW(slope) remained unchanged at 72.0+/-11.4 and 73.7+/-12.9 mm Hg at 2 and 3 h after declamp and were significantly higher (p<0.025 and <0.001) than the corresponding values in the control group. The slope of the end systolic pressure volume relationship did not differ between groups at 1 and 2 h after declamp, but were 1.85+/-0.86 and 2.51+/-0.96 mm Hg ml(-1) in controls and in esmolol-treated animals, respectively, after 3h (p<0.025). CONCLUSIONS: Esmolol administered prior to cold oxygenated cardioplegic arrest alleviates left ventricular dysfunction in the early hours after cardiopulmonary bypass.

The female gender has a positive effect on survival independent of background life expectancy following surgical resection of primary non-small cell lung cancer: a study of absolute and relative survival over 15 years.

Surgical resection is the treatment of choice for non-advanced lung cancer, but is encumbered with an overall relative poor long time prognosis. The purpose of this study was to examine if long time survival for patients operated for non-small cell lung cancer have changed over a 15 years period. We retrospectively studied hospital records of the 351 patients operated, with the intention to cure, for a primary non-small cell carcinoma (NSCLC) in our department between 1 January 1988 and 31 December 2002. Preoperative clinical variables were noted together with variables allowing staging based on pathological examination. Absolute survival and survival relative to expected was studied for the whole group using uni- and multivariate Cox analyses. Early 30 days mortality was 2.0%. The 5-year absolute and relative survivals for all patients were 46.3% and 52.6%, respectively. After 10 years corresponding values were 32.9% and 44.6%. At the end of the study, the 15-year absolute survival was 27.8% with a relative survival of 46.2%. Univariate analysis revealed that age, gender, nodular stage, tumour size, p-stage, type of resection, time of operation and additional cardiovascular disease at the time of operation significantly influenced survival. Multivariate analysis for all patients revealed that low age, female gender, low nodular stage, and operation late in the study period were significant prognostic factors predicting improved survival. When including a population based age- and gender-adjusted median expected life time for every patient as a predictor for survival, only female gender and low nodular stage were additional significant and independent positive prognostic factors.

Preoperative hair removal--a systematic literature review.

This article describes a systematic literature review on whether, how, and when to perform preoperative hair removal. By searching electronic databases and reference lists of relevant articles, team members identified 20 clinical studies that deal with preoperative hair removal. No strong evidence was found to advocate against preoperative hair removal. Furthermore, there was strong evidence to recommend that when hair removal is considered necessary, shaving should not be performed. Instead a depilatory or electric clipping, preferably immediately before surgery, should be used.

Acute obstruction by Pannus in patients with aortic medtronic-hall valves: 30 years of experience.

BACKGROUND: Acute dysfunction of mechanical aortic valve prostheses is a life-threatening adverse event. Pannus overgrowth, which is fibroelastic hyperplasia originating from the periannular area, is one cause of dysfunction. The aim of this study was to determine the annual incidence of readmittance resulting from acute obstruction caused by pannus during 30 years of observation in patients with Medtronic-Hall aortic valve prostheses and to analyze the risk factors associated with pannus development. METHODS: From 1982 to 2004, 1,187 patients in our department underwent aortic valve replacement with Medtronic-Hall mechanical monoleaflet valve prostheses. As of December 31, 2012, 27 of these patients (2.3%) had presented with acute valve dysfunction caused by pannus obstruction. RESULTS: The annual incidence of pannus was 0.7 per 1,000. The median time from the primary operation to prosthetic dysfunction was 11.1 years (range, 1.2 to 26.8 years). Of the 20 patients who underwent reoperation, 2 died. Seven patients died before reoperation. Women had a higher risk for the development of obstructing pannus, and patients with pannus obstruction were younger. Valve size was not an independent risk factor. CONCLUSIONS: Women and younger patients are at higher risk for pannus development. When acute dysfunction by pannus is suspected in a mechanical aortic valve, an immediate echocardiogram and an emergency aortic valve replacement should be carried out because of the potential of a fatal outcome.

Myocardial deformation in aortic valve stenosis: relation to left ventricular geometry.

OBJECTIVE: To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS). DESIGN: Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/height(2.7) > or =46.7/49.2 g/m(2.7) in women/men and concentric LV geometry if relative wall thickness > or =0.43. LV geometry was assessed from LV mass/height(2.7) and relative wall thickness in combination. Setting Department of Heart Disease, Haukeland University Hospital, Bergen, Norway. PATIENTS: 70 patients with AS (mean age 73+/-10 years, 54% women). INTERVENTIONS: None. Main outcome measures Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS. RESULTS: Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI (all p<0.05). Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (beta=0.15), lower ejection fraction (beta=-0.16), systolic blood pressure (beta=-0.16) and energy loss index (beta=-0.20) (all p<0.05) (R(2)=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass (beta=0.21, p<0.05) (R(2)=0.73). CONCLUSIONS: In patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS.

Multidose cold oxygenated blood is superior to a single dose of Bretschneider HTK-cardioplegia in the pig.

BACKGROUND: A single-dose strategy for cardioplegia is desired in minimal invasive approaches to valve surgery and aortic arch repairs. We hypothesized that a single infusion of Bretschneider HTK solution offers myocardial protection comparable to repeated cold oxygenated blood. METHODS: Sixteen pigs on bypass with 60 minutes of aortic cross-clamping were randomized to a single dose of Custodiol (HTK group) or repeated oxygenated blood cardioplegia (CBC group). Left ventricular function and perfusion were evaluated by conductance catheter, echocardiography, and microspheres. Myocardial injury was assessed with serum troponin-T. RESULTS: Baseline values showed no group differences. One hour after declamping cardiac index was reduced in the HTK group, 3.5 +/- 0.2 L x min(-1) x m(-2) (mean +/- standard error of the mean) compared with 4.7 +/- 0.4 L x min(-1) x m(-2) in the CBC group (p < 0.0005), decreasing to 4.0 +/- 0.2 and 3.9 +/- 0.2 L x min(-1) x m(-2) after 2 and 3 hours, respectively (p < 0.005 versus 1 hour). In the HTK group cardiac index remained low and unchanged. In the CBC group preload recruitable stroke work was 72.6 +/- 1.2 mm Hg 1 hour after declamping, decreasing to 65.2 +/- 2.5 and 60.3 +/- 3.9 mm Hg after 2 and 3 hours, respectively (p < 0.05 versus 1 hour). In the HTK group corresponding values after 1, 2, and 3 hours were low at 47.2 +/- 4.4, 48.4 +/- 4.2, and 50.7 +/- 4.3 mm Hg, respectively (p < 0.025 versus CBC for all). Subendocardial radial peak systolic strain averaged 80.5% +/- 4.8% after declamping in the CBC group versus 53.4% +/- 5.5% in the HTK group (p = 0.002). Serum troponin-T release was lower in the CBC group. CONCLUSIONS: Repeated oxygenated blood cardioplegia provides better myocardial protection and preservation of left ventricular function than a single dose of HTK during the early hours after declamping.

Impact of hypertension on left ventricular hypertrophy regression and exercise capacity in patients operated for aortic valve stenosis.

OBJECTIVES: To assess the influence of concomitant hypertension on left ventricular hypertrophy regression and exercise capacity in patients operated for aortic stenosis. DESIGN: We performed echocardiography 1 week, 6- and 18-month postoperatively in 78 patients, aged 70 (28-86) years, who received Medtronic Hall (33), Biocor (8), Carpentier-Edwards S.A.V. (14) and Freestyle (23) prosthetic valves for severe aortic stenosis. Forty nine patients participated in treadmill tests with ergospirometry at the 6- and 18-month visits. RESULTS: Left ventricular mass index was comparably reduced in normotensive and hypertensive patients (34 vs. 40 g/m2 after 6 months, and 43 vs. 46 g/m2 after 18 months, ns). In multiple regression analysis, adjusting for baseline left ventricular mass index, larger reduction in left ventricular mass index was associated with younger age and having a Freestyle prosthesis, but not with gender or history of hypertension (multiple R2=0.68, p < 0.05). Exercise capacity assessed as peak oxygen uptake increased from early to late evaluation in normotensive patients (VO2max 24.27 vs. 27.08 ml/kg/min, p < 0.05) while remained unchanged in hypertensive patients (VO2max 22.2 vs. 21.1 ml/kg/min). In multiple regression analysis, higher improvement in exercise capacity was predicted by male gender, younger age and absence of hypertension, while no independent association was found with Freestyle prosthesis (multiple R2 = 0.37, p < 0.05). CONCLUSIONS: In patients operated for aortic stenosis, concomitant hypertension is associated with lack of improvement in exercise capacity in spite of early left ventricular hypertrophy reduction comparable to what is found in normotensive patients.

Exercise capacity in young adults with hypertension and systolic blood pressure difference between right arm and leg after repair of coarctation of the aorta.

Coarctation of the aorta represents 5-7% of congenital heart defects. Symptoms and prognosis depend on the degree of stenosis, age at surgery, surgical method and the presence of other heart defects. Postoperative complications are hypertension, restenosis and an abnormal blood pressure response during exercise. This study includes 41 patients, 15-40 years old, operated in the period 1975-1996. All were exercised on a treadmill until maximal oxygen consumption was achieved. Blood pressure was measured in the right arm and leg before and immediately after exercise, and in the right arm during exercise. Oxygen consumption was monitored and we defined an aerobic phase, an isocapnic buffering phase and a hypocapnic hyperventilation phase. The resting systolic blood pressure correlates with the resting systolic blood pressure difference between right arm and leg. A resting systolic blood pressure difference between the right arm and leg of 0.13 kPa (1 mmHg) to 2.67 kPa (20 mmHg) corresponds with a slight increase in resting systolic blood pressure. This rise in blood pressure increases the aerobic phase of the exercise test, helping the patients to achieve higher maximal oxygen consumption. A resting systolic blood pressure difference of more than 2.67 kPa (20 mmHg) corresponds with severe hypertension and causes reduction in the aerobic phase and maximal oxygen consumption. Resting systolic blood pressure and resting systolic blood pressure difference between the right arm and leg are not indicators for blood pressure response during exercise. Exercise testing is important to reveal exercise-induced hypertension and to monitor changes in transition from aerobic to anaerobic exercise and limitation to exercise capacity.

Magnetic resonance imaging of patients with increased blood pressure and altered blood pressure response to exercise after coarctation repair.

OBJECTIVE: Patients successfully operated for coarctation of the aorta are frequently subjected to altered blood pressure (BP) at rest and BP response during exercise. The relationship between these variables and blood flow, peak velocity, restenosis and other morphological features of the thoracic aorta as revealed by magnetic resonance imaging (MRI) was evaluated. DESIGN: Fifty-one patients subjected to coarctectomy of the aorta were examined by MRI. In addition, a control group of 23 healthy volunteers was evaluated. Morphology of the aorta was demonstrated with both ECG-triggered SE imaging and gadolinium-enhanced MR aortography. Flow-weighted MRI was applied for quantitative flow and velocity measurements. RESULTS: Structural alteration of the aorta was more commonly seen in those patients having increased BP at rest or altered BP response during exercise than those with a normal BP profile. The luminal diameter of the narrowest site of the aorta was decreased in all patient groups. Accordingly, the peak velocity at the corresponding site was significantly (p < 0.01) increased. However, blood flow was significantly (p < 0.01) decreased among those patients with normal BP profile compared with the other patient groups as well as the controls. CONCLUSION: Other structural changes than restenosis may contribute as well to the altered BP profile of patients subjected to coarctectomy. Reduced blood flow appears to correlate with normal BP profile, whereas the peak velocity measurements that are obtained by MRI are not able to differentiate between the patient groups. The comprehensive and reliable data obtained by non-invasive techniques, i.e. MRI and Doppler, may replace catheterization when deciding the need for intervention.