Minimally invasive mitral valve reconstruction on the fibrillating heart for high-risk patients.

BACKGROUND AND AIM OF THE STUDY: Mitral valve surgery after previous cardiac surgery is technically demanding and risky. In patients after coronary artery bypass grafting (CABG), mitral valve surgery is associated with a high risk of injury to the bypass graft with concomitant myocardial ischemia. An aortic valve prosthesis usually severely impairs access to the mitral valve, so that these patients are often denied surgery. Furthermore, patients with porcelain aorta may be inoperable. METHODS: A series of 10 patients undergoing minimally invasive mitral valve repair via a right-sided anterolateral minithoracotomy without aortic cross-clamping on the fibrillating heart was investigated. Four patients had an aortic valve prosthesis in situ, six patients had undergone previous CABG, and two patients presented with porcelain aorta. RESULTS: Reconstruction was possible in nine patients. Cannulation was performed femorally in three patients, and via the axillary artery in seven patients. No fatalities were observed. One patient required rethoracotomy for bleeding and subsequently developed a right-sided pneumonia, and a second patient experienced lower-limb ischemia. The postoperative course of the other eight patients was uneventful. No patient presented with significant residual mitral insufficiency at control echocardiography. CONCLUSION: Minimally invasive mitral valve reconstruction via a right-sided minithoracotomy represents an attractive surgical option in a high-risk reoperative setting.

Alternative valve-in-root concepts for redo procedures.

Since aortic root reoperations are challenging procedures, alternative lower-risk procedures should be considered in certain cases. Herein are presented two different approaches to high-risk root reoperations. The first patient, a 59-year-old male who had undergone root replacement 11 years previously with an Edwards Prima stentless valve, presented with severe aortic regurgitation and a heavily calcified aortic root. An open implantation of an Edwards Sapien valve was performed via an aortotomy distal to the calcified aortic root. The second patient, a 60-year-old female, underwent transapical implantation of an Edwards Sapien transcatheter valve for stenosis of the aortic valve in an aortic homograft implanted 11 years previously. The long-term durability of these implants has yet to be evaluated.

Neurological outcome of septic cardioembolic stroke after infective endocarditis.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate mortality and neurological outcomes of cardioembolic cerebral stroke in infective endocarditis (IE) patients requiring cardiac surgery. METHODS: A consecutive series of 214 patients undergoing cardiac surgery for IE was followed up for 20 years. In 65 patients (mean age, 52 years), IE was complicated by computed tomography- or magnetic resonance imaging-verified stroke (n=61) or transient ischemic attack (n=4). Perioperative (30-day) and long-term mortality was assessed with regression models adjusting for age. Complete neurological recovery of IE survivors was defined by a modified Rankin score of < or = 1 and a Barthel index of 20 points. RESULTS: Fifty of 61 stroke patients (81.9%) survived surgery. In comparison with nonstroke patients, the age-adjusted perioperative mortality risk was 1.70-fold (95% CI, 0.73 to 3.96, P=0.22) higher and long-term mortality risk was 1.23-fold (95% CI, 0.72 to 2.11, P=0.45) higher in stroke patients. Patients with complicated stroke (meningitis, hemorrhage, or brain abscess) showed a higher perioperative mortality rate (38.9% vs 8.5%, P=0.007) but no higher neurological complication rate than patients with uncomplicated ischemic stroke. Complete neurological recovery was achieved in 35 IE survivors (70%, 95% CI, 55% to 82%). However, in the case of middle cerebral artery stroke, recovery was only 50% and was significantly lower compared with non-middle cerebral artery stroke (P=0.012). CONCLUSIONS: Uncomplicated IE-related stroke showed a favorable prognosis with regard to both long-term survival and neurological recovery. The formidable risk of secondary cerebral hemorrhage due to cardiac surgery seems to be much lower than previously thought.

Combined CMV prophylaxis improves outcome and reduces the risk for bronchiolitis obliterans syndrome (BOS) after lung transplantation.

BACKGROUND: The benefit of cytomegalovirus (CMV) hyperimmune globuline in preventing CMV infection after lung transplantation still remains unclear. The aim of this study was to investigate the effect of combined prophylaxis using ganciclovir (GAN) and CMV hyperimmune globulin (CMV-IG) on CMV infection, CMV disease, survival and its role in preventing Bronchiolitis obliterans syndrome (BOS). METHODS: A consecutive series of 68 CMV high-risk lung transplant recipients (D+/R-, D+/R+), who had a minimum follow-up of 1 year posttransplant were analyzed. Thirty patients (44.1%) received single GAN prophylaxis for 3 months (control group) and 38 recipients (55.9%) received GAN together with CMV-IG 7 times during the first postoperative month (study group). Median follow-up was 16.5 months in the control and 23.8 months in the study group (P = 0.54). RESULTS: Five CMV-related deaths (16.7%) occurred in the control group (P = 0.014). Fifteen recipients suffered from CMV pneumonitis and three patients had CMV syndrome. In the control group, 13 recipients (43.3%) suffered from clinically manifested CMV disease compared to 5 (13.2%) in the study group (P = 0.007). Additionally, recipient survival was significantly better in the study group (P = 0.01). One year freedom from CMV affection was 52.1% in the control and 71.5% in the study group (P = 0.027). Three-year freedom from BOS was significantly higher in the study group (54.3% vs. 82%, P = 0.024). CONCLUSIONS: In CMV high risk patients, additional CMV-IG administration seems to be effective to reduce CMV-related morbidity and to avoid CMV-related mortality. Reduced incidence of BOS may result from improved CMV prevention, although randomized trials are warranted.

Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis.

BACKGROUND: Successful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed. METHODS: Owing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis. RESULTS: None of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis. CONCLUSIONS: The Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined.

Freestyle root replacement for complex destructive aortic valve endocarditis.

OBJECTIVES: In destructive aortic valve endocarditis with abscess formation in the root, homografts are used more often than xenografts. Because we had reliable perioperative results with Freestyle (Medtronic Inc, Minneapolis, Minn) xenograft root replacement in these complex patients, we analyzed the long-term outcome in this high-risk indication. METHODS: Of 126 consecutive patients with aortic valve endocarditis treated by surgery from 1997 to 2012, 32 (25.4%) received a Freestyle aortic root replacement for severe, destructive valve endocarditis and were studied retrospectively with approval of the local ethical committee. Perioperative complications, recurrence of endocarditis, and long-term morbidity and mortality were analyzed. The follow-up period was 3 months to 11.5 years. RESULTS: Indication for surgery was native (n = 9) and prosthetic valve endocarditis (n = 23). In 18 patients, concomitant procedures were performed: coronary bypass (n = 9), additional valve surgery (n = 6), and ascending aortic surgery (n = 7). Thirty-day mortality was 19.4% (n = 6). There were no instances of technical failure requiring modification of the surgical strategy or reoperation for anastomotic bleeding. Actuarial survival at 5 and 10 years was 61.9% and 54.2%, respectively. Freedom from death, reoperation for prostheses dysfunction, and recurrence of endocarditis as the composite end point at 5 and 10 years was 56.3% and 53.1%, respectively. CONCLUSIONS: The Freestyle root was used successfully with no technical complications in all patients with most severe destructive aortic root endocarditis. In view of this complex patient population, short- and long-term results make this conduit a reliable choice for treatment of this condition.

Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis.

BACKGROUND: The aim of this study was to investigate whether transvenous lead removal is safe and effective in patients with lead vegetations greater than 1 cm in size. METHODS: From 1991 to 2005, a total of 53 patients underwent pacemaker or ICD lead removal for vegetations. Transvenous lead removal using locking stylets and sheaths was performed in 30 patients (56.6%) and was found to be effective in 29 of those patients. In 1 patient, due to rupture of the lead, open heart removal of the ventricular lead remnant and tricuspid valve repair had to be performed due to persistent infection. In 23 of these patients, transesophageal echocardiography (TEE) verified vegetations greater than 1 cm in size. The remaining patients underwent primary lead removal using sternotomy and extracorporeal circulation (ECC). Pacemaker pocket infection was found in 16 patients (55.2%) of the transvenous study group and in 11 patients (45.8%) of the ECC group (P = 0.72). RESULTS: Perioperative mortality was 5.7% (3 patients); all of them underwent primary ECC removal and had severe endocarditis of the tricuspid valve. None of the patients who underwent transvenous lead removal died and there were no further complications such as pericardial tamponade or major pulmonary embolism requiring further interventions, even in patients demonstrating large vegetations. CONCLUSIONS: This study demonstrates that transvenous lead removal is a safe and highly effective procedure for the removal of infected pacemaker and ICD leads, even in patients with large vegetations. Embolism to the lung proceeds mainly without further complications; however, patients with vegetations that might obstruct a main stem of the pulmonary artery should undergo ECC removal.

Human metapneumovirus infection in lung transplant recipients: clinical presentation and epidemiology.

BACKGROUND: In immunocompromised patients, respiratory viruses are likely to lead to lower respiratory tract infections that cause severe morbidity and mortality. We conducted a prospective study from September 2003 to March 2004 to investigate the epidemiology and impact of human metapneumovirus (hMPV) on lung transplant recipients. METHODS: We collected 265 nasopharyngeal aspirates and bronchoalveolar lavages: 51 samples originated from immunocompromised adults, 49 from lung transplant recipients, and 2 from a bone marrow recipient. Additionally, 209 samples from hospitalized non-immunocompromised children and 5 samples from immunocompromised children were analyzed for replicating hMPV by a combined cell culture and reverse transcriptase polymerase chain reaction method that includes DNA sequencing of selected isolates. RESULTS: Twelve samples from lung transplant recipients (25%), 29 from non-immunocompromised children (14%), and 2 from a child with a renal transplant were positive for hMPV. Most of the cases clustered within 2 outbreaks in October/November and March. In immunocompromised patients, hMPV was isolated throughout the entire observation period. The same viral strains circulated in hospitalized children and in lung transplant recipients. A different strain was isolated during the interepidemic period, suggesting that hMPV infections may be transmitted among lung transplant recipients independently from the community outbreak situation. Clinical signs and symptoms varied from no symptoms to severe pneumonia or acute graft rejection. Significantly, the only deaths occurred in the hMPV-positive group. Of interest, identification of replicating hMPV significantly correlated with rejection symptoms present at the time point of sample collection. CONCLUSIONS: Results of the study suggest that hMPV may be added to the list of pathogens that are possibly associated with episodes of allograft rejection.