Aortic valve repair in endocarditis: scope and results

Purpose

Infective endocarditis (IE) remains a prevalent and life-threatening disease. The choice to repair or replace the infected valve still remains a matter of debate, especially in aortic valve (AV) infections. We retrospectively analyze our two decades of experience in aortic valve repair (AVr) in IE. Long-term outcomes are described with particular attention to the impact of valve configuration and the use of patch techniques.

Methods

From September 1998 to June 2017, 42 patients underwent AVr in a single center for IE. Techniques include leaflet patch repair and resuspension and aortic annulus stabilization.

Results

Hospital mortality was 2.4% (n = 1). The median follow-up was 90.6 months. Survival was 89 ± 9.4% and 76.6 ± 16% at 5 and 10 years, respectively, with no significant differences between tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV). Freedom from reoperation was 100% and 92.9 ± 7.1% in TAV and 81.8 ± 18.2% and 46.8 ± 28.8% in BAV at 5 and 10 years, respectively (TAV vs BAV, p = 0.02). BAV, degree of preoperative aortic insufficiency, and AVr including patch were factors predicting a higher risk of reoperation during the follow-up.

Conclusion

In our experience, AVr is a safe, feasible, and efficient choice in selected patients with healed or active IE. Durability of the repair is excellent in patients with limited lesions and in patients with TAV even with patch repair. Reoperations occurred principally in patients with BAV and severe preoperative AI, in whom patch repair was performed. In those patients, we actually recommend to replace the valve in case of active endocarditis.

Re-repair of the failed mitral valve: insights into aetiology and surgical management

OBJECTIVES

Mitral valve (MV) repair is the gold standard for treatment of degenerative mitral regurgitation. A variety of surgical techniques allow surgeons to achieve a high rate of MV repair even with MV diseases of other aetiologies. However, a certain number of repairs fail over time. The aim of this study was to review our single-centre experience of MV re-repair and analyse the mode of repair failure, re-repair safety and efficiency in relation to the initial aetiology.

METHODS

Between 1997 and 2015, 91 patients underwent redo MV re-repair. The first MV repair was performed in our institution in 59% of cases. Follow-up information was available for 93% of our patients. The median follow-up was 56 months.

RESULTS

The initial aetiology was degenerative disease in 40 (44%) patients, rheumatic disease in 25 (27.5%), endocarditis in 10 (11%), ischaemic in 6 (7%), severe mitral annulus calcification in 5 (5.5%), congenital disease in 4 (4%) and unknown in 1 (1%). The mean age was 58 ± 15 years. The median delay between the 1st and 2nd repair was 49 months with 6 early re-repairs. Re-repair was urgent or emergent in 19% of cases; indications for surgery were mitral regurgitation in 48%, stenosis in 19%, endocarditis in 19%, mitral disease in 11%, ring thrombosis in 2% and systolic anterior motion in 1%. The main mechanisms of failure included technical error (30%), progression of disease (35%), new disease (29%) and unknown (6%.) Re-repair was performed through a median sternotomy in 96% of cases, and 34% of patients had concomitant procedures. Eight (9%) postoperative deaths (4 of mitral annulus calcification, 2 of endocarditis, 1 of degenerative disease, 1 of ischaemia) and 5 (6%) early failures occurred (3 of rheumatic disease, 1 of degenerative disease, 1 of a congenital condition), requiring MV replacement in 4 and new repair in 1. Overall survival at 5 and 10 years was 76% and 57%, 83% and 49% in patients with degenerative diseases and 95% and 95% in patients with rheumatic disease. Overall freedom from reoperation at 5 and 10 years was 82% and 61%, 94% and 87% with degenerative disease and 60% and 45% with rheumatic disease.

CONCLUSIONS

MV re-repair is feasible and has good mid-term results in patients with degenerative MV disease. Rheumatic MV disease is associated with a certain risk of failure over time; nevertheless, these patients show excellent survival after re-repair.

Congenital bicuspid pulmonary valve. An uncommon impede for Ross procedure

We report a case of successful heterograft aortic valve replacement following an impede Ross procedure in a 48-year-old man presenting with a congenital bicuspid pulmonary valve. The patient was admitted for aortic valve stenosis that required an aortic valve replacement (AVR). Owing to his young age and reluctance to long-term anticoagulation therapy, it was decided to do an AVR by pulmonary autograft. During surgery, the anatomical unsuitability of the graft was discovered leading to the procedure's readjustment.

Over 20 years experience with aortic homograft in aortic valve replacement during acute infective endocarditis

OBJECTIVES

Despite the controversy, the aortic homograft is supposedly the best option in acute infective endocarditis (AIE), due to its resistance to reinfection. However, the technical complexity and the risk of structural deterioration over time have limited its utilization. The aim of this study was to evaluate the long-term results of aortic homograft for the treatment of infective endocarditis in our institution with particular attention to predictors of survival and homograft reoperation.

METHODS

The cohort includes 112 patients who underwent aortic valve replacement with an aortic homograft for AIE between January 1990 and December 2014.

RESULTS

Fifteen patients (13.4%) died during the first 30 days after the operation. Two patients were lost to follow-up after discharge from the hospital; therefore, 95 patients were available for long-term analysis. The median duration of follow-up was 7.8 years (IQR 4.7-17.6). Five patients (5.3%) suffered a recurrence of infective endocarditis (1 relapse and 4 new episodes). Sixteen patients (16.8%) were reoperated for structural valve degeneration (SVD; n = 14, 87.5%) or for infection recurrence (n = 2, 12.5%). Freedom from homograft reoperation for infective endocarditis or structural homograft degeneration at 10 and 15 years postoperatively was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively. For patients requiring homograft reoperation, the median interval to reintervention was 11.6 years (IQR 8.3-14.5). Long-term survival was 63.6% (95% CI 52.4-72.8%) and 53.8% (95% CI 40.6-65.3%) at 10 and 15 years, respectively.

CONCLUSIONS

The use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to SVD is significant after one decade especially in young patients. The aortic homograft seems to be ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective process especially in early surgery.

Does Postoperative Cardiac Troponin-I Have Any Prognostic Value in Predicting Midterm Mortality After Congenital Cardiac Surgery?

OBJECTIVES

This study evaluated the prognostic value of postoperative cardiac troponin-I (cTnI) in predicting all-cause mortality up to 3 months after normothermic congenital cardiac surgery.

DESIGN

Prospective observational study.

SETTING

University hospital.

PARTICIPANTS

All children ages 0 to 10 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

cTnI was measured after the induction of anesthesia but before the surgery, at the pediatric intensive care unit arrival, and at 4, 12, and 24 hours postoperatively. Follow-up was extended up to 6 months. Overall, 169 children were analyzed, of whom 165 were survivors and 4 were nonsurvivors. cTnI levels were significantly higher in nonsurvivors only at 24 hours (p = 0.047). Children undergoing surgery with cardiopulmonary bypass (CPB) had significantly higher cTnI concentrations compared with those without CPB (p<0.001). Logistic regression analysis was performed on the 146 children in the CPB group with the following predictive variables: CPB time, postoperative cTnI concentrations, the presence of a cyanotic malformation, and intramyocardial incision. None of the variables predicted mortality. Postoperative cTnI concentrations did not predict 6 months׳ mortality. Only cTnI at 24 hours predicted the length of stay in the pediatric intensive care unit.

CONCLUSIONS

This study did not find that postoperative cTnI concentration predicted midterm mortality after normothermic congenital heart surgery. (ClinicalTrials.gov identifier: NCT01616394).

Long-Term Results of Balloon Valvuloplasty as Primary Treatment for Congenital Aortic Valve Stenosis: a 20-Year Review

In the presence of new surgical techniques, the treatment of congenital valvular aortic stenosis is under debate. We reviewed the results and late outcomes of all 93 patients aged 1 day to 18 years, treated with balloon valvuloplasty (BAV) as first-line therapy for congenital aortic valve stenosis in our center from January 1991 to May 2012. Mean age at procedure time was 2.4 years; 37 patients underwent BAV at age ≤30 days (neonates), 29 patients at age ≥1 month and <1 year (infants), and 27 patients were older than 1 year (children). The invasive BAV peak-to-peak aortic valve gradient (mean 59 ± 22 mmHg) was immediately reduced (mean 24 ± 12 mmHg). The observed diminution of gradient was similar for each age group. Four patients had significant post-BAV AI. Mean follow-up after BAV was 11.4 ± 7 years. The last echo peak aortic gradient was 37 ± 18 mmHg and mean gradient was 23 ± 10 mmHg, and two patients had significant AI. Actuarial survival for the whole cohort was 88.2 and 72.9 % for the neonates. All infants, except one, and all children survived. Sixty-six percent of patients were free from surgery, and 58 % were free from any reintervention, with no difference according to age. Freedom from surgery after BAV at 5, 10, and 20 years, respectively, was 82, 72, and 66 %. Our study confirms that BAV as primary treatment for congenital AS is an efficient and low-risk procedure in infants and children. In neonates, the prognosis is more severe and clearly related to "borderline LV."

The Ross procedure in young adults: over 20 years of experience in our Institution

OBJECTIVES

The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution.

METHODS

All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population.

RESULTS

Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions.

CONCLUSIONS

The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement.

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES

To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease.

METHODS

From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months.

RESULTS

No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred.

CONCLUSIONS

AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium.

Surgery for Primary Cardiac Tumors in Children

Background—

To evaluate indications and results of surgery for primary cardiac tumors in children.

Methods and Results—

Eighty-nine patients aged ≤18 years undergoing surgery for cardiac tumor between 1990 and 2005 from 16 centers were included retrospectively (M/F=41/48; median age 4.3 months, range 1 day to 18 years). Sixty-three patients (68.5%) presented with symptoms. Surgery consisted of complete resection in 62 (69.7%) patients, partial resection in 21 (23.6%), and cardiac transplant in 4 (4.5%). Most frequent histotypes (93.2%) were benign (rhabdomyoma, myxoma, teratoma, fibroma, and hemangioma). Postoperative complications occurred in 29.9%. Early and late mortality were 4.5% each (mean follow-up, 6.3±4.4 years); major adverse events occurred in 28.2% of the patients; 90.7% of patients are in New York Heart Association class I. There were no statistically significant differences in survival, postoperative complications, or adverse events after complete and partial resection in benign tumors other than myxomas. Cardiac transplant was associated significantly with higher mortality rate ( P= 0.006). Overall mortality was associated to malignancy ( P =0.0008), and adverse events during follow-up ( P =0.005).

Conclusions—

Surgery for primary cardiac tumors in children has good early and long-term outcomes, with low recurrence rate. Rhabdomyomas are the most frequent surgical histotypes. Malignant tumors negatively affect early and late survival. Heart transplant is indicated when conservative surgery is not feasible. Lack of recurrence after partial resection of benign cardiac tumors indicates that a less risky tumor debulking is effective for a subset of histotypes such as rhabdomyomas and fibromas.

Preservation of the pulmonary autograft after failure of the Ross procedure

OBJECTIVE

Failure of the pulmonary autograft following the Ross Procedure is mainly due to dilatation and/or cusp prolapse causing insufficiency. We analysed the result of pulmonary autograft valve sparing and repair, using techniques developed for native aortic root and valve.

METHODS

Of a total of 275 patients who underwent Ross operation between 1991 and 2009, 31 needed autograft re-operation. Of the 28 patients re-operated in our centre, 26 (93%) had autograft valve preservation and they represent the study cohort. At the initial Ross procedure, root remplacement technique was performed in 20 patients and autograft inclusion technique was performed in 6. Mean redo interval was 9.3 + or - 3.5 years and mean age at redo was 44 + or - 13 years. Indications for re-operations were neo-aorta dilatation (n=12; 46%), autograft insufficiency (n=4; 15%) and dilatation with autograft insufficiency (n=10; 40%). Neo-aorta dilatation was repaired using valve-sparing root replacement (n=12, 46%) or ascending aorta replacement (n=10; 40%). Cusp prolapse was repaired by commissural re-suspension (n=1), free margin plication (n=10) or re-suspension with polytetrafluoroethylene (PTFE; n=6). Cusp repair was performed in isolation (n=4) or in association with sparing (n=5) or ascending aorta replacement (n=4).

RESULTS

There was no in-hospital mortality. Two patients having undergone isolated cusp repair needed valve replacement for recurrent insufficiency after 5 days and 8 years postoperatively. At follow-up (100% complete, median: 27 months) all patients were alive, in New York Heart Association (NYHA) class I (n=22; 84%) or II (n=4; 16%). No autograft regurgitation was present in nine patients (five sparing and four ascending aorta replacement); grade I insufficiency was present in 11 (six sparing and five ascending aorta replacement), grade 2 in two (one sparing and one isolated cusp repair) and grade 3 in two (one ascending aorta replacement and one isolated cusp repair). At 3 years, overall freedom from autograft insufficiency > or = grade 3 was 80%.

CONCLUSION

Preservation of the pulmonary autograft valve can be safely performed in selected patients. At midterm, repair of neo-aorta dilatation using valve-sparing root replacement or ascending aorta replacement showed acceptable results. In contrast, results of cusp repair for isolated autograft insufficiency were unsatisfactory.

Endovascular treatment of acute aortic isthmic rupture: concerning midterm results

BACKGROUND

We evaluated midterm results of endovascular management of traumatic aortic isthmic ruptures.

METHODS

Between 2001 and 2008, 10 patients (seven males, mean age 38 years) underwent endovascular treatment of an acute aortic rupture. Eight procedures were emergent, with four cases of hemodynamic instability with Glasgow scores of 3, 5, and 7. Associated traumas were severe brain, liver, and pelvic bone injuries. All procedures were performed with transoesophageal echocardiography monitoring. We used two AneuRx and nine Medtronic Talent or Valiant stent grafts.

RESULTS

All patients survived their traumatic isthmic rupture. In nine patients, stent-graft deployment was successful. One patient experienced a distal migration needing a laparotomy and deployment of an additional new thoracic stent graft. The mean intensive care unit stay was 48 hr (range 24-168). The mean hospital stay was 11 days (range 8-43). All patients were controlled clinically and by contrast computed tomography (CT) according to the EUROSTAR protocol. There were no endoleaks, stent graft-related complications, or late deaths during a mean follow-up of 49 months. The control CT showed a lack of apposition of the proximal part of the stent graft at the inner curve of the aortic arch in three patients.

CONCLUSION

The midterm results of endovascular treatment of acute traumatic aortic isthmic rupture are encouraging and compare favorably to the surgical approach. Late follow-up is required to exclude possible stent-graft complications, especially in young patients with angulated aortic arches.

Huge left ventricular aneurysm in a minimally symptomatic 11-year-old boy

An 11-year-old boy presented with mild shortness of breath and tachycardia and was diagnosed with a huge left ventricular aneurysm ruptured in a secondary pseudoaneurysm. This report highlights the complementary use of echocardiography and cardiac magnetic resonance imaging in the preoperative assessment of this anomaly.

Stump pressure and somatosensory evoked potentials for predicting the use of shunt during carotid surgery

The aim of this study is to compare measurement of stump pressure (SP) and somatosensory evoked potentials (SSEP) made during carotid surgery as criteria upon which to base the decision whether or not to use a shunt. We included 288 patients who underwent for carotid surgery under general anaesthesia. We performed 247 endarterectomies with patch closure (85.7%), 25 carotid transsection with reimplantation (8.7%), and 16 carotid bypasses (5.6%). SSEP monitoring showed no modification in 225/288 patients (78.1%), moderate modification in 32/288 patients (11.1%), and severe modification in 31/288 patients (10.8%). Shunt was used if there was moderate or severe SSEP modification in response to carotid clamping, which represents 63 patients in our series. A shunt was used in 47/288 patients (16.3%). In 16 patients, despite SSEP modifications, the shunt was not used because these SSEP modifications occurred only in the last minutes of the procedure just before off clamping the carotid. The mean SP for all patients was 51 mm Hg. In the shunted patients, the mean SP was 33 mm Hg. Variation of SP was correlated with the SSEP modifications. There was just one perioperative stroke in this series (1/288 = 0.3%). We concluded that the threshold of SP below which shunting is indicated in our study was 44 mm Hg with 81% sensibility and 68% specificity.

Reconstructive surgery in active mitral valve endocarditis: feasibility, safety and durability

OBJECTIVE

To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis.

METHOD

Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients.

RESULTS

The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class > or =3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60+/-37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73+/-12% and 69+/-13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93+/-8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89+/-10% and 72+/-24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95+/-5% and 98+/-1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade < or =I, only 11% had grade II on transthoracic echocardiography.

CONCLUSION

Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients

BACKGROUND

The replacement of the diseased aortic valve with a pulmonary autograft has been shown to provide excellent hemodynamic results and to be associated with low morbidity and mortality rates.

METHODS

From 1991 to 2005, 219 patients undergoing the Ross operation were identified. All patients underwent transthoracic echocardiography at discharge and were scheduled for a yearly study thereafter. The echocardiographic study consisted of a morphologic analysis of the pulmonary autograft with measurement of end-systolic diameters at three levels: annulus, sinuses of Valsalva, and origin of the ascending aorta 2 cm above the sinotubular junction. The dynamic analysis evaluated the function of the aortic autograft and the pulmonary homograft. Maximal and mean aortic and pulmonary transvalvular pressure gradients were investigated.

RESULTS

The 30-day mortality was 1.8% (n = 4). Cardiac deaths were not related to the autograft. The 10-year actuarial survival was 95.7% +/- 2.1%. Six patients (2.8%) had grade 2 autograft valve regurgitation. No grade 3 or 4 pulmonary regurgitation was identified. At their most recent follow-up, 28 patients (13.1%) had grade 1 insufficiency of the pulmonary homograft, and 10 patients (4.6%) had a peak transvalvular gradient of 17.9 +/- 10.2 mm Hg.

CONCLUSIONS

Our current experience suggests that replacement of the aortic root with a pulmonary autograft can be safely performed in infants, children, and adults and is associated with low mortality and morbidity rates. It constitutes an elegant alternative to the use of prosthetic valves in the treatment of aortic valve diseases.

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.

Right Ventricular Outflow Tract Reconstruction With Contegra Monocuspid Transannular Patch in Tetralogy of Fallot

BACKGROUND

Pediatric diminutive right ventricular outflow tract (RVOT) reconstruction with homografts or porcine xenografts remains challenging because of limited availability, early degeneration, tissue ingrowth, and child growth. The objective of this study was to assess whether Contegra valved bovine conduit, implanted as monocuspid transannular patch, might be an interesting alternative to overcome these problems.

METHODS

We reconstructed the RVOT of 12 patients with tetralogy of Fallot, by the use of a Contegra conduit, tailored as a monocuspid valved transannular patch. The patients were 4 females and 8 males, with a mean age of 12.8 +/- 15.1 months and a mean weight of 7.2 +/- 1.9 kg. The mean pulmonary artery annulus size was 8.2 +/- 1.6 mm.

RESULTS

The Contegra tissue was suitable for suturing and for reconstruction of even severely hypoplasic RVOT. We did not observe any sign of conduit or valve degeneration during the follow-up of 28.1 +/- 17.1 months. There were no early or late deaths, and no device-related adverse events. A peak transvalvular gradient of 36.5 +/- 4.7 mm Hg was measured by echocardiography in 4 patients postoperatively, and it decreased during the follow-up to 20 +/- 7.6 mm Hg. Pulmonary valve incompetence was grade 3 in 2 patients and grade 4 in 2 patients.

CONCLUSIONS

The Contegra monocuspid transannular patch is widely applicable to RVOT reconstruction with satisfactory midterm results, particularly in patients with small pulmonary annulus. Its main advantage is to reduce the potential risk of supravalvular stenosis due to the narrowing at the distal suture line, as demonstrated when used as conduits, especially in the smaller sizes.

Intensive care outcome of adult patients operated on for congenital heart disease

OBJECTIVE

To describe the ICU outcome and the most frequent complications observed in adult patients operated on for a congenital heart disease.

DESIGN AND SETTING

Retrospective analysis of prospectively collected data and chart review in an adult cardiovascular ICU of a university hospital.

PATIENTS

156 patients older than 15 years with congenital heart disease undergoing cardiac surgery between June 2001 and June 2005.

RESULTS

According to the initial cardiac malformation, patients were divided in four groups with different operative risk based on the Euroscore: those diagnosed bicuspid aortic valve (n = 73) had a score of 5, those with tetralogy of Fallot (n = 33) 5.5, those with simple cardiac defect (n = 26) 3, and those with complex malformations (n = 24) 6. Only two patients (one with tetralogy of Fallot and one with complex malformations) died during the hospitalization (1.2%).

CONCLUSION

Euroscore clearly overestimates the risk of surgery in this population of adults with congenital heart disease. Mortality and morbidity were low in those diagnosed bicuspid aortic valve, tetralogy of Fallot, or simple cardiac defect, justifying early surgery for incipient complications. Patients with complex congenital defect require prolonged ICU stay, sometimes with mechanical cardiac support, but their overall good outcome justifies these efforts.

Replacement of chordae tendineae with polytetrafluoroethylene (PTFE) sutures in mitral valve repair: early and long-term results

BACKGROUND AND AIM OF THE STUDY

A variety of reliable techniques are now available for chordal disease management and repair of the anterior mitral valve leaflet prolapse. The study aim was to review the authors' experience with polytetrafluoroethylene (PTFE), using a standardized technique for length adjustment, and to analyze the long-term results in patients who underwent mitral valve repair.

METHODS

A total of 111 patients (mean age 56.2 +/- 16.1 years) underwent mitral valve repair with PTFE neochordae, in addition to a variety of other surgical procedures. Etiologies were degenerative in 82 patients (73.9%), Barlow disease in 13 (11.7%), rheumatic in 10 (9%), and infection in six (5.4%). Prolapse of the anterior leaflet was present in 78 patients (70.3%), of the posterior leaflet in 15 (13.5%), a bileaflet prolapse was present in 12 (10.8%), and a commissural prolapse in six (5.4%). In all cases the anterior annulus was used as the reference level in order to assess the appropriate length of the PTFE neochordae.

RESULTS

The mean number of PTFE neochordae used was 6 +/- 4 per patient. In-hospital mortality was 1.8% (n = 2); mean follow up was 36.8 +/- 25.6 months (range: 12-94 months). There were no late deaths. At five years postoperatively the patient overall survival was 98.2 +/- 1.8%, freedom from reoperation rate 100%, and freedom from grade 1+ mitral regurgitation rate 97.2 +/- 2.8%. There were no documented thromboembolism or hemorrhagic events.

CONCLUSION

In degenerative and myxomatous mitral valve disease, leaflet prolapse can be successfully repaired by implantation of PTFE neochordae. Both immediate and long-term results proved the versatility, efficiency and durability of this technique.

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.

Repair of Bicuspid Aortic Valves in Patients With Aortic Regurgitation

Background— Bicuspid aortic valve regurgitation can be caused by a defect in the valve itself or by dysfunction of one or more components of the aortic root complex. A successful repair thus requires correction of all aspects of the problem simultaneously. We review our experience addressing both the valve and the aortic root when correcting bicuspid valve regurgitation.

Methods and Results— Between 1996 and 2004, we treated 68 patients for aortic regurgitation. Thirty patients had isolated aortic regurgitation, and 38 had an associated ascending aortic aneurysm. All patients were treated using a standardized and integrated surgical technique, which included resection of the median raphe or leaflet plication, subcommissural annuloplasty, reinforcement of the leaflet free edge, and sinotubular junction plication. In the 38 patients with proximal aortic dilatation, reimplantation or remodeling of the aortic root was performed. Immediate postoperative echocardiography showed grade ≤1 aortic regurgitation in all patients. Three patients nonetheless needed an early re-operation because of recurrent regurgitation. No hospital mortality was observed. At a mean follow-up of 34 months after surgery, all patients were in New York Heart Association (NYHA) class 1 or 2. Two patients needed a re-operation (23 and 92 months, respectively). Echocardiographic follow-up showed no progression of the regurgitation in 58 surviving patients. Four patients progressed to grade 2 regurgitation.

Conclusion— Our data indicate that regurgitant bicuspid aortic valves, whether alone or in association with a proximal aortic dilatation, can be repaired successfully provided that both the valve and the aortic root problems are treated simultaneously.

Intra-operative acute leg ischaemia after free fibula flap harvest for mandible reconstruction

Osteosarcomas of the cranial bones need a large surgical radical resection. The best option to reconstruct mandible defect after resection is the free fibula flap. In our patient an acute ischaemic leg occurred just after the free fibula flap harvest for mandible reconstruction. The abnormal distribution of the calf arteries leads to catastrophic consequences. The peroneal artery could be the main dominant artery of the leg in a small number of patients. We reported an extremely rare case of "peronea magna", described in less than 0.2% of the global population. A careful pre-operative workup of the calf vessels is required in all the patients who need free fibula flap harvest.

Giant Aneurysm of Aortocoronary Saphenous Vein Graft Compressing the Left Pulmonary Artery

This is a case report of a 78-year-old patient with a 7-cm aneurysm of the saphenous vein graft that was used 17 years before to perform a coronary artery bypass grafting on the circumflex artery. CT scan displayed a mass with an internal lumen compressing the left atrium as well as the left pulmonary artery.

Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures

PURPOSE OF REVIEW

Patients with aortic root pathology may benefit from 'valve-conservation' surgery although application of this philosophy is limited by a lack of 'standardized' surgical techniques. A functional classification of aortic root and valvular abnormalities has been developed in 260 patients and correlated with the etiology of the pathologic process and the surgical procedure performed. Early outcome was assessed using hospital records and medium-term follow-up by cardiological review.

RECENT FINDINGS

From January 1995 until March 2001, 260 patients were operated on for aortic root pathology using valve-conserving surgical techniques. Hospital mortality was 2%; intra-operative echocardiography showed residual aortic regurgitation (Grade 1-2) in 11%, none in the remaining patients. Follow-up at a mean of 20 months (87% of patients) showed trivial or Grade 1 aortic regurgitation in 80%.

SUMMARY

Application of a simple functional classification for aortic root pathology and aortic valve disease allows the logical application of 'valve-conserving' surgical procedures with excellent early and medium-term results.

Reoperation for severe right ventricular dilatation after tetralogy of Fallot repair: pulmonary infundibuloplasty should be added to homograft implantation

BACKGROUND AND AIM OF THE STUDY

Right ventricular dilatation observed after tetralogy of Fallot repair regresses after pulmonary valve implantation, unless the dilation is too severe. The presence of an akinetic patch in the right ventricular outflow tract (RVOT), a known factor promoting right ventricular dilatation, may prevent right ventricular recovery after valve implantation. The exclusion of a large akinetic RVOT area during reoperation of patients presenting with severe post-repair right ventricular dilatation was investigated.

METHODS

Eight patients underwent a pulmonary infundibuloplasty between May 2000 and October 2002. Their mean preoperative cardothoracic index was 0.66 +/- 0.08, and preoperative NYHA class II (n = 4), III (n = 3) or IV (n = 1). Three patients were offered heart transplantation but refused. All had severe pulmonary regurgitation and underwent a RVOT valve implantation except one patient who had a previous homograft pulmonary valve insertion. Concomitant procedures were tricuspid ring implantation (n = 3), atrial septal defect closure (n = 2), mitral valve repair (n = 1) and modified right atrial Maze (n = 1).

RESULTS

Median follow up time was 13 months (range: 6 -29 months). One patient suffered a fatal ventricular fibrillation at home. All patients but one were in NYHA class I. After a mean of 5 +/- 3 months, their mean workload capacity rose from 115 +/- 19 W to 155 +/- 62 W, and mean VO2max rose from 16.5 +/- 2 to 18.3 +/- 2 ml/min/kg.

CONCLUSION

Pulmonary infundibuloplasty may be a useful adjunct in reoperation of tetralogy of Fallot patients presenting with severe right ventricular dilatation and large akinetic area of the RVOT.