A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) af... more A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) after mitral valve repair; however, predictors and long-term consequences remain unclear.
Objective To evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing eit... more Objective To evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing either valve repair or replacement and to compare them to patients undergoing repair for myxomatous mitral valve disease. Methods We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between 03/17/1960 and 09/12/2011 for mitral regurgitation and performed a subanalysis of those with repairs compared to case-matched patients with myxomatous mitral valve disease who had repairs (03/14/1995-07/05/2013). Results Of 61 consecutive patients, 40 patients underwent mitral repair and 21 underwent mitral replacement (mean [SD] age, 40 [18] vs 31 [19] years; P=.09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P=.87). Ten-year survival was significantly better in Marfan syndrome patients with mitral repair vs replacement (80% vs 41%; P=.01). Mitral reintervention did not differ between mitral re...
The Journal of thoracic and cardiovascular surgery
OBJECTIVES: Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <... more OBJECTIVES: Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe ischemic mitral regurgitation have a poor survival with medical therapy alone. Left ventricular assist device as destination therapy is reserved for patients who are too high risk for conventional surgery. We evaluated our outcomes with conventional surgery within this population and the comparative effectiveness of these 2 therapies. METHODS: We identified patients who underwent conventional surgery or left ventricular assist device as destination therapy for severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe mitral regurgitation. The era for conventional surgery spanned from 1993 to 2009 and from 2007 to 2011 for left ventricular assist device as destination therapy. We compared baseline patient characteristics and outcomes in terms of end-organ function and survival. RESULTS: A total of 88 patients were identified; 55 patients underw...
The Journal of thoracic and cardiovascular surgery
Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performan... more Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performance. We sought to determine whether there are clinically important early differences among these devices. Three hundred adults with severe aortic valve stenosis undergoing aortic valve replacement were randomized to receive the Edwards Magna, Sorin Mitroflow, or St. Jude Epic bioprostheses (n = 100, n = 101, n = 99, respectively). Early hemodynamic performance was studied by echocardiography. Mean patient age was 76 ± 8 years and there were 203 men (68%). There were no significant differences in baseline characteristics among implant groups. Early mortality was 1.7%, and there were no differences in early adverse events. Postoperative echocardiography showed small but statistically significant differences overall between the Magna, Mitroflow, and Epic valves in mean gradient (14.2 mm Hg, 16.3 mm Hg, 16.5 mm Hg, respectively; P = .011), aortic valve area (2.05 cm(2), 1.88 cm(2), 1.86 cm(2)...
Page 1. 167 Ulisses Alexandre Croti1, Lilian Beani2, Domingo Marcolino Braile3, Joseph A Dearani4... more Page 1. 167 Ulisses Alexandre Croti1, Lilian Beani2, Domingo Marcolino Braile3, Joseph A Dearani4 ... The following is the full speech: Speech Friday, September 16, 2011 Good evening, Ladies and gentlemen, friends of Children's HeartLink, its collaborators and volunteers. ...
Operative Techniques in Thoracic and Cardiovascular Surgery
E bstein's anomaly is a congenital malformation of the right ventricle and tricuspid valve th... more E bstein's anomaly is a congenital malformation of the right ventricle and tricuspid valve that is characterized by mul-tiple features that can exhibit an infinite spectrum of malfor-mation. 1 Abnormalities of the tricuspid valve and right ven-tricle include the following: (1) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamina-tion); (2) anterior and apical rotational displacement of the functional annulus (septal posterior anterior leaflet); (3) dilation of the "atrialized" portion of the right ventricle with variable degrees of hypertrophy and thinning of the wall; (4) redundancy, fenestrations, and tethering of the anterior leaf-let; (5) dilation of the right atrioventricular junction (the true tricuspid annulus); and (6) variable ventricular myocardial dysfunction. These anatomical and functional abnormalities cause important tricuspid regurgitation, which results in right atrial and right ventricular dilation and atrial and ven-t...
The Journal of Thoracic and Cardiovascular Surgery, 2015
To determine outcomes of repair of ascending aortic aneurysms in patients with histopathologic di... more To determine outcomes of repair of ascending aortic aneurysms in patients with histopathologic diagnoses of aortitis. We reviewed histopathologic findings and outcomes of elective repair of ascending aortic aneurysms between January 1, 1955, and December 31, 2012. Noninfectious aortitis was identified in 186 patients, and we compared outcomes for these patients with outcomes for others operated on at the same time with diagnoses of medial degeneration (n = 317) or atherosclerosis (n = 232). Early mortality (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 days postoperatively) for patients with aortitis was 2%, and overall 10-year survival was 45%, compared with 66% for patients with medial degeneration, and 45% for patients with atherosclerosis (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001 vs medial degeneration). In addition to histopathologic diagnosis, overall mortality was influenced by older age at operation (hazard ratio [HR]: 1.060; 95% confidence interval [CI], 1.046-1.077; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), chronic obstructive pulmonary disease (HR: 1.560; 95% CI: 1.136-2.136; P = .006); concomitant coronary artery bypass grafting (HR: 1.980; 95% CI: 1.520-2.600; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001); and use of circulatory arrest (HR: 1.500; 95% CI: 1.148-1.960; P = .003). Risk of aortic reoperation at 10 years was 21% for aortitis patients, compared with 11% for those with medial degeneration, and 19% for patients with atherosclerosis (P = .028). Patients with repaired ascending aneurysms secondary to noninfectious aortitis have low early mortality, but late risks of death and aortic reoperation are increased, compared with these outcomes for patients with aneurysms that result from medial degeneration.
Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitrof... more Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitroflow bovine pericardial prosthesis (Sorin Group, Inc) and without anticalcification treatment. Recent reports warn of early senescence in younger adults. From January 2004 through December 2011, 1,003 adults underwent Mitroflow AVR. The mean follow-up time was 25.0 (standard deviation [20.6]) months (total, 2,060 patient-years; maximum, 9 years). The patients were stratified for analysis according to age at implantation: group A, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years (n = 63, 6.3%); group B, 60-69 years (n = 173, 17.2%); group C, 70-79 years (n = 432, 43.1%); and group D, 80 years or older (n = 335, 33.4%). The mean age was 74.8 years (SD 9.8), and 609 patients (60.7%) were men. Aortic valve stenosis was present in 912 patients (90.9%), and 113 (11.3%) had severe aortic regurgitation. There were 27 (2.7%) early deaths, 15 of 431 (3.5%) underwent concomitant coronary artery bypass grafting while 12 of 572 (2.1%) did not (p = 0.18), and 151 patients (15.1%) died during follow-up. Nineteen AVRs (1.9%) required re-replacement through August 2013; 12 (63.2%) were associated with structural valve deterioration. The overall rates of freedom from valve-related reoperation at 3 and 5 years were 98.3% and 93.8%, respectively. Group A had the greatest number of reoperations (6/63; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). The overall survival rates at 1 and 5 years were 91.2% and 67.3%, respectively. Independent predictors of mortality were poorer New York Heart Association functional class (hazard ratio [HR], 2.1; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), atrial fibrillation (HR, 1.8; p = 0.002), and prior cardiac operation (HR, 1.8; p = 0.003). Midterm follow-up shows acceptable hemodynamic performance of the Mitroflow biologic aortic valve prosthesis in selected patients 60 years old and older. Ongoing follow-up will be necessary to understand long-term performance and outcomes.
The Journal of Thoracic and Cardiovascular Surgery, 2015
The impact of prior alcohol septal ablation in patients who require septal myectomy for hypertrop... more The impact of prior alcohol septal ablation in patients who require septal myectomy for hypertrophic obstructive cardiomyopathy is unknown. Thirty-one patients with unsuccessful alcohol septal ablation who underwent septal myectomy were matched 1:2 to patients having had a myectomy as the only invasive procedure for hypertrophic obstructive cardiomyopathy. Study outcomes were cardiac death, advanced heart failure, and appropriate implantable cardioverter defibrillator discharge. The results of surgery, echocardiograms, and pathology specimens were compared between groups. Patients with previous alcohol septal ablation had increased diastolic dysfunction in preoperative echocardiography, as well as more implantable cardioverter defibrillators implanted (32% vs 11%, P = .01), more arrhythmias in preoperative Holter monitoring (43% vs 13%, P = .02), and a higher incidence of postoperative complete heart block (19.4% vs 1.6%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). Two patients died early postoperatively in the prior alcohol septal ablation group, and no patients died in the primary myectomy group. One patient in each group had an implantable cardioverter defibrillator (PÂ =Â .52). At a mean follow-up of 3.2 years, 7 of 31 patients and 6 of 62 patients progressed to advanced heart failure in the prior alcohol septal ablation group and the primary myectomy group, respectively (PÂ =Â .1) Histopathologic analysis demonstrated greater interstitial (70% vs 26%, PÂ &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;Â .01) and endocardial fibrosis (87% vs 67%, PÂ =Â .04) in the alcohol septal ablation group. Patients with prior alcohol septal ablation undergoing surgical septal myectomy may have an increased risk of cardiac death, advanced heart failure, and implantable cardioverter defibrillator discharges. This supports septal myectomy as the preferred treatment for septal reduction therapy, avoiding scarring and diastolic dysfunction inherent to alcohol septal ablation.
Interactive cardiovascular and thoracic surgery, Jan 4, 2015
Open aortic arch surgery after type A dissection repair is challenging. We sought to review our s... more Open aortic arch surgery after type A dissection repair is challenging. We sought to review our surgical experience to analyse the causes and timing, establish the risk profile for this patient population, and better define outcomes. From 2000 to 2014, we identified 55 patients who required aortic arch surgery after a previous type A dissection repair. Medical records were available for review including computerized tomographic angiograms, cerebral protection strategies and follow-up. The mean interval from previous type A dissection repair to aortic arch surgery was 5.7 ± 5.4 years. At reoperation 36 patients (65%) had total arch replacement and 19 (35%) had hemiarch replacement. Indications for reoperations were: enlarging aneurysm in 27 (49%), impending rupture in 12 (22%), chronic dissection in 10 (18%) and aneurysms in 6 (11%). Arterial peripheral cannulation was used in 80% of patients. Selective antegrade cerebral perfusion was used in 35 patients (64%) and retrograde perfusi...
Improvement in surgical techniques, anesthesia, and perioperative care has resulted in the majori... more Improvement in surgical techniques, anesthesia, and perioperative care has resulted in the majority of children born with congenital heart defects surviving into adulthood with a normal or near-normal quality of life. A careful transition from pediatric to adult care providers is important to avoid issues related to loss of continuity of care and any undue financial or psychological burdens to the patients and their families. The patients, their families, and the health care providers are faced with many challenges during this transition process that can be optimized and overcome by education about the heart defects and a team approach with clear lines of communication. This review addresses the challenges related to the transition of care from pediatrics to adults and provides the necessary recommendations to ensure a smooth transition process.
Current treatment options in cardiovascular medicine, 2009
Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure ... more Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure of delamination of the tricuspid valve leaflets from the underlying endocardium, leading to severe tricuspid valve regurgitation and some degree of right ventricular dysfunction. In neonates or infants who remain in congestive heart failure or profoundly cyanotic while receiving appropriate medical therapy, operation is required. Current strategies include biventricular or single-ventricle repair. In children and adults, medical management may be used, but most patients eventually require surgery. Tricuspid valve repair is preferred; we believe the cone repair is the most anatomic repair and is the operation of choice. Tricuspid valve replacement may be necessary in cases in which the valve is not repairable. A bidirectional cavopulmonary shunt is useful in patients with severe right ventricular dilatation and/or dysfunction. Transplantation rarely is necessary.
The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are ... more The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are controversial. Herein are reported the results and trends of this surgical approach over the past 24-year period. Patients were identified in refractory heart failure due to ICM with NYHA functional class III/IV symptoms, left ventricular ejection fraction < or =35% and MR who underwent mitral surgery between 1979 and 2002. The early and late outcomes were analyzed and compared for the different surgical eras classified as early (1979 to 1986), middle (1987 to 1994), and late (1995 to 2002). Mitral repair (70%) and replacement (30%) were performed with coronary artery bypass grafting (CABG) (85%) and tricuspid valve repair (7%) in 179 patients (mean age 68 +/- 9 years). The overall one- and five-year survival rates were 84% and 51%, respectively, and the corresponding freedom from recurrent MR after repair 86% and 55%. An increasing number of patients underwent surgery from the early ...
Current treatment options in cardiovascular medicine, 2005
In the current era of superb surgical results for congenital heart disease, several management op... more In the current era of superb surgical results for congenital heart disease, several management options are available for patients born with double outlet right ventricle (DORV). The surgical repair of DORV is tailored to address the variety of abnormalities associated with this lesion. The treatment strategies are dependent upon the anatomy and relationship of the ventricular septal defect (VSD) and the great arteries. For patients with subaortic or doubly committed VSDs, without right ventricular outflow tract obstruction, the usual repair is an intraventricular tunnel from the VSD to the aorta. If right ventricular outflow tract obstruction exists, then augmentation of the right ventricular outflow tract or conduit placement from the right ventricle to the pulmonary artery is necessary. For the "Taussig-Bing anomaly" (subpulmonary VSD) an arterial switch operation is indicated with tunneling of the VSD to the neoaorta. For patients with a remote VSD, complex atrioventric...
To review the outcome of cardiac transplantation undertaken in patients with congenital heart def... more To review the outcome of cardiac transplantation undertaken in patients with congenital heart defects. Between November 1991 and March 1998 at our institution, cardiac transplantation was performed in 16 patients with congenital heart disease (age range, 3 to 57 years; mean, 26.1). Preoperative diagnoses included univentricular heart (N = 4); complete transposition of the great arteries (N = 3); Ebstein's anomaly (N = 2); tetralogy of Fallot (N = 2); levotransposition (N = 2); dextrocardia, corrected transposition, ventricular and atrial septal defects, and pulmonary stenosis (N = 1); double-outlet right ventricle (N = 1); and hypertrophic obstructive cardiomyopathy (N = 1). All patients had undergone from one to five previous palliative operations. Four patients required permanent pacemaker implantation during the first month postoperatively because of bradycardia; more than 2 years later, another patient required a permanent pacemaker because of sick sinus syndrome. In additio...
Background. Left-sided partial anomalous pulmonary venous connection (PAPVC) is a congenital defe... more Background. Left-sided partial anomalous pulmonary venous connection (PAPVC) is a congenital defect where pulmonary veins from the left lung drain into the right atrium. If left untreated, PAPVC may result in severe right ventricular failure and pulmonary vascular disease. We sought to determine the effectiveness and long-term outcome after surgical correction of this anomaly. Methods. From 1954 to 2006, 376
A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) af... more A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) after mitral valve repair; however, predictors and long-term consequences remain unclear.
Objective To evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing eit... more Objective To evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing either valve repair or replacement and to compare them to patients undergoing repair for myxomatous mitral valve disease. Methods We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between 03/17/1960 and 09/12/2011 for mitral regurgitation and performed a subanalysis of those with repairs compared to case-matched patients with myxomatous mitral valve disease who had repairs (03/14/1995-07/05/2013). Results Of 61 consecutive patients, 40 patients underwent mitral repair and 21 underwent mitral replacement (mean [SD] age, 40 [18] vs 31 [19] years; P=.09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P=.87). Ten-year survival was significantly better in Marfan syndrome patients with mitral repair vs replacement (80% vs 41%; P=.01). Mitral reintervention did not differ between mitral re...
The Journal of thoracic and cardiovascular surgery
OBJECTIVES: Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <... more OBJECTIVES: Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe ischemic mitral regurgitation have a poor survival with medical therapy alone. Left ventricular assist device as destination therapy is reserved for patients who are too high risk for conventional surgery. We evaluated our outcomes with conventional surgery within this population and the comparative effectiveness of these 2 therapies. METHODS: We identified patients who underwent conventional surgery or left ventricular assist device as destination therapy for severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe mitral regurgitation. The era for conventional surgery spanned from 1993 to 2009 and from 2007 to 2011 for left ventricular assist device as destination therapy. We compared baseline patient characteristics and outcomes in terms of end-organ function and survival. RESULTS: A total of 88 patients were identified; 55 patients underw...
The Journal of thoracic and cardiovascular surgery
Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performan... more Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performance. We sought to determine whether there are clinically important early differences among these devices. Three hundred adults with severe aortic valve stenosis undergoing aortic valve replacement were randomized to receive the Edwards Magna, Sorin Mitroflow, or St. Jude Epic bioprostheses (n = 100, n = 101, n = 99, respectively). Early hemodynamic performance was studied by echocardiography. Mean patient age was 76 ± 8 years and there were 203 men (68%). There were no significant differences in baseline characteristics among implant groups. Early mortality was 1.7%, and there were no differences in early adverse events. Postoperative echocardiography showed small but statistically significant differences overall between the Magna, Mitroflow, and Epic valves in mean gradient (14.2 mm Hg, 16.3 mm Hg, 16.5 mm Hg, respectively; P = .011), aortic valve area (2.05 cm(2), 1.88 cm(2), 1.86 cm(2)...
Page 1. 167 Ulisses Alexandre Croti1, Lilian Beani2, Domingo Marcolino Braile3, Joseph A Dearani4... more Page 1. 167 Ulisses Alexandre Croti1, Lilian Beani2, Domingo Marcolino Braile3, Joseph A Dearani4 ... The following is the full speech: Speech Friday, September 16, 2011 Good evening, Ladies and gentlemen, friends of Children's HeartLink, its collaborators and volunteers. ...
Operative Techniques in Thoracic and Cardiovascular Surgery
E bstein's anomaly is a congenital malformation of the right ventricle and tricuspid valve th... more E bstein's anomaly is a congenital malformation of the right ventricle and tricuspid valve that is characterized by mul-tiple features that can exhibit an infinite spectrum of malfor-mation. 1 Abnormalities of the tricuspid valve and right ven-tricle include the following: (1) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamina-tion); (2) anterior and apical rotational displacement of the functional annulus (septal posterior anterior leaflet); (3) dilation of the "atrialized" portion of the right ventricle with variable degrees of hypertrophy and thinning of the wall; (4) redundancy, fenestrations, and tethering of the anterior leaf-let; (5) dilation of the right atrioventricular junction (the true tricuspid annulus); and (6) variable ventricular myocardial dysfunction. These anatomical and functional abnormalities cause important tricuspid regurgitation, which results in right atrial and right ventricular dilation and atrial and ven-t...
The Journal of Thoracic and Cardiovascular Surgery, 2015
To determine outcomes of repair of ascending aortic aneurysms in patients with histopathologic di... more To determine outcomes of repair of ascending aortic aneurysms in patients with histopathologic diagnoses of aortitis. We reviewed histopathologic findings and outcomes of elective repair of ascending aortic aneurysms between January 1, 1955, and December 31, 2012. Noninfectious aortitis was identified in 186 patients, and we compared outcomes for these patients with outcomes for others operated on at the same time with diagnoses of medial degeneration (n = 317) or atherosclerosis (n = 232). Early mortality (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 days postoperatively) for patients with aortitis was 2%, and overall 10-year survival was 45%, compared with 66% for patients with medial degeneration, and 45% for patients with atherosclerosis (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001 vs medial degeneration). In addition to histopathologic diagnosis, overall mortality was influenced by older age at operation (hazard ratio [HR]: 1.060; 95% confidence interval [CI], 1.046-1.077; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), chronic obstructive pulmonary disease (HR: 1.560; 95% CI: 1.136-2.136; P = .006); concomitant coronary artery bypass grafting (HR: 1.980; 95% CI: 1.520-2.600; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001); and use of circulatory arrest (HR: 1.500; 95% CI: 1.148-1.960; P = .003). Risk of aortic reoperation at 10 years was 21% for aortitis patients, compared with 11% for those with medial degeneration, and 19% for patients with atherosclerosis (P = .028). Patients with repaired ascending aneurysms secondary to noninfectious aortitis have low early mortality, but late risks of death and aortic reoperation are increased, compared with these outcomes for patients with aneurysms that result from medial degeneration.
Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitrof... more Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitroflow bovine pericardial prosthesis (Sorin Group, Inc) and without anticalcification treatment. Recent reports warn of early senescence in younger adults. From January 2004 through December 2011, 1,003 adults underwent Mitroflow AVR. The mean follow-up time was 25.0 (standard deviation [20.6]) months (total, 2,060 patient-years; maximum, 9 years). The patients were stratified for analysis according to age at implantation: group A, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years (n = 63, 6.3%); group B, 60-69 years (n = 173, 17.2%); group C, 70-79 years (n = 432, 43.1%); and group D, 80 years or older (n = 335, 33.4%). The mean age was 74.8 years (SD 9.8), and 609 patients (60.7%) were men. Aortic valve stenosis was present in 912 patients (90.9%), and 113 (11.3%) had severe aortic regurgitation. There were 27 (2.7%) early deaths, 15 of 431 (3.5%) underwent concomitant coronary artery bypass grafting while 12 of 572 (2.1%) did not (p = 0.18), and 151 patients (15.1%) died during follow-up. Nineteen AVRs (1.9%) required re-replacement through August 2013; 12 (63.2%) were associated with structural valve deterioration. The overall rates of freedom from valve-related reoperation at 3 and 5 years were 98.3% and 93.8%, respectively. Group A had the greatest number of reoperations (6/63; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). The overall survival rates at 1 and 5 years were 91.2% and 67.3%, respectively. Independent predictors of mortality were poorer New York Heart Association functional class (hazard ratio [HR], 2.1; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), atrial fibrillation (HR, 1.8; p = 0.002), and prior cardiac operation (HR, 1.8; p = 0.003). Midterm follow-up shows acceptable hemodynamic performance of the Mitroflow biologic aortic valve prosthesis in selected patients 60 years old and older. Ongoing follow-up will be necessary to understand long-term performance and outcomes.
The Journal of Thoracic and Cardiovascular Surgery, 2015
The impact of prior alcohol septal ablation in patients who require septal myectomy for hypertrop... more The impact of prior alcohol septal ablation in patients who require septal myectomy for hypertrophic obstructive cardiomyopathy is unknown. Thirty-one patients with unsuccessful alcohol septal ablation who underwent septal myectomy were matched 1:2 to patients having had a myectomy as the only invasive procedure for hypertrophic obstructive cardiomyopathy. Study outcomes were cardiac death, advanced heart failure, and appropriate implantable cardioverter defibrillator discharge. The results of surgery, echocardiograms, and pathology specimens were compared between groups. Patients with previous alcohol septal ablation had increased diastolic dysfunction in preoperative echocardiography, as well as more implantable cardioverter defibrillators implanted (32% vs 11%, P = .01), more arrhythmias in preoperative Holter monitoring (43% vs 13%, P = .02), and a higher incidence of postoperative complete heart block (19.4% vs 1.6%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). Two patients died early postoperatively in the prior alcohol septal ablation group, and no patients died in the primary myectomy group. One patient in each group had an implantable cardioverter defibrillator (PÂ =Â .52). At a mean follow-up of 3.2 years, 7 of 31 patients and 6 of 62 patients progressed to advanced heart failure in the prior alcohol septal ablation group and the primary myectomy group, respectively (PÂ =Â .1) Histopathologic analysis demonstrated greater interstitial (70% vs 26%, PÂ &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;Â .01) and endocardial fibrosis (87% vs 67%, PÂ =Â .04) in the alcohol septal ablation group. Patients with prior alcohol septal ablation undergoing surgical septal myectomy may have an increased risk of cardiac death, advanced heart failure, and implantable cardioverter defibrillator discharges. This supports septal myectomy as the preferred treatment for septal reduction therapy, avoiding scarring and diastolic dysfunction inherent to alcohol septal ablation.
Interactive cardiovascular and thoracic surgery, Jan 4, 2015
Open aortic arch surgery after type A dissection repair is challenging. We sought to review our s... more Open aortic arch surgery after type A dissection repair is challenging. We sought to review our surgical experience to analyse the causes and timing, establish the risk profile for this patient population, and better define outcomes. From 2000 to 2014, we identified 55 patients who required aortic arch surgery after a previous type A dissection repair. Medical records were available for review including computerized tomographic angiograms, cerebral protection strategies and follow-up. The mean interval from previous type A dissection repair to aortic arch surgery was 5.7 ± 5.4 years. At reoperation 36 patients (65%) had total arch replacement and 19 (35%) had hemiarch replacement. Indications for reoperations were: enlarging aneurysm in 27 (49%), impending rupture in 12 (22%), chronic dissection in 10 (18%) and aneurysms in 6 (11%). Arterial peripheral cannulation was used in 80% of patients. Selective antegrade cerebral perfusion was used in 35 patients (64%) and retrograde perfusi...
Improvement in surgical techniques, anesthesia, and perioperative care has resulted in the majori... more Improvement in surgical techniques, anesthesia, and perioperative care has resulted in the majority of children born with congenital heart defects surviving into adulthood with a normal or near-normal quality of life. A careful transition from pediatric to adult care providers is important to avoid issues related to loss of continuity of care and any undue financial or psychological burdens to the patients and their families. The patients, their families, and the health care providers are faced with many challenges during this transition process that can be optimized and overcome by education about the heart defects and a team approach with clear lines of communication. This review addresses the challenges related to the transition of care from pediatrics to adults and provides the necessary recommendations to ensure a smooth transition process.
Current treatment options in cardiovascular medicine, 2009
Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure ... more Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure of delamination of the tricuspid valve leaflets from the underlying endocardium, leading to severe tricuspid valve regurgitation and some degree of right ventricular dysfunction. In neonates or infants who remain in congestive heart failure or profoundly cyanotic while receiving appropriate medical therapy, operation is required. Current strategies include biventricular or single-ventricle repair. In children and adults, medical management may be used, but most patients eventually require surgery. Tricuspid valve repair is preferred; we believe the cone repair is the most anatomic repair and is the operation of choice. Tricuspid valve replacement may be necessary in cases in which the valve is not repairable. A bidirectional cavopulmonary shunt is useful in patients with severe right ventricular dilatation and/or dysfunction. Transplantation rarely is necessary.
The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are ... more The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are controversial. Herein are reported the results and trends of this surgical approach over the past 24-year period. Patients were identified in refractory heart failure due to ICM with NYHA functional class III/IV symptoms, left ventricular ejection fraction < or =35% and MR who underwent mitral surgery between 1979 and 2002. The early and late outcomes were analyzed and compared for the different surgical eras classified as early (1979 to 1986), middle (1987 to 1994), and late (1995 to 2002). Mitral repair (70%) and replacement (30%) were performed with coronary artery bypass grafting (CABG) (85%) and tricuspid valve repair (7%) in 179 patients (mean age 68 +/- 9 years). The overall one- and five-year survival rates were 84% and 51%, respectively, and the corresponding freedom from recurrent MR after repair 86% and 55%. An increasing number of patients underwent surgery from the early ...
Current treatment options in cardiovascular medicine, 2005
In the current era of superb surgical results for congenital heart disease, several management op... more In the current era of superb surgical results for congenital heart disease, several management options are available for patients born with double outlet right ventricle (DORV). The surgical repair of DORV is tailored to address the variety of abnormalities associated with this lesion. The treatment strategies are dependent upon the anatomy and relationship of the ventricular septal defect (VSD) and the great arteries. For patients with subaortic or doubly committed VSDs, without right ventricular outflow tract obstruction, the usual repair is an intraventricular tunnel from the VSD to the aorta. If right ventricular outflow tract obstruction exists, then augmentation of the right ventricular outflow tract or conduit placement from the right ventricle to the pulmonary artery is necessary. For the "Taussig-Bing anomaly" (subpulmonary VSD) an arterial switch operation is indicated with tunneling of the VSD to the neoaorta. For patients with a remote VSD, complex atrioventric...
To review the outcome of cardiac transplantation undertaken in patients with congenital heart def... more To review the outcome of cardiac transplantation undertaken in patients with congenital heart defects. Between November 1991 and March 1998 at our institution, cardiac transplantation was performed in 16 patients with congenital heart disease (age range, 3 to 57 years; mean, 26.1). Preoperative diagnoses included univentricular heart (N = 4); complete transposition of the great arteries (N = 3); Ebstein's anomaly (N = 2); tetralogy of Fallot (N = 2); levotransposition (N = 2); dextrocardia, corrected transposition, ventricular and atrial septal defects, and pulmonary stenosis (N = 1); double-outlet right ventricle (N = 1); and hypertrophic obstructive cardiomyopathy (N = 1). All patients had undergone from one to five previous palliative operations. Four patients required permanent pacemaker implantation during the first month postoperatively because of bradycardia; more than 2 years later, another patient required a permanent pacemaker because of sick sinus syndrome. In additio...
Background. Left-sided partial anomalous pulmonary venous connection (PAPVC) is a congenital defe... more Background. Left-sided partial anomalous pulmonary venous connection (PAPVC) is a congenital defect where pulmonary veins from the left lung drain into the right atrium. If left untreated, PAPVC may result in severe right ventricular failure and pulmonary vascular disease. We sought to determine the effectiveness and long-term outcome after surgical correction of this anomaly. Methods. From 1954 to 2006, 376
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