Aortic root abscess and secondary infective mitral valve disease: results of surgical endocarditis treatment.

OBJECTIVE: Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women. METHODS: Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality. RESULTS: In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV. CONCLUSIONS: Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.     

Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess

BACKGROUND: The valve substitute of choice in active infective aortic valve endocarditis complicated by annulus abscess in our institution is the cryopreserved homograft. To avoid implantation of any prosthetic material, the Shelhigh No-React stentless valves and conduits may be considered an alternative when no suitable homograft is available. METHODS: Between March 1986 and January 2001, 452 homografts were implanted in the aortic position. From January 2000 to August 2001, 75 Shelhigh No-React prostheses were implanted at our institution. In 25 consecutive patients (study group) with aortic annulus abscess, urgent aortic valve replacement with the Shelhigh SuperStentless and Stentless Aortic Valve Conduit was undertaken. Patients (16 male, 9 female; age, 49 +/- 19 years) were studied with follow-up until March 2002. The control group comprised 68 consecutive historical patients (46 male, 22 female; age, 53 +/- 14.4 years) with similar disease treated between January 1997 and December 1999 in whom an aortic homograft was implanted. This group was also followed up until March 2002. Demographic data and preoperative characteristics of the patients were without significant differences. Patients were studied by echocardiography. RESULTS: Sixty-day mortality was 16% (11 patients) in the control group compared with 12% (3 patients) in the study group. Recurrent infection occurred in 4% in both groups. The instantaneous and mean Doppler gradients yielded no significant differences (19.4 +/- 10.4 mm Hg and 11.8 +/- 5.7 mm Hg versus 18.2 +/- 8.7 mm Hg and 10.9 +/- 5.3 mm Hg, respectively). The mean effective orifice area calculated from Doppler flow velocity for the stentless valve was 2.3 +/- 0.6 cm2. Preoperative evaluation of left ventricular dimensions and global left ventricular systolic function did not vary significantly between the two groups. However, postoperatively evaluated left ventricular end-diastolic diameter dimensions in the study group were significantly smaller than those in the control group (47.6 +/- 7.9 mm versus 56 +/- 9.5 mm; p = 0.05). Ejection fraction was similar in both groups (56.2% +/- 12.8% for the study [Shelhigh] and 52.6% +/- 16.8% for the control [homograft] group). CONCLUSIONS: Our experience with both the Shelhigh No-React SuperStentless and Stentless Aortic Valve Conduit in patients with native or prosthetic aortic valve endocarditis appears to demonstrate good results, similar to those of cryopreserved homografts. Ease of implantation and favorable effective orifice area and pressure gradients, as well as the No-React anticalcification treatment, are promising factors.     

Does conservative surgical approach improve early and late outcome in patients with acute type A aortic dissection?

OBJECTIVE: Acute type A aortic dissection (AAAD) represents an emergency in cardiac surgery that requires immediate treatment to prevent death due to its fatal complications. The surgical approach is dependent on the involvement of AAAD. METHODS: Sixty-one patients were operated for AAAD at our clinic. 48 (78.7%) were male and 13 (21.3%) were female with a mean age of 51+/-12.3 yr (range, 21-80 yr). Only the ascending aorta was replaced in 33 (54.1%) patients (Group I) and aortic arch replacement was included in 28 (45.9%) patients (Group II). The aortic valve was preserved in 43 (70.5%) patients (Group A) and replaced in 18 (29.5%) patients (Group B). RESULTS: Early mortality rate was 23% (14/61). Multivariate analysis revealed that previous cardiac operations (P=0.048), renal complications (P=0.024), pump time (P=0.024), and cardiac complications (P=0.017) were significantly factors increasing early mortality. Late mortality rate was 8.5% (4/47) and multivariate analysis revealed that pulmonary complication (P=0.015) was the only statistically significant independent risk factor. Arch replacement or aortic valve replacement was not a predictor for early or late mortality. Cumulative survival was 73.8+/-5.63% at 1 yr and 68.3+/-6.46% at 7.5 yr. Cumulative survival was not different between groups (P>0.05). CONCLUSIONS: Both radical and conservative surgical approaches in AAAD do not differ in mean of early or late results. Surgery before development of hemodynamic instability and prevention of other system complications improves the outcome of surgical treatment in AAAD.     

Early hemodynamic results of the Shelhigh SuperStentless aortic bioprostheses

BACKGROUND: Stentless valves have been demonstrated excellent hemodynamic performances favoring the recovery of left ventricular function and the ventricular hypertrophy regression. The aim of the study was to evaluate the early hemodynamic performance of the Shelhigh SuperStentless aortic valve (AV). METHODS: Between July 2003 and June 2005, 35 patients (18 females; age 70.8 +/- 11.7 years, range: 22-85) underwent AV replacement with the Shelhigh SuperStentless bioprostheses. Most recurrent etiology was senile degeneration in 25 (71%) patients and 24 (69%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant coronary artery bypass grafting was performed in nine patients (25.7%) and mitral valve surgery in two patients (5.7%). Doppler echocardiography was performed before surgery, at six-month and one-year follow-up. RESULTS: There were no hospital deaths and no valve-related perioperative complications. During one-year follow-up, no endocarditis or thromboembolic events were registered, no cases of structural dysfunction or valve thrombosis were noted. Mean and peak transvalvular gradients significantly decrease after AV replacement, with an evident reduction to approximately 50% of the preoperative values at six months. A 20% reduction was also observed for left ventricular mass (LVM) index at six months, with a further regression at one year. Correspondingly, significant increases in effective orifice area (EOA) and indexed EOA were determined after surgery (0.87 +/- 0.14 versus 1.84 +/- 0.29 cm2 and 0.54 +/- 0.19 versus 1.05 +/- 0.20 cm2/m2, respectively). Valve prosthesis-patient mismatch was moderate in five patients and severe in one case. CONCLUSIONS: Shelhigh SuperStentless AV provided good and encouraging hemodynamic results. Long-term follow-up is necessary to evaluate late hemodynamic performance and durability of this stentless bioprosthesis.     

Heart valve operations in patients with active infective endocarditis

Sixty-two consecutive patients underwent heart valve operation for active infective endocarditis. There were 42 men and 20 women whose mean age was 49 years (range, 21 to 79 years). The infection was in the aortic valve in 37 patients, the mitral valve in 18, the aortic and mitral valves in 5, and the tricuspid valve in 2. Twenty-four patients had prosthetic valve endocarditis. Staphylococcus and Streptococcus were responsible for 86% of the infections. Annular abscess was encountered in 33 patients. Complex valve procedures involving reconstruction of the left ventricular inflow or outflow tract or both were performed in 31 patients. There were three operative deaths (4.8%). Predictors of operative mortality were prosthetic valve endocarditis, preoperative shock, and annular abscess. Patients were followed for 1 month to 130 months (mean follow-up, 43 months). Only 1 patient required reoperation for persistent infection. There were ten late deaths. Most survivors (96%) are currently in New York Heart Association class I or II. The 5-year actuarial survival was 79% +/- 7%. These data demonstrate excellent results in patients with native valve endocarditis, and support the premise that patients with prosthetic valve endocarditis should have early surgical intervention.     

Redo aortic root replacement: experience with 31 patients

BACKGROUND: Aortic root re-replacement is being performed with increased frequency. Limited information is available regarding the surgical approaches and clinical outcomes of this reoperation. METHODS: Between May 1980 and May 1999, 31 patients (mean age, 45 +/- 15 years) underwent redo composite replacement of the aortic valve and ascending aorta. Indications for reoperation were prosthetic valve endocarditis in 12 patients (39%), failed biological valve in 17 (55%), and false aneurysm in 2 (6%). At reoperation, mechanical valves were implanted in 24 patients and biologic valves in 7. All patients with endocarditis had annular abscess and required reconstruction of the left ventricular outflow tract before implantation of a new valved conduit. Mechanical valves were used in 24 patients, aortic homograft in 4, and bioprosthetic valves in 3. The coronary button technique was used to reimplant the coronary arteries whenever possible. Extension of one or both coronary arteries with a short segment of saphenous vein or a synthetic graft was used in 16 patients (52%). The aortic arch was replaced in 7 patients (23%). RESULTS: There was one operative death (3%) because of rupture of an abdominal aortic aneurysm. The mean follow-up was 47 +/- 46 months and was 100% complete. There were five late deaths (16%), three of which were cardiac related. The actuarial survival was 71% +/- 12% at 5 years. Three patients experienced recurrent prosthetic valve endocarditis 4 months to 8 years after operation. The 8-year freedom from endocarditis for patients operated on for endocarditis was 82% +/- 11% compared with 100% for those operated on for other reasons (p = 0.1). At the last follow-up, 21 of 25 survivors (84%) were in New York Heart Association functional classes I or II, and 4 were in class III. CONCLUSIONS: Redo aortic root replacement can be performed with good early and late results. Patients operated on for prosthetic root endocarditis may have an increased risk of recurrent late endocarditis.     

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.     

Mitral valvuloplasty, a better alternative. Comparative study between valve reconstruction and replacement for rheumatic mitral valve disease

Valvuloplasty is now a well accepted alternative method of surgical treatment of mitral valve disease. To analyse its relative performance in rheumatic valvulopathies, three groups of patients who had mitral valvuloplasty (1980-1984; 241 patients) or mitral valve replacement with mechanical (1980-1984; 386 patients) or biological prostheses (1976-1980; 289 patients) were reviewed. The early mortality was 3.3% for valvuloplasty, 7.8% for mechanical valve replacement and 6.6% for bioprostheses (P less than 0.05). Late mortality occurred at the rate of 2.6% per patient year (15 patients) for valvuloplasty, 5.7% per patient year (70 patients) for mechanical valves and 7.4% per patient year (41 patients) for bioprostheses (P less than 0.01), but valve-related mortality was 1.0% per patient year, 2.5% per patient year and 4.2% per patient year, respectively (P less than 0.01). Reoperation was more frequent after valve replacement with bioprostheses (6.7% per patient year) than after valvuloplasty (4.3% per patient year) and after mechanical valve replacement (1.5% per patient year; P less than 0.02), and was necessitated mainly by residual or recurrent valve dysfunction after valvuloplasty, bland or infected periprosthetic leaks in mechanical valves and degradation of bioprostheses. Valve failure occurred at the rate of 6.1% per patient year for valvuloplasty, 5.7% per patient year for mechanical valves and 11.1% per patient year for bioprostheses (P less than 0.05). In actuarial terms, global survival and survival free from valve related complications were 90% +/- 4% and 70% +/- 6% for patients who had valvuloplasty, 76% +/- 3% and 71% +/- 5% for the mechanical prosthetic replacement group and 62% +/- 7% and 30% +/- 7% for bioprosthetic valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long term results of cardiac valve replacement in patients aged 75 years and older.

From June 1978 to December 1989, 158 patients over 75 years of age (mean: 78 years; range 75 to 86 years) underwent 164 valve replacements: 134 in the aortic, 18 in the mitral and 6 in double mitral and aortic positions. One hundred and seven of these valves (66%) were bioprostheses, 93 aortic and 14 mitral and 57 valves (34%) were mechanical prostheses; 47 aortic and 10 mitral. Hospital mortality (less than or equal to 30 days) was 7% (11 patients, all in NYHA class III or IV) but was higher in patients who had undergone associated procedures (9.8%; 6/61 patients) or in patients who had mitral valve replacements (11%) and in double valve replacement (16.6%). Because of a minimal delay of one year, long term follow-up information (100%) was only obtained from the first 110 patients discharged from hospital. Late mortality has been 13.6% and actuarial survival at 11 years was 71.5% +/- 5. Therefore, despite a hospital mortality of more than twice that of patients operated upon under 75 years of age (3.3%), an actuarial survival at 11 years, similar to that of patients under 75 years (77 +/- 5%) and the functional improvement obtained (95% of survivors are NYHA class I or II) certainly justify surgery in these patients. Because of the incidence of anticoagulant related hemorrhages in these patients (1.7% patient year) and since, structural deterioration of the bioprostheses was non existent in this series, a bioprosthesis appears to be the best valvular substitute in patients over 75 years of age.     

Clinical evolution of heart transplantation in patients with previous valvular cardiomyopathy

OBJECTIVE: Heart transplantation (HT) due to valvular cardiomyopathy is rare, namely, about 3% of cases in the Registry of the International Society for Heart and Lung Transplantation (ISHLT). Usually, these patients present some risk factors such as previous valvular operations and pulmonary hypertension. Since there are few studies in the literature, we retrospectively analyzed our early and long-term results. MATERIALS AND METHODS: We studied our experience in 22 HT cases for valvular cardiomyopathy (9.3% of our total experience), namely, 12 men and 10 women, of overall mean age of 52.6 +/- 10 years. Five patients had mitral; 8, aortic; and 1, tricuspid valve disease; 7 had double valve disease and 1, triple valve disease. Nineteen patients (87%) had been operated previously between 1 and 4 times. The mean ejection fraction was 23% +/- 7.3% and the mean New York Heart Association (NYHA) functional class was 3.7. Fifty-three percent of the patients had pulmonary hypertension. Two patients were operated as an emergency "O." We used the standard HT technique. RESULTS: Four patients (18%) were reoperated due to hemorrhage. The hospital mortality was 2 cases (9%). Another patients (9%) died on follow-up due to cardiac allograft vasculopathy. All surviving patients have been followed to the end of 2006. The mean follow-up has been 72 +/- 53 months. They are functional class I or II. CONCLUSIONS: HT for this indication was more frequent in our experience than in the Registry of the ISHLT. The immediate and long-term results were good, with an 82% mean survival at 6 years. HT can be a good treatment for patients with valvular cardiomyopathy and bad ventricular function and/or multiple valvular reoperations.     

Long-term results of multivalve surgery for infective multivalve endocarditis.

OBJECTIVE: The natural history of medically treated multivalvular endocarditis is associated with dismal short and long term survival. However, the impact of surgical intervention on these results is relatively unknown. The objective of this retrospective study was to report our long-term results in patients requiring multivalve surgery for multivalvular endocarditis. METHODS AND RESULTS: Over a 24 year period beginning in 1972, multivalve surgical procedures were performed on 63 patients for infective endocarditis. Prosthetic valve endocarditis was present in 25 (40%), and acute or active endocarditis in 38 (60%). The early mortality was 16%. Out of 53 patients discharged from the hospital 87+/-4% were alive at 5 years and 64+/-9% at 10 years. There was no difference in early or late mortality between patients with prosthetic and native endocarditis (P=0.15 and P=0.77 for early and late mortality, respectively). The presence of active endocarditis did not affect operative outcome or late mortality. Twenty-one patients (88%) were in NYHA FC I, and none were in NYHA FC IV. The only prognostic factor of early and late mortality was the presence of an abscess at the time of the surgery. CONCLUSIONS: These results indicate that multivalve infective endocarditis treated surgically is associated with acceptable early and late mortality and excellent postoperative functional status. The early surgical intervention prior to an abscess formation offers the best chance for survival of patients with multivalve endocarditis.     

Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1)

Objectives: Assessment of long-term results of immunodeficiency virus type-1 (HIV-1)-infected patients undergoing cardiac surgery. Methods: Retrospective analysis of profile and outcomes of 31 HIV-1-infected patients (35 operations, 1985–2002). Results: Twenty-seven males and four females (mean age 34.67) in three groups: acute infective endocarditis (AIE) 21 (67.74%), coronary (CAD) 5 (16.13%) and non-infective valvular disease (NIVD) 5 (16.13%). HIV factors: drug addiction (23–74.19%), homosexuality (5–16.12%), heterosexuality (3–9.67%), hemodialysis (1–3.22%). HIV stage: A (17), B (2), C (2) in AIE; A (2), B (3) in CAD and A (3), C (2) in NIVD. Mean preoperative CD4 count was 278 cells/μL (12<200 cells/μL, 38.7%). The most frequent pathogens: S. aureus (52.38%), S. viridans (23.8%), Candida (19.04%). Native valve involved in 22 cases (78.33%) and prostheses in 8 (26.67%); 8.57% were operated in 1980–1985, 14.28% in 1986–1990, 22.85% in 1991–1995 and 54.28% in 1996–2002 with 16 elective (48.17%), 17 urgent (45.71%) and two emergencies (5.71%); mean aortic clamping and cardiopulmonary bypass time 78.9 and 107.47 min. Hospital mortality was 22.58 and 28.57% in AIE. No CAD patient died. Nine patients (37.5%) died between 2 and 171 months (mean 54.5). Mortality was 50% in AIE. CD4 count increased from 185.33 to 396.55 cells/μL (P=0.43) in nine patients on antiretrovirals. Fifteen-year actuarial survival is 58.16% overall and 48.01% for AIE. Conclusions: There is an increase in HIV-1-infected patients requiring cardiac surgery, a decrease in AIE, however NIVD and CAD increasingly seen. Cardiac surgery did not blunt CD4 response induced by antiretrovirals. The late cause of death were not AIDS-related events.     

Surgical management of acute aortic root endocarditis with viable homograft: 13-year experience.

OBJECTIVE: Cryopreserved homograft valves have been used for acute infective aortic root endocarditis with great success but it is compounded by its availability in all sizes. The long-term clinical results of geometric mismatched homografts are not well defined and addressed. METHODS: Over a 15-year period (April 1986-June 2001), 816 patients presented with active infective endocarditis. One hundred and eighty-two of the patients aged between 9 and 78 years (mean: 51.0 +/- 1.13 years) consisting of 142 males and 40 females received homograft aortic valves. One hundred and ten patients were in NYHA functional class III and 72 in class IV and in cardiogenic shock. Of the patients, 2.7% suffered from septic embolism. One hundred and twenty-four (68.1%) patients presented with periannular abscesses and 58 (31.9%) with no abscess while 107 native valve (NVE) and 75 prosthetic valve (PVE) endocarditis were diagnosed preoperatively by transesophageal echocardiography (TEE) and confirmed intraoperatively. Freehand subcoronary implantation (FSCI) was used in 106 patients and root replacement in 76 patients. RESULTS: The operative death was 8.5% and for patients in NYHA functional class IV and in cardiogenic shock was 14.5%. Late mortality rate was 7.9%. Patient survival after discharge from hospital at 1 year was 97% and at 10 years was 91%, respectively. Thirty-one (22.1%) patients underwent reoperation after 1.7 years (mean) with two deaths (6.4%). Early (< or = 60 days) and late reinfection rate was 2.7 and 3.6%, respectively. Freedom from reoperation for matched and undersized homografts at 10-13 years was 85 and 55%, respectively. The univariate model identified undersized homograft (P=0.002), FSCI (P=0.09) and reinfection (P=0.0001) as independent risk factors for developing early and late valve dysfunction resulting in reoperation and homograft explant. CONCLUSION: Early aggressive valve replacement with homograft for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery. Homografts exhibit excellent clinical performance and durability with a low rate of reinfection, if properly inserted. Undersized homograft is an incremental risk factor for early and late reoperation.     

Splenic abscess associated with active infective endocarditis

Splenic abscess is a rare complication in infective endocarditis. Here, we present two cases of splenic abscess associated with active infective endocarditis. Body computed tomography before emergency valvular surgery revealed abscess in the spleen. In case 1, the abscess was localized within the spleen; splenectomy and valve replacement were performed through the same median skin incision. In case 2, the splenic abscess was diagnosed as ruptured; valve replacement was performed, followed by splenectomy through a separate skin incision. No recurrence of infection occurred after surgery in either case. In surgical treatment for active infective endocarditis, body computed tomography is essential to diagnose splenic abscess preoperatively. If there is an abscess, then splenectomy and valvular surgery should be performed simultaneously to prevent reinfection after valvular surgery. The approach to the spleen should be individualized according to the extension of the abscess.     

Tricuspid valve replacement with bioprostheses: long-term results and causes of valve dysfunction

BACKGROUND: Although the clinical performance of bioprostheses after valve replacement in the aortic and mitral position has been reported, little is known of the performance of tricuspid bioprostheses. The mechanism of bioprosthetic valve dysfunction after tricuspid valve replacement (TVR) is not clear. METHODS: We reviewed 98 cases of TVR with bioprostheses. To clarify the causes of valve dysfunction, pathologic examination of the explanted valve at the reoperation was performed. RESULTS: Actuarial survival at 18 years was 68.7% +/- 5.8%. There were 12 redo TVRs. In six of the 12 cases, isolated redo TVR was performed. In the other cases, concomitant cardiac procedures were performed. The causes of prosthetic valve dysfunction were pannus formation on the cusps of the right ventricle side (four cases), native valve attachment (two cases), pannus formation + native valve attachment (two cases), sclerotic change (one case), pannus formation + sclerotic change (one case), and native valve attachment + valve infection (one case). Freedom from reoperation, structural valve deterioration, and nonstructural dysfunction at 18 years was 62.7% +/- 10.7%, 96.0% +/- 2.9%, and 76.7% +/- 8.3%, respectively. CONCLUSIONS: In our 18 years of experience, although the survival after TVR with bioprostheses is acceptable, the reoperation free rate is not satisfactory. Pannus formation on the cusps of the ventricular side seems to be a serious problem that causes bioprosthetic dysfunction in the tricuspid position.     

Psoas abscess in patients with an infected aortic aneurysm

BACKGROUND: Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. Infected aortic aneurysms could be complicated by psoas abscess. METHODS: A retrospective chart review was conducted to examine the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with an infected aortic aneurysm. RESULTS: Between 1996 and 2007, 40 patients (32 men) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). In 38 patients a blood or tissue culture had a positive result. The most common responsible pathogen was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One patient underwent endovascular repair but died. In-situ graft replacement was done in 32 patients. Persistent or recurrent infection occurred in seven (22%) of 32 operated on patients. The mortality rate was 86%, and the overall aneurysm-related mortality rate of in situ graft replacement was 22% (7/32). In eight (20%) of the 40 patients, aortic infection was complicated by psoas abscess. Infection complicated by psoas abscess was present in seven of 32 operated patients. It was associated with higher incidence of emergency operation, hospital mortality, prosthetic graft infection, and aneurysm-related mortality than infection without abscess. CONCLUSION: Psoas abscess was common in patients with infected infrarenal aortic aneurysm. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.     

Emergency valve replacement for active infective endocarditis

During the last 12 years, 14 patients were subjected to emergency heart valve replacement in acute bacterial endocarditis. Operative mortality was 21% (3/14); significant postoperative periprosthetic regurgitation or reinfection occurred in none of the survivors. Risk factors with unfavourable prognosis are: (1) virulent pathogens ("Non-Viridans"-germs); (2) previously normal heart valves; (3) acute aortic insufficiency with premature closure of the mitral valve; (4) floating vegetations shown by echocardiography. Our results provide further evidence for the efficacy of early surgical intervention in patients with bacterial endocarditis with an unfavourable etiology or a complicated course.     

Patient-prosthesis mismatch and left ventricular remodelling after implantation of Shelhigh SuperStentless aortic valve prostheses

AIM: Aortic valve replacement is a standard procedure for the treatment of severe aortic valve stenosis. Due to lower flow velocities stentless valves are associated with a more effective regression of left ventricular hypertrophy in comparison to stented valves. However, mismatch between body surface area and valve size supports unfavourable hemodynamic RESULTS: The aim of the study was to analyze hemodynamic parameters by echocardiography after implantation of the Shelhigh SuperStentless(TM) bioprosthesis and to analyze the occurrence of patient-prosthesis mismatch and left ventricular remodelling in this specific valve type. METHODS: A total of 20 patients with severe aortic stenosis underwent implantation of a Shelhigh Super Stentless(TM) prosthesis. Clinical and echocardiographic assessment was done prior to, immediate after and six months after surgery. RESULTS: All surgical procedures were successful, no surgery-related complication was documented perioperatively. One patient died after development of multiorgan failure. Echocardiography during the first eight days after surgery showed mean gradients of 16 mmHg, mean valve orifice areas of 1.8 cm(2) and indexed effective orifice areas at 0.95 cm(2)/m(2). Six-months follow-up data were obtained in 19/20 patients. There were no relevant changes in echocardiographic hemodynamic findings at the time of follow-up measurements. Significant regression of left ventricular hypertrophy was shown (P=0.0088). A patient-prosthesis mismatch occurred in one patient (0.54 cm(2)/m(2)). No recurrent symptoms were documented. CONCLUSION: Patient-prosthesis mismatch after implantation of SuperStentless Shelhigh(TM) prosthesis is rare. A significant regression of left ventricular hypertrophy could be shown after six months. Hemodynamic valve function assessed by echocardiography may be predicted early after surgery.     

Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality.

OBJECTIVE: The long-term outcome of patients with aortic bioprosthetic valves could be improved by decreasing the reoperative mortality rate. METHODS: Predictors of emergency reoperation and reoperative mortality were identified retrospectively in 172 patients who had the first bioprosthetic aortic valve replacement between 1975 and 1988 (mean age 46+/-13 years) and were subjected to replacement of the degenerated bioprostheses between 1978 and 1997 (mean age 56+/-14 years). Emergency reoperation had to be performed in 31 patients (18%). RESULTS: The operative mortality was 5.2% (9/172), 22.6% for emergency (odds ratio 11.17; 95%-confidence limit 4.33-28.85) and 1.4% for elective replacement of the degenerated aortic bioprosthesis (P<0.0001; OR=20.3). Patients who died at reoperation had higher transvalvular gradients before the primary aortic valve replacement (P=0.007), received smaller bioprostheses at the first operation (P=0.03), had later recurrence of symptoms after the first aortic valve replacement (P=0.04), a higher pre-reoperative New York Heart Association (NYHA) class (P=0.02), and a higher incidence of coronary artery disease (P=0.001) and pulmonary artery hypertension (P=0.009). Endocarditis before the primary aortic valve replacement (P=0.004), postoperative pneumonia at the first operation (P=0.005), pulmonary hypertension (P=0.0004) acquired during the interval, later recurrence of symptoms (P=0.04) after the first operation, a lower ejection fraction at the time of reoperation (P=0.03) and acute onset of bioprosthetic regurgitation (P=0.00002) were predictors for emergency surgery. Higher transvalvular gradients at the primary aortic valve replacement (P=0. 006), coronary artery disease (P=0.003) acquired during the interval, the need for concomitant coronary artery revascularization (P=0. 001), sex (P=0.02) and size (P=0.05) and type of the bioprostheses used (P=0.007) were incremental predictors for reoperative mortality which were independent of emergency surgery. CONCLUSIONS: Elective replacement of failed aortic bioprostheses is safe. Patients undergoing emergency reoperation have a considerably higher mortality. They can be identified by a history of native aortic valve endocarditis, higher transvalvular gradients at primary aortic valve replacement, smaller bioprostheses, and pulmonary hypertension or coronary artery disease acquired during the interval. A failing bioprosthesis must be replaced at its first sign of dysfunction.     

Carpentier-Edwards pericardial aortic valve in middle-aged patients comparison with the St. Jude medical valve

Objective The objective of the present study was to compare long-term results of single aortic valve replacement (AVR) with mechanical (St. Jude Medical valves: standard) and biologic (the Carpentier-Edwards pericardial) prostheses. Method: Between 1995 and 2002, 95 patients who underwent single AVR with mechanical (n=46) or biologic (n=49) prostheses were enrolled in this study. The mean age at the operation was 54.0±9.6 years (range: 20 to 69 years) with the mechanical and 68.8±7.1 years (range: 44 to 85 years) with the biologic prosthesis. Results: The 9-year actuarial survival rate, which was calculated by taking perioperative mortality into account, was 90.3±4.6% for patients with mechanical valves and 87.6 ±4.8% for patients with bioprostheses, with no difference between the two groups (p=0.342). The 9-year freedom rate from thromboembolism, reoperation, endocarditis was 94.8+3.6%, 100% and 97.8 ±2.2% for patients with mechanical valves and 98.0 ±2.0%, 97.5 ±3.4% and 95.0 ±3.4% for those with bioprostheses, respectively. After 9 years, freedom from cardiac death averaged 97.8% in the group with mechanical valves compared with 95.3% in those with bioprostheses (p=0.541). Conclusion: We conclude that the mid-term durability of the Carpentier-Edwards pericardial valve in the aortic position for the elderly is excellent. Nevertheless, the risk of tissue valve reoperation progressively increases with time, and a longer follow-up may be necessary to provide its value compared with the mechanical valves in a country like Japan with a high life expectancy. (Jpn J Thorac Cardiovasc Surg 2005; 53:465-469)