THIRTY YEARS EXPERIENCE WITH HEART VALVE SURGERY: ISOLATED AORTIC VALVE REPLACEMENT

Background: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic aortic valve replacement during this period. Methods: Questionnaires and personal contact have been used to generate a combined database of pre-operative and postoperative information and long-term follow-up on 1322 patients who underwent isolated prosthetic aortic valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1992. Results: Complete survival follow-up data were obtained for 94% (1241) of the patients. The Bjork-Shiley valve was used in 668 (875) of the patients, a Starr-Edwards prosthesis in 31% (412). a St Jude prosthesis in 2% (26). and only 0.7% (9) bioprosthetic valves were inserted. The hospital mortality rate for the 30-year period was 2.9%. Progressively older and less fit patients have undergone surgery in recent years. The long-term survival of patients with aortic stenosis and aortic incompetence was not significantly different. Long-term survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications, and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following aortic valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Conclusions: Aortic valve replacement can be performed with low hospital mortality and complication rates, and significant symptomatic improvement can be expected. Aortic valve recipients have a favourable prognostic outcome compared with an age- and sex-matched population, and risk factors that determine long-term survival can be identified pre-operatively.     

A 12-year experience of endovascular repair for ruptured abdominal aortic aneurysms in all patients

ObjectiveEndovascular aneurysm repair (EVAR) has been increasingly performed for ruptured abdominal aortic aneurysms (rAAAs). However, multiple randomized trials have failed to demonstrate a survival benefit compared with open aortic surgery. During a 12-year period, 100% of patients without a history of aneurysm surgery had undergone EVAR for a rAAA at Örebro University Hospital, with no emergent open aortic surgery performed. In the present study, we evaluated the mortality and technical success during this “EVAR-only” period.MethodsA single-center, retrospective observational study was conducted. We identified all patients who had presented to Örebro University Hospital with a rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic, and thoracoabdominal aortic ruptures were not included. Patients who had received previous aortic interventions (open or endovascular) and patients who had received palliative treatment instead of surgical intervention were also excluded. The patient characteristics, perioperative and postoperative data, and mortality rate were investigated.ResultsEVAR had been performed in 100 patients. Preoperative hemodynamic instability had been present in 54 patients (54%), and 18 (18%) had undergone aortic balloon occlusion. The aneurysm location was infrarenal in 89 patients (89%). Bifurcated stent grafts had been used in 97 patients (97%), and adjunct endovascular techniques had been used for 27 patients (27%). Of 98 patients, EVAR had been performed with the patient under local anesthesia for 62 patients (63%). Peri- and postoperative complications at 30 days had occurred in 20 of 100 patients (20%) and 22 of 79 patients (28%), respectively. The overall mortality at 30 days was 27% (27 of 100 patients), and the mortality for those with an isolated infrarenal rAAA was 24% (21 of 89 patients). The overall mortality at 1 year was 39% (39 of 100 patients) and for those with an isolated infrarenal rAAA was 37% (33 of 89 patients). The presence of preoperative hemodynamic instability and the use of ABO were statistically significantly and independently associated with increased 30-day mortality on multivariate logistic regression analysis.ConclusionsAll 100 patients who had undergone surgery for a rAAA had been treated using EVAR and endovascular adjuncts, with a relatively low mortality rate, thus continuing the “EVAR-only” approach. A low proportion of rAAA patients were considered surgically unsuitable. These findings support the applicability of EVAR for the treatment of all rAAAs at suitable centers.     

Effect of permanent pacemaker on mortality after transcatheter aortic valve replacement

Objectives. Transcatheter aortic valve implantation (TAVI) is an established treatment for high-grade aortic valve stenosis in patients found unfit for open heart surgery. The method may cause cardiac conduction disorders requiring permanent pacemaker (PPM) implantation, and the long-term effect of PPM implantation remains ambiguous. Design One hundred sixty-eight patients who underwent TAVI from 2008 to 2012 were included. Patient characteristics, ECGs and PPM data were collected through medical records. Kaplan–Meier plots and Cox regression analysis were performed. Results. Forty subjects were excluded, leaving 128 patients for final inclusion. 41 (32%) received a PPM (mean age 82 vs. 80 in patients without PPM, p?=?.06) within 30 days of the TAVI procedure. Median follow-up was ～4 years and 37 (29%) died. One-year mortality was 14% for non-PPM patients vs. 2% in PPM patients, and mortality at 5yrs 70% vs. 54%, respectively. Kaplan–Meier survival analysis showed higher mortality in patients without PPM (p?=?.008). In multivariate survival analysis significant variables were: No PPM (HR 2.6; CI 1.1–6.2; p?=?.03), chronic obstructive pulmonary disease (HR 2.4; CI 1.2–5.0; p?=?.02) and either pre- or post-procedural chronic or paroxystic atrial fibrillation (HR 2.3; CI 1.2–4.7; p=?.02). Conclusion. TAVI-patients with a PPM had better survival than patients in whom a PPM was not implanted.     

Durability and clinical experience using a bovine pericardial prosthetic aortic valve

ObjectivesTo report the implant experience and long-term outcomes from a large tertiary care referral center on surgical aortic valve replacement (SAVR) with a contemporary stented pericardial bioprosthesis with anticalcification treatment.MethodsPatients underwent SAVR using the Trifecta valve at a single institution. Endpoints included procedural outcomes, adverse events, prosthesis–patient mismatch (PPM), long-term survival, and valve durability. Follow-up included 30-day, 6-month, and annual assessments. Treatment for structural valve deterioration (SVD) included surgical explant and valve-in-valve (V-in-V) transcatheter aortic valve implantation (TAVI).ResultsSAVR was performed in 1241 patients (median age, 73.5 ± 6.4 years; 54% male; median logistic EuroSCORE, 7.8) with concomitant procedures in 713 cases (57.5%). Intraprocedural mortality was 1.4%, and 30-day mortality was 6.0%. At hospital discharge, 68 patients (5.5%) had moderate PPM, and no patients had severe PPM. Adverse events included cardiac arrhythmias (44.7%, mostly atrial fibrillation), respiratory failure (22.9%), acute renal failure requiring temporary renal replacement therapy (12.9%), and low cardiac output syndrome (3.3%). Follow-up data were available over a total of 5469 patient-years (median duration of follow-up, 4.7 years). Freedom at 8 years from all-cause mortality, valve-related mortality, reoperation for SVD (redo SAVR or V-in-V TAVI), and endocarditis were 78.4%, 98.0%, 93.3%, and 96.5%, respectively. Of the 30 patients with SVD, 17 were treated by V-in-V TAVI and 13 underwent surgical explant.ConclusionsOutcomes from this large single-center cohort at increased surgical risk demonstrate excellent long-term durability of the Trifecta valve for SAVR and feasibility of treating SVD by V-in-V TAVI.     

Effects of Suprarenal Aortic Cross-Clamping and Adjunctive Renal Reconstruction on Outcomes of Open Abdominal Aortic Aneurysm Repair

Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy.     

Incidence, risk factors and prognosis of acute kidney injury after transcatheter aortic valve implantation

Aim: Transcatheter aortic valve implantation (TAVI) poses a significant risk of acute kidney injury (AKI). Little is known of the impact of TAVI and AKI on long‐term kidney function and health cost. We explored the predictive factors and prognostic implications of AKI following TAVI. Methods: Single‐centre retrospective analysis of 52 elderly patients undergoing TAVI was conducted. The primary endpoint was renal outcome which included the incidence of AKI and 12‐month renal function after TAVI. Secondary endpoints were mortality, the length of hospital stay (LOS) and cost. Results: AKI occurred in 15/52 (28.8%) patients (mean age 84 ± 6) and three patients (6%) required dialysis. Patients with AKI (AKI+) had greater comorbidity (diabetes and cerebrovascular disease) and a trend towards reduced estimated glomerular filtration rate (eGFR) at baseline compared with those without AKI (56.6 vs AKI?: 65.7 mL/min per 1.73 m², P = 0.07). Following TAVI, AKI? patients experienced an immediate improvement in eGFR, which remained significantly higher at all time points compared with AKI+ patients (70.4 vs 46.9 at 6 months and 73.7 vs 53.0 at 12 months, P < 0.001). Cumulative mortality for AKI+versus AKI? group was 26.7% and 2.7% (P = 0.006). LOS doubled (P < 0.001) and average hospitalization cost per patient was 1.5 times higher in the AKI+ group (P < 0.001). Independent predictors of AKI were peri‐procedural blood transfusion (OR: 2.4, 95% CI: 2.0–3.1), trans‐apical approach (OR: 9.3, 95% CI: 4.3–23.7) and hypertension (OR: 6.4, 95% CI: 2.9–17.3). Conclusion: AKI developed in 28.8% of patients after TAVI and was associated with procedural technique and transfusion requirement, and an increased LOS and mortality. However, most patients achieved a significant and sustained improvement in eGFR.     

Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients

BACKGROUND: Cirrhotic patients who present for elective and emergent surgery pose a formidable challenge for the surgeon because of the high reported morbidity and mortality. The Child-Turcotte-Pugh (CTP) score previously has been used to evaluate preoperative severity of liver dysfunction and to predict postoperative outcome. Recently, a more objective scoring classification, the model for end-stage liver disease (MELD), has been shown to predict accurately the 3-month mortality for cirrhotic patients awaiting transplantation. We sought to compare the CTP and MELD scores in predicting outcomes in cirrhotic patients undergoing surgical procedures requiring general anesthesia. METHODS: During the study period, 40 patients with a history of cirrhosis who required elective (E) or emergent (EM) surgical procedures under general anesthesia were reviewed (E = 24, EM = 16). The preoperative CTP and MELD scores were calculated and patient short- (30-day) and long-term (3-month) outcomes were recorded. RESULTS: There was a significant difference in the 1-month and 3-month mortality rates between the emergent and elective groups (EM group: 1 mo = 19%, 3 mo = 44%; E group: 1 mo = 17%, 3 mo = 21%, P <0.05). There was good correlation between the CP and MELD scores, which was greater in the emergent groups as compared with the elective group (EM: r = 0.81; E: r = 0.65). CONCLUSIONS: Our study shows that cirrhotic patients who undergo surgery under general anesthesia have an extremely high 1- and 3-month mortality rate that progressively increases with severity of preoperative liver dysfunction. Additionally, the MELD score correlates well with the CTP score, providing a more objective predictor of postoperative mortality in cirrhotic patients undergoing surgery.     

Which factors increase the risk of conversion to open surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators.

OBJECTIVE: to identify factors that increase the risk of conversion to open surgery following endovascular repair of abdominal aortic aneurysms (AAAs) and to assess their outcome. Design analysis of 1871 patients enrolled in the EUROSTAR collaborators registry. MATERIALS AND METHODS: patient characteristics, anatomic features of the aneurysm, type of endovascular device, institutional experience and the year in which the procedure was performed were related to risk of conversion. RESULTS: forty-nine patients (2.6%) required conversion. In 38 patients conversion was performed during the first postoperative month (primary conversions) and in 11 patients during follow-up (secondary conversions). Primary conversion was mostly due to access problems and device migration. Secondary conversions were performed for rupture in six and for a persistent endoleak, with or without aneurysmal growth, in five patients. Patients who were converted were significantly older, had a lower body weight, and had a higher prevalence of chronic obstructive pulmonary disease. Conversion was associated with shorter, wider infrarenal necks and larger aneurysms. The conversion rate was lower when a team had performed more than 30 procedures, and in procedures performed during the last two years of the study period. The conversion rate was higher with EVT or Talent devices. Patients who required primary conversion had an 18% mortality rate, compared to 2.5% mortality in patients without conversion (p<0.01). Secondary conversion was associated with a perioperative mortality of 27%, and when performed for rupture 50%. CONCLUSION: both primary conversion and secondary conversion for rupture carry a high operative mortality. Awareness of the risk factors may reduce conversion rate as well as early and medium term mortality.     

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians

ObjectivePatients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up.MethodsRetrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics.ResultsThe study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group.ConclusionsEVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.     

Long-term outcome in type I biliary atresia

Purpose

This retrospective study reviews the long-term outcome of type I biliary atresia (BA).

Methods

Three hundred twenty-three patients with BA, including 50 with type I, underwent corrective surgery. The surgical results, role of cholangiograms during the corrective surgery, late complications, and current statuses were evaluated.

Results

The overall survival rate of the nontransplant type I patients was better than that of the type II/III patients (52% vs 33%, P = .0009). Cholangiograms of 32 patients were classified into 3 types: cloudy (48%), treelike (13%), and mixed (39%). Of 26 patients who underwent corrective surgery in 1972 or later, 7 (50%), 7 (78%), and 3 (100%) patients of the cloudy type, mixed type, and treelike type, respectively, have survived without liver transplantation (LTx). Of 18 type I patients who survived more than 20 years without LTx, 7 developed severe late complications. Two of them eventually required LTx after 20 years old.

Conclusions

Use of cholangiograms during corrective surgery might have a long-term prognostic value. The overall survival rate of type I BA was better than that of type II/III. The incidence of late complications was, however, considerably high in the type I survivors. All patients required careful long-term follow-up.     

Determinants of long-term survival after major surgery and the adverse effect of postoperative complications

OBJECTIVE: The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. SUMMARY BACKGROUND DATA: The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. METHODS: NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. RESULTS: The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. CONCLUSIONS: The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.     

Effects of coronary artery bypass related conduction defects: a 10-year follow-up study

OBJECTIVES: The aim of this study is to determine the long-term prognostic significance of new permanent conduction defects (CDs) related to coronary artery bypass grafting (CABG), and to assess predisposing factors for increased mortality after CABG. DESIGN: One hundred and eighty patients who underwent an elective CABG without any evidence of preoperative CDs were followed on average for 9.6 years. Long-term outcome was observed in terms of Kaplan-Meier survival analysis, and several potential pre-, intra- and postoperative factors for increased mortality were analysed using the Cox regression model. RESULTS: Sixty-three (35.0%) of the patients developed a new CD (CD+ group) before hospital discharge. Early (<30 days) and long-term (>30 days) survival rates were 98.9 and 86.1%, respectively. The long-term survival in CD+ patients was significantly lower that in CD- patients (77.8% vs 90.4%, p = 0.02). However, cardiac survival in CD+ patients and CD- patients did not differ from each other (88.9% and 92.3%, respectively, p=NS). Five independent predictors for increased all cause mortality were identified: diabetes (relative risk ratio 5.99 [2.43-14.78]), number of distal anastomoses (3.20 [1.30-7.88]), a new intraoperative conduction defect (2.83 [95% CI 1.24-6.49]), preoperative ejection fraction <50% (2.60 [1.08-6.27]) and perfusion time (1.02 [1.01-1.03]). CONCLUSIONS: Excellent survival rates can be obtained 10 years after CABG. CDs were not related to increased cardiac mortality. The appearance of preoperative diabetes, intraoperative perfusion time, number of distal anastomoses performed, CABG derived permanent CDs and low preoperative ejection fraction are associated with higher all cause mortality during the long-term follow-up.     

Conversion to sinus rhythm does not improve long-term survival after valve surgery: insights from a 20-year follow-up study.

OBJECTIVE: Atrial fibrillation (AF) is frequently associated with valvular heart disease and a common complication of valve surgery. Its contribution to long-term mortality and morbidity remains debated. Our objective was to determine the impact of AF on long-term mortality and embolic complications after valvular surgery and the benefit of conversion to sinus rhythm. This may provide insight to the clinical advantages of surgical anti-AF procedures. METHODS: Data concerning rhythm status, mortality and embolic complications were prospectively collected for 5466 patients with valve surgery. Patients had surgery between 1979 and 2003. Follow-up was complete and all patients had a yearly EKG. RESULTS: Patients with preoperative AF had poorer long-term survival than patients without preoperative AF (20-year survival 23.7 and 33.4%, respectively, P<0.0001). However, preoperative AF was not an independent risk factor of long-term mortality (HR=1.04, P=0.6). In patients with preoperative sinus rhythm, postoperative development of AF had an impact on long-term mortality (HR=1.46, P=0.0012). In patients with preoperative AF, postoperative rhythm did not influence mortality when adjusted for other variables (AF vs. sinus rhythm, HR=1.07, P=0.5709). Mitral valve surgery (HR=1.55, P=0.0270) but not preoperative or postoperative AF had a significant impact on the advent of embolic complications. CONCLUSIONS: The conversion to sinus rhythm did not improve long-term survival or reduce the incidence of embolic complications after valve surgery. Patients with preoperative AF had poorer survival than patients without preoperative AF. AF may be a marker of advanced disease in these patients.     

Incidence and treatment of procedural cardiovascular complications associated with trans-arterial and trans-apical interventional aortic valve implantation in 412 consecutive patients

Objective: Trans-catheter aortic valve implantation (TAVI) technology is rapidly evolving, with 412 procedures having been performed at our institution. Herein, we report a complete, prospective analysis of complications occurring during transvascular and trans-apical implantations with two different prostheses. Methods: Between June 2007 and June 2010, 412 patients (258 female, mean age 80.3 ± 7.2 years, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) 20.2% ± 13.0%) underwent TAVI through either a retrograde (n = 252 transfemoral, n = 28 transaxillary, and n = 5 transaortic) or antegrade (n = 127 trans-apical) approach at our institution. The trans-apical access was chosen only in cases where transvascular implantation was not possible. As many as 283 CoreValve and 129 Edwards Sapien prostheses were implanted. Results: Thirty-day survival was 90.9%. Vascular complications occurred in 42 patients (10.2%). In four patients, lethal aortic root (n = 3) or abdominal (n = 1) aortic rupture occurred. Pericardial effusion developed in 53 patients (12.8%), which resulted in cardiac tamponade in 12 patients (2.9%). Twenty-three patients (5.6%) with valve malplacement were treated interventionally. In five patients (1.2%), emergency institution of cardiopulmonary bypass was required during the procedure for temporary support; all patients survived. Seventeen patients underwent re-intervention on the catheter valve (4.1%). Conclusions: With growing experience, complications with TAVI may be avoided by proper patient selection and skillful management. Other complications, when they occur, require a specific treatment algorithm to avoid delay in decision making. A considerable number of complications after TAVI require surgical treatment. Therefore, the ideal environment for TAVI procedures is a hybrid operating room, where a multidisciplinary team of surgeons, cardiologists, and anesthesiologists is best fitted to meet the current needs associated with TAVI technology. A reduction in complications was seen after 300 cases. This finding attests to the complexity of the procedure in addition to the experience required to reduce the incidence of complications.     

Surgical treatment for cardiovascular lesions of patients with Marfan syndrome

OBJECTIVE: Without treatment, the life expectancy of patients with Marfan syndrome is reduced by the associated cardiovascular abnormalities. In this study, we reviewed our experience of the surgical treatment of this condition to identify the primary indication for surgical repair and the optimal surgical management. METHODS: Between January 1986 and December 2000, 44 patients underwent surgery for Marfan syndrome at Shizuoka City Hospital. There were 28 male and 16 female patients, with a mean age of 40.9 +/- 15.0 years. Nineteen of the patients had developed type A dissection of the aortic arch. Three patients underwent remodelling of the aortic root. Ten patients required multiple repeat surgical interventions. RESULTS: There were four early and five late deaths. The survival rate at 1, 5, and at 10 years was 90.9%, 80.5%, and 74.3%, respectively. Freedom from postoperative events, which included cardiac death, additional surgery, and new or repeat aortic dissection at 1, 5, and at 10 years was 93.0%, 69.1%, and 53.2%, respectively. Among patients having type A dissection, the mean annual enlargement in the diameter at the level of the proximal descending aorta was 4.0 +/- 4.0 mm. Postoperative echocardiography with Doppler studies was performed in series on patients who had received remodelling of the aortic root, with subsequent mild aortic regurgitation in 2 patients and moderate regurgitation in 1 patient. CONCLUSIONS: Repeated postoperative studies with CT scans and earlier surgical intervention before the onset of aortic dissection are mandatory for improvement in the long-term survival rate of patients with Marfan syndrome. A valve-sparing procedure for a deformed aortic valve is promising, although the long-term results are not yet clear.     

Compelling nature of arterial manifestations in Behcet disease

INTRODUCTION: We present our experience with surgical treatment of arterial complications in Behcet disease (vasculo-Behcet disease), and the long-term results and pitfalls of surgical treatment. MATERIAL AND METHODS: Between January 1990 and January 2003, 20 consecutive patients underwent surgery to treat vasculo-Behcet disease. Most patients (17 of 20) were men, with mean age of 38.4 years. RESULTS: Thirty-four operations were performed in 20 patients. The operative mortality rate was 5.8% (2 patients). There were 17 emergency operations, 6 because of ruptured primary abdominal aneurysms. There were five others with critical limb ischemia, resulting in 3 amputations. All patients were followed up postoperatively on average for 44 months (range, 6 months-14 years). Two additional patients were lost to follow-up. After the initial operation 10-year survival rate was 30%, 10-year complication-free survival rate was 13%, and 5-year repeat operation-free survival rate was 26%. CONCLUSION: Although surgical intervention should be postponed until active inflammation has subsided, often this is not possible, because of the emergent nature of these problems. Most arterial complications of vasculo-Behcet disease present with a pseudoaneurysm rupture or with impending rupture. An aggressive surgical approach can be life-saving in such instances, and should be undertaken regardless of long-term complications, which are more common when the operation is performed in the presence of active inflammation. Early and late results can be improved by individualizing, selecting a disease-free area for reconstruction, and eliminating use of autologous graft material.     

Surgery for infective valve endocarditis in children

Objective: Surgery for endocarditis in children is relatively uncommon. Our aim is to assess operative mortality, recurrent infection, re-operation and long-term survival rates following surgery for infective valve endocarditis in children. Patients: Sixteen consecutive children (ten female, six male, mean age 11.8 years, range 25 days–16 years) undergoing surgery between 1972 and 1999 in Southampton were studied. The aortic valve was affected in five, mitral in four, aortic and mitral in one, tricuspid in five and a pulmonary homograft in one patient. Prosthetic valve endocarditis was present in three. Twelve surgical interventions were emergency and four urgent. Indications for operation included cardiac failure in five, severe valvular dysfunction in nine, vegetations in nine, persistent sepsis in four and embolization in four patients. The offending micro-organism was identified in 13. Valve replacement was performed in 11 and excision of vegetations in two and excision of vegetations and repair in three. Follow-up was complete (mean 11.2 years, range 2 months to 26.3 years, total 179.5 patient years). Results: There was one operative death (6.2%) in a 25-day-old neonate who presented in a moribund condition. Endocarditis recurred in one patient (6.25%). Freedom from recurrent infection at 10 and 20 years was 100.0 and 87.5%. Seven surgical re-interventions were required in four (25.0%) patients with no operative mortality. Freedom from re-operation at 1, 5, 10 and 20 years, was 84.6, 76.1, 76.1 and 60.9%, respectively. Two patients died 15 and 23 years after their first operation. The cause of the late deaths was non-cardiac in the first and unknown in the other. Actuarial survival, including operative mortality, at 1, 15 and 20 years was 93.7, 93.7 and 78.1%. Conclusions: Surgery in children with infective valve endocarditis can be performed with low operative mortality. Although some patients may require re-operation, freedom from recurrent infection and long-term survival are satisfactory.     

Immediate and long-term results of coronary revascularization in patients undergoing chronic hemodialysis.

OBJECTIVE: To evaluate morbidity and long-term survival in end stage renal disease (ESRD) patients, undergoing coronary artery bypass graft surgery. METHODS: We identified 22 such patients who underwent bypass grafting between 1987 and 1997. Symptomatic status of angina was rated using the classification of the Canadian Cardiovascular Society (CCS) and the functional status, was assessed using the Karnofsky scoring system. The patients were hemodialyzed the day before surgery and 24-48 h after surgery. RESULTS: Two patients operated on for acute myocardial infarction died after 4 days. Follow-up was completed in the remaining 20 patients (the mean follow-up time was 25+/-15 months). The survival rates at 1, 2 and 3 years was 84.5%, 74% and 59%, respectively. The symptoms diminished and the functional status was significantly improved. CONCLUSION: We conclude that elective coronary artery bypass in dialysis patients can be performed with acceptable morbidity and mortality. We advocate early surgical treatment. However, long-term survival is limited and this requires further investigation.     

Reoperations on the aortic valve combined with replacement of the ascending aorta

OBJECTIVE: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. PATIENTS AND METHODS: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. RESULTS: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%+/-4% for patients who had composite replacement of the aortic valve and ascending aorta. CONCLUSIONS: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Reoperations on the Aortic Valve Combined with Replacement of the Ascending Aorta

ABSTRACT Objective: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. Patients and Methods: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. Results: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%± 4% for patients who had composite replacement of the aortic valve and ascending aorta. Conclusions: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.