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.     

Stentless bioprosthetic aortic valve replacement after a homograft root replacement: Toronto SPV implantation after a homograft root

Stentless bioprosthetic valves for the aortic position offer excellent hemodynamic characteristics, making them an attractive choice ahead of other valve prostheses. We present a unique case in which a patient underwent aortic valve replacement with a stentless porcine valve and mitral valve repair for severe aortic and mitral regurgitation 1 year after a homograft root replacement for acute aortic endocarditis. The rationale for our approach is outlined in the context of current surgical trends.     

Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: a 14-year experience

OBJECTIVE: There is a paucity of data regarding gastrointestinal (GI) complications after descending thoracic and thoracoabdominal aortic (DTA/TAA) surgical repairs. We examined our 14-year experience with these repairs to determine the incidence, outcomes, and risk factors for postoperative GI complications. METHODS: Between February 1991 and February 2005, we repaired 1,159 DTA/TAA. Data were prospectively collected. The mean patient age was 68 years and 36% were women. Complications were classified as biliary disease, hepatic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, and ileus. Risk factors for the occurrence of GI complications were ascertained by univariate and multivariable analysis. RESULTS: Of the 1,159 patients, 81 had 109 GI complications, for a 7% incidence. The mortality associated with GI complications was 39.5% compared with 13.5% (P < .0001) in patients without GI complications. The incidences of complications were bowel ischemia, 2.5% with 62% mortality; biliary disease, 0.3% with 75% mortality; hepatic dysfunction, 1.6% with 38% mortality; acute pancreatitis, 0.3% with 20% mortality; GI bleeding, 1.5% with 29% mortality; peptic ulcer disease, 0.9% with 30% mortality; and ileus, 2.2% with 26% mortality. Postoperative biliary disease (odds ratio [OR], 16.58; P = .001), hepatic dysfunction (OR, 3.58; P = .006), and bowel ischemia (OR, 10.03; P = .0001) were significantly associated with an increased postoperative mortality. Risk factors for the occurrence of GI complications were visceral involvement of the aortic repair (TAA extent II, III, and IV) (OR, 2.08; P = .002) and low preoperative glomerular filtration rate (OR, .98; P = .0002). CONCLUSION: Biliary disease, hepatic dysfunction, and bowel ischemia after DTA/TAA surgical repairs were associated with an increased mortality. Visceral involvement and preoperative renal insufficiency were risk factors for the occurrence of GI complications.     

Microbiology of subphrenic abscesses: a 14-year experience.

The objective of the review was to study the aerobic and anaerobic microbiology of subphrenic abscesses in relation with predisposing conditions. A retrospective review of clinical and laboratory data of 52 patients treated between 1974 and 1988 was conducted. Forty-three (83%) patients developed the abscesses after an operative procedure. These included 11 patients after colonic, 9 patients after gastric or duodenal, 7 patients after abdominal trauma, 7 patients after biliary, and 6 patients after appendix surgery. A total of 194 organisms (3.7 isolates/specimen), 83 aerobic (1.6/specimen), and 111 anaerobes (2.1/specimen) were recovered. Aerobic bacteria only were recovered in 7 (13%) abscesses, anaerobic bacteria only in 11 (21%), and mixed aerobic and anaerobic bacteria in 34 (65%). Polymicrobial infection was present in 47 (90%). The predominant aerobic isolates were Escherichia coli (28 isolates), Enterococcus group D(9), and Staphylococcus aureus (9). The predominant anaerobes were Peptostreptococcus species (33 isolates), Bacteroides fragilis group (25), Clostridium species (13), and Prevotella species (6). The number of isolates/site varied. The number of anaerobic bacteria/site outnumbered or was equal to the number of aerobic or facultatives in all instances, except in abscesses after biliary surgery. Their number/site was especially high in abscesses after appendectomy, and the number of aerobic and anaerobic bacteria was the lowest after gastric or duodenal surgery. S. aureus predominated after gastric, duodenal and posttrauma surgery; B. fragilis predominated after colonic, appendix, and postabdominal trauma surgery; Enterococcus group D predominated after biliary surgery; Fusobacterium and Prevotella species predominated after gastric or duodenal surgery; and Clostridium species predominated after colonic or appendix surgery. These data highlight the polymicrobial aerobic-anaerobic nature of subphrenic abscesses and their correlation with predisposing surgery.     

Surgery for aortic root aneurysm in children: a 21-year experience in 50 patients

BACKGROUND: Ascending aortic aneurysms are unusual in children and have received little attention to develop guidelines for management. This study reviewed our experience with 50 children who have undergone aortic root replacement for ascending aortic aneurysm. METHODS: A retrospective clinical review was conducted using hospital charts and office records. Patients or their physicians were contacted for follow-up and recent echocardiograms were obtained and reviewed. RESULTS: There was no operative or hospital mortality. Twenty-six children had aortic root replacement with a composite graft, 10 patients had replacement with a homograft aortic root, and 14 patients had a David II valve-sparing procedure. Factors related to late morbidity and mortality were analyzed. Long-term results were excellent in the 26 children receiving a composite graft. Twenty-three of these children were New York Heart Association class I (19) or II (4) at study closure. There were 3 late deaths (11, 16, and 17 years postoperative). Seven of 10 children receiving a homograft aortic root are long-term survivors and all 14 children having a valve-sparing procedure are alive. Generally, late results with the David II remodeling procedure have been good although 3 patients developed late aortic insufficiency and two required valve replacement. CONCLUSIONS: Aortic root replacement in children with aneurysms has low operative risk and good long-term results. Composite grafts in particular carry a low risk of endocarditis, thromboembolism, and hemorrhagic events. Homografts are suitable for small patients but lack durability. Late results with the David II remodeling valve-sparing procedure in children have been compromised by late root dilatation.     

Highly selective vagotomy: a 14-year experience

Since August 1971, 244 highly selective vagotomies were performed for pyloric and duodenal ulceration by one surgeon (W.A.F.M.). There was one postoperative death. Twenty (8 per cent) patients were lost to follow-up. The remaining 223 patients were followed up for 1 to 14 years (mean 4.2 years). On the modified Visick grading system 83.4 per cent were Visick I or II and 16.6 per cent were Visick III or IV. The failures were mainly recurrences. The recurrence rate was 11.2 per cent. Certain factors were examined to try to elucidate those influencing recurrence rate but no significant prognostic indicator was found. Acid studies were analysed and no significant relationship between these and the development of a recurrence could be found. The second 100 vagotomies were better than the first as judged by the results of studies of insulin-stimulated acid. Finally, we question whether all recurrences should automatically be regarded as treatment failures and the patients classified as Visick IV.     

A 23-year experience with composite valve graft replacement of the aortic root.

BACKGROUND: This is a retrospective study of early and long-term results of composite valve graft replacement of the aortic root. METHODS AND RESULTS: Between July 1974 and July 1997, 244 patients underwent aortic root replacement with a composite valve graft. Mean age was 54+/-15 years. The inclusion technique was used in 178 patients (73.0%), the open technique in 65 (26.5%), and the Cabrol II technique in 1 patient (0.5%). Hospital mortality was 7.8% (70% confidence limit, 6.1% to 9.5%). Independent determinants of hospital mortality were preoperative creatinine level more than 150 micromol/L (p = 0.04), prolonged cardiopulmonary bypass time (p = 0.006), intraoperative technical problems (p = 0.048), and year of operation (p = 0.015). Follow-up was 99.6% complete, median 96 months (range, 2 to 256 months). Fifty-seven patients (25.3%; 70% confidence limit, 22.4% to 28.2%) died during follow-up. Cumulative survival at 5, 10, and 20 years was 76%, 62%, and 33%. Independent risk factors for late death were postoperative complications (p = 0.027), technique for coronary reattachment (p = 0.028), and concomitant aortic arch operation (p = 0.01). Twenty patients (8.8%; 70% confidence limit, 7.0% to 10.6%) underwent reoperation on the aortic root. Estimated freedom from reoperation for pseudoaneurysms at 3 years was 96% in the inclusion group and 94% in the open group (p = 0.236). CONCLUSIONS: Aortic root replacement with a composite valve graft can be performed with low hospital mortality and morbidity. Pseudoaneurysms did occur in the inclusion group, but also in the open group.     

Composite graft replacement of the aortic root after previous cardiac surgery: a 20-year experience

BACKGROUND: An aging population and prolonged survival of patients after cardiac operations has meant that composite aortic root replacement after previous cardiac operation is being performed with increasing frequency. METHODS: From January 1979 to July 1999, 32 patients underwent "reoperative" composite replacement of the aortic root at our institution. Previous operations were 16 aortic valve replacement, 9 coronary artery bypass grafting, 5 repair aortic dissection, and 7 others. Indications for operation included ascending aortic aneurysm in 16 patients, ascending aortic dissections in 10 patients, and other in 6 patients. RESULTS: The unit elective mortality was 3 of 26 (11.5%). One surgeon's elective mortality was 1 of 22 (4.6%). The unit emergent mortality was 6 of 6 (100%). There has been one late death. Morbidity was low. CONCLUSIONS: Reoperative aortic root replacement is a technically demanding procedure, but expertise in the area achieves low elective mortality. Consideration should be given to aortic root replacement at the initial procedure. Close follow-up of postcardiac operation patients is necessary to proceed with elective aortic root replacement if indicated. Emergent presentation in the reoperative setting has a very poor prognosis.     

Contemporary trends in aortic valve surgery: a single centre 10-year clinical experience

The purpose of this study is to present a comprehensive profile of the trends in aortic valve replacement at a single institution over the past decade. Prospectively collected data concerning 873 patients undergoing aortic valve replacement (AVR), with and without coronary artery bypass grafting (CABG), were analysed. The patients were divided into three time periods: period I, (1990 to 1993); period II, (1994 to 1996); and period III, (1997 to 2000). Actuarial survival of AVR patients with and without CABG at 7 years was 82.9 +/- 2.4% and 79.1 +/- 3.3% (p = 0.17), respectively. Actuarial survival at 7 years for stentless, mechanical, and stented valve patients were 89.5 +/- 2.7%, 85.5 +/- 2.8%, and 76.0 +/- 3.2%, respectively. There was a significant difference in survival between the stentless and stented valve groups (p = 0.014). Age (63.8 +/- 12.9 yrs, 66.2 +/- 11.0 yrs, 67.9 +/- 10.3 yrs; p = 0.01), the incidence of peripheral vascular disease (5.1%, 10.8%, 16.6%; p = 0.001), and the extent of coronary artery disease necessitating CABG (34.0%, 38.8%, 41.0%; p = 0.05) have increased significantly in the later time period. However, operative mortality has remained constant (4.7%, 4.8%, 4.5%; p = 0.9). Moreover, perioperative complications have decreased significantly (27.4%, 18.0, 16.0%; p = 0.001). Multivariate analysis identified more recent time period as independent protective factor for early mortality and morbidity (period I, RR 1.00; period II, RR 0.47; period III, RR 0.40).     

Burn injuries in native Canadians: a 10-year experience

Between 1977 and 1986, 1598 patients were admitted to the Firefighters' Burn Unit of the University of Alberta Hospital in Edmonton, Alberta. One hundred and twenty-five (7.8 per cent) of these patients were Treaty Indians or Metis compared to 4.2 per cent of the general population in the same given area. The data show native people suffered larger total body surface area (TBSA) burns, were hospitalized on average 16.9 days longer and required 0.7 more operations than their non-native counterparts. Natives are also three times more likely to remain within the health care system as inpatients for rehabilitation after acute burn management has been completed. Mortality rates as a result of these burns were similar for natives (4.8 per cent) and non-natives (4.3 per cent). This review indicates that the native population is at higher risk of suffering burn injury even after adjusting for certain demographic variables, consequently impacting the utilization of the health care system.     

Thymectomy for myasthenia gravis: 14-year experience.

Forty-eight consecutive patients with myasthenia gravis (MG) attended by generalized weakness were treated by complete thymectomy, performed transsternally in 46 patients and through a left thoracotomy in two with thymomas. There were no operative deaths. A 12-year-old child with fulminating MG died of acute pneumonia shortly after hospital discharge. Of the remaining 47 evaluable patients, thymectomy resulted in complete remission in six, marked improvement with a reduced need for medication in 20, and mild improvement on the same dosage of medication in 18. Neither the age of the patient, nor the histopathology of the excised thymus, nor the postoperative change in acetylcholine receptor antibody titer were found to have a significant influence on the response to thymectomy. If the ten patients who were 20 years of age or younger were excluded, the patients with a shorter duration of MG achieved a better response to operation. The authors conclude that thymectomy is effective treatment for MG, regardless of the age of the patient or the type of thymic pathology.     

Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation.

BACKGROUND: We assessed the results of a modified technique for aortic root reconstruction including preservation of the native aortic valve and sinuses. METHODS: A modified technique for reconstruction of the aortic root was devised in which the native aortic sinuses are preserved and remodeled, the diameter of the sinotubular junction is reduced, the ventriculoaortic junction is reinforced with a Dacron prosthesis, and the coronary ostia are reimplanted. Since January 1995, this modified operative technique was performed in 13 patients with a mean age of 54 +/- 21 years. The median grade of aortic regurgitation was 3; in 10 patients it was caused by dilatation of the sinotubular junction, and 3 had additional annuloaortic ectasia. RESULTS: The aortic crossclamping time was 61 +/- 18 minutes. In-hospital mortality was 2 of 13 (15. 3%) patients, both deaths being related to complications of aortic dissection. In 1 patient aortic regurgitation increased to grade 3, necessitating aortic valve replacement. At a mean follow-up of 2.1 years, the remaining 10 patients had stable aortic valve function with a median grade of regurgitation of 1. The mean New York Heart Association functional class was 1.2. CONCLUSIONS: Aortic root reconstruction with preservation of the native aortic valve and sinuses allows symmetric reconstruction of the aortic sinuses and adaptation of the diameters of the sinotubular and ventriculoaortic junctions, thus optimizing aortic valve function. Moreover, it prevents contact of the aortic valve leaflets with the Dacron graft, which may enhance the durability of the repair.     

A 14-year experience with 6 cm as a criterion for surgical treatment of abdominal aortic aneurysm.

BACKGROUND: It remains unclear when to recommend operation for an asymptomatic abdominal aortic aneurysm (AAA). This study examined a prospective series of patients for whom standard criteria were applied. METHODS: Some 584 consecutive patients with an AAA of diameter 3 cm or greater detected by ultrasonographic screening have been observed for up to 14 years. Repeat ultrasonographic examinations have been performed at intervals. Surgery was not considered unless the aneurysm measured 6 cm in diameter, expanded at a rate equivalent to at least 1 cm per year, caused the patient symptoms, or an iliac aneurysm was present that required treatment. RESULTS: Operation was performed on 127 patients; the majority (80; 63 per cent) had an aneurysm that reached 6 cm in diameter. Use of the above criteria prevented rupture in all but 24 (4 per cent) of the 584 patients over the 14-year interval. Of these 24 patients, 11 were unfit for planned surgery and eight declined operation or follow-up. Rupture in the five remaining patients (1 per cent) who were available for treatment compared favourably with the reported 30-day mortality rate for elective surgical treatment of 1.4-12 per cent. CONCLUSION: Repeated observation is preferable to surgical intervention until an aortic aneurysm measures 6 cm in diameter, expands by 1 cm per annum or causes symptoms. Presented as a poster to the 52nd Annual Meeting of the Society for Vascular Surgery, San Diego, California, USA, June 1998     

Management of traumatic aortic rupture: a 30-year experience

OBJECTIVE: To present the authors' 30-year experience with traumatic aortic rupture (TAR). SUMMARY BACKGROUND DATA: TAR is a highly lethal injury. Most institutions manage a small number of cases, and most surgeons receive only modest exposure during training. METHODS: Between 1971 and 2001, the authors operated on 219 patients with a diagnosis of TAR. Diagnosis of TAR since 1994 has been based exclusively on the use of contrast-enhanced spiral computed tomography, with angiography reserved for equivocal cases (periaortic mediastinal hematoma without aortic wall abnormalities). Patients were divided according to surgical technique. Eighty-two patients (group A) were operated on with a clamp-and-sew technique. Sixty-four patients (group B) underwent surgery with the use of a passive shunt, and 73 patients (group C) were treated using heparin-less partial cardiopulmonary bypass. RESULTS: Mortality was 18 patients for group A (21.9%), 23 patients for group B (35.9%), and 13 patients for group C (17.8%) (P =.03). Paraplegia occurred in 15 of 64 survivors in group A (23.4%), 7 of 41 survivors in group B (17%), and 0 of 60 survivors in group C ( P=.0005). Aortic occlusion without lower body perfusion for longer than 30 minutes (P =.004) and surgical technique without lower body bypass support (P =.0005) were associated with paraplegia. CONCLUSIONS: Surgery for TAR based on spiral computed tomography screening and diagnosis is reliable. The use of heparin-less distal cardiopulmonary bypass in the authors' hands is safe and is associated with a reduced incidence of paraplegia.     

Empyema thoracis: 14-year experience in a teaching center

One hundred two patients with empyema thoracis were managed at the Royal Melbourne Hospital between 1976 and 1989. Fifty-five cases of empyema thoracis were postpneumonic, 8 followed esophageal rupture, and 5 were associated with thoracic trauma. Some form of systemic illness was a major contributing factor in the presentation of 29 patients. A single causal organism was found in 53 patients (the most common being Staphylococcus aureus), multiple organisms in 36, and no growth in 13. During the years 1983 to 1989 there was an increased incidence of empyemas caused by multiple or antibiotic-resistant organisms. Operative drainage was required in 90 patients and 12 were managed by thoracentesis or intercostal tube drainage alone. The in-hospital mortality rate for patients managed nonoperatively was 58% (7 of 12 patients); it was 16% (14 of 90 patients) for those receiving operative drainage. There were seven late deaths, four empyema related and three nonrelated. Early adequate operative drainage is recommended for patients with empyema thoracis.