Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation.

OBJECTIVES: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team. BACKGROUND: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. METHODS: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified. RESULTS: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II. CONCLUSIONS: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.

Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results.

BACKGROUND: We analyzed our 22 years of experience with extraanatomic bypass grafting for repair of aortic arch coarctation in adults. Results from early and midterm follow-up with clinical evaluation and magnetic resonance angiography are reported. METHODS: Between November 1979 and December 2001, 18 consecutive patients aged 18 to 61 years (mean, 31.8 +/- 13.3 years) underwent extraanatomic bypass grafting to repair coarctation of the aortic arch. Six patients (33.3%) had recoarctation after previous repair through a left thoracotomy, and 3 (16.7%) had associated cardiac diseases. The operative technique used in all patients was ascending aorta-to-descending thoracic aorta bypass with a polyethylene terephthalate fiber (Dacron) graft through a median sternotomy and posterior pericardial approach. RESULTS: Follow-up was completed in all patients, with a mean duration of 5.6 +/- 5.7 years (range, 12 months to 22 years). The follow-up interval exceeded 10 years in 5 patients. No neurologic complications, early or late mortality, late reoperations, or graft complications occurred. Six patients (33.3%) had mild hypertension. All patients were asymptomatic with patent Dacron grafts confirmed by echocardiography. Magnetic resonance angiography, performed in 15 (83.3%) patients, revealed that the Dacron grafts were still patent at a mean interval of 4.0 +/- 6.2 years (range, 5 days to 22 years) after repair. CONCLUSIONS: Extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic arch coarctation in adults is safe, with low morbidity and no mortality. The favorable midterm results indicate this technique is a safe and less invasive means of repairing aortic arch coarctation or recoarctation in adults.

Multivariate analysis of risk factors for hospital mortality in valvular reoperations for prosthetic valve dysfunction.

OBJECTIVES: The purpose of the study was to analyze risk factors for hospital mortality in patients undergoing valvular reoperations for prosthetic valve dysfunction. METHODS: We performed a prospective analysis of 146 patients who underwent valvular reoperations for prosthetic valve dysfunction between July 1995 and June 1999 at the Heart Institute of the University of São Paulo Medical School. Multivariate statistical analysis with logistic regression was used to analyze preoperative and intraoperative variables to determine risk factors for hospital mortality. RESULTS: The overall hospital mortality was 10.9% (16 patients). Univariate analysis showed that the following variables were associated with higher mortality rates: advanced New York Heart Association (NYHA) functional class, increased creatinine level, prolonged extracorporeal circulation time and treatment of annular abscess. Logistic multivariate analysis identified advanced NYHA functional class and a creatinine level higher than 1.5 mg/dl as independent predictors of hospital mortality. CONCLUSIONS: Advanced NYHA functional class and higher creatinine levels were independent predictors of hospital mortality in patients submitted for valvular reoperations for prosthetic valve dysfunction.

Aneurysm of the left atrial appendage.

We present the case of a 33-year-old woman with atrial tachyarrhythmias and chest pain. The transthoracic echocardiography demonstrated an intrapericardial liquid mass confirmed as an aneurysm of the left atrial appendage by a nuclear magnetic imaging study. Aneurysmectomy was performed with the assistance of cardiopulmonary bypass with a bilateral submammary skin incision and subsequent median sternotomy. The patient had an uneventful postoperative course. We suggest aneurysmectomy aided by cardiopulmonary bypass as a safer method of treatment for this rare cardiac anomaly.