Early onset of prosthesis failure after aortic valve replacement.

We report an unusual case of a 78-year-old male who underwent an aortic valve replacement with a 21 mm Labcor tissue porcine aortic valve due to symptomatic aortic stenosis of his native valve. Only 3 months after an uncomplicated postoperative course, on a routine follow-up, transthoracic echo showed restrictive motion of the non-coronary cusp, incomplete closure of the coaptation line and severe aortic regurgitation. The patient was scheduled for a new operation during which the previous prosthetic valve was explanted and a different model was used.

Cardiac surgery after heart transplantation: coronary artery bypass grafting and heart valve replacement.

INTRODUCTION: Due to increasing need for and a shortage of donor organs, therapeutic procedures such as heart valve replacement for valve insufficiency and coronary artery bypass grafting (CABG) for graft vasculopathy (GVP) must be performed to improve allograft function to avoid retransplantation. METHODS: We performed a retrospective analysis of patients who underwent surgical procedures after orthotopic heart transplantation. Since 1989, we have performed more than 1400 heart transplantation procedures. Valve replacement was necessary in 8 patients and CABG was necessary in 3 patients. Five patients received valve prostheses (3 bioprostheses and 2 mechanical valves) at the tricuspid position. Three patients received a Hancock bioprosthesis at the mitral position. One of the 3 received the valve 3 years after heart transplantation while suffering from mitral regurgitation grade IV, and another patient received the valve 1 year following heart transplantation while suffering from mitral insufficiency grade III due to infective endocarditis. Three patients underwent coronary artery revascularization, 2 patients underwent the procedure 1 and 7 years after heart transplantation because of GVP, 1 patient underwent the procedure simultaneously with heart transplantation because of donor coronary artery disease. One patient received concomitant CABG with heart transplantation because of 75% left anterior descending stenoses in the donor organ, and one patient received CABG 1 year after heart transplantation because of rapidly progressive GVP in the left anterior descending artery. The third patient had 3-vessel disease with 95% left stem and 75% ramus circumflex, ramus marginalis, and ramus diagonalis. RESULTS: Two patients who underwent CABG and 4 patients who underwent valve replacement are still alive and maintain good clinical performance. One patient with a graft at the mitral position died 9 years after heart transplantation and 6 years after mitral valve replacement. Two patients with a graft at the tricuspid position died 17 and 4 years after heart transplantation (6 and 3 years after valve replacement, respectively). One patient with a bioprostheses at the tricuspid position had to be retransplanted 2 years following valve replacement while suffering from a paravalvular leakage grade III. CONCLUSION: Cardiac surgical procedures can be safely performed after heart transplantation. To improve graft and patient survival, such procedures must be carefully performed after heart transplantation to avoid retransplantation. The shortage of donor organs will and must lead to an increase in the number of conventional procedures performed to improve allograft function in transplanted hearts.

Initial experience with the medtronic ADVANTAGE valve prosthesis in the mitral position--clinical outcome and analysis of complications.

OBJECTIVE: The Medtronic ADVANTAGE prosthetic heart valve is a bileaflet mechanical heart valve which has two main design modifications. The prosthesis has an enlarged central orifice to improve blood flow characteristics and an asymmetric butterfly pivot recess with expanded outflow component designed to enhance the blood flow washing through the pivot region. This report summarizes the initial experience with 55 patients who underwent isolated mitral valve replacement. METHODS: We prospectively followed 55 patients undergoing mitral valve replacement with the Medtronic ADVANTAGE prosthesis in a single center study. All patients were operated on via a median sternotomy and a left atrial approach. RESULTS: The age of the patients at implant ranged from 42 years to 77 years with a mean of 61.8 years. Forty-five percent of the patients were male. Seventy-five percent of the patients were in NYHA functional class III or IV prior to valve replacement. The diameters of the implanted prostheses were as follows: 25 mm in 2 patients, 27 mm in 12 patients, 29 mm in 20 patients, and 31 mm in 21 patients. Coronary artery bypass grafting was performed with valve replacement in 16.4 % of patients and additional tricuspid repair in 10.9 %. After one year, 97.6 % and after two years 100 % of the included patients were in NYHA functional class I or II. All patients had Coumadin (warfarin) therapy postoperatively with a target INR range of 2.5 to 3.5, or 3.0 to 4.0. There were 4 thromboembolic events (7.3 %) in the early period and 2 late events (2.6 %). Episodes of valve thrombosis were not seen during the follow-up, which consisted of 76.5 patient years. The hemodynamic performance was favorable and within clinically acceptable ranges. The incidence of valve-related mortality and morbidity in this preliminary study was extremely low, indicating good clinical results comparable to those reported for other bileaflet valves. CONCLUSION: The ADVANTAGE valve is a safe and effective option for mitral valve replacement with a very low incidence of valve-related complications.

Papillary fibroelastoma of the ascending aorta presenting with cardiogenic shock.

We describe an uncommon case of a 58-year-old woman who presented with cardiogenic shock. The echocardiography examination revealed a papillary fibroadenoma located in the ascending aorta which was subsequently surgically treated.

Aortico-left ventricular tunnel, an unusual congenital cardiac anomaly in adult: application of a new operative technique.

Aortico-left ventricular tunnel is a rare congenital cardiac anomaly. A 45-year-old man was referred to our clinic with unstable angina pectoris. The patient had an aortico-left ventricular tunnel that had been operated on 15 years before and that now showed a recurrence. We performed a new surgical technique, including closure of orifices of the tunnel by resection of the aorta at the left coronary ostium, reconstruction of the aorta with patch plasty, and formation of a neo-left main branch by applying a saphenous magna vein patch at the noncoronary cusp. In this technique, the possibility of aortic regurgitation caused by stretching and distortion of the aortic ring and leaflets by primary suture closure of tunnel is eliminated. The postoperative 2-D colored Doppler echocardiography and cardiac MRI showed an excellent result of the procedure. Coronary flow could be restored, and thus anginal symptoms disappeared.

Pediatric patients with Kawasaki disease and a case report of Kitamura operation.

Kawasaki disease (KD), also called mucocutaneous lymph node syndrome, is an acute, self-limiting, small-vessel vasculitis with an unknown cause that affects children between the ages of 6 months and 5 years. It is the most common cause of acquired coronary artery disease in childhood. Acute myocardial infarction and coronary artery aneurysm are major complications. We present a cohort of patients with KD who were followed up and treated in the Heart Center, North Rhine-Westphalia. Included is a review of important relevant items common to cases of KD, such as clinical data and management, including medical management of the acute condition and the diagnosis and management of coronary vasculitis and aneurysms as well as the application of coronary artery bypass grafting (CABG) in those conditions. Between January 2002 and January 2006, we evaluated the findings and characteristics of 18 pediatric patients with a history of KD and their long-term outcome. The acute illness occurred between the ages of 4 months and 14 years of age. Anomalies of the coronary arteries were found in 6 patients ranging in age from 5 months to 10 years. One patient had acute myocardial infarction; another underwent CABG after 5 years from disease onset at the age of 15 years. Kitamura operation was performed successfully. The other patients are still under observation.Coronary artery aneurysms and stenosis requiring surgery are rare in KD; nevertheless, CABG is the standard therapy when myocardial ischemia is detected. Kitamura operation provides good growth potential and long-term graft patency.

Mechanical valve replacement of the systemic atrioventricular valve in children.

In children with systemic atrioventricular valve disease (SAVVD), reconstructive surgery is the primary goal. However, in cases with severely dysplastic valves or failed repair, valve replacement is the only option. The purpose of this study was to assess the early and late outcome following mechanical valve replacement in SAVVD. Between 1989 and 2003, 31 children underwent mechanical valve replacement (19 St. Jude Medical, 12 Carbomedics) in SAVVD (27 mitral, 3 tricuspid in corrected transposition of the great arteries, 1 common in an univentricular heart) at our institution. The ages ranged from 3 months to 15 years (mean 4 years) and body weight varied between 4.2 and 57 kg (mean 13.3 kg). The size of prostheses ranged between 16 and 31 mm (mean 23.9 mm). The main indication for valve replacement was severe insufficiency of left atrioventricular valve (84%); 84% of the patients had had a previous cardiac operation. The overall hospital mortality was 6.5% The mean follow up was 7.7 years (range 2-13 years). Ninety percent of children represent sinus rhythm, 87% are in NYHA class I. All patients were placed on a regimen of Phenprocoumon aiming to maintain the international normalized ratio (INR) between 3.0 and 4.0. Since 1994, INR self-management of oral anticoagulation was performed either by the patient or his or her parents. There was no anticoagulation-related complication in this patient group. Mechanical valve replacement in left atrioventricular valve disease carries a low operative risk across the spectrum of pediatric age despite previous operations in most cases. Long-term survival and quality of life are good in nearly all cases. The rate of anticoagulation-related complications is very low, especially when INR self management is performed.

Acute myocardial infarction in a young adult: a case report and literature review.

Sudden cardiac death related to sports in young patients can have many causes. Hypertrophic cardiomyopathy, congenital coronary abnormalities, and myocarditis make up about half of the causes of sudden cardiac death after sports. Screening for all athletes is important to prevent such episodes. This involves yearly examinations including clinical examinations, stress echocardiograms, echocardiography, and laboratory investigations. Also, behavioral follow up should be addressed, as cocaine administration and doping can both lead to cardiac problems and sudden cardiac death after sports. We present a case of a 17-year-old boy who collapsed after an ice hockey competition as a result of an acute myocardial infarction, which was first represented by ventricular fibrillation. We also review the main causes of sudden cardiac death in such young athletes and the main investigations that have to be performed to reach the proper diagnosis and etiology of the condition.

Anterolateral right thoracotomy for mitral valve procedure after previous coronary artery bypass grafting with functioning internal mammary artery grafts.

AIM: Mitral valve procedure after previous coronary artery bypass grafting (CABG) with functioning internal mammary artery (IMA) grafts has high risk. Especially, internal mammary artery grafts injury may be fatal. The anterolateral right thoracotomy affords easy access to the right atrium with minimal dissection, and minimizes the risk of injury to the IMA grafts. We reviewed our operative technique and outcome after mitral valve procedure after previous CABG with functioning IMA grafts. METHODS: Thirteen patients (11 male and 2 female, mean age of 67.7+/-8.5 years, range 54 to 80 years) underwent mitral valve replacement after previous CABG with functioning IMA grafts from march 1993 to september 2002. The mean interval between the previous CABG and the mitral valve procedure was 3.8 years (range 9 months to 8 years). Four patients had simultaneous mitral valve procedures at initial CABG (2 repairs and 2 replacements). The operation has performed through the anterolateral right thoracotomy, under ventricular fibrillation with moderate hypothermia and without cardioplesia. RESULTS: Mitral valve repair was performed in 3 patients, mitral valve replacement in 10 patients. The mean coronary bypass time was 69.1+/-16.2 min (range 45 to 98 min). The operation time was 159.3+/-29.4 min (range 120 to 219 min). Intensive care unit stay days was 1.9+/-1.6 days (range 1 to 5 days). Peak CK/CK-MB values were 555.1+/-290.4 IU/16.6+/-10.7 IU (range 176 to 924 IU/7 to 44 IU). Peak troponin I value was 9.5+/-5.2 pg/mL (range 4 to 17.8 pg/mL). There was no IMA injury and no early death. Other complications were newly arrhythmia in 3 patients, renal insufficiency in 1 patient, reoperation for bleeding in 1 patient. CONCLUSIONS: Anterolateral right thoracotomy approach, ventricular fibrillation with moderate hypothermia without cardioplesia were a safe and good method for mitral valve operation after previous CABG with functioning IMA graft.

Pre-existing elevated pulmonary vascular resistance: long-term hemodynamic follow-up and outcome of recipients after orthotopic heart transplantation.

BACKGROUND: Elevation of pulmonary vascular resistance (PVR) has been considered to predict a bad outcome after orthotopic heart transplantation (HTx). A transpulmonary gradient (TG) > or =15 mmHg and PVR > or =5 wood (w) are correlated with a three-fold increase in 2-days as well as 30-days and 6-, 12-month mortality. METHODS: We performed a retrospective analysis of 400 consecutive transplanted patients (pts) on hemodynamic data over a time period of 3.5 years. In 83 pts (23%) preoperative PVR was > or =5 w and TG >15 mmHg. Vasodilator studies were performed in this group of pts in order to evaluate pulmonary vasoreactivity or hemodynamic improvement. RESULTS: Hemodynamic follow-up post-transplantation showed a significant (p<0.001) decrease in mean TG to 8.8 mmHg within the first, 7.7 after the fifth year as well as decrease in PVR from 5.5 to 1.6, within the first and fifth year post-transplantation. Compared to the control group (n=286) (re-transplants n=6 and pediatric pts n=25 excluded) pts with TG <15 mmHg and/or PVR <5 w, transplanted within the same period, 30-day mortality and cumulative survival after 1 and 5 years do not show any significant difference with a mortality of 3%, 22% and 33% (p<0.05). Subgroup analysis for pts with endstage of ischemic versus dilatative cardiomyopathy has not shown any significant difference in mortality. CONCLUSIONS: In a retrospective analysis of 400 pts elevated PVR does not predict a bad outcome after orthotopic heart transplantation in early and late mortality.

INR self-management following mechanical heart valve replacement.

INR self-management can reduce severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement. Beginning anticoagulation therapy immediately in the postoperative period further reduces anticoagulant-induced complications. Data were collected from the first 600 surviving patients (from a total study sample of 1200 patients) who completed follow-up of at least 2 years. Patients were randomly divided into a self-management group and a control group. INR self-management reduced severe hemorrhagic and thromboembolic complications (P=0.018). Nearly 80% of INR values recorded by patients themselves, regardless of educational level, were within the target therapeutic range of INR 2.5-4.5, compared with 62% of INR values monitored by family practitioners. Only 8.3% of patients trained in self-management immediately after surgery were unable to continue with INR self-management. The results differed slightly between patient groups with different levels of education. We conclude that all patients for whom anticoagulation is indicated are candidates for INR self-management regardless of education level.

Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures.

OBJECTIVE: Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results. METHODS: From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection. RESULTS: There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%. CONCLUSION: On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.

Extended donor criteria: hemodynamic follow-up of heart transplant recipients receiving a cardiac allograft from donors > or = 60 years of age.

BACKGROUND: Heart transplantation (HT) has become a therapeutic option for patients suffering from endstage heart failure. The increasing demand for cardiac allografts has led to a shift toward extended donor criteria. In a retrospective analysis of 859 HT recipients, we report on the hemodynamic outcome of 19 HT patients who received cardiac allografts from donors > or =60 years of age. METHODS: From March 1989 to December 1997, we performed 883 orthotopic HT in 74 children and 809 adults at our transplant center. Within this period, 19 patients (17 women and 2 men) received cardiac allografts from donors > or =60 years of age. Recipient age ranged from 57 to 78 years (mean, 65+/-5 years). RESULTS: HT could be performed successfully in 19 cases. The early mortality rate was 16% (n=3). The late mortality rate was 37% (n=7). All long-term survivors are stable at New York Heart Association classification II (New York Heart Association Class II = resting hemodynamics: cardiac output normal; left ventricular end diastolic filling pressure elevated; clinically not compromised during mild to moderate workout). Although only 19 patients were retrospectively evaluated, there was a statistically significant (P<0.05) difference in survival among patients who received organs from male (11 vs. 8*) compared with female (8 vs. 2*) (*=death) donors. CONCLUSION: In our experience, it is possible to increase the cardiac donor pool by accepting allografts from donors, preferably female, > or =60 years of age in selected cases without a coronary angiogram, if hemodynamic parameters are in a normal range on mild-to-moderate inotropic support. We do not recommend cardiac allografts from donors > or =60 if there are signs of coronary insufficiency in the electrocardiogram, if left ventricle filling pressures are above normal on mild-to-moderate inotropic support and optimum hemodynamic management, or if there are signs of segmental dysfunction or mitral insufficiency >I in the echocardiogram.

Pulsatile and nonpulsatile extracorporeal circulation using Capiox E terumo oxygenator: a comparison study with Ultrox and Maxima membrane oxygenators.

An open randomised, prospective study was undertaken on 90 patients who underwent routine myocardial revascularization. The aim of the study was to demonstrate that the Capiox E polypropylene fiber membrane oxygenator with a conventional single pulsatile/nonpulsatile blood pump for cardiopulmonary bypass (CPB) was comparable in performance to that of the Maxima and the Ultrox membrane oxygenators using a double pump system. The patients were divided into six groups according to perfusion mode and oxygenator type. Laboratory parameters, fluid balance and oxygenation was examined at set times before during and after cardiopulmonary bypass. Net fluid input was lower in the Capiox E groups regardless of perfusion mode: 2932 +/- 562 ml (Capiox E), compared to 3646 +/- 531 ml (Ultrox) and 3593 +/- 582 ml (Maxima). Net fluid balance 1288 +/- 534 ml was lowest in the Capiox/NP group, compared to 1604 +/- 460 ml (Ultrox/NP) and 1881 +/- 594 ml (Maxima/NP), (p < 0.05). The higher net fluid balance in the Capiox E/PP group 1649 +/- 580 ml compared to 1592 +/- 583 ml (Ultrox E/PP) and 1494 +/- 542 ml (Maxima/PP) was attributed to a technicality whereby the recommended priming volume of the Capiox E oxygenator was exceeded for safety reasons. The values of plasma free Hb were slightly higher in the PP than NP groups: Maxima/PP 80 mg/dl, /NP 50 mg/dl; Ultrox/PP 62 mg/dl, /NP 48 mg/dl; Capiox E/PP 55 mg/dl, /NP 48 mg/dl. The FiO2 was higher in the Capiox E groups 0.77 (PP) and 0.88 (NP) compared to Maxima/PP (0.66), /NP (0.65) and Ultrox/PP (0.64), /NP (0.63). Reciprocally, the venous saturation was higher in the Ultrox and Maxima groups compared to Capiox E at end of CPB. The study demonstrated that the CapioxE oxygenator with a single blood pump system can compare to the Maxima and Ultrox oxygenators with a double blood pump for CPB with regard to blood handling, oxygenation and fluid balance in routine cardiac surgery.