Cost and clinical effectiveness of aggressive surgical debridement and delayed primary closure of infected cardiac surgical wounds.

OBJECTIVE: Postoperative wound infection in cardiac surgery remains a subject of significant concern due to associated morbidity, prolonged hospital stay and rise in treatment cost. A conservative management approach to postoperative wound infection with topical dressings and healing by secondary intention is not cost-effective and cosmetic results are less acceptable. We developed our institutional protocol for the treatment of infected postoperative cardiac surgical wounds to reduce hospital stay and improve cosmetic outcome. This study aims to compare our institutional protocol with the conservative management approach. METHODS: Adult patients with postoperative superficial or deep sternal and/or leg wound infection were divided into two equal-sized groups and data collected from medical records. Group A was treated according to our institutional protocol of aggressive surgical debridement and delayed primary closure. Group B was treated according to conservative management with topical antiseptic wound dressings and healing by secondary intention. Data were analysed in retrospect with comparative statistics. RESULTS: A total of 30 patients took part in the study. Group A (n=15, seven male, eight female) had a mean age of 55.34±12.84 years. Group B (n=15, eight male, seven female) had a mean age of 56.46±10.21 years. Mean length of hospital stay in Group A and Group B was 5.13±2.06 and 36.67±22.28 days, respectively (p<0.0001). Calculated mean hospital costs were 16,271.61±6815.50 Saudi Riyals (approximately equivalent to $4330±700 USD) in Group A and 116,212.2±26,311 Saudi Riyals (approximately equivalent to $30,932±1813 USD) in Group B (p<0.05). Patients in Group A had linear scars comparable with primary postoperative wound scars, whereas patients in Group B had excessive non-linear scarring. CONCLUSION: In this study, cost and clinical effectiveness of aggressive surgical debridement and delayed primary closure was superior to conservative management with topical antiseptic wound dressings and healing by secondary intention in terms of a shorter hospital stay and better cosmetic outcome.

Extracorporeal membrane oxygenation in adults: experience from the Middle East.

BACKGROUND: The literature reports conflicting results for survival after extracorporeal membrane oxygenator support, and survival differs in pediatric and adult patients. We present our institutional experience of adult extracorporeal membrane oxygenator support. METHODS: From January 2007 to December 2009, 19 adult patients required extracorporeal membrane oxygenator support after cardiac surgery or catheter interventions. It was provided on an emergency basis to 11 patients, urgently to 5, and electively to 3. Indications included post-cardiotomy cardiogenic shock, post-cardiotomy acute respiratory failure, emergency cardiac resuscitation, and post-percutaneous coronary intervention cardiogenic shock. The mean duration of support was 4 days (range, 1-11 days). RESULTS: Seven (36.84%) patients could be weaned off extracorporeal membrane oxygenator support; one (14.28%) of them survived to hospital discharge and the other 6 (85.71%) died in hospital. Twelve (63.15%) patients could not be weaned off and died while still on extracorporeal membrane oxygenator support. Overall 30-day hospital mortality was 94.73%, and survival to discharge was 5.26%. CONCLUSION: Our institutional experience of extracorporeal membrane oxygenator support for cardiac indications in adult patients indicates poor survival. It significantly increased costs by delaying imminent death and prolonging stay in the intensive care unit.

A high-volume heart transplantation center in an Islamic country.

Cardiac transplants are performed sporadically or not at all in the majority of predominantly Muslim countries in the Middle East. We examined our experience in 76 patients who underwent heart transplantation between January 2005 and May 2010 in our center in Saudi Arabia. Excluded were 50 transplants performed between 1989 and 2004, due to incomplete data. Primary outcomes were complications, 30-day and late mortality rates, and 1-year survival. The heart transplant activity between 2005 and 2010 (15.0 per year) was 4.5-fold higher than that between 1989 and 2004 (3.3 per year). There were 61 (80%) men and 15 (20%) women, with a mean age of 35 years (range, 13-57 years). The mean waiting list time was 64 days (range, 1-262 days), and hospital stay was 30 days (range, 12-166 days). Major complications were infection (10), low-grade rejection (9), reoperation for hemorrhage (8), and sternal dehiscence (2). The 30-day mortality was 7.8% (6/76). Actuarial survival was 87.4% at 1 year and 81.5% at 3 years. A hospital in a Muslim country can increase cardiac transplant activity with excellent 30-day mortality and early survival comparable to that in worldwide counterparts.

Hybrid management strategy for percutaneous Fontan completion without surgery: early results.

BACKGROUND: We report early results of surgical preparation and subsequent percutaneous Fontan completion strategy for the treatment of single-ventricle defects. METHODS: Two hundred twenty-seven patients underwent bidirectional cavopulmonary connection (BDCPC) between 2002 and 2007. Thirty-four patients had lateral tunnel created at time of BDCPC, fenestrated with 10 to 14 mm openings with the cardiac superior vena cava end patched to maintain BDCPC physiology. At second stage, Fontan circulation was established by superior vena cava patch perforation, tunnel dilatation, and stenting plus fenestration device closure. RESULTS: Thirty-four patients underwent Fontan preparation with BDCPC. Median age was 7.7 months (5 to 51) and 29 patients (85%) had previous palliation. Mean bypass and ischemic times were 141 and 72 minutes, respectively. Median ventilation, intensive care, and hospital stay durations were 1, 5, and 10 days, respectively. There was one early death and two take-downs. Twenty-eight patients underwent Fontan procedure: surgical (n = 3), percutaneous (n = 25). None of the patients who underwent percutaneous Fontan completion required inotropes, chest tube insertion, or mechanical ventilation. Median intensive care and hospital stay durations were 1 and 6 days, respectively. There were no early mortalities after percutaneous Fontan but one late death and one surgical revision. Overall survival after BDCPC with Fontan preparation was 77%. CONCLUSIONS: Despite longer bypass and ischemic times, Fontan preparation at time of BDCPC is feasible and associated with encouraging early outcomes. Percutaneous Fontan completion is associated with short recovery, low morbidity and excellent early dynamics, and echocardiographic and clinical outcomes. Further follow-up is needed to confirm those favorable results.

Determinants of short- and long-term outcomes following triple valve surgery.

BACKGROUND AND AIM OF THE STUDY: Triple valve surgery (3VS) is required in some cardiac disorders that simultaneously involve the aortic valve (AV), mitral valve (MV), and tricuspid valve (TCV). Herein are reported details of the authors' experience with 3VS, and their attempts to identify those factors associated with a poor clinical outcome. METHODS: The medical records of patients who underwent 3VS between 1985 and 2005 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after 3VS, namely death, valve reoperation, and survival without subsequent valve reoperation. RESULTS: A total of 206 consecutive patients (124 females, 82 males; median age 34 years; range: 12-82 years) underwent 3VS. The most common underlying pathology for all valves was rheumatic, followed by repair failure and prosthesis dysfunction for AV and MV, and functional regurgitation for TCV. In total, 72 patients (35.0%) had undergone prior valve surgery. At 3VS, the MV and AV were usually replaced (> 70%), whereas the TCV was usually repaired (91%). The operative mortality (prior to hospital discharge) was 11%, and 15-year survival 68%. At 15 years after 3VS, 21% of the patients had died, without subsequent valve reoperation, 50% had undergone valve reoperation, and 30% remained alive without valve reoperation. Baseline factors associated with early mortality after 3VS were older age at operation, TCV replacement, and the use of a mechanical MV during 3VS. A late risk of mortality was associated with poor left ventricular function and renal impairment at the time of the initial 3VS, and MV prosthesis prior to the initial 3VS. Younger age at 3VS and MV repair during the index 3VS were associated with a higher constant risk of valve reoperation, while female gender, MV prosthesis prior to index 3VS, MV replacement with a bioprosthesis during 3VS, and rheumatic TCV disease were associated with an increased late risk of valve reoperation. CONCLUSION: Both, primary and reoperative 3VS can be performed with acceptable operative mortality and long-term survival. However, patients continue to be at risk of valve reoperation, which steadily increases over time.

Superior results following the Ross procedure in patients with congenital heart disease.

BACKGROUND AND AIM OF THE STUDY: The Ross procedure is a versatile operation that can be applied for aortic valve replacement (AVR) in patients with congenital heart disease (CHD), including small infants and those with complex left ventricular outflow tract (LVOT) obstruction. Herein, the clinical outcome is reported following the Ross procedure in patients with CHD at the authors' institution. METHODS: The medical records of patients who underwent the Ross procedure for CHD between 1991 and 2007 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after the Ross procedure, namely death prior to subsequent cardiac reoperation, cardiac reoperation, and survival without subsequent reoperation. RESULTS: A total of 151 patients (98 males, 53 females) was identified. The median age at the time of surgery was 8.6 years (range: 4 days to 33 years). Previously, 103 patients (68%) had undergone cardiac interventions, and 43 (28%) required LVOT enlargement (modified Ross-Konno procedure). A competing-risk analysis showed that, at 10 years after the Ross procedure, 8% of patients had died without subsequent reoperation, 26% underwent cardiac reoperation, and 66% remained alive without further reoperation. The 10-year freedom from autograft and homograft reoperation was 95% and 71%, respectively. Factors associated with early risk of mortality were age < 1 year and no prior surgical/percutaneous intervention at the time of the Ross procedure. Surgical factors associated with cardiac reoperation were concurrent cardiac surgery and the use of fresh homografts. There were no bleeding or thromboembolic complications, and the 15-year freedom from endocarditis was 95%. Ultimately, 99% of the survivors were in NYHA class I or II. CONCLUSION: The Ross procedure remains the authors' procedure of choice for AVR in patients with CHD. Outcomes in infants aged < 1 year may improve with better patient selection and palliative surgical/percutaneous interventions prior to valve replacement. The late survival was excellent and valve-related complications were minimal. The high autograft longevity led to few patients requiring late reoperation for graft replacement.

Simultaneous aortic and mitral valve replacement in children: time-related outcomes and risk factors.

BACKGROUND AND AIM OF THE STUDY: Valve replacement in children is problematic, and associated with high anticoagulation-related complications and increased reoperation requirements. Multiple valve replacement may further increase morbidity and worsen outcome. The results are reported of combined aortic valve replacement (AVR) and mitral valve replacement (MVR) in children. METHODS: The medical records of children who underwent simultaneous AVR and MVR between 1984 and 2004 were reviewed, and the short-term and long-term results and variables affecting outcomes explored. The mean duration of follow up was 9.7 +/- 6.6 years. RESULTS: A total of 84 patients (62 males, 22 females; mean age 15.0 +/- 2.2 years) was identified. The underlying pathology was mainly rheumatic (94%) and endocarditis (4%). Among the patients, 21 (25%) had undergone a prior cardiac surgery. The implanted valves were either mechanical (n = 71) or bioprosthetic (n = 13). The average aortic and mitral valve sizes were 22 mm and 29 mm, respectively. In total, 21 patients had concomitant cardiac surgery, most commonly tricuspid valve repair (n = 18). The mean cardiopulmonary bypass time and ischemic time were 142 +/- 47 min and 107 +/- 33 min, respectively. Survival at 30 days and at one year was 96% and 94%, respectively. The overall 15-year survival was 78% (bioprosthesis 92% versus mechanical 76%; p = 0.4). The 15-year freedom from cardiac reoperation was 59%, and 68% and 75% for mitral and aortic reoperation, respectively. Significant risk factors for reoperation were the use of a bioprosthetic valve (p = 0.003) and female gender (p = 0.03). Freedom rates from endocarditis, thromboembolic and bleeding complications at 15 years were 90%, 92%, and 96%, respectively. Among survivors, 95% were in NYHA class I/II. CONCLUSION: Children with rheumatic fever and endocarditis may require simultaneous AVR and MVR. Although the operative mortality is acceptable, patients continue to have constant attrition with time, especially those who have received mechanical prostheses. The risk of cardiac reoperation requirement is high in all patients. Despite the greater need for reoperation, bioprosthetic valves could be offered to selected patients, such as females and those who are non-compliant with anticoagulation regimens.

Intermediate results following complex biventricular repair of left ventricular outflow tract obstruction in neonates and infants.

OBJECTIVES: Although the majority of infants with severe left ventricular outflow tract obstruction (LVOTO) can be managed with balloon or surgical aortic valvotomy, a more complex biventricular repair may be required in a subset of infants with multi-level obstruction, failure of or complication to prior intervention. In the presence of normal left ventricle size and inflow, the Ross procedure is applied in patients with/without ventricular septal defect (VSD), while the Yasui procedure is applied only in those with VSD. We report mid-term outcomes in a single institution. METHODS: Thirty-five consecutive infants with severe LVOTO underwent complex biventricular repair using the Ross (n=21) or Yasui (n=14) procedure. Outcomes were studied using univariate and multivariable parametric models. RESULTS: The Ross procedure was done at a median age of 88 days (8-353 days), in 8/21 (38%) neonates. As many as 12/21 (57%) had prior catheter and/or surgical intervention. Concomitant procedures included arch reconstruction (n=4/21, 19%) and mitral valve repair (n=6/21, 29%). In addition, 14/21 (67%) had annular enlargement (modified Ross-Konno). Haemodynamic manifestation was isolated obstruction (n=10/21, 48%) or mixed obstruction/regurgitation (n=11/21, 52%). Survival was 81% at 1 month, 70% at 1 year and 63% at 5 years. In multivariable regression models, factors associated with increased risk of mortality included neonatal surgery (p=0.007), mitral valve repair (p=0.02), longer cross-clamp time (p=0.003), and postoperative extracorporeal membrane oxygenator (ECMO) (p=0.004). Freedom from any cardiac re-operation was 86% at 5 years. The Yasui procedure was done at a median age of 36 days (7-207 days), 6/14 (43%) in neonates. As many as 13/14 procedures (93%) were primary and one procedure followed a prior single-stage Norwood palliation. A total of 10/14 (71%) had critical aortic stenosis and 4/14 (29%) had atresia. All patients had VSD, and 11/14 (79%) required concomitant arch reconstruction. Survival was 79% at 1 month and 5 years while 5-year freedom from re-operation was 57%. CONCLUSIONS: Complex biventricular repair can be performed in neonates and infants with severe LVOTO with mid-term survival that is equivalent to that published following balloon or surgical aortic valvotomy. Associated lesions are significant factors that influence outcome and proper patient selection may further improve survival. In neonates with concomitant arch obstruction and VSD, the Yasui operation may be associated with lower early mortality risk. Neonates with concomitant mitral valve pathology may be better served with single ventricle palliation strategy.

The Ross procedure in children: preoperative haemodynamic manifestation has significant effect on late autograft re-operation.

OBJECTIVES: The Ross procedure is the aortic valve-replacement procedure of choice in children. Nonetheless, late autograft re-operation for dilatation and/or valve regurgitation is of concern. We examined whether preoperative haemodynamic manifestation (e.g., stenosis, regurgitation and mixed aortic valve disease) affected late re-operation risk. METHODS: Medical records of 227 children who underwent the Ross procedure (1991-2004) were reviewed. Competing-risks methodology determined time-related prevalence and associated factors for two mutually exclusive end-states after the Ross procedure: (1) death prior to subsequent autograft re-operation and (2) autograft re-operation, with the remainder of patients being alive and free from subsequent autograft re-operation. RESULTS: There were 162 male patients (71%) in this study. Median age at surgery was 12.1 years (range: 1 week-18 years). The haemodynamic aortic valve dysfunction was primarily stenosis (n=40, 18%), primarily regurgitation (n=109, 48%) and mixed disease (n=78, 35%). Underlying pathology was rheumatic fever (n=104, 46%), congenital heart disease (n=113, 50%) and endocarditis (n=8, 3%). Competing-risks analysis showed that, at 10 years following the Ross procedure, ∼5% of patients had died, 16% had undergone autograft re-operation with aortic valve replacement and 79% were alive and free from autograft re-operation. Ten-year freedom from autograft re-operation for patients with preoperative stenosis, regurgitation and mixed disease was 97%, 69% and 93%, respectively, (p<0.001 for regurgitation vs others). Risk factors for increased risk of autograft re-operation were rheumatic fever (parameter estimates (PEs): 2.09 ± 0.75, p=0.006), and earlier year of surgery (PE: 0.20 ± 0.06, p=0.001). Ten-year freedom from homograft replacement was 81% and was not dependent on haemodynamic manifestation (PE: -0.16 ± 0.38, p=0.68). Significant factors for homograft replacement included fresh homografts (PE: 2.2 ± 0.63, p=0.01) and annular enlargement (PE: 1.11 ± 0.3, p=0.01). Ten-year freedom from cardiac re-operation other than auto-/homograft was 85%, higher in patients with preoperative aortic regurgitation (PE: 1.01 ± 0.42, p=0.02). Concomitant cardiac surgery was a significant factor for late cardiac re-operation other than auto-/homograft replacement (PE: 1.79 ± 0.39, p<0.001). CONCLUSIONS: The Ross procedure in children is associated with excellent survival. Late autograft re-operation may be required; however, it is more common in children with preoperative aortic regurgitation, especially those with rheumatic fever. Better patient selection in later era has mitigated the risk of autograft re-operation. Continued improved candidate selection, along with modifications in autograft implantation and root/sinotubular stabilisation techniques, may further decrease late autograft failure.

Results after mitral valve replacement with mechanical prostheses in young children.

OBJECTIVE: We examined outcomes after mitral valve replacement in children younger than 8 years. METHODS: Medical records of patients who underwent mitral valve replacement from 1990 to 2006 were reviewed. Competing-risks methodology determined time-related prevalence and associated factors for death, repeated valve replacement, and survival without reoperation. RESULTS: In total, 79 patients, median age 24 months (40 days-8 years) underwent 91 mitral valve replacements (10 had repeated procedures). Underlying pathology was congenital heart disease in 95% of cases. Forty-six patients (58%) had undergone previous operations. Operative mortality was 18%, 30% for those 2-years old and younger and 6% for those older than 2 years. Competing-risks analysis showed that 10 years after initial mitral valve replacement, 40% of patients had died without repeated replacement, 20% had undergone a second replacement, and 40% remained alive without further replacement. Factors associated with death included higher prosthesis size/patient weight ratio (P < .0001) and longer crossclamp time (P < .0001). Second replacement 6 +/- 4 years after initial replacement was necessary for 10 survivors. At second replacement, larger prostheses were implanted (mean 24 mm vs 19 mm initially). Repeated MVR was associated with younger age at surgery (p = .006). Permanent pacemaker implantation was eventually needed by 11% of hospital survivors. CONCLUSIONS: Mortality and repeated valve replacement are common after mitral valve replacement in children younger than 8 years, especially younger patients with significantly oversized valves. At valve reoperation, larger prostheses could be implanted, suggesting continued annular growth.

Silent meningioma - a rare cause of stroke in post-cardiopulmonary bypass patients.

Stroke in cardiac patients undergoing surgery is usually attributed to the use of cardiopulmonary bypass. In this report, we present an unusual cause of cerebral dysfunction: a meningioma leading to stroke, following coronary artery bypass grafting in a 62-year-old patient. Diagnosis and treatment options of the pathology are discussed with the guidance of the literature.

Results of left atrioventricular valve reoperations following previous repair of atrioventricular septal defects.

OBJECTIVES: We report results of left atrioventricular valve reoperations (LAVVR) following atrioventricular septal defect (AVSD) repair and examine variables predictive of outcome. METHODS: Multiple demographics and operative variables were analyzed to determine factors affecting survival and reoperation. RESULTS: Forty patients following partial (n = 9) or complete (n = 31) AVSD repair underwent 47 LAVVR (1992-2005). Median age was 0.87 years (24 days-7.7 years) at initial AVSD repair and 3.15 years (84 days-13.6 years) at subsequent LAVVR with median interval between AVSD repair and LAVVR of 1.76 years (1 day-12.9 years). First LAVVR included repair (n = 20) or replacement (n = 20). Operative mortality was 10% and five-year survival was 76 +/- 6%. Significant risk factors were complete AVSD (p < 0.001), valve replacement (p < 0.001) for early death, and young age at time of LAVVR (p = 0.03) for late death. Five-year freedom from LAVV re-intervention was 100% for replacement versus 55 +/- 13% for repair (p = 0.006). Overall, ejection fraction increased to 61 +/- 3% versus 42 +/- 2% preoperatively (p < 0.01), and left-ventricle end-diastolic dimension Z-score decreased to 0.05 +/- 0.36 versus 3.1 +/- 0.3 preoperatively (p < 0.01). Eighty-seven percent of children were in New York Heart Association class I/II at latest follow-up. CONCLUSIONS: LAVVR results in significant clinical improvement and lasting recovery in ventricular chamber function and size. Valve repair offers survival advantage and should be aggressively attempted; however, it is only achievable in 50% of cases. Valve replacement is necessary in cases associated with complex LAVV morphology or following repair failure. At intermediate follow-up, patients continue to be at risk of major valve-related morbidity, requirement for re-intervention, and cardiac death.

Open heart surgery in patients with sickle cell hemoglobinopathy.

BACKGROUND: In patients with sickle cell trait or disease, reduced life expectancy and a tendency for complications are believed to negatively affect likelihood of survival after open heart surgery. The aim of this study was to review retrospectively the perioperative results of patients undergoing cardiac surgery at our institution. METHODS AND RESULTS: Between January 1995 and December 2006, 47 patients with either sickle cell disease or sickle cell trait underwent open heart surgery at our institution. The average age of the 29 male and 18 female patients was 20 years. Patient outcomes were analyzed through the use of the institutional database. Clinical and echocardiographic follow-up was complete in all patients except 3, with a mean follow-up period of 46 months. Current status could be confirmed in 32 patients. The most common operations included the treatment of congenital and valvular heart diseases. There were no coronary artery bypass grafting procedures. Average weight of the patients was 45 kg. Exchange transfusion was performed both preoperatively and during surgery. Mean preoperative hemoglobin S concentration was 30.4 + or - 3.2% and decreased to 8.1 + or - 2.6% while on pump. Average on-pump hematocrit value was 25.4 + or - 3.7%; in the postoperative period, it increased to 32.7 + or - 4.9%. Mean cardiopulmonary bypass and cross-clamp times were 95 and 69 minutes, respectively. None of the patients had sickling crisis or acidosis. Postoperative complications included exploration for hemorrhage in 3 patients (6.4%), stroke in 2 patients (4.3%), renal failure in 2 patients (4.3%), and prolonged ventilation in 1 patient (2.1%). Average hospital stay was 8.3 days (range, 4 to 27 days). Early in-hospital death occurred in 1 patient (2.1%); currently, 31 patients (66%) remain alive and free of cardiac symptoms. CONCLUSIONS: Heart valve surgery and surgery for congenital heart diseases can be performed safely in patients with sickle cell disease or sickle cell trait with acceptable outcome and survival rates.

The rastelli procedure for transposition of the great arteries: resection of the infundibular septum diminishes recurrent left ventricular outflow tract obstruction risk.

BACKGROUND: The Rastelli procedure is the standard surgical treatment of d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and pulmonary stenosis. Late morbidity is significant due to recurrent left ventricular outflow obstruction (LVOTO), early conduit obstruction, and arrhythmias, with troublesome late mortality. To avoid recurrent LVOTO, we routinely enlarge the VSD and resect the infundibular septum before LV baffling to the aorta. We examined the efficacy of this approach in mitigating recurrent LVOTO risk. METHODS: Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed. RESULTS: The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation. CONCLUSIONS: Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.

The prevalence, clinical characteristics, and prognosis of diastolic heart failure: a clinical study in elderly Saudi patients with up to 5 years follow-up.

Data from 519 patients older than 65 years with congestive heart failure (CHF) were analyzed after 5 years of clinical follow-up. Two groups were included in the analysis: 321 patients with ejection fractions > or =50% (group with diastolic heart failure) and 198 patients with reduced ejection fraction <50% (group with systolic heart failure). Hypertension (81%) was the strongest predictor of congestive heart failure, followed by diabetes (46%) and coronary disease (33%). Diastolic heart failure was more predominant in elderly female (P=.007), hypertensive (P=.0001), and hypertrophic (P=.001) patients. Length of hospital stay, readmission rate, all-cause morbidity, and cumulative mortality were not statistically significant between both groups (P=.09).

Aortic and mitral valve replacement in children: is there any role for biologic and bioprosthetic substitutes?

OBJECTIVE: The ideal valve substitute in children does not exist. Biologic and bioprosthetic valves do not require anticoagulation, however their use is complicated by accelerated degeneration and requirement for reoperation. We examine results following mitral (MVR) or aortic (AVR) replacement with biologic and bioprosthetic valves at our institution. METHODS: Medical records of children who underwent AVR or MVR from 1986 to 2006 were reviewed. Median follow-up duration was 10.5 years. Competing-risks methodology determined time-related prevalence and associated factors for three mutually exclusive end states: death, valve reoperation, and survival without subsequent reoperation. RESULTS: One hundred and ten children (age 15.6+/-2.6 years, 80% females) underwent 123 valve replacements with biologic and bioprosthetic substitutes including 87 MVR and 36 AVR (13 had both). Underlying pathology was mainly rheumatic fever (91%). Thirty-nine patients (35%) had undergone a previous cardiac surgery. Most common mitral substitute was Hancock (73%) and homograft (8%); most common aortic substitute was homograft (41%) and Carpentier-Edwards (39%). Competing-risks analysis showed that 15 years after valve replacement, 16% of patients had died without subsequent reoperation, 66% underwent valve reoperations, and only 18% remained alive without further reoperation. Factors associated with increased reoperation risk included younger age at surgery (p=0.005), AVR (p=0.005), male gender (p=0.02) and homograft use (p=0.007) especially in the mitral position (p=0.002). Fifteen-year freedom from endocarditis was 97% while freedom from bleeding and thrombo-embolic complications was 100%. Majority of patients (95%) were in NYHA functional classes I/II at last follow-up. CONCLUSION: While valve reoperation is inevitable following AVR and MVR with biologic and bioprosthetic substitutes; favorable results such as low valve-related morbidity rate, good long-term survival and functional status encourage their consideration as valid replacement alternatives in selected children especially females. Valve durability is higher in the mitral position and longevity of bioprosthetic valves is greater than that of homografts especially in the mitral position.

Mechanical valves versus the Ross procedure for aortic valve replacement in children: propensity-adjusted comparison of long-term outcomes.

OBJECTIVE: We aimed to identify characteristics differentiating children undergoing aortic valve replacement by using mechanical prostheses versus the Ross procedure and to compare survival and the need for aortic valve reoperation after each procedure. METHODS: From 1983 to 2004, 346 children underwent aortic valve replacement (215 underwent the Ross procedure and 131 underwent placement of a mechanical prosthesis). Factors associated with procedure choice were used to construct a propensity score for use as a covariate in regression models to adjust for potential confounding by indication. RESULTS: Patients undergoing the Ross procedure were younger, more likely to have a congenital cause, and less likely to have a rheumatic or connective tissue cause. They had a lower frequency of regurgitation, required more annular enlargement, and had less concomitant cardiac surgery. Competing-risk analysis showed that 16 years after aortic valve replacement, 20% of patients had died without subsequent aortic valve replacement, 25% underwent second aortic valve replacement, and 55% remained alive without further replacement. After propensity adjustment, factors associated with early-phase death included mechanical valves and a nonrheumatic cause. Mechanical valves were also associated with constant-phase mortality. Repeated aortic valve replacement was associated with the Ross procedure and a rheumatic cause. Both factors were also associated with all-cause cardiac reoperation. In children receiving mechanical prostheses, younger age and smaller valve size were significant risk factors for death. Freedom from homograft replacement after the Ross procedure was 82% at 16 years of follow-up. CONCLUSION: Results from this study showed good outcomes and an acceptable complication rate with both valve choices. Given the significantly increased risk of early and late death in younger children receiving smaller mechanical valves, the Ross procedure confers survival advantage in this age group at the expense of increased reoperation risk, especially in patients with a rheumatic cause.