Thirty-year experience with a bileaflet mechanical valve prosthesis.

BACKGROUND: The objective was to evaluate the long-term outcomes of the St Jude Medical (Saint Paul, Minn) mechanical valve prosthesis implantation. METHODS: Since 1979, every patient receiving this prosthesis has been followed annually. RESULTS: From January 1979 to December 2014, 1023 patients were accrued. Patients' ages ranged from 18 to 85 years. Aortic valve replacement was performed in 584 patients, and mitral valve replacement was performed in 439 patients. Follow-up was 95% complete. Operative mortality was 3% (17/584, aortic valve replacement) and 4% (18/439, mitral valve replacement). In patients undergoing aortic valve replacement, late actuarial survival was 62% ± 2%, 32% ± 2%, and 14% ± 3% at 10, 20, and 30 years, respectively. Thirty-year freedom from reoperation, thromboembolism, valve thrombosis, bleeding, and endocarditis was 92% ± 2%, 79% ± 3%, 96% ± 1%, 56% ± 5%, and 92% ± 2%, respectively. In patients undergoing mitral valve replacement, late actuarial survival was 64% ± 3%, 28% ± 3%, and 14% ± 3% at 10, 20, and 30 years, respectively. Thirty-year freedom from reoperation, thromboembolism, valve thrombosis, bleeding, and endocarditis was 85% ± 5%, 55% ± 6%, 99% ± 1%, 57% ± 6%, and 95% ± 2%, respectively. The incidence of bleeding was 2.5% and 2.0% per patient-year for aortic valve replacement and mitral valve replacement, respectively. The incidence of thromboembolism was 1.6% and 2.9% per patient-year for aortic valve replacement and mitral valve replacement, respectively. CONCLUSIONS: Annual follow-up of all of our patients receiving a St Jude Medical mechanical valves prosthesis has allowed better identification valve-related issues and events. After 3 decades of observation with close follow-up, the St Jude Medical mechanical valve continues to be a reliable prosthesis.

Apicoaortic conduits: indications, complications, and imaging techniques.

Left ventricular apex to descending aorta conduits may be used as a last resort treatment of severe left ventricular outflow tract obstruction in cases in which alternative therapies are contraindicated. Although this technique is rarely used in current practice for congenital cases, its use in the elderly population is increasing, largely due to the expansion of this patient cohort and associated comorbidities precluding aortic valve replacement, the most common of which are a severely calcified "porcelain" aorta and/or previous coronary artery bypass grafts preventing aortic root manipulation. Diagnostic imaging is essential in the presurgical workup and subsequent follow-up of these patients, as complications of the procedure are potentially life threatening and are not rare. Several imaging modalities may be used, each with advantages and disadvantages. Both anatomic and functional assessments play a role in the comprehensive evaluation of both presurgical and postsurgical patients.

Early postoperative outcomes and blood product utilization in adult cardiac surgery: the post-aprotinin era.

BACKGROUND: Aprotinin was a commonly used pharmacological agent for homeostasis in cardiac surgery but was discontinued, resulting in the extensive use of lysine analogues. This study tested the hypothesis that early postoperative adverse events and blood product utilization would affected in this post-aprotinin era. METHODS AND RESULTS: Adult patients (n=781) undergoing coronary artery bypass, valve replacement, or both from November 1, 2005, to October 31, 2008, at a single institution were included. Multiple logistic regression modeling and propensity scoring were performed on 29 preoperative and intraoperative variables in patients receiving aprotinin (n=325) or lysine analogues (n=456). The propensity-adjusted relative risk (RR) for the intraoperative use of packed red blood cells (RR, 0.75; 95% confidence interval [CI], 0.57 to 0.99), fresh frozen plasma (RR, 0.37; 95% CI, 0.21 to 0.64), and cryoprecipitate (RR:0.06; 95% CI, 0.02 to 0.22) were lower in the aprotinin versus lysine analog group (all P<0.05). The risk for mortality (RR, 0.53; 95% CI, 0.16 to 1.79) and neurological events (RR, 0.87; 95% CI, 0.35 to 2.18) remained similar between groups, whereas a trend for reduced risk for renal dysfunction was observed in the aprotinin group. CONCLUSIONS: In the post-aprotinin era, with the exclusive use of lysine analogues, the relative risk of early postoperative outcomes such as mortality and renal dysfunction have not improved, but the risk for the intraoperative use of blood products has increased. Thus, improvements in early postoperative outcomes have not been realized with the discontinued use of aprotinin, but rather increased blood product use has occurred with the attendant costs and risks inherent with this strategy.

Combined carotid endarterectomy and coronary artery bypass grafting versus coronary artery bypass grafting alone: a retrospective review of outcomes at our institution.

BACKGROUND: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. METHODS: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. RESULTS: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. DISCUSSION: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone.

Pacemaker and internal cardioverter defibrillator lead extraction: a safe and effective surgical approach.

BACKGROUND: Need for pacemaker or internal cardioverter defibrillator lead removal is increasing. Removal can be dangerous, difficult, or unsuccessful. METHODS: We retrospectively reviewed our results and the techniques we used in 365 patients from 1992 through 2009 for successful complete removal of leads and complications. Various techniques of extraction were analyzed for effectiveness and complications. The eras before (1992 to 1999) and after the availability of laser sheath extraction (2000 to 2009) are compared. RESULTS: Of 365 patients who underwent transvenous lead extraction, of which 235 were infected, and 130 had lead removal for noninfectious indication. Staphylococcus aureus was the infecting organism in 40%, and coagulase-negative Staphylococcus occurred in 33%. One-half of the organisms were methicillin resistant. Preimplant risk factors for infection included more than one device implant procedure in 105 (47%), preimplant Coumadin therapy (Bristol-Myers Squibb, Princeton, NJ) in 74 (31%), and hemodialysis in 9 (4%). Laser extraction became available in 2000. The era with the availability of laser extraction was associated with a better complete extraction rate (93% vs 89.55%) a lower bleeding rate (1.9% vs 3.1%), and complete extraction without the additional use of femoral workstation extraction tools. Mortality was 1.1%. No death was due to device removal. All deaths were the result of severe preoperative and continuing postextraction sepsis. CONCLUSIONS: A lead extraction protocol that included procedures done in an operating room environment allowing rapid, open intervention for bleeding, a varied choice of extraction tools, arterial line monitoring, transesophageal echocardiography, general anesthesia, and an experienced team yielded complete extraction in more than 90% of patients, with a low complication rate and no procedurally related deaths.

Twenty-five year experience with the St. Jude medical mechanical valve prosthesis.

BACKGROUND: We evaluated all adult St. Jude mechanical valve recipients at our institution since the initial implant in January 1979 and now present our 25-year experience. METHODS: Nine hundred forty-five valve recipients were followed prospectively at 12-month intervals from January 1979 to December 2007. RESULTS: Operative mortality was 3% in the aortic valve recipients and 5% in the mitral valve recipients. Follow-up was 95% complete. Among aortic valve recipients, late actuarial survival was 81% +/- 2%, 59% +/- 2%, 41% +/- 3%, 28% +/- 3%, and 17% +/- 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five-year freedom from reoperation, thromboembolism, bleeding, and endocarditis was 90% +/- 2%, 69% +/- 5%, 67% +/- 3%, and 9% 3 +/- 2% respectively. Among mitral valve recipients late actuarial survival was 84% +/- 2%, 63% +/- 3%, 44% +/- 3%, 31% +/- 3%, and 23% +/- 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five-year freedom from reoperation, thromboembolism, bleeding and endocarditis was 81% +/- 10%, 52% +/- 8%, 64% +/- 6%, and 97% +/- 1%. Freedom from valve-related mortality and morbidity at 25 years was 26% +/- 7% and 29% +/- 6% for aortic and mitral valve replacement, respectively. Freedom from valve-related mortality was 66% +/- 8% and 87% +/- 3% for aortic and mitral valve replacement, respectively. CONCLUSIONS: These results compare favorably with those for other mechanical prostheses. After two and a half decades of observation with close follow-up, the St. Jude mechanical valve continues to be a reliable prosthesis.

Removal of embedded central venous catheters.

BACKGROUND/PURPOSE: Long-term central venous access devices (CVAD) play an integral role in the management of children who require nutritional support, chemotherapy, blood drawing, and transfusion of blood products. Infrequently, the CVAD may be difficult or impossible to remove with traction. PATIENT POPULATION: Four patients, with ages ranging from 6 to 13 years, had 4 CVAD in place for 431, 730, 2232, and 3285 days which could not be removed by manual traction and local exploration. RESULTS: With the use of technology developed for removal of embedded transvenous pacemaker catheters, each CVAD was successfully dislodged using a lead locking device (n = 3) or a lead locking device and an excimer laser (n = 1). There were no complications of the procedure in our series. CONCLUSIONS: There is no consensus on optimal management of embedded CVADs. In this small series, devices used routinely to remove embedded transvenous pacemaker wires were used to extract 4 embedded CVADs without complication; however, use of this technology in pediatric surgical patients is controversial because a small percentage of adult cases have resulted in tamponade or hemothorax, potentially resulting in death. Selection of patients and use of the technology in the appropriate setting are important considerations in weighing the risks vs the benefits of extracting such catheters or leaving them in place.

Use of recombinant activated factor VII concentrate to control postoperative hemorrhage in complex cardiovascular surgery.

BACKGROUND: Complex cardiovascular surgery often results in postoperative hemorrhage. Excessive blood product use may cause systemic thrombosis, end-organ dysfunction, and edema preventing chest closure. Recombinant activated factor VII (rFVIIa) concentrate may decrease hemorrhage where other treatment measures failed. We reviewed our experience with rFVIIa after complex cardiovascular surgery. METHODS: A retrospective review evaluating 846 complex cardiovascular surgery patients of whom 36 received rFVIIa between January 1, 2001, and December 31, 2006, was performed. Efficacy and safety data were collected for the entire cohort in addition to delayed sternal closure requirements, reoperation, and operative mortality in the patient cohort temporally separated into two groups (pre-rFVIIa era, 2001 to 2003, 1 patient received rFVIIa; rFVIIa era, 2004 to 2006, 35 patients received rFVIIa). RESULTS: A total of 36 patients received 41 rFVIIa doses with an in-hospital survival of 91.7%. Hemorrhage was controlled in 83.3% of patients, with 1 dose sufficient in 75.0%. There was a significant decrease (p < 0.005) in all blood product requirements post-rFVIIa compared with pre-rFVIIa administration. In the intensive care unit (n = 6), rFVIIa significantly reduced chest tube output (p = 0.028) and prevented reexploration for bleeding in 5 patients. The requirement for delayed sternal closure was significantly higher in the pre-rFVIIa era versus the rFVIIa era (p = 0.011). The incidence of thrombosis in all patients receiving rFVIIa was 11.1%. In the rFVIIa era, a higher incidence of postoperative renal failure (p = 0.005) and pneumonia (p < 0.002) was detected in patients receiving rFVIIa. CONCLUSIONS: Recombinant activated factor VII appears to be effective in patients with refractory coagulopathy undergoing high-risk cardiovascular surgery.

Outcomes of a cardiothoracic intensive care web-based online intravenous insulin infusion calculator study at a Medical University Hospital.

BACKGROUND: The purpose of this study was to examine whether a web-based, on-line intravenous insulin (IVI) infusion calculator (IVIIC) program for the delivery of IVI therapy in coronary artery bypass graft (CABG) patients was superior to a prior IVI protocol used in the cardiothoracic intensive care unit at our institution. METHODS: The study included 97 CABG patients studied from October 2004 to February 2005 pre-protocol (type 2 diabetes) and October 2005 to February 2006 post-protocol (with or without type 2 diabetes). The IVIIC was programmed to resemble an algorithm whereby any patient with type 2 diabetes or a blood glucose (BG) greater than 120 mg/dL was started on IVI with an insulin sensitivity factor, a multiplier of 0.03. The calculator used the following mathematical formula: rate of insulin infusion/hour = (current BG - 60 mg/dL) x 0.03. RESULTS: Pre- and post-protocol groups for patients with type 2 diabetes were similar in all demographics measured, including initial age, mean age, percentage female, and percentage African-American. Significant differences were observed between pre- and post-protocol groups in mean BG recorded over a 48-h period (P < 0.0001), percentage not at target within 48 h (P < 0.0001), mean hours to first BG between 80 to 120 mg/dL (P < 0.0001), mean hours to target (three consecutive BGs 80-120 mg/dL) (P < 0.0001), and hyperglycemic index (P < 0.0001). The incidence of hypoglycemia (percentage BG < 70 mg/dL) was not significantly increased in the post-protocol groups (P = 0.2581). CONCLUSIONS: We conclude that the IVIIC is a safe nurse-driven protocol with excellent BG outcomes.

Valve surgery in renal dialysis patients.

BACKGROUND AND AIM OF THE STUDY: Mechanical valves are used in dialysis patients due to the presumed rapid degeneration of tissue valves. The study aim was to compare the results of mechanical and tissue valves placed in renal dialysis patients. METHODS: Information obtained from a computer-based valve replacement database, telephone interviews and patient charts was reviewed for follow up data. RESULTS: Between 1991 and 2004, 50 dialysis patients underwent left-sided valve replacement. Of these patients, 17 received 21 St. Jude Medical mechanical valves (12 aortic, nine mitral), and 33 received 39 tissue valves (19 aortic, 20 mitral). The mean follow up for the mechanical and tissue valve groups was 19.4 +/- 21.3 and 21.4 +/- 18.7 months, respectively. Mortality at four years was 65% (11/17) for the mechanical valve group, and 42% (14/33) for the tissue valve group (p = 0.15). Freedom from reoperation was not significantly different. The tissue valve group had significantly higher Kaplan-Meier freedom from thromboembolism (100% versus 75 +/- 15%, p = 0.01), hemorrhage (97 +/- 3% versus 44 +/- 17%, p = 0.002), valve-related morbidity (74 +/- 9% versus 42 +/- 16%, p = 0.043), and valve-related morbidity and mortality (69 +/- 9% versus 37 +/- 14%, p = 0.037) at three years. Linearized rates of hemorrhage (21 versus 2%/pt-yr; p = 0.005), valve-related morbidity (36 versus 12%/pt-yr; p = 0.02) and valve-related morbidity and mortality (50 versus 17%/pt-yr; p = 0.008) were all significantly higher in the mechanical valve group. CONCLUSION: Dialysis patients had poor survival; prosthetic valve degeneration was negligible. Incidences of thromboembolism, bleeding and valve-related morbidity and mortality were higher with mechanical valves. Linearized, as opposed to actuarial, analysis further accentuated the unacceptably high rates of complications and death with mechanical valves.

Cardiac transplantation in South Carolina: 300 transplants.

For nearly 20 years, the Medical University's Heart Transplant Program has been providing the citizens of South Carolina with excellent results with a minimum of delay. We present here the results of our first 300 heart transplants, spanning the first 18 years of the Cardiac Transplant Program at the Medical University. Overall survival has been very good, with one, five and ten year survival rates in the adults being 92 +/- 2%, 78 +/- 3%, and 58 +/- 4%. The children's group showed survival rates of 94 +/- 5%, 79 +/- 11%, and 79 +/- 11% over the same lengths of time. Most recently, the federally sponsored Scientific Registry of Transplant Recipients (www.ustransplant.org, July 2005) reports for MUSC a one-year survival of 97.67% and three-year survival of 90.74%; both leading the Southeast. We attribute this success to the dedicated work of health care workers at all levels who believe in attention to detail and that the patient always comes first. It is our hope that we will be able to continue to provide expert, state-of-the-art, cardiac transplant services long into the future, while continuing to expand our heart failure management program as dictated by further developments in this rapidly evolving specialty.

Preoperative statin treatment is associated with reduced postoperative mortality and morbidity in patients undergoing cardiac surgery: an 8-year retrospective cohort study.

BACKGROUND: Cardiac surgical procedures can be associated with significant morbidity and mortality. Recently, it has been recognized that statins might induce multiple biologic effects independent of lipid lowering that could potentially ameliorate adverse surgical outcomes. Accordingly, this study tested the central hypothesis that pretreatment with statins before cardiac surgery would reduce adverse postoperative surgical outcomes. METHODS: Demographic and outcomes data were collected retrospectively for 3829 patients admitted for planned cardiac surgery between February 1994 and December 2002. Statin pretreatment occurred in 1044 patients who were comparable with non-statin-pretreated (n = 2785) patients with regard to sex, race, and age. Primary outcomes examined included postoperative mortality (30-day) and a composite morbidity variable. RESULTS: The odds of experiencing 30-day mortality and morbidity were significantly less in the statin-pretreated group, with unadjusted odds ratios of 0.43 (95% confidence interval [CI], 0.28-0.66) and 0.72 (95% CI, 0.61-0.86), respectively. Risk-adjusted odds ratios for mortality and morbidity were 0.55 (95% CI, 0.32-0.93) and 0.76 (95% CI, 0.62-0.94), respectively, by using a logistic regression model and 0.51 (95% CI, 0.27-0.94) and 0.71 (95% CI, 0.55-0.92), respectively, in the propensity-matched model, demonstrating significant reductions in 30-day morbidity and mortality. In a subsample of patients undergoing valve-only surgery (n = 716), fewer valve-only patients treated with statins experienced mortality, although these results were not statistically significant (1.96% vs 7.5%). CONCLUSIONS: These findings indicate that statin pretreatment before cardiac surgery confers a protective effect with respect to postoperative outcomes.

Papaverine delivery to the internal mammary artery pedicle effectively treats spasm.

BACKGROUND: Left internal mammary artery spasm is well recognized during coronary artery bypass operations. Papaverine has been used by many surgeons to maximize mammary artery flow perioperatively, but the best delivery method is not known. We analyzed two techniques used at our institution. METHODS: Fifty-eight patients were randomized into three groups to compare papaverine's ability to prevent spasm and to treat established spasm. Group 1 was control and no treatment was employed. In group 2, papaverine was injected with a blunt needle through the endothoracic fascia parallel to the mammary artery before harvest to assess spasm prevention. In group 3, papaverine was delivered perivascular in an identical manner to group 2 but after the mammary artery was dissected from the chest wall. This group was an evaluation of spasm treatment. Drug dosage was the same for both groups and routine bypass grafting was performed. Before anastomosing the mammary artery to the left anterior descending artery, blood flow was recorded for 15 seconds and flow per minute calculated. Cardiopulmonary bypass pressures were maintained at 70 mm Hg during collection. RESULTS: Mean blood flows were: group 1 = 86.2 mL/min, group 2 = 122.5 mL/min, and group 3 = 139.7 mL/min. Left internal mammary artery flow in group 3 was statistically different from control (p = 0.0457). Group 2 flow approached but did not reach statistical significance (p = 0.0874). Mammary artery dissection times for the three groups were not different. CONCLUSIONS: Papaverine delivery to the left internal mammary artery after dissection treats spasm effectively, improves blood flow at the time of its anastamosis to the left anterior descending artery, and avoids any risk of intimal injury. Injection of papaverine before mammary artery harvest does not shorten dissection time, and flow is not statistically improved.

A prospective, randomized study of endothelin and postoperative recovery in off-pump versus conventional coronary artery bypass surgery.

OBJECTIVE: The objectives are 2-fold: (1). to serially determine endothelin (ET) levels in arterial vascular compartments in patients undergoing coronary artery bypass surgery using either cardiopulmonary bypass or off-pump techniques, and (2). to define potential relationships between endothelial levels and specific perioperative parameters of patient recovery. METHODS: In a prospective, randomized study, endothelin plasma content was measured from patients undergoing coronary artery bypass grafting using either off-pump techniques (OPCAB group, n = 25) or conventional cardiopulmonary bypass (CPB group, n = 25) before surgery, before and after coronary artery anastomosis, and 6 and 24 hours postoperatively. Specific indices of patient recovery including pulmonary artery pressures, ventilation requirement, and hospital stay were documented for patients in both study groups. RESULTS: Postoperative systemic arterial ET levels were significantly increased by 200% in the CPB group and 50% in the OPCAB group. ET levels remained significantly higher in the CPB group relative to the OPCAB group throughout the postoperative period of observation (p < 0.05). Pulmonary artery pressures, ventilation requirement, and hospital stay were significantly increased in patients in the CPB group. CONCLUSIONS: Postoperative ET levels were higher in patients who underwent CPB for coronary artery bypass surgery. Increased ET in the postoperative period may contribute to a more complex recovery from coronary artery bypass surgery in patients undergoing cardiopulmonary bypass.

Twenty-year experience with the St Jude Medical mechanical valve prosthesis.

BACKGROUND: We have prospectively followed all adult St Jude Medical mechanical valve recipients at the Medical University of South Carolina since the initial implant in January 1979 and now present our 20-year experience. METHODS: We prospectively followed 837 valve recipients (aortic valve replacement; n = 478; mitral valve replacement; n = 359) from January 1979 to December 2000 at 12-month intervals. RESULTS: Ages ranged from 19 to 84 years. Follow-up averaged (mean +/- standard deviation) 7 +/- 5 years (98% complete). Patients were in New York Heart Association class III or IV in 77% (aortic valve replacement) and 89% (mitral valve replacement) preoperatively. A 19-mm valve was implanted in 15.5% of aortic valve replacement patients. Coronary bypass was required in 31% of aortic valve replacements and 20% of mitral valve replacements. Operative mortality was 17/478 (3.6%) in aortic valve replacement and 19/359 (5.3%) in mitral valve replacement, and multivariable predictors were 19-mm valve size, 3 or more coronary bypass grafts, and New York Heart Association class IV for aortic valve replacement and New York Heart Association class IV and age for mitral valve replacement. Actuarial survivorship at 10 and 20 years was 57% +/- 3% and 26% +/- 5% for aortic valve replacement and 61% +/- 3% and 39% +/- 4% for mitral valve replacement. Multivariable predictors of late death were African-American ethnicity, New York Heart Association class III or IV, coronary bypass, and age for aortic valve replacement and New York Heart Association class III or IV, coronary bypass, and age for mitral valve replacement. For aortic valve replacement, effective orifice area was univariately (P =.002) but not multivariately (P =.378) predictive of late death. Structural valve deterioration was not observed. For aortic valve replacement, actuarial freedom (at 10 and 20 years) from reoperation was 93% +/- 1% and 90% +/- 2%; thromboembolism, 82% +/- 3% and 68% +/- 8%; bleeding events, 77% +/- 3% and 66% +/- 6%; prosthetic valve endocarditis, 94% +/- 1% and 94% +/- 1%; valve-related mortality, 94% +/- 2% and 86% +/- 4%; and valve-related mortality or morbidity, 58% +/- 3% and 32% +/- 8%. For mitral valve replacement, actuarial freedom (at 10 and 20 years) from reoperation was 96% +/- 1% and 90% +/- 3%; thromboembolism, 77% +/- 3% and 59% +/- 7%; bleeding events, 86% +/- 2% and 65% +/- 8%; prosthetic valve endocarditis, 98% +/- 1% and 96% +/- 2%; valve-related mortality, 89% +/- 0.2% and 74% +/- 8%; and valve-related mortality or morbidity, 63% +/- 3% and 29% +/- 7%. CONCLUSIONS: After 2 decades of observation with close follow-up, the St Jude Medical mechanical valve continues to be a reliable prosthesis.

Traumatic disruption of the fibrous skeleton of the heart, with injury of the tricuspid and mitral valves, aortic annulus, and ventricular septum.

In an automobile accident, a young man sustained blunt trauma to the chest that caused injury to the fibrous skeleton of the heart. The mitral and tricuspid valves and their annuli were lacerated, the aortic annulus was separated from the ventricular septum, and the ventricular septum was disrupted; however, with surgical management, the patient survived.