16S rDNA sequencing of valve tissue improves microbiological diagnosis in surgically treated patients with infective endocarditis.

OBJECTIVES: The aim was to evaluate 16S rDNA sequencing in heart valves in patients with infective endocarditis undergoing surgery. METHODS: Fifty-seven patients with infective endocarditis were examined in this prospective study by analysing heart valves with 16S rDNA sequencing and culturing methods and comparing the results to blood cultures. As controls, heart valves from 61 patients without any signs of endocarditis were examined. RESULTS: All together 77% of the endocarditis patients were positive for 16S rDNA, 84% had positive blood cultures and 23% had positive cultures from heart valves, whereas only 16% of the cultures from heart valves were concordant with results from blood cultures or 16S rDNA. Concordant results between 16S rDNA sequencing and blood cultures were found in 75% patients. All controls were negative for 16S rDNA. In 4 out of 9 patients with negative blood cultures, the aetiology was established by 16S rDNA alone, i.e. viridans group streptococci. CONCLUSION: In this Swedish study, 16S rDNA sequencing of valve material was shown to be a valuable addition in blood culture-negative cases. The value of heart valve culture was low. Molecular diagnosis using 16S rDNA sequencing should be recommended in patients undergoing valve replacement for infective endocarditis.

Survival and quality of life in cardiac surgery patients with prolonged intensive care.

BACKGROUND: The clinical outcome in discharged cardiac surgery patients after prolonged postoperative intensive care needs further investigation. The aim was to study survival, functional status, and quality of life in cardiac surgery patients with more than 10 days postoperative intensive care unit stay. METHODS: We performed a population-based study including 4,086 cardiac surgery patients and identified 141 patients who had a postoperative intensive care unit stay of more than 10 days. Data regarding patients and outcome were collected, and all discharged patients alive in May 2008, or a family member, were contacted to assemble information regarding functional status and quality of life using the Karnofsky performance scale and the Short Form-36 questionnaire. RESULTS: Early mortality was 33%. Risk factors for early mortality were advanced age and postoperative dialysis. Survival at 1, 3, and 5 years was 62%, 56%, and 52%, respectively. Ninety-five patients were discharged from the hospital, and during a mean follow-up of 1.9 years, 62% were readmitted at least once. In discharged patients, 65% had a Karnofsky score of 80 or more. We found significantly lower physical (39.7 versus 43.6; p = 0.03), and mental (44.1 versus 50.8; p = 0.001) scores in the study group compared with a reference group. CONCLUSIONS: Early mortality was high, especially in patients who required dialysis. However, long-term survival and functional status were encouraging. Quality of life was worse compared with the general population in both physical and mental aspects, but the difference was moderate. Extensive efforts in this patient group seem reasonable despite high resource utilization.

Catheter-guided open ligation of a pulmonary artery to left atrium connection.

Congenital malformations causing mild cyanosis can be overlooked. A large intrapulmonary right pulmonary artery to left atrium connection was the unusual etiology of arterial oxygen desaturation and erythrocytosis in an asymptomatic 30-year-old patient. The shunt was not possible to detect at echocardiography. It was closed via a median sternotomy without the aid of cardiopulmonary bypass. A novel technique was to use an angiographic catheter inserted through the wide shunt into the left atrium before the operation to securely identify it at the surgical dissection.

Hemodynamics at rest do not match clinical improvement after surgical ventricular restoration.

OBJECTIVES: The aim was to study the change in cardiac index (CI) and pulmonary artery pressure (PAP) by intra-cardiac measurements after surgical ventricular restoration (SVR) in patients with left ventricular aneurysm and symptoms of heart failure. Aspects of functional improvement were analyzed as secondary outcomes. DESIGN: Mean PAP and CI were obtained before and 6 months postoperatively in 22 patients who underwent SVR. RESULTS: There were no significant changes in CI (2.3 vs. 2.4 L/min/m(2); p=0.91) or mean PAP (22 vs. 22 mmHg; p=0.64) at rest before and six months after surgery. Left ventricular ejection fraction improved from 25 to 38% (p<0.001). Before surgery 15 patients (68%) were in NYHA class III-IV and 6 months after the operation 19 (86%) patients were in NYHA class I-II (p<0.001). CONCLUSIONS: Invasive hemodynamic measurements under resting conditions do not correspond well to the significant clinical improvement noted in these patients. Studies during exercise conditions are necessary to further evaluate this procedure.

Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control.

OBJECTIVES: Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR). DESIGN: The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers. RESULTS: Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia. CONCLUSIONS: Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: the Karolinska approach.

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery.

BACKGROUND AND AIMS: To identify pre-operative risk factors for delirium in patients undergoing elective cardiac surgery, using clearly defined diagnostic criteria for delirium, and a thorough clinical assessment. METHODS: The incidence of post-operative delirium in 107 patients >or=60 years undergoing elective cardiac surgery was calculated. None of the patients included suffered from dementia. Pre-operative cognitive function in all patients was assessed using the Mini Mental State Examination (MMSE) and post-operative delirium was diagnosed using the Confusion Assessment Method (CAM). Post-operative clinical and cognitive assessments were carried out for all patients. RESULTS: Twenty-five patients (23.4%) developed delirium post-operatively. Clinical parameters, including age, gender, co-morbidities, medications, and peri-operative parameters, were similar in patients with and without post-operative delirium. Patients with pre-operative subjective memory complaints and lower MMSE scores, undergoing valve operation or valve + coronary artery bypass grafting (CABG), exhibited an increased risk of developing post-operative delirium. Additionally, delirious patients had a significant decline in post-operative MMSE score compared with the non-delirious ones. CONCLUSIONS: The main pre-operative risk factors for post-operative delirium after elective cardiac operations were subjective memory complaints, mild cognitive impairment, and type of cardiac surgery, such as valve procedures. This study suggests that cognitive evaluation should be included in pre-operative assessment.

Edge-to-edge mitral repair without annuloplasty in combination with surgical ventricular restoration.

BACKGROUND: Functional mitral regurgitation is common in ischemic dilated cardiomyopathy. Edge-to-edge repair is an option for correction and can be performed through the ventriculotomy during surgical ventricular restoration (SVR). This report describes the durability of the edge-to-edge repair without annuloplasty in combination with SVR. METHODS: From March 1997 to July 2002, 31 patients with left ventricular aneurysm or ischemic dilated cardiomyopathy and functional ischemic mitral regurgitation grade II (n = 18), III (n = 10), and IV (n = 3) underwent SVR and edge-to-edge repair without annuloplasty with concomitant coronary artery bypass grafting. Long-term valve competence was assessed by echocardiography. Early and late survival and hospital readmission for heart failure were analyzed. RESULTS: Early mortality was 5 (16%) of 31 patients. At 1, 3, and 5 years, actuarial survival was 77%, 55%, and 48%. The cumulative follow-up was 117 patient-years (4.5 years mean follow-up). Late echocardiograms performed at a mean of 3.1 years postoperatively showed patients had mitral regurgitation at grade 0 (n = 4), I (n = 10), II (n = 9), and III (n = 1). Two patients underwent reoperation owing to grade III-IV recurrent mitral regurgitation. Freedom from hospital readmission or cardiac death was 56% at 1 year and 48% at 3 years. CONCLUSIONS: Combined mitral valve repair and SVR carries high operative risk and long-term prognosis is worse than after SVR alone. The edge-to-edge repair without annuloplasty for functional ischemic mitral regurgitation seems to be fairly durable in conjunction with SVR. To improve results a transventricular annuloplasty may be added.

Improved health-related quality of life and functional status after surgical ventricular restoration.

BACKGROUND: Surgical ventricular restoration (SVR) has been shown to improve hemodynamics and survival among patients with coronary artery disease, left ventricular aneurysm, and heart failure. The aim of this study was to investigate functional status and health-related quality of life after SVR. METHODS: Over a period of 2 years beginning in March 2003, 23 patients with left ventricular aneurysm and depressed left ventricular function were included in a prospective study. Functional status and quality of life was analyzed preoperatively, 6 months postoperatively, and at late follow-up by assessment of New York Heart Association (NYHA) functional class, 6-minute walk test, and the Medical Outcome Study 36-Item Short Form. RESULTS: There was no early mortality. Before surgery, 17 patients (74%) were in NYHA class III to IV; and 6 months after SVR, 20 patients (87%) were in NYHA class I to II (p < 0.001). At late follow-up, (mean, 22 months postoperatively), all patients alive (n = 20) were in NYHA class I to II. Mean 6-minute walk distance increased by 41 meters (p = 0.06) at 6 months postoperatively and by 57 meters (p = 0.03) at late follow-up. Quality of life, assessed by the physical component summary score of the Medical Outcome Study 36-Item Short Form, improved significantly (p = 0.04) at 6 months postoperatively. A significant and clinically relevant improvement in both physical aspects (+25%, p < 0.001) and mental aspects (+37%, p = 0.003) of quality of life was found at late follow-up. CONCLUSIONS: Functional status and quality of life improved 6 months after SVR, and the improvement was sustained at late follow-up almost 2 years after surgery.

Changes in B-type natriuretic peptides after surgical ventricular restoration.

OBJECTIVE: The aim of this study was to prospectively investigate changes in brain natriuretic peptide (BNP) and amino terminal pro-BNP (NT-pro-BNP) in relation to functional status after surgical ventricular restoration (SVR). METHODS: Between March 2003 and May 2006, 29 patients (20 men and 9 women, mean age 65 years, mean ejection fraction 24%) with post-infarction left ventricular aneurysm and depressed left ventricular function underwent SVR according to the Dor technique at our institution. Twenty-two patients (76%) were in New York heart association (NYHA) functional class III or IV. Multi-vessel disease was present in 26 patients. Natriuretic peptides, functional status, ejection fraction and left ventricular volumes were analyzed at baseline, after 6 months, and late postoperatively. RESULTS: There was no early mortality. Survival at 24 months was 93%. Six months postoperatively 25/29 (86%) patients were in NYHA class I and II (p<0.001) and at late (mean 21 months) follow-up, all patients were in NYHA class I and II. There was a persistent reduction of NT-pro-BNP (2406 pg/ml vs 1510 pg/ml; p=0.03 and 975 pg/ml; p=0.03) and BNP (312 pg/ml vs 228 pg/ml; p=0.12 and 191 pg/ml; p=0.20) 6 months postoperatively and at late follow-up, respectively. Ejection fraction improved from 24% to 37% (p<0.001) at 6 months. End-diastolic (110 ml/m(2) vs 90 ml/m(2), p=0.009) and end-systolic (75 ml/m(2) vs 52 ml/m(2), p=0.006) volume index were reduced at 6 months. Functional improvement correlated significantly with reduction in BNP (r=0.61, p=0.01) and NT-pro-BNP (r=0.58, p=0.003) 6 months after surgery. Ejection fraction correlated inversely with BNP (r=-0.58, p=0.02) and NT-pro-BNP (r=-0.51, p=0.04), and end-systolic volume correlated with BNP (r=0.65, p=0.03) and NT-pro-BNP (r=0.62, p=0.03) 6 months after surgery. CONCLUSIONS: Heart failure secondary to post-infarction left ventricular remodeling can be reversed by SVR. Improvement in these patients was associated with reduced levels of B-type natriuretic peptides 6 months after surgery. Clinical improvement was maintained and peptide levels were further reduced at late follow-up.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration.

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Risk factors for mortality and hospital re-admission after surgical ventricular restoration.

BACKGROUND: Surgical ventricular restoration is an option in patients with coronary artery disease, heart failure, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aims of this study were to investigate survival and re-admission for heart failure and to identify predictors for early and long-term mortality and re-admission after surgical ventricular restoration. METHODS: Pre- and postoperative data were collected for 136 consecutive patients who underwent surgical ventricular restoration for postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy during 1994-2005. Survival and risk factors for mortality and hospital re-admission were analyzed by using multivariable models. RESULTS: Early mortality was 10/136 (7.4%). At 1, 3, 5 and 9 years overall actuarial survival was 89%, 80%, 68% and 62%. Increasing age, diabetes and mitral regurgitation grade III-IV were associated with an increased risk for late mortality. Freedom from re-hospitalization due to heart failure or cardiac death in operative survivors at 1, 3 and 5 years was 78%, 72% and 58%. Risk factors for re-hospitalization or cardiac death in operative survivors were increasing age and increasing grade of mitral regurgitation. CONCLUSIONS: Surgical ventricular restoration by the Dor procedure can achieve good long-term survival and a high degree of freedom from readmission for heart failure in patients with advanced ischemic heart disease. We found a strong association between increasing grade of mitral regurgitation and both long-term mortality and re-admission for heart failure.

Left ventricular reconstruction as an alternative to heart transplantation: a case report.

A 57-year-old man with dilated cardiomyopathy was referred to our institution to be assessed for heart transplantation. He had symptoms of severe heart failure and left ventricular dysfunction. We proposed surgical ventricular restoration (the Dor procedure) as an alternative to heart transplantation. The patient underwent successful surgery and an uneventful postoperative course. Pre- and postoperative investigations are presented. One year after surgery, the patient is in good clinical and functional condition. This case illustrates that surgical ventricular restoration can be an alternative to heart transplantation.