Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons.

OBJECTIVE: The survey aimed to assess the practice patterns of Canadian cardiac surgeons on the size threshold at which patients with ascending aortic aneurysm would be offered surgery. METHODS: A 18-question electronic survey was electronically distributed to 148 practicing cardiac surgeons in Canada via email from January to August 2020. Questions presented clinical scenarios focusing on modifying a single variable, and respondents were asked to identify their surgical size threshold for each of the clinical scenarios. RESULTS: The individual response rate was 62.0% (91/148) and institutional response rate was 89.3% (25/29). For an incidental asymptomatic ascending aortic aneurysm in a 60-year-old otherwise-healthy male patient with a tricuspid aortic valve and bicuspid aortic valve of 1.9 m2, 20.2% of the respondents would recommend surgery when the aneurysm was <5.5 cm. A significant number of surgeons modified their surgical threshold in response to changes to BSA, bicuspid aortic valve, growth rate, age, occupation, symptom, and family history (P < .01). Notably, if the patient had a bicuspid aortic valve, 41.0% of respondents lowered their threshold for surgery, with only 43.0% recommending surgery at ≥5.5 cm (P < .01). CONCLUSIONS: Practice variations exist in the current size threshold for surgery of ascending aortic aneurysms in Canada. These differences between surgeons are further accentuated in the context of bicuspid aortic valve, smaller body stature, younger age, low growth rate, family history, and for the performance of isometric exercise. These represent important areas where future prospective studies are required to inform best practice.

How detrimental is reexploration for bleeding after cardiac surgery?

OBJECTIVE: To establish the risk factors and impact of reexploration for bleeding in a large modern cardiac surgical cohort. METHODS: At a tertiary referral center, baseline, index procedural, reexploration, outcome, and readmission characteristics of 16,793 consecutive adult cardiac surgery patients were prospectively entered into dedicated clinical databases. Correlates of reexploration for bleeding, as well as its association with outcomes and readmission, were examined with multivariable regression models. RESULTS: The mean patient age was 65.9 ± 12.1 years, and 11,991 patients (71.4%) patients were male. Perioperative mortality was 2.8% (458 of 16,132) in those who did not undergo reexploration for bleeding and 12.0% (81 of 661) in those who underwent reexploration for bleeding, corresponding to an odds ratio of 3.4 ± 0.5 (P <.001) over other predictors of mortality, including Euroscore II. Mortality was highest in patients who underwent reexploration after the day of index surgery (odds ratio, 6.4 ± 1.1). Hospital stay was longer in patients who underwent reexploration for bleeding (median, 12 days, vs 7 days in patients who did not undergo reexploration; P <.001), to an extent beyond any other correlate. Reexploration for bleeding also was independently associated with new-onset postoperative atrial fibrillation, renal insufficiency, intensive care unit readmission, and wound infection. Risk factors for reexploration for bleeding were tricuspid valve repair, on-pump versus off-pump coronary artery bypass grafting, emergency status, cardiopulmonary bypass (CPB) duration, low body surface area, and lowest CPB hematocrit of <24%. CONCLUSIONS: Reexploration for bleeding is a lethal and morbid complication of cardiac surgery, with a detrimental effect that surpasses that of any other known potentially modifiable risk factor. All efforts should be made to minimize the incidence and burden of reexploration for bleeding, including further research on transfusion management during CPB.

Long-Term Follow-Up of Outcomes With F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging-Assisted Management of Patients With Severe Left Ventricular Dysfunction Secondary to Coronary Disease.

BACKGROUND: Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)-assisted strategy in patients with suspected ischemic cardiomyopathy. When patients adhered to F-18-fluorodeoxyglucose PET recommendations, outcome benefit was observed. Long-term outcomes of viability imaging-assisted management have not previously been evaluated in a randomized controlled trial. METHODS AND RESULTS: PARR-2 randomized patients with severe left ventricular dysfunction and suspected CAD being considered for revascularization or transplantation to standard care (n= 195) versus PET-assisted management (n=197) at sites participating in long-term follow-up. The predefined primary outcome was time to composite event (cardiac death, myocardial infarction, or cardiac hospitalization). After 5 years, 105 (53%) patients in the PET arm and 111 (57%) in the standard care arm experienced the composite event (hazard ratio for time to composite event =0.82 [95% confidence interval 0.62-1.07]; P=0.15). When only patients who adhered to PET recommendations were included, the hazard ratio for the time to primary outcome was 0.73 (95% confidence interval 0.54-0.99; P=0.042). CONCLUSIONS: After a 5-year follow-up in patients with left ventricular dysfunction and suspected CAD, overall, PET-assisted management did not significantly reduce cardiac events compared with standard care. However, significant benefits were observed when there was adherence to PET recommendations. PET viability imaging may be best applied when there is likely to be adherence to imaging-based recommendations. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00385242.

Clinical Impact of Changes in Left Ventricular Function After Aortic Valve Replacement: Analysis From 3112 Patients.

BACKGROUND: Our objectives were to identify correlates of mortality and congestive heart failure after aortic valve replacement (AVR) according to preoperative left ventricular (LV) function and to describe the incidence, time course, and correlates of LV recovery and mass regression postoperatively. METHODS AND RESULTS: A total of 3112 patients with AVR were assessed in a follow-up clinic with echocardiography (median follow-up, 6.0 years). At operation, their mean age was 67.8±13.4 years, one third were female, and 29% had LV dysfunction (ejection fraction <50%). In severe patients with severe aortic stenosis and LV dysfunction, transaortic valve mean pressure gradient <40 mm Hg, longer cardiopulmonary bypass duration, and prosthesis-patient mismatch (indexed effective orifice area ≤0.85 cm(2)/m(2)) were independent correlates of the composite outcome of death or congestive heart failure after AVR. In patients with severe aortic regurgitation and LV dysfunction, older age and higher preoperative LV mass were identified. LV recovery correlated with better survival and freedom from heart failure in patients with aortic stenosis. Maximum LV mass regression took 24 months in patients with aortic stenosis and nearly 5 years with aortic regurgitation; independent correlates included smaller LV end-systolic diameter in patients with aortic stenosis and low New York Heart Association class with aortic regurgitation. CONCLUSIONS: Incomplete LV recovery, prosthesis-patient mismatch, low transaortic valve pressure gradient, and higher LV mass are associated with increased mortality or heart failure after AVR in patients with LV dysfunction. Higher LV end-systolic diameter and symptoms correlate with less LV mass regression, which takes at least 2 years. These findings help surgeons and cardiologists refine the indications, timing, prognostication, and follow-up of patients before and after AVR.

Endovascular treatment for cerebral septic embolic stroke.

This case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke.

Cerebral microembolization after bioprosthetic aortic valve replacement: comparison of warfarin plus aspirin versus aspirin only.

BACKGROUND: No human physiological data exists on whether aspirin only is as effective as warfarin plus aspirin in preventing cerebral microembolization in the early postoperative period after bioprosthetic aortic valve replacement (bAVR). METHODS AND RESULTS: We prospectively enrolled 56 patients who had no other indication for oral anticoagulation, who underwent bAVR and received, in an open-label fashion, either daily warfarin (for INR 2.0-3.0) plus 81 mg of aspirin (n=28) or 325 mg of aspirin only (n=28). Cerebral microembolization was quantified at 4 hours (baseline) and at 1 month postoperatively, by recording 1-hour bilateral middle cerebral artery (MCA) microembolic signals (MES). Platelet-function analysis (PFA) of closure times (CT) on collagen was also used as a marker of platelet-dependent activation. Follow-up to 1 year was complete. Preoperative demographics and baseline platelet function were equivalent in both groups. There was no mortality, stroke, or transient ischemic attack at 1 year in either group. No significant differences were found in the proportion of patients with MES among those receiving warfarin plus aspirin versus aspirin only, at baseline (68% versus 82%, respectively; P=0.4) and at 1 month (46% versus 43%; P=1.0) after bAVR. The total MES and PFA were also equivalent between groups, at baseline and follow-up. CONCLUSIONS: Early after bAVR, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bAVR in patients who have no other indication for oral anticoagulation.

Long-term evaluation of biological versus mechanical prosthesis use at reoperative aortic valve replacement.

OBJECTIVES: Recent evidence indicated that the use of a bioprosthesis in young patients at first-time aortic valve replacement (AVR) is associated with an increased reoperation risk, but not with an increase in long-term mortality, when compared with the use of a mechanical valve. However, at reoperative AVR, follow-up data by prosthesis type have been lacking from the literature. Therefore, we examined long-term survival and valve-related complications according to the type of prosthesis used at reoperative AVR. METHODS: We studied 437 patients who underwent reoperative AVR, at a mean age of 58.6 ± 14.2 years, for failure of a previously implanted aortic valve prosthesis. Thirty-day mortality at reoperative AVR was 6% (n = 27). A bioprosthesis was used in 135 (31%) patients. Patients were subsequently followed up for a mean of 7.6 ± 6.8 years after reoperative AVR. RESULTS: The use of a bioprosthesis at reoperative AVR was not associated with impaired survival on adjusted analysis (hazard ratio [HR], 0.8 ± 0.4; P = .6). Freedom from thromboembolism, and endocarditis were similar between valve types (both P > .05); however, late postoperative major hemorrhage occurred only in patients who received a mechanical prosthesis at reoperative AVR. Risk factors for third-time AVR included the use of a bioprosthesis (HR, 14.0) and younger age (HR, 1.05 per decreasing year) at reoperative AVR (both P < .001). Thirty-day mortality of third-time AVR was 4% (n = 1/27). CONCLUSIONS: At reoperative AVR, the use of a bioprosthesis is associated with equivalent long-term survival compared with a mechanical prosthesis. Patients who receive a bioprosthesis at reoperative AVR are less likely to experience major hemorrhage but more likely to require third-time AVR, albeit with an acceptable third-time perioperative mortality risk. Therefore, the patient's informed preferences regarding prosthesis choice should prevail, even in a reoperative context.

Statin therapy and saphenous vein graft disease after coronary bypass surgery: analysis from the CASCADE randomized trial.

BACKGROUND: Current guidelines recommend statin therapy after coronary artery bypass grafting (CABG) to attain low-density lipoprotein (LDL) levels less than 100 mg/dL. Whether achieving LDL levels less than 70 mg/dL improves postoperative graft patency remains unknown. METHODS: The CASCADE (Clopidogrel after Surgery for Coronary Artery Disease) trial was a randomized study that evaluated the addition of clopidogrel to aspirin on the development of saphenous vein graft disease after CABG. Patients received the standard of care regarding postoperative statin therapy with targeted LDL levels less than 100 mg/dL. Twelve months postoperatively, patients returned for a coronary angiogram and saphenous vein graft (SVG) intravascular ultrasonogram. In this post hoc analysis, the impact of statin therapy on graft patency and vein graft intimal hyperplasia was assessed. RESULTS: LDL levels significantly declined over the period of the trial (p = 0.002). Twelve months postoperatively, 58.4% patients achieved LDL levels less than 70 mg/dL. Twelve-month graft patency was higher for patients with LDL levels less than 100 mg/dL (96.5%) compared with patients with LDL levels >100 mg/dL (83.3%, p = 0.03), even after adjustment in multivariate analysis (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.3-21.6; p = 0.02). However, no improvement in graft patency was noted with further LDL reduction to less than 70 mg/dL (p = 1.00). Consistent statin use throughout the trial period was independently associated with less vein graft intimal hyperplasia documented by intravascular ultrasound at 12 months (p = 0.04). CONCLUSIONS: Statin therapy to achieve LDL levels less than 100 mg/dL was independently associated with improved graft patency in the CASCADE trial. Randomized clinical trials are warranted to prospectively evaluate postoperative LDL reduction to less than 70 mg/dL and its impact on graft patency after CABG.

Reoperation of left heart valve bioprostheses according to age at implantation.

BACKGROUND: Evidence supporting the use of bioprostheses for heart valve replacement in young adults is accumulating. However, reoperation data, which may help guide clinical decision making in young patients, remains poorly defined in the literature. METHODS AND RESULTS: We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823). There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259). The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age. Multivariable risk factors associated with reoperation following bioprosthetic AVR include age (hazard ratio [HR] 0.94 per year, 95% CI 0.91 to 0.96, P<0.001) and concomitant coronary artery bypass grafting (HR 0.34, 95% CI 0.11 to 0.99, P=0.04). The median interval to reoperation of contemporary mitral bioprostheses was 8.11 years (95% CI 5.79 to 16.50 years) in patients less than 40 years, and 10.14 years (95% CI 8.64 to 11.14 years) in patients between 40 and 60 years of age. As for AVR, age (HR 0.96 per year, 95% CI 0.95 to 0.98, P<0.001) and concomitant coronary artery bypass grafting (HR 0.55, 95% CI 0.32 to 0.93, P=0.03) were associated with decreased reoperation risk following bioprosthetic MVR. CONCLUSIONS: These data constitute clinically relevant age-specific prognostic information regarding reoperation in young patients, who may wish to select a bioprosthesis at initial left heart valve replacement.

Long-term clinical and hemodynamic performance of the Hancock II versus the Perimount aortic bioprostheses.

BACKGROUND: The Medtronic Hancock II and the Carpentier-Edwards Perimount are among the world's most commonly used aortic bioprostheses. However, a direct comparison of their clinical performance is lacking. To minimize biases inherent to between-center comparisons, we examined these prostheses within a large, contemporary, single-center cohort. METHODS AND RESULTS: Between 1990 and 2007, 1659 patients (mean age, 73.1±9.3 years) underwent aortic valve replacement with either the Hancock II (N=1021) or the Perimount (N=638). Patients were prospectively followed-up with serial clinic visits and echocardiograms for up to 16 years (mean, 5.0±3.3 years). There was no significant difference in aortic root size preoperatively (P=0.7). Aortic root enlargement was more commonly performed with the Perimount (P<0.001), and the manufacturer valve size of the implanted prosthesis was larger with the Hancock II (P<0.001). Postoperatively, peak and mean transprosthesis gradients were higher for the Hancock II (32.7±0.7 and 16.0±0.3 mm Hg, respectively) than for the Perimount (24.9±0.7 and 13.4±0.4 mm Hg, respectively; P<0.001). However, no difference in left ventricular mass regression was observed at late follow-up (P=0.9). Unadjusted 10-year survival was 59.4%±2.4% for the Hancock II and 70.2%±3.8% for the Perimount (P=0.07). Multivariable predictors of survival did not include prosthesis type (P=0.2). CONCLUSIONS: For the same manufacturer valve size, the Perimount is larger, which may warrant enlarging the aortic root more often, and it is associated with better hemodynamics than the Hancock II. These differences do not impact survival or left ventricular mass regression, and the long-term clinical performances of the Hancock II and Perimount bioprostheses are equivalent.

Postoperative lipid-lowering therapy and bioprosthesis structural valve deterioration: justification for a randomised trial?

OBJECTIVE: Bioprosthesis structural valve deterioration (SVD) is an incompletely understood process involving the accumulation of calcium and lipids. Whether this process could be delayed with lipid-lowering therapy (LLT) is currently unknown. The purpose of this observational study was to evaluate if an association exists between early LLT and a slowing of bioprosthesis SVD, with a view to designing a prospective trial. METHODS: We followed 1193 patients who underwent aortic valve replacement with contemporary bioprostheses between 1990 and 2006 (mean follow-up 4.5+/-3.1 years, maximum 17.3 years). Of these patients, 150 received LLT (including statins) early after surgery. Prosthetic valve haemodynamics on echocardiography and freedom from re-operation for SVD were compared between patients who did and did not receive postoperative LLT. RESULTS: After bioprosthetic implantation, the progression of peak and mean trans-prosthetic gradients during echocardiographic follow-up (mean 3.3 years) was equivalent between patients treated with and without LLT (peak increase: 0.9+/-7.7 vs 1.1+/-10.9 mmHg, LLT vs no LLT, P=0.87; mean increase: 0.8+/-4.1 vs 0.2+/-5.9 mmHg, LLT vs no LLT, P=0.38). The annualised linear rate of gradient progression following valve replacement was also similar between groups (peak increase per year: 2.0+/-12.1 vs 1.0+/-12.9 mmHg per year, LLT vs no LLT, P=0.52; mean increase per year: 0.5+/-2.2 vs 0.6+/-6.0 mmHg per year, LLT vs no LLT, P=0.94). The incidence of mild or greater aortic insufficiency on the most recent echocardiogram was comparable (16.3% vs 13.8%, LLT vs no LLT, P=0.44), and there was no difference in the 10-year freedom from re-operation for SVD between the two groups [98.9% (95% confidence interval (CI): 91.9%, 99.8%) vs 95.4% (95% CI 90.5%, 97.9%), LLT vs no LLT, P=0.72]. CONCLUSIONS: In this observational study, there was no association demonstrated between early postoperative LLT and a slowing of bioprosthesis SVD. With the excellent durability of bioprostheses in the current era, a prospective randomised trial of statin therapy to prevent bioprosthetic SVD does not appear to be justified, let alone feasible.

Relationship between natriuretic peptides and inflammation: proteomic evidence obtained during acute cellular cardiac allograft rejection in humans.

BACKGROUND: Cardiac natriuretic peptides (NPs) atrial natriuretic factor (ANF) and brain natriuretic peptide (BNP) are polypeptide hormones secreted by the heart. Previously, we found that BNP, but not ANF, plasma levels may increase during an acute cellular cardiac allograft rejection episode. In vitro, the pro-inflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) produced a selective increase of BNP gene expression and secretion. Other pro-inflammatory cytokines had no such effects. METHODS: We identified cytokines associated with the selective upregulation of BNP during cardiac allograft rejection using a proteomics approach to measure 120 cytokines and related substances in the plasma of 16 transplant patients before, during and after an acute rejection episode. The values obtained were correlated with BNP plasma levels. Cytokines identified as being significantly related to BNP plasma levels were tested in neonatal rat ventricular cardiocytes in culture for their ability to selectively promote BNP secretion. The signaling pathway related to this phenomenon was pharmacologically characterized. RESULTS: Regulated-on-activation, normal T-expressed and secreted (RANTES), neutrophil-activating protein-2 (NAP-2) and insulin growth factor binding protein-1 (IGFBP-1) had significant correlations with BNP plasma levels during Grade 3A (Grade 2 revised [2R]) or above rejection as diagnosed by endomyocardial biopsy score according to the International Society for Heart and Lung Transplantation (ISHLT) grading system. In rat neonatal ventricular cardiocyte cultures, IGFBP-1 and RANTES were capable of promoting BNP, but not ANF secretion, as observed in rejecting patients. The BNP-promoting secretion activity of the identified cytokines was abolished by SB203580, a specific p38 MAP kinase inhibitor. CONCLUSIONS: This work shows that cytokines other than pro-inflammatory cytokines correlate with BNP plasma levels observed during acute cardiac allograft rejection, and that the substances identified have in common p38 signaling. This finding provides a unifying mechanistic explanation regarding the relationship between inflammation and cardiac hormone production in acute cardiac allograft rejection.

Enlargement of the small aortic root during aortic valve replacement: is there a benefit?

BACKGROUND: Aortic root enlargement (ARE) at the time of aortic valve replacement (AVR) is an often proposed but still unproven technique to prevent prosthesis-patient mismatch. To evaluate the risks and benefits of ARE, we examined the outcomes of patients with small aortic roots who underwent AVR with or without the use of ARE. METHODS: Patients (n = 712) with small aortic roots who underwent AVR were prospectively followed (follow-up, 3,730 patient-years; mean, 5.2 +/- 4.1 years). All patients had a small aortic annulus that would have led to the insertion of an aortic prosthesis of 21 or less in size. Multivariate techniques were used to compare outcomes between patients who underwent AVR alone (n = 540) versus AVR plus ARE (n = 172). RESULTS: Aortic cross-clamp times were 9.9 minutes longer in the AVR+ARE group (p = 0.0002). There were no differences in reopening or stroke rates or perioperative mortality (all p = not significant). All patients in the AVR-alone group received size 19 to 21 prostheses, whereas 51% of the AVR+ARE patients received size 23 prostheses. Postoperative gradients were reduced (p < 0.01) and indexed effective orifice areas were larger (p < 0.0001) in the AVR+ARE group. While the incidence of postoperative prosthesis-patient mismatch (indexed effective orifice area < or = 0.85 cm2/m2) was lower in the AVR+ARE group (p < 0.0001), the presence of mismatch did not significantly impact long-term outcomes after surgery. The ARE was associated with a trend toward better freedom from late congestive heart failure (p = 0.19), but not an improvement in long-term survival (p = 0.81). CONCLUSIONS: For patients with small aortic roots, ARE at the time of AVR is a safe procedure that reduces postoperative gradients and the incidence of prosthesis-patient mismatch. However, ARE does not appreciably improve long-term clinical outcomes.

Very long-term survival implications of heart valve replacement with tissue versus mechanical prostheses in adults <60 years of age.

BACKGROUND: Several centers favor replacing a diseased native heart valve with a tissue rather than a mechanical prosthesis, even in younger adult patients. However, long-term data supporting this approach are lacking. We examined the survival implications of selecting a tissue versus a mechanical prosthesis at initial left-heart valve replacement in a cohort of adults <60 years of age who were followed for over 20 years. METHODS AND RESULTS: Comorbid and procedural data were available from 6554 patients who underwent valve replacement at our institution over the last 35 years. Of these, 1512 patients contributed follow-up data beyond 20 years, of whom 567 were adults <60 years of age at first left-heart valve operation (mean survivor follow-up, 24.0+/-3.1 years). Late outcomes were examined with Cox regression. Valve reoperation, often for prostheses that are no longer commercially available, occurred in 89% and 84% of patients by 20 years after tissue aortic and mitral valve replacement, respectively, and was associated with a mortality of 4.3%. There was no survival difference between patients implanted with a tissue versus a mechanical prosthesis at initial aortic valve replacement (hazard ratio 0.95; 95% CI: 0.7, 1.3; P=0.7). For mitral valve replacement patients, long-term survival was poorer than after aortic valve replacement (hazard ratio 1.4; 95% CI: 1.1, 1.8; P=0.003), but again no detrimental effect was associated with use of a tissue versus a mechanical prosthesis (hazard ratio 0.9; 95% CI 0.5, 1.4; P=0.5). CONCLUSIONS: In our experience, selecting a tissue prosthesis at initial operation in younger adults does not negatively impact survival into the third decade of follow-up, despite the risk of reoperation.

The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement.

OBJECTIVES: The incidence of patient-prosthesis mismatch after mitral valve replacement and its effect on late outcomes have remained unclear. This study was conducted to determine the impact of patient-prosthesis mismatch on recurrent congestive heart failure, postoperative pulmonary hypertension, and late survival after mitral valve replacement. METHODS: Between 1985 and 2005, 884 patients, with a mean age 63 +/- 12 years, underwent mitral valve replacement (657 mechanical, 227 bioprosthesis) with contemporary prostheses. Mean clinical and echocardiographic follow-up was 5.1 +/- 4.1 years (4344 patient-years). Patient-prosthesis mismatch was defined as an indexed effective orifice area of 1.25 cm2/m2 or less. Parametric and nonparametric analyses were used to determine predictors of outcomes. RESULTS: The incidence of patient-prosthesis mismatch was 32%. Predictors of recurrent congestive heart failure included low indexed effective orifice area, low ejection fraction, elevated postoperative mean mitral gradient, and use of a bioprosthesis (P < or = .05). Postoperative pulmonary hypertension was associated with small mitral size, elevated mean mitral gradient, low ejection fraction, and atrial fibrillation (P < or = .05); indexed effective orifice area did not predict postoperative pulmonary hypertension (P = .89). Poor late survival was predicted by low indexed effective orifice area (< or =1.25 cm2/m2), New York Heart Association class 3 or 4, elevated right ventricular pressure, stroke, older age, coronary artery disease, and bioprosthesis use (P < or = .05). Survival for patients with patient-prosthesis mismatch versus those without patient-prosthesis mismatch at 1, 3, 5, and 10 years was 91% versus 95%, 85% versus 90%, 78% versus 86%, and 65% versus 75%, respectively (P = .05). CONCLUSIONS: Patient-prosthesis mismatch after mitral valve replacement is not uncommon; it is associated with recurrence of congestive heart failure and postoperative pulmonary hypertension and independently affected late survival. This study emphasizes the importance of implanting a sufficiently large prosthesis in adult patients undergoing mitral valve replacement.

Management of acute severe perioperative failure of cardiac allografts: a single-centre experience with a review of the literature.

BACKGROUND: Early graft failure is associated with high mortality and is the main cause of death within the first 30 days after transplantation. The purpose of the present study was to examine the investigators' experience of severe perioperative acute graft failure and to review the literature. METHODS: Nine of 385 cardiac transplants (2.3%) performed from 1984 through 2005 developed severe perioperative acute graft failure either in the operating room or within 24 h after cardiac transplantation. Four patients had primary graft failure, two had right heart failure secondary to pulmonary hypertension, one had hyperacute rejection, one had accelerated acute rejection and one possibly sustained a particulate coronary embolus intraoperatively. RESULTS: All except the two patients who had right heart failure secondary to pulmonary hypertension received mechanical circulatory support. Three patients were supported with total artificial hearts, two patients received a left ventricular assist device, one patient was supported with extracorporeal life support followed by a right ventricular assist device when the left ventricle recovered, and one patient was supported for several hours with cardiopulmonary bypass. Three patients were retransplanted after mechanical circulatory support, but only one survived. Only one of the nine patients (11%) survived; this patient was supported with a total artificial heart followed by retransplantation. CONCLUSION: The outcome of severe perioperative acute graft failure is very poor. Mechanical circulatory support and retransplantation are not as successful as in other situations. Due to the shortage of donors and poor outcomes, retransplantation for hyperacute rejection is not advisable.

Combined atrial fibrillation ablation with mitral valve surgery.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the efficacy and outcome of radiofrequency (RF) atrial fibrillation (AF) ablation in patients undergoing mitral valve (MV) surgery. METHODS: Between March 2002 and December 2004, 61 patients (mean age 65.4 +/- 10 years) underwent isolated endo-left atrial AF ablation using a unipolar RF device (Cardioblate; Medtronic, USA) in conjunction with 34 MV repairs and 27 MV replacements. AF was paroxysmal in 13 patients (21%), and permanent in 48 (79%), with a mean duration of 3.6 +/- 3.5 years. The etiology was degenerative in 35 patients (57%), rheumatic in 17 (28%), and ischemic in nine (17%). All patients received amiodarone postoperatively. RESULTS: No patients died during the study, and there were no thromboembolic complications. All patients had intraoperative conversion. Forty-one patients (67%) presented with postoperative relapse; definitive conversion was achieved in 34 (83%) cases within three months. The overall success rate was 75.4% at 14 +/- 8.8 months; success was greater in the MV repair group (85%) than in the MV replacement group (66.7%), though not significantly so (p = 0.09). Factors associated with definitive conversion included smaller left atrial size (p = 0.007), decreased left ventricular end-diastolic diameter (p = 0.04), and NYHA class I (p = 0.05). Age, AF duration and etiology were not associated with conversion, but associated coronary artery bypass grafting showed a strong trend towards significance (p = 0.07). In these patients, AF duration did not predict conversion to sinus rhythm. CONCLUSION: Combined AF ablation with MV surgery is safe and effective. Although AF ablation seems more beneficial with MV repair, the success rate may vary significantly according to patient characteristics.

Mechanical versus bioprosthetic valve replacement in middle-aged patients.

OBJECTIVE: The current trend towards decreasing the age for selection of a tissue over a mechanical prosthesis has led to a dilemma for patients aged 50-65 years. This cohort study examines the long-term outcomes of mechanical versus bioprosthetic valves in middle-aged patients. METHODS: Patients (N = 659) aged between 50 and 65 years who had first-time aortic valve replacement (AVR) and/or mitral valve replacement (MVR) with contemporary prostheses were followed prospectively after surgery. The total follow-up was 3,402 patient-years (mean 5.1 +/- 4.1 years; maximum 18.3 years). Outcomes were examined with multivariate actuarial methods. A composite outcome of major adverse prosthesis-related events (MAPE) was defined as the occurrence of reoperation, endocarditis, major bleeding, or thromboembolism. RESULTS: Ten-year survival was 73.2 +/- 4.2% after mechanical AVR, 75.1 +/- 12.6% after bioprosthetic AVR, 74.1 +/- 4.6% after mechanical MVR, and 77.9 +/- 7.4% after bioprosthetic MVR (P=NS). Ten-year reoperation rates were 35.4% and 21.3% with aortic and mitral bioprostheses, respectively. Major bleeding occurred more often following mechanical MVR (hazard ratio [HR]: 3.3; 95% confidence interval [CI] 1.2, 9.0; P = 0.022), and the incidence of any thromboembolic event was more common after mechanical MVR (HR: 4.7; CI 1.4, 13.3; P = 0.01). Overall freedom from MAPE at 10 years was 70.2 +/- 4.1% for mechanical AVR patients, 41.0+/-30.3% for bioprosthetic AVR patients, 53.3 +/- 8.8% for mechanical MVR patients, and 61.2 +/- 9.2% for bioprosthetic MVR patients. Although a trend existed towards more MAPE amongst middle-age patients with tissue valves, multivariate analysis did not identify the presence of a bioprosthesis as an independent risk factor for MAPE (HR: 1.3; CI 0.9, 2.0; P = 0.22). CONCLUSIONS: In middle-aged patients, MAPE may occur more often in patients with bioprosthetic valves, but definitive conclusions necessitate the accumulation of additional follow-up. At present, these data do not support lowering the usual cutoff for implantation of a tissue valve below the age of 65.

Papillary fibroelastoma of the pulmonary valve.

There is a lack of information regarding the diagnosis and management of papillary fibroelastoma of the pulmonary valve due to the rarity of the tumour at this location. A case of pulmonary valve papillary fibroelastoma in a 60-year-old woman is reported and the approach for diagnosis and management is described.