Coronary ostium topography: an implication for transcatheter aortic valve implantation?

OBJECTIVES: Shorter distances from coronary ostia to the calcified aortic valve may result in occlusion with potential infarction during transcatheter aortic valve implantation. We hypothesized that preoperative CT-scan measurements might predict coronary occlusion. METHODS: Distances from the coronary ostia to the calcified aortic valve were measured during open heart aortic valve replacement in 60 consecutive patients. Distances were compared to preoperative CT-scan measurements evaluating distance of the coronary ostia as well (n = 15). RESULTS: The distances of the lower lip of the left and the right coronary artery ostia measured from the aortic annulus were 14.7 ± 3.9 mm and 13.4 ± 4.0 mm, respectively. The left, right and noncoronary cusp heights were 13.9 ± 2.5 mm, 12.8 ± 3.0 mm and 13.3 ± 3.1 mm, respectively. Coronary ostia topography indicated variations from the middle to the noncoronary commissure in 40% for the left and 63% for the right coronary ostium. CT-scan based measurements resulted in a distance of 12.8 ± 3.5 mm for the left and 13.9 ± 4.0 mm for the right coronary ostium, compared to 14.2 ± 4.2 mm and 13.5 ± 4.3 mm measured intraoperatively. A mild correlation between both measurements could be observed (r = 0.374, P = 0.188, left and r = 0.46, P = 0.09, n = 15). CONCLUSIONS: CT-scan-based measurements differed from the intraoperative measurements, however preoperative CT-scan evaluation may be a useful tool to identify patients with short distance of coronaries.

Risk of aortic valve replacement in patients with aortic stenosis and chronic obstructive pulmonary disease.

BACKGROUND AND AIM OF THE STUDY: Patients with aortic stenosis (AS) and chronic obstructive pulmonary disease (COPD) have been considered at high risk for aortic valve replacement (AVR), which results in some patients being denied this life-saving operation. Hence, the study aim was to assess the operative, 30-day, and long-term mortality in individuals with COPD undergoing AVR for AS in the modern surgical era. METHODS: This retrospective cohort of patients had documented COPD (FEV1/FVC < 70%), and underwent isolated AVR for severe AS between 1993 and 2007 at the Mayo Clinic in Rochester, MN. RESULTS: Of the 68 patients who met the study criteria, 27 had mild/moderate COPD (FEV1 > 50%), 35 had severe COPD (FEV1 30-50%), and six had very severe COPD (FEV1 < 30%). The overall operative and 30-day mortality was 4.8%. More severe COPD was associated with a longer stay in the intensive care unit (42 h for mild/moderate versus 115 h for severe/very severe: p = 0.02), but did not influence the operative or 30-day mortalities. Female gender was associated with an increased length of hospital stay. Long-term mortality was significantly higher in patients with a history of cerebrovascular disease (HR 4.3, p < 0.001), NYHA class III or IV heart failure (class III HR 2.79, p = 0.05; class IV HR 3.97, p = 0.03), and increased age (HR 1.06, p = 0.003). The severity of COPD was an independent risk factor for long-term mortality. CONCLUSION: Patients with severe AS and COPD are at an acceptable risk for AVR (30-day mortality < 5%). The severity of COPD is not associated with an increased in-hospital or 30-day mortality, but does influence long-term mortality.

Does metabolic syndrome influence bioprosthetic mitral valve degeneration and reoperation rate?

BACKGROUND: Evidence suggests that metabolic syndrome (MbS) is associated with early senescence of bioprosthetic aortic valve prostheses. The purpose of this study was to determine whether MbS is also associated with accelerated failure of bioprosthetic valves prostheses in the mitral position. METHODS: Records of all patients undergoing bioprosthetic mitral valve replacement (MVR) from 1993 to 2000 were reviewed. RESULTS: Of 114 patients undergoing bioprosthetic MVR, 48 (42%) had MbS. Mean age was 73 years (vs. 74 years for no MbS). Patients underwent MVR for regurgitation (n = 97; 85%), stenosis (n = 12; 11%), or mixed lesions (n = 4; 4%). Etiology was degenerative (n = 35; 32%), rheumatic (n = 26; 24%), ischemic (n = 30; 28%), calcific (n = 9; 8%), and endocarditis (n = 8; 8%). Mean follow-up was 4.5 years. Overall survival at 5 and 10 years was 56% and 26%, respectively. Survival was similar between groups (p = 0.15). Five patients (2 MbS; 4% vs. 3 no MbS; 5%) required mitral reoperation at a mean of 3.8 years after initial MVR. The risk of prosthetic valve failure was not different between groups (p = 0.66). Despite no initial difference in transmitral gradients, gradients beyond five-year follow-up were greater for those with MbS (6.8 mmHg MbS vs. 4.7 mmHg no MbS, p = 0.007). Independent predictors of gradient progression beyond two years were MbS (p = 0.027) and female gender (p = 0.012). There were no significant differences in valve area, regurgitation, or ejection fraction. CONCLUSIONS: Although overall survival following bioprosthetic MVR is challenging, MbS did not predict diminished survival or excess reoperative risk compared to non-MbS patients. The trend toward more rapid progression of transprosthetic gradients in MbS patients warrants further investigation.

A prospective, randomized, double-blind trial of 3 regimens for sedation and analgesia after cardiac surgery.

OBJECTIVE: The aim of this study was to evaluate cardiac risk as a consideration for selecting postoperative sedation and analgesia regimens used for cardiac surgical patients requiring cardiopulmonary bypass and early extubation. DESIGN: An observer-blind, randomized, controlled trial. SETTING: A tertiary referral medical center involving an intensive care unit. PARTICIPANTS: One hundred forty-five adults requiring elective cardiac surgery. INTERVENTIONS: Patients were stratified preoperatively as low, moderate, or high cardiac risk based on established criteria and then assigned to 1 of 3 postoperative regimens: propofol infusion beginning at 25 µg/kg/min and morphine boluses (P), fentanyl infusion beginning at 2 µg/kg/h and midazolam boluses (F), or propofol and fentanyl infusions beginning at 25 µg/kg/min and 0.5 µg/kg/h (PF), respectively. MEASUREMENTS AND MAIN RESULTS: Postoperative regimen P was associated with a significantly reduced time to extubation (median value, 264 minutes; p = 0.05) compared with F (295 minutes) but not PF (278 minutes) in patients characterized as low cardiac risk. The time to extubation did not differ among regimens in patients of moderate/high cardiac risk. CONCLUSION: Patients with low cardiac risk undergoing cardiac surgery had statistically significantly shorter times to extubation with propofol infusion and intermittent morphine than a fentanyl infusion and intermittent midazolam. These differences were not sustained in patients considered at higher cardiac risk. The time to extubation after cardiac surgery may further improve if postoperative sedation and analgesia are not administered uniformly to all patients but selected based on individual characteristics.

Prosthetic valve endocarditis: clinicopathological correlates in 122 surgical specimens from 116 patients (1985-2004).

BACKGROUND: Few studies have documented the clinicopathological features of prosthetic valve endocarditis independently of native valve endocarditis. STUDY DESIGN: Retrospective analysis of patients undergoing cardiac surgery for prosthetic valve endocarditis at our institution (1985-2004). METHODS: Medical records and microscopic slides were reviewed from 116 patients for demographics, infecting organisms, comorbidities, and pathologic features. RESULTS: Patients were 12-86 years old (mean, 59 years). Among 122 valves, 64% were from men and 67% were purely regurgitant. Aortic prosthetic valve endocarditis frequently affected men (76%); mitral prosthetic valve endocarditis often affected women (62%). Embolization occurred in 35% and heart failure in 32%. Prevalent predisposing conditions were the prosthetic valve alone (43%) and diabetes mellitus (20%). Prosthetic valve endocarditis was aortic or mitral in 98% and was active in 70%. Annular abscess or paravalvular leak affected mechanical valves more frequently than bioprosthetic (89% vs. 65%; P=.001). Causative organisms (n=116) included Staphylococcus aureus (30%), coagulase-negative staphylococcus (22%), viridans streptococci (18%), enterococci (10%), other streptococci (8%), and other organisms (12%). S. aureus was the most prevalent cause of early-onset (38%) and late-onset (30%) prosthetic valve endocarditis. Coagulase-negative staphylococcus caused early-onset (31%) and most intermediate-onset (40%) disease and had a shorter median implantation-to-infection time than other organisms (6.5 vs. 61.3 months; P<.001). Viridans streptococci and enterococci primarily caused late-onset endocarditis. For active infections by cocci, most cases exhibited strong Gram staining, but four showed only strong Grocott methenamine silver staining. CONCLUSIONS: Cocci accounted for 83% of infections. Early-onset prosthetic valve endocarditis was primarily staphylococcal, and late-onset prosthetic valve endocarditis resembled native valve endocarditis. Both Gram and Grocott methenamine silver stains were necessary to reliably identify organisms microscopically.

Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management.

BACKGROUND: We aimed to review recent experience at our institution in the diagnosis and treatment of pericardial effusion after cardiac surgery and to identify risk factors for its development. METHODS: We searched our clinical database for patients 18 years or older who had cardiac surgery with cardiopulmonary bypass from 1993 through 2005. For patients with pericardial effusion (study group), medical records were reviewed to evaluate its manifestations and management. To identify risk factors for effusion, study patients were compared with patients without effusions. A second analysis compared the study group with a cohort without effusions who had routine postoperative echocardiographic examination. RESULTS: Of 21,416 patients identified, 327 (1.5%) had pericardial effusion (study group), 280 (86%) of whom had nonspecific symptoms. Clinical features of tamponade were documented in 138 patients (42%). Effusions were evacuated by echocardiography-guided pericardiocentesis (n = 169, 52%) or surgical drainage (n = 75, 23%). Effusion resolved after left thoracocentesis for pleural effusion in 3 patients (1%); 67 patients (20%) were treated conservatively. In 13 cases (4%), recurrent effusion required drainage after initial pericardiocentesis. Independent risk factors for effusion were larger body surface area, pulmonary thromboembolism, hypertension, immunosuppression, renal failure, urgency of operation, cardiac operation other than coronary artery bypass grafting, and prolonged cardiopulmonary bypass. Previous cardiac operations were associated with lower risk of effusion. CONCLUSIONS: In our study, pericardial effusion occurred in 1.5% of patients, and symptoms were nonspecific. Several factors, mainly related to preoperative characteristics and type of operation, predispose patients to effusion. Echocardiography-guided pericardiocentesis is effective and safe in these patients.

Safety and durability of mitral valve repair for anterior leaflet perforation.

OBJECTIVE: We sought to evaluate mitral valve repair for anterior leaflet perforation. METHODS: Between October 1987 and October 2006, 26 patients with mitral valve anterior leaflet perforation underwent mitral valve repair (median age, 54 years; 18 [69%] were male). RESULTS: The indication for operation was severe mitral regurgitation only in 14 patients, both aortic regurgitation and mitral regurgitation in 11, and ventricular septal defect repair in 1. Twenty-four (92%) patients had endocarditis and 13 (50%) had at least mild aortic regurgitation preoperatively. Left atriotomy was performed in 17 (65%) and aortotomy in 8 (31%). Six (23%) patients had visible vegetations at the time of repair. For anterior leaflet repair, a patch was used in 11 (42%) patients and primary suture closure in 15 (58%). Eighteen patients underwent concomitant cardiac surgical procedures. Postoperative follow-up (mean, 6 years) was available for 25 (96%) patients. There was 1 early death from multiorgan failure and 2 late deaths. Patient survival was 95% at 1 year and 90% at 5 years. Left ventricular end-diastolic dimension improved significantly after mitral valve repair at dismissal (n = 16; -9.4 mm; P < .01) and during follow-up (n = 11; -10.8 mm; P < .01). Only 1 (4%) patient had mitral valve reoperation after 7 years owing to recurrent endocarditis 6 months after repair. CONCLUSIONS: Mitral valve anterior leaflet perforation may be safely repaired with good midterm survival and durability.

Concomitant surgery for renal neoplasm with pulmonary tumor embolism.

OBJECTIVE: Gross tumor pulmonary embolism from renal carcinoma is rarely diagnosed preoperatively. Individual cases of intraoperative embolization of tumor during radical resection of the kidney have been reported. We report on 9 patients who underwent pulmonary arterial tumor removal concomitant with nephrectomy. METHODS: Between 2000 and 2008, 9 patients underwent simultaneous nephrectomy and removal of gross embolic tumor from the pulmonary arteries. In 7 of these patients the diagnosis was made preoperatively by either computed tomography or magnetic resonance imaging. Cardiopulmonary bypass was used in all cases. Bilateral removal of pulmonary artery tumor was required in 7 patients and unilateral in 2. RESULTS: All patients survived to hospital discharge after a median stay of 8.8 days (mean, 6-17 days). Two patients are currently alive 4 and 56 months after the operation. Six patients died of distant metastasis or local recurrence of disease after 6, 9, 12, 17, 25, and 29 months. Actuarial survival at 6 months, 1, 2, and 3 years was 100%, 75%, 50%, and 25%, respectively. CONCLUSIONS: Pulmonary artery embolic tumor removal concomitant with nephrectomy for renal carcinoma can be performed safely. Survival of patients with combined surgery is comparable with that of patients with the same stage of renal neoplasm without pulmonary tumor embolism. The pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of vena caval tumor but not as a distant metastasis. Pulmonary tumor removal provides symptomatic relief and may provide a survival benefit in these patients.

Management of mild aortic stenosis at the time of coronary artery bypass surgery: should the valve be replaced?

BACKGROUND: General consensus favors aortic valve replacement (AVR) for patients with moderate aortic stenosis (AS) undergoing coronary artery bypass graft surgery (CABG); however, the management of similar patients with mild AS is controversial. We therefore investigated such patients to determine incremental risk of concomitant AVR, progression of AS among those undergoing CABG alone, and operative risk of AVR after prior CABG. METHODS: Between January 1993 and December 2003, 316 consecutive patients with mild AS (mean gradient >15, <30 mm Hg) underwent CABG only (107) or CABG plus AVR (209). Follow-up was obtained by review of the medical record, the Social Security Death Index, and postal questionnaire. RESULTS: The operative mortality was 3.7% for CABG only and 4.3% for CABG plus AVR (p = 1). Survival at a mean of 5.4 +/- 3.6 years was similar. Multivariate predictors of late mortality included comorbid illnesses (Charlson comorbidity score and age-weighted summary of diseases; p = 0.001), small body surface area (p = 0.001), low ejection fraction (p = 0.007), preoperative permanent pacemaker (p = 0.04), and congestive heart failure (p = 0.046), but not AVR. Twenty-three CABG-only patients (21%) underwent subsequent AVR (mean 5.6 +/- 1.8 years) without mortality. Aortic valve replacement at the time of initial CABG (p <0.001) and older age (p = 0.02) were multivariate predictors of freedom from reoperation. CONCLUSIONS: Prophylactic AVR for mild AS at CABG does not confer a survival benefit, and the likelihood of requiring AVR after CABG alone is low in the first 5 years. The decision to intervene on the valve is critically dependent upon the incremental operative risk imposed by concomitant AVR and late survival.

Results of mitral valve annuloplasty with a standard-sized posterior band: is measuring important?

OBJECTIVE: This study was undertaken to determine hemodynamic and clinical outcomes of annuloplasty with a standard-sized (63 mm) posterior band in adult patients undergoing mitral valve repair for degenerative valve disease. METHODS: We studied 511 patients who underwent isolated mitral valve repair for degenerative disease with a 63-mm posterior band used for annuloplasty. Operations were performed between 1994 and 2001, and average follow-up was 4.8 +/- 3.1 years. Echocardiographic data were reviewed, with specific focus on the relationship between patient size and residual mitral regurgitation and gradient. RESULTS: Mean age at the time of operation was 59.3 +/- 13.5 years, and 72% were male. Body mass index was 25.8 +/- 4.1 kg/m(2), and body surface area was 1.97 +/- 0.24 m(2). Preoperative mean ejection fraction was 64% +/- 7%, and 96% of patients had severe mitral regurgitation on preoperative echocardiography. The 30-day mortality was 0.8%. At hospital discharge, the mean gradient was 4.7 +/- 3.1 mm Hg. Body surface area, body mass index, and weight were not associated with postoperative gradients or residual regurgitation at discharge. At last follow-up, 89% of patients had no or mild regurgitation, and the mean ejection fraction was 58% +/- 9%. At 5 years, survival was 95% and cumulative risk of reoperation was 3%. CONCLUSION: A standard-sized (unmeasured) posterior annuloplasty band provided excellent intermediate results with good durability. There were neither excess gradients in larger patients nor excess regurgitation in smaller patients. Measured annuloplasty is unnecessary for most adults undergoing mitral valve repair.

Recovery of left ventricular function after surgical correction of mitral regurgitation caused by leaflet prolapse.

OBJECTIVE: Recovery of ventricular function after surgical correction of mitral regurgitation is often incomplete. We studied clinical and echocardiographic factors influencing return of normal left ventricular ejection fraction after mitral valve repair or replacement for mitral regurgitation caused by leaflet prolapse. METHODS: We evaluated 1063 patients who had mitral valve repair or replacement between January 1, 1980, and December 31, 2000. A total of 2488 echocardiograms with follow-up ejection fractions were available for analysis. RESULTS: Of the patients, 761 were men, 924 had valve repair, and 85% underwent surgery during the study's second decade. Compared with patients who had the operation in the 1980s, patients who had surgery in the 1990s had significantly smaller preoperative left heart dimensions and a 2.4-fold greater likelihood of an ejection fraction more than 60% during follow-up. Factors independently associated with higher ejection fraction at follow-up included valve repair (vs replacement), freedom from preoperative myocardial infarction, operation in the 1990s, greater preoperative ejection fraction, and smaller left ventricular dimensions. Patients with an ejection fraction of less than 50% at discharge were 3.5-fold less likely to recover normal ejection fraction during long-term follow-up (P < .001). Patients had a greater likelihood of a follow-up ejection fraction more than 60% if preoperative ejection fraction was more than 65% (hazard ratio, 1.7) or left ventricular end-systolic dimension was less than 36 mm (hazard ratio, 2.0). CONCLUSION: Early repair of mitral regurgitation caused by leaflet prolapse, before deterioration in left heart size or function, increases the likelihood of subsequent normalization of left ventricular ejection fraction.

Management of moderate functional mitral regurgitation at the time of aortic valve replacement: is concomitant mitral valve repair necessary?

OBJECTIVE: The optimal management of moderate functional mitral regurgitation at the time of aortic valve replacement remains undefined. METHODS: We retrospectively identified 686 consecutive patients undergoing aortic valve replacement between 1993 and 2006 with at least moderate (grade 2 or more) functional mitral regurgitation. Patients with structural valve abnormalities or significant coronary artery disease were excluded, leaving 190 in the study. Analyses for predictors of residual mitral regurgitation and survival were performed. The impact of mitral regurgitation on survival was further analyzed among 91 patients case matched for age, gender, and left ventricular ejection fraction to individuals without mitral regurgitation undergoing isolated aortic valve replacement. RESULTS: The mean age of the study group was 74 +/- 11years, 45% were male, and 78% had New York Heart Association III or IV Class classification. The mean preoperative ejection fraction was 48% +/- 17%. Operative mortality was 5% (n = 9). Follow-up echocardiographic data were available for 88% of patients at discharge and 57% of patients at midterm. Mitral regurgitation was improved at discharge in 76% of patients and at mid-term follow-up in 67% of patients. Independent predictors of improved mitral regurgitation were lesser degrees of preoperative tricuspid regurgitation or prebypass mitral regurgitation, absence of cerebrovascular disease, and lower left ventricular ejection fraction. Postoperatively, 89% of patients were New York Heart Association Class I or II Symptom; No reoperations for mitral regurgitation were performed. Survival was 68% at 5 years and 42% at 10 years. Independent predictors of late mortality were increasing age, diabetes, dialysis-dependent renal failure, and increased tricuspid regurgitation severity. The survival of 91 patients from this cohort did not differ from case-matched patients without mitral regurgitation undergoing aortic valve replacement (P = .33). CONCLUSION: Moderate functional mitral regurgitation improved in most patients after aortic valve replacement. Residual mitral regurgitation did not affect survival independently of left ventricular function.

Survival and reoperation risk following bicuspid aortic valve-sparing root replacement.

BACKGROUND AND AIM OF THE STUDY: The mid-term outcome of aortic valve-sparing root replacement, reimplanting native bicuspid versus tricuspid aortic valves, is unclear. METHODS: The records of 84 consecutive patients (66 men, 18 women; mean age 46.6 years) who had undergone aortic valve-sparing root replacement using the reimplantation technique between January 1997 and July 2006, were reviewed. Among the patients, 26 (31%) had Marfan syndrome and 14 (17%) had a bicuspid aortic valve. The mean follow up period was 4.1 years. RESULTS: There were three early deaths (4%) and five late deaths (6%). Late survival (>30 days) at five and eight years was 95% and 88%, respectively. The presence of significant coronary artery disease (p = 0.001), a lower preoperative ejection fraction (p = 0.03) and older age (p = 0.04) were the only univariate predictors of death. Freedom from moderate-severe or severe (grade 3 or 4) aortic valve regurgitation at one and five years was 91% and 77%, respectively. Ten patients (12%) required aortic valve reoperation at a mean of 3.4 years after surgery (3/14 bicuspid, 7/70 tricuspid); however, only one reoperation was required among patients undergoing the initial surgery after the year 2000. Freedom from aortic valve reoperation at one and five years was 95% and 83%, respectively. The predischarge degree of aortic valve regurgitation was the sole univariate factor associated with aortic valve reoperation (p = 0.008). Bicuspid valve morphology was not a predictor of either recurrent aortic valve regurgitation, nor of aortic valve reoperation. CONCLUSION: Bicuspid aortic valves may be safely spared by reimplantation during replacement of the aortic root, with similar mid-term durability as for tricuspid aortic valves.

Indexed left ventricular dimensions best predict survival after aortic valve replacement in patients with aortic valve regurgitation.

BACKGROUND: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation. METHODS: Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status. RESULTS: Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001). CONCLUSIONS: In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.

Embolic potential of cardiac tumors and outcome after resection: a case-control study.

BACKGROUND AND PURPOSE: Embolic events have long been thought to occur in patients with cardiac tumors secondary to embolization of tumor fragments; however, there are no large studies examining the epidemiology and occurrence of embolism in this group of patients. METHODS: From 1957 to 2006, 323 consecutive patients with primary cardiac tumors were treated surgically at our institution. Of these, patients who experienced an embolic event included 80 (cerebrovascular accident 31 [9.7%], transient ischemic attack 30 [9.3%], and other 19 [6%]). Those with no history of an embolic event (n=243 [75%]) were defined as control subjects. RESULTS: Age was similar between the case and control groups (mean 54.5 versus 53.9 years, P=0.8). A multivariate logistic regression model including tumor location, tumor burden, tumor histology, and cerebrovascular risk factors, indicated that left atrial tumors (OR, 1.95; P=0.04), aortic valve tumors (OR, 4.17; P=0.002), and smaller tumor burden (OR, 2.20; P=0.01) were the most significant factors in the occurrence of embolism (P<0.001). The presence of mitral regurgitation (OR, 0.12; P=0.006) and decreased functional status (New York Heart Association III/IV; OR, 0.31; P<0.001) were protective against the occurrence of embolism. Follow-up was obtained in 82% at a mean follow-up time of 6.17+/-6.9 years. There were no recurrent embolic events at follow-up. A Kaplan-Meier survival curve demonstrated no difference in survival between both groups (P=0.78). CONCLUSIONS: Aortic valve and left atrial tumors have the greatest anatomic risk for embolism. Furthermore, patients with smaller tumors, minimal symptomatology, and no evidence of mitral regurgitation have a high risk of embolism. Cardiac tumors can be resected with low early mortality, and late survival after operation in the context of an embolic event is similar to patients with cardiac tumors who undergo resection for other indications.

Neuronal ceroid lipofuscinosis in a 31-year-old woman presenting as biventricular heart failure with restrictive features.

A 31-year-old woman presented with dyspnea and left-sided chest discomfort and was found to have biventricular heart failure with impaired ventricular filling. Clinically, she was thought to have restrictive cardiomyopathy or constrictive pericarditis. Transmission electron microscopy of myocardial tissue unexpectedly revealed crosshatched, curvilinear, and fingerprint depositions, which were characteristic for neuronal ceroid lipofuscinosis. Cardiac involvement by this inherited disorder is discussed in light of the findings in this patient and in 15 other reported cases.

Survival after resection of primary cardiac tumors: a 48-year experience.

BACKGROUND: Primary cardiac tumors are rare but have the potential to cause significant morbidity if not treated in an appropriate and timely manner. To date, however, there have been no studies examining survival characteristics of patients who undergo surgical resection. METHODS AND RESULTS: From 1957 to 2006, 323 consecutive patients underwent surgical resection of primary cardiac tumors; 163 (50%) with myxomas, 83 (26%) with papillary fibroelastomas, 18 (6%) with fibromas, 12 (4%) with lipomas, 28 (9%) with other benign primary cardiac tumors, and 19 (6%) with primary malignant tumors. Operative (30 day) mortality was 2% (n=6). Univariate analysis indicated that patients who underwent resection of fibromas and myxomas had superior survival characteristics in comparison to the remainder of tumor variants; these results were consistent after adjusting for age at surgery, year of surgery, and cardiovascular risk factors. Based on actuarial characteristics of the 2002 U.S. population, patients who underwent myxoma resection had survival characteristics that were not significantly different from that of an age and gender matched population (SMR 1.11, P=0.57) whereas those who underwent resection of fibromas (SMR 11.17, P=0.002), papillary fibroelastomas (SMR 3.17, P=0.0003), lipomas (SMR 5.0, P=0.0003), other benign tumors (SMR 4.63, P=0.003), and malignant tumors (SMR 101, P<0.0001) had significantly poorer survival characteristics. Furthermore, malignant tumors in younger patients were highly fatal (HR 0.899, P<0.0001). Although the most significant predictor of mortality was tumor histology, survival was also influenced the by the duration of CPB and NYHA III/IV; the impact of these risk factors varied with time. The cumulative incidence of myxoma recurrence was 13% and occurred in a younger population (42 versus 57 years, P=0.003) with the risk of recurrence decreased after 4 years. CONCLUSIONS: Surgical resection of primary cardiac tumors is associated with excellent long-term survival; patients with cardiac myxomas have survival characteristics that are not significantly different from that of a general population. Predictors of mortality are primarily related to tumor histology but also include clinical characteristics such as symptomatology and duration of CPB.

Is the European System for Cardiac Operative Risk Evaluation model valid for estimating the operative risk of patients considered for percutaneous aortic valve replacement?

OBJECTIVE: The European System for Cardiac Operative Risk Evaluation has been used to define a particularly high-risk group of patients for aortic valve replacement in whom alternative procedures, such as stent-mounted percutaneous valve procedures, may be appropriate. Our objective was to assess the validity of this risk assessment at a large-volume, tertiary cardiac surgical center. METHODS: From January 1, 2000, to December 30, 2006, a total of 1177 patients underwent isolated aortic valve replacement at the Mayo Clinic. Patient and operative demographics were recorded in a prospective database. Early mortality (< or = 30 days) was obtained. Additive and logistic European System for Cardiac Operative Risk Evaluations were calculated for each patient. RESULTS: The mean patient age was 68.0 years (+/-14.7 years) at the time of surgery, and 36.8% were female. Variables used in the calculation of the European System for Cardiac Operative Risk Evaluation included chronic lung disease (15% of our cohort), extracardiac arteriopathy (13.8%), neurologic dysfunction (0.2%), previous cardiac surgery (23.2%), renal failure (6.5%), active endocarditis (3.1%), recent myocardial infarction (1.1%), unstable angina (0.1%), and severe pulmonary hypertension (6.5%). The ejection fraction was severely reduced (< or = 30%) in 4.9% of patients and moderately reduced (< or = 50%) in 12.7% of patients. One percent of patients were in a critical state, and operation was performed urgently in 3.4% of patients. Although mean mortality estimates were 6.9% +/- 3.4% (additive European System for Cardiac Operative Risk Evaluation) and 10.9% +/- 12.7% (logistic European System for Cardiac Operative Risk Evaluation), actual overall operative mortality in our patients was 2.5%. Additive and logistic European System for Cardiac Operative Risk Evaluations overestimated operative mortality in low, intermediate, and high-risk subgroups by up to 17.8%. CONCLUSIONS: The European System for Cardiac Operative Risk Evaluation should not be used to determine the operability of patients for isolated aortic valve replacement. Elevated European System for Cardiac Operative Risk Evaluations alone do not appropriately define a population for use of a percutaneous aortic valve.

Determinants of early decline in ejection fraction after surgical correction of mitral regurgitation.

OBJECTIVE: We sought to echocardiographically examine the early changes in left ventricular size and function after mitral valve repair or replacement for mitral regurgitation caused by leaflet prolapse. METHODS: Preoperative and early postoperative echocardiograms of 861 patients with mitral regurgitation caused by leaflet prolapse who underwent mitral valve repair or replacement (with or without coronary revascularization) were studied. Among the patients, 625 (73%) were men and 779 (90%) had mitral valve repair. RESULTS: The rate of valve repair increased from 78% in the first decade of the study to 92% in the second decade. At early echocardiography (mean, 5 days postoperatively), we observed significant decreases in left ventricular ejection fraction (mean, -8.8) and left ventricular end-diastolic dimension (mean, -7.5). The magnitude of the early decline in ejection fraction was similar in patients who had mitral valve repair and replacement. The decrease in postoperative ejection fraction was independently associated with a lower preoperative ejection fraction, the presence of atrial fibrillation, advanced New York Heart Association functional class, greater left ventricular end-diastolic and end-systolic dimensions, and larger left atrial size. CONCLUSION: Surgical correction of mitral regurgitation results in an early decrease in ejection fraction, particularly in symptomatic patients with increased left heart dimensions.

Improving results of open arch replacement.

BACKGROUND: The rapid evolution of endovascular approaches to arch reconstruction such as brachiocephalic debranching and endovascular stent grafting renders an accurate understanding of contemporary outcomes of conventional open arch surgery particularly relevant. METHODS: Cases of arch reconstruction were identified by search of the computerized cardiovascular surgical database. Perioperative (30-day) outcomes as per The Society of Thoracic Surgeons database were evaluated. RESULTS: Between January 1, 1993, and June 30, 2007, 347 patients (195 male, 152 female; median age, 69 years; range, 21 to 88 years) underwent aortic arch replacement. Procedures were elective in 232 cases. Total arch replacement was performed in 95, including 15 with concomitant replacement of the descending thoracic aorta by means of bilateral thoracosternotomy. Modalities adjunctive to profound hypothermia and circulatory arrest for cerebral protection have been introduced, including retrograde cerebral perfusion and, more recently, selective antegrade cerebral perfusion. The overall mortality rate was 8.9% (elective procedures, 6.0%) and stroke rate was 8.4% (elective procedures, 6.9%). The mortality rate for total arch replacement has declined with adjuncts overall from 34.6% (9 of 26) with profound hypothermia and circulatory arrest to 21.1% (4 of 19) with retrograde cerebral perfusion and to 6.0% (3 of 50) with selective antegrade cerebral perfusion (p < 0.01), and for elective cases from 30.0% (6 of 20) with profound hypothermia and circulatory arrest to 14.3% (2 of 14) with retrograde cerebral perfusion, and 2.7% (1 of 37) with selective antegrade cerebral perfusion (p < 0.01). The corresponding stroke rates were 19.2% (5 of 26) with profound hypothermia and circulatory arrest, 5.3% (1 of 19) with retrograde cerebral perfusion, and 6.0% (3 of 50) with selective antegrade cerebral perfusion (p = 0.18) overall and 15.0% (3 of 20) with profound hypothermia and circulatory arrest, 7.1% (1 of 14) with retrograde cerebral perfusion, and 5.4% (2 of 37) with selective antegrade cerebral perfusion (p = 0.46) for elective cases. CONCLUSIONS: Currently, open aortic arch replacement can be accomplished under elective circumstances with low operative mortality, particularly with adjunctive measures for cerebral protection. The results of endovascular therapies should be measured against contemporary surgical series.