An eye-opening case report of constrictive pericarditis.

Background: Constrictive pericarditis is characterized by the encasement of the heart by a stiff pericardium leading to impaired diastolic function, which ultimately leads to congestive heart failure. Case summary: We report a case of a young woman, who first presented to the ophthalmologist with the sudden appearance of floaters and vision reduction. Eventually, invasive haemodynamic assessment led to the diagnosis of constrictive pericarditis leading to venous congestion. Conclusion: Understanding the pathophysiology and integrating the results of invasive and non-invasive diagnostic work up is important in making this challenging diagnosis.

Midterm Comparison Between Different Annuloplasty Techniques for Functional Tricuspid Regurgitation.

BACKGROUND: Several tricuspid annuloplasty (TA) techniques are used for concomitant repair of functional tricuspid regurgitation (TR). This study compared the midterm clinical and valvular outcome among 3 annuloplasty techniques. METHODS: TA was performed in 307 patients (aged 75.9 ± 10.4 years) with a rigid ring (RA) in 184, a flexible band (FA) in 80, or a suture annuloplasty (SA) in 43. Study end points were survival and recurrence of TR >grade 2 at 5 years. RESULTS: TA was performed concomitantly to mitral valve surgery in 136 patients (44.3%), aortic valve surgery in 18 (5.9%), coronary artery bypass grafting in 13 (4.2%), or a combined procedure in 140 (45.6%). Most had TR >grade 2 (78.5%), without significant differences between the TA groups (P = .878). Within a median follow-up of 3.4 years (interquartile range, 2.2-5.0 years), the 5-year survival was 80.1% ± 3.4% for RA, 83.5% ± 4.7% for FA, and 85.1% ± 6.5% for SA (P = .471). Independent risk factors for late mortality were renal impairment (hazard ratio [HR], 2.83; 95% CI, 1.16-6.89; P = .022), diabetes (HR, 2.10; 95% CI, 1.07-4.11; P = .030), and severe right ventricular dysfunction by tricuspid annulus plane systolic excursion <10 mm (HR, 11.52; 95% CI, 4.98-26.66; P < .001). Pulmonary hypertension was nearly significant (HR, 1.92; 95% CI, 0.98-3.74; P = .057). The cumulative incidence of TR recurrence at 5 years was 15.9%, 19.4%, and 21.1% for RA, FA, and SA, respectively (P = .342). Severe pulmonary hypertension (HR, 2.64; 95% CI, 1.38-5.07; P = .003), preoperative TR grade (HR, 1.82; 95% CI, 1.01-3.27; P = .046), and residual TR >grade 2 at discharge (HR, 3.38; 95% CI, 1.64-6.96; P = .001) were predictive for later TR recurrence, regardless of the annuloplasty technique. CONCLUSIONS: This study demonstrates that advanced pathophysiological right circulatory impairment, such as severe pulmonary hypertension and right ventricular dysfunction, affects the midterm survival and TR recurrence rate more than the annuloplasty technique used for concomitant repair of functional TR.

Heart Transplantation Complicated by COVID-19 Infection.

The influence of Coronavirus-2019 (COVID-19) on heart transplantation is considerable. Reports of COVID-19 infection in recently transplanted patients are scarce. We present a 60-year-old male patient with COVID-19 infection, diagnosed 6 days after transplantation. His clinical course revealed 2 phases. Initially, there were mild respiratory symptoms for which he was treated with remdesivir and noninvasive respiratory support. In a second phase with clinical deterioration on postoperative day 22, further respiratory decline led to the administration of convalescent plasma, with satisfactory response and further improvement of his condition.

Repeat aortic valve surgery: contemporary outcomes and risk stratification.

OBJECTIVES: Redo aortic valve surgery (rAVS) is performed with increasing frequency, but operative mortality is usually higher compared to that associated with primary aortic valve surgery. We analysed our patients who had rAVS to determine the current outcomes of rAVS as a surgical benchmark in view of the growing interest in transcatheter valve techniques. METHODS: We retrospectively reviewed 148 consecutive patients [median age 67.7 years (interquartile range 54.9-77.6); 68.2% men] who underwent rAVS following aortic valve replacement (81.6%), aortic root replacement (15%) or aortic valve repair (3.4%) between 2000 and 2018. RESULTS: Indications for rAVS were structural valve dysfunction (42.7%), endocarditis (37.8%), non-structural valve dysfunction (17.7%) and aortic aneurysm (2.1%). Valve replacement was performed in 69.7%, and 34 new root procedures were necessary in 23%. Early mortality was 9.5% (n = 14). Female gender [odds ratio (OR) 6.16], coronary disease (OR 4.26) and lower creatinine clearance (OR 0.95) were independent predictors of early mortality. Follow-up was 98.6% complete [median 5.9 (interquartile range 1.7-10.9) years]. Survival was 74.1 ± 3.7%, 57.9 ± 5.1% and 43.8 ± 6.1% at 5, 10 and 14 years, respectively. Cox regression analysis revealed female gender [hazard ratio (HR) 1.73], diabetes (HR 1.73), coronary disease (HR 1.62) and peripheral vascular disease (HR 1.98) as independent determinants of late survival. CONCLUSIONS: Despite many urgent situations and advanced New York Heart Association functional class at presentation, rAVS could be performed with acceptable early and late outcomes. Risk factors for survival were female gender, coronary disease and urgency. In this all-comers patient cohort needing rAVS, only a minority would eventually qualify for transcatheter valve-in-valve procedures.

Haemodynamic management of patients with left ventricular assist devices using echocardiography: the essentials.

Mechanical circulatory support with continuous-flow left ventricular assist devices (LVADs) has emerged as a viable treatment modality for patients with advanced heart failure. LVAD support results in unique haemodynamic and echocardiographic alterations that must be understood to provide optimal care for these patients. In this review, we propose essential echocardiographic and haemodynamic elements for the assessment of optimal LVAD function based on the literature and the use of simulation software. A key element of LVAD physiology remains the interaction between an unloaded left ventricle and a loaded right ventricle. The echocardiographic assessment and treatment of the pathophysiology of the right-sided part of the heart remains critical to maintaining optimal LVAD support.

Ten-year results of aortic valve replacement with first-generation Mitroflow bioprosthesis: is early degeneration a structural or a technical issue?

OBJECTIVES: Concerns have been raised about the durability of the first-generation Mitroflow aortic bioprosthesis (model 12 A-LX) due to the lack of anticalcification treatment. This study reflects a 10-year experience with this prosthesis for aortic valve replacement. METHODS: From June 2003 to May 2012, the Mitroflow prosthesis was used for aortic valve replacement in 510 patients, of whom only 467 with complete clinical follow-up were included for analysis. Study end-points were survival and incidence of structural valve degeneration (SVD). Analysis of SVD was based on cumulative incidence function and competing-risk Cox regression. RESULTS: The mean patient age was 76.4 ± 6.1 years. Valve sizes from 23 to 25 were used in 70.4%, whereas sizes from 19 to 21 were used in only 19.2%, thereby avoiding patient-prosthesis mismatch in 89.1%. Within a median follow-up time of 6.6 years (interquartile range 4.4), a cumulative 2375 patient-years, the survival rate was 86.2%, 67.3% and 33.3% at 1, 5 and 10 years, respectively. The cumulative incidence of SVD, with death as a competing risk, was 0%, 0.7% and 6.2% at 1, 5 and 10 years, respectively. Only age <75 years tended to affect the late hazard of SVD (hazard ratio 0.50, 95% confidence interval 0.23-1.08, P = 0.08), regardless of valve-specific issues. CONCLUSIONS: The data do not support the concerns about early accelerated structural degeneration of the first-generation Mitroflow bioprosthesis used for aortic valve replacement in patients older than 75 years. We postulate that limiting the number of small prostheses using a proper implantation technique has enhanced the reduction in risk of significant patient-prosthesis mismatch as the main determinant of early SVD.

Low target-INR anticoagulation is safe in selected aortic valve patients with the Medtronic Open Pivot mechanical prosthesis: long-term results of a propensity-matched comparison with standard anticoagulation.

OBJECTIVES: To investigate the long-term results of a low international normalized ratio (INR)-anticoagulation program in selected patients after aortic valve replacement (AVR) with the Medtronic Open Pivot mechanical heart valve (OPMHV). METHODS: From January 1993 to December 2012, 909 OPMHV valves were used for single AVR. Patients with preserved sinus rhythm and left ventricular function (Low-INR, n = 552), were managed to an INR of 1.5-2.5 and compared to patients (Standard-INR, n = 357) treated with standard anticoagulation (INR 2.5-3.5). Long-term outcome was analysed for survival and valve-related events, on propensity score matched pairs of 169 patients/group. RESULTS: Within a follow-up cumulating 3096 patient-years, 10- and 15-year survival was significantly better for Low-INR patients: 79% and 63% vs 63% and 34% ( P < 0.001). Multivariate analysis of late mortality identified older age [odds ratio (OR) = 1.05], chronic pulmonary disease (OR = 1.90) and coronary artery disease (OR = 1.57) as patient-related risk factors, and erratic INR (OR = 2.57) as anticoagulation-related factor. The linearized thromboembolic rate was 0.72%/patient-year in Low-INR patients, vs 0.87%/patient-year in Standard-INR patients ( P = 0.59), revealing INR variability as sole predictor (OR 3.54, 95% confidence interval (CI) 1.20-10.51, P = 0.022). The linearized bleeding incidence was respectively 0.61%/patient-year and 1.21%/patient-year for Low-INR and Standard-INR patients ( P = 0.04), retaining older age (OR 1.06, 95% CI 1.02-1.12, P = 0.009), hypertension (OR 2.06, 95% CI 1.00-4.25, P = 0.05) and erratic INR (OR 9.83, 95% CI 5.21-18.56, P < 0.001) as independent risk factors. CONCLUSIONS: This study demonstrated that application of an anticoagulation regimen, aiming a low INR, individualized to selected aortic OPMHV patients, is safe and effective over more than 20 years, without increasing the thromboembolic complication rate while lowering the haemorrhagic events. However, INR variability remains worrisome because of its deleterious effect on outcome.

Twenty-year single-center experience with the medtronic open pivot mechanical heart valve.

BACKGROUND: Since May 1992 the Medtronic Open Pivot mechanical heart valve has been implanted routinely at the authors' institution. The study aim was to analyze, retrospectively, the 20-year clinical results of the valve. METHODS: Between May 1992 and December 2011 a total of 1,520 valves was inserted into 1,382 consecutive patients (1,012 aortic, 473 mitral, 26 tricuspid, 9 pulmonary). The mean age of the patients was 61±13.2 years. Preoperatively, 65% of the patients were in New York Heart Association (NYHA) class III or greater. Frequent comorbidities included atrial fibrillation (n=419), coronary disease (n=357), and diabetes (n=255). The 99% complete follow-up totaled 10,527 patient-years (range 12 to 244 months). RESULTS: Ninety-day mortality was 5.2% (n=73, 8 valve related). Of the 550 total deaths, 240 were cardiac and 56 valve related. Multivariate analysis selected age, NYHA III or greater, concomitant coronary revascularization, and respiratory insufficiency as risk factors for death. Renal failure was considered a risk factor in the aortic and atrial fibrillation in the mitral subgroup. Erratic international normalized ratio (INR), NYHA class III or greater, and non-sinus rhythm were risk factors for thromboembolism; likewise redo operations in the aortic subgroup. Erratic INR and age were risk factors for bleeding as were over-coagulation and coronary revascularization in the aortic subgroup and redo operations and renal failure in mitral patients. CONCLUSIONS: This 20-year experience demonstrated excellent clinical outcomes with no structural valve failure. Odds ratio defined aortic patients as the lowest risk for adverse events. By contrast atrial fibrillation and elderly age, in combination with instable anticoagulation, yielded the worst long-term results.

Reappraisal of a single-centre policy on the contemporary surgical management of active infective endocarditis.

OBJECTIVES: We studied a contemporary cohort of adult patients treated surgically for infective endocarditis (IE) in order to evaluate the surgical approach and predictors of outcomes, in relation to the intercurrent adaptation of the 2006 ACC/AHA guidelines. METHODS: One hundred and eighty-six consecutive patients operated on for active IE from August 1999 to September 2012 were reviewed retrospectively. Clinical presentation, surgical management and outcomes in the two study periods before and after January 2007 were compared (Period 1: n = 95 and Period 2: n = 91). RESULTS: The mean (SD) follow-up was 4.3 (3.8) years and was 99.5% complete. Patients in Period 2 had more frequently associated coronary artery disease (31 vs 18%, P = 0.06), while the microbiology revealed more Staphylococcus species (43 vs 26%, P = 0.02), predominantly Staphylococcus aureus (31 vs 19%; P = 0.07), and less culture-negative cases (7 vs 17%; P = 0.05). The median delay between diagnosis and surgery was 7 days in Period 2 compared with 14 days in Period 1 (P = 0.001). Surgery in Period 2 included more root replacements for aortic valve endocarditis (11 vs 2%; P = 0.02) and mitral valve repairs (18 vs 5%; P = 0.01), while the use of homografts for aortic valve endocarditis was almost abandoned (1 vs 15%; P = 0.001). Hospital mortality was 13% and did not change significantly over both periods (P = 0.66). The independent predictors of hospital mortality were age (P = 0.03), female gender (P = 0.02), previous cardiac surgery (P = 0.02), preoperative serum creatinine level >2 mg/dl (P = 0.05), S. aureus infection (P = 0.02), emergent or salvage operation (P = 0.001) and concomitant coronary artery bypass grafting (P = 0.03). The 1-, 3-, 5- and 10-year survival were 84, 72, 64 and 57%, respectively. Late survival was negatively influenced by S. aureus endocarditis (P < 0.001) and peripheral vascular disease (P = 0.03), whereas associated coronary artery disease (P = 0.07) had a strong impact. CONCLUSIONS: Adaptation of the 2006 ACC/AHA guidelines in the contemporary management of IE led to a shorter interval between diagnosis and surgery. Despite a more extensive and earlier operative approach, IE caused by S. aureus still remains a major determinant of early and late outcomes.

Acute and critically ill peripartum cardiomyopathy and 'bridge to' therapeutic options: a single center experience with intra-aortic balloon pump, extra corporeal membrane oxygenation and continuous-flow left ventricular assist devices.

INTRODUCTION: Peripartum cardiomyopathy (PPCM) patients refractory to medical therapy and intra-aortic balloon pump (IABP) counterpulsation or in whom weaning from these therapies is impossible, are candidates for a left ventricular assist device (LVAD) as a bridge to recovery or transplant. Continuous-flow LVADs are smaller, have a better long-term durability and are associated with better outcomes. Extra corporeal membrane oxygenation (ECMO) can be used as a temporary support in patients with refractory cardiogenic shock. The aim of this study was to evaluate the efficacy and safety of mechanical support in acute and critically ill PPCM patients. METHODS: This was a retrospective search of the patient database of the Ghent University hospital (2000 to 2010). RESULTS: Six PPCM-patients were treated with mechanical support. Three patients presented in the postpartum period and three patients at the end of pregnancy. All were treated with IABP, the duration of IABP support ranged from 1 to 13 days. An ECMO was inserted in one patient who presented with cardiogenic shock, multiple organ dysfunction syndrome and a stillborn baby. Two patients showed partial recovery and could be weaned off the IABP. Four patients were implanted with a continuous-flow LVAD (HeartMate II, Thoratec Inc.), including the ECMO-patient. Three LVAD patients were successfully transplanted 78, 126 and 360 days after LVAD implant; one patient is still on the transplant waiting list. We observed one peripheral thrombotic complication due to IABP and five early bleeding complications in three LVAD patients. One patient died suddenly two years after transplantation. CONCLUSIONS: In PPCM with refractory heart failure IABP was safe and efficient as a bridge to recovery or as a bridge to LVAD. ECMO provided temporary support as a bridge to LVAD, while the newer continuous-flow LVADs offered a safe bridge to transplant.

Ten years single-centre experience with intra-aortic balloon pump.

OBJECTIVES: The objective of this study was to investigate the patient characteristics and outcomes in 1406 patients undergoing intra-aortic balloon pump (IABP) counterpulsation. METHODS: Between 1998 and 2008, 1406 consecutive patients were recorded in a prospective database. Based on the main clinical indication for IABP use, we defined 3 groups: group A, 630 cases of coronary ischaemia or infarction without serious left ventricular (LV) dysfunction; group B, 466 patients with left ventricular failure or cardiogenic shock; group C, 310 patients where IABP was used for miscellaneous procedures such as weaning from cardiopulmonary bypass or during high-risk angioplasty or surgery. RESULTS: Global mortality was 28% (n = 390), with a significant difference between group A (15%, n = 95) and group B (41%, n = 191) (P < 0.001). Mortality in group C was 34% (n = 104). Most insertions were done in the catheterization laboratory (n = 943) with subsequent mortality of 23% whereas 199 balloons were inserted in the operation room with 34% mortality. 170 balloons inserted in the intensive care unit resulted in 46% mortality (P < 0.001). Major IABP-induced complications were 6.8% with no statistical differences between the three groups. Advanced age, left ventricular failure and low BMI were identified as prognostic risk factors for early mortality. CONCLUSIONS: IABP deployed at an early clinical stage yields the best results, especially for acute coronary patients with preserved LV function whereas LV failure and late insertion result in worse outcome.

The effect of CABG on neurocognitive functioning.

Post-operative cognitive decline occurs in 20-70% of the coronary artery bypass surgery patients during the first week after surgery. After 6 weeks the incidence declines to 10-40% and remains at this level thereafter.Although the neuropsychological consequences are subclinical, they can interfere with daily life. In this paper, we discuss the impact of surgical factors, with a focus on the use of the heart-lung machine and its intra-operative embolic load. The pre-morbid cardiac condition of the patient as another underlying mechanism for cognitive decline is addressed. We also describe the methodological pitfalls in arriving at an adequate estimation of the prevalence of cognitive decline. Among these are the definition of cognitive decline, testing intervals, the choice of cognitive domains and the appropriate use of control groups.We also pay attention to the relation between cognition, depression and anxiety. Finally, the ecological validity of this study domain is discussed. It is concluded that (1) the literature remains undecided on the role of intra-operative emboli and cognitive decline after surgery. Researchers should focus on the composition, size and location instead of the absolute number of intra-operative emboli; (2) growing awareness of neurocognitive decline in chronic vascular disease patients must challenge both clinicians and investigators.The preoperative cognitive status can increase the risk for post-operative cognitive decline; (3) researchers should include--at the least--the core battery as stated in the Statement of Consensus on assessment of neurobehavioural outcomes after cardiac surgery. They also should work towards a consensus on the definition of cognitive decline and the definition of control groups; (4) depression and anxiety as confounders for postoperative cognitive decline might lead to an overestimation of cognitive decline at least for the majority of neuropsychological domains; (5) much more attention should go to the ecological validity of this research.

Fifteen years' single-center experience with the ATS bileaflet valve.

BACKGROUND AND AIM OF THE STUDY: Since its introduction in May 1992, the bileaflet ATS Open Pivot valve has been implanted routinely at the authors' institution. The study aim was to analyze, retrospectively, the 15-year clinical results of these implanted ATS valves. METHODS: Between May 1992 and December 2005, a total of 1,160 ATS valves (749 aortic, 381 mitral, 21 tricuspid, nine pulmonary) was implanted in 1,047 consecutive patients (655 males, 392 females; mean age 62.1 +/- 12.4 years). Preoperatively, 75% of the patients were in NYHA class III or higher (mean 3.1). The most frequent comorbidities included atrial fibrillation (n = 381), coronary disease (n = 288) and diabetes (n = 172). RESULTS: The mean follow up was 78 months (range: 24-183 months); the total follow up was 6,887 patient-years (pt-yr) and was 99.8% complete. In-hospital mortality was 4% (n = 43; three valve-related). Survival (Kaplan-Meier) at five and 10 years was significantly better for aortic than for mitral valve patients (84% and 65% versus 75% and 41%, respectively) (Mantel-Cox, p < 0.001). A log rank analysis detected no statistical difference in the incidence of thromboembolism (p = 0.182) or bleeding (p = 0.375) between both groups. The overall linearized incidences were: thromboembolism 1.08%/pt-yr; bleeding 0.91%/pt-yr; endocarditis 0.22%/pt-yr; paravalvular leakage 0.33%/pt-yr; and valve thrombosis 0.21%/pt-yr. Multivariate analysis (Cox regression) indicated age > 70 years (p < 0.0001), NYHA class > or = III (p < 0.0001), non-sinus rhythm (p = 0.001), concomitant CABG (p = 0.008) and higher INR values (p = 0.013) to be significant risk factors for death. CONCLUSION: This 15-year experience with the ATS bileaflet prosthesis showed excellent clinical outcomes for patients, with no structural failure and an acceptable incidence of adverse events.

Short-term systolic and diastolic ventricular performance after surgical ventricular restoration for dilated ischemic cardiomyopathy.

OBJECTIVE: Based on the adverse relationship between left ventricular (LV) remodeling and clinical outcome in ischemic cardiomyopathy, surgical ventricular restoration (SVR) is proposed as a valuable adjunct procedure. This study reports on the short-term clinical and hemodynamical performance of SVR. METHODS: Using end-systolic LV volume as indication for SVR, 78 patients with ischemic cardiomyopathy are divided in two groups: group 1 comprised 55 patients treated by coronary revascularization and mitral annuloplasty, group 2 comprised 23 patients undergoing additional SVR. Hemodynamic investigation included echocardiographic assessment of systolic and diastolic function. Clinical follow-up focused on survival and functional status with exercise performance. RESULTS: Both surgical approaches resulted in improvement of NYHA class (2.9-1.6 in group 1; 3.3-1.5 in group 2, p<0.001), achieving similar exercise performance (peak VO2 13.7 vs 15.4 ml/kgmin in groups 1 and 2, p=0.25) and plasma BNP values (group 1: 1350 pg/ml and group 2: 767 pg/ml, p=0.23). SVR provided additional benefit as patients basically had a worse NYHA class (2.9 in group 1 vs 3.3 in group 2, p=0.03). Within mean follow-up of 20 months, survival rate was 84% in group 1 and 74% in group 2 (p=0.11), including operative mortality of 7% and 13% (p=0.42). Through effective volume reduction (LVEDVI 41%; LVESVI 49%) systolic function improved immediately after SVR (LVEF 27-39% in group 2, p<0.05). Worsening of diastolic function was specifically observed after SVR within the first year (E/A-ratio 1.38-1.74 cm/s, p=0.02). Recurrent mitral regurgitation (p=0.004) and secondary remodeling (p=0.01) were major determinants of decreasing LV compliance. Clinical outcome in terms of cardiac events and survival was compromised by restrictive diastolic function (p=0.02) and increased LV volumes (p=0.04). CONCLUSION: SVR in addition to coronary revascularization and restrictive mitral annuloplasty results in significant clinical improvement in selected patients with advanced ischemic heart disease and severely dilated ventricles. SVR entails immediate improvement of systolic function, which remains sustained during short-term follow-up. Serial assessment of diastolic function is mandatory as LV compliance seems more sensitive to early changes induced by recurrence of mitral regurgitation and secondary ventricular dilation. Moreover, worsening of diastolic dysfunction should be timely recognized because of its adverse clinical impact.

Neuropsychological functioning 3-5 years after coronary artery bypass grafting: does the pump make a difference?

OBJECTIVE: Neurocognitive sequelae after coronary artery bypass grafting (CABG) are frequently reported. The present study investigated the possible difference between on- and off-pump CABG patients in a long-term perspective. METHODS: We administered seven standardized neuropsychological tests 1 day before, 6 days after, 6 months after and 3-5 years after CABG. We measured intra-operative high intensity transient signals (HITS) as a reflection of embolic load by transcranial Doppler ultrasonography. RESULTS: Of the 74 patients originally recruited, 54 of the patients (73%) (mean age 59 years+/-7.5 years) completed the neuropsychological battery. Cognitive decline was defined as 20% decline on two or more tests. Three to 5 years after the operation, 30% of the patients showed neurocognitive problems in domains of non-verbal immediate memory and attention, speed for visual search, visual attention and mental flexibility. Neither difference in frequency of cognitive dysfunction nor a difference in evolution over the 5 year time period between on- and off-pump patients was observed. No significant predictors for cognitive decline were found. CONCLUSIONS: Three to 5 years after the CABG surgery no difference in neurocognitive deficits is found between on- and off-pump CABG patients, indicating that the extracorporeal circulation (ECC) may not be the main cause of late neuropsychological decline.

Autologous glue: part of the sticky mystery unraveled.

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of an autologous surgical tissue adhesive. METHODS: Autologous glue was made out of canine concentrated plasma proteins mixed with 7.5% glutaraldehyde. Tensile strength and cytotoxicity of the autologous glue were tested. In a dog model, 8 transectioned iliac arteries were reanastomosed by using the animal's glue as the sole fixation method. After 120 days, all animals were angiographically controlled for patency and killed for histologic and immunohistochemical examination of the anastomosis. RESULTS: The autologous glue showed sufficient tensile strength (557 +/- 135 N/mm2). The elasticity of the glue is influenced by variations of concentrations in both proteins and glutaraldehyde. Glutaraldehyde remained cytotoxic, even at low concentrations of 2.5%. All operative procedures were successful. Angiographs performed before animal death showed all but 1 vessel to be patent and showed manifest compression signs in 3 anastomoses. Histological examination revealed only a foreign-body reaction adjacent to the surface of the glue. The autologous glue does not trigger any immune response on immunochemistry. Because fibroblastic neo-endothelial lining was near to normal, potential glutaraldehyde leaching does not seem too harmful for the vascular juncture in the dog model. CONCLUSIONS: Autologous glutaraldehyde glue has been used successfully as a vascular adhesive. In contrast to our previous studies with heterologous glue, we did not find a fierce acute inflammatory reaction indicating immune triggering. Nevertheless, glutaraldehyde remains a cytotoxic cross-linker. It is yet not known whether autologous glutaraldehyde glue can be used safely in clinical practice.

Stentless and stented aortic valve replacement in elderly patients: Factors affecting midterm clinical and hemodynamical outcome.

OBJECTIVE: To report on the midterm results of aortic valve replacement (AVR) with stented and stentless bioprosthesis in an elderly population by analyzing the factors affecting survival and hemodynamical performance. METHODS: In a retrospective study, 145 patients with a Toronto stentless prosthesis are compared with 110 patients with a stented Carpentier-Edwards valve. The 5- to 10-year clinical outcome, transprosthetic gradients, and early and late left ventricular mass (LVM) regression are analyzed in view of specific prosthesis- and patient-related factors. RESULTS: Actuarial survival at 5 years is 82% after stentless AVR versus 68% after stented AVR (p < 0.001) in elderly patients. However, there was no difference in survival at 8 years, being 55.9% and 59.5%, respectively. Univariate analysis revealed that advanced age at the time of operation, NYHA class IV, use of a stented xenograft, presence of patient-prosthesis mismatch (PPM) (IEOA < or = 0.85 cm2/m2), and severe preoperative left ventricular (LV) hypertrophy (LVMI > 180 g/m2) affected survival adversely. But multivariate analysis determined only age, NYHA class IV and excessive LV hypertrophy as independent predictors of late mortality. Stented and stentless xenografts were equally effective in terms of transprosthetic gradients and LVMI regression. The use of a stentless valve significantly reduced the occurrence of PPM (18% vs 41%, p < 0.01). Early LVMI regression at 1 year was optimized by the avoidance of PPM, indicated by a higher absolute (43.7+/-28.3 g/m2 vs 58.6+/-33.8 g/m2, p = 0.003) and relative (25.0+/-12.7% vs 31.4+/-14.9%, p=0.004) mass regression. However, late LV remodeling was predominantly affected by systemic hypertension and severe preoperative LV hypertrophy, resulting in the incomplete LVMI resolution in 61.3% and 66.7% of these patients, respectively. CONCLUSION: In elderly patients, aortic valve replacement appears to be equally effective with a stentless or stented bioprosthesis. Midterm clinical outcome is mainly determined by patient-related factors such as age, advanced NYHA class, and severity of preoperative LV hypertrophy. Regarding post-AVR left ventricular remodeling, patient-prosthesis mismatch influences the early phase, whereas arterial hypertension affects the late regression more. However, the left ventricular remodeling is continuously compromised by the preoperative presence of excessive hypertrophy, despite the efficacy of the aortic valve replacement.

Scanning electron microscopic surface topography of ablation catheter perforations and calcific tear in an explanted bioprosthetic heart valve.

The authors report a triplet of leaflet destruction in a bioprosthetic aortic valve explanted at 12 years after iatrogenic ablation catheter perforation in a patient who underwent coronary artery bypass surgery and multiple ablative procedures in the interim. Lesions were examined topographically by scanning electron microscopy. Calcium content was evaluated by mass spectrometry and Von Kossa staining. Leaflets exhibited little calcification, except at the commissures of the valve. Scanning electron microscopy revealed distinct lesion topography. The authors present the scanning electron microscopic characteristics of these lesions and of an incision into the valve made for comparison using a pair of scissors. This is believed to be the first report of scanning electron micrographs of ablation catheter perforations and a calcific tear in the same explanted valve. The findings provide a source for comparison in the etiological determination of explanted bioprosthetic valve lesions using scanning electron microscopy.