Premeasured Chordal Loops for Mitral Valve Repair.

Premeasured expanded polytetrafluoroethylene chordal loops with integrated sutures for attachment to the papillary muscle and leaflet edges facilitate correction of mitral valve prolapse. Configured as a group of 3 loops (length range 12 to 24 mm), the loops are attached to a pledget that is passed through the papillary muscle and tied. Each of the loops has 2 sutures with attached needles; these needles are passed through the free edge of the leaflet and then the sutures are tied to each other, securing the chordal loop to the leaflet.

Intermittent right coronary artery obstruction.

Although prospectively electrocardiogram-triggered acquisition is frequently used for coronary CT angiography examinations in routine clinical practice to achieve low radiation dose, the use of retrospectively electrocardiogram-gated techniques may be useful for cases that potentially have a dynamic temporal element or involve the valves. In this case of a valvular fibroelastoma, CT could demonstrate dynamic obstruction of the right coronary ostium.

Frequency of severe valvular disease caused by mediastinal radiation among patients undergoing valve surgery in a community-based, regional academic medical center.

BACKGROUND: Our goal was to define the prevalence of radiation-induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community-based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long-term cardiac complications, including radiation-induced valvular heart disease, can occur years after the radiation treatments. HYPOTHESIS: Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease. METHODS: Between January 1, 1998 and September 1, 2007, we retrospectively analyzed our institution's cardiac surgical database over a 10 year period and identified 189 consecutive patients ≤ 50 years of age who underwent valve surgery. Using case-control matching, we assessed the prevalence of mediastinal radiation among these young patients with valve disease necessitating surgery and to their matched controls from all patients admitted to the hospital. RESULTS: Nine individuals (4.8%) were identified as having received previous mediastinal radiation, significantly increased from controls (p<0.0001), and 8 of whom had surgical or pathologic findings consistent with radiation damage. Compared with a matched case-control population, individuals who had severe valve disease and underwent valve replacement had a markedly increased prevalence of prior mediastinal radiation therapy. CONCLUSIONS: In conclusion, cardiologists must remain aware of the potential long term valvular complications in patients treated with mediastinal radiation. Increased surveillance for RIVD may be considered in the decades following radiation therapy.

Left ventricular diverticulum mimicking ventricular pseudoaneurysm in an adult.

True diverticulum of the left ventricle is very rarely seen in adults: the condition typically occurs in children and can be associated with other anatomic defects that involve the thoracoabdominal midline. Left ventricular diverticulum, which is usually asymptomatic and typically discovered incidentally, can pose a substantial challenge to the surgeon.Herein, we report the case of a 46-year-old man who presented with worsening exertional angina and ST-segment elevation in the inferior electrocardiographic leads. After a stent was deployed in the patient's occluded right coronary artery, left ventriculography revealed outward pouching of the left ventricular inferior wall, suggesting an aneurysm or a contained free-wall rupture. Transesophageal echocardiography showed a sizable defect and a possible intracavitary thrombus. The presumptive diagnosis was a postinfarction subacute pseudoaneurysm of the left ventricle. However, during surgery, we saw no clots, intrapericardial blood accumulation, or perforation. A localized area of thinned muscle in the region of the posterior descending coronary artery was consistent with a ventricular diverticulum. The left ventricular epicardial surface was reinforced with a small bovine pericardial patch. The patient's recovery was uneventful. We discuss the forms of congenital left ventricular diverticulum and offer considerations regarding differential diagnosis.

Mitral annular remodeling to treat functional mitral regurgitation: a pilot acute study in a canine model.

BACKGROUND: The aim of this study was to evaluate the feasibility and efficacy of the injection of a nonabsorbable substance into the base of the left ventricle (LV) to treat functional mitral regurgitation (MR). METHODS: Tyramine-based hyaluronan hydrogel was injected into the base of the LV of the beating heart in a canine model of rapid ventricular pacing-induced functional MR (n = 4). The severity of MR was evaluated by epicardial echocardiography before and after hydrogel injection. RESULTS: The injection improved MR grade from 3.4 +/- 0.8 to 1.3 +/- 0.5 (P = .006) without inducing hemodynamic instability or any evidence of myocardial ischemia. We noted significant decreases in the septal-lateral dimension at the mitral annulus (3.4 +/- 0.4 cm to 2.9 +/- 0.3 cm; P = .039) and MR volume (20.6 +/- 7.3 mm3 to 5.2 +/- 2.2 mm3; P = .044). CONCLUSIONS: A novel treatment consisting of hydrogel injection into the base of the LV between the 2 papillary muscles was found to be feasible and effective for reducing functional MR in a canine model.

Acute myocardial infarction requiring mechanical bridge to transplantation in a patient with undiagnosed anti-phospholipid antibody syndrome.

We present a young man who sustained an acute myocardial infarction with hemodynamic instability requiring placement of a left ventricular assist device and subsequent cardiac transplantation. Hematologic work-up revealed anti-phospholipid antibody syndrome. To our knowledge this is the first reported case of severe acute heart failure due to anti-phospholipid antibody syndrome in which the patient survived through assist device placement and successful transplantation.

Spontaneous coronary dissection in late pregnancy: a multidisciplinary approach to management.

Spontaneous coronary dissection is a rare but potentially life-threatening condition. It often occurs in late pregnancy and may pose significant risks for the patient and the fetus. Its cause remains uncertain, and established guidelines for management have not been developed. In this report, close multidisciplinary collaboration has led to excellent outcomes in this condition.

Influence of different implantation techniques on long-term survival after orthotopic heart transplantation: an echocardiographic study.

BACKGROUND: Orthotopic heart transplantation (OHT) was initially done by the biatrial technique, although the bicaval technique has recently become more popular. The aim of this study was to compare OHT outcomes when using the bicaval technique vs the biatrial technique. METHODS: A total of 615 patients were transplanted at the Cleveland Clinic Foundation from January 1993 and October 2003 (biatrial technique: n = 293; bicaval technique: n = 322). The average follow-up period was 4.2 +/- 2.9 years (range 1 to 11 years). Patients who were supported with a left ventricular assist device (prior to transplant) and who could not be weaned off respiratory support were excluded. RESULTS: Patients in both groups were similar with regard to pre-operative characteristics. The peri-operative mortality showed no statistical significant differences between the two groups. The left atrium was significantly more enlarged in the biatrial group. The bicaval group showed a significantly reduced incidence of tricuspid regurgitation. Survival at 10-year follow-up was 87.3% in the bicaval group and 79.9% in the biatrial group (p < 0.05). Left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF) and moderate to severe tricuspid regurgitation were significant risk factors for death in both groups. The bicaval technique showed a significantly better mortality outcome. CONCLUSIONS: This study showed that the bicaval technique for OHT offers a better outcome than the biatrial technique. The significant reduction of left atrial size and atrioventricular valve regurgitation in the bicaval group may have a major impact on the long-term preservation of cardiac function and survival.

Pre-measured artificial chordae for mitral valve repair.

There is growing interest in the application of artificial chordae to correct mitral valve regurgitation caused by prolapse. Application of pre-measured artificial chordae facilitates creation of chordae of appropriate length. Herein we illustrate the technique for creation of pre-measured artificial chordae, documenting neo-chordal length and number in 50 patients with anterior leaflet prolapse, highlighting the need for chordae of more than one length in 14% of patients.

Does right thoracotomy increase the risk of mitral valve reoperation?

OBJECTIVE: The study objective was to determine whether a right thoracotomy approach increases the risk of mitral valve reoperation. METHODS: Between January of 1993 and January of 2004, 2469 patients with mitral valve disease underwent 2570 reoperations (1508 replacements, 1062 repairs). The approach was median sternotomy in 2444 patients, right thoracotomy in 80 patients, and other in 46 patients. Multivariable logistic regression was used to identify factors associated with median sternotomy versus right thoracotomy, mitral valve repair versus replacement, hospital death, and stroke. Factors favoring median sternotomy (P < .03) included coronary artery bypass grafting (30% vs 2%), aortic valve replacement (39% vs 2%), tricuspid valve repair (27% vs 13%), fewer previous cardiac operations, more recent reoperation, and no prior left internal thoracic artery graft. These factors were used to construct a propensity score for risk-adjusting outcomes. RESULTS: Hospital mortality was 6.7% (163/2444) for the median sternotomy approach and 6.3% (5/80) for the thoracotomy approach (P = .9). Risk factors (P < .04) included earlier surgery date, higher New York Heart Association class, emergency operation, multiple reoperations, and mitral valve replacement. Stroke occurred in 66 patients (2.7%) who underwent a median sternotomy and in 6 patients (7.5%) who underwent a thoracotomy (P = .006). Mitral valve replacement (vs repair) was more common in those receiving a thoracotomy (P < .04). CONCLUSIONS: Compared with median sternotomy, right thoracotomy is associated with a higher occurrence of stroke and less frequent mitral valve repair. Specific strategies for conducting the operation should be used to reduce the risk of stroke when right thoracotomy is used for mitral valve reoperation. In most instances, repeat median sternotomy, with its better exposure and greater latitude for concomitant procedures, is preferred.

Regional referral system for patients with acute mechanical support: experience at the Cleveland Clinic Foundation.

Regional referral networks ("hub and spoke") have been created to facilitate the transfer of patients on mechanical circulatory support. Although individual centers report good success, overall outcomes have remained poor. We investigated whether preoperative variables influenced survival and could be used to help select patients best served by referral. A retrospective chart review was conducted on all patients transferred to our institution supported on cardiac assist devices. Between January 1995 and September 2003, 39 patients were received in transfer for continued care after the implantation of a cardiac assist device. Eighty-five percent of patients had the ABIOMED BVS 5000 implanted. The most common indication was postcardiotomy shock. Sixty-four percent of patients were not candidates for heart transplantation due to medical or social contraindications. The 30-day mortality of this group was 62%. Survivors had less comorbidity and were less likely to have complex surgeries, neurologic impairment, and multisystem organ failure when presenting to our center. Devices were weaned in 30% of cases. Only six patients (15%) were successfully transplanted, and five of these patients have done well at follow-up. Based on our experience, we believe that cardiogenic shock patients benefit from a regional referral system if they have not had complex cardiac surgical procedures or developed multisystem organ failure. Furthermore, there is a survival advantage when using long-term devices because this allows possible recovery or transplantation.

Safety of targeted perioperative mupirocin treatment for preventing infections after cardiac surgery.

BACKGROUND: Indiscriminate antibiotic use may lead to development of antibiotic resistance. Preoperative mupirocin treatment decreases Staphylococcus aureus carriage and may reduce subsequent surgical site infection, but is unlikely to benefit noncarriers. This study was undertaken to evaluate whether avoiding mupirocin in noncarriers places them at increased risk for subsequent postoperative infection. METHODS: We conducted a retrospective cohort study examining incidence of postoperative infection in patients undergoing cardiac surgery at the Cleveland Clinic after introduction of a protocol of polymerase chain reaction screening for nasal S aureus carriage, and avoiding mupirocin treatment of noncarriers. RESULTS: Between August 1, 2002, and May 31, 2004, 6,334 patients were screened for nasal carriage of S aureus before undergoing cardiac surgery. There was no significant difference in infection rates between carriers and noncarriers when examining the incidence of all infections (5.6% and 5.0%; relative risk [RR] 1.11 [95% confidence interval (CI): 0.86 to 1.43]), infections caused specifically by S aureus (1.04% and 0.80%; RR 1.30 [95% CI: 0.71 to 2.39]), any surgical site infection (3.1% and 3.2%; RR 0.97 [95% CI: 0.69 to 1.36]), S aureus surgical site infection (0.82% and 0.58%; RR 1.41 [95% CI: 0.71 to 2.82]), any bloodstream infection (3.1% and 2.5%; RR 1.21 [95% CI: 0.86 to 1.71]), and S aureus bloodstream infection (0.37% and 0.48%; RR 0.77 [95% CI: 0.30 to 2.03]). Mupirocin use declined substantially after introduction of the protocol. CONCLUSIONS: A strategy of targeting perioperative mupirocin treatment to carriers leads to significant reduction in mupirocin use without increasing early postoperative infectious complications in noncarriers.

Ventricular assist devices and aggressive immunosuppression: looking beyond overall survival.

BACKGROUND: Patients bridged to heart transplantation with a ventricular assist device (VAD) developed coronary vasculopathy at the same rate as non-bridged patients despite having higher levels of pre-formed antibodies. We hypothesized that allosensitized VAD patients have higher levels of immunosuppression and thus different morbidity and causes of mortality. METHODS: Patients who received a transplant between January 1996 and May 2002 were separated into 2 groups based on the need for VAD support as a bridge to transplantation. Transplant and Inpatient Pharmacy Databases and charts were queried for date of transplantation, degree of allosensitization, use of desensitization therapy, immunosuppressive strategies, number of treated rejection episodes, and specific causes of death. RESULTS: This study investigated 238 patients (125 VAD patients, 113 non-VAD patients). VAD patients were more likely to be allosensitized than non-VAD patients (20% vs 5%, p < 0.01). OKT3 was given to 22% of VAD patients as anti-rejection prophylaxis and 14% received pre-transplant plasmapheresis. Non-VAD patients rarely were desensitized (2.6% of non-VAD patients). After transplantation, 68 VAD patients (54%) and 44 non-VAD patients (39%) had episodes of severe rejection requiring therapy. Episodes of rejection in VAD patients were commonly treated with steroids (90%), plasmapheresis (10%), and OKT3 (7%), and episodes of rejection in non-VAD patients were treated with steroids (76%) and OKT3 (8%). The 5-year survival for both groups was similar (90% and 86% respectively, p = 0.31). VAD patients commonly died of sepsis (75%), and non-VAD patients died of rejection (39%) and ischemic transplant cardiomyopathy (30%). CONCLUSION: When short-term outcomes between bridged and non-bridged heart transplant recipients were compared, overall survival was similar but causes of death differed. Findings in this study might aid in the post-operative management of patients bridged to transplantation with a VAD.

Preoperative cholesterol levels do not predict explant for structural valve deterioration in patients undergoing bioprosthetic aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Structural valve deterioration (SVD) is the most common cause of bioprosthetic valve failure. Coronary disease risk factors, including hypercholesterolemia, might predict SVD. Here, the relationship was examined between preoperative cholesterol levels and SVD in patients undergoing bioprosthetic aortic valve replacement (AVR). METHODS: A total of 7,150 patients (mean age 68 +/- 12 years) was identified who underwent bioprosthetic AVR at the Cleveland Clinic Foundation, between January 1975 and December 2002. Preoperative and postoperative variables were retrieved from a prospective, computerized database. A parametric method was used to estimate the distribution of valve explants; a multivariable risk factor model was then developed to include patient demographics, cardiac and non-cardiac comorbidities, valve type and interactions. The primary end-point was explant for SVD. All explants were examined, and observations were censored at the time of any explant or death. Bootstrap analysis was used to validate the model. RESULTS: Among 7,150 patients, 208 had explants for SVD. Mean preoperative total cholesterol (TC) was 203 +/- 48 mg/dl, HDL-cholesterol 45 +/- 15 mg/dl, and LDL-cholesterol 121 +/- 41 mg/dl. The average follow up was 3.7 years, and 1,169 patients (16%) were followed for more than eight years. In multivariable analysis, only younger age (p < 0.0001), greater body weight (p < 0.0001), elevated serum creatinine level (p = 0.0004) and use of a pericardial valve (p = 0.04) predicted SVD. Neither preoperative cholesterol nor its fractions predicted valve explant for SVD (log-rank p = 0.19) Moreover, no cardiovascular risk factors were predictive of SVD. CONCLUSION: Preoperative cholesterol levels do not predict SVD in patients undergoing bioprosthetic AVR. Whether long-term hypercholesterolemia or statin therapy impacts SVD requires further investigation.

Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery?

OBJECTIVE: To determine whether adding right internal thoracic artery to previous left internal thoracic artery bypass at reoperation increases deep sternal wound infection and hospital mortality, particularly in diabetic patients. METHODS: Reoperations (n = 2875; 2381 men) in patients with previous left internal thoracic artery bypass were performed between January 1990 and January 2003; 1939 (67%) had no repeat internal thoracic artery grafting, 923 (32%) received an additional right internal thoracic artery graft, and 13 (0.5%) had bilateral internal thoracic artery grafting with reuse of the left internal thoracic artery. Of the patients, 352 (12%) were insulin-treated and 590 (21%) non-insulin-treated diabetics. Multivariable logistic regression analysis was used to identify preoperative variables associated with right versus non-right internal thoracic artery use in diabetics and nondiabetics and to formulate propensity models. Propensity scores were used for matching and adjusted multivariable analyses of deep wound infection and hospital mortality. RESULTS: Deep wound infection occurred in 3.0% (7/230) of diabetics receiving right internal thoracic artery grafts, 2.2% (5/230) of propensity-matched diabetics receiving non-right internal thoracic artery grafts (P = .6), in 1.1% (6/538) of nondiabetics receiving right internal thoracic artery grafts, and in 1.0% (5/538) of matched non-diabetic patients receiving non-right internal thoracic artery grafts (P = .8). Corresponding hospital mortality in these matched groups was 1.7% (4/230) versus 6.1% (14/230) for diabetics (P = .02) and 2.6% (14/538) versus 3.5% (19/538) for nondiabetics (P = .4). Risk factors for deep wound infection included higher weight (P = .0003), higher New York Heart Association functional class (P = .03), and less severe left anterior descending disease (P = .03). Risk factors for death were (P < .02) emergency operation, mitral valve replacement, and greater number of saphenous vein grafts. CONCLUSIONS: Use of the right internal thoracic artery for reoperations does not increase the risk of deep wound infections in diabetics or nondiabetics and does not increase mortality.