Efficacy of Aortic Valve Replacement through Full Sternotomy and Minimal Invasion (Ministernotomy).

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

Disc impediment in medtronic-Hall aortic valve prosthesis followed by successful reoperation.

This case report describes the diagnostic and treatment challenges of the combined disc impediment caused by pannus ingrowth in combination with thrombus formation in a 21-mm Medtronic-Hall aortic valve prosthesis. A combined obstruction of a Medtronic-Hall prosthesis in the aortic position is a rare, but potentially fatal clinical condition for the first time reported in Vilnius University Hospital Santariskiu Klinikos. Despite the difficulties in determining a correct diagnosis, our critically ill patient was clinically stabilized by partially successful thrombolysis and then successfully treated by a surgical thrombectomy together with pannus excision during the rotation of the disc within the valve housing 3 years after the valve implantation.

[Results of surgical treatment of aortic root infection]. / Aortos saknies infekcijos chirurginio gydymo rezultatai.

AIM OF THE STUDY: To investigate preoperative status and results of surgery of patients with confirmed diagnosis of aortic root infection. MATERIALS AND METHODS: We have analyzed data of 21 patients who were operated on at the Heart Surgery Center, Vilnius University, since January 1, 1997, till December 31, 2006. All these patients underwent surgery because of aortic root infection. The patients were aged 25-72 years (mean age, 53+/-14 years). There were 17 (80.9%) male patients. Sixteen patients (76%) preoperatively were in NYHA class IV. The abscesses of aortic root were confirmed preoperatively by means of esophageal echocardiography in 18 patients (86%). Blood cultures positive for Staphylococcus aureus were found in four patients (19.9%). All the patients underwent replacement of the aortic valve by mechanic prosthesis; one of these patients was reoperated because of persistent sepsis, and replacement of the aortic root with homograft was performed. The duration of follow-up of the patients was 1 to 10 years. RESULTS: Inhospital mortality rate was 14.3%. The causes of death included sustained heart failure and sepsis. All these patients were in NYHA functional class IV preoperatively; one of these patients had culture positive for Staphylococcus aureus. Inhospital survival was 85.7%, one-year postoperative survival - 80.9%, and both five-year and ten-year survivals were 76.0%. The long-term survival was negatively influenced by recurrent infective endocarditis, heart failure, and age. Death occurred in 1 patient (11.1%) of the 9 patients who at the time of surgery were younger than 50 years and 4 patients (33.3%) of the 12 who were older than 50 years at the time of operation. CONCLUSIONS: The infection of aortic root is not common pathology; however, it is a complicated disease. Esophageal echocardiography is an informative method while diagnosing aortic root abscesses. The inhospital mortality is increased by the heart failure persisting after the operation and sepsis. The long-term survival is decreased by preoperative infective endocarditis of the prosthesis and heart failure. The mortality rate of patients older than 50 years is 3-fold higher than mortality rate of younger ones.

[Survival rate of patients with ascending aorta aneurysm and aortic valve regurgitation in the late postoperative period]. / Pacientu, operuotu esant letinei kylanciosios aortos aneurizmai ir aortos voztuvo nesandarumui, isgyvenamumas velyvuoju pooperaciniu laikotarpiu.

UNLABELLED: The aim of the study was to evaluate the long-term survival in patients undergoing surgical treatment for chronic aortic aneurysms with aortic regurgitation. MATERIAL AND METHODS: We analyzed survival data of 188 patients during follow-up period of 1 month to 20 years postoperatively. The patients were divided into the following groups according to the clinical course: Group 1--chronic dissecting aneurysm of ascending aorta with aortic regurgitation (42 patients, 22.3%); Group 2--chronic nondissecting aneurysm of ascending aorta with aortic regurgitation (146 patients, 77.7%). Mean NYHA functional class of the patients was 3.5+/-0.06. In the Group 1, 64.3% of the patients were in NYHA functional class IV; 35.7% of the patients were in NYHA class III. In the Group 2, the majority of the patients (58.2%) were in class III; in class IV - 41.8%. The most common etiological factors in both groups were atherosclerosis, arterial hypertension, and Marfan's syndrome. RESULTS: No differences in overall and long-term survival rates between the groups were found. However, the patients who were in class III before the operation showed significantly higher overall and long-term survival rates in comparison with the survival rate of the patients who were in NYHA class IV preoperatively (overall survival rate, 91.4+/-3.0% vs 62.9+/-6.9%; and long-term survival rate, 93.2+/-2.7% vs 72.9+/-5.6; respectively). There were 24 deaths (12.8%) during the late postoperative period. The main causes of death were progressive heart failure and infective prosthetic endocarditis (Group 2), chronic heart failure and dysfunction of the conduit (Group 1). CONCLUSIONS: The analysis of patients' long-term survival demonstrated the efficacy of surgical treatment of such a complex pathology as chronic aneurysm of the ascending aorta with aortic valve regurgitation. The survival rate in the late postoperative period was higher in NYHA class III patients. The main causes of death were chronic heart failure and infective prosthetic endocarditis.

[Radiofrequency modified maze procedure with mitral valve surgery: mid-term follow-up results]. / Modifikuota radiodaznine labirinto procedura ir mitralinio voztuvo ydos korekcija: vidutines trukmes pooperacinio stebejimo rezultatai.

OBJECTIVE: The Cox-maze procedure is an effective established surgical method for elimination of atrial fibrillation. The aim of this study was to evaluate the efficacy and safety of radiofrequency ablation as a surgical adjunct in treating atrial fibrillation and to adapt maze principles to mitral valve surgery using transseptal approaches. MATERIAL AND METHODS: Thirty-six patients underwent radiofrequency modified maze procedure using standard and cooled ablation electrodes in combination with surgery for hemodynamically significant mitral valve disease and chronic, persistent or paroxysmal atrial fibrillation. Fourteen (39%) patients had mitral valve repair and 22 (61%) patients had mitral valve replacement; 33 (91.6%) patients underwent concomitant surgical procedures. RESULTS: The cardiopulmonary bypass time was 162+/-38 min, the aortic cross-clamp time - 98+/-22 min. The additional aortic cross-clamp time required for the radiofrequency modified maze procedure was 21+/-3 min. Postoperative mortality was 2.8%. In 7 of 36 pts (19.4% ) significant bradycardia requiring permanent pacing (six - AAI, one - DDD) was seen after the operation. Patients were followed up for 4 months to 2.5 years after surgery (mean 11.2+/-7.4 months). There were no deaths, no thromboembolic complications during follow-up. Freedom from atrial fibrillation or flutter was 100% at the end of operation, but during 0.5-3 months after operation atrial fibrillation or flutter were observed in 41.6% (15/36) patients. In 2 (5%) patients chronic atrial fibrillation developed. Freedom from atrial fibrillation/flutter was 86% (12/14) at 1 year postoperatively. CONCLUSIONS: The radiofrequency modified maze as an adjunctive procedure is safe and effective in eliminating atrial fibrillation using standard and cooling-tip ablation electrodes in combination with surgery for mitral valve disease.

[Risk of second and third reoperation on prosthetic heart valves]. / Trecioji ir ketvirtoji sirdies voztuvu operacija tam paciam ligoniui. Ar didele operaciju rizika?

As the volume of heart valve replacements increases, more patients are undergoing repeated operations. There are many reasons for reoperations that include incomplete or imperfectly executed primary operation, infection on valve prostheses, valve related complications. Repeated operations have their own specific technical problems, and from them depends mortality and complications rate. At Vilnius University Heart Surgery Clinic from 1967 we performed 6200 heart valve replacement operations. At the same time we performed 428 reoperations for 394 patients. Two reoperations were performed for 28 patients and 3 reoperations for 3 patients (65 reoperations for 31 patient). Main course of reoperation - sepsis and periprosthetic leaks (50%). Half of patients at the time of last reoperation were in functional class V (NYHA). Mortality rate after second reoperation was 28%, after third reoperation all three patients died. Main course of operative mortality - sepsis, heart failure, hemorrhage.

[Eleven year experience of treatment mediastinitis after open heart surgery]. / Mediastinitu po sirdies operaciju gydymo patirtis.

The frequency of infective mediastinitis after open heart surgery, according data of various authors, ranges from 0.1% to 1%. In order to decrease amount of this type of complications the specialised department with 12 beds was established at the Heart Surgery Clinic of Vilnius University in January 1, 1991. Since that time till January 1, 2002, 330 patients were operated because infective mediastinitis after open heart operations. Original method of treatment of infective mediastinitis was elaborated. Mean stay of the patients treated by means of this method ranged from 14 to 34 days (mean - 24 day). Twenty four (7.4%) patients died because of progressing sepsis (8 patients - 33.3%), heart failure (10 patients - 41.6%), multiorgan failure - 4 (16.6%), other causes - 2 (8.3%). Although there is no common method of treatment of infective mediastinitis after open heart operations, we consider our method of treatment to be effective.

[Septical complications after ascending aorta replacement]. / Septines komplikacijos ligoniams, kurie operuoti del kylanciosios aortos aneurizmos ir aortos voztuvo nesandarumo ar be jo.

Between December 1972 and January 2002, 201 patients had replacement of the ascending aorta at Vilnius University Heart Surgery Clinic. 171 of them had aortic valve replacement, too, and 30 patients - without aortic valve correction. Septical complications post operation had 24 (11.94%) patients. Their age ranged from 30 to 73 years (mean 49.4 years). Most of the patients were male (87.5%) and IV functional class NYHA (70.8%) preoperatively. Main etiological factor of ascending aorta aneurysm was atherosclerosis, rare - Marfan's syndrome. Sepsis, prosthetic infective endocarditis was detected in 10 (41.7%), mediastinitis - in 9 (37.5%) and sepsis with mediastinitis - in 5 (20.8%) cases. Hospital period (< 1 month) septical complications were diagnosed in 91.7% of all cases. Total sepsis related hospital period mortality was 3.5%, late - 4.0% from all 201 operated. Septical complications were not common in patients after ascending aorta replacement. Reoperations were associated with early mortality and satisfactory long-term results. Conservative treatment was not successful.