Infective endocarditis.

BACKGROUND: Infective endocarditis continues to pose a therapeutic challenge to treating clinicians. We believe that the successful management of endocarditis mandates a thorough understanding of the risk factors for adverse outcomes and a co-ordinated team approach. METHODS: Between the years 2000 and 2009, 85 patients required surgery for infective endocarditis, with a total of 112 infected valves being treated surgically. Data was analysed to determine factors significantly associated with morbidity and mortality. RESULTS: The mean age was 50.5 years. Nine (10.5%) of these patients had Prosthetic Valve Endocarditis, the remaining 76 (89.5%) had Native Valve Endocarditis. Twenty-nine percent of patients were NYHA 4 pre-operatively, 15% of patients were haemodynamically unstable requiring inotropic support, 34% were persistently febrile despite antibiotic therapy, and 48% had suffered any embolic event, 20% suffered cerebral emboli. The commonest causative organism in our series was Staphylococcus Aureus (54.1%) with 2.3% of cases being due to MRSA. The second commonest organism isolated was Streptococcus spp. at 21.1%. Operative mortality was 12.9%, of which on-table mortality was 2.2%. Mean follow-up was 56 months (range 1-151). Early recurrence rates (<3 months) were 2.3%. Late recurrence was 7.0%. The pre-operative factors associated with increased mortality were age over 65, inotropic requirement, uncontrolled sepsis and cerebral emboli. We summarise our experience and recommendations for a team approach to the management of infective endocarditis.

Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: the SOURCE ANZ registry: outcomes at 30 days and one year.

BACKGROUND: We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. METHODS: This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. RESULTS: The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p=0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p=0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p=0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p=0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p=0.91). CONCLUSION: TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

Aortic root replacement for ascending aortic disease: a 10 year review.

BACKGROUND: Bentall's procedure and its modifications have been used for over 40 years for the treatment of ascending aortic disease. This study reviewed 10 years of experience with Aortic Root Replacement (ARR) in a major cardiac surgical centre. METHODS: Eighty-nine patients underwent ARR between 1999 and 2009. The records were scrutinised by retrospective chart review. RESULTS: The mean age was 54 years. Seventy-nine percent of patients were male and 21% female. The indications for the procedure were Aortic Root Aneurysm (ARA) (65%), type A dissection (28%), infective endocarditis (4.4%) and prosthetic valve regurgitation (2.2%). Fifty-seven percent of these were performed electively and 43% as an emergency. A bicuspid aortic valve was present in 37%. Arch surgery was required in 15.7%, bypass grafting in 12.3% and mitral valve surgery in 5.6%. The descending aorta was involved in 16.8%. Operative mortality was 3.3% and in-hospital mortality 12.3%. Mean follow-up was 67.05 months (range 2-143). No patients required re-operation. CONCLUSIONS: The factors associated with increased in-hospital mortality were pre-operative haemodynamic instability, concommitant coronary artery disease and acute renal failure. The presence of a bicuspid valve may be associated with lower rates of complications, but no difference in mortality.

Successful treatment of ventricular assist device associated ventricular thrombus with systemic tenecteplase.

We report a case of intracardiac thrombus in a patient supported by the Jarvik 2000 Flowmaker successfully treated with a single dose of peripherally administered TNK-tissue plasminogen activator (Tenecteplase, Metalyse, Boehringer Ingelheim). This strategy may be considered in the case of life-threatening VAD associated thrombosis to avoid the need for intracardiac drug delivery or VAD replacement. We also discuss the apparent increased thrombotic risk in patients receiving a VAD for chemotherapy induced cardiomyopathy and the implications this may have for the choice of VAD.

Preoperative intraaortic balloon pumps in high-risk patients undergoing open heart surgery.

BACKGROUND: The use of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatomy is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival in high-risk patients having open heart surgery. METHODS: Prospectively collected data for 645 consecutive patients were reviewed. Patients receiving an IABP were identified and grouped as follows: group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP). Risk-adjusted hospital mortality rates in these three groups was compared using the modified Parsonnet score for preoperative risk stratification. RESULTS: IABPs were used in 101 cases (16%). The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in group C (group A vs group B, p = 0.0014; group A vs group C, p = 0.012). IABP-related morbidity occurred in 3% of cases (all in group C). CONCLUSIONS: Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.

Cardiac operations in patients with low-grade small lymphocytic malignancies.

BACKGROUND: Low-grade small lymphocytic (B cell) malignancies (encompassing chronic lymphocytic leukemia and some types of non-Hodgkin lymphoma) are diseases of the elderly. Open cardiac procedures are known to have increased risk of postoperative infection and other morbidities in these immunodeficient patients. Outcome of open cardiac procedures in these patients was reviewed retrospectively. PATIENTS: Thirteen patients (aged 58-82 years, 11 men, 2 women) with these lymphocytopathologic diseases (8 with chronic lymphocytic leukemia and 5 with non-Hodgkin lymphoma) underwent cardiac operations between January 1977 and June 1998. Mean age was 72 +/- 2.1 years. Isolated coronary artery bypass grafting was performed in 11 and combined procedures and double valve replacement were performed in 1 each. Preoperatively, 9 patients were in a low-risk clinical stage. Mean preoperative duration of lymphocytopathologic disease was 6.1 +/- 1.6 years. Mean preoperative New York Heart Association functional class was 2.8. RESULTS: There was no operative death. Average stay in the intensive care unit was 41.4 +/- 8.6 hours. Postoperative leg and superficial sternal wound infections were encountered in 3 patients. Average postoperative hospital stay was 10.0 +/- 1.7 days. During the follow-up up to 72 months, 1 patient underwent a second cardiac operation. There was 1 late death 4 years later. Coronary stenting was done in 1 patient and a cardioverter-defibrillator was implanted in another patient for recurrent angina. Three patients underwent chemotherapy. Cardiac and lymphocytopathologic status remained stable in others. CONCLUSIONS: Acceptable outcome may be anticipated after cardiac operations in patients with low-grade chronic lymphocytic leukemia and non-Hodgkin lymphoma in early stages. However, the possibility of infection and progression of cardiac and lymphocytopathologic status in these patients should call for caution.

Cardiac reoperations in octogenerians.

OBJECTIVE: In recent years, satisfactory outcome of primary cardiac operation in octogenerians and increased ageing of cardiac surgical population in western hospitals have led to increased expectations and referrals for reoperation. Outcome of reoperation in this aged subset was analysed. METHODS: Consecutive 18 octogenerians (mean age 81.2 years, 10 men, eight women) undergoing cardiac reoperations from November 1989 through August 1998 were retrospectively reviewed. RESULTS: They represented 6.2% of all octogenerian cardiac surgical patients and 2.7% of all reoperations during the same period. Mean preoperative NYHA class was 3.4 and Parsonnet score was 29.4. The interval to reoperation was 114.5+/-11.96 (4-188) months. Priority was urgent in 11 and elective in seven patients. The procedures included four AVRs, five MVRs (including two associated TVAs), six CABGs and one each of MVR with CABG, AVR with CABG and AVR, MVR and CABG. Average graft/patient was 2.3. Mean ICU stay was 4.6+/-1.5 (1-28) days. There was one hospital death (5.5%) on 18 pod after MVR in an 83-year-old woman. Mean postoperative stay was 20.2+/-5.13 (8-93) days. There were three late deaths (17.6%)--at 32 months after MVR, at 44 and 63 months after CABG. Long-term survivors were 90% among men and 50% among women who were followed up for 42.7+/-6.9 (9-93) months. Mean Karnofsky score in survivors at 1 year of follow-up was 78.5+/-2.9. Despite continued medication in all survivors, mean current NYHA is 1.9 and most have improved lifestyle. CONCLUSIONS: Satisfactory outcome may be expected after cardiac reoperations in highly selected octogenerians. However, increased procedural risks, complications, hospital stay and slower convalescence during early follow-up may be anticipated, and will indicate very careful screening. These results indicate a need to reconsider the treatment policy in primary operation with regard to choice of graft conduits and prosthetic valves in other elderly patients.

Fat necrosis in surveillance biopsies of heart transplants.

Fat necrosis was observed in surveillance biopsies of five patients following heart transplant. This reaction is poorly documented in the literature, but in personal communication, some pathologists working in the field have had experience with it. Four of the cases developed two to six days after transplantation, but in the fifth case, fat necrosis developed ten months after transplantation. Autopsy study of one case showed extensive severe fat necrosis involving both donor and recipient tissues. The cause is not known, and the changes are independent of rejection. However, the fat necrosis can be found within the interstitial tissues of the myocardium and subendocardium and may be mistaken for rejection if lymphocytes and polymorphs are part of the inflammatory response. The only clinical finding thought to be related to the fat necrosis was the development of transient complete heart block in a patient in whom the International Society for Heart and Lung Transplantation (ISHLT) standardised rejection grading was never greater than IA.

Tracheal mucormycosis.

Pulmonary mucormycosis is a recognized entity occurring in diabetics and immunocompromised patients. It has a poor prognosis unless early diagnosis is made and appropriate surgical therapy instituted along with appropriate antifungal therapy. We describe here one of few cases of tracheal involvement by mucormycosis. Extensive destruction of the trachea and bibasal pneumonia led to the patient's death.

Outcome in paired recipients of single lung transplants from the same donor.

BACKGROUND AND METHODS: We compared outcome measures in twenty single lung transplant recipients: 10 patients received the first lung of a donor pair (group 1), and 10 patients received the second lung (group 2) to determine the feasibility of sequential use, respectively, of donor lungs from the same donor in the same institution. The paired recipients underwent transplantation in the same operating room by the same surgical team. Both groups were well matched for age, gender, pretransplantation symptom class and diagnosis. RESULTS: The ischemic time for group 1 versus group 2 was 164 +/- 53 minutes (mean +/- standard deviation) (range 103 to 250 minutes) versus 377 +/- 53 minutes (range 315 to 445 minutes), respectively, (p < 0.001), but the longer ischemic time for group 2 did not adversely affect time to extubation (10.5 +/- 5.1 hours versus 10.3 +/- 7.6 hours; p = Not significant), early gas exchange (partial pressure of arterial oxygen on a fractional concentration of oxygen in inspired gas of 0.60: 237 +/- 61 versus 267 +/- 88 mm Hg; p = Not significant), length of hospital stay (16 +/- 13 days versus 16 +/- 5 days; p = Not significant), or actuarial one-year survival (80 +/- 12% versus 90 +/- 12%; p = Not significant). However, acute lung rejection (expressed as events/100 days) was more common within the first 3 months in group 1 versus group 2 (2.68 +/- 0.57 versus 1.32 +/- 0.38, respectively; p < 0.01), as were infectious events (2.07 +/- 0.50 versus 0.99 +/- 0.33; p < 0.01). CONCLUSIONS: These data confirm the safety of using the second lung from a donor pair sequentially in the same institution. The longer cold ischemic time for the second lung does not impair demonstrably early graft function and may be associated with a lower perioperative morbidity from acute rejection and subsequent infection. One-year outcome appears favorable for both groups.

Outcome in peripartum cardiomyopathy after heart transplantation.

From 1983 to 1991, 27 women with peripartum cardiomyopathy were considered for heart transplantation. Of 27 patients, 11 (41%) improved with medical therapy, 10 (37%) underwent transplantation, and six (22%) died. Results in the 10 patients with peripartum cardiomyopathy who underwent transplantation were compared with results in 39 women who underwent transplantation for dilated cardiomyopathy (idiopathic, Adriamycin, valvular, or familial) to determine whether there were differences in survival, rejection, or infection rates. The two groups were, by chance, well matched for number of pregnancies, peak panel reactivity, and cross-match. Mean time from delivery to transplantation was 24 weeks (range 2 to 188 weeks), and this time did not correlate with rejection rates. The linearized rate of rejection from 0 to 3 months was 30% higher in the group with peripartum cardiomyopathy (3.4 +/- 0.7 vs 2.6 +/- 0.3 episodes/100 patient days; p = 0.05). The mean postoperative day to first rejection was day 26 for peripartum cardiomyopathy and day 28 for women with dilated cardiomyopathy. Rejection requiring cytolytic therapy occurred in 40% of women with peripartum cardiomyopathy and 21% of the comparison group (difference not significant). Linearized (treated) infection rates were 1.8 +/- 0.5 for the group with peripartum cardiomyopathy versus 1.5 +/- 0.2 episodes/100 patient days for others (p = 0.05). Actuarial survival was excellent in both groups with 88% and 86% 2-year survival rates, respectively. In conclusion, women who undergo transplantation for peripartum cardiomyopathy have a 30% higher rate of early rejection than do those who undergo transplantation for idiopathic cardiomyopathy and tend to have a greater need for cytolytic therapy. Infection rates are consequently higher.(ABSTRACT TRUNCATED AT 250 WORDS)

Optimal approach to the mitral valve: dissection of the interatrial groove.

Surgical exposure of the mitral valve has challenged surgeons for more than 30 years. Many ingenious, but often complex approaches have been devised during this time. Using the dissection of the interatrial groove to bring the left atrial incision more anterior and medial, we have achieved excellent exposure in more than 300 mitral valve procedures. This simple technique does not lengthen the procedure and is not associated with an increased risk of either early or late morbidity.

Acute bacterial endocarditis. Optimizing surgical results.

BACKGROUND: Acute bacterial endocarditis continues to be a condition with high morbidity. Although the majority of patients are treated by high-dose antibiotics, a high-risk patient group requires surgical intervention, which is the subject of this article. METHODS AND RESULTS: From 1972 to 1991, 3,820 patients underwent heart valve replacement at the Brigham and Women's Hospital, Boston. Of this group, 158 patients underwent surgery for acute bacterial endocarditis: 109 had native valve endocarditis (NVE), and 49 had prosthetic valve endocarditis (PVE). There were 108 men and 50 women with a mean age of 49 years (range, 16-79 years); 64% were New York Heart Association functional class IV before surgery, and 12% of the group had a history of intravenous drug abuse. In both NVE and PVE groups, Streptococcus was the predominant infecting agent. Uncontrolled sepsis, progressive congestive failure, peripheral emboli, and echocardiographically demonstrated vegetations were the most common indications for surgery. Eighty-five percent of patients had a single-valve procedure, 15% had a multivalve procedure, and 34 patients had other associated major cardiac procedures. The operative mortality was 6% in NVE and 22% in PVE. Long-term survival at 10 years was 66% for NVE and 29% for PVE. Freedom from recurrent endocarditis at 10 years was 85% for NVE and 82% for PVE. The main factors associated with decreased survival overall were PVE and nonstreptococcal infection. CONCLUSIONS: The morbidity and mortality after surgical treatment of acute endocarditis depend on the site, the severity, and the subject infected. Early aggressive surgical intervention is indicated to optimize surgical results, especially in patients with nonstreptococcal infection or PVE.

Abdominal aortic dissection due to idiopathic medial aortopathy in a 32-year-old Caucasian man.

A case of dissection of the abdominal aorta in a 32-year-old Caucasian man associated with a histological diagnosis of granulomatous aortitis and a clinical diagnosis of idiopathic medial aortopathy is described. The relationship between giant cell "temporal" arteritis, Takayasu's disease and idiopathic medial aortopathy is discussed.