BioGlue® is not associated with polypropylene suture breakage after aortic surgery.

Objective: We have encountered broken or damaged polypropylene sutures (Prolene®) at the anastomotic sites during aortic reoperations. Because a surgical sealant, bovine serum albumin-glutaraldehyde (BioGlue®), was used in previous aortic surgery in some of these cases, we undertook this in vitro study to evaluate whether the use of BioGlue® was associated with breakage of polypropylene sutures at the aortic anastomosis. Materials and methods: The broken polypropylene sutures, anastomotic sites and aortic tissue at the location of suture breakage were visually inspected and evaluated intraoperatively. Six human cadaveric aortic samples were incised circumferentially and anastomosed proximally to a valved conduit with running 4-0 polypropylene sutures (Prolene®). In the test group (n = 3), BioGlue® was applied directly to the Prolene® sutures at the anastomotic sites, while in the control group (n = 3) the anastomoses were not sealed with any surgical adhesive. The six samples were immersed in Dulbecco's phosphate buffered saline solution and mounted on a M-6 Six Position Heart Valve Durability Testing System and tested up to 120 million cycles for a 2-year period. During and upon completion of the testing, the integrity of Prolene® sutures, the anastomosis and aortic tissues was regularly assessed by visual inspection. Results: Intraoperative findings included a stretched and thin aortic wall (some with thrombus), a small cleft between the aortic tissue and the Dacron vascular graft. An excessive amount of BioGlue® was often found around the anastomosis, with cracking material, but no signs of mechanical damage were observed in these cases. Upon visual inspection during and after in vitro testing, there was no apparent damage to the polypropylene sutures on the interior or exterior of the aortic anastomoses in any of the samples. No difference was observed in the physical integrity of the polypropylene sutures at anastomotic lines, the anastomoses and aortic tissues between the test and control samples. Conclusions: The results of this study suggest that the use of BioGlue® was not associated with breakage of the polypropylene sutures at the anastomotic sites after aortic dissection repair.

Opposite trends in coronary artery and valve surgery in a large multisurgeon practice, 1979-1999.

BACKGROUND: Trends in coronary artery bypass (CAB) and valve operations (VO) may help predict the future of cardiac surgery in the context of changing case mix, shifting paradigms, emerging technology, and population demographics. METHODS: We retrospectively reviewed all 30,319 adult CAB and VO in our group from 1979 to 1999 according to specific procedures. RESULTS: Coronary artery bypass volumes peaked in 1996 at 1,895 cases, declining 15.3% to 1,605 cases in 1999 with a decrease in risk profile and percent reoperations and an increase in mean age and percent octogenarians, prior percutaneous coronary interventions (PCI), left internal mammary artery (LIMA) graft usage, off-pump technology usage, and hospital mortality of reoperations. Right internal mammary grafts were employed infrequently and radial artery grafts transiently. Overall VO volumes continued to increase 24.0% since 1996, from 470 to 583 cases with a decreased risk profile, increased mean age, and percent octogenarians and prior PCI. The percentage of mechanical valve implants decreased, while the percentage of various tissue solutions for valve disease increased. Limited access incisions and port-access were employed transiently with CAB and VO. CONCLUSIONS: Coronary artery bypass volumes are decreasing, with an increasing percentage of LIMA grafts and off-pump cases. Valve operation volumes are steadily increasing, with a decreasing percentage of mechanical valve implants, in favor of various tissue solutions.

Morbidity and mortality of a failed attempt at mitral valve repair converted to replacement at the same operation.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair (MVRpr) is the preferred operation for mitral disease worldwide, some surgeons are reluctant to attempt this, believing that excess morbidity and mortality will result if the attempt fails and conversion to mitral valve replacement (MVR) is necessary during surgery. METHODS: Typical preoperative, operative and postoperative parameters were reviewed retrospectively on 2,017 consecutive adults undergoing mitral valve operations (MVO), with and without additional cardiac surgery, between 1986 and 1999. Morbidity and mortality were compared for all MVRpr, MVR and attempted repairs, which failed and were converted to replacement at the same operation (FRpr). RESULTS: Although cross-clamp and extracorporeal pump times were longer for FRpr than for MVRpr and MVR, neither blood product use, morbidity, nor length of ICU or hospital stay was increased. Perioperative myocardial infarction was higher in FRpr, but less than 5%. Although operative mortality was lower for successful MVRpr compared with MVR, there was no difference between FRpr and either MVRpr or MVR, whether as an isolated or combined procedure. The addition of other cardiac procedures to a specific MVO appeared to be the important variable in mortality in all the groups, rather than the length of cross-clamp or extracorporeal pump times. CONCLUSION: An attempted MVRpr which fails and is converted to replacement at the same operation does not appear to be associated with excess morbidity or mortality, despite longer cross-clamp and pump times. Accordingly, MVRpr can be safely undertaken when indicated, even with additional cardiac procedures.

Replacement of the aortic valve in patients under 50 years of age: long-term follow-up of the St. Jude Medical prosthesis.

BACKGROUND: Aortic valve replacement in the young adult (aged 18 to 50 years) is a choice between a mechanical prosthesis with attendant lifelong anticoagulation or biological prostheses of varying types that may have limited life expectancy in this age group. METHODS: The Cardiac Surgical Research Foundation database was accessed to determine long-term outcomes in patients having aortic valve replacement with the St. Jude Medical Valve. This database has been privately maintained since the world's first St. Jude Medical (SJM) valve implant in 1977. Patients were contacted by questionnaire or by telephone if the survey was not returned. Follow-up was 93% complete. RESULTS: From October 1977 through October 1997, 271 patients less than 50 years of age had isolated aortic valve replacement. Follow-up was 1957 patient years. Thirty-day operative mortality was 1.1% with 18 late deaths, 4 of which were valve related. Ninety percent of survivor INR responses indicated a frequency of monthly INR checks or less. Valve-related events including percent per patient year and mortality related to these events included thromboembolism, 6 episodes (0.3% per patient year, no deaths); anticoagulant-related bleeding, 6 events (0.3% per patient year, 2 deaths); paravalvular leak, 6 events (0.3% per patient year, 2 deaths); valve thrombosis, 2 events (0.1% per patient year, no deaths); and endocarditis, 3 events (0.15% per patient year, no deaths). There was no incidence of structural valve failure. CONCLUSIONS: The SJM valve has a long record of excellent performance with durability lasting more than 20 years. The incidence of untoward events is low and death over time due to valve-related complications is low (4 of 271). The SJM valve has become our valve of choice for younger patients.

Trends in mitral valve surgery in a large multi-surgeon, multi-hospital practice, 1979-1999.

BACKGROUND AND AIM OF THE STUDY: Trends in mitral valve operations (MVO) may help to predict the future of mitral valve surgery in the context of changing case mix, population demographics, emerging technology and shifting paradigms. METHODS: All adults undergoing single mitral valve operations (MVO) between 1979 and 1999 were reviewed retrospectively according to age, gender and other typical clinical variables, surgical complexity, specific operation and immediate outcome. RESULTS: A total of 2,055 single MVO was performed. Although coronary artery bypass volumes declined by 15.3% from 1996 to 1999, MVO volumes have continued to increase 58.0% since 1996. For the entire period, there was an insignificant increase in mean age, but an increase in percent male gender and in the prevalence of degenerative and ischemic etiology and mitral regurgitation (MR) pathophysiology. During the 1990s, trends in surgical complexity included a stable 40% prevalence of combined MVO and a stable 9:1 distribution of first operations to reoperations. Technology adoption included a decreased prevalence of mechanical valve usage at the expense of an increased prevalence of mitral valve repair (MVRpr). The prevalence of MVRpr among individual surgeons appeared to be related to a threshold case load of 20 mitral valve operations per year. Predictors of hospital mortality rates for MVO included age > or = 65 years, reoperations and combined MVO. Age > or = 65 years was a predictor of hospital mortality for each category of overall, isolated and combined MVO, mitral valve replacement (MVR) and MVRpr except for combined MVR. Hospital mortality rates for overall MVO, first-op MVO and combined MVO decreased during the 1990s. Hospital mortality comparisons between MVR and MVRpr favored MVRpr, either significantly or by insignificant trend, in every category of overall, isolated and combined groups and when evaluated by age > or = or < 65 year, in overall, isolated and combined groups. CONCLUSION: MVO volumes are steadily increasing apparently as a result of the increase in octogenarians and the beginning of the 'baby boomer' wave. Degenerative and ischemic etiologies with MR pathophysiology are on the rise, while rheumatic and endocarditis etiologies are static. The prevalence of MVR with mechanical prostheses has decreased in favor of MVRpr. The prevalence of MVRpr among individual surgeons appears to be related to an annual threshold volume of overall MVO. Hospital mortality risk is related to age and surgical complexity, but is modest and has continued to trend down during the past decade. Hospital mortality appears to favor MVRpr over MVR in all categorical comparisons, either significantly or by insignificant trend. These opposite trend lines for MVR and MVRpr likely represent a paradigm shift away from mechanical solutions in favor of tissue solutions for mitral valve disease, especially for MVRpr.

Trends in aortic valve surgery in a large multi-surgeon, multi-hospital practice, 1979-1999.

BACKGROUND AND AIM OF THE STUDY: Trends in aortic valve operations (AVO) may help to predict the future of aortic valve surgery in the context of changing case mix, population demographics, emerging technology and shifting paradigms. METHODS: All adults undergoing single AVO between 1979 and 1999 were reviewed retrospectively according to age, gender and other typical clinical variables, surgical complexity, specific operation and immediate outcome. RESULTS: There were 3,917 single AVO. Although coronary artery bypass (CAB) volumes declined by 15.3% between 1996 and 1999, AVO volumes have continued to increase by 11.7% since 1996. Over the entire period, there was no significant change in mean age or percent female gender, but increases in the prevalence of octogenarians and aortic stenosis were noted. During the 1990s, degenerative valve disease predominated and the prevalence of sicker patients according to heart failure class and surgical priority decreased. Trends in surgical complexity included an increase in AVO combined with CAB, but a stable 9:1 distribution of first operations to reoperations. Technology adoption included a decreased prevalence of mechanical valve use at the expense of increased use of tissue valves, especially stented xenografts and homografts. Transient technology adoption included stentless xenografts. Small numbers of pulmonary autografts, aortic valve repairs and valve-sparing aortic replacements were carried out. Predictors of hospital mortality rates for AVO included age 65 years, reoperation and combined AVO. Hospital mortality rates for AVO decreased for most age groups between the 1980s and 1990s, but not during the 1990s. CONCLUSION: AVO volumes are steadily increasing, apparently as a result of the increase in octogenarians and the start of the 'baby boom' wave. Hospital mortality risk is related to age and surgical complexity, but is modest and has stabilized during the past decade. The prevalence of mechanical valve implants has decreased in favor of tissue valve replacement categories. The fastest growth rates have been with stented xenografts, and especially homografts. This may represent a paradigm shift away from mechanical solutions in favor of tissue solutions for aortic valve disease.