Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters.

OBJECTIVES: The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population. METHODS: All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group. RESULTS: Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups. CONCLUSIONS: MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.

Long-term follow-up of tracheoplasty using autologous pericardial patch and strips of costal cartilage.

OBJECTIVES: To evaluate long-term results of tracheoplasty using autologous pericardial patch and strips of costal cartilage for relieving severe long-segment tracheal stenosis. METHODS: Data were collected retrospectively by clinical chart review. Between 1995 and 2013, 21 patients underwent tracheoplasty. Follow-up was performed by outpatient chart review; otherwise, referring physicians and parents were contacted and asked to fill in a questionnaire. RESULTS: Median age at the time of operation was 0.9 (range 0.5-44) years. Aetiology of tracheal stenosis was double aortic arch in 9 patients, right arch with a left ductus in 3, innominate artery compression in 1 patient, complete tracheal rings in 7, 3 of whom with pulmonary artery sling and 2 with agenesis of one lung, and other causes in 1 patient. Previous surgery was performed in 6 (29%) patients. Patch tracheoplasty was performed using autologous pericardial patch and external stenting using costal cartilage. Major complications were mediastinitis and patch dehiscence in 2 patients, 2 patients needed tracheal cannula and 1 patient had stent implantation. Three (14%) patients died in the late postoperative period: 1 patient died of sepsis, 1 had patch dehiscence and 1 erosion of tracheal stent and consequently intractable bleeding. Follow-up was 6.1±2.7 years (0.75-10 years). At follow-up, 2 (11%) patients were still symptomatic, 4 (22%) had occasionally mild symptoms and 12 (67%) were free of symptoms. CONCLUSIONS: Treatment for severe tracheal stenosis remains challenging. With tracheoplasty using autologous pericardial patch and strips of costal cartilage, long and narrow tracheal stenosis can be repaired. There are no limitations as to the length and location and severity of the stenosis. Tracheoplasty is associated with a high complication rate. A multidisciplinary approach is mandatory to ensure favourable long-term outcomes.

Reoperation for neoaortic root pathology after the arterial switch operation.

OBJECTIVES: To evaluate incidence and results of surgical intervention for neoaortic root pathology following arterial switch operation (ASO) for transposition of the great arteries (TGA). METHODS: Between April 1996 and August 2013, 12 patients underwent reoperation for neoaortic root dilatation (ARD) and/or neoaortic valve regurgitation (AR). Maximal aortic sinus and annulus diameter Z-scores were recorded. Original diagnoses were TGA/IVS (6), TGA/ventricular septal defect (VSD) (4) and Taussig-Bing anomaly (2) with ASO at a median age of 0.1 (range: 0-10.6) years. Age at ASO, VSD and complex TGA were reviewed as possible risk factors for reoperation. RESULTS: Twelve patients with tricuspid neoaortic valves underwent 15 root operations; indications were root dilatation (4) and root dilatation with AR (8). Median age was 18.0 (3.0-29.0) years at first reoperation. Median aortic root Z-score at reoperation was 6.33 (range: 3.84-12.15). Procedures were: Bentall procedure (6), aortic valve replacement (2), neoaortic valve plasty (1), supracoronary tube (1) and switch-back operation (2). Mean follow-up was 7.0 ± 5.7 years and complete. No mortality occurred. One patient had two reoperations for late endocarditis. Technical difficulties were encountered related to specific anatomy post-ASO concerning coronary anatomy, poor exposure and thin-walled aorta at the site of pulmonary artery bifurcation after Lecompte manoeuvre. Valve sparing surgery seemed not feasible due to specific anatomy of the neoaortic root and valve. No risk factors for reoperation could be identified. CONCLUSIONS: After ASO, surgery for neoaortic root pathology may become necessary when follow-up is long enough and regardless of primary diagnosis or other risk factors. Redo neoaortic surgery can be performed with low risk taking into account the specific technical difficulties.

Levosimendan improves renal function in patients with advanced chronic heart failure awaiting cardiac transplantation.

BACKGROUND: Long-term impact of levosimendan on renal function remains undefined. Prospectively, we evaluated effects of levosimendan on renal function in patients with advanced chronic heart failure awaiting cardiac transplantation. METHODS AND RESULTS: Of 40 patients, 20 were randomized to receive levosimendan (10-minute bolus 12 microg/kg, followed by 0.1 microg/kg/min for 24 hours; LS Group), and 20 received no levosimendan (Controls). The groups did not differ in age, heart failure etiology, left ventricular ejection fraction, and plasma brain natriuretic peptide. Patients were followed for 3 months. At baseline, the groups did not differ in serum creatinine (1.92 +/- 0.13 mg/dL in LS Group versus 1.91 +/- 0.12 mg/dL in Controls, P = .81) and creatinine clearance (43.7 +/- 2.9 mL/min versus 43.9 +/- 2.8 mL/min, P = .84). At 3 months, we found a decrease in serum creatinine and an increase in creatinine clearance in LS Group, but not in Controls, leading to a significant intergroup difference in serum creatinine (1.60 +/- 0.26 mg/dL in LS Group versus 1.90 +/- 0.14 mg/dL in Controls, P = .005) and creatinine clearance (53.6 +/- 8.6 mL/min versus 44.0 +/- 3.3 mL/min, P = .005). An improvement in creatinine > or = 0.5 mg/dL occurred in 50% patients from LS Group compared with 10% of Controls (P = .005). CONCLUSIONS: Levosimendan improves long-term renal function in advanced chronic heart failure patients awaiting cardiac transplantation.

Statin-associated QTc interval shortening as prognostic indicator in heart transplant recipients.

Statin treatment promotes survival after cardiac transplantation by reducing cholesterol levels, allograft rejection, and transplant coronary artery disease. Analysis of data from 114 heart transplant recipients (including 86 treated with statins for < or =1 year post-transplantation) revealed that statins were associated with shortened corrected QT intervals (QTc), reduced low-density lipoprotein cholesterol, and reduced transplant coronary artery disease incidence at 1 year and improved survival at 5 years. Statin-associated QTc shortening thus appears to be a favorable prognostic sign after transplantation.

Survival, graft atherosclerosis, and rejection incidence in heart transplant recipients treated with statins: 5-year follow-up.

BACKGROUND: Few studies have examined the long-term benefits of statin treatment in heart transplant recipients. METHODS: In this observational study, we retrospectively reviewed data pertaining to 5-year follow-up of patients who underwent heart transplantation between 1993 and 1996 and who survived the first 30 days after transplantation. Patients were assigned to groups according to whether or not they received pravastatin after transplantation, and then compared with regard to transplant rejection, transplant coronary artery disease, and survival. RESULTS: Ninety-one patients received pravastatin after transplantation, whereas 37 did not receive any statins and served as controls. Pravastatin did not affect the overall incidence of rejections or number of rejection episodes. Hemodynamically significant rejection episodes occurred in 5 patients (5%) in the pravastatin group and 4 patients (11%) in the control group. Thus, pravastatin treatment apparently reduced the incidence of hemodynamically significant rejection episodes by 50% (p = 0.04). Transplant coronary artery disease (CAD) occurred in 10 patients (11%) in the pravastatin group and 9 patients (24%) in the control group. Treatment with pravastatin significantly reduced the incidence of transplant CAD (p = 0.05). Three- and 5-year survival rates in the pravastatin group were significantly better than in the control group (87% vs 68% and 82% vs 58%, respectively; p = 0.009). CONCLUSIONS: Pravastatin therapy offers long-term benefits to heart transplant recipients. It improves 5-year survival, lowers the risk of transplant CAD, and lowers the incidence of hemodynamically significant rejection episodes.