The architecture of the human language faculty has been one of the main foci of the linguistic research of the last half century. This branch of linguistics, broadly known as Generative Grammar, is ...concerned with the formulation of explanatory formal accounts of linguistic phenomena with the ulterior goal of gaining insight into the properties of the 'language organ'. The series comprises high quality monographs and collected volumes that address such issues. The topics in this series range from phonology to semantics, from syntax to information structure, from mathematical linguistics to studies of the lexicon. To discuss your book idea or submit a proposal, please contact Birgit Sievert
Background The Carpentier-Edwards pericardial valve was designed to minimize structural valve deterioration. Excellent durability and low incidence of valve-related complications have been reported. ...The objective of the present study was to analyze clinical results after 25 years of experience with this valve implanted in the aortic position. The effect of patient age at the time of surgery was also evaluated. Methods This is a retrospective cohort study of 2,405 patients from November 1981 to March 2011. Primary outcomes of interest were survival and freedom from major adverse effects such as thromboembolic, endocarditis, and reoperation. Results Sixty percent were male, with a mean age of 71 ± 9 years old. Actuarial survival rates including early deaths averaged 78% ± 2%, 55% ± 2%, and 16 % ± 2% after 5, 10, and 20 years of follow-up, respectively. The freedom rate of valve reoperation for prosthesis dysfunction and all other causes averaged 98 % ± 0.2%, 96% ± 1%, and 67% ± 4% at 5, 10, and 20 years. Patients younger than 60 years of age had a 15-year survival averaging 54% ± 5% compared with patients aged between 60 and 70 years of age averaging 46% ± 3% and with patients older than 70 years of age averaging 28% ± 3% ( p = 0.001). Survival at 5, 10, and 20 years for patients who had concomitant CABG coronary artery bypass grafting were 78% ± 1%, 55% ± 2%, and 9% ± 3% compared with no concomitant CABG (84% ± 1%, 62% ± 2%, and 22% ± 3% ( p < 0.001)). Conclusions Carpentier-Edwards pericardial valve implantation in the aortic position is secure and durable. The effects of age influence reoperation rate and survival as well as a concomitant coronary artery bypass procedure.
There is growing awareness of the long-term impact of a Fontan circulation on the associated morbidity and mortality. Comparative data on the incidence of supraventricular arrhythmia and sinus node ...dysfunction following extracardiac conduit (EC) and lateral tunnel (LT) Fontans are controversial. We performed a meta-analysis pooling all available long-term results comparing the EC and LT Fontan, with a special focus on arrhythmia.
We performed a systematic search of PubMed, Embase, and the Cochrane Library for articles reporting long-term results of Fontan comparing the EC and the LT Fontan.
Twelve studies were selected with 3,330 patients (1,729 EC, 1,601 LT). Freedom from tachyarrhythmia was significantly higher in the EC group (92% versus 83% at 15 years; p < 0.0001), while there was no difference in term of bradyarrhythmias (p = 0.7). The survival was 93% and 89% at 20 years in the EC and LT groups, respectively (p = 0.007). The risk of thromboembolic events was 2.87% patient-years in the EC group versus 0.9% in the LT group (odds ratio, 2.15; 95% confidence interval, 0.95 to 4.85; p = 0.07).
The EC Fontan confers long-term survival advantage over the LT Fontan without a higher rate of reoperations. The EC Fontan preserves the sinus node function and reduces significantly the incidence of long-term postoperative arrhythmia.
Background Sutureless self-expandable aortic bioprostheses rely on radial forces for stabilization, raising concern that these devices may increase the risk of postoperative conduction disease. The ...purpose of this study was to determine the incidence of conduction disorders after sutureless aortic valve replacement (AVR) with the Perceval S (Sorin Group, Saluggia, Italy) bioprosthesis. Methods Between June 2011 and March 2013, 108 consecutive patients underwent sutureless AVR with the Perceval S prosthesis. Six patients (6%) had a permanent pacemaker (PPM) preoperatively and were excluded from the present study. Mean electrocardiographic follow-up was 14.6 ± 6.0 months. Results Mean age was 79.2 ± 4.8 years (52% female). During the postoperative period, 34 patients (34%) had first-degree atrioventricular block, 2 (2%) had Mobitz-II atrioventricular block, and 16 (16%) had complete atrioventricular block. New-onset left bundle branch block and right bundle branch block were observed in 33 patients (33%) and 22 patients (22%), respectively. Inhospital postoperative PPM implantation was required in 23 patients (23%). Preoperative aortic valve area, age more than 85 years, and preoperative right bundle branch block were found to be independently associated with inhospital PPM implantation or new-onset postoperative conduction disorder. At follow-up, 3 more patients (3%) underwent PPM implantation. The cumulative incidences of PPM dependency and ventricular pacing more than 25% of the time were 18% ± 11% and 21% ± 10%, respectively, at 18 months. Conclusions In the present study, the postoperative PPM implantation rate (23%) after sutureless AVR with the Perceval S prosthesis was high. Surgical strategies aimed at mitigating this risk should be further investigated.
Background The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical ...outcome, and identification of risk factors. Methods Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. Results Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. Conclusions The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.
Abstract Objectives The aim of this study was to determine immediate results and long-term outcomes after surgical management of paravalvular leak (PVL). Methods Between 1995 and 2012, a total of 190 ...patients underwent primary surgical repair (n = 142) or valve replacement (n = 48) for a PVL at our institution. The PVL was mild in 6 (3%) patients, moderate in 85 (45%), moderate to severe in 84 (44%), and severe in 15 (8%). Among these, 120 (63%) had PVL in the mitral position, 63 (33%) had PVL in the aortic position, and 7 (4%) had PVL in both valves. Mean follow-up was 5.3 ± 4.6 years. Results Mean age at surgery was 63 ± 12 years (64% men). Operative mortality occurred in 13 (7%) patients (10 8% in mitral; 2 3% in aortic; and 1 14% in double valve procedures). Survival at 1, 5, and 10 years was 85% ± 3%, 73% ± 4%, and 56% ± 5%, respectively. The cumulative incidence of PVL recurrence was 3% ± 1%, 14% ± 3%, and 32% ± 6%, at 1, 5, and 10 years, respectively. The number of previous surgeries was a predictor of survival and PVL recurrence. Freedom from New York Heart Association class ≥III was 96% ± 2%, 82% ± 4%, and 58% ± 6%, at 1, 5, and 10 years, respectively. The freedom from rehospitalization for heart failure was 92% ± 2%, 83% ± 4%, and 67% ± 6%, at 1, 5, and 10 years. Conclusions Surgical treatment of PVL resulted in acceptable outcomes. Nevertheless, the continued risk of PVL recurrence is higher in patients who have had multiple previous surgeries. More studies are needed to compare these results with the transcatheter PVL reduction technique.
Abstract Objectives The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients ...randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. Methods Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. Results Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. Conclusions The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.
Abstract Objective Bicuspid aortic valve (BAV) is generally considered to be a contraindication to sutureless aortic valve replacement (AVR). The aim of this study was to evaluate the feasibility and ...perioperative outcomes of this technique in patients with BAV. Methods From June 2011 to January 2014, a total of 25 patients who underwent sutureless AVR had documented BAV. Thirteen patients (52%) had median sternotomy, and 12 patients (48%) a minimally invasive approach. Results The study population included 17 (68%) men with a median age of 77.8 ± 5.4 years. The mean EuroSCORE II was 3.4% ± 2.6%. Concomitant procedures included coronary artery bypass grafting in 8 patients (32%), 2 AVRs (8%), 1 mitral valve repair (4%), 1 septal myomectomy (4%), and 1 atrial septal defect closure (4%). The mean transaortic valve gradient decreased from 49.4 ± 15.7, to 14.5 ± 5.4 mm Hg postoperatively. The mean aortic valve area increased from 0.78 ± 0.18, to 1.75 ± 0.43 cm2 postoperatively. Five patients (20%) suffered from atrioventricular block that required permanent pacemaker implantation. Two patients (8%) suffered a stroke. No major paravalvular leakage occurred, and no postoperative valve migration. In-hospital mortality occurred in 1 patient (4%). The mean intensive care unit length of stay was 3 ± 2 days postoperatively. Conclusions This study demonstrates that a sutureless aortic valve can be deployed in patients with BAV without increasing the risk of paravalvular leakage. BAV should not be considered a contraindication to sutureless AVR.
Objectives To review our experience with sutureless aortic valve replacement (AVR) in the setting of concomitant mitral valve (MV) surgery and discuss the technical considerations. Methods Between ...January 2012 and March 2013, 10 patients underwent sutureless AVR with the Perceval prosthesis in the setting of concomitant mitral disease. Five patients underwent MV repair, 4 underwent MV replacement, and 1 had a previously implanted mechanical mitral prosthesis. Results The median age was 79 years and 7 patients (70%) were male. Median logistic EuroSCORE II was 6.2%. All valves were successfully implanted with no 30-day mortality. There was no residual aortic paravalvular leak. Two patients had from third-degree atrioventricular block requiring permanent pacemaker implantation. At a mean follow-up of 8 ± 4 months (range, 2-16 months), the overall survival was 80% with 2 non−valve-related deaths and the mean transaortic gradient and aortic valve area had improved to 11.1 ± 4.6 mm Hg and 1.5 ± 0.3 cm2 , respectively. There was no evidence of mitral dysfunction in any patient. Conclusions In our experience, sutureless AVR in the setting of concomitant mitral surgery is a feasible and reproducible procedure. Elderly patients undergoing multiple valve surgery present a higher operative risk, therefore extending the indication for sutureless AVR to patients with concomitant mitral disease could greatly benefit this specific population.
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