...we suspect that the increase of overall streptococcal IE is not related to rising viridans group IE cases due to failing AHA guidelines, but rather to an increase of enterococcal IE hidden in the ...work of Pant et al.
Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to ...initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies—particularly with regard to extent of surgery—are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
Objective The aim of the study was to establish clinical event rates for the On-X bileaflet mechanical heart valve (On-X Life Technologies Inc, Austin, Tex) using an audit of data from the 3 centers ...within Europe with the longest history of implanting. Methods All patients receiving the On-X valve between March 1, 1998, and June 30, 2009, at 3 European centers were studied. Data were collected using questionnaire and telephone surveys augmented by outpatient visits and examination of clinical records. Results There were 691 patients, with a mean age of 60.3 years, who received 761 valves in total: 407 mitral valve replacements, 214 aortic valve replacements, and 70 aortic + mitral valve replacements (dual valve replacement). Total follow-up was 3595 patient-years, with a mean of 5.2 years (range, 0–12.6 years). Early (≤30 days) mortality was 5.4% (mitral valve replacement), 0.9% (aortic valve replacement), and 4.3% (dual valve replacement). Linearized late (>30 days) mortality expressed per patient-year was 3.6% (mitral valve replacement), 2.2% (aortic valve replacement), and 4.1% (dual valve replacement), of which valve-related mortality was 0.5% (mitral valve replacement), 0.2% (aortic valve replacement), and 1.8% (dual valve replacement). Late linearized thromboembolism rates were 1.0% (mitral valve replacement), 0.6% (aortic valve replacement), 1.8% (dual valve replacement). Bleeding rates were 1.0% (mitral valve replacement), 0.4% (aortic valve replacement), and 0.9% (dual valve replacement). Thrombosis rates were 0.1% (mitral valve replacement), 0% (aortic valve replacement), and 0.3% (dual valve replacement). Reoperation rates were 0.6% (mitral valve replacement), 0.2% (aortic valve replacement), and 1.2% (dual valve replacement). Conclusions The On-X valve has low adverse clinical event rates in longer-term follow-up (mean 5.2 years and maximum 12.6 years).
Objective Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with ...thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed. Methods Thirty-four adult patients with unsuccessful catheter ablations (range 1–4, mean 2 ± 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3–10 years), 13 years (5–25 years), and 9 years (3–15 years), respectively. Results There was no mortality during the procedure or follow-up (mean 16 ± 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 ± 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 ± 4 and 47 ± 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis. Conclusions Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.
Background The optimal timing of cardiac operations in patients with infective endocarditis continues to be debated. This observational study analyzed the profile and outcome of patients with active ...infective endocarditis undergoing operations. Methods Between June 2000 and June 2006, 95 surgically treated patients with definite infective endocarditis by the modified Duke criteria were included. Results Fifty-eight patients were operated on within the first 7 days after diagnosis of infective endocarditis and 37 at more than 7 days after diagnosis up to immediately after completion of antibiotic treatment. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 15%. Early operation showed a trend towards increased mortality vs late operation. In univariable analysis, factors associated with 6-month mortality included staphylococci and septic shock. Multivariable analysis revealed that septic shock predicted 6-month mortality. Despite early operation in patients experiencing septic shock, 57% died. No patients without heart failure died after undergoing (early or late) procedures for severe regurgitation. Conclusions The prognosis in surgically treated patients was determined by the occurrence of septic shock. The outcome in patients who underwent late operations was favorable compared with the early group. This difference was probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefit in length of hospitalization and prevention of development of new heart failure.
A patient with chronic pulmonary artery hypertension and acute dissection of a main and right pulmonary aneurysm (82 mm) presented with acute myocardial infarction and cardiogenic shock secondary to ...compression of the left main coronary artery. She required emergency pulmonary artery replacement. She ultimately died due to multiorgan failure and sepsis. (Level of Difficulty: Intermediate.)
Display omitted
A patient with chronic pulmonary artery hypertension and acute dissection of a main and right pulmonary aneurysm (82 mm) presented with acute…
PDF
