The aim of this study was to investigate the early and late outcomes of patients undergoing pulmonary embolectomy for acute massive pulmonary embolus.
Twenty-one patients (15 male, 6 female) ...underwent pulmonary embolectomy at our institution between March 2001 and July 2010. The median age was 55 years (range, 24 to 70 years). Of these, 9 patients presented with out-of-hospital cardiac arrest and 8 presented with New York Heart Association class III or IV. Sixteen patients underwent preoperative transthoracic echocardiography, which showed evidence of right ventricular dilatation in all, whereas in 14 patients (66.6%) pulmonary artery pressures were significantly elevated with moderate to severe tricuspid regurgitation. The median preoperative Euroscore was 9 (range, 3 to 16), and 11 patients (52.1%) received systemic thrombolysis preoperatively. There were 6 salvage (28.5%), 10 emergency (47.6%), and 5 urgent (23.8%) procedures. Concomitant procedures were performed in 3 patients (14.2%), and surgery was performed without the use of cardiopulmonary bypass in 3 patients (14.2%). The median follow-up was 38 months (range, 0 to 114 months).
The in-hospital mortality was 19% (n = 4). Postoperative complications included stroke (n = 3, 14.2%), lower respiratory tract infection (n = 6, 28.5%), wound infection (n = 3, 14.2%), acute renal failure requiring hemofiltration (n = 4, 19%), and supraventricular tachyarrhythmias (n = 4, 19%). At discharge, transthoracic echocardiography showed mild to moderate right ventricular dysfunction and dilatation in 11 survivors (64.7%). Two patients died during follow-up, and actuarial survival at 5 years was 76.9% ± 10.1% and at 8 years was 51.2% ± 22.0%. At final follow-up, 11 of the 15 survivors (73.3%) were New York Heart Association class I, and no patients required further intervention.
Patients who undergo surgery for massive pulmonary embolism have an acceptable outcome despite being high-risk.
The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement (redo-MVR) at our institution. Forty-nine patients (24 males) underwent ...redo-MVR with either bioprosthetic (n = 24) or mechanical valves (n = 25) between January 2000 and 2010. Median age of patients was 63 years (range 21-80 years), and the mean additive EuroSCORE was 12 ± 4. Median time to re-operation was 8.2 ± 6.6 years for first time redo-MVR and 6.4 ± 5.6 years for second-time redo-MVR. Indications included prosthetic endocarditis (n = 22), para-prosthetic leak (n = 12), structural valve degeneration (n = 8), prosthetic valve thrombosis (n = 6) and malignancy (n = 1). The mean follow-up was 47.5 ± 37.0 months (range 0.1-112.3 months). In-hospital mortality was 12% (n = 6). Mean hospital stay was 17 ± 11 days (range 8-50 days). Actuarial survival at 1 and 5 years was 81 ± 5% and 72 ± 6%, respectively. Three patients required re-intervention: two for prosthetic valve endocarditis and one for para-prosthetic leak. Multivariate analysis showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P < 0.001) and urgent surgery (P = 0.03).
OBJECTIVES
Significant mitral regurgitation (MR) may arise from isolated annular dilatation secondary to lone atrial fibrillation (AF) and associated atrial remodelling. The aim of the present study ...is to assess the outcome of surgery for this condition.
METHODS
Between November 2007 and July 2011, 20 patients underwent mitral valve (MV) repair for severe MR secondary to AF. The median age of patients was 77.5 years (45-82 years) and the mean pre-operative duration of AF was 84.6 ± 92 months. The left ventricle was moderately (ejection fraction 30-50%; n = 6) or severely (<30%; n = 1) impaired in seven patients pre-operatively. Mean logistic EuroSCORE was 8.1 ± 5.9 and mean follow-up was 18.0 ± 12.5 months.
RESULTS
All operations were elective. Concomitant anti-arrhythmic procedures (maze procedure, pulmonary vein isolation) or left atrial (LA) appendage amputation were performed in all patients; tricuspid valve repair was undertaken in 12 patients and coronary artery bypass grafting in 2 patients. Ring annuloplasty was performed in all patients. The median ring size was 30 mm (range 24-36 mm). On-table transoesophageal echocardiography post-repair showed mild residual MR in two patients and no MR in the remainder. There were no cases of systolic anterior motion. There was one re-exploration for bleeding. No patients required haemofiltration or suffered from stroke and deep sternal wound infections. There was no in-hospital mortality. At discharge mean left ventricular (LV) end-diastolic diameter was 4.8 ± 0.7 cm compared with 5.6 ± 0.7 cm pre-operatively (P < 0.005), while mean LV end-systolic diameter was 3.2 ± 0.8 cm when compared with 4.0 ± 0.7 cm pre-operatively (P < 0.005). The mean LA size was 5.2 ± 1.0 cm when compared with 6.1 ± 1.6 cm pre-operatively (P = 0.03). There was mild MR in two patients, but none in the rest. The mean MV area was 3.0 ± 0.7 cm2. The mean systolic pulmonary artery pressure was 40.4 ± 15.5 mmHg when compared with 54.1 ± 12.2 mmHg pre-operatively (P = 0.02). Seventeen patients (85%) were in NYHA class I/II at latest follow-up (P < 0.0001 vs pre-operatively). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths.
CONCLUSIONS
MV annuloplasty for annular dilatation secondary to AF has a good mid-term outcome.
Abstract
Objective: The Carpentier-Edwards (CE) Physio II ring is a new prosthetic ring designed to accommodate the changing pathology seen in the spectrum of degenerative valve disease, particularly ...the larger anterior leaflet in repair of the Barlow valve. The aim of our study was to assess the safety and efficacy of mitral valve (MV) repair with the CE Physio II ring. Methods: Between April 2009 and March 2010, 100 patients underwent MV repair using the Physio II ring. Median age of patients was 70 years (54-85 years). The left ventricle (LV) was moderately (30-50%; n = 21) or severely (<30%; n = 6) impaired in 27 patients preoperatively. Mitral regurgitation (MR) was due to degenerative disease in 87 patients (bileaflet prolapse: 34 patients). Mean logistic EuroSCORE was 10.07 ± 8.9 and mean follow-up was 6.3 ± 2.4 months. Results: Seventeen patients were non-elective (eight emergencies), five were re-do operations and 23 Maze ± pulmonary vein isolations, and 14 tricuspid annuloplasties were performed. Neo-chordae were inserted in 50 patients (50%), whereas sliding annuloplasty was performed only in three patients. The median ring size was 32 mm (range 26-40 mm). On-table trans-oesophageal echocardiography (TOE) showed trivial/no MR in 87 patients, and mild in 13 patients, and there were no cases of systolic anterior motion (SAM). There were two re-explorations for bleeding and two patients required haemofiltration. There were no strokes or deep sternal wound infections (DSWIs). There was one hospital death (1%). At discharge, mean left ventricular end-diastolic (LVEDD) was 4.8 ± 0.7 cm compared with 5.5 ± 0.8 cm preoperatively (p = 0.03) and mean left ventricular end-systolic (LVESD) was 3.3 ± 0.5 cm as compared with 3.6 ± 0.8 preoperatively (p = 0.4). There was no MR in 87 patients and mild MR in 13 patients. The mean mitral valve area (MVA) was 2.8 ± 0.7 cm2. The mean systolic pulmonary artery pressure (SPAP) was 26.6 ± 7.3 mmHg as compared with 50.9 ± 17.2 mmHg preoperatively (p = 0.02). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths. Conclusions: MV repair with the Physio II ring has excellent short-term results, including subgroups with large anterior mitral valve leaflet (AMVL). Moreover, the dimensional ratios of the ring may allow it to be used for MV repair for degenerative MV disease, irrespective of anterior leaflet size.
During recent years there has been an increase in the referral pattern for surgery for non-rheumatic calcific mitral stenosis (CMS). Valve replacement for this condition presents some unique ...challenges, yet the management of CMS remains inadequately described. Herein are discussed the techniques and outcomes of surgery for CMS.
We sought to compare the feasibility and accuracy of transthoracic real-time 3-dimensional echocardiography (RT-3DE) with transesophageal echocardiography (TEE) for the preoperative functional ...assessment of patients with mitral valve prolapse.
In 44 patients with severe mitral regurgitation caused by type 2 valve dysfunction, TEE and RT-3DE were performed 24 hours before surgery and analyzed by two separate observers. TEE and RT-3DE images were acquired digitally and stored for offline analysis. The echocardiographic results were validated intraoperatively.
Five patients did not have image quality suitable for analysis with RT-3DE and were excluded from analysis, leaving a sample size of 39. In total, 54 of 334 analyzed mitral valve segments were diseased. Prolapse of a single mitral valve segment was present in 25 patients and 14 patients had complex disease involving two or more segments. Sensitivity, specificity, and accuracy for TEE in identification of diseased segments were 94%, 100%, and 96%, respectively. The same values for RT-3DE were 91%, 100%, and 94%, respectively. The differences were not statistically significant. Accuracies were not significantly different according to segment location. Interobserver agreement was 92% for TEE and 88% for RT-3DE (P = nonsignificant).
RT-3DE is feasible with comparative accuracy to TEE for precise anatomic localization of prolapsing mitral valve segments. However, the technique is limited by poor image quality in 11% of patients.
Pseudoaneurysms of the internal mammary artery (IMA) following median sternotomy are very uncommon and were first reported in 1973. Presentation and treatment of such a complication has been ...variable. We are presenting a case of a patient with pseudoaneurysm of IMA after mitral valve replacement. Selective embolization of the branches of right IMA was performed. Hematoma was evacuated after a week without any complication. Patient was reviewed in the clinic after 6 weeks and she was doing very well.
OBJECTIVES
This study aimed to investigate the early and late outcomes of patients undergoing aortic valve replacement (AVR) with previous coronary artery bypass grafting (CABG) and patent grafts.
...METHODS
Between January 2000 and March 2010, 104 patients (87 males) with previous CABG ± concomitant surgery and patent grafts underwent AVR. The median age of the patients was 75 years (range: 37-90 years; inter-quartile range: 69-79 years) and the mean logistic EuroScore was 25.37 ± 16.8. The median time since the previous operation was 9 years (range 1-25; inter-quartile range: 7-14 years). The left internal mammary artery (LIMA) had been used in 75 patients (72.1%) and remained patent in 72 cases (96.0%).
RESULTS
Thirty-day mortality was 7.7% (n = 8), which is less than the predicted mean logistic EuroScore. Isolated AVR was performed in 66 patients (63.5%). The LIMA was dissected and isolated (clamped or blocked with balloon) in 60 patients. The median hospital stay was 10 days (range: 4-183 days; inter-quartile range: 7-15.25 days). Nineteen patients (18.3%) had pulmonary complications, while 12 (11.5%) had acute kidney injury. Seven patients (6.7%) required permanent pacemaker. Six LIMAs (8.3%) were injured and repaired. Prolonged aortic cross-clamp (AXC) time (P = 0.038) and the presence of a previous LIMA graft (P = 0.045) were identified as independent predictors of 30-day mortality. The actuarial survival at 1 and 5 years was 89.4 ± 0.3 and 81.5 ± 0.5%, respectively. Perioperative intra-aortic balloon pump use (P = 0.036), prolonged AXC time (P = 0.004) and prolonged cardiopulmonary bypass time (P = 0.022) were associated with worse long-term overall survival on multivariate analysis.
CONCLUSIONS
AVR post-CABG with patent grafts can be performed in high-risk patients with excellent short- and long-term outcomes and appears to be superior to published catheter-based interventions. In the absence of randomized trial data, we believe that open AVR remains the treatment of choice for aortic valve disease following prior CABG.
Background: The aging of the population has resulted in an increasing number of elderly patients undergoing cardiac operations. We reviewed our experience in patients over the age of 80 undergoing ...primary aortic valve replacement (AVR) with or without CABG. Methods: Between 2000 and 2008, 345 patients (226 male) ≥80 years underwent primary AVR in our unit. The notes of these patients were retrospectively reviewed and follow‐up information was obtained from their general practitioners. They had a mean age of 82.9 ± 2.3 years and a median logistic EuroSCORE of 13.4 (IQR 9.4, 19.1). Isolated AVR was performed in 161 patients (45.5%), and 184 (51.6%) patients underwent combined AVR and CABG. A quality of life questionnaire was sent to all survivors. Results: Hospital mortality occurred in 17 patients (4.9%), which was significantly lower than the mortality predicted by logistic EuroSCORE (16.2%, p < 0.01). Hospital mortality was comparable between patients undergoing isolated AVR and those undergoing additional CABG (4.3% vs. 5.4%, respectively). Actuarial survival at one and five years was 90.1 ± 1.6% and 77.2 ± 2.9%, respectively. There was a 62% response on the questionnaire showing 70% of the patients were NYHA I and 83.7% were satisfied with the operation outcome. Conclusions: AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk‐scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR. (J Card Surg 2011;26:466‐471)
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