Armin Gorski

Factors associated with the development of aortic valve regurgitation over time after two different techniques of valve-sparing aortic root surgery

OBJECTIVE Early results after aortic valve-sparing root reconstruction are excellent. Longer-term follow-up, especially with regard to aortic valve function, is required for further judgment of these techniques. METHODS Between July of 1993 and September of 2006, 108 consecutive patients (mean age 53.0 +/- 15.8 years) underwent the Yacoub operation (group Y) and 83 patients underwent the David operation (group D). Innovative multilevel hierarchic modeling methods were used to analyze aortic regurgitation over time. RESULTS In general, aortic regurgitation increased with time in both groups. Factors associated with the development of a significant increase in aortic regurgitation were Marfan syndrome, concomitant cusp intervention, and preoperative aortic anulus dimension. In Marfan syndrome, the initial aortic regurgitation was higher in group Y versus group D (0.56 aortic regurgitation vs 0.29 aortic regurgitation, P = .049), whereas the mean annual progression rate of aortic regurgitation was marginally higher in group Y (0.132 aortic regurgitation vs 0.075 aortic regurgitation, P = .1). Concomitant cusp intervention was associated with a significant aortic regurgitation increase in both groups (P < .0001). There was a trend that smaller preoperative aortic annulus diameters in group D and larger diameters in group Y were associated with increased aortic regurgitation over time. CONCLUSION In regard to aortic regurgitation grade over time, patients with Marfan syndrome and a large preoperative aortic annulus diameter were better treated with the reimplantation technique, whereas those with a smaller diameter were better treated with the remodeling technique. Concomitant free-edge plication of prolapsing cusps was disadvantageous in both groups. Considering these factors may serve to improve the aortic valve longevity after valve-sparing aortic root surgery.

Autograft Reinforcement to Preserve Autograft Function After the Ross Procedure A Report From the German-Dutch Ross Registry

Background— Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis. Methods and Results— 1335 adult patients (mean age:43.5±12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09±3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root−R) group was associated with a 6× increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P<0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root−R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group. Conclusions— For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.

Major Adverse Cardiac and Cerebrovascular Events After the Ross Procedure A Report From the German-Dutch Ross Registry

Background— The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. Methods and Results— One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. Conclusions— Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry

OBJECTIVES Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients. METHODS Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years. RESULTS The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7 and 86.7%, respectively, whereas freedom from homograft reoperation was 97.6, 95.5 and 92.3%, respectively. The overall freedom from reoperation was 94.9, 91.1 and 82.7%, respectively. Longitudinal modelling of functional valve performance revealed a low (<5%) probability of a patient being in higher autograft regurgitation grades throughout the first decade. Similarly, excellent homograft function was observed throughout the first 15 years. CONCLUSION The autograft principle results in postoperative long-term survival comparable with that of the age- and gender-matched general population and reoperation rates within the 1%/patient-year boundaries and should be considered in young, active patients who want to avoid the shortcomings of conventional prostheses.

Rate of paraplegia and mortality in elective descending and thoracoabdominal aortic repair in the modern surgical era.

BACKGROUND The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. METHODS From July 1993 to April 2006, 56 patients (mean age 55+/-16 years, range 25 to 80 years, 62.5% males) underwent elective surgical repair of the descending (n=37, 66.1%) and thoracoabdominal aorta (n=19, 33.9%), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n=21), type B aortic dissection (n=24), and Marfans syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n=11), respectively. Most patients were operated using deep hypothermic circulatory arrest. RESULTS Thirty-day mortality was 5.4 % (n=3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6% (n=2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78%. CONCLUSIONS If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.

False aneurysm with aortopulmonary shunt after replacement of the ascending aorta.

From the Departments of Cardiothoracic Surgery and Radiology, University Hospital Wurzburg, Wurzburg, Germany and the Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany. Disclosures: None. Received for publication Sept 22, 2008; accepted for publication Nov 19, 2008; available ahead of print Feb 9, 2009. Address for reprints: Wilko Reents, MD, Department of Cardiothoracic Surgery, University Hospital Wurzburg, Oberdurrbacher Strasse 6, 97080 Wurzburg, Germany. (E-mail: wilko.reents@herzchirurgie.de). J Thorac Cardiovasc Surg 2010;139:e62-3 0022-5223/

Cardiac surgery antibiotic prophylaxis and calculated empiric antibiotic therapy

36.00 Copyright 2010 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2008.11.022

Higher Incidence of Acute Aortic Dissections in Winter Months- Results of the German Registry for Acute Aortic Dissection Type A

Background Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients. Methods A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy. Results The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents. Conclusion This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.

Degree of Carotid Artery Stenosis in Neurologically Asymptomatic Cardiac Surgical Patients Suffering from Perioperative Stroke: Results of an Observational Study

Background: Most cardiovascular events have their peak during the cold winter months. Especially for myocardial infarctions the accumulation is already well described. Several studies have investigated the incidence of acute aortic dissections (AAD) but a seasonal increase of AADs could not be shown yet due to the limited power of these studies. Therefore, we investigated the German Registry for Acute Aortic Dissection Type A (GERAADA) data for seasonal accumulations. Methods: All 2137 patients who have been registered in GERAADA from 7/2006 to 6/2010, which is a prospective, multi-centre registry of the German Society of Thoracic and Cardiovascular Surgery, have been analysed. The incidences per year, quarter, season and month were investigated considering covariates such as age, gender and etiology using poisson regression. Results: The distribution of the incidences differed significantly between the quarters. More patients were treated in quarters IV and I (p=0.002). In the months October-February there were more cases than in the rest of the year (p=0.017). Although age, gender, the underlying disease (p 0.5). Conclusions: Our data show that there is a peak of surgically treated AADs within German speaking Europe during winter months independent from patient related factors and the aetiology of the AAD.

Results of tricuspid valve reconstruction using a semirigid ring or a flexible band

Background Postoperative stroke in cardiac surgical patients remains a serious adverse outcome. Methods A total of 2,784 consecutively operated cardiac surgical patients without preoperative neurologic impairment were analyzed retrospectively with regard to impact of preoperative carotid stenosis on the incidence of postprocedural new onset of stroke. Therefore, all analyzed patients were assigned to four groups depending on preoperative degree of carotid artery stenosis detected by carotid duplex sonography (group I: < 50%, group II: 50-75%, group III: 76-89%, and group IV: > 90%). Results All pre-, intra-, and postoperative risk factors for neurological disorders were comparable throughout the cohort. Of the 2,784 patients, 65 (2.3%) met the inclusion criteria (preoperatively neurologically asymptomatic status, preoperatively carotid duplex ultrasonography study not older than 6 months, heart surgery with extracorporeal circulation, stroke until 48 hours after operation). Of the 65 patients who met the inclusion criteria, 43 (66.2%) were in group I, 11 (16.9%) in group II, 5 (7.7%) in group III, and 6 (9.2%) in group IV (p = 0.175). The overall incidence of an ipsilateral stroke relating to the carotid stenosis was 38 (1.4%) patients. Of these, 27 (71.1%) patients were in group I, 6 (15.8%) patients in group II, 2 (5.3%) patients in group III, and 3 (7.9%) patients in group IV (p = 0.568). Conclusion This observational study demonstrates that the degree of carotid stenosis in neurologically asymptomatic cardiac surgical patients is not able to predict the probability of perioperative stroke. Until further results from prospective randomized trials with neurologically asymptomatic cardiac surgical patients are presented, a cautious attitude for concomitant carotid endarterectomy is still justified.