F Girrbach

Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients.

OBJECTIVE To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE). METHODS From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis. RESULTS Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01). CONCLUSIONS Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.

Impact of Perfusion Strategy on Outcome After Repair for Acute Type A Aortic Dissection

BACKGROUND The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial. METHODS We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90). RESULTS Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups (p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% (p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009). CONCLUSIONS Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge.

Acute type A aortic dissection: characteristics and outcomes comparing patients with bicuspid versus tricuspid aortic valve

OBJECTIVES The aim of this study is to investigate the clinical characteristics and postoperative outcome of patients with a bicuspid aortic valve (BAV) suffering acute dissection in comparison with their tricuspid peers. METHODS Between 1995 and 2011, 460 consecutive patients underwent emergency repair for acute type A aortic dissection. In 379 patients without connective tissue disease, the aortic valve morphology could clearly be specified (91.6% tricuspid and 8.4% bicuspid). RESULTS At the time of dissection, patients with a bicuspid valve were younger (46.7 ± 13 vs 61.6 ± 12 years, P < 0.001) with the entry tear more often located in the root compared with those with a tricuspid valve (bicuspid: 31.3% vs tricuspid: 6.3%, P < 0.001). Consequently, surgical repair warranted root replacement in 93.8% of bicuspid vs 28.8% of tricuspid valve patients (P < 0.001). The leading pathology was medial necrosis/degeneration in bicuspid and atherosclerosis in tricuspid patients (P = 0.166). Hospital mortality was 20.3% and not significantly different between the two valve morphologies, even despite the younger age of bicuspid patients: 28.1% among bicuspids vs 19.6% among tricuspids (P = 0.255). Survival after discharge was 63.3% at 10 years for all patients. BAV patients had a significantly better survival with 100% at 10 years compared with 60.2% in tricuspid valve patients (P = 0.011). Mean follow-up among survivors was comparable for bicuspid and tricuspid patients (3.7 and 4.1 years, respectively). CONCLUSIONS Patients with BAV have a distinctive dissection pattern with the entry tear frequently located in the aortic root and-despite their younger age-are subject to substantial hospital mortality. For bicuspid patients suffering from dissection, composite root replacement yields an excellent outcome equal to an age- and gender-matched normal population.

Longevity After Aortic Root Replacement Is the Mechanically Valved Conduit Really the Gold Standard for Quinquagenarians

Background— The choice of the best conduit for root/ascending disease and its impact on longevity remain controversial in quinquagenarians. Methods and Results— A total of 205 patients (men=155) between 50 and 60 years (mean, 55.7±2.9 years) received either a stentless porcine xenoroot (n=78) or a mechanically valved composite prosthesis (n=127) between February 1998 and July 2011. Of these, 166 patients underwent root replacement for aneurysmal disease (porcine: 39% [n=65]; mechanical: 61% [n=101]; P=0.5), 25 for acute type A aortic dissection (porcine: 32% [n=8]; mechanical: 68% [n=17]; P=0.51), and 14 for endocarditis/iatrogenic injury involving the aortic root (6.4% [n=5] versus 7.1% [n=9]; P=1.0). The predominant aortic valve pathology was stenosis in 19% (n=38), regurgitation in 50% (n=102), combined valvular dysfunction in 26% (n=54), and normal aortic valve function in 5% (n=11). Concomitant procedures included coronary artery bypass grafting (13%), mitral valve repair (7%), and partial/complete arch replacement (12%/4%), with no significant differences between porcine and mechanical root replacement. Overall hospital mortality was 7.3%, with no difference between the 2 types of valve prostheses (7.7% for porcine and 7.1% for mechanical root replacement; P=1.0). Follow-up averaged 5.4±3.7 years (1096 patient-years) and was 100% complete. Freedom from aorta-related reoperation at 12 years was not statistically different between the groups (porcine: 94.9% versus mechanical: 96.1%; P=0.73). Survival was equivalent between both groups, with a 5-year survival of 86±3% (porcine: 88±4%; mechanical: 85±3%; P=0.96) and a 10-year survival of 76% (porcine: 80±7%; mechanical: 75±5%; P=0.84). The linearized mortality rate was 3.1%/patient-year (porcine: 2.9%/patient-year; mechanical: 3.2%/patient-year). Conclusions— In quinquagenerians, long-term survival after stentless porcine xenograft aortic root replacement is equivalent to that after a mechanical Bentall procedure. These results bring into question the predominance of mechanical composite conduits for root replacement in quinquagenerians, particularly in the current era of transcatheter valve-in-valve procedures for structural valve deterioration.

Long-term survival after composite mechanical aortic root replacement: A consecutive series of 448 cases

OBJECTIVE To determine the effect of different etiologies on the outcome and mortality after mechanical composite aortic root/ascending replacement. METHODS From February 1998 to June 2011, 448 consecutive patients (358 men, age, 52.8 ± 12.3 years) underwent composite mechanical aortic root replacement. Of these 448 patients, 362 (80.8%) were treated for degenerative/atherosclerotic root/ascending aortic aneurysm (287 men, age, 53.0 ± 12.1 years), 65 (14.5%) for emergent acute type A aortic dissection (49 men, age, 51.0 ± 13.1 years), and 21 (4.7%) for active infective endocarditis (20 men, age, 46.5 ± 13.6 years); 15% (n = 68) were reoperative or redo procedures. RESULTS The overall hospital mortality after composite root/ascending replacement was 6.7% (n = 30). It was 3.9% (n = 14) after elective/urgent aneurysm replacement, 20.0% (n = 13) after emergency repair for acute type A aortic dissection, and 14.3% for active infective endocarditis (n = 3). The overall 1-year mortality--as a measure of operative success--was 5.2% (n = 19) after elective/urgent degenerative/atherosclerotic root/ascending aortic aneurysm repair, 21.5% (n = 14) after emergency repair for acute type A aortic dissection, and 14.3% (n = 3) after active infective endocarditis (degenerative/atherosclerotic root/ascending aortic aneurysm vs acute type A aortic dissection, P = .03; degenerative/atherosclerotic root/ascending aortic aneurysm vs active infective endocarditis, P = .08; acute type A aortic dissection vs active infective endocarditis, P = .8). Long-term survival was 88.3% at 5 years and 72.2% at 10 years, with a linearized mortality rate after 30 days of 2.5%/patient-year. Long-term survival after surgery for acute type A aortic dissection and active infective endocarditis was 72% and 72.3% at 5 years and 64.9% and 62% at 10 years, respectively, with a linearized mortality rate of 2.6%/patient-year for acute type A aortic dissection and 3.7% for active infective endocarditis. Survival after composite root replacement after the first year paralleled that of an age- and gender-matched population, regardless of the etiology. Women appeared to have less favorable longevity. CONCLUSIONS Composite root replacement remains a versatile choice for various pathologic features with excellent longevity and freedom from reoperation and should be strongly considered if conditions for valve-sparing repair are less than perfect.

Transapical Aortic Valve-in-Valve-in-Valve Implantation as a Procedural Rescue Option

Device malposition and dysfunction with resultant severe aortic insufficiency are known complications of transcatheter aortic valve implantation (TAVI). Fortunately, these complications can often be successfully treated with a transcatheter valve-in-valve (VinV) implantation. However, prosthetic leaflet dysfunction or immobility from the VinV configuration can lead to severe central aortic insufficiency. We report the first known case of implantation of a third SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA) during TAVI as a valuable bailout strategy to deal with severe aortic insufficiency after VinV implantation.

Epicardial lipoma—a rare differential diagnosis in cardiovascular medicine

Cardiac lipomas are benign tumours that represent an uncommon cause of chest discomfort. We report the case of a 52-year-old woman who was admitted to our institution with a mediastinal mass. Computed tomography and magnetic resonance imaging scans revealed an intrapericardial mass mainly located around the left atrium/left ventricle. After midline sternotomy, the pericardial mass was entirely resected after luxating the heart into the right pleural space. Histopathological examination confirmed the diagnosis of two intrapericardial lipomas with a total weight of 122 g.

Longevity after mechanical aortic root replacement--do men live longer?

OBJECTIVE To investigate whether longevity after mechanical aortic root replacement is influenced by the patients gender. METHODS From February 1998 to June 2011, 476 patients (376 men, 100 women, mean age, 53±12 years; range, 18-88) underwent composite aortic root replacement. Of these patients, 398 (312 men) were included in the present analysis. The indications for root replacement were aortic valve dysfunction (mostly stenosis) and concomitant aneurysmal disease in 334 (83.9%), acute type A aortic dissection in 51 (12.8%), and infective endocarditis in 10 (2.5%). Other indications were technical or anatomic considerations (0.8%). RESULTS The women who presented for surgery were significantly older (men, 52±12 years vs women, 56±12 years; P=.01). However, no significant differences were found with regard to previous cardiac surgery (5.3%, 20 men [6.4%] vs 1 woman [1.2%]; P=.06), concomitant procedures (38%; 117 men [37.5%] vs 35 women [40.7%]; P=.62), or additive EuroSCORE (men, 5.1±2.2; women, 5.2±2.2; P=.55). The mean diameter of the ascending aorta was not significantly different between the 2 groups (men, 54±9 mm; women, 56±14 mm; P=.97). The median follow-up period was 7.4 years (range, 0-13; 2366 cumulative patient-years), with no significant difference in hospital mortality (men, 6.7% vs women, 10.5%; P=.25). Overall, men enjoyed significantly better longevity than did women. After 10 years, 73%±3% of the men and only 60%±6% of the women were alive (P=.03). Although no long-term survival benefit for either gender was found in an age-matched subgroup among young patients (P=.66), men experienced much more favorable longevity after 55 years of age (P=.04). Consequently, the longevity in men-but not in women-was equal to an age-matched normal population. CONCLUSIONS Overall, long-term survival after mechanical aortic root replacement was significantly better among men. However, comparing age-matched subgroups≤55 years old, no significantly different life expectancy was found after mechanical root replacement.