Farhad Bakhtiary

Long-Term Results After Repair of Complete Atrioventricular Septal Defect With Two-patch Technique

BACKGROUND Surgical management of patients with complete atrioventricular septal defect (AVSD) has advanced over the last decades. Definitive early surgical repair for AVSD has become the treatment of choice at many centers. This trend has contributed to the recent decline in postoperative mortality and good long-term results. METHODS We reviewed long-term results of 100 consecutive patients with complete AVSD undergoing definitive early repair with a two-patch technique and complete cleft closure operated on between June 1999 and June 2009. Valve performance, mortality, morbidity, and indications for reoperation were retrospectively studied. RESULTS Median age at operation was 3.8 months (range, 15 days to 4.7 years); median weight was 5.0 kg (range, 3.0 to 19 kg). Follow-up was 99% complete (mean 58 months; range, 1 to 120 months). Early definitive repair was performed in all patients who initially presented to our institution over the study period. There was no perioperative, in-hospital mortality, or late mortality. At the latest follow up, left atrioventricular valve (LAVV) regurgitation was absent or trace in 80 patients (80%), mild to moderate in 15 patients (15%), and moderate to severe in 4 patients (4%). Right AV valve regurgitation was none or trace in 86 patients (86%), mild to moderate in 11 patients (11%), and moderate to severe in 2 patients (2%). Actuarial freedom from reoperation for LAVV dysfunction at 1, 3, 5, and 10 years was 98%, 95%, 94%, and 94%, respectively. Actuarial freedom from reoperation for left ventricular outflow tract obstruction at 1, 3, 5, and 10 years was 100%, 99%, and remained constant by 99% at 5 and 10 years. CONCLUSIONS Definitive early repair for complete AVSD can be performed with excellent results. The two-patch technique with complete cleft closure is a safe and reproducible surgical method that can achieve very low mortality and stable long-term outcomes, even in neonates.

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.

Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses

OBJECTIVES To evaluate the early and long-term outcomes in patients undergoing complex aortic root reconstructions for complicated aortic root abscesses. METHODS A total of 1199 patients underwent aortic valve surgery for aortic valve endocarditis between July 1999 and June 2012. Of these, 150 patients, who underwent complex isolated aortic root operations for aortic root abscesses, were included in this study. Radical resection of the abscess was performed in all patients followed by an aortic root replacement (ARR) in 91 (61.7%) or an aortic valve replacement with patch reconstruction of the aortic root in 59 (39.3%) patients. Prosthetic valve endocarditis was observed in 74 patients (49.3%). Logistic regression analysis identified the predictors of 30-day mortality. Estimated mean follow-up was 7.0 ± 0.5 years (range 0-12.6 years). RESULTS Mean age was 62 ± 15 years and 87% (n = 130) were male. The majority of patients (91%; n = 137) underwent urgent or emergent surgery. Overall 30-day mortality was 19% (n = 29; ARR 21%; AVR 17%; P = 0.4). Postoperative low cardiac output, stroke and dialysis developed in 10.7, 4.7 and 25.3% of patients, respectively. Sepsis was the only independent predictor of 30-day mortality (odds ratio: 2.8; 95% confidence interval: 1.1-7.3; P = 0.03). The 1-, 5- and 10-year survival was 66 ± 5, 54 ± 5 and 51 ± 6%, respectively. Overall, 9% of surviving patients required a reoperation for recurrent endocarditis resulting in a 1-, 5- and 10-year freedom from reoperation of 93 ± 2, 91 ± 3 and 85 ± 5%, respectively, which was not influenced by surgical technique used (ARR vs AVR with patch reconstruction; log rank P = 0.9). CONCLUSIONS The surgical treatment of aortic root abscess is a challenging operation and is associated with a high early morbidity and mortality. However, the long-term survival and freedom from reoperation is satisfactory.

Outcome of Aortic Valve Replacement for Active Infective Endocarditis in Patients on Chronic Hemodialysis

BACKGROUND The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. METHODS Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed. RESULTS Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause. CONCLUSIONS In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE.

Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.

OBJECTIVES Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort. METHODS Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%). RESULTS The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90). CONCLUSION Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.

Outcome and Incidence of Re‐Intervention After Surgical Repair of Tetralogy of Fallot

Timing of primary repair of tetralogy of Fallot (TOF) remains controversial. We evaluated the long‐term outcome of early primary treatment strategy in a patient cohort with TOF less than eight months of age.

Mid-term outcome after surgical repair of congenital supravalvular aortic stenosis by extended aortoplasty

OBJECTIVES Congenital supravalvular aortic stenosis (SVAS) is a rare arteriopathy associated with the Williams-Beuren syndrome (WBS) and other elastin gene deletions. Our objective was to review the mid-term outcomes of SVAS repair with extended aortoplasty. METHODS Congenital SVAS repairs from 2001 to 2010 were retrospectively reviewed. The follow-up records, reintervention and reoperation data and most recent echocardiograms were obtained. RESULTS From 2001 to 2010, 21 patients (15 males) underwent surgical repair of SVAS by extended aortoplasty with autologous pretreated pericardium, which is a modification of the Doty technique. The mean age was 3.1 ± 4.2 years. WBS was diagnosed in 14 of the patients. There was no early mortality, but one late death was observed. At the latest follow-up (mean follow-up, 4.3 ± 2.9 years; range, 1-108 months), echocardiograms revealed a peak Doppler gradient across the aortic outflow tract of 15 ± 8 mmHg. The majority of the patients had minimal to mild aortic insufficiency. No reoperation or reintervention was required. CONCLUSIONS Extended aortoplasty provides excellent mid-term relief of SVAS and, in addition, reshapes the aortic root geometry to a much more favourable anatomical configuration. It can be performed without any increase in operative risks. The mid-term results are excellent.

Protective Effects of Pulsatile Flow During Cardiopulmonary Bypass

BACKGROUND Children with congenital heart disease are often operated at a very young age. Cardiopulmonary bypass (CPB) has become indispensable for these sometimes very complex operations, but one cannot neglect a possible negative impact of CPB on organ function. Traditionally, CPB was developed with non-pulsatile flow but there are clinical observations that pulsatile flow might be superior with improved patient outcomes. Therefore, we attempted to elucidate whether CPB with pulsatile flow preserves organ integrity compared with nonpulsatile flow. METHODS We studied 27 piglets of 4 weeks age and divided them into 3 experimental groups: control group (no CPB); non-pulsatile and pulsatile-CBP with 90-minutes CPB and 120-minutes recovery and reperfusion. Thereafter, histology of kidney, liver, and hippocampus was performed. Moreover, we measured adenosine triphosphate (ATP) content in these organs. RESULTS Histologic evaluation revealed that laminar flow produced significant cellular edema in the kidney and hippocampus. Additionally, markers for hypoxia, apoptosis, and nitrosative stress were elevated but predominately in the hippocampus and proximal tubules of the kidney. Most of these alterations were reduced to or near control levels with pulsatile CPB. Moreover, ATP content of all 3 organs examined was higher and kidney and liver enzymes were lower in the pulsatile group compared with the non-pulsatile CPB. With regard to histologic changes, the liver seemed to be a less sensitive organ. CONCLUSIONS In our study during pulsatile CPB, organ damage was significantly attenuated as compared with non-pulsatile CPB. Therefore, in pediatric patients pulsatile CPB may improve clinical outcomes.

Midterm Outcome After Surgical Correction of Anomalous Left Coronary Artery From Pulmonary Artery

Background: Early establishment of a two-coronary artery system has become the standard surgical approach in patients with anomalous origin of the left coronary artery from the pulmonary artery. After surgical repair, presentation of severely impaired ventricular function and mitral regurgitation is a common finding. Methods: We reviewed midterm outcome of 18 consecutive patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) undergoing surgical repair for establishment of dual coronary system operated on between September 1999 and July 2009. Mortality, morbidity, echocardiography assessment of left ventricular function, mitral valve regurgitation, and indications for reoperation were studied retrospectively. Results: The mean age at the time of surgery was 26 ± 44 months (range, 14 days-12.7 years), 14 patients were younger than 6 months. There was no in-hospital or late mortality. Recovery of left ventricular function was associated with improvement in the degree of mitral valve regurgitation. At the latest follow-up, mitral valve regurgitation was none or trace in 14 patients (78%), mild to moderate in 3 patients (16%), and remained severe in 1 patient (6%). Left ventricular function normalized in 16 patients and remained mildly impaired in 2 patients. Late postoperative echocardiograms demonstrated a patent left coronary artery in 17 patients. In 5 patients temporary left heart bypass (LHB) was needed. Conclusions: Early establishment of a 2-coronary artery system artery results in complete recovery of left ventricular function and without relevant mitral valve dysfunction. Reoperation rates are acceptable. Our results support the use of LHB in patients with refractory low cardiac output. The need of mechanical circulatory support was short and very effective in our patient cohort.

Paediatric coronary artery bypass grafting for coronary hypoperfusion late after arterial switch operation

A case of left main coronary artery stenosis is presented in a boy late after an arterial switch operation, with significant ischaemia during exercise with good collateralisation through the right coronary artery. The problem was successfully managed with minimally invasive off-pump coronary artery bypass through median re-sternotomy.