Gianluca Casali

Fate of the Aortic Root Late After Ross Operation

Background—The Ross operation is an alternative to mechanical aortic valve replacement in the young. Early dilatation of the pulmonary autograft root exposed to the systemic circulation has been reported. To define the prevalence of, risk factors for, and consequences of late autograft dilatation, outcome in all consecutive patients operated since May 1994 was reviewed. Methods and Results—Ninety one patients, 77 males and 14 females, with at least 1 year of follow-up underwent cross-sectional clinical and echocardiographic examination. Age at operation was 27±10 years (range 6 to 49), and the indication was aortic regurgitation in 54 (59%) patients and bicuspid valve was present in 62 (68%). End-points of the study were freedom from autograft dilatation (root diameter >4 cm or 0.21 cm/m2), from (moderate) autograft regurgitation and from reoperation. Follow-up (4.0±1.9, range 1 to 8 years) autograft root diameters were anulus, 29±4 mm (18–39); sinus of Valsalva, 38±7 mm (24–53); sinotubular junction, 37±6 mm (23–54); and ascending aorta, 37±5 mm (27–54). Late autograft dilatation was identified in 31 (34%) patients and regurgitation in 13 (14%), 7 of whom had autograft dilatation. At 7 years, freedom from dilatation was 42±8%, freedom from regurgitation was 75±8%, and freedom from reoperation was 85±10%. Cox proportional hazard analysis identified younger age (P =0.05), preoperative sinus of Valsalva (P =0.02), root replacement technique (P =0.03), and absence of pericardial buttressing (P =0.04) as predictive of autograft dilatation, whereas female sex (P =0.002), follow-up sinus of Valsalva (P =0.003), and sinotubular junction diameter (P =0.02) as predictive of autograft regurgitation. Conclusions—Autograft dilatation is common late after the Ross procedure, particularly in younger patients, in those with preoperative aortic aneurysm, and those having root replacement without support of anulus and sinotubular junction. Bicuspid aortic valve is not a risk factor. Significant autograft valve dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilatation.

Video-assisted thoracic surgery lobectomy: can we afford it?

INTRODUCTION Although video-assisted thoracoscopic (VATS) lobectomy offers advantages with regard to pain, respiratory function and mobility, concern is often expressed concerning the cost of stapling devices and increased operative time. We have therefore compared the costs of VATS and open lobectomy in order to assess the overall economic sustainability of a VATS programme. MATERIALS AND METHODS Between January 2004 and December 2006 346 patients underwent pulmonary lobectomy mainly for stage I or II lung cancer (93 VATS lobectomy, 253 thoracotomy). In the VATS group 47% of patients had an upper lobectomy versus 52% in the open group (p=ns). Direct medical costs (disposables, theatre time, high dependency unit stay, hospital stay) were determined and stratified by lobectomy type. RESULTS Mean theatre cost for a VATS lobectomy was 2533+/-230 euro versus 1280+/-54 euro for a thoracotomy lobectomy (p=0.00001). Mean high dependency unit (HDU) cost was 1713+/-236 euro and 2571+/-80 euro for a VATS and a thoracotomy lobectomy, respectively (p=0.00001). Mean cost of hospital stay for a VATS lobectomy was 3776+/-281 euro versus 4325+/-154 euro for an open one (p=0.00001). The overall cost for a VATS lobectomy was 8023+/-565 euro which was less than an open lobectomy 8178+/-167 euro (p=0.0002). VATS bilobectomy was slightly more expensive than an open one: 8702+/-350 euro versus 8655+/-466 euro but this difference (47 euro) was not significant (p=ns). CONCLUSION VATS lobectomy is less expensive than conventional lobectomy. Increased theatre costs (disposables and time) are counteracted by shorter hospital stay. Importantly, the reduced HDU and ward bed stays free resources for other patients.

Recurrence of aortic insufficiency after aortic root remodeling with valve preservation

BACKGROUND Aortic root remodeling (ARR) has recently been proposed for patients with aortic aneurysms and valve insufficiency (AI). To define factors associated with a favorable functional outcome, a review of the mid-term results with ARR was undertaken. METHODS Between March 1994 and October 1997, 17 consecutive patients (11 men, 6 women), aged 57 +/- 11 years (range 35-71), had elective ARR for aortic aneurysm with or without annuloaortic ectasia (13), sinus of Valsalva aneurysm (3), or chronic aortic dissection (1). Moderate or severe AI was present in 11 patients (65%). Preoperative aortic root diameter was 58 +/- 5 mm (range 51-70). ARR involved replacement of all three aortic sinuses and coronary button reimplantation, using grafts with a mean diameter of 28 +/- 2 mm (range 24-30). RESULTS There was one early death (6%) due to multiple organ failure. Survivors were followed for 16 +/- 12 months (range 1-44). Actuarial 3-year survival was 94% +/- 6%. Discharge echocardiogram showed a decrease in AI in all patients: AI was absent in 11 (69%) and mild in 5 (31%). Recurrence of moderate or severe AI after a mean of 16 +/- 9 months (range 9-28) was noted in 6 patients (37%), 3 of whom had no AI at discharge. Five of 6 patients required aortic valve replacement. Comparison of demographic and operative variables showed that severe preoperative AI (67% vs 20%, p = 0.06), annuloaortic ectasia (100% vs 20%, p = 0.002), and cystic medial necrosis (100% vs 20%, p = 0.002) were significantly more prevalent in patients developing severe AI at follow-up. The 10 patients (63%) with absent AI showed durable competence of the valve and relief from symptoms at follow-up. CONCLUSIONS Despite early restoration of valve competence, AI may recur and progress after ARR at medium-term follow-up in a proportion of patients. The severity of preoperative AI and the nature of aortic root disease may negatively influence the durability of repair. Continued observation of results with ARR appears mandatory to identify the appropriate surgical candidates.

Survival after stentless and stented xenograft aortic valve replacement: a concurrent, controlled trial

BACKGROUND To define the impact of stentless versus stented valve design on survival late after xenograft aortic valve replacement, a retrospective analysis of all consecutive patients operated on between January 1992 and April 2000 was undertaken. METHODS Two hundred ninety-two patients had stented (group 1) and 376 stentless (group 2) xenograft aortic valve replacements. Age was older in group 1 (75 +/- 4 vs 70 +/- 7 years, p = 0.01), whereas male gender and aortic stenosis were equally prevalent. Advanced New York Heart Association class III-IV (85% vs 78%, p = 0.03) and associated procedures (53% vs 41%, p = 0.01) were more common in group 1. Aortic cross-clamp (80 +/- 28 vs 96 +/- 23 minutes, p = 0.01) and bypass (91 +/- 56 vs 129 +/- 34 minutes, p = 0.01) times were shorter in group 1. Logistic regression and Cox proportional hazard methods were used to define the role of demographic and operative variables on hospital and late survival, freedom from valve-related mortality, and reintervention. RESULTS Early mortality was higher in group 1 (6.2% vs 2.6%, p = 0.02). Smaller aortic anulus (p = 0.008), aortic cross-clamp (p = 0.03), and coronary disease requiring bypass (p = 0.03) were associated with hospital mortality. During follow-up (37 +/- 30 vs 43 +/- 35 months, p = NS), 66 late deaths were recorded (12% vs 9%, p = NS). At 8 years, survival (70 +/- 5% vs 81 +/- 3%, p = 0.01), freedom from cardiac- (85 +/- 1% vs 92 +/- 3%, p = 0.02), and valve-related death (79 +/- 5% vs 95 +/- 2%, p = 0.004) were higher in group 2. Freedom from structural deterioration was similar (92 +/- 5% vs 93 +/- 3%, p = NS), but freedom from reoperation was lower in group 2 (99 +/- 1% vs 90 +/- 4%, p = 0.009). Multivariate analysis showed female gender (p = 0.02), age (p = 0.03), and smaller valve size (p = 0.05) to be associated with late mortality; age (p = 0.06) and diagnosis of aortic stenosis (p = 0.008) with cardiac mortality; longer intensive care unit stay (p = 0.001) and stented xenografts (p = 0.05) with valve-related mortality; and younger age (p = 0.01) and stentless xenograft (p = 0.05) with reoperation. CONCLUSIONS Use of stentless xenografts correlates with better survival and freedom from cardiac- and valve-related mortality than stented valves. However, bias favoring stented valves in older and sicker patients exists. Selective survival advantage of stentless xenograft is confined to valve-related mortality. Stentless valves are more likely to be replaced for dysfunction.

Mid-term results after extensive vein patch reconstruction and internal mammary grafting of the diffusely diseased left anterior descending coronary artery

OBJECTIVE To analyze the results of extensive reconstruction of the left anterior descending coronary artery (LAD) by an autologous vein patch, with or without endarterectomy (EA), associated with left internal mammary artery grafting onto the patch. METHODS Between January 1994 and April 2001, among 5871 myocardial revascularizations, 83 patients (1.4%), 77 male (93%), with a mean age+/-SD of 64+/-8 years (range 44-84) underwent the above mentioned procedure. Seventy-three of them (88%) were in Canadian Cardiovascular Society (CCS) Class III or IV, and 78 (94%) had a three-vessel disease. Mean preoperative ejection fraction was 58+/-12%. Risk factors included hypertension (63%), family history (51%), hyperlipidemia (41%), smoking (38%), diabetes (19%). Mean number of anastomoses/patient was 3+/-0.6. Mean length of vein patch was 2.8+/-0.9 cm (range 2-6 cm). A total of 16% of the patients underwent associated LAD-EA (mean cardiopulmonary bypass time: 132+/-21 min; mean aortic crossclamp time: 81+/-15 min). RESULTS There was one hospital death (recurrent MI, 1.2%). Seven patients (8%) had a perioperative myocardial infarction, in three cases in the region supplied by the LAD (none after associated LAD-EA). Mean follow-up period was 47+/-20 months (range 5-90) and is 99% complete. There were five late cardiac deaths (6%). A total of 74% survivors have no symptoms, 12% are in CCS Class I-II, and 14% in III-IV. Actuarial freedom from recurrent angina at 3 and 5 years is 77 and 69%, respectively. Follow-up angiograms (49 patients, 60%) revealed a full patent LAD graft in 82% of the cases (GI), versus poor run-off/occluded graft in the remaining 18% (GII). Anginal status was significantly worse in GII patients (P<0.05). CONCLUSIONS Extended reconstruction of the LAD coronary artery increases surgical risk. The procedure however enhances the probability for a complete revascularization in patients with an unfavourable anatomical substrate, with acceptable mid-term results.

Does Failed Video-Assisted Lobectomy for Lung Cancer Prejudice Immediate and Long-Term Outcomes?

BACKGROUND Lobectomy for lung cancer by video-assisted thorascopic surgery (VATS) remains an infrequently performed operation despite numerous publications showing the benefits of successful VATS compared with an open thoracotomy approach. However, concern remains regarding patient safety, notably the need for emergency intraoperative conversion to open thoracotomy leading to potential adverse consequences. We therefore compared the outcomes of converted VATS patients with open thoracotomy controls. METHODS Between May 1992 and April 2006, 30 of 286 VATS lobectomies for lung cancer required intraoperative conversion to open thoracotomy. Four patients were of advanced stage and excluded from the study. The remaining patients were matched 2:1 with open thoracotomy controls by age, sex, cancer stage, year, and type of operation. Postoperative complications and pathology were determined from the hospital discharge summary and pathology report. Long-term survival information was obtained from the family doctor or central registry. RESULTS There were no statistically significant differences in postoperative complications between the two groups (p = 0.093). There were no in-hospital deaths in the converted VATS group. Kaplan-Meier survival analysis for cancer-related or unassociated death demonstrated no statistically significant difference (log-rank p = 0.1627). CONCLUSIONS Conversion during attempted VATS resection does not prejudice short-term or long-term surgical outcomes. We therefore suggest that VATS lobectomy should be the treatment strategy of choice for stage I and II non-small cell lung cancer in view of the well-established short-term benefits and equivalent survival associated with successful VATS resection.

Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic surgery for thymoma

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups. CONCLUSION VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials.

Predicting outcome after reoperative procedures on the aortic root and ascending aorta

OBJECTIVE Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed. METHODS Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively. RESULTS Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications. CONCLUSIONS Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.

Over twenty-year follow-up of the standard Hancock porcine bioprosthesis implanted in the mitral position

BACKGROUND To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980. METHODS Of 331 patients (225 male patients, 68%), mean age 49+/-10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years. RESULTS Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71%+/-2%, 46%+/-3%, 30%+/-3%, and 22%+/-2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95%+/-1%, 67%+/-3%, 32%+/-3%, and 14%+/-3%; from reoperation were 96%+/-1%, 72%+/-3%, 36%+/-4%, and 18%+/-4%; from thromboembolism were 89%+/-2%, 82%+/-3%, 74%+/-4%, and 51%+/-2%; and from anticoagulant-related hemorrhage were 98%+/-1%, 96%+/-1%, 91%+/-1%, and 86%+/-4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89%+/-2%, 76%+/-3%, 64%+/-4%, and 48%+/-4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration. CONCLUSIONS The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

Blood versus crystalloid cardioplegia for myocardial protection of donor hearts during transplantation: a prospective, randomized clinical trial

OBJECTIVE To assess the safety and efficacy of myocardial protection of the donor heart during transplantation with the use of blood cardioplegia, a prospective randomized clinical trial was undertaken between January 1997 and March 1998. METHODS Forty-seven consecutive patients were assigned either to crystalloid (27 patients; group 1) or blood cardioplegia (20 patients; group 2). Comparison of recipient age (54 +/- 11 years vs 55 +/- 7 years; P =. 9), sex (89% vs 90% male patients; P =.9), diagnosis (63% vs 65% dilated cardiomyopathy; P =.8), elevated pulmonary vascular resistance (30% vs 30%; P =.9), prior cardiac operations (22% vs 30%; P =.5), need for urgent heart transplantation (7% vs 20%; P =. 2), donor age (32 +/- 11 years vs 31 +/- 13 years; P =.7), cause of death (33% vs 40% vascular; P =.5), and global myocardial ischemia (176 +/- 51 minutes vs 180 +/- 58 minutes; P =.5) showed no difference. Hemodynamically unstable donors (15% vs 45%; P =.02) were more prevalent in group 2. RESULTS Operative mortality rates (4% vs 5%; P =.8), high-dose inotropic support (41% vs 30%; P = 0.6), and postoperative mechanical assistance (11% vs 10%; P = 0.9) were comparable in the 2 groups. Prevalence of acute right heart failure (27% vs 0; P =.02) and of temporary complete atrioventricular block (52% vs 20%; P =.02) were greater in group 1. Spontaneous sinus rhythm recovery was more prevalent in group 2 (11% vs 40%; P =.02). Higher peak creatine kinase (1429 +/- 725 u/L vs 868 +/- 466 u/L; P =.01) and creatine kinase MB (144 +/- 90 u/L vs 102 +/- 59 u/L; P =. 06) levels suggested more severe ischemic injury in group I. CONCLUSION Use of blood cardioplegia was associated with a lower prevalence of right heart failure, cardiac rhythm dysfunction, and laboratory evidence of ischemia.