James C. Halstead

Are stentless valves superior to modern stented valves? A prospective randomized trial.

Background— It is presumed that stentless aortic bioprostheses are hemodynamically superior to stented bioprostheses. A prospective randomized controlled trial was undertaken to compare stentless versus modern stented valves. Methods and Results— Patients with severe aortic valve stenosis (n=161) undergoing aortic valve replacement (AVR) were randomized intraoperatively to receive either the C-E Perimount stented bioprosthesis (n=81) or the Prima Plus stentless bioprosthesis (n =80). We assessed left ventricular mass (LVM) regression with transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI). Transvalvular gradients were measured postoperatively by Doppler echocardiography to compare hemodynamic performance. There was no difference between groups with regard to age, symptom status, need for concomitant coronary artery bypass surgery, or baseline LVM. LVM regressed in both groups but with no significant difference between groups at 1 year. In a subset of 50 patients, MRI was also used to assess LVM regression, and again there was no significant difference between groups at 1 year. Hemodynamic performance of the 2 valves was similar with no difference in mean and peak systolic transvalvular gradients 1 year after surgery. In patients with reduced ventricular function (left ventricular ejection fraction [LVEF] <60%), there was a significantly greater improvement in LVEF from baseline to 1 year in stentless valve recipients. Conclusions— Both stented and stentless bioprostheses are associated with excellent clinical and hemodynamic outcomes 1 year after AVR. Comparable hemodynamics and LVM regression can be achieved using a second-generation stented pericardial bioprosthesis. In patients with ventricular impairment, stentless bioprostheses may allow for greater improvement in left ventricular function postoperatively.

Conservative surgical treatment of valvular injury after blunt chest trauma

BACKGROUND Blunt injury to the cardiac valves leads to progressive ventricular failure often requiring surgical management. Most frequently, prosthetic replacement is the chosen management. METHODS Three consecutive patients presenting to one surgeon with blunt traumatic valve lesions formed the study group. RESULTS At operation, the valvular pathology was assessed, and reparative techniques were used to correct the defects. All the patients had an excellent outcome at follow-up periods of 2 to 3 years. CONCLUSIONS Conservative operation to repair traumatic valve lesions is feasible and has potential advantages over replacement.

A novel method to prevent retrograde displacement of ureteric calculi during intracorporeal lithotripsy

The ureteric orifice of the affected side is cannulated with a 9.8 F ureteroscope with a leading hydrophilic guidewire. The position of the calculus in the ureter is identified after passing the guidewire, which is advanced to the calculus and can be withdrawn after visualizing the stone. A 6 F ureteric access catheter is then inserted and advanced within the ureteroscope, or if the operator wishes to use a smaller ureteroscope which would prohibit passage of a large ureteric catheter, the catheter can be inserted before ureteroscopy. Although this method does not allow for direct visualization of the calculus the catheter can be inserted along a guidewire under fluoroscopic control. Radio-opaque calculi can be visualized on fluoroscopy, facilitating the accurate placing of the ureteric catheter before instilling the jelly. However, if the calculus is radiolucent, directing the catheter into the ideal position may prove difficult. The catheter should be advanced beyond the calculus so that its tip lies proximal to it in the ureter. Once the catheter is in the correct position a 5–20 mL syringe is attached to the distal end of the ureteric catheter. The jelly is injected into the catheter; a considerable degree of force is required to propel the jelly through the catheter and into the ureter because the jelly is viscous. The use of a smaller ureteric catheter precludes injecting the jelly, as a satisfactory lumen is required for the jelly to be advanced. Only 1–2 mL of jelly needs to be extruded from the catheter tip and this volume is suitable for placing proximal to the stone. After instilling the jelly into the ureter the calculus can be exposed to a source of kinetic energy for disintegration. Importantly, the jelly will eventually be absorbed and washed from its intended position, and thus there is a limited period during which the energy should be applied, or the proximal barrier will be lost and retrograde displacement will still be possible.

Pyrexia after cardiac surgery: natural history and association with infection.

BACKGROUND Pyrexia is common after major surgery, and infection is often an important consideration. To investigate the natural history and association with infection, we performed a prospective observational study. METHODS From November 2000 to January 2001, we studied 219 patients undergoing cardiac surgery screening daily for wound, respiratory, urinary tract, and other infections. Pyrexia was defined as temperature above 37.5 degrees C. RESULTS Of 219 patients, 7 intraoperative deaths occurred and 1 patient was excluded because of preoperative endocarditis, leaving 211. The mean age (SD) was 64 (10) years, consisting of 172 male patients (81.5%). The proportion pyrexial on days 1, 2, and 5 was 30.0%, 25.8%, and 10.3%, respectively. More patients undergoing urgent or emergency procedures (17.7% versus 7.8%; P =.03) subsequently developed pyrexia. However, there were no differences in wound infection (3.4% versus 8.3%; P =.13), positive cultures for respiratory (14.7% versus 11.4%; P =.16), urinary tract (5.2% versus 2.0%; P =.09), or other infection (8.6% versus 7.3%; P =.71) in patients experiencing postoperative pyrexia compared with those who did not. CONCLUSIONS Pyrexia is common after cardiac surgery and resolves in the majority of patients by day 5. Because there is no association between early pyrexia and infection, diagnosis of early postoperative infection by pyrexia alone is insufficient and is better established by clinical assessment with microbiological evidence.

A simple model to predict coronary disease in patients undergoing operation for mitral regurgitation

BACKGROUND Coexistent coronary disease can be identified in a third of patients with mitral valve disease. This study aims to evaluate candidate selection strategy using risk factor identification and logistic regression and to develop an additive model for the prediction of coexistent coronary disease. METHODS The sample is a consecutive series of patients who had mitral repair from 1987 to 1999. Sensitivities and specificities were calculated for each risk factor. Variables for prediction of coronary disease were entered into a univariate analysis, and predictors were entered into a forward and backward stepwise multivariate logistic regression model to form a predictive score. An additive model was derived from transformation of the logistic model. Receiver operating characteristic curves were used to compare discrimination and precision quantified by the Hosmer-Lemeshow statistic. RESULTS The American Heart Association and American College of Cardiology risk factor identification selection criteria for the 359 patients who had screening coronary angiography yielded 100% sensitivity and 1% specificity. Risk prediction with our logistic model produced a receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.4 (p = 0.9). Similar discriminating ability for our patients was achieved by the Cleveland Clinic logistic model (receiver operator characteristic curve area of 0.79; Hosmer-Lemeshow score of 12; p = 0.1). Our five-item additive model produced receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.81 (p = 0.80). CONCLUSIONS Simple risk factor identification has excellent sensitivity but is limited by specificity. Logistic regression modeling is an accurate risk prediction method but is difficult to apply at the bedside. Simplicity and accuracy may be achieved by the logistic regression-derived simple additive model.

Replacement of a Regurgitant Pulmonary Valve with a Stentless Bioprosthesis

Acquired surgical disease of the pulmonary valve is rare. We report a 72-year-old man who presented with subacute endocarditic pulmonary regurgitation. This lesion was surgically corrected with a stentless bioprosthesis. Previously, homografts and various xenografts have been used for replacement of the pulmonary valve both in the pediatric population and in adult patients with congenital heart disease. Pulmonary regurgitation is a rare lesion, but if it is encountered our case demonstrates that it can be successfully and easily treated with pulmonary valve replacement by using a stentless bioprosthesis.

A Method for Descending Thoracic Aortic Replacement Retaining a Posterior Strip Bearing Intercostal Vessels

Operations for aneurysms of the descending thoracic aorta are still fraught with danger. Spinal cord injury remains a major cause of morbidity. Many therapeutic strategies have been suggested to reduce the incidence of this devastating complication, including reimplantation of intercostal vessels. However, reimplantation of intercostal vessels, both individually or in groups, is time consuming and compounded by the absence of a reliable means of identifying which vessels actually supply the cord. We present a technique that allowed inclusion of all potentially important descending aortic branching vessels into the repair leading to a favorable outcome in a series of patients.