Jean Perron

Valved homograft conduit repair of the right heart in early infancy

BACKGROUND Valved homograft conduit repair in neonates and young infants creates a physiologically normal biventricular circulation, and unlike shunts, avoids surgery on the branch pulmonary. METHODS Retrospective chart review was used for 84 patients operated on between 1990 and 1995 (mean age 26+/-28 days, mean weight 3.3+/-0.8 kg) undergoing homograft conduit repair in the first 3 months of life. Cases were divided into simple and complex, eg, absent pulmonary valve syndrome or associated interrupted arch. Mean homograft size was 9.0+/-2 mm. RESULTS Early mortality was 4.7% (simple) and 30% (complex). Mean hospital stay was 18 days. Mean follow-up was 34 months. Thirty-seven (47%) patients underwent conduit replacement. Median time to reoperation was 3.1 years. Mean size of replacement homograft was 17+/-2 mm. There were no deaths at reoperation. Mean hospital stay at conduit change was 6.3 days. Probability of survival at 5 years is 75%. CONCLUSIONS Biventricular repair employing a conduit can be performed safely in noncomplex anomalies in the first 3 months of life. Time interval until repeat surgery is relatively short but equal or greater than that with most palliative procedures.

Permanent pacemaker implantation following isolated aortic valve replacement in a large cohort of elderly patients with severe aortic stenosis

Objectives To assess the incidence of conduction disturbances leading to permanent pacemaker implantation (PPI) following isolated aortic valve replacement (AVR) in a large cohort of elderly patients with severe symptomatic aortic stenosis, and to determine the predictive factors and prognostic value of PPI following AVR in such patients. Methods A total of 780 consecutive elderly patients (age 77±4 years, logistic EuroSCORE 10.4±8.5%, STS score 3.5±1.5%) with severe aortic stenosis and no previous pacemaker were analysed. Main outcome measures The incidence, clinical indications, timing and predictive factors of PPI within 30 days after AVR and their prognostic value were evaluated. Results Baseline ECG showed the presence of conduction abnormalities in 37.1% of the patients. Twenty-five patients (3.2%) needed PPI during the index hospitalisation due to the occurrence of complete atrioventricular block (2.6%) or severe bradycardia (0.6%). The presence of preprocedural left bundle branch block (OR 4.65, 95% CI 1.62 to 13.36, p=0.004) or right bundle branch block (OR 4.21, 95% CI 1.47 to 12.03, p=0.007) predicted the need for PPI after AVR. The need for PPI was associated with a longer hospital stay (p<0.0001). Thirty-day mortality rates were similar between patients with and without PPI (4% vs 3.2%, p=0.56). Survival rate at 5-year follow-up was 75%, with no differences between patients with and without PPI (p=0.12). Conclusions The need for PPI following isolated AVR in elderly patients with severe symptomatic aortic stenosis was low. Pre-existing bundle branch block predicted the need for PPI. PPI determined a longer hospital stay, but had no effect on acute and long-term mortality.

Life-threatening hemoptysis following the Fontan procedure

Two cases of life-threatening recurrent hemoptysis occurring 10 years after a Fontan operation are presented. Bleeding from aortopulmonary collateral vessels was responsible for this complication in both cases, and the importance of systematic selective angiography of all potential origins of such abnormal vessels, including those arising from the abdominal aorta, is highlighted. Although coil embolization of aortopulmonary collateral vessels is usually definitive, pulmonary lobectomy may be necessary. The present report demonstrates, for the first time, that rescue extracorporeal membrane oxygenation support can be used as a bridge to surgery in case of severe uncontrollable hemoptysis in such cases.

Long-term outcomes of the Ross procedure in adults with severe aortic stenosis: single-centre experience with 20 years of follow-up

OBJECTIVES The optimal prosthesis option for aortic valve replacement in adult patients<60 years of age with severe aortic stenosis (AS) remains controversial. The objective was to determine the long-term outcomes of the Ross procedure in this population. METHODS Between 1990 and 2013, 276 patients aged 18 years and above (mean 40.3±10.6) underwent an elective Ross procedure. Among them, 221 patients had predominant severe AS; these patients form the study group. The Ross procedure was performed either by aortic root replacement (n=190; 86%) or the subcoronary technique (n=31; 14%). There were 169 patients with bicuspid valves and 33 redo operations including previous aortic valve repair (n=6) and replacement (n=9) for severe AS. Demographic, preoperative, postoperative and longitudinal clinical and echocardiographic data were collected prospectively. The median and mean follow-up were 11.4 years (range: 1-20.1 years) and 10.1±5.9 years, respectively. The follow-up was complete in all patients. Kaplan-Meier actuarial survival analysis was performed to assess long-term survival, freedom from reoperation for autograft and/or homograft failure and freedom from autograft valve insufficiency. Cox regression risk analysis was performed to identify factors associated with autograft or homograft reoperations. RESULTS The perioperative mortality rate was 0.9% (n=2). The incidence rate of early reoperation for bleeding was 5.9%. The actuarial survival rate at 10 and 15 years following surgery was 92.1 and 90.5%, respectively. Ross-related reoperations occurred in 21 patients during follow-up: autograft dysfunction (n=9), homograft dysfunction (n=6) and both (n=6). The rate of freedom from Ross-related reoperation was 94.7 and 87.7% at 10 and 15 years, respectively. The rate of freedom from reoperation for autograft failure was 97.6 and 91.5%, the rate of freedom from reoperation for homograft failure was 95.7 and 90.8%, and the rate of freedom from moderate or severe autograft regurgitation was 94.1 and 85.6% at 10 and 15 years, respectively. CONCLUSIONS Compared with available aortic bioprosthetic alternatives in young adults with severe AS, the Ross procedure provides an excellent long-term option for patients with predominant severe AS who seek a durable operation without anticoagulation.

Delayed Improvement in Valve Hemodynamic Performance After Percutaneous Pulmonary Valve Implantation

We report the case of a 21-year-old woman with a severely stenotic pulmonary homograft who underwent percutaneous pulmonary valve implantation, with no significant change in transvalvular gradient within the 24 hours after the procedure. Major improvement in hemodynamic valve performance of more than 60% decrease in transvalvular gradient and more than 30% increase in pulmonary valve area was observed 3 months after the procedure, showing that hemodynamic improvement can occur late after pulmonary valve implantation. An echocardiogram after 3 months should be done before concluding the procedure failed and that reintervention is necessary.

Risk factors of mortality after surgical correction of ventricular septal defect following myocardial infarction: Retrospective analysis and review of the literature

BACKGROUND Rupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition. METHODS We review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. A retrospective study was performed on 34 consecutive patients who had undergone surgical repair for VSDs following AMI from December 1991 to July 2014. Preoperative, clinical and echocardiographic variables were studied by uni-and multivariate analyses. RESULTS Mortality was analyzed for the entire group of patients. Mean age was 69 ± 7 years with 44% women. VSDs were anterior in 11 (32%) and posterior in 23 (68%) patients. A majority, 24 (71%) patients were in cardiogenic shock. Median interval from myocardial infarction to VSDs repair was 7 days. The 30 days operative mortality was 65%. Mortality within the posterior VSDs group was 74% and the anterior VSDs group was 46% (P=0.14). Concomitant coronary artery bypass graft (CABG) did not influence early or late survival. Multivariate analysis identified older age (HR=1.11, P=0.0001) and shorter time between AMI and surgery (HR=0.90, P=0.015) as independent predictors of 30-day and long-term mortality. CONCLUSION In conclusion, surgical repair of post-AMI VSDs carries a high operative mortality. An algorithm of treatment for the management of these patients is suggested.

Vascular Burden Impact on Echocardiographic Valvular Graft Degeneration Following a Ross Procedure in Young Adults

Mechanical valves require anticoagulation therapy, and biosprotheses have a relatively short lifetime, especially in young adult patients [(1)][1]. The Ross procedure may overcome these issues without any anticoagulation needed and allow for possible longer graft integrity. However, studies have