Marcus P. Haw

Early and Late Clinical Outcomes of Pulmonary Embolectomy for Acute Massive Pulmonary Embolism

BACKGROUNDnThe aim of this study was to investigate the early and late outcomes of patients undergoing pulmonary embolectomy for acute massive pulmonary embolus.nnnMETHODSnTwenty-one patients (15 male, 6 female) underwent pulmonary embolectomy at our institution between March 2001 and July 2010. The median age was 55 years (range, 24 to 70 years). Of these, 9 patients presented with out-of-hospital cardiac arrest and 8 presented with New York Heart Association class III or IV. Sixteen patients underwent preoperative transthoracic echocardiography, which showed evidence of right ventricular dilatation in all, whereas in 14 patients (66.6%) pulmonary artery pressures were significantly elevated with moderate to severe tricuspid regurgitation. The median preoperative Euroscore was 9 (range, 3 to 16), and 11 patients (52.1%) received systemic thrombolysis preoperatively. There were 6 salvage (28.5%), 10 emergency (47.6%), and 5 urgent (23.8%) procedures. Concomitant procedures were performed in 3 patients (14.2%), and surgery was performed without the use of cardiopulmonary bypass in 3 patients (14.2%). The median follow-up was 38 months (range, 0 to 114 months).nnnRESULTSnThe in-hospital mortality was 19% (n = 4). Postoperative complications included stroke (n = 3, 14.2%), lower respiratory tract infection (n = 6, 28.5%), wound infection (n = 3, 14.2%), acute renal failure requiring hemofiltration (n = 4, 19%), and supraventricular tachyarrhythmias (n = 4, 19%). At discharge, transthoracic echocardiography showed mild to moderate right ventricular dysfunction and dilatation in 11 survivors (64.7%). Two patients died during follow-up, and actuarial survival at 5 years was 76.9% ± 10.1% and at 8 years was 51.2% ± 22.0%. At final follow-up, 11 of the 15 survivors (73.3%) were New York Heart Association class I, and no patients required further intervention.nnnCONCLUSIONSnPatients who undergo surgery for massive pulmonary embolism have an acceptable outcome despite being high-risk.

Prolonged survival with left atrial spindle cell sarcoma

Primary spindle cell sarcoma of the left atrium is a rare tumour. Optimal treatment is to obtain complete surgical clearance of the tumour. The anatomic location of the tumour, infiltration into vital structures and difficult access provides a surgical challenge for resection of the lesion and reconstruction of the defect. The prognosis of patients with a primary cardiac sarcoma is very poor because of their resistance to treatment with chemotherapy and radiotherapy. Metastases and local recurrences are common despite optimal multimodality treatment. This report describes a 48-year-old gentleman who underwent multiple surgeries to achieve an 11-year survival since the diagnosis. The operative techniques have been described.

The angle of the components of the common atrioventricular valve predicts the outcome of surgical correction in patients with atrioventricular septal defect and common atrioventricular junction

BACKGROUNDnThree-dimensional echocardiography offers new insights into valvar function in atrioventricular septal defects (AVSDs). The aim of this study was to identify a morphological marker to predict the functional outcomes of left atrioventricular valves (AVVs) following the repair of AVSDs.nnnMETHODSnTwenty-nine consecutive patients were evaluated preoperatively using 2-dimensional and 3-dimensional echocardiography. The angle of the AVV relative to the crux of the heart was measured in multiplanar review mode.nnnRESULTSnThe severity of postoperative left AVV regurgitation was correlated with preoperative valvar angle, being more acute in patients with moderate or severe regurgitation (mean, 57 +/- 13 degrees vs 83 +/- 9 degrees in patients with no or mild regurgitation; P = .002). Angles < or = 59 degrees predicted severe regurgitation with 79% specificity.nnnCONCLUSIONSnMultiplanar review of 3-dimensional data sets is valuable for the assessment of the functional morphology of AVSD valves. Using this technique, more acute AVV angles predicted increased likelihood of severe regurgitation following surgical repair.

Use of Extracorporeal Membrane Oxygenation in the Management of Septic Shock With Severe Cardiac Dysfunction After Ravitch Procedure

We report the case of an 18-year-old patient who underwent Ravitch procedure for pectus carinatum and subsequently had septic shock develop with severe cardiac dysfunction requiring treatment with extracorporeal membrane oxygenation. We advocate the use of extracorporeal membrane oxygenation in adult patients with intractable cardiorespiratory failure due to sepsis post-thoracic surgery unresponsive to conventional therapy.

Aortic valve replacement in patients with previous coronary artery bypass grafting: 10-year experience

UNLABELLEDnOBJECTIVES; This study aimed to investigate the early and late outcomes of patients undergoing aortic valve replacement (AVR) with previous coronary artery bypass grafting (CABG) and patent grafts.nnnMETHODSnBetween January 2000 and March 2010, 104 patients (87 males) with previous CABG ± concomitant surgery and patent grafts underwent AVR. The median age of the patients was 75 years (range: 37-90 years; inter-quartile range: 69-79 years) and the mean logistic EuroScore was 25.37 ± 16.8. The median time since the previous operation was 9 years (range 1-25; inter-quartile range: 7-14 years). The left internal mammary artery (LIMA) had been used in 75 patients (72.1%) and remained patent in 72 cases (96.0%).nnnRESULTSnThirty-day mortality was 7.7% (n = 8), which is less than the predicted mean logistic EuroScore. Isolated AVR was performed in 66 patients (63.5%). The LIMA was dissected and isolated (clamped or blocked with balloon) in 60 patients. The median hospital stay was 10 days (range: 4-183 days; inter-quartile range: 7-15.25 days). Nineteen patients (18.3%) had pulmonary complications, while 12 (11.5%) had acute kidney injury. Seven patients (6.7%) required permanent pacemaker. Six LIMAs (8.3%) were injured and repaired. Prolonged aortic cross-clamp (AXC) time (P = 0.038) and the presence of a previous LIMA graft (P = 0.045) were identified as independent predictors of 30-day mortality. The actuarial survival at 1 and 5 years was 89.4 ± 0.3 and 81.5 ± 0.5%, respectively. Perioperative intra-aortic balloon pump use (P = 0.036), prolonged AXC time (P = 0.004) and prolonged cardiopulmonary bypass time (P = 0.022) were associated with worse long-term overall survival on multivariate analysis.nnnCONCLUSIONSnAVR post-CABG with patent grafts can be performed in high-risk patients with excellent short- and long-term outcomes and appears to be superior to published catheter-based interventions. In the absence of randomized trial data, we believe that open AVR remains the treatment of choice for aortic valve disease following prior CABG.

Long-Term Outcomes in Octogenarians Following Aortic Valve Replacement

Abstractu2002 Background:u2002The aging of the population has resulted in an increasing number of elderly patients undergoing cardiac operations. We reviewed our experience in patients over the age of 80 undergoing primary aortic valve replacement (AVR) with or without CABG. Methods: Between 2000 and 2008, 345 patients (226 male) ≥80 years underwent primary AVR in our unit. The notes of these patients were retrospectively reviewed and follow‐up information was obtained from their general practitioners. They had a mean age of 82.9 ± 2.3 years and a median logistic EuroSCORE of 13.4 (IQR 9.4, 19.1). Isolated AVR was performed in 161 patients (45.5%), and 184 (51.6%) patients underwent combined AVR and CABG. A quality of life questionnaire was sent to all survivors. Results: Hospital mortality occurred in 17 patients (4.9%), which was significantly lower than the mortality predicted by logistic EuroSCORE (16.2%, p < 0.01). Hospital mortality was comparable between patients undergoing isolated AVR and those undergoing additional CABG (4.3% vs. 5.4%, respectively). Actuarial survival at one and five years was 90.1 ± 1.6% and 77.2 ± 2.9%, respectively. There was a 62% response on the questionnaire showing 70% of the patients were NYHA I and 83.7% were satisfied with the operation outcome. Conclusions: AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk‐scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR.u2002(J Card Surg 2011;26:466‐471)

Long-term follow-up after primary complete repair of common arterial trunk with homograft: A 40-year experience

BACKGROUNDnWe sought to determine the long-term performance of homograft and truncal valve after complete repair of common arterial trunk.nnnMETHODSnFrom January 1964 to June 2008, 32 patients (median age, 14 days; range, 5 days to 2.5 years) underwent primary homograft repair of common arterial trunk. Twenty-four (75%) were neonates. The homograft used in the right ventricular outflow tract was aortic in 24 patients and pulmonary in 8 patients (mean diameter, 15.8 +/- 3.5 mm; median diameter, 16 mm [range, 8-24 mm]). The median follow-up was 24.5 years (range, 5.6 months to 43.5 years).nnnRESULTSnThere were 3 hospital deaths and 1 late death. The actuarial survival at 30 years was 83.1% +/- 6.6%. Of the 28 survivors, 25 reoperations were performed in 19 (76%) patients. The mean and median times to homograft reoperation were 11.5 +/- 7.4 and 12.1 years (range, 1.0-26.1 years), respectively. Overall freedom from homograft reoperation after 10, 20, and 30 years was 68.4% +/- 8.7%, 37.4% +/- 9.5%, and 26.7% +/- 9.3%, respectively. Twelve patients retained the original homografts at a median follow-up of 16.4 years (range, 0-30.2 years). Six underwent a truncal valve replacement with a mechanical prosthesis at a median of 10.5 years (range, 3.4-22 years) after truncus repair. Freedom from truncal valve replacement at 10 and 30 years was 93.1% +/- 4.7% and 81.8% +/- 8.9%, respectively. In the 22 surviving patients who did not undergo truncal valve replacement, the peak truncal valve gradient was 8.9 +/- 8.3 mm Hg at a median follow-up of 24.5 years (range, 5.6 months to 32.9 years). At the last follow-up, 27 (96.4%) patients had good left ventricular function, and 24 patients (85.7%) were New York Heart Association class I.nnnCONCLUSIONSnOversizing the homograft at the time of the initial repair can lead to a homograft lasting more than 12 years. During long-term follow-up, 20% of patients require truncal valve replacement.

Primary Biventricular Repair of Atrioventricular Septal Defects: An Analysis of Reoperations

BACKGROUNDnThe purpose of this study was to analyze the factors affecting reoperation after primary biventricular atrioventricular septal defect (AVSD) repair.nnnMETHODSnBetween April 1997 and April 2007, 93 consecutive patients underwent surgery for biventricular correction of AVSD with a median age of 5.8 months (range, 9 days to 68.9 years). Fifty-three patients had complete AVSD, 6 patients had an intermediate type, and 29 patients had partial AVSD; 4 patients had a complete AVSD with associated tetralogy of Fallot, and 1 patient had a complete AVSD with double-outlet right ventricle.nnnRESULTSnThere was no in-hospital mortality. There were 2 late deaths (2.2%). Forty-three reoperations were performed in 23 patients (24.7%), of which 18 were for repair of significant left atrioventricular valve regurgitation and 8 were mitral valve replacements. Seven patients (7.5%) required insertion of a permanent pacemaker. The overall 5-year freedom from reoperation after AVSD repair was 73.6% +/- 4.8%. In the multivariate analysis for complete AVSDs, Down syndrome (p = 0.01) and the presence of right ventricular dominance (p = 0.03) were independent predictors of reoperation. At last follow-up, 76 patients (83.5%) were in New York Heart Association class I, and 68 patients (74.7%) were not taking any heart failure medications. Echocardiographic examination showed absent to mild left atrioventricular valve regurgitation in 76.5%; moderate, in 19.8%; and severe, in 3.7% of patients.nnnCONCLUSIONSnDown syndrome and right ventricular dominance are independent predictors of reoperation after complete AVSD repair. Biventricular repair of isolated AVSD with a small left ventricle can be successfully accomplished with no mortality.

Renal Function of Patients with a Failing Fontan Circuit Undergoing Total Cavopulmonary Revision Surgery

This report characterizes renal dysfunction after total cavopulmonary (TCPC) revision surgery for atriopulmonary Fontan (APF) circulations, a known risk factor for a poor outcome. The perioperative data for 23 consecutively identified patients were reviewed. The preoperative mean glomerular filtration rate (GFR) was 101xa0±xa030xa0ml/min/1.73xa0m2, decreasing to 65xa0±xa041xa0ml/min/1.73xa0m2 early in the postoperative period. The preoperative GFR was highly correlated with age at APF (rxa0=xa0−0.5; pxa0=xa00.024), age at TCPC (rxa0=xa0−0.5; pxa0=xa00.01), and mixed venous saturation (rxa0=xa00.6; pxa0=xa00.01). Three of four patients requiring renal replacement therapy (RRT) died at a median age of 3xa0months (range, 18xa0days to 9xa0months). Determinants of early GFR and RRT were preoperative GFR (pxa0=xa00.016) and creatinine (pxa0=xa00.035). Younger age at primary Fontan (pxa0=xa00.008), higher preoperative mixed venous saturation (pxa0=xa00.019), and higher preoperative blood pressure (pxa0=xa00.006) independently predicted better GFRs at the latest follow-up evaluation. Renal function declines acutely after TCPC revision, often necessitating RRT. A requirement for RRT marks greater mortality. Higher preoperative creatinine levels identify those at greatest risk.

Long-term outcome following repair of acute type A aortic dissection after previous cardiac surgery.

We evaluated the outcome after repair for acute spontaneous type A aortic dissection in patients with previous cardiac surgery. From January 2000 to December 2009, 114 patients underwent emergency repair for acute spontaneous type A dissection at Southampton University Hospital. Eleven (median age 64xa0years; range 36-83xa0years; two females) patients (9.8%) had undergone previous cardiac surgery and were included in this study. Aortic root replacement was performed in three patients (27%), aortic arch replacement in four patients (36%) and two patients (18%) required aortic valve re-suspension. The elephant trunk operation was performed in two patients (18%). There were two hospital deaths (18%). Two patients (18%) suffered a stroke, two needed re-opening for bleeding (18%) and two patients (18%) required haemofiltration postoperatively. Median length of hospital stay was 16xa0days (range 6-34xa0days). Actuarial survival at five and eight years for redo compared to first-time surgery was 68±3.63% vs. 81±5.34% and 51±3.8% vs. 61±5.4%, respectively (P=0.365). In conclusion, acute type A aortic dissection repair in patients with previous cardiac surgery has an acceptable mortality and comparable long-term outcome to first-time surgery.