Steve A. Livesey

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.

Outcome after redo-mitral valve replacement in adult patients: a 10-year single-centre experience

The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement (redo-MVR) at our institution. Forty-nine patients (24 males) underwent redo-MVR with either bioprosthetic (n = 24) or mechanical valves (n = 25) between January 2000 and 2010. Median age of patients was 63 years (range 21-80 years), and the mean additive EuroSCORE was 12 ± 4. Median time to re-operation was 8.2 ± 6.6 years for first time redo-MVR and 6.4 ± 5.6 years for second-time redo-MVR. Indications included prosthetic endocarditis (n = 22), para-prosthetic leak (n = 12), structural valve degeneration (n = 8), prosthetic valve thrombosis (n = 6) and malignancy (n = 1). The mean follow-up was 47.5 ± 37.0 months (range 0.1-112.3 months). In-hospital mortality was 12% (n = 6). Mean hospital stay was 17 ± 11 days (range 8-50 days). Actuarial survival at 1 and 5 years was 81 ± 5% and 72 ± 6%, respectively. Three patients required re-intervention: two for prosthetic valve endocarditis and one for para-prosthetic leak. Multivariate analysis showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P < 0.001) and urgent surgery (P = 0.03).

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.

Mitral valve repair for severe mitral regurgitation secondary to lone atrial fibrillation

OBJECTIVESnSignificant mitral regurgitation (MR) may arise from isolated annular dilatation secondary to lone atrial fibrillation (AF) and associated atrial remodelling. The aim of the present study is to assess the outcome of surgery for this condition.nnnMETHODSnBetween November 2007 and July 2011, 20 patients underwent mitral valve (MV) repair for severe MR secondary to AF. The median age of patients was 77.5 years (45-82 years) and the mean pre-operative duration of AF was 84.6 ± 92 months. The left ventricle was moderately (ejection fraction 30-50%; n = 6) or severely (<30%; n = 1) impaired in seven patients pre-operatively. Mean logistic EuroSCORE was 8.1 ± 5.9 and mean follow-up was 18.0 ± 12.5 months.nnnRESULTSnAll operations were elective. Concomitant anti-arrhythmic procedures (maze procedure, pulmonary vein isolation) or left atrial (LA) appendage amputation were performed in all patients; tricuspid valve repair was undertaken in 12 patients and coronary artery bypass grafting in 2 patients. Ring annuloplasty was performed in all patients. The median ring size was 30 mm (range 24-36 mm). On-table transoesophageal echocardiography post-repair showed mild residual MR in two patients and no MR in the remainder. There were no cases of systolic anterior motion. There was one re-exploration for bleeding. No patients required haemofiltration or suffered from stroke and deep sternal wound infections. There was no in-hospital mortality. At discharge mean left ventricular (LV) end-diastolic diameter was 4.8 ± 0.7 cm compared with 5.6 ± 0.7 cm pre-operatively (P < 0.005), while mean LV end-systolic diameter was 3.2 ± 0.8 cm when compared with 4.0 ± 0.7 cm pre-operatively (P < 0.005). The mean LA size was 5.2 ± 1.0 cm when compared with 6.1 ± 1.6 cm pre-operatively (P = 0.03). There was mild MR in two patients, but none in the rest. The mean MV area was 3.0 ± 0.7 cm(2). The mean systolic pulmonary artery pressure was 40.4 ± 15.5 mmHg when compared with 54.1 ± 12.2 mmHg pre-operatively (P = 0.02). Seventeen patients (85%) were in NYHA class I/II at latest follow-up (P < 0.0001 vs pre-operatively). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths.nnnCONCLUSIONSnMV annuloplasty for annular dilatation secondary to AF has a good mid-term outcome.

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)

Iatrogenic pseudoaneurysm of internal mammary artery: case report and literature review.

Abstractu2002 Pseudoaneurysms of the internal mammary artery (IMA) following median sternotomy are very uncommon and were first reported in 1973. Presentation and treatment of such a complication has been variable. We are presenting a case of a patient with pseudoaneurysm of IMA after mitral valve replacement. Selective embolization of the branches of right IMA was performed. Hematoma was evacuated after a week without any complication. Patient was reviewed in the clinic after 6 weeks and she was doing very well.

Initial experience of mitral valve repair using the Carpentier-Edwards Physio II annuloplasty ring

OBJECTIVEnThe Carpentier-Edwards (CE) Physio II ring is a new prosthetic ring designed to accommodate the changing pathology seen in the spectrum of degenerative valve disease, particularly the larger anterior leaflet in repair of the Barlow valve. The aim of our study was to assess the safety and efficacy of mitral valve (MV) repair with the CE Physio II ring.nnnMETHODSnBetween April 2009 and March 2010, 100 patients underwent MV repair using the Physio II ring. Median age of patients was 70 years (54-85 years). The left ventricle (LV) was moderately (30-50%; n=21) or severely (<30%; n=6) impaired in 27 patients preoperatively. Mitral regurgitation (MR) was due to degenerative disease in 87 patients (bileaflet prolapse: 34 patients). Mean logistic EuroSCORE was 10.07 ± 8.9 and mean follow-up was 6.3 ± 2.4 months.nnnRESULTSnSeventeen patients were non-elective (eight emergencies), five were re-do operations and 23 Maze ± pulmonary vein isolations, and 14 tricuspid annuloplasties were performed. Neo-chordae were inserted in 50 patients (50%), whereas sliding annuloplasty was performed only in three patients. The median ring size was 32 mm (range 26-40 mm). On-table trans-oesophageal echocardiography (TOE) showed trivial/no MR in 87 patients, and mild in 13 patients, and there were no cases of systolic anterior motion (SAM). There were two re-explorations for bleeding and two patients required haemofiltration. There were no strokes or deep sternal wound infections (DSWIs). There was one hospital death (1%). At discharge, mean left ventricular end-diastolic (LVEDD) was 4.8 ± 0.7 cm compared with 5.5 ± 0.8 cm preoperatively (p=0.03) and mean left ventricular end-systolic (LVESD) was 3.3 ± 0.5 cm as compared with 3.6 ± 0.8 preoperatively (p=0.4). There was no MR in 87 patients and mild MR in 13 patients. The mean mitral valve area (MVA) was 2.8 ± 0.7 cm(2). The mean systolic pulmonary artery pressure (SPAP) was 26.6 ± 7.3 mmHg as compared with 50.9 ± 17.2 mmHg preoperatively (p=0.02). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths.nnnCONCLUSIONSnMV repair with the Physio II ring has excellent short-term results, including subgroups with large anterior mitral valve leaflet (AMVL). Moreover, the dimensional ratios of the ring may allow it to be used for MV repair for degenerative MV disease, irrespective of anterior leaflet size.

Repair of acute type A aortic dissection: results in 100 patients.

To determine short- and long-term outcomes after repair of type A aortic dissection, we reviewed data of 100 consecutive patients (64 men; mean age, 63u2009±u200912.2 years) who underwent acute type A aortic dissection repair between January 2000 and June 2008. They were divided into group A, open anastomosis (circulatory arrest; nu2009=u200959) and group B, closed anastomosis (no circulatory arrest; nu2009=u200941). Aortic valve re-suspension or replacement was performed in 77 patients, aortic root replacement in 29, and aortic arch procedures in 31. The median follow-up was 2.8 years (range, 0–8.6 years). The 30-day mortality was 14%; 16.9% in group A and 9.8% in group B. None of the 23 variables analyzed to determine predictors of death or stroke was significant on multivariate analysis. Postoperatively, there was no difference between the 2 groups with respect to stroke, sepsis, renal failure, multiorgan failure, or reoperation. Overall actuarial survival at 1, 3, 5, and 8 years was not significantly different between the 2 groups. Considerable morbidity is still associated with repair of type A aortic dissection, despite a significant improvement in mortality.