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Importance: There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. Objective: To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. Design, Setting, and Participants: A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Main Outcomes and Measures: Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. Results: During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Conclusions and Relevance: Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.. more...

Background: The purpose of this study was to evaluate the single-center experience in initial femoral versus central cannulation of the extracorporeal circulation for acute aortic dissection type A (AADA). Methods: Between January 2003 and December 2015, 235 patients underwent repair of AADA. All patients were evaluated for the type of arterial cannulation (femoral vs . central) for initial bypass. Demographic data and outcome parameters were accessed. Results: One hundred and twenty seven (54.0%) were initially cannulated in the central aortic vessels (ascending aorta or subclavian/axillary artery) and 108 (46.0%) in the femoral artery. Patients were comparable between age (62.4±14.4 vs . 62.9±14.4 years, P=0.805), gender (male, 62.2 vs . 69.4%, P=0.152) and previous sternotomy (15.7 vs . 16.7%, P=0.861) between both cannulation groups; while EuroSCORE I (11.5±4.0 vs . 12.7±4.2, P=0.031) and ASA Score (3.5±0.81 vs . 3.8±0.57, P=0.011) were significantly higher in the femoral artery cannulation group. Bypass (249±102 vs . 240±81 min, P=0.474), X-clamp (166±85 vs . 157±67 min, P=0.418) and circulatory arrest time (51.6±28.7 vs . 48.3±21.7 min, P=0.365) were similar between the groups as were lowest temperature (18.1±2.0 vs . 18.1±2.2, P=0.775). Postoperative neurologic deficit and 30-day mortality were comparable between both cannulation groups (11.7 vs . 7.2%, P=0.449 and 20.2 vs . 16.9%, P=0.699, central vs . peripheral cannulation). Multivariate analysis revealed only EuroScore I above 13 as single preoperative predictor for mortality. Conclusions: AADA can be operated with both femoral and central cannulation with similar results. Risk for early mortality was driven by the preoperative clinical and hemodynamic status before operation rather than the cannulation technique. more...

OBJECTIVES: Since blood flow impairment by aortic valve prosthesis is characteristically dynamic, this dynamic component is best and thoroughly appreciated by exercise Doppler echocardiography. We sought to determine the haemodynamics of a new pericardial aortic bioprosthesis [Trifecta™-aortic valve bioprosthesis (T-AVB), St Jude Medical, MN, USA] at rest and during exercise and a 10-min recovery period in comparison with alternative aortic valve prostheses, e.g. Ross operation (RO), stentless aortic valve [Medtronic freestyle-aortic valve bioprosthesis (MF-AVB)] and a healthy control group (CO). METHODS: Haemodynamics at rest and during supine exercise stress testing and a 10-min recovery period were evaluated in 32 patients (mean age: 70.8±6.7 years) with T-AVB (mean follow-up: 5±2 months), 49 with RO (mean age: 43.5±13.7 years), 39 with an MF-AVB (mean age: 64.6±9.4 years) and 26 healthy patients (mean age: 39±9 years). Measurements included mean outflow tract gradient (δp mean, mmHg), effective orifice area index (EOAI, cm 2 /m 2 ) and valvular resistance (vR, dyn s cm −5 ). RESULTS: Mean body surface area for T-AVB was 1.93±0.24 m 2 (median 1.97 m 2 ). Mean δp mean at rest was 7.2±3.4 mmHg, mean EOAI 0.86±0.23 cm 2 /m 2 and mean vR 50.7±23.2 dyn s cm −5 . Supine stress testing did increase the mean EOAI to 0.98±0.27 cm 2 /m 2 ,t he mean vR to 62.6±25.3 dyn s cm −5 and the mean δp mean to 10.21±4.7 mmHg, respectively (P more...

Background: The Ross operation provides the advantage of growth potential of the pulmonary autograft in the aortic position. However, development of autograft dilatation and regurgitation may occur. We sought to assess the progression of autograft diameters and aortic regurgitation (AR) with regard to patient age at the time of the Ross operation. Methods: Autograft echo dimensions from 48 children Results: The mean z values of all patients showed a significant increase with follow-up time at the sinus (0.5 ± 0.1/year, P < .001) and the sinotubular junction (0.7 ± 0.2/year, P < .001) but not at the annulus (0.1 ± 0.1/year, P = .59). There was no significant difference in the z values of sinus and the sinotubular junction between younger and older children at implantation and with time. The initial annulus z value was significantly larger in younger children ( P < .0001), whereas the annual increase was significantly higher in older children ( P = .021). Age at operation has no impact on the initial AR grade ( P = .60). The AR tends to increase more quickly in older patients ( P = .040). Sinus and sinotubular junction dilate with time, regardless of patient age. Conclusions: Young children show larger initial annulus sizes than older children. However, annulus diameters tend to normalize in young children, whereas they increase in older children. Autograft regurgitation develops slowly, but significantly, and predominantly in older children. Stabilizing measures to prevent autograft root dilatation are warranted in adolescents, but they are not required in young children. more...

OBJECTIVES: The Ross operation in the setting of a bicuspid aortic valve (BAV) remains controversial. Using data from the German Ross Registry, we sought to investigate the effect of the presence of a BAV on autograft function and diameters over time after the Ross operation compared with the presence of a tricuspid aortic valve (TAV). METHODS: A total of 1277 patients (mean age 42.2 + or - 15.3 years) with intra-operatively documented aortic valve morphology during the Ross operation were analysed in the present study (sub-coronary technique, n=648, root replacement technique, n=629 patients). A BAV was present in 70.9% of patients. Clinical and echocardiographic follow-up was performed preoperatively and at pre-specified intervals (mean follow-up 5.7 + or - 3.8 years, 6806 patient-years). Hierarchical multilevel modelling techniques were used for the statistical analysis of serial measurements and comparisons among groups. RESULTS: Initial neo-aortic regurgitation was lower in the BAV group (0.52 vs 0.62 aortic insufficiency (AI) grades, p=0.008), whereas the annual increase of it did not differ among groups. In both surgical techniques, no significant development of neo-aortic regurgitation ( more...

Objective: The use of stentless bioprostheses for aortic valve replacement provides excellent haemodynamics; however, these valves bear the potential risk of progressive regurgitation over time. To overcome this disadvantage, a new generation of pericardial stentless prostheses has been developed. This study aims to assess the tolerance of such bioprotheses against progressive sinotubular junction dilatation. Methods: Five specimens of both the 3F Aortic and Sorin Solo stentless bioprotheses (diameter 25 mm) were investigated in a pulsatile flow simulator incorporating a device for gradual expansion of the sinotubular junction diameter. Closing characteristics were obtained by high-speed video imaging and the corresponding regurgitations were determined by ultrasonic flow measurements. The diameters DR, at which primary distinct regurgitation occurs, were correlated to the original diameters DA and expressed as percentage values. Results: The highest tolerance against sinotubular junction dilatation was found for the 3F Aortic (156 5%) compared to the Sorin Solo (145 6%, p = 0.0127) bioprothesis. Visualisation of the valves revealed strong leaflet folding at labelled diameter, similar in both valve types. Conclusions: New-generation pericardial stentless bioprotheses provide favourable adaptability to sinotubular junction dilatation, more pronounced for the 3F prosthesis. Whether undue leaflet folding caused by the redundant tissue influences long-term function remains to be established. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. more...

Background: For children who require aortic valve replacement, the pulmonary autograft may be the ideal substitute. However, re-operations for conduit exchange in the pulmonary position are inevitable. In addition, re-operations on the autograft may be necessary due to dilatation and neo-aortic insufficiency. We sought to assess predictors for re-intervention in an international Ross-operated paediatric population. Methods: Data of 152 children below 16 years of age at the time of the Ross operation were analysed using Cox proportional hazard modelling. Mean follow-up time was 6.1 +/- 4.2 years. Results: The median age at the time of the Ross operation was 10.1 years (range 54 days to 15 years). Early mortality was 2.6%. Survival at 5 and 10 years was 93.9 +/- 2.0% and 90.4 +/- 3.1%, respectively. Seven patients required autograft re-intervention (explantation n = 6 and reconstruction n = 1). Freedom from autograft re-intervention at 5 and 10 years was 99.3 +/- 0.7% and 95.5 +/- 2.7%, respectively. Prior endocarditis (p = 0.061), prior aortic regurgitation ( p = 0.061) and longer follow-up time (p = 0.036) emerged as risk factors for autograft re-intervention. Seventeen patients required 36 conduit re-interventions (replacement n = 16, percutaneous valvuloplasty n = 10). Freedom from conduit re-intervention at 5 and 10 years was 89.3 +/- 2.9% and 79.6 +/- 6.1%, respectively. Implantation of an aortic homograft (p = 0.013), and smaller conduit size (p = 0.074) emerged as risk factors for conduit re-intervention. Conclusions: There is a consistent need for conduit re-intervention following the Ross operation in children. Re-interventions on the autograft are rare within the first decade after surgery. However, the number of autograft re-interventions may increase after the first decade, since longer follow-up time is a risk factor for autograft failure. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. more...

Background. The Ross operation may be the ideal aortic valve replacement in pediatric patients. However, reoperations for replacement of the homograft in the pulmonary position are inevitable. This study determined influencing factors for the development of homograft stenosis and regurgitation in pediatric Ross patients. Methods. Follow-up echocardiograms of 116 children (86 boys) undergoing Ross operations at a mean age, 9.3 +/- 4.9 years were analyzed using hierarchic multilevel modeling. Mean duration of the echocardiographic follow- up was 5.3 +/- 4.2 years (609 patient-years, 398 examinations). Results. Median homograft diameter z value was 0.3 (range -2.2 to +7.3). Mean homograft pressure gradient at implantation was 5.0 mm Hg with a significant increase of 4.2 mm Hg/y (p < 0.001) within the first 2 years and a steady state thereafter. Older donor age was significantly associated with lower mean pressure gradient at implantation (p = 0.037). Larger z value had no significant influence on the annual increase of pressure gradient (p = 0.87). Mean grade of regurgitation at implantation was 0.9, without significant annual increase (0.02 grade/y, (p = = 0.32). Older recipient (p = 0.005) and donor age (p < 0.0001) were significantly associated with lower mean regurgitation at implantation. Larger z value was associated with a higher annual increase of regurgitation (p = 0.014). Conclusions. Relevant midterm homograft regurgitation is rare in children after the Ross operation. However, a significant annual increase occurs in the pressure gradient that cannot be influenced by larger graft size. Homograft oversizing may lead to a higher annual increase of regurgitation. (Ann Thorac Surg 2009; 88: 609-15) (C) 2009 by The Society of Thoracic Surgeons more...

BackgroundAcute aortic dissection (AAD) is a life-threatening condition with high mortality and a relatively unclarified pathophysiological mechanism. Although differentially expressed genes in AAD have been recognized, interactions between these genes remain poorly defined. This study was conducted to gain a better understanding of the molecular mechanisms underlying AAD and to support the future development of a clinical test for monitoring patients at high risk.Materials and MethodsAortic tissue was collected from 19 patients with AAD (mean age 61.7 ± 13.1 years), and from eight other patients (mean age 32.9 ± 12.2 years) who carried the mutated gene for Marfan syndrome (MS). Six patients (mean age 56.7 ± 12.3 years) served as the control group. The PIQOR™ Immunology microarray with 1076 probes in quadruplicates was utilized; the differentially expressed genes were analysed in a MedScan search using PathwayAssist software. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and protein analysis were performed.ResultsInteractions of MS fibrillin-1 (FBN1) in the MedScan pathway analysis showed four genes, fibulin-1 (FBLN1), fibulin-2 (FBLN2), decorin (DCN) and microfibrillar associated protein 5 (MFAP5), which were differentially expressed in all tissue from AAD. The validation of these genes by qRT-PCR revealed a minimum of three-fold downregulation of FBLN1 (0.5 ± 0.4 vs. 6.1 ± 2.3 fold, p = 0.003) and of DCN (2.5 ± 1.0 vs. 8.5 ± 4.7 fold, p = 0.04) in AAD compared to MS and control samples.ConclusionsDownregulation of fibrillin-1 (FBN1) may weaken extracellular components in the aorta and/or interfer with the transmission of cellular signals and eventually cause AAD. Additional research on these four identified genes can be a starting point to develop a diagnostic tool. more...

Background The Ross procedure has gained increasing interest as an attractive alternative to a prosthetic aortic valve substitute within the last decade. Because of a probably better resistance to infection as one of its advantages, the pulmonary autograft is theoretically preferable for active endocarditis. Methods Between June 1994 and July 2003, the Ross procedure was performed using the subcoronary and inclusion technique in 296 patients (231 male, 65 female). Twenty patients had an active endocarditis of the aortic valve at the time of operation. A bicuspid valve was present in 10 patients. One patient had previous aortic valve surgery. Clinical and echocardiographic follow-up was complete. Results Early mortality was 1, late mortality was 0. There were no recurrence of endocarditis and no neurologic events during the mean follow-up of 47.3 ± 28.6 months. All patients were in New York Heart Association class I. Mean and maximum pressure gradient across the autograft was 3.5 ± 2.0 and 6.5 ± 3.4, respectively, with no autograft insufficiency in 15, 1+ in 4. Comparing postoperative with the last investigations, there were no significant changes of pressure gradients or grade of regurgitation. Mean and maximum homograft pressure gradients were 7.9 ± 3.7 and 16.2 ± 8.1 mm Hg, respectively, at last investigation; most patients had no or mild homograft regurgitation (0+, n=13; 1+, n=5; 2+, n=1). Conclusions Native valve endocarditis can be treated with excellent results using the Ross procedure with the subcoronary and inclusion technique, with low mortality and morbidity rates and a very low recurrence rate of endocarditis. more...

ObjectiveThe Ross procedure has gained increasing interest as an attractive alternative for aortic valve replacement. Despite its advantages, there is a certain risk of structural valve deterioration, especially of the pulmonary homograft as a result of shrinkage and subsequent stenosis predominantly at the muscular annulus. Theoretically, reduction of homograft muscle tissue could reduce this risk.MethodsFrom February 1996 through December 2002, a total of 238 patients (mean age 44 ± 13.2 years) underwent the Ross procedure with the subcoronary technique with follow-up investigations before discharge and after 12 and 24 months. To estimate the importance of homograft muscle reduction within our institution-specific risk factor scale for change of transhomograft pressure gradient with time, we performed a generalized estimating equation approach, which identified homograft muscle reduction, higher body surface area in male patients, younger patient age, smaller homograft diameter, blood transfusions, and follow-up time as independent risk factors demonstrating a high β value (−2.8638) for muscle reduction. To find out whether muscle reduction influences transhomograft pressure gradient, we compared patients with (group A, n = 39) and without (group B, n = 199) muscle reduction. The other mentioned independent risk factors were not different between groups, except for blood transfusions (group A greater than B, P < .01), indicating a negative bias for group A.ResultsThe maximum pressure gradient across the homograft was lower in patients with muscle reduction before discharge (4.5 ± 2.8 mm Hg group A vs 6.2 ± 3.8 mm Hg group B, P = .004) and after 1 (9.3 ± 5.8 vs 13.1 ± 8.4 mm Hg, P = .028) and 2 years (10.8 ± 7.6 vs 13.7 ± 7.5 mm Hg, P = .013). No significant differences were found concerning homograft insufficiency.ConclusionsWe provide some evidence that transhomograft pressure gradient can be reduced significantly within the first 2 years after operation by homograft muscle reduction. Longer term follow-up is necessary to evaluate this promising operative technique further. more...

Atrial fibrillation (AF) is associated with increased risks of stroke, cardiac failure, and mortality. The underlying mechanisms and pathology of AF remain elusive. The aim of this study is to proteomically analyze the left atrial appendage tissue obtained from patients suffering from subtypes (paroxysmal, persistent, and long-standing persistent) AF. MALDI Imaging mass spectrometry (MALDI-IMS) was applied to differentiate in classification of pathophysiological AF subtypes, through the direct (in situ) analysis of formalin-fixed paraffin embedded (FFPE) left atrial appendage (LAA) tissue. FFPE LAA tissue were collected from patients with predisposed paroxysmal (n = 9, mean age 69.0±3.1 years), persistent (n = 18, mean age 67.0±2.7 years), and long-standing persistent AF (n = 19, mean age 71.0±2.0 years). Sections were dewaxed and thereupon soused by trypsin solutions using an automated spraying device. Spectra were acquired at a mass range of m/z 800-3500Da and lateral resolution of 80 μm. Two hundred laser shots were acquired per pixel and random walk of 50/position. Data analyses were performed using SCiLS Lab software. Component analysis of MALDI Imaging data through probabilistic latent semantic analysis results in a clear discrimination in the first 3 components of atrial fibrillation. Employing receiver operating characteristic analysis (AUC > 0.7), characteristic intensity distribution in given m/z values, which are discriminative for the considered cluster, was determined to distinguish between paroxysmal vs. persistent AF, and persistent vs. long-persistent AF, m/z values were determined between persistent vs long-persistent AF (1.59±0.12 vs 6.85±3.02, p = 0.02). Follow-up of neurological events in case-controlled assessment presented 13±12% in paroxysmal, 56±12% in persistent and 42±12% long-persistent AF. The tissue-based proteomic approach provides clinically relevant beneficial information in improving risk stratification for AF patients. In the future, this obtained information might be considered new biomarker to support the diagnosis of the severity of AF status. They also suggest a new criterion to determine the most appropriate procedure for each AF subtype to improve postoperative outcomes. more...

Transannular patching is often performed to relieve congenital pulmonary stenosis, especially in tetralogy of Fallot. Theoretically, a monocusp patch can reduce patch-related pulmonary regurgitation, but the optimal size relation between the implant and the native hypoplastic pulmonary root is not well defined.In 11 pigs, peak pressure gradient and regurgitation fraction across the pulmonary root were measured. During cardiopulmonary bypass, two cusps including the pulmonary artery wall were resected and the midpoint of the free margin of the remaining cusp was sutured to the sinus wall to imitate a hypoplastic pulmonary root. Transannular patching was performed using a noncoronary segment of a porcine aortic root. After discontinuation of cardiopulmonary bypass, all measurements were repeated. Thereafter, the cusp of the patch was resected, and all measurements again repeated. Anatomic dimensions were determined after the pigs had been sacrificed.Regurgitation fraction increased from 0.2% +/- 3.4% at baseline to 15.5% +/- 6.2% after reconstruction with a monocusp patch and to 60.0 +/- 18.6% after the cusp of the monocusp patch had been resected (p0.001). The median peak pressure gradient increased from 0 to 1 to 6 mm Hg (p = 0.013), respectively. The regurgitation fraction negatively correlated with the ratio of the length of the monocusp patch to that of the hypoplastic pulmonary root (r = -0.63, p = 0.037).A monocusp patch for reconstruction of a hypoplastic pulmonary root results in significantly less regurgitation than a nonvalved patch of the same size, while the peak pressure gradient remains normal. The lowest regurgitation fraction was observed with a monocusp patch two-times the length of the circumference of the hypoplastic pulmonary root. more...

Background: Increased cardiac troponins in blood are observed after virtually every open heart surgery, indicating perioperative myocardial cell injury. We sought to determine the optimum time point for blood sampling and the respective cutoff value of cardiac troponin T (cTnT) for risk assessment in patients undergoing cardiac surgery. Methods: In a series of 204 patients undergoing scheduled open heart surgery, mainly for coronary artery bypass grafting (n = 132) or valve repair (n = 27), cTnT concentrations were measured before and 4 and 8 h after cross-clamping and then daily for 7 days. Individual risk was assessed by use of the Cleveland Clinic Foundation Risk score and intraoperative risk indicators such as duration of cardiopulmonary bypass, cross-clamping, and perioperative release of cardiac markers. Patients were followed for 28 months. Results: Cardiac mortality, all-cause mortality rates, and rates of nonfatal acute myocardial infarction (AMI) at 28 months were 6.9%, 8.8%, and 6.8%, respectively. cTnT was higher in patients with Q-wave AMI or postoperative heart failure requiring inotropic support, and in nonsurvivors. The ROC curve revealed a cTnT ≥0.46 μg/L at 48 h as the optimum discriminator for long-term cardiac mortality. Stepwise logistic regression identified higher Cleveland Clinic Risk Score [odds ratio (OR) = 2.6 per point], cross-clamp time >65 min (OR = 6.6), and cTnT (OR = 4.9) as significant and independent predictors of long-term cardiac mortality. Conclusions: A single postoperative cTnT measurement can be used to estimate myocardial cell injury that impacts long-term survival after open heart surgery. It adds independently to established risk indicators. more...

The pathologic modifications characterizing vein graft disease resemble those observed in native arteriosclerosis, but in accelerated form. Although both disorders are considered to be inflammatory diseases, it remains to be determined whether diseased vein grafts and atherosclerotic coronary arteries differentially express inflammatory mediators. Therefore, we examined whether differences in the expression of proinflammatory cytokines by these two distinct vascular pathologies favor the accelerated inflammation within diseased vein grafts.The messengerRNA expression of various cytokines (interleukin-1 beta [IL-1 beta], IL-6, IL-8, tumor necrosis factor-alpha [TNF-alpha], interferon-gamma [IFN-gamma]) was quantified using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) in tissue samples of native saphenous veins (NSV, n = 5), diseased coronary arteries (CAD, n = 25), and diseased vein grafts (VG, n = 13).Native saphenous veins did not contain any detectable transcripts except for IFN-gamma. As expected, CAD was characterized by the expression of IL-1 beta, IL-6, IL-8, IFN-gamma, and TNF-alpha mRNA. Interestingly VG also expressed these mediators, but at markedly higher levels. Quantification by RT-PCR revealed that, compared with specimens from the CAD group, VG specimens contained 5.8 +/- 1.2 times, 286 +/- 22 times, and 29 +/- 7.3 times as many transcripts for the cytokines IL-1 beta, IL-6 and TNF-alpha, respectively, as well as 25 +/- 8.3 times more transcripts for the chemokine IL-8. In contrast, the expression of IFN-gamma transcripts did not differ among the groups.The elevated expression of proinflammatory cytokine transcripts supports the hypothesis that diseased vein grafts, compared with atherosclerotic coronary arteries, are characterized by enhanced inflammatory activity that might accelerate atherosclerotic modifications. This may implicate new therapeutic strategies for the prevention of vein graft disease. more...

Background Aortic valve-sparing operations for acute type A dissection are appealing and innovative but less well defined surgical techniques requiring further evaluation. Methods We reviewed all consecutive patients with acute type A dissection who underwent either the remodeling (group 1, n=21) or the reimplantation valve-sparing technique (group 2, n=15) since October 1994. Patients were followed up clinically and echocardiographically for as long as 41.3 months (group 1) and 87 months (group 2). Results Hospital mortality was 19% (n = 4) for group 1 and 20% (n = 3) for group 2. Permanent new neurologic symptomatology occurred in 1 patient (3.6%). Three patients in group 1 required reoperation owing to redissection. No patient had an aortic insufficiency of more than grade 1. No late neurologic or thrombembolic events occurred. There was no statistically significant difference between both groups with respect to clinical and hemodynamic data. Conclusions Remodeling and reimplantation aortic valve-preserving operations in acute type A dissection can be performed with adequate perioperative risk and excellent midterm aortic valve function. We found no evidence of one technique being superior to the other, however durability of the remodeling technique needs critical consideration especially in Marfan syndrome and when glue is used. more...

Objective: The value of prophylactic brachytherapy on vein graft disease is unknown. Methods and results: Vein bypass grafts in 23 hypercholesterolemic pigs after ex vivo gamma irradiation of the vein grafts (10, 20, and 40 Gy) and 16 control veins were analyzed regarding: (1) expression of platelet-derived growth factor (PDGF-AA and -BB, ELISA); (2) smooth muscle cell (SMC) proliferation/cell death (double-immunohistochemistry Mib-1/TUNEL/SMC a-actin); and (3) vessel wall dimensions. Planimetric data on vessel wall dimensions revealed no positive effect of gamma radiation on neointima formation and inner lumen diameter. On the contrary, vein grafts subjected to 40 Gy were significantly more likely to be occluded and to have reduced inner lumen and increased neointima formation. Radiation therapy had no effect on PDGF expression and SMC proliferation/cell death. The mean inner lumen diameter decreased as PDGF-AA expression increased. Conclusions: Prophylactic gamma radiation of unaffected vein grafts failed to prevent vein graft disease in a hypercholesterolemic porcine model. High-dose radiation (40 Gy) resulted in more frequent graft occlusion and vein sclerosis. q 2003 Elsevier Science B.V. All rights reserved. more...

Background — As shown previously in goats, clenbuterol increased the power of electrically conditioned skeletal muscle ventricles (SMVs) of clinically relevant size (150 mL), which were constructed around a mock system. They pumped against a pressure of 60 to 70 mm Hg immediately during surgery and up to several months after, finally at >1 L/min. SMVs without clenbuterol administration failed. Thus, we expected that clenbuterol-supported SMVs might become integrated into the circulation by a 1-step operation instead of the 2-step procedure required up to now. Methods and Results — In adult Boer goats (n=5), latissimus dorsi muscle was wrapped around a polyurethane chamber of 150 mL that was connected to the descending aorta. This muscular flow-through pumping chamber containing a stabilizing inner layer (called a biomechanical heart [BMH]) was formed and immediately made to work against a systemic load with the support of clenbuterol (5×150 μg/wk). During surgery, the mean stroke volume of BMHs was 53.8±22.4 mL. One month after surgery, in peripheral arterial pressure, the mean diastolic (P MD ) and minimal diastolic (P min ) pressures of BMH-supported heart cycles differed significantly from unsupported ones (P MD =+2.9±1.1 mm Hg [ P min =−2.4±0.9 mm Hg [ P max , increased by 20.5±8.1% ( P Conclusions — Under support of clenbuterol, BMHs of a clinically relevant size can be trained effectively in the systemic circulation after a 1-step operation and offer the prospect of a sufficient volume shift and probably unloading of the left ventricle. more...

Objective: During extracorporeal circulation design and orientation of aortic cannulae tips mainly determine flow pattern in the aortic arch and arch vessels which is the objective of this in vitro study, comparing single versus multiple stream cannulae. Methods: In an aortic arch glass model, jet streams of 21‐24 French aortic cannulae which were inserted in the ascending aorta were directed alternatively at the different arch vessels. Flows and pressures in the arch vessels were measured at pump flows of 3‐6 l/min. Results: With optimal orientation of the jet stream in the aortic arch, no preferential flow in the arch vessels was seen. In the single jet stream aortic cannulae group a significant parallel increase in flow and pressure in the jet streamed arch vessels compared to the non-jet streamed arch vessels occurred (P , 0.05). With the jet stream directed on vessel 2 (left carotid vessel) there was a significant pressure and flow difference comparing the two non-jet streamed vessels with each other (P , 0.03). In the single stream 24 French cannulae the highest vessel pressure of 168 mmHg and an increase in flow of 186 ml/min was measured in the jet streamed left carotid artery at 6 l/min pump flow. The multiple stream cannulae provoked the highest vessel pressure of 106 mmHg in the corresponding jet streamed vessel and an increase in flow of 20 ml/min. Conclusion: Tip design of aortic cannulae and the orientation of its jet stream are potential sources of remarkable imbalance of arch vessel perfusion especially with single jet stream cannulae. These effects are more pronounced with single jet stream cannulae. These results may have important clinical implications regarding perfusion of arch vessels during extracorporeal circulation. © 1999 Elsevier Science B.V. All rights reserved. more...

Objective: The clinical benefit in terms of angina reduction after transmyocardial laser revascularization (TMLR) in patients with diffuse coronary artery disease who are not candidates for conventional procedures has been proved. The exact mechanisms of TMLR however, are still unknown. The aim of this study was to investigate the cellular changes in relation to intramyocardial partial oxygen pressure (ptiO2) after TMLR in a model of acute ischemia in pigs by electron microscopical methods (TEM). Methods: Seven pigs were included in this study (five animals with acute myocardial ischemia and additional TMLR and two animals with acute myocardial ischemia and without TMLR for control). Acute ischemia was induced by ligation of diagonal branches of the left anterior descending artery (LAD). Intramyocardial partial oxygen pressure was measured before induction of ischemia and thereafter continuously for up t o6hi n allanimals. Biopsies of all animals were taken before induction of ischemia and thereafter at 30 min, 3 and 6 h. Analysis of the myocardial ultrastructure was focused on mitochondria, cell nucleus, T-tubules and myofibrils. Results: Ultrastructural changes were seen in all animals. At 6 h after induction of ischemia, mitochondria showed a destruction of the internal as well as the external membrane and of the cristae. The nuclei showed margination of the chromatin. Myofibrils were characterized by ruptures in the Z-stripes. Lipid droplets as an indicator of ischemia could be identified. PtiO2 between 40 and 80 mmHg before intervention decreased down to 0‐2 mmHg within the first 9 min after diagonal branch ligation and did not increase even after TMLR. Conclusions: In this acute ischemic model using pigs, TEM evaluation following TMLR proves irreversible changes of the myocardial ultrastructure. Furthermore, TMLR was not able to increase ischemically induced decrease of ptiO2. These data provide some evidence that TMLR thus, may not be able to ameliorate acute ischemia at least in the pig model. Further investigations are needed to investigate the effect of TMLR in chronic myocardial ischemia. © 1997 Elsevier Science B.V. All rights reserved. more...

MicroRNAs (miRNAs) are critical regulators of most major cellular processes and seem to play a vital role in the pathogenesis of numerous diseases including atrial fibrillation, the most commonly encountered cardiac rhythm disorder. Among the several miRNAs that appear to be involved in pathogenesis of atrial fibrillation, miRNA 208a is linked to fibrosis and proper cardiac conduction. We quantified the expression levels of miRNA 208a in left atrial appendage tissue of patients with paroxysmal (n=2), persistent (n=10), and long-standing persistent (n=7) arrhythmia using quantitative PCR. In paroxysmal atrial fibrillation, miRNA 208a was expressed moderately, whereas the expression was enhanced in persistent atrial fibrillation and significantly reduced in long-standing persistent atrial fibrillation. The difference between persistent and long-standing persistent atrial fibrillation was significant at p=0.02. The findings from our study suggest a decline in miRNA 208a expression with ongoing arrhythmia, possibly preceded by a rise in expression from paroxysmal to persistent atrial fibrillation or even long-standing persistent. The significant changes in miRNA 208a expression over the course of the disease may be used as an additional diagnostic tool to monitor the progression of atrial fibrillation. more...

Objective: To assess the impact of a dynamic cardiomyoplasty on failing hearts, it is essential to estimate the contraction force of the skeletal muscle and how its contraction is synchronized with the heart cycle. Methods: In a 6-month study a small fluid-filled, balloon-mounted catheter was placed between the myocardium and the muscular wrap in five adult female Boor goats and two female domestic pigs. The catheter was connected to a subcutaneous measuring chamber whereby pressure monitoring could be accomplished. Distinct pressure signals as a result of function of the dynamic cardiomyoplasty and the heart were detected initially in all animals. Results: Maximal relative pressure from the dynamic cardiomyoplasty was calculated as 336.2% ± 69.4% on day 24 ± 6.1 ( n = 7) and end-stage pressure as 59.8% ± 9.7% on day 174.6 ± 13.1 ( n = 4). A functional loss of pressure signals from the dynamic cardiomyoplasty was correlated to severe histologic muscle damage ( n = 3). Pressure signals transferred from the contracting myocardium to the catheter showed defined segments of contraction, ejection, and filling periods, allowing a mechanical synchronization of the dynamic cardiomyoplasty to the heart cycle. Conclusions: This monitoring catheter enabled the assessment of the functional state of the dynamic cardiomyoplasty and allowed a synchronization to the heart cycle. It will promote understanding and might help to avoid muscle damage in dynamic cardiomyoplasty for an improved outcome of the surgical treatment of end-stage heart failure. (J Thorac Cardiovasc Surg 1997;114:1097-106) more...

doi:10.1016/j.jtcvs.2004.06.014 See related article on page 562. R eduction ascending aortoplasty (RAA) is alive, but the real question is whether it should be. Dr Robicsek and colleagues deserve a lot of credit for renewing the discussion on the appropriate treatment of ascending aortic dilatation–aneurysm. To evaluate RAA’s inevitably requires examining the problem of decision making. This is influenced by many factors used to balance the risk and benefit of nonsurgical versus surgical treatment. The risk of the nonsurgical natural course is predominantly determined by the development of aneurysm, as well as by morbidity and mortality caused by dissection and rupture. The main actors of these events are the wall tension, as calculated by Laplace’s law, including pressure, size, and wall thickness, and, furthermore, wall pathology (genetic collagen disorders, chronic dissection, sex, aging, degeneration, and arteriosclerosis), hemodynamic load caused by aortic valve pathology, concomitant aortic valve replacement, and the growth rate of the dilatation. The benefit of the nonsurgical natural course is that those who would never experience the above detrimental events would experience neither its related morbidity and mortality nor the risks of surgical intervention. The risks of surgical intervention are well known, and the benefits are associated with the type of intervention; they are, briefly, total eradication of diseased tissue with a tube graft, reduction of size by RAA, and external reinforcement by wrapping. In addition to all these parameters, life expectancy and individual experience of the surgeon contribute to decision making. Not all of these factors are equally important or easily quantified, but the size of the ascending aorta together with aortic wall morphology are the most important and currently used determinants. The size of the ascending aorta depends on, among other factors, body surface area (BSA) and, more significantly, age. There is now general agreement that intervention for ascending aortic aneurysm is indicated in adults at a diameter of greater than 5.5 cm for degenerative aneurysms. For patients with Marfan disease and familial ascending aortic aneurysms, the indication is given even for smaller diameters of between 4.5 and 5 cm, especially if size progression is observed. For these large diameters and the special entities, there seems to be no rationale for the RAA because too much diseased tissue is left in place, with an uncertain risk of late complications. A prosthetic tube graft either placed supracommissural or inclusive of the aortic root and, if necessary, extending into the aortic arch is the procedure of choice. The tube graft is relatively simple to sew into place, with 2 circumferential suture lines and relatively low long-term risks, including thromboembolism, false aneurysm at the suture lines, infection, and increased wall stress in the aortic root, possibly promoting the development of aneurysms. The abovementioned size thresholds, however, are rather crude, without any adjustment for patient conditions. Evolving knowledge on the natural course, especially in patients with Marfan disease, and a growth rate of 0.07 cm per year for degenerative dilatation indicate that there is still a risk for typical complications if smaller dilatations are left 5 untreated. Together with refined and safer operative techniques and increased more...

Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, with an estimated incidence of 1%–2% in the general population. Patients with BAV are predisposed to early and frequent stenosis, regurgitation, and endocarditis, often accompanied by aneurysm and dissection. A family-based genome-wide analysis found that BAV was linked to chromosomal regions 5q, 13q, and 18q, with autosomal dominant inheritance, reduced penetrance and a non-Mendelian inheritance pattern. Mutations in the transmembrane receptor-encoding gene NOTCH1 have been detected in familial and sporadic BAV cases. Mutations in the vascular smooth muscle cell alpha actin gene (ACTA2) have also been identified in BAV patients. Expression of UFD1L, a gene that is highly expressed in the outflow tract during embryogenesis, was downregulated in the cusps of BAV patients compared with those of controls. BAV is associated with left ventricular outflow tract abnormality, including aortic coarctation, arch hypoplasia, and supravalvular and mitral valve stenosis. A male predominance of more than 3:1 has been reported for BAV. This anomaly is very frequent in X0 Turner’s syndrome. Many studies have observed similarities between the histology of aortic aneurysmal tissue in the connective tissue disorder Marfan syndrome (MFS) and the histology of the corresponding tissue in BAV. In this lecture, we review our present understanding of BAV malformation and ascending thoracic aortic aneurysm pathogenesis. We discuss the genetic basis and the basic pathology underlying BAV and aortopathy and compare these with known mechanisms underlying MFS. more...

Aims. Dysregulated expression of the endothelial nitric oxide synthase (eNOS) is observed in aortic aneurysms associated with bicuspid aortic valve (BAV). We determined eNOS protein levels in various areas in ascending aortic aneurysms.Methods and Results. Aneurysmal specimens were collected from 19 patients, 14 with BAV and 5 with tricuspid aortic valve (TAV). ENOS protein levels were measured in the outer curve (convexity), the opposite side (concavity), the distal and above the sinotubular junction (proximal) aneurysm. Cultured aortic cells were treated with NO synthesis inhibitor L-NAME and the amounts of 35 apoptosis-related proteins were determined. In patients with BAV, eNOS levels were significantly lower in the proximal aorta than in the concavity and distal aorta. ENOS protein levels were also lower in the convexity than in the concavity. While the convexity and distal aorta showed similar eNOS protein levels in BAV and TAV patients, levels were higher in TAV proximal aorta. Inhibition of NO synthesis in aneurysmal aortic cells by L-NAME led to a cytosolic increase in the levels of mitochondrial serine protease HTRA2/Omi.Conclusion. ENOS protein levels were varied at different areas of the aneurysmal aorta. The dysregulation of nitric oxide can lead to an increase in proapoptotic HTRA2/Omi. more...

The anatomy and physiology of the aortic valve is ingenious, complex and greatly unknown, particularly its relationship to the left ventricular outflow tract and the ascending aorta. Sophisticated studies have shown that all parts of the aortic valve and the adjacent anatomic structures play together in a finely tuned concert during the cardiac cycle [1], allowing for optimal performance in every aspect, e.g. stress reduction of cusps, adaptation to varying flow conditions, optimizing function of the circulation and also the left ventricle. Theoretically, repair of the regurgitant aortic valve offers the advantage of preserving autologous, orthotopic living tissue, ideal for long-term function, especially when the pathological process is functional in origin and less tissue-related. However, a repaired valve remains a repaired valve. We cannot yet achieve the conditions of a normal valve concerning the function and durability that must be known by the surgeon and the patients. Nevertheless, results in specialized centres are promising for the first postoperative decade [2], but widespread acceptance of aortic valve repair is reserved. One of the reasons is the low level of standardization of repair procedures, particularly when an enlarged annulus is involved in the disease. This again starts with the problem of the terminology of the annulus [3] and the question ‘when is an annulus enlarged in relation to the geometry of the cusps?’, a relationship that is seldom normal and quite different in the different aortic valve pathologies. Rankin et al .[ 4] present, in this issue, a possible solution to this problem, namely the implantation of an aortic annuloplasty ring showing excellent results in animals with normal cusp geometry. This annuloplasty ring has an elliptical base geometry and subcommissural posts, giving a crown-shaped appearance. The design is based on the normal human aortic valve and intends to reconstruct the whole aortic valve functional unit [5] from base to commissures. The similarity of the shape of this aortic annuloplasty ring to the normal valve implies that ideally the cusps of the valve to be repaired should also have normal geometry, which is not always the case. In bicuspid aortic valves, commissures are either absent or underdeveloped [6], and the annulus is often asymmetrically dilated and deeper at the aorto-mitral junction, rendering the adaptation of this annuloplasty ring to the bicuspid valve configuration not ideal. Also, the often significantly elongated commissure between the right and non-coronary sinus in Marfan patients may present a difficult anatomic situation for this type of ring. Functional aortic valve insufficiency due to root dilatation, which is one possible indication for that ring, is nowadays repaired by valve-sparing procedures with excellent results, including the advantage of resecting the aneurysmal sinus tissue and allowing for adaptation to valve asymmetry [7]. Of concern is the fact that the coronet-shaped annuloplasty ring may come into cyclic contact with the cusps potentially causing abrasion of cusp tissue especially at the commissures with a long-term risk of cusp deterioration. This problem seems to be avoided by a special implantation technique, as studied in very short-term, 2-month animal trials [4]. Applied to the mitral situation a flat annuloplasty ring remodelling the annulus at the base only may be an alternative to bring together the three sinuses and the corresponding more...

In 2004, a 68-year-old man received aortocoronary bypass surgery and a 23-mm Hancock porcine bioprosthesis (Medtronic, Minneapolis, Minnesota). Six years later, in January 2011, cardiac re-evaluation was performed due to progressive dyspnea. Invasive angiography showed open bypass grafts and severe more...

Glutaraldehyd-fixed heart valve prostheses with long durability and function are desirable as a treatment option of heart valve disease. They do not require chronic anticoagulation therapy, however break down quickly in young patients ( 15 years in patients older than 70 years. It is generally accepted that the break down of bioprosthetic heart valves is due to calcification occurring because of immunologic and chemical processes. Thus, new nanotechnological methods in combination with chemical and biochemical procedures concerning detoxification and titanization of glutardialdehydefixed collagen scaffolds are applied on glutardialdehyde fixed pericardial samples. Nanotechnology with titanium using a plasma application under high alternating current, developed elsewhere (GfE Nurnberg, Germany, patent number EP 0 897 997 A1) might decrease the immune response caused by coating and improve endothelialization by detoxification and the biocompatibility of titanium. A plasma-activated surface of collagen allows a titanization under room temperature described later on. Immune response with secondary dystrophic calcification may be why glutaraldehyde fixed xenograft valves fail, especially in young patients. Hypothesis is, detoxification and titanization may reduce immunologic reactions and enable an endothelialization. more...

For more than 95% of the patients with end-stage heart failure there is no definitive treatment option up to now (AHA, 2009). This fact is caused by a severe shortage in donor hearts on the one hand and on the other hand by technical and economic limitations of cardiac assist devices and artificial hearts. Thus there is a big need for alternative treatement options. Basically heart failure is due to the inability of adult cardiomyocytes to divide and repair damaged heart muscle. For myocardial regenerative medicine stem cells which show the ability to differentiate into functional cardiomyocytes might be a promising source. Although human embryonic stem cells can differentiate into beating cardiomyocytes (Xu et al, 2002), however the therapeutic use of these cells is not without legal and ethical problems. Previous studies in animal models have demonstrated the therapeutical potential of intramyocardial injection of adult murine stem cells. In a cell-cell contact dependent manner in mammals, mesenchymal stem cells aquired a cardiomyocyte phenotype (OrlicK Choi et. al., 2004). But up to now neither in animals nor in humans cardiomyocytes were generated from pancreatic stem cells. Due to the clinical need of cardiomyocytes, we investigated the differentiation of human pancreatic stem cell cultures more...

The high mobility group AT-hook 2 (HMGA2) gene is proposed to regulate the genes involved in the epithelial-mesenchymal transition (EMT). One form of EMT is endothelial-mesenchymal transition (EndMT). We analyzed the expression profile of the HMGA2 gene in different human aortic diseases. Aortic specimens were collected from 51 patients, including 19 with acute aortic dissection, 26 with aortic aneurysm, two with Marfan syndrome and four aortic valves. Quantitative real-time polymerase chain reaction was carried out for HMGA2 and immunohistochemical analyses were performed for HMGA2, SNAI1, Vimentin, CD34, MKI-67 and TGFB1. The expression of let-7d microRNA, which is assumed to play a role in the regulation of HMGA2, was also quantified. The level of HMGA2 gene expression was significantly higher in acute aortic dissection compared with all the other samples (193.1 vs. 8.1 fold normalized to calibrator, P0.001). The immunohistochemical investigation showed that HMGA2, SNAI1, and Vimentin proteins were mainly detected in the endothelial cells of the vasa vasorum. The HMGA2 gene is upregulated in acute aortic dissection. This is the first report describing a link between HMGA2 and acute aortic dissection. The HMGA2, SNAI1 and Vimentin proteins were mainly detected in the endothelium of the vasa vasorum. It seems that HMGA2 overexpression in acute aortic dissection occurs in a let-7d-independent manner and is associated with EndMT of the vasa vasorum. more...

The bicuspid aortic valve (BAV), the most common congenital cardiac malformation, is associated with ascending thoracic aneurysms and appears to reflect a common developmental defect. (Hahn et al., 1992; Roberts, 1970) The average time of patients with BAV undergoing surgery (of the aortic valve and/or because of complications associated with it) is a decade earlier than patients with a normally developed aortic valve. Accordingly, it is contended that if a diseased BAV must be replaced because of a diseased BAV, the aneurysmal ascending aorta should also be replaced. Valve replacement surgery without replacing the aorta would simplify the surgical intervention and shorten the time of operation. In contrast, an enlarged ascending aorta represents an increased likelihood of the patient undergoing the same surgical procedure after a few years. Replacing the aortic valve in patients with BAV does not prevent the progressive dilation of the aortic root and ascending aorta. (Yasuda et al., 2003) Cellular and extracellular processes are involved in the pathogenesis of the ascending aortic aneurysms in patients with BAV. (Bonderman et al., 1999; Mohamed et al., 2010; Nataatmadja et al., 2003; Tang et al., 2005) Many studies have demonstrated the abnormalities of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in aneurysmal tissues. (Boyum et al., 2004; Koullias et al., 2004; Longo et al., 2002) Using tissue microarray techniques, Koullias et al. detected a significantly higher MMP-2 and MMP-9 levels in BAV compared with normal tricuspid aortic valves (TAV), and even significantly higher MMP-2, MMP-9 and TIMP-1 levels compared with all other tissues (control and TAV together). LeMaire et al. observed a lack of inflammatory processes and an increased MMP-2 level and normal MMP-9, TIMP-1 and TIMP-2 expression levels in aneurysmal tissues obtained from patients with BAV. In contrast, in aneurysmal tissues obtained from patients with TAV, they observed increased inflammatory processes and MMP-9 levels. (Lemaire et al., 2005) Furthermore, they showed an increased incidence of cultured vascular smooth muscle cell (VSMC) loss in BAV and Marfan syndrome (MFS) compared with control samples and suggested that a link between the upregulation of MMP-2 and VSMC apoptosis may exist in MFS. Certainly, there are similarities between the histology of the aneurysmal tissue of the aorta in MFS and that BAV. (Longo et al., 2002) In MFS, a mutation in the gene encoding for the extracellular matrix protein fibrillin-1 can be observed; this mutation leads to dysregulation of the transforming growth factor-beta (TGF-b) signaling. (Dietz et al., 2005) In this chapter, we review the present knowledge for elucidating the ascending aortic aneurysm pathogenesis, particularly in patients with BAV. more...

Background— The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. Methods and Results— One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. Conclusions— Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409. more...

Background— Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis. Methods and Results— 1335 adult patients (mean age:43.5±12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09±3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root−R) group was associated with a 6× increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P Conclusions— For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure. more...

Background— Twenty-four–hour Holter monitoring (24HM) is commonly used to assess cardiac rhythm after surgical therapy of atrial fibrillation (AF). However, this “snapshot” documentation leaves a considerable diagnostic window and only stores short-time cardiac rhythm episodes. To improve accuracy of rhythm surveillance after surgical ablation therapy and to compare continuous heart rhythm surveillance versus 24HM follow-up intraindividually, we evaluated a novel implantable continuous cardiac rhythm monitoring (IMD) device (Reveal XT 9525). Methods and Results— Forty-five cardiac surgical patients (male 37, mean age 69.7±9.2 years) with a mean preoperative AF duration of 38±45 m were treated with either left atrial epicardial high-intensity focus ultrasound ablation (n=33) or endocardial cryothermy (n=12) in case of concomitant mitral valve surgery. Rhythm control readings were derived simultaneously from 24HM and IMD at 3-month intervals with a total recording of 2021 hours for 24HM and 220 766 hours for IMD. Mean follow-up was 8.30±3.97 m (range 0 to 12 m). Mean postoperative AF burden (time period spent in AF) as indicated by IMD was 37±43%. Sinus rhythm was documented in 53 readings of 24HM, but in only 34 of these instances by the IMD in the time period before 24HM readings (64%, P Conclusion— For “real-life” cardiac rhythm documentation, continuous heart rhythm surveillance instead of any conventional 24HM follow-up strategy is necessary. This is particularly important for further judgment of ablation techniques, devices as well as anticoagulation and antiarrhythmic therapy. more...

Objective During the past decade the Ross procedure using the full root has become the predominant surgical technique. However, progressive autograft dilatation and eventual failure remain a concern. Here we report on the surgical techniques and results of the subcoronary technique over a 14-year period. Methods A total of 501 patients (mean age, 44.9 ± 12.9 years; 117 female; 384 male) were operated on from June 1994 to December 2007. The follow-up database, with a completeness of 98.2%, was closed on December 2008, comprising of 2931 patient-years with a mean follow-up of 5.9 ± 3.6 years (range, 0.1–14.1 years). Results Surgical details are presented. Early and late mortality were 0.4% (n = 2) and 4% (n = 20), respectively, valve-related mortality was 1.2% (n = 6), whereas the overall survival did not differ from that of the normal population. Neurologic events occurred in 22 patients, major bleeding in 9, autograft endocarditis in 8, and homograft endocarditis in 10. Freedom from autograft and homograft reoperation was 91.9% at 10 years. For the majority of patients, hemodynamics was excellent and no root dilatation was observed. Conclusions Midterm results after the original subcoronary Ross procedure are excellent, including normal survival and low risk of valve-related morbidity. Longer-term results are necessary for continuous judgment of the subcoronary technique. more...

Background. For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR). Methods. Neoaortic echo dimensions from 48 children (< 16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years). Results. The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow- up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40). Conclusions. Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR. (Ann Thorac Surg 2009; 88: 594-600) c 2009 by The Society of Thoracic Surgeons more...

Introduction: Surgical atrial fibrillation (AF) therapy is gaining widespread acceptance among cardiothoracic surgeons. However, assessment of therapy success is until now solely based on short time -“snapshot”-rhythm surveillance often at irregular time intervals. In order to evaluate the ablation’s success we intraindividually compared two different types of follow-up strategies: conventional 24h-Holter monitoring and direct long time rhythm surveillance achieved by a new implantable monitor device (IRMD). Methods: 20 cardiac surgical patients (male 16, mean age 69±9y) with a mean AF of 30±48m (paroxysmal n=7, persistent n=9, long standing persistent n=4) were treated intraoperatively with epicardial high intensity focus ultrasound (HIFU) ablation (+CABG n=10, +AVR n=5, +AVR/CABG n=2, +valve preserving ascending aorta replacement n=2, +endoaneurymoraphy n=1, lone atrial fibrillation n=1). Postoperative heart rhythm monitoring was accomplished in all patients with a 24h-Holter-monitor at prescheduled time intervals and additionally with a new implantable monitor device (Reveal XT, Medtronic®, MN, USA). A more than 0.5% of “time in AF” as reported by the IRMD was considered as recurrence of AF. Telemetry of the IRMD was performed simultaneously after completion of 24h-Holter monitoring. Results: During a mean FU of 8.7±1.4m a total of 29 24 h-Holter-monitors were obtained. Sinus rhythm was documented in 21, the IMRD however revealed AF recurrence in 11 of these cases. Thus, conventional 24 h ECG monitoring failed to identify AF recurrence in 59% of cases (p Conclusion: In order to evaluate better “real life” outcomes after atrial fibrillation ablation therapy, long term continuous heart rhythm surveillance instead of -“snapshot” - heart rhythm monitoring is mandatory. This is particularly important for the decision to alter medical therapies, e.g. oral anticoagulation or antiarrhythmic treatment. more...

In this study, we report on our first experience with the construction of a valve using autologous vena cava tissue for right ventricular outflow tract reconstruction. Simulating the clinical situation valves were built from tubular pieces of porcine inferior vena cava placed in a PTFE tube and investigated in a pulsatile flow simulator. Based on the given vena cava dimensions, conduits were constructed with diameters of 19 mm in bicuspid or tricuspid and 22 mm and 24 mm in bicuspid configuration. The lowest pressure gradients were observed in the 22 mm vena cava valves in bicuspid configuration (8.6+/-0.5 mmHg) compared to 24 mm valves (10.6+/-0.9 mmHg, P=0.0004) and 19 mm valves (13.4+/-1.5 mmHg, P=0.005). No differences could be found between 19 mm bicuspid and tricuspid valves. Concerning valve opening movements, a complete opening in the 19 mm and a nearly unhindered opening in 22 mm valves were registered. In 24 mm valves opening was incomplete. Leakage was increased in 19 mm bicuspid valves due to leaflet prolapse. In conclusion, construction of a valve mechanism from vena cava tissue is feasible. The in-vitro hemodynamic results are encouraging, animal experiments are ongoing to investigate the midterm function of these valves. more...

Gastrointestinal bleeding is a known problem in patients with left ventricular assist devices (LVADs). The exact source of the bleeding is sometimes difficult to ascertain. In gastroenterology, wireless capsule videoendoscopy has become an important diagnostic tool, especially when the small intestine is involved. It is not known, however, whether an implanted LVAD would interfere with signal transmission from the capsule, nor whether the signals from the capsule would cause malfunction of the LVAD. We report the case of a patient in whom significant gastrointestinal bleeding developed after implantation of a HeartMate II LVAD (Thoratec Corporation, Pleasanton, Calif). The source of the bleeding was successfully identified by wireless PillCam SB capsule videoendoscopy (Given Imaging Ltd, Yoqneam, Israel). more...

Objectives Biventricular pacing acutely improves left ventricular function in patients with heart failure and left ventricular dyssynchrony. Pressure-volume loop analysis has shown acute perioperative hemodynamic benefits of biventricular pacing immediately after weaning from cardiopulmonary bypass in patients undergoing coronary artery bypass grafting, but whether these effects can be maintained for the early postoperative period is unclear. We hypothesized that biventricular pacing is superior to atrioventricular universal pacing at right ventricular outflowtract and atrial inhibited pacing in patients undergoing coronary artery bypass grafting. Methods Ninety-four patients (mean age, 67 ± 9 years; mean ejection fraction, 35% ± 4%) were prospectively randomized to undergo biventricular, atrioventricular universal, or atrial inhibited pacing at 90 beats/min for 96 postoperative hours. Clinical end points and postoperative hemodynamics, aminoterminal pro–brain natriuretic peptide, inotropic support, atrial fibrillation, ventricular arrhythmias, and renal function were evaluated. Results Diastolic pulmonary arterial pressure, mean arterial pressure, mixed venous saturation, cardiac index, and cardiac power index did not differ significantly among groups for all time points. Neither raw aminoterminal pro–brain natriuretic peptide nor differential from preoperative values differed significantly among groups at any time point. Median intensive care unit stay (19.5 hours) did not differ significantly by pacing mode. Incidences of postoperative atrial fibrillation were 40% for atrial inhibited, 29% for atrioventricular universal, and 37% for biventricular (differences not significant). Renal function was unaffected by pacing mode. Conclusion Despite short-term hemodynamic benefits for patients with reduced left ventricular function, biventricular pacing did not lead to improved postoperative hemodynamics or clinical outcome. more...