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OBJECTIVES There is growing interest in the use of bilateral internal thoracic arteries (BITAs) for myocardial revascularization. This study sought to compare the balance between early benefits and long-term outcomes of skeletonized or non-skeletonized conduits and to determine whether differences in outcomes are affected by other patient risk factors. METHODS BITAs were used in 1504 cases with either SK or NSK conduits. Propensity matching was completed using 22 covariates identifying 441 pairs of patients. The primary outcomes are the sternal wound infection in the short term and the composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure. Outcomes were assessed using paired analysis techniques and Cox proportional hazards regression models stratified using the matched pairs. RESULTS Incidences of in-hospital mortality and perioperative myocardial infarction were similar in both groups. There were fewer sternal wound infections in the SK group (5.4 vs 9.1%, P  = 0.033). Homogeneity testing of the relative risk estimates confirmed that there was a protective effect of skeletonization in men that was not demonstrated in women (P  = 0.020). SK had a protective effect in diabetics not seen in non-diabetics (P  = 0.048). The composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure at a median of 5.6 years was comparable in both groups (hazard ratio 0.81, 95% confidence interval 0.57–1.15). CONCLUSION Skeletonization results in better perioperative outcomes and comparable cardiac outcomes in patients undergoing BITA with the greatest benefit in men and patients with chronic obstructive pulmonary disease. [ABSTRACT FROM AUTHOR]

Background: The impetus for aortic valve (AV) repair is to decrease valve-related complications in comparison to prosthetic valve replacement. However, relatively few data are available to confirm this hypothesis. We analyzed valve-related complications in a large series of patients undergoing AV repair. Methods: Between 1995 and 2010, 475 patients underwent elective AV repair for aortic insufficiency or aortic aneurysm. The mean age was 53 years, and 81% were male. Valve-related outcomes were defined as per published guidelines. Survival and freedom from valve-related events were reported using the Kaplan-Meier method and linearized event rates. Clinical follow-up was 98.3% complete with a mean follow-up time of 4.6 years. Results: Thirty-day mortality was 0.8% (n = 4). At 10 years, overall survival was 73% ± 5%, freedom from cardiac death was 81% ± 4%, and freedom from valve-related death was 90% ± 3%. Freedom from significant aortic insufficiency was 84% ± 3%. A total of 28 patients needed early (n = 7) or late (n = 21) AV reoperation; all of them survived reoperation, and 8 had repeat repair. Ten-year freedom from AV reoperation was 86% ± 3%, and freedom from AV replacement was 90% ± 3%. Freedom from AV reoperation was similar in tricuspid and bicuspid valve. During the follow-up period, linearized rate of thromboembolic event, bleeding, and AV endocarditis was 1.1%, 0.23%, and 0.19% per year, respectively. Ten-year freedom from valve-related events including AV reoperation, thromboembolic event, bleeding, and endocarditis was 74% ± 3%. Conclusions: The current findings confirm that AV repair is associated with low mortality, acceptable durability, and a low risk of valve-related events. [ABSTRACT FROM AUTHOR]

Objectives: Studies have emphasized the importance of normal fibrinogen concentrations in surgical patients. The primary hypothesis of this study was that fibrinogen levels significantly decrease in on-pump coronary artery bypass graft (CABG) surgery versus off-pump coronary artery bypass graft (OPCAB) surgery. The second objective was to show that ROTEM (TEM International, GmbH, Munich, Germany) rapidly detects these abnormalities compared with standard tests. Design: A prospective, nonrandomized study. Setting: A university hospital. Participants: Forty-two and 62 patients in the CABG and OPCAB groups, respectively, undergoing first-time bypass surgery were included. Interventions: CABG versus OPCAB surgery. Measurements and Main Results: Routine coagulation tests and ROTEM values were measured before anesthesia (T0), after the first dose of heparin (T1), after protamine (T2), upon intensive care unit arrival (T3), and 4 hours postoperatively (T4). The outcome measures were followed until 4 hours postoperatively. Fibrinogen concentrations were significantly lower in the CABG versus the OPCAB group at T2 (170 ± 44 v 243 ± 73 mg/dL, p < 0.001) and T3 (179 ± 42 v 232 ± 68 mg/dL, p < 0.001). This was confirmed by significantly lower FIBTEM maximal clot firmness values at T2 (9 ± 4 v 14 ± 5 mm, p < 0.001) and T3 (9 ± 4 v 13 ± 6 mm, p < 0.001). In the CABG group, patients received significantly more transfusions of all blood products except fresh frozen plasma. Conclusions: Fibrinogen concentration significantly decreases after cardiopulmonary bypass. ROTEM helps in its fast detection. [Copyright &y& Elsevier]

OBJECTIVES The long-term advantages of multiple arterial grafts, particularly a third arterial conduit, for coronary artery bypass (CABG) are not clear. This study was designed to test whether multiple arterial grafts would provide better long-term outcomes when compared with approaches using fewer arterial conduits. METHODS Between 1985 and 1995, prospective data were collected for 588 patients undergoing isolated CABG at our institution. We examined long-term survival and freedom from cardiac death. The primary analysis compared patients receiving bilateral internal thoracic artery (BITA) vs. single ITA (SITA). In a subgroup analysis, BITA patients receiving a right gastroepiploic artery (RGEA) were compared with those receiving a saphenous vein graft (SVG) as a third conduit. Cox proportional hazard modelling was used to adjust for relevant confounders. The Kaplan–Meier method was used to create survival curves over the follow-up period. RESULTS The mean age was 59 ± 9 years and 49% received BITA. Mean follow-up was 16.1 ± 5.4 years. Multivariable analysis revealed that overall survival [hazard ratio (HR): 0.74, P = 0.017] and cardiac survival (HR: 0.61, P = 0.004) was significantly improved in the presence of BITA compared with SITA. The survival at 10 and 20 years was 90.2 ± 3.4 and 56.9 ± 6.4% for the BITA vs. 82 ± 4.4 and 40.9 ± 6% for the SITA, respectively. In the subgroup of BITA patients, those receiving the RGEA as a third conduit had superior overall survival (HR: 0.41, P = 0.0032) and cardiac survival (HR: 0.18, P = 0.004) compared with those receiving an SVG. The survival at 10 and 20 years was 98.9 ± 2 and 68.9 ± 18% for the BITA/RGEA vs. 87.2 ± 4.6 and 50.3 ± 7% for the BITA/SVG, respectively. CONCLUSIONS In a single-institution experience, the use of multiple arterial grafting is independently associated with superior outcomes. Furthermore, the use of a third arterial conduit (RGEA) targeted to the right coronary artery should be considered to improve long-term survival. [ABSTRACT FROM AUTHOR]

Objectives: To assess root replacement and annular stabilization in bicuspid aortic valve repair, we compared results of reimplantation technique versus subcommissural annuloplasty or no annuloplasty. Methods: Between 1995 and 2010, 161 consecutive patients underwent bicuspid aortic valve repair. Patients undergoing subcommissural annuloplasty or no annuloplasty (group 1, n = 87) had larger root dimensions and less aortic insufficiency than did patients undergoing reimplantation technique (group 2, n = 74). We matched groups 1 to 1 on basis of those criteria. After matching (n = 106, n = 53 per group), root dimensions (41.5 ± 5 vs 40 ± 4 mm; P = .2) and degree of insufficiency (2.6 ± 1.2 vs 2.7 ± 1; P = .6) were similar between groups. Results: Techniques of cusp repair were similar between groups. Group 2 had smaller preoperative left ventricular size (P = .02), fewer concomitant procedures (P = .02), and shorter follow-up (41 ± 30 vs 63 ± 40 months; P = .003). There were no in-hospital deaths. At discharge, residual aortic insufficiency was similar between groups, but peak gradient greater than 25 mm Hg was more frequent in group 1 (13% vs 30%; P = .04). At 6 years, overall survival was 98% ± 3% in both groups. Freedoms from reoperation and aortic insufficiency greater than 2+ were significantly better in group 2 (100% vs 90% ± 8%; P = .03; 100% vs 77% ± 14%; P = .002). Conclusions: In bicuspid aortic valve repair, root replacement with the reimplantation technique stabilizes the ventriculoaortic junction, improves valve mobility (low gradient), and is associated with improved outcomes. [ABSTRACT FROM AUTHOR]

Background: Cusp prolapse management is important in aortic valve (AV) sparing and repair to achieve durable results. We analyzed the midterm outcomes of two different techniques for trileaflet AV prolapse repair. Methods: Between 1996 and 2008, 376 patients underwent elective AV repair: 88 with trileaflet AV (23%) had cusp prolapse repair, plication technique was performed in 34 (39%), resuspension technique in 33 (37%) and plication plus resuspension in 21 (24%). One cusp was repaired in 55 (62%), 2 cusps in 18 (21%), and 3 cusps in 15 (17%). Results: No hospital deaths occurred. Patients undergoing resuspension with or without plication had more preoperative aortic insufficiency (AI; p = 0.01) and multiple cusp prolapses (p = 0.01). During follow-up (median, 41 months), 4 deaths occurred and 2 were cardiac related. Overall survival at 5 years was 95% ± 5%. Two patients needed AV reoperation because of recurrent AI or AI plus AV stenosis. Recurrent AI grade ≥3+ developed in 4 patients; 1 with moderate AV stenosis. Freedom from reoperation at 5 years was 100% for plication, 96% ± 4% for resuspension, and 93% ± 7% for plication plus resuspension (p = 0.6); respective freedom from AI ≥3+ at 3 years was 100%, 92% ± 8%, and 89% ± 11% (p = 0.8). Conclusions: Cusp plication or resuspension are efficient and durable techniques to correct cusp prolapse in the trileaflet AV. Plication is typically the first choice because of its ease of use and lower risk of overcorrection; however, free margin resuspension is useful in specific situations. [Copyright &y& Elsevier]

Objective: Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair. Methods: From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age − 54 ± 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism. Results: In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29–73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 ± 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 ± 3% and 92 ± 4% respectively and patients with type I (82 ± 9%; 93 ± 5%) or II (95 ± 5%; 94 ± 6%) had better outcomes compared to type III (76 ± 17%; 84 ± 13%). Conclusion: Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair. [Copyright &y& Elsevier]

OBJECTIVES Because of the limited availability of pulmonary homografts (PH), porcine stentless xenografts (SX) have been proposed as an alternative for pulmonary valve replacement in the Ross operation. However, it is unknown whether they have similar good long-term durability. Therefore, we compared mid- to long-term outcomes between those two right ventricular outflow tract (RVOT) substitutes. METHODS In 288 adults (>18 years) undergoing a Ross operation between 1991 and 2012, Freestyle® SX was used in 18 patients and a cryopreserved PH was used in 270 for RVOT reconstruction. Only patients with follow-up >2 years were included. According to the operative period, gender and age, 37 patients with PH could be matched with 17 SX patients. Clinical and echocardiographic follow-up were obtained. In a subset of patients (SX, n = 11 and PH, n = 25), a cardiac computed tomographic (CT) scan was performed to analyse graft calcification. RESULTS The mean follow-up period was 8.2 ± 4.0 (range 2–14.6 years). During this period, 3 patients died from cancer, 2 in the SX group and 1 in the PH group (P = 0.15). No patient needed RVOT reoperation. At follow-up, RVOT peak gradient was 21 ± 5.9 mmHg in the SX and 16.3 ± 8.7 in the PH groups (P = 0.07). Peak gradient >40 mmHg was observed in only 1 patient in the PH group. Mean RVOT regurgitation was 0.1 ± 0.4 in the SX group and 0.8 ± 0.6 in the PH group (P = 0.008). CT scan analyses showed progressive calcification mainly of the graft wall, while the valve remained relatively free of calcium. Patients with the SX presented significantly higher calcium scores than those with PH (P = 0.01). CONCLUSIONS In adult patients having the Ross operation, calcic degeneration is observed in both the PH and the SX used as pulmonary substitutes. Calcification progresses more rapidly in the SX compared with the PH. In both grafts, calcifications affect mainly the wall, while the valve remains relatively free of calcium. As a consequence, both grafts show good and similar haemodynamic outcomes at mid- to long-term follow-up. The Freestyle® SX can be considered as an acceptable alternative for RVOT reconstruction when PH is not available. [ABSTRACT FROM PUBLISHER]

Objective: During the last 2 decades, we have applied a repair-oriented surgical approach to patients with active mitral valve endocarditis. We retrospectively analyzed the long-term outcomes with this repair-oriented approach. Method: Between 1991 and 2010, 137 patients underwent operation for active mitral valve endocarditis; of these, 109 patients (80%) had mitral valve repair and represent the study cohort. Repair techniques without patch extension (no-patch techniques) include triangular or quadrangular resection (n = 49), sliding plasty (n = 24), neochordae (n = 18), chordal transfer (n = 12), and others (n = 5). Repair techniques using patch extension (patch techniques) included pericardium (n = 42), tricuspid autograft (n = 8), flip-over technique (n = 7), and partial mitral valve homograft (n = 5). Patches were used in 67 patients (61%). Ring annuloplasty was performed in 60 patients, and a pericardial band was used in 13 patients. Clinical and echocardiographic follow-up were performed. Median follow-up was 48 months. Results: Hospital mortality was 16%. At 8 years, overall survival was 62% ± 10% with no differences between patients with or without patch repair (P = .5). Freedom from mitral valve repair failure was 81% ± 14% in patients with patch repair and 90% ± 10% in patients without patch repair (P = .09). The rate of thromboembolic or bleeding event was 1% per patient-year, and the rate of endocarditis recurrence was 0.3% per patient-year. Univariable predictors of mortality were age more than 70 years (P < .0001), perivalvular abscess (P = .002), diabetes mellitus (P = .0002), and renal failure (P = .04). Predictors of repair failure were renal failure (P = .035) and perivalvular abscess (P = .033). Conclusions: In active mitral valve endocarditis, a repair-oriented surgical approach achieves a reparability rate of 80% with acceptable morbidity and good long-term results. The use of patch techniques offers a durability rate that approximates the rate obtained with the no-patch techniques. [ABSTRACT FROM AUTHOR]

Techniques for transcatheter aortic valve implantation involve manipulation of the native aortic valve and the aortic arch. As a result, excellent technical outcomes of this technique remain counterbalanced by a level of neurologic complications that remain unacceptably high. We present here a report of a new potential combined approach to reduce periprocedural neurologic events. After a 6-cm J-shaped upper-mini-sternotomy, 26-mm Sapien valve (Edwards Lifesciences, Irvine, CA) was deployed through a transaortic approach. In addition, the Embol-X device (Edwards Lifescience) was directly inserted in the distal ascending aorta was deployed during all the procedure. Postoperative evolution was clinically uneventful. Postoperative magnetic resonance imaging revealed no new ischemic lesions in this first patient. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined. Methods: Since 1996, 55 patients (mean age: 65±13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%). Results: AI severity was not significantly associated with the presence of cusp pathology (p =0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p <0.001). There was no hospital mortality and overall survival was 94±4% and 75±10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87±7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome. Conclusions: Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome. [Copyright &y& Elsevier]

B-type natriuretic peptide (BNP) has been shown to predict outcomes after conventional aortic valve replacement. The aim of the present study was to investigate whether BNP also predicts the outcomes after transcatheter aortic valve implantation (TAVI). A total of 58 patients (36 men, age 84 ± 5 years) underwent TAVI in our institution for severe aortic stenosis (aortic valve area 0.6 ± 0.1 cm2, mean gradient 41 ± 15 mm Hg) at high risk of surgery (logistic European System for Cardiac Operative Risk Evaluation 34 ± 17%). BNP was measured before and 24 hours after TAVI. The 30-day survival rate was 91%. Although the baseline clinical and hemodynamic characteristics were similar among the 30-day survivors (n = 53) and nonsurvivors (n = 5), the BNP levels were significantly lower in the 30-day survivors, at both baseline (463 ± 265 vs 1,067 ± 655 pg/ml; p = 0.005) and 24 hours after TAVI (488 ± 238 vs 1,632 ± 1,028 pg/ml; p <0.0001). The BNP levels were significantly greater in patients experiencing one major adverse event at 30 days. On multivariate analysis, only BNP levels (baseline value and change at 24 hours) were independent predictors of 30-day survival. Kaplan-Meier analysis showed that 30-day survival was significantly lower in patients with than in those without both a baseline BNP level >428 mg/dl (p = 0.04) and a significant BNP increase of >170 pg/ml at 24 hours after TAVI (p = 0.001). In conclusion, BNP is a strong predictor of 30-day outcomes after transcatheter aortic valve implantation, at both baseline and 24 hours after the procedure. [ABSTRACT FROM AUTHOR]